Atrial Septal Defect (ASD)

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Epidemiology
What is Atrial Septal Defect (ASD)?
Atrial septal defect (ASD) sometimes referred to
as a hole in the heart is a congenital heart defect in which the wall that separates the upper
heart chambers (atria) does not close completely. Congenital means the defect is present at
birth.
The wall is called septum which separates the hearts left and right sides. So when there is a
large defect between the artia, a large amount of oygen!rich (red) blood lea"s from the
hearts left side bac" to the right side. Then this blood is pumped bac" to the lungs, despite
already ha#ing been refreshed with oygen. This is inefficient, because already!oygenated
blood displaces blood that needs oygen. $any people with this defect ha#e few, if any,
symptoms.
A heart murmur is the increased blood flow to the lungs which creates creates a swishing
sound. This heart murmur, along with other specific heart sounds that can be detected by a
cardiologist, may be clues that a child has an ASD.
%owe#er, atrial septal defect is a type of congenital heart defect in which there is an abnormal
opening in the di#iding wall between the upper filling chambers of the heart (the atria). &n
most cases ASDs are diagnosed and treated successfully with few or no complications.
ASDs can be located in different places on the atrial septum, and they can be different si'es.
The symptoms and medical treatment of the defect will depend on those factors. &n some rare
cases, ASDs are part of more comple types of congenital heart disease. &ts not clear why,
but ASDs are more common in girls than in boys.
What are the causes of Atrial Septal Defect?
ASDs occur during faetal de#elopment of the heart and are present at birth. During the first
wee"s after conception, the heart de#elops. &f a problem occurs during this process, a hole in
the atrial septum may result. &n some cases, the tendency to de#elop a ASD may be genetic (
there can be genetic syndromes that cause etra or missing pieces of chromosomes that can
be associated with ASD. )or the #ast ma*ority of children with a defect, howe#er, theres no
clear cause of the ASD.
&n fetal circulation, there is normally an opening between the two atria (the upper chambers
of the heart) to allow blood to bypass the lungs. This opening usually closes around the time
the baby is born.
&f the ASD is persistent, blood continues to flow from the left to the right atria. This is called
a shunt. &f too much blood mo#es to the right side of the heart, pressures in the lungs build
up. The shunt can be re#ersed so that blood flows from right to left. $any problems can
occur if the shunt is large, but small atrial septal defects often cause #ery few problems and
may be found much later in life.
ASD is not #ery common. +hen the person has no other congenital defect, symptoms may be
absent, particularly in children. Symptoms may begin any time after birth through childhood.
&ndi#iduals with ASD are at an increased ris" for de#eloping a number of complications
including,
Atrial fibrillation (in adults)
%eart failure
-ulmonary o#ercirculation
-ulmonary hypertension
Stro"e
What are the signs and symptoms for Atrial Septal Defect?
The si'e of an ASD and its location in the heart will determine what "inds of symptoms a
child eperiences. $ost children who ha#e ASDs seem healthy and appear to ha#e no
symptoms. .enerally, children with an ASD feel well and grow and gain weight normally.
&nfants and children with larger, more se#ere ASDs, howe#er, may possibly show some of the
following signs or symptoms,
poor appetite
poor growth
fatigue
shortness of breath
lung problems and infections, such as pneumonia
Small!to!moderate!si'ed defects may produce no symptoms, or not until middle age or later.
Symptoms that may occur can include,
Difficulty breathing (dyspnea)
)re/uent respiratory infections in children
Sensation of feeling the heart beat (palpitations) in adults
Shortness of breath with acti#ity
&f an ASD is not treated, health problems can de#elop later, including an abnormal heart
rhythm ("nown as an atrial arrhythmia) and problems in how well the heart pumps blood. As
infants and children with ASDs get older, they may also be at an increased ris" for stro"e,
since a blood clot that de#elops can pass through the hole in the wall between the atria and
tra#el to the brain. -ulmonary hypertension (high blood pressure in the lungs) may also
de#elop o#er time in older patients with larger untreated ASDs.
)ortunately, most "ids with ASD are diagnosed and treated long before the heart defect
causes physical symptoms. Due to the complications that ASDs can cause later in life,
paediatric cardiologists often recommend closing ASDs early in childhood.
How is Atrial Septal Defect diagnosed?
.enerally, a childs doctor hears the heart murmur caused by ASD during a routine chec"!up
or physical eamination. ASDs are not always diagnosed as early in life as other types of
heart problems, such as #entricular septal defect (a hole in the wall between the two
#entricles). The murmur caused by an ASD is not as loud and may be more difficult to hear
than other types of heart murmurs, so it may be diagnosed any time between infancy and
adolescence (or e#en as late as adulthood).
&f a doctor hears a murmur and suspects a heart defect, the child may be referred to a
paediatric cardiologist, a doctor who specialises in diagnosing and treating childhood heart
conditions. &f an ASD is suspected, the cardiologist may order one or more of the following
tests,
chest 0!ray, which produces an image of the heart and surrounding organs
electrocardiogram (12.), which records the electrical acti#ity of the heart and can
indicate #olume o#erload of the right side of the heart
echocardiogram (echo), which uses sound wa#es to produce a picture of the heart and
to #isuali'e blood flow through the heart chambers. This is often the primary tool
used to diagnose ASD.
The doctor may hear abnormal heart sounds when
listening to the chest with a stethoscope. A murmur may be heard only in certain body
positions, and sometimes a murmur may not be heard at all. The physical eam may also
re#eal signs of heart failure in some adults.
&f the shunt is large, increased blood flow across the tricuspid #al#e may create an additional
murmur when the heart relaes between beats.
Tests that may done include,
1chocardiography
%eart $3&
Transesophageal echocardiography (T11)
Cardiac catheteri'ation
Chest !ray
Coronary angiography (for patients o#er 45 years old)
Doppler study of the heart
1C.
What are the treatments for Atrial Septal Defect?
6nce an ASD is diagnosed, treatment will depend on the childs age and the si'e, location,
and se#erity of the defect. &n "ids with #ery small ASDs, the defect may close on its own.
7arger ASDs usually wont close, and must be treated medically. $ost of these can be closed
in a cardiac catheteri'ation lab, although some ASDs will re/uire open!heart surgery.
A child with a small defect that causes no symptoms may simply need to #isit a pediatric
cardiologist regularly to ensure that there are no problems8 often, small defects will close
spontaneously without any treatment during the first years of life. &n general, a child with a
small ASD wont re/uire restrictions on his or her physical acti#ity.
&n most children with ASD, though, doctors must close the defect if it has not closed on its
own by the time a child is old enough to start school.
ASD may not re/uire treatment if there are few or no symptoms, or if the defect is small.
Surgical closure of the defect is recommended if the defect is large, the heart is swollen, or
symptoms occur.
A procedure has been de#eloped to close the defect without surgery. The procedure in#ol#es
placing an ASD closure de#ice into the heart through tubes called catheters. The health care
pro#ider ma"es a tiny surgical cut in the groin, then inserts the catheters into a blood #essel
and up into the heart. The closure de#ice is then placed across the ASD and the defect is
closed.
9ot all patients with atrial septal defects can ha#e this procedure.
-rophylactic (pre#enti#e) antibiotics should be gi#en prior to dental procedures to reduce the
ris" of de#eloping infecti#e endocarditis immediately after surgery for the ASD, but they are
not re/uired later on.
Surgical Therapy
Closing an atrial septal defect in childhood can pre#ent serious problems later in life. The
long!term outloo" is ecellent. &f atrial septal defects are diagnosed in adulthood, the defect is
also repaired. 3arely, the defect is left unrepaired if theres pulmonary hypertension (high
blood pressure in the lungs). :our cardiologist can determine if the defect should be closed.
Depending on the position of
the defect, many children with ASD can ha#e it corrected with a cardiac catheteri'ation. &n
this procedure, a thin, fleible tube called a catheter is inserted into a blood #essel in the leg
that leads to the heart. A cardiologist guides the tube into the heart to ma"e measurements of
blood flow, pressure, and oygen le#els in the heart chambers. A special implant can be
positioned into the hole in the septum. The de#ice is designed to flatten against the septum on
both sides to close and permanently seal the ASD. &n the beginning, the natural pressure in
the heart holds the de#ice in place. 6#er time, the normal tissue of the heart grows o#er the
de#ice and co#ers it entirely. This non!surgical techni/ue for closing an ASD eliminates the
scar on the chest needed for the surgical approach, and has a shorter reco#ery time, usually
*ust an o#ernight stay in the hospital.
;ecause there is a small ris" of blood clots forming on the closure de#ice while new tissue
heals o#er it, children who undergo de#ice closure of an ASD may need to be on medications
for se#eral months after the procedure to pre#ent clots from forming.
&f surgical repair for ASD is necessary, a child will undergo open!heart surgery. &n this
procedure, a surgeon ma"es a cut in the chest and a heart!lung machine is used to do the wor"
of the circulation while the heart surgeon closes the hole. The ASD may be closed directly
with stitches or by sewing a patch of surgical material o#er the defect. 1#entually, the tissue
of the heart heals o#er the patch or stitches, and by < months after the surgery, the hole will
be completely co#ered with tissue.
)or < months following catheteri'ation or surgical closure of an ASD, antibiotics are
recommended before routine dental wor" or surgical procedures to pre#ent infecti#e
endocarditis. 6nce the tissue of the heart has healed o#er the closed ASD most people who
ha#e had their ASDs corrected no longer need to worry about ha#ing a higher ris" of infecti#e
endocarditis.
:our doctor will discuss other possible ris"s and complications with you prior to the
procedure. Typically, after repair and ade/uate time for healing, children with ASD rarely
eperience further symptoms or disease.
+hat is the 6ngoing Care for Atrial Septal Defect=
Regular onitoring, After an ASD is closed, patients need follow!up with a cardiologist.
6nly rarely will they need to ta"e medicine. :our cardiologist can monitor you with
nonin#asi#e tests if needed. These include electrocardiograms, %olter monitors, eercise
stress tests and echocardiograms. They will help show if more procedures, such as a cardiac
catheteri'ation, are needed.
edications!
Acti"ity Restrictions, are almost ne#er needed unless there are associated problems that you
and your doctor ha#e discussed.
Endocarditis #re"ention, 9ot needed.
After undergoing surgery for ASDs, patients usually go home after a few days in the hospital
if there are no complications. After surgical ASD repair, the main medical concern is the
healing of the chest incision. &n general, the younger patients are when they ha#e their
surgical repairs, the less pain they will ha#e during reco#ery. The patient will be watched
closely for signs or symptoms that may indicate a problem. &f the patient has trouble
breathing, is not eating, has fe#er, or redness or pus oo'ing from the incision, get medical
treatment right away. &n most cases, patients who ha#e had ASD surgery reco#er /uic"ly and
without problems
Children who undergo cardiac catheterisation to close an ASD usually spend the night in the
hospital after the procedure. Those who ha#e had a catheterisation procedure should also be
"ept out of gym class or sports practice for a wee"8 after a wee", they can usually return to
their normal physical acti#ities, with their doctors 62.
&n the wee"s following surgery or cardiac catheterisation, your doctor will chec" on your
childs progress. :our child may undergo another echocardiogram to ma"e sure that the heart
defect has closed completely. Children who ha#e undergone ASD repair will continue to ha#e
follow!up #isits with the cardiologist.
$ost children who undergo treatment for ASDs reco#er /uic"ly and you may e#en notice that
within a few wee"s of treatment, your child is eating more and is more acti#e than before
surgery. %owe#er, some signs and symptoms may indicate a problem. &f your child is ha#ing
trouble breathing, call the doctor or ta"e your child to the emergency department
immediately. 6ther symptoms that may indicate a problem include,
a bluish tinge or color (cyanosis) to the s"in around the mouth or on the lips and tongue
poor appetite or difficulty feeding
failure to gain weight or weight loss
listlessness or decreased acti#ity le#el
prolonged or uneplained fe#er
increasing pain, tenderness, or pus oo'ing from the incision
Call your doctor if you notice any of these signs in your child after closure of the ASD.
Any time a child is diagnosed with a heart condition, it can be scary. ;ut the good news is
that your paediatric cardiologist will be #ery familiar with this condition and how to best
manage it. $ost children who#e had an ASD corrected ha#e a normal life epectancy and go
on to li#e healthy, acti#e li#es.
What #ro$lems can arise?
-eople with repaired atrial septal defects rarely ha#e any problems. Those who ha#e
palpitations or faint need to be ree#aluated by their cardiologist and may need medical
therapy. Also, if the ASD is diagnosed late in life, the heart may be less able to pump. This
can re/uire diuretics, drugs to help the heart pump better and drugs to control blood pressure.
&f pulmonary hypertension de#elops (which is rare), some people may need more
medications.
+ith a small!to!moderate atrial septal defect, a person may li#e a normal life span without
symptoms. 7arger defects may cause disability by middle age because of increased blood
flow and shunting of blood bac" into the pulmonary circulation.
-ossible complications
Arrhythmias, particularly atrial fibrillation
%eart failure
-ulmonary hypertension
Stro"e
Will %ou &eed ore Surgery?
6nce an ASD has been closed, its unli"ely that more surgery will be needed. 3arely, a
patient may ha#e a residual hole. +hether it will need to be closed depends upon its si'e.
-re#ention There is no "nown way to pre#ent the defect, but some of the complications can
be pre#ented with early detection.
3elated 7in"s>)urther 3eading
http,>>www.cincinnatichildrens.org>health>heart!encyclopedia>anomalies>asd.htm
http,>>www.americanheart.org>presenter.*html=identifier?@@A<5
http,>>"idshealth.org>parent>medical>heart>asd.htmlBen.wi"ipedia.org>wi">iAtrialCseptalCdefe
ct
http,>>www.nlm.nih.go#>medlineplus>ency>article>AAA@5D.htm
Atrial septal defect (ASD) hole in heart
Left and right atrium are separated by septum called Inter atrial septum, which
prevents mixing of deoxygenated blood coming from systemic circulation to right
atrium with oxygenated blood coming from pulmonary circulation to left atrium.
ASD is congenital heart disease, in which there is hole or defect in inter atrial
septum this leads to mixing of blood at the atrial level.
Blood from left atrium moves to right atrium, this is called left to right shunting.
his is because right ventricle is more complained so it distends easily as
compared to left ventricle.
!ight atrium is overloaded with more blood, leading distention of right atrium,
right ventricle and also pulmonary artery.
This increase fow on right side of heart leads following clinical signs
" #$ection systolic murmur at pulmonary valve.
" %ixed and wide splitting of second heart sound
" &id diastolic murmur of tricuspid valve 'Larger atrial septal defect(
Incidence of Atrial septal defect
1. ) to *+ , of all congenital heart disease, as isolated anomaly
2. &ore common in females 'male to female ratio *-.(
3. ASD is associated with other congenital heart disease in /+01+, of cases
Types of Atrial septal defect
I. 2stium Secundum defect, most common )+03+, of all ASDs
II. 2stium primium defect, /+, of all ASDs
III. Sinus venosus defect, *+, of all ASDs
I4. 5oronary sinus defect, rare variety of ASD
ypes of ASD
Electrocardiographic ndings
!ight axis deviation &ild !ight ventricle hypertrophy with !BBB rS!6 pattern in
lead 4* .
!hest "#ray
5ardiomegaly 'enlarged heart(, enlargement of !ight atrium and ventricle and
prominent pulmonary artery.
Echocardiography
his is most important investigation, which will detect ASD and helps in typing
the ASD, and also gives valuable information in regard to weather given ASD
needs closer by transcatheter 'see below( approach or open heart surgery.
In older patients if trance thoracic imaging by #chocardiography is not proper
some times, then patient may need trance esophagus echocardiographic study.
#chocardiography demonstrates
" ype of ASD
" Associated cardiac anomalies
" Si7e of ASD
" !ims around the defect whether they are good to hold ASD closer device
" 8ulmonary artery pressure is estimated, if it is high then ASD cannot be
closed.
$at%ral history of ASD
" 2stium secundum ASD have tendency to close by themselves
" 2stium secundum of less than /mm in si7e detected within /months after
birth all of them ie *++, will close themselves within * and half year of age
" 2stium secundum of / 9 :mm in si7e detected within /months after birth
:+, will close by themselves within one and half year of age
" 2stium secundum ASD of more than :mm rarely close by themselves.
" 2ther type i.e. premium, sinus venosus type and coronary type do not close
by themselves.
Sy&pto&atic &edical &anage&ent
" &ost children of ASD are asymptomatic
" !arely develop heart failure in infancy
" ;ntreated large defect may lead to pulmonary hypertension at the age of .+
to /+ years
" ASD in adult may cause atrial <brillation.
" =o need for infective endocarditis prophylaxis
" #xercise restriction is unnecessary
Transe catheter closer of ASD
ranse catheter closer of ASD
*. >hat is transe cathter closer of ASD ?
a. Done for 2stium Secundum ASD
b. In this procedure chest is not opened.
c. %rom anterior aspect of thigh through femoral artery device is delivered at
the inter atrial septum
d. 8atient is discharged with one or two days after procedure
e. Device used to plug the ASD are most commonly Amplat7er, 5ardio seal,
Sideris buttoned device, Angel wings device
.. ranse catheter closer is indicated in
a. ASD of si7e more than )mm
b. @p to @s ratio 'blood movement in right heart verses left heart ( more then
*.) -* 'more the ratio suggest more shunting of blood from left to right heart.
c. Aeart failure present in infancy
/. !im around the defect has to at least 1mm in si7e, to hold the umbrellas of
device, if not this procedure cannot be done.
1. Advantages of transe catheter closer are, no scar , very little pain i.e one
in$ection in groin, * to . day of hospital stay, rapid recovery
). Disadvantages little more chance of minimal residual shunt, compared to
open heart surgery.
B. 8ost procedure
a. Aspirin :*mgCday for Bmonths
b. #chocardiography
i. 5on<rm no obstruction of pulmonary veins by device
ii. 5on<rm no obstruction of coronary sinus
iii. 5on<rm free movement of tricuspid and mitral valve
leaDets
'pen heart s%rgery
*. Done only in cases where rims of ASD can not hold device
.. 2ther types of ASD i.e. 2stium primium, Sinus venosus, 5oronary sinus type
are closed by open heart sugary.
/. 5omplication of open heart surgery
a. Less than +.), mortality for open0heart surgery for ASD
b. SicE sinus syndrome following surgical closer of sinus venosus defect
c. 5ardiomegaly 'enlargement of heart(
d. 3, to .+, may develop atrial arrhythmias
e. !esidual shunt
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