Cardiology Department

Faculty of Medicine, Hasanuddin University

2015

case report

Atrial Septal
Defect
Type : Secundum
PRESENTED BY :TRI KURNIAWAN (C11111323)
SUPERVISOR : DR. ABDUL HAKIM ALKATIRI, SPJP, FIHA

Patients Identity

Name

: Ms J

Age

: 22 years old

Gender

: Female

Adress

: Cilellang Selatan, Kab. Barru

Medical Record No.

: 6996xx

Admission

: August, 8th 2015

HISTORY TAKING

Chief complaint

Palpitation

Guided-Anamnesis

Experienced since 3 months ago.

DOE (+), Orthopnea (-), PND (-).

Chest pain was felt intermittently on active state

Epigastric pain (-), cough (-), fever (-)

Fatigue (+)

Headache (-), Nausea and vomiting (-)

Syncope (-), history of syncope (-)

Urination and defecation remains normal

HISTORY TAKING

Previous illness
Goiter (+)
Hypertension (-)
Diabetes Mellitus (-)
Recurrent respiratory tract infection (-)

Risk Factor

Modifiable : (-)

Non-Modifiable : History of alcohol, drugs, or illness of mother during

pregnancy (-), histoy of family with same disease (-)

Physical Examination

General State

Moderate illness/ well-nourished/ compos mentis

Vital sign

BP : 110/80 mmHg
HR : 78 x/minutes, regular,
RR : 22 x/minutes
Temp : 36,5 C (Axilla)

Head and Neck

Conjungtiva
Lips
Neck

: Anemia (-), Icterus (-)

: Cyanosis (-)
: JVP R+2 cmH20 on 30 supine position
Lymphadenopathy (-)
Tumor Mass (-)
Thyroid enlargement (+), grade IB

Physical Examination

Thorax :
Inspection : symmetric left=right, normothorax
Palpation : tenderness (-), tumor (-), vocal fremitus
left=right
Percussion: sonor left=right,
Liver and Lung margin ICS VI dextra
Right Back Lung margin ICS IX dextra
Left Back Lung margin ICS X sinistra
Auscultation

: BS : vesicular; Ronchi (-/-), Wheezing -/-

Physical Examination

Heart

Inspection

: Ictus cordis isnt visible

Palpation

: Ictus cordis is not palpable, thrill is not palpable

Percussion

: Upper border ICS III sinistra

Right border linea parasternalis dextra
Left border medioclavicularis sinistra

Auscultation

: HS I/II pure, regular

Sistolic ejection murmur hear on ICS II sinistra

Physical Examination

Abdominal Exam

Inspection

: Flat, simetrical, follows breath movement

Auscultation : Peristaltic (+), normal

Palpation
palpable

: tenderness (-), tumor mass (-), liver and spleen not

Percussion

: Tympani (+), Ascites (-)

Extremity

Warm, edema pretibial (-/-), edema dorsum pedis (-/-)

Electrocardiography

Interpretation

Basic rhytm

QRS rate :

94 x/minutes

Regularity :

regular

PR interval

Axis

Morphology

15/8/2015

sinus

0,20 second

right axis deviation

Gelombang P :
Kompleks QRS

0,08 second, inverted on V1

:

0,12 second, theres RsR configuration on

lead III, rsR on V3, wide and notch R wave on lead II, AVF,
and V4, reciprocal morphology RsR on AVL,
widening S wave on lead I, and deep S ( 12 mm)
on lead V5 dan V6
ST segmen

Normal on all lead

Gelombang T :

Normal on all lead

Conclusion : Sinus Rhtym, Right axis deviation with incomplete

Right Bundle Branch Block

Chest X-Ray PA

6/8/2015

Conclusion :

Cardiomegaly with the sign of

Left to Right Shunt

Laboratory FIndings
Parameter

Result

UNIT

WBC

5,1

(10/UI)

RBC

4,71

(106/UI)

HGB

12,1

(gr/dL)

HCT

36,2

(%)

PLT

212

(103/uL)

GDS

85

mg/dL

Ureum/Creatinin

19/0,5

mg/dL

SGOT

18

mmol/L

SGPT

19

mg/dL

BT

2,30

minutes

CT

7,00

minutes

PT

11,9

seconds

aPTT

28,4

seconds

INR

1,11

Natrium

142

mmol/L

Kalium

3,9

mmol/L

Klorida

111

mmol/L

11/8/2015

Conclusion :

All Parameters are remain in normal

limit

Echocardiography transthoracal (21/5/2015)

Conclusion :
Huge ASD Secundum (2,6 cm) with left to the right shunt
Moderate Pulmonary Hypertension
Enlargement of right atrium and right ventricle

Echocardiography

transesophageal (13/8/2015)

Conclusion :

Huge ASD Secundum (2,9cm)

Diagnosis

Atrial Septal Defect type : Secundum

Management

ASD Closure with using Percutaneus Catheterization Amplatzer

Septal Occluder

Discussion

ATRIAL SEPTAL DEFECT

Congenital Heart Disease on Adults

Definition

Atrial septal defect (ASD) is one of the more

commonly recognized congenital cardiac
anomalies presenting in adulthood. Atrial
septal defect is characterized by a defect in the
interatrial septum allowing pulmonary venous
return from the left atrium to pass directly to
the right atrium.

Result Left to Right Shunt, Right to left shunt

(worse prognosis)

Classification

Ostium secundum: The most common type of ASD accounting for 75% of all ASD
cases, representing approximately 7% of all congenital cardiac defects and 30-40% of all
congenital heart disease in patients older than 40 years.
Ostium primum: The second most common type of ASD accounts for 15-20% of all
ASDs. Primum ASD is a form of atrioventricular septal defect and is commonly associated
with mitral valve abnormalities
Sinus venosus: The least common of the three, sinus venosus (SV) ASD is seen in 510% of all ASDs. The defect is located along the superior aspect of the atrial septum.
Anomalous connection of the right-sided pulmonary veins is common and should be
expected. Alternate imaging is generally required.

Epidemiology

Incidence : ASD occur on 1 by 1500 live birth,

Gender :ASD occurs with a female-to-male ratio of approximately

2:1

Age : Patients with ASD can be asymptomatic through infancy

and childhood, though the timing of clinical presentation depends
on the degree of left-to-right shunt. Symptoms become more
common with advancing age. By the age of 40 years, 90% of
untreated patients have symptoms of exertional dyspnea, fatigue,
palpitation, sustained arrhythmia, or even evidence of heart
failure.

ETIOLOGY
Atrial
septal
defect
(ASD) may
occur on a
familial
basis.

Holt-Oram syndrome characterized by an autosomal

dominant pattern of inheritance and deformities of the
upper limbs (most often, absent or hypoplastic
radii) has been attributed to a single gene defect in
TBX5. The penetrance is nearly 100% for Holt-Oram
syndrome.
Fetal alcohol syndrome about one in four patients
with fetal alcohol syndrome has either an ASD or a VSD.
Down syndrome patients with Down Syndrome have
higher rates of ASDs, especially a particulartype that
involve ventricular wall. As many as one half of Down
Syndrome patients have some type of septal defect.
Idiopathic

Risk Factor

Risk factor which predict influencing the incidence of ASD are :

Infection of German Measles (rubella) during pregnancy

Exposure of medicine, cigarettes, alcohol, and existence of lupus
and diabetes mellitus during pregnancy

Pathogenesis

ASD Secundum
Sinus venosus
Hyperresorbtion of septum
There isduring
abnormality
primum
formation of
of fusion
ostiumbetween
secundum
embryonal sinus
Disruption of development of
venosus and atrium
septum secundum

ASD Primum
Disruption of closure of ostium
primum on septum primum during
formation of ostium secundum
Failure of fusion between septum
primum and endocardial cushion

Pathophysiology

Pathomechanism of Symptoms

Dyspnea

Long
Standing L
to R shunt

Hypervasc
ularization
of
pulmonary
circulation

Vascular
bed filled
with blood

Pulmonary
hypertensi
on and
Hydrostatic
pressure
elevated

Transudati
on of fluid
from
capillary to
interstitial

Inhibition
of diffusion
O2 on lung

Dyspnea

Pathomechanism of Symptoms

Fatigue

L to R shunt

Volume
systolic of LV
decrease

Blood
containing
oxygen
decrease

Perfusion
decrease

Ischemic and
metabolism
disorder

Fatigue

Pathomechanism of Symptoms

Angina

Systemic
circulation
decrease

Coronary
circulation
decrease

Right
volume
overload

Pulmonary
hypertensi
on

Wall-Stress
increases
of RV

Oxygen
demand
increaseOxygen
supply
decrease

Angina

Pathomechanism of Symptoms

Palpitation

Left to Right Shunt Dilatation of right atrium and right ventricle Prolonged of
conduction pathway re-entry current Atrial Fibrillation/ SVT/ MAT
Palpitation

Recurrent of respiratory tract infection

Hypervascularization of pulmonary circulation vascular bed filling Hydrostatic

pressure increases Edema of lower respiratory tract disruption of immunity
system susceptible of infection

Physical Examination
Inspection
Hard

to find abnormalities

Palpation
Thrill

can be palpated

Pulsation

of right ventricle can be felt

Percussion
Cardiomegaly
Auscultation
Wide-fixed
S2

Louder

Systolic
A

split of S2

ejection murmur on ICS

mid-diastolic murmur at lower left sternal border

Electrocardiography

Complete or
incomplete right
bundle branch block

Right Axis deviation

Right Ventricle
Hypertophy

Abnormality of Q wave

Echocardiography

Findings :
Defect on interatrial septum
On color Echocardiography, there is shunt between left and right atrium, following systolic and
Diastolyc cycle of heart
Dilatation of right atrium and right ventricle
Pulmonary hypertension (conditional)
Mitral regurgitation (occasionally on ASD primum)
Tricuspid regurgitation secondary caused by dilatation of annulus

Another Examination

Chest X-ray

Not Specific Cardiomegaly

Blood profile

Not specific

Cardiac catheterization

Gold Standar to detect atrial septal defec (invasive, high side effect,
takes time) prefer Echocardiography instead of cathetherization

Management

Definitif and Symptomatic (Antiarrhytmia, Dorner, Furosemid)

Definitif treatment Interventional and Surgical

Interventional : Percathetherization devices Amplatzer Septal Occluder
Indication for closure with ASO :
ASD Secundum, defect >5 mm
Right-sided heart enlargement with/without symptoms
Presence of Paradoxical embolism
There is left-right shunt proved, pulmonary artery pressure <2/3 systemic pressure
Qp : Qs = <1,5:1

Indication of surgical
ASD primum or Sinus Venosus
Interventional is a contraindication

Complication

PULMONARY
HYPERTENSI
ON

ARITMIA

RIGHT-SIDED
HEART
FAILURE

DISABILITY
LIMITATION

EISENMENGER
SYNDROME

References

1. Ghanie A. Penyakit Jantung Kongenital pada Dewasa. In: Sudoyo A, Setiyohadi, B., Alwi, I., Simadibrata,
M., Setiati, S, editor. Ilmu Penyakit Dalam. V ed. Jakarta: Interna Publishing; 2009.

2. Child J. Congenital Heart Disease in the Adult. In: Fauci ea, editor. Harrison's Principle of Internal
Medicine. 17th ed. USA: MC-Graw Hill; 2008.

3. Atler DH ea. Atrial Septal Defect. Medscape; 2014 [cited 2015 August, 19th]; Available from:
http://emedicine.medscape.com/article/162914-overview#a6 .

4. anonim. Risk factor atrial septal defect. USA: Mayo Clinic; 2014 [cited 2015 August 19th]; Available
from: http://www.mayoclinic.org/diseases-conditions/atrial-septal-defect/basics/risk-factors/con-20027034 .

5. Robert J. Sommer MZMH, MD, MPH; John F. Rhodes Jr, MD. Pathophysiology of Congenital Heart Disease
in the Adult. AHA Journals. 2008;117:1090-9.

6. Berg D. BD. Patophysiology of Heart Disease. 5th edition ed. Lily Lea, editor. USA: Lippincott williams
and wilkins; 2011.

7. Kim NK PS, Choi JY. Transcatheter Closure of Atrial Septal Defect: Does Age Matter? Korean Circ J.
2011;41(11): 6338.

8. Warnes C, et al. ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart
Disease: Executive Summary. AHA Journals. 2008.