ASD

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ASD

• Dr. H. Sadeghian

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• ASD ostium secondum in the central portion of
  Atrial septum in the position of foramen ovalis
• Sinus venosus in the region of SVC, RA junction
  or IVC RA junction
• Unroofing coronary sinus between ostium of CS to
  RA and LA
• septum primum and endocardial cushion
  defect
• 4. ASD ostium primum
• Rudolph chapter 7

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• Sinus venosus 3 10
• ASD ostiom serondun more common
• F / M 2/1
• 5 ASD PS (valvuler)
• Muller, chapter 22

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• PVR abn
• lt 10 AsD ostium secondum
• almost always ASD SV
• Associates PVRAb
• Braunwald

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Morphologic and Embriologic considerations

• Septum primum grows from posterosuperior side
  (SVC side) toward A-V junction where endocardial
  cushion separotes Atria from ventricles. The
  lower part of the septum primum is completed by
  fusion with endocardial cushion tissue.
• Rudolph chapter 7

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• Some fenestrations develop in midportion of
  septum primum. Septum secrodum just grows in the
  posterosuperior portion of IAS (near SVC) but
  right to the septum primum.
• It grows toward the AV junction and it partly
  covers the central hole of septum prinum. It has
  a semilunar edge which is concave toward TV.
• Rudolph chapter 7

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Ostium secondum defects

• Large hole in septum primum or
• Inadequite development of septum secondum
• Rudolph chapter 7

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• Sinus venosus defects septum primum or secondum
• Unroofing CS the well between CS and LA, may
  involved a portion of septum or whole septum and
  are frequently associated with LPSVC
• Rudolph chapter 7

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• LAP 1-2 mmHg gtRAP
• two ventricles fill with one pressure so RV will
  be distended.
• Rudolph chapter 7

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• The degree of left to right
• Shout depends on the
• 1- The size of the defect
• 2- Filling pressure of ventricles
• Braunwald

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Infants

• Large defects QP/Qs gt 2.5 1
• ? Produce symptoms
• Medium size defects do not cause symptoms during
  infancy and early childhood
• Rudolph chapter 7

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ASD beyond infancy

• The majority of children even those with large
  defeats do not experience symptoms.
• Unlike VSD most of them tend to be smaller with
  growing, ASD usually grows in proportion to heart
  size and there is evidence suggesting that some
  defects may become larger as age increase.
• Rudolph chapter 7

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• 40 ASDs in infants will close spontonously
• ASD lt 3 mm in first 3 months ? always close
• ASD gt 8 mm is unlikely to close
• Muller, chapter 22

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• Spontanous closure of ASD may occur within the 1
  year of life.
• lt 7 mm in neonatal period may reduce in size
  and require no intervention
• Braunwald

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• Natural history of growth of ASD ostiun secondum
  and implication
• Heart 2002, 87, 256-9

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• 104 Patients
• Exclusion criteria multiple ASDs or
• fenestrated 91 98
• 3 6 mm small ASD
• ? 6 12 moderate
• ? 12 large
• 65 patients ? size with ASD 30 gt 50
  increase in size
• spontanous closure in 4 patients
• 12 ? 20 mm
• Only factor associated with ASD growth was
  initial size
• Heart 2002, 87, 256-9

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• ASD growth was independent of age of patients
• Conclusion 2/3 of ASDs growth with time
• Heart 2002, 87, 256-9

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• Defects lt 6 mm
• 66 spontanous closure
• Mean age of diagnosis 4.5 years
• F / M / 2.2/1
• Heart 2002, 87, 256-9

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Small ASD group

• 33 had small defects(34P)
• FO
• 3p closed spontounsly
• 26 (27p) ASD
• 1 small ? mod
• 3 small ? large
• 1.6 mm/y ? size
• Mean FO 3.2 y
• Heart 2002, 87, 256-9

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Mod ASD group

• 40 p (38)
• FO 31 mod
• 3 ? small
• 8 ? large
• 1.6 mm/y ? mean FO 3.3 y
• Heart 2002, 87, 256-9

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Large ASD defeats

• 30 p (29) large
• 43 (45) FO large
• 1.9 mm/y FO 2.9 year
• Heart 2002, 87, 256-9

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• 66 ? ASD size
• 14 decrease
• 20 no change
• Initial size, final size correlated
• Heart 2002, 87, 256-9

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The main concerns in individuals with ASD are

• PV Resistance
• Atrial arrhythmia
• Cardiac failure
• Rudolph chapter 7

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• The association of PVD and ASD are infrequent
  during childhood. Singificant PVD is unusual
  before age of 25-30 years.
• Beyond this age, PVD occurred in 5-10 ASDs and
  is related to high altitude PVD f/M 2 1
• Altitude gt 4000 ft PVD in earlier ages
• Rudolph chapter 7

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PVR

• PVR in ASD usually is normal ,
• 1 unit / m2
• 3 ? considerable
• Rudolph chapter 7

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Atrial arrhythmia

• Af , Flutter , PAT occurs commonly in older
  patients. They are probably related to large
  shunts.
• lt 20 y 1 - 2
• gt 20 y 15 - 50
• Rudolph chapter 7

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Cardiac failure

• gt20 y , Right sided
• Failure
• Rudolph chapter 7

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ECG

• SV defects P ware ? 0
• AV may be moderately prolonged with large defects
  
• QRS Axis RAD (90 to 180)
• rsR? or rSR? , incomplete RBBB
• R in right precordial 10 15 mm
• gt ? PVD
• Rudolph chapter 7

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• Negative P in Inferior leads ?
• ASD SV below SVC
• Braunwald

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Echo

• RV Enlargement
• QP/QS
• PVR , SVR
• PAP , TR , PAPm , d
• RV function
• Rudolph chapter 7

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Subcostal bicaval
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Pressures

• 15 30 mmHg Pressure RV-PA
• 10 15 mmHg MPA , branches
• Rudolph chapter 7

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• 30 of the patients have effort dyspnea in third
  decade and more than 73 by fifth decade
• Braunwald

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• SV arrhythmia and RSF 10gt 40y
• Paradoxical embolic may occur
• Braunwald

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Cyanosis

• 1- Isenmenger
• 2- Prominent eustachien valve which leads IVC
  flow to ASD
• 3- ASD SV below IVC
• Braunwald

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Management

• Large ASD
• QP/Qs lt 2 1
• QP/QS lt 1.5 1 ? Follow up
• Rudolph chapter 7

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Indications for Intervention

• The presence of RSF ASD gt 5 mm with no sign of
  spontaneous closure
• 18 month 3/4 ASDs may close spontaneously
• Muller and Hoffman

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• QP QS lt 1.5 dont want
• Closure except for paradoxical emboli
• Braunwald

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• Significant ASD QP / QS gt 1.5 1
• Or RV volume overload ? intervention
• P HTN PAP gt 2/3 systemic
• Or
• PVR gt 2/3 SVR
• 1- QP / QS gt 1.5 / 1 ?
• 2- Challenge to O2 or No
• 3- Lung biopsy ? reversibility
• ? ASD closure
• Braunwald

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Device closure

• Stretch diameter lt 41 mm
• Adequate rim
• Complications embolization
• thronbus formation lt 1
• atrial perforation
• Comparing surgery to device closure
• 1- better preservation RV function
• 2- lower complication rate
• Braunwald

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Surgery

• - Sinus venosus
• - Ostium primum
• - Ostium serondum not suitable for device
  closure
• Mortality lt 1
• Braunwald

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ASD with P HTN

• PVR gt 8 12 unit / m2 high mortality
• PVR gt 12 unit / m2 ? FO
• PVR 4 8 unit / m2 ? mortality 10
• Rudolph chapter 7

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After device closure

• - Aspirin 6 mouths
• - Prophylaxis of IE 6 mouths
• Braunwald

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Long surveillance

• 1- ASD SV Caval or PV stenosis
• 2- RV Failure
• 3- Atrial arrhythmia
• Braunwald

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• lt 10 ASD PHTN
• PPHTN in association with ASD
• gt 50 patients gt 45y AF
• Muller, chapter 22

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Post op Atrial arrhythmia

• Soon after surgery to later years 30 50
  incidence
• PAT , AF and flutter but brady-tachy arrhythmia ?
  pace
• Transcatheter closure ? incidence arrhythmia?
• Rudolph chapter 7

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• AF 25 patients gt 20 y
• 5 patients lt 20 y
• Late post operative arrhythmia
• 2 - 9 children
• 2 - 33 adults
• Early after repair 14 Atrial arrhthmia
• espicially in SV defects
• Muller

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JASE 2004

• Rim lt 3m deficient
• Anteroinferior mitral to ASD apical 4C
• Antero superior Aort
• Postero superior RUPV in Apical 4C back wall LA
• Superior SVC (90?)
• Postero inferior IVC
• Mathewson et al

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