Atrial Septal Defect: from A to Z

1
Atrial Septal Defect from A to Z

• Sulafa KM Ali FRCPCH, FACC
• Consultant Paediatric Cardiologist

2
Prevalence

• 5-10 of all CHD
• 40 of patients with CHD have ASD as part of
  their congenital defect.
• More in females (3 times males)

3
Types

• Anatomy
• Size

4
Anatomy

• Secundum ASD 50-70
• Primum ASD 30 (Atrioventricular septal defect
  AV canal)

5

• Sinus venosus ASD 10. Associated with partial
  anomalous pulmonary venous drainage.
• Coronary sinus ASD

6
Green Secundum ASD 70 Red Primum
ASD 20 Orange Sinus venosus ASD 6-8 Blue
Coronary sinus Rare defect (unroofed CS)
Diagram of the Interatrial Septum Viewed from the
Right Atrial Side
7
Anatomy ASDII

• Single /multiple
• Fenestrated
• AS Aneurysm

8
ASD Rims
SP Superior posterior (4CV) SA Superior
anterior (aortic)(SAV) IP Inferior posterior
(IVC)(SUBCOSTAL) IA Inferior, anterior(4CV)
9
(No Transcript)
10
Low secundum ASD
11
Associations

• MV prolapse
• Partial anomalous PVD
• Other

12
TEE 3-D TEE
13
Intracardiac Echo
14
Primum ASD

• Primum ASD is an atrioventricular septal defect
  (AVSD-AVC)
• A common AV junction with abnormal AV valve
• The AV valves are named left and Rt AVV

15
Common AV Valve
16
Primum ASD

• Look carefully at the short axis
• Papillary muscles rotated anti clockwise
• Large pseudo cleft

17
Sinus Venosus ASD
18
(No Transcript)
19
Size

• PFO less than 5 mm with a flap valve.
• Small ASD lt 8 mm in size , no dilatation of the
  right heart chambers.
• Moderate-large ASD gt 8 mm with dilatation of the
  right atrium and ventricle.

20
Pathophysiology of ASD

• The shunt through the ASD depends on
• 1. The size of the defect
• 2. The compliance of the right and left
  ventricles (age)

21
Pathophysiology of ASD

• RV compliance is better than LV so
• L R shunt occurs.
• Increased blood flow to the main pulmonary artery
  through the RA and RV.
• Dilatation of the RA, RV and main PA
• No increased pressure transmitted through ASD

22
Pathophysiology of ASD

• With increasing age LV compliance becomes worse
  and the shunt increases.
• Dilatation of RA and RV
  arrhythmias
• Increased pulmonary blood flow
  signs of heart failure.
• Changes in pulmonary vascular bed
  Eisenmengers physiology.

23
Clinical Presentation

• Asymptomatic in infants and children
• Children usually discovered because of a heart
  murmur.
• Presentation with heart failure, palpitations
  (atrial fibrillation) in 30-40 years of age.

24

• Presentation due to associated mitral
  regurgitation (MV Prolapse in ASD II) or left AVV
  regurg in primum ASD can bring patients earlier.

25
(No Transcript)
26
Clinical Examination

• Patients usually have normal growth.
• Ejection systolic murmur at the pulmonary area
  due to increased flow across the pulmonary
  artery.
• Wide fixed splitting of S2
• Tricuspid flow murmur (diastolic)

27

• CXR Cardiomegally (RV, RA )
• Increased pulmonary arterial markings
• Dilated main pulmonary artery
• LV and LA are not dilated

28
ECG

• RSr pattern
• RVH in moderate-large ASD
• Superior QRS axis in primum ASD.
• Arrhythmia in adults.
• Superior P wave axis in sinus venosus ASD.

29
Echo Assessment

• Anatomy
• Size in mm
• Color Doppler
• RV Volume overload
• Associations
• Is it suitable for cath closure?

30
Management

• No treatment needed in infants
• Moderate/large ASDs need to be closed.
• Timing for closure 4-5 years of age

31
Transcatheter Closure

• Size of the defect
• Shape of the defect
• Size of the patient (length of the interatrial
  septum
• Trans oesophageal echo (TEE)

32

• Can be done under transthoracic echo

Schubert S, Kainz S, Peters B, Berger F, Ewert
P Interventional closure of atrial septal defects
without fluoroscopy in adult and pediatric
patients. Clin Res Cardiol. 2012
33
Choosing the device size
34

• Avoid over sizing

Carlson KM.Transcatheter atrial septal defect
closure modified balloon sizing technique to
avoid overstretching the defect and oversizing
the Amplatzer septal occluder.Catheter Cardiovasc
Interv. 2005 Nov66(3)390-6
35
Amplatzer occluder Occulotech Lifetech Starway
36
Complications (8)

• Short term
• Embolization
• Malposition
• Thrombus on LA
• Bleeding/tamponad perforation (size)
• Arrhythmias
• Need for urgent surgery 2.3

• Long term (rare)
• Peripheral embolization
• AV block
• Sudden death (0.2)

37
Surgery for complicated cath closure

• Three hospital deaths (mortality 5.4).
• Complications leading to surgery included
• thrombosis/thrombo-embolism
• residual shunt
• aortic or atrial perforation/erosion .
• haemopericardium with tamponade

European Congenital Heart Surgeons
Association-2010
38
Hybrid techniques

• Mini thoracotomy
• Not open heart surgery
• Device closure under TEE

39

• Transcatheter patch

40
When should we Refer to the Surgeon?

• Defects larger than ?35 mm
• Defects relatively large for the size of the
  patient
• Deficient more than one rim
• ASDs other than secundum

41
Minimally Invasive Sx

• Sub mamary
• Axiallary
• Robotic

42
Pros and Cons
Catheter
Surgery

• Success rate of 95
• - Minor complications in 1-2
• - Less post -operative complications
• -No scar
• -Shorter hospital stay of 24 hours

• Success rate approaching 100
• Open Heart Surgery.
• - Longer hospital stay of 5-7 days
• -Post operative complications

43
The cost is the sameabout 3000 USD
44
PFO to Close or not to Close????

45

• PFO implicated in cryptogenic stroke (migraine)
• If R to L shunt is demonstrated PFO closure may
  be indicated
• Poor evidence

. Irwin B, Ray S Patent foramen ovale-assessment
and treatment. Cardiovasc Ther. 2012
Jun30(3)e128-35 Davis D, Gregson J Patent
Foramen Ovale, Ischemic Stroke and Migraine
Systematic Review and Stratified Meta-Analysis of
Association Studies. Neuroepidemiology. 2012 Oct
1140(1)56-67.
46
(No Transcript)
47
ASD and Pregnancy

• Patients usually do not deteriorate unless they
  have Eisenmengers
• Risk of paradoxical embolism.

48
Conclusion

• ASD is a disease that is asymptomatic in infants
  and children.
• ASD should be closed in children before school
  age
• Transcatheter closure is feasible in almost all
  moderate and large size secundum ASDs.