Atrial Septal Defect

Cardiovascular

Clinicals - History

Fact Explanation
Asymptomatic It is usually asymptomatic in about 25% of adults. Asymptomatic
It is usually asymptomatic in about 25% of adults.
Fatigue Mainly due to heart failure secondary to pulmonary hypertension. Fatigue
Mainly due to heart failure secondary to pulmonary hypertension.
Dyspnea on exertion This is the commonest presenting complain and it is due to heart failure. Dyspnea on exertion
This is the commonest presenting complain and it is due to heart failure.
Palpitations May be due to the presence of arrhythmia or due to heart failure. Palpitations
May be due to the presence of arrhythmia or due to heart failure.
Recurrent respiratory tract infections Due to pulmonary congestion. Recurrent respiratory tract infections
Due to pulmonary congestion.
Eisenmenger syndrome In untreated Atrial Septal Defect (ASD) severe pulmonary hypertension develops and it reverses the direction of blood flow through the shunt. Once this happens patient develops clubbing and cyanosis. Eisenmenger syndrome
In untreated Atrial Septal Defect (ASD) severe pulmonary hypertension develops and it reverses the direction of blood flow through the shunt. Once this happens patient develops clubbing and cyanosis.
sudden death Death may be due to several reasons including congestive cardiac failure, recurrent respiratory tract infections and due to arrhythmia. sudden death
Death may be due to several reasons including congestive cardiac failure, recurrent respiratory tract infections and due to arrhythmia.
Transient ischemic attack Paradoxical embolization causes transient ischemic attacks. Transient ischemic attack
Paradoxical embolization causes transient ischemic attacks.

Clinicals - Examination

Fact Explanation
Pulse Detects atrial fibrillation (irregularly irregular pulse). This is due to the right atrial dilatation. Pulse
Detects atrial fibrillation (irregularly irregular pulse). This is due to the right atrial dilatation.
Right ventricular lift Felt over the subxiphoid area and due to right ventricular dilatation. Right ventricular lift
Felt over the subxiphoid area and due to right ventricular dilatation.
Wide and fixed splitting of the second heart sound (S2) This is the most reliable sign. Wide and fixed splitting of the second heart sound (S2)
This is the most reliable sign.
Loud pulmonary component of the S2 This is due to pulmonary hypertension. Loud pulmonary component of the S2
This is due to pulmonary hypertension.
Soft pulmonary flow murmur Due to the increased blood flow across the pulmonary valve. Soft pulmonary flow murmur
Due to the increased blood flow across the pulmonary valve.
Diastolic rumble over the tricuspid area Due to the increased blood flow through the tricuspid valve. This occurs in large ASDs. Diastolic rumble over the tricuspid area
Due to the increased blood flow through the tricuspid valve. This occurs in large ASDs.
Murmur of mitral regurgitation Commonly occurs with osteum primum ASD. This is a pan systolic murmur. Murmur of mitral regurgitation
Commonly occurs with osteum primum ASD. This is a pan systolic murmur.
Presence of mitral stenosis Presence of mitral stenosis in the presence of ASD is Lutembacher syndrome. Mitral stenosis causes rumbling mid-diastolic murmur. Presence of mitral stenosis
Presence of mitral stenosis in the presence of ASD is Lutembacher syndrome. Mitral stenosis causes rumbling mid-diastolic murmur.
Clinical features of heart failure Distended jugular veins, tender hepatomegaly and peripheral edema are examination findings of right heart failure. Clinical features of heart failure
Distended jugular veins, tender hepatomegaly and peripheral edema are examination findings of right heart failure.

Investigations - Diagnosis

Fact Explanation
Electrocardiogram (ECG) Detects atrial fibrillation and flutter. First degree heart block is a common association with osteum primum ASD. Electrocardiogram (ECG)
Detects atrial fibrillation and flutter. First degree heart block is a common association with osteum primum ASD.
Chest x-ray May be normal. Right heart dilation, pulmonary plethora, small aortic knuckle are prominent features. Features of heart failure like cardiomegaly, pulmonary edema, and Kerly B lines are also seen. Chest x-ray
May be normal. Right heart dilation, pulmonary plethora, small aortic knuckle are prominent features. Features of heart failure like cardiomegaly, pulmonary edema, and Kerly B lines are also seen.
Transthoracic echocardiogram Transthoracic echocardiogram will confirm the diagnosis and enable measuring the size of the defect. Doppler studies will demonstrate the direction of blood flow through the ASD.
It is able to detect other associated cardiac lesions as well. Eg: mitral stenosis in Lutembacher syndrome and anomalous pulmonary venous drainage.
Transthoracic echocardiogram
Transthoracic echocardiogram will confirm the diagnosis and enable measuring the size of the defect. Doppler studies will demonstrate the direction of blood flow through the ASD.
It is able to detect other associated cardiac lesions as well. Eg: mitral stenosis in Lutembacher syndrome and anomalous pulmonary venous drainage.
Trans esophageal echocardiography (TOE) This provides more accurate information. The treatment of choice is better planned after a TOE. Trans esophageal echocardiography (TOE)
This provides more accurate information. The treatment of choice is better planned after a TOE.
Cardiovascular Magnetic Resonance Imaging (MRI) Although not routinely practiced MRI can provide same information like the TOE, but it is less invasive than TOE. Cardiovascular Magnetic Resonance Imaging (MRI)
Although not routinely practiced MRI can provide same information like the TOE, but it is less invasive than TOE.
Cardiac catheterization This is not a routine investigation. Cardiac catheterization
This is not a routine investigation.

Investigations - Management

Fact Explanation
Cardiac catheterization Although this is an invasive investigation, it provides many vital information. The degree of pulmonary hypertension can be estimated. Severity of the pulmonary hypertension is the single most important factor in decision making on further management. Patients with severe pulmonary hypertension should not undergo shunt closure. Cardiac catheterization
Although this is an invasive investigation, it provides many vital information. The degree of pulmonary hypertension can be estimated. Severity of the pulmonary hypertension is the single most important factor in decision making on further management. Patients with severe pulmonary hypertension should not undergo shunt closure.
Exercise ECG Assess the exercise tolerance and the fitness of the patient. Exercise ECG
Assess the exercise tolerance and the fitness of the patient.

Management - Supportive

Fact Explanation
Pharmacological management of heart failure Symptomatic heart failure should be managed. Pharmacological management of heart failure
Symptomatic heart failure should be managed.
Permanent pacing Brady arrhythmia may need permanent pacing. Permanent pacing
Brady arrhythmia may need permanent pacing.

Management - Specific

Fact Explanation
Device closure of the ASD Amplatzer Septal Occluder is commonly used as the preferred method of treatment for osteum secondum ASD and it has minimal complications and shorter hospital stay. However the size of the lesion should be relatively small (less than 40mm in diameter). Closure of the ASD should ideally be done during the second or third decade of life. The minimum diameter of more than 10 mm ASDs should be closed. Device closure of the ASD
Amplatzer Septal Occluder is commonly used as the preferred method of treatment for osteum secondum ASD and it has minimal complications and shorter hospital stay. However the size of the lesion should be relatively small (less than 40mm in diameter). Closure of the ASD should ideally be done during the second or third decade of life. The minimum diameter of more than 10 mm ASDs should be closed.
Surgical closure This is not commonly practiced now because of the high complication rate and increased mortality and morbidity when compared to device closure. Surgical closure
This is not commonly practiced now because of the high complication rate and increased mortality and morbidity when compared to device closure.

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