ATRIAL SEPTAL DEFECT (ASD)

Compiled by: Dr. M. Akram Asi

Case presentation:
• On Inspection, there are no visible scar marks, visible pulsation or chest deformity.
• On Palpation, Apex beat is 5th ICS medical to LMC-line, is of normal character.
There is left parasternal lift, there are no thrill or palpable heart sounds.
• On Auscultation, first heart sound is normal. There is a wide fixed splitting of
second heart sound. (In case of Pulmonary HTN, pulmonary component of second
Heart sound is loud)
• At 2nd left-ICS a Soft systolic murmur was heard

Q: What are the different causes of Splitting of second heart sound (S2)
widened splitting of S2: reversed/Paradoxical Fixed splitting of S2:
split of S2 (P2 occurs before
A2):
1.Deep inspiration. 1. Severe Aortic Stenosis. 1. Uncomplicated ASD (Ostium Secundum)
2.Pulmonary Stenosis. 2. WPW type B. In this condition, closure of the PV is delayed
3.Severe Mitral regurgitation 3. PDA because of the increased flow through the
4.Right bundle branch block: 4. LBBB right-sided cardiac chambers and an increase
It delays RV activation and (LV activation is late→ in pulmonary vascular capacitance, con-
ejection and is therefore delayed of closure of the tributing to a widened split of S2.
associated with widened aortic valve) On inspiration, augmentation of the systemic
splitting of S2. 5. RV Pacing. venous return is counterbalanced by a
(LV activation is late→ reciprocal decrease in the volume of the left-
delayed of closure of the to-right shunt, such that RV filling and the
aortic valve). timing of P2 relative to A2 do not change,
resulting in the fixed splitting.

Q: How will you say clinically this is large ASD (L-R shunt) on examination?
Ans: There are many features that clinically support for a large ASD.
• JVP- Large V wave
• Left parasternal lift→ RVH
• A diastolic flow murmur at tricuspid area.
• Systolic flow murmur in the PV region due to increased pulmonary flow
• other features are related about pulmonary HTN.

Note: Diastolic murmur at left sternal border (at tricuspid area): If the shunt is more
than a shunt fraction (Qp/Qs) of 2.5:1, there may be a diastolic murmur secondary to
increased flow across the tricuspid valve. This murmur is heard at left sternal border and
louder on inspiration.

How will you differentiate between splitting of S2 and opening snap?

Ans: I would like to ask the patient to stand up.
• On standing, Preload decreases and physiological splitting of S2 becomes SINGLE.
• On standing, Preload decreases and opening snap also decreases.

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Q: what are the findings you may have on ECG of a patient with ASD?

Ans:
It depends upon the type of ASD.
The rhythm may be sinus, but may also be atrial fibrillation or atrial flutter.
Secundum ASD Primum ASD
a. RSR′ pattern in lead V1 a. RSR′ pattern in lead V1
b. QRS duration < 0.11 seconds b. Left-axis deviation and superior
(incomplete right bundle branch block c. First-degree AV block, classically seen
due to RV conduction delay) with right bundle branch block and left
c. Right-axis deviation or vertical anterior fascicular block
d. RV hypertrophy
e. First-degree AV block (20%)
f. RA enlargement (about 50%) with a
prominent P-wave in lead II

Sinus venosus defect: Inverted P-waves in the inferior leads suggest an absent or
nonfunctional sinus node and may be seen in sinus venosus defects.
Note: Left axis deviation in Primum ASD is due to hypoplasia of left anterior
fascicular.
Mnemonic:
--SiR: Secundum→RAD
--PLz: Primum→ LAD

Q: in Sinus venosus defect, what will you expect on ECG and why?
Ans:
Inverted P-waves in the inferior leads suggest an absent or nonfunctional sinus node and
may be seen in sinus venosus defects.

Q: why do you have Left axis deviation in Primum ASD?

Ans:
Left axis deviation in Primum ASD is due to hypoplasia of left anterior fascicular.

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Q: When you see an echo drop out on apical 4-C view, what is your next step?
Ans
• Subcostal view
• Contrast study (agitated saline study)
• Look for right sided chambers
• TEE
Q: In which phase of cardiac cycle, you will measure ASD size?
Ans: Diastolic phase.

Q; how many different margins of ASD do you know?

Ans: There are 6 ASD margins (It needs correction)
1. SVC or superior margin
2. IVC or inferior margin
3. Posterior margin
4. Anterior margin or retro-aortic margin
5. Mitral rim
6. AV margins

Q: How many types of ASDs do you know?

ASD TYPES/ CLASSIFICATION ACCORDING TO LOCATION

1. Ostium secundum defects or secundum ASDs
(In the region of the fossa ovalis)
2. Ostium primum defects or primum ASDs (in the lower portion of the atrial
septum, actually part of an atrioventricular AV canal defect)
3. Sinus venosus septal defects
(In the upper part of the septum near the entrance of the superior vena cava
or at the entrance of the inferior vena cava)
4. Coronary sinus septal defect/unroofed coronary sinus
(Communication between the coronary sinus and left atrium)

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Q: How will you manage this case?
1. PHARMACOLOGICAL TREATMENT (diuretic, BB, anticoagulation)
2. NON- PHARMACOLOGICAL TREATMENT/CLOSURE OF ASD:
• Primary surgical closure.
• Transcatheter closure

Q: What are the indications of ASD closure?

Indications for closure are:
1. Evidence of a hemodynamically significant shunt (Qp/Qs ≥ 1.5:1).
2. Evidence of right heart dilation,
3. Evidence of probable paradoxical embolism or associated symptoms.

In the setting of pulmonary hypertension, pulmonary reactivity to vasodilators

should be documented and a net left-to-right shunt demonstrated during
catheterization before consideration for closure.
Alternatively, the defect can be temporarily balloon occluded at the time of
catheterization, and the hemodynamic effects are directly measured.

Q: what are types of ASDs favorable for primary surgical closure?

i) Primary surgical closure:
Generally, surgical closure is the treatment of choice for:
a) Ostium primum.
b) Sinus venosus.
c) Coronary sinus defects.
 Ostium primum defects require patch closure as well as repair of the likely cleft
mitral valve.
 Repair of sinus venosus defects is technically more challenging, as the pulmonary
veins often have anomalous drainage and require rerouting.

Q: What are the indications of primary surgical closure of Secundum ASD?

Ans:

a) secundum ASDs with anatomy not suitable to percutaneous closure.

b) Secundum ASD having diameter > 35 mm.
c) Inadequate septal rims to permit device deployment (poor septal margins.)
d) Secundum ASD closed to AV valves, coronary sinus, or venae cavae)
 Depending on the defect size and location, the secundum ASD can be closed by
primary suture or, if needed, by the use of an autologous pericardial or synthetic
patch.

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What are the complications of surgical closure?
Ans:
Complications of surgical closure:
1. Heart blocks.
2. postpericardiotomy syndrome
3. Atrial arrhythmias may persist in short- and long-term follow-ups because the
RA and RV sizes may take time to return to normal.
4. Others are:
❖ Pericardial effusion, Residual shunt, MR or TR, Pulmonary vein stenosis
(after closure of sinus venosus defects)

What are the complications of Transcatheter closure?

Ans:
i. Device misalignment/embolization.
ii. Device erosion of atrial wall or aorta.
iii. Device impingement on adjacent structures like AV valve, coronary sinus, SVC
and pulmonary veins etc.
iv. Infections including endocarditis.
v. Allergic reactions.
vi. Residual shunt

Q: What about antiplatelet therapy after device closure?

Ans:
• After closure, antiplatelet therapy, frequently aspirin, is prescribed for a
minimum of 6 months.
• After which time the device is generally believed to be endothelialized.

Q: What about Endocarditis antibiotic prophylaxis for ASD?

Ans:
Endocarditis antibiotic prophylaxis during dental procedures is not required in the
setting of an isolated ASD before surgery.
But it is warranted for 6 months after surgical or device closure (American Heart
Association/American College of Cardiology class IIa).

Q: How will you follow the patient after ASD device closure?
Follow up after device closure:
❖ Clinically it is important to assess symptoms due to arrhythmia, chest pain or
embolic events.
❖ Echocardiography is done just after the procedure to find residual shunt or
pericardial effusion.
❖ Frequency of follow up Echocardiography: at 24 hours, 1st month, 6th month
and 12th month
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 Extra Questions about ASD.
Q: What do you know about pregnancy and ASD?
Ans:
PREGNANCY AND ASD
Pregnancy is well tolerated in patients after ASD closure.
Pregnancy is also well tolerated in women with unrepaired ASDs, but the risk of
paradoxical embolism is increased (it is still very low) during pregnancy and in the
postpartum period.
Pregnancy is contraindicated in Eisenmenger syndrome because of the high mortality
rates for the mother (≈50%) and fetus (≈60%)

Q: What are different syndromes associated with ASD?

Ans:
SYNDROME ASSOCIATION with ASD
1. Holt-Oram syndrome
(ASD + limb defects): 60 % cases have ASD.
2. Ellis van Creveld.
3. Noonan
4. Down syndrome: 42 % have primum and secundum ASD.
5. Budd Chiari syndrome.
6. Jarcho-Levine.

What are the causes of dilatation of coronary sinus?

The ostium of the normal coronary sinus is 12 ± 2mm. If its diameter is > 15 mm, then it is
considered as dilated and one should find the cause, e.g.:
1. Coronary sinus type of ASD.
2. Unroofed coronary sinus.
3. Abnormal venous drainage in the left SVC
4. Coronary artery to Coronary sinus fistula.
5. Coronary sinus diverticulum.
6. Total anomalous intra-cardiac pulmonary venous
drainage.
7. Severe tricuspid regurgitation.

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What is Qp/Qs?
Ans:
The significance of the defect can be assessed by calculating the shunt fraction (Qp/Qs),
which is the ratio of pulmonary blood flow (Qp) to systemic blood flow (Qs).
Qp/Qs = Aortic saturation-mixed venous saturation
Pulmonary vein saturation-pulmonary artery saturation
--The mixed venous saturation is obtained in the setting of an ASD by multiplying the SVC
saturation by 3, adding the IVC saturation, and then dividing the sum by 4.
--If the pulmonary vein saturation is not directly measured, it can be assumed in the
absence of considerable lung disease to be 95%.

Note: In general, the higher the pulmonary arterial oxygen saturation, the greater is the
shunt, with a value greater than 90% suggesting a large shunt.

QUESTION
Which of the following statements regarding atrial septal defects (ASDs) is TRUE?
a) Percutaneous device closure of ASDs improves functional status in symptomatic
patients and exercise capacity in both asymptomatic and symptomatic patients
b) Children who have undergone repair of an isolated secundum defect should receive
lifelong endocarditis prophylaxis
c) Murmurs are not typically present in patients with uncomplicated ASDs
d) Left-axis deviation of the QRS complex on the ECG suggests the presence of a sinus
venosus ASD
e) Surgical or device closure is not indicated in a patient with a pulmonary to systemic
shunt ratio (Qp/Qs) <2.5

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ANSWER TO QUESTION - A

Although atrial septal defects (ASDs) are frequently asymptomatic, children may
experience exertional dyspnea or frequent chest infections.
Physical examination
usually demonstrates wide fixed splitting of the second heart sound. Other common
findings include
• a systolic murmur of increased flow across the pulmonic valve or
• a mid-diastolic rumble due to increased flow through the tricuspid valve.

ECG
may be helpful in determining the type of ASD.
• Secundum ASD patients often exhibit right-axis deviation on the ECG, whereas
• those with primum ASD characteristically exhibit left-axis deviation.
• Patients with sinus venosus ASD exhibit left-axis deviation of the P wave.

ASD repair
• is advised for patients with a Qp/Qs ≥1.5, particularly if the anatomy is suitable for
percutaneous transcatheter device closure.
• Repair improves New York Heart Association functional class in symptomatic
patients.
• For adults who are asymptomatic or mildly symptomatic, device closure improves
exercise capacity.

endocarditis prophylaxis
• In patients who undergo successful repair of an isolated secundum defect (by
surgery or by transcatheter device), lifelong endocarditis prophylaxis is not
required.
• Prophylaxis is appropriate for the first 6 months after device closure, while the
device endothelializes.