Atrial septal defect: Difference between revisions
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==Background== | ==Background== | ||
[[File:Asd-web.jpg|thumb|Atrial septal defect]] | |||
*Many ASDs go undiagnosed in childhood | *Many ASDs go undiagnosed in childhood | ||
*By 40s, patients may develop symptoms | *From superior to inferior, ASDs occur in<ref>Warnes CA, Williams RG, Bashore TM, et al. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease. J Am Coll Cardiol. 2008;52:e143–263.</ref>: | ||
**Sinus venosus (5%) | |||
**Ostium secundum (75%), ostium primum (15-20%) | |||
**Very rarely coronary sinus ASD | |||
*Spontaneous closure in up to 40% of patients within the first 5 years of life | |||
*By 40s, patients may develop symptoms<ref>Craig RJ, Selzer A. Natural history and prognosis of atrial septal defect. Circulation. 1968;37:805–15.</ref> | |||
**Small ASDs < 5 mm in diameter may not generate symptoms | |||
**5-10 mm defects lead to symptoms in 4th and 5th decade of life | |||
**> 10 mm defects present with symptoms in 3rd decade | |||
*LV stiffness increases as a part of normal aging, impairing left heart diastolic filling<ref>Fleg JL, Shapiro EP, O’Connor F, Taube J, Goldberg AP, Lakatta EG. Left ventricular diastolic filling performance in older male athletes. JAMA. 1995;273:1371–5.</ref><ref>Swinne CJ, Shapiro EP, Lima SD, Fleg JL. Age-associated changes in left ventricular diastolic performance during isometric exercise in normal subjects. Am J Cardiol. 1992;69:823–6.</ref> | |||
**Increases left to right shunt across ASD | |||
**Produces RA and RV volume overload | |||
*May predispose to paradoxical embolus, causing [[stroke]], [[TIA]], [[acute limb ischemia]], [[mesenteric ischemia]], etc.<ref>Ward R, Jones D, Haponik EF. Paradoxical embolism. An underrecognized problem. Chest. 1995;108:549–58.</ref> | |||
**Right to left shunt may occur during coughing, for example | |||
**[[Pulmonary hypertension]] produces this shunting pattern even at rest | |||
*Unlike ventricular septal defects, uncomplicated ASDs are not associated with high risk of bacterial endocarditis (lower turbulence and velocity of blood flow) | |||
==Clinical Features== | ==Clinical Features== | ||
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*[[Palpitations]] | *[[Palpitations]] | ||
*[[Syncope]] | *[[Syncope]] | ||
*Right heart failure | *Right heart failure | ||
*[[A. fib]] | *[[A. fib]] | ||
*[[Stroke]] (via an embolism) | *[[Stroke]] (via an embolism) | ||
*[[Pulmonary hypertension]], marker of late disease and increased mortality<ref>Gabriels C, De Meester P, Pasquet A, et al. A different view on predictors of pulmonary hypertension in secundum atrial septal defect. Int J Cardiol. 2014;176:833–40.</ref> | |||
*[[Eisenmenger syndrome]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
| Line 18: | Line 35: | ||
==Evaluation== | ==Evaluation== | ||
===[[ECG]] Findings=== | |||
[[File:crochetage pattern.png|thumbnail|Crochetage pattern on ECG for atrial septal defect]] | [[File:crochetage pattern.png|thumbnail|Crochetage pattern on ECG for atrial septal defect]] | ||
*An [[ECG]] may show the “crochetage” pattern (92% specific)—a notch near the apex of the R wave in inferior limb leads<ref>Heller, J et al. “Crochetage” (Notch) on R wave in inferior limb leads: A new independent electrocardiographic sign of atrial septal defect. J Am Coll Cardiol. 1996;27(4):877-882 [http://content.onlinejacc.org/article.aspx?articleid=1121056#tab1 full text]]</ref> | *An [[ECG]] may show the “crochetage” pattern (92% specific)—a notch near the apex of the R wave in inferior limb leads<ref>Heller, J et al. “Crochetage” (Notch) on R wave in inferior limb leads: A new independent electrocardiographic sign of atrial septal defect. J Am Coll Cardiol. 1996;27(4):877-882 [http://content.onlinejacc.org/article.aspx?articleid=1121056#tab1 full text]]</ref> | ||
**Large notches signify a larger shunt | **Large notches signify a larger shunt | ||
* | *Other ECG findings | ||
*(Incomplete [[right bundle branch block]], very sensitive | |||
**1st degree [[AV block]] | |||
**[[Atrial flutter]] or [[atrial fibrillation]] in ~20% of adults with ASDs requiring surgery<ref>Gatzoulis MA, Freeman MA, Siu SC, Webb GD, Harris L. N Engl J Med. 1999 Mar 18; 340(11):839-46.</ref> | |||
**[[Right axis deviation]] ([[pulmonary hypertension]]) | |||
==Management== | ===[[Echocardiography]]=== | ||
[[File:Echokardiogram von Atriumseptumdefekt (Ostium secundum).jpg|thumb|[[Echo]] in subcostal view. The apex is towards the right, the atria are to the left. ASD secundum seen as a discontinuation of the white band of the atrial septum. The enlarged right atrium is below. The enlarged pulmonary veins are seen entering the left atrium above.]] | |||
[[File:Positive+bubble+test+thepocusatlas.gif|thumbnail|Positive Bubble Test in a pediatric patient demonstrating a Atrial Septal Defect <ref>http://www.thepocusatlas.com/echocardiography/</ref>]] | |||
*Subcostal view preferred window, due to interatrial septum perpendicular to echo signal (apical four-chamber is parallel to ASD echo signal) | |||
*Clues to ASD | |||
**Hypermobile interatrial septum | |||
**Abrupt septal irregularity | |||
**RA and/or RV volume overload | |||
**Pulmonary artery dilation | |||
**High pulmonary artery pressures | |||
*TTE with Doppler can demonstrate most shunting | |||
*Agitated saline with Valsalva maneuver to increase right to left shunting is more diagnostic<ref>Shub C, Dimopoulos IN, Seward JB, et al. Sensitivity of two-dimensional echocardiography in the direct visualization of atrial septal defect utilizing the subcostal approach: experience with 154 patients. J Am Coll Cardiol. 1983;2:127–35.</ref> | |||
==Management<ref>Martin SS et al. Atrial Septal Defects – Clinical Manifestations, Echo Assessment, and Intervention. Clin Med Insights Cardiol. 2014; 8(Suppl 1): 93–98.</ref>== | |||
*Medical management of complications (Afib, pulmonary HTN, etc.) | |||
*Avoid pregnancy and exertional activity in ASD complicated by [[pulmonary hypertension]] | |||
*Indications for ASD closure | |||
**Right heart overload with RA or RV enlargement | |||
**Complicated ASDs | |||
==Disposition== | ==Disposition== | ||
* | *If no acute complications → discharge with outpatient follow-up | ||
==See Also== | ==See Also== | ||
*[[Congenital heart disease]] | *[[Congenital heart disease]] | ||
| Line 32: | Line 73: | ||
==External Links== | ==External Links== | ||
*[https://ecgweekly.com/2016/04/amal-mattus-ecg-case-of-the-week-april-4-2016/ ECG Weekly Apr 4 2016] | |||
==References== | ==References== | ||
Latest revision as of 18:21, 6 November 2024
Background
- Many ASDs go undiagnosed in childhood
- From superior to inferior, ASDs occur in[1]:
- Sinus venosus (5%)
- Ostium secundum (75%), ostium primum (15-20%)
- Very rarely coronary sinus ASD
- Spontaneous closure in up to 40% of patients within the first 5 years of life
- By 40s, patients may develop symptoms[2]
- Small ASDs < 5 mm in diameter may not generate symptoms
- 5-10 mm defects lead to symptoms in 4th and 5th decade of life
- > 10 mm defects present with symptoms in 3rd decade
- LV stiffness increases as a part of normal aging, impairing left heart diastolic filling[3][4]
- Increases left to right shunt across ASD
- Produces RA and RV volume overload
- May predispose to paradoxical embolus, causing stroke, TIA, acute limb ischemia, mesenteric ischemia, etc.[5]
- Right to left shunt may occur during coughing, for example
- Pulmonary hypertension produces this shunting pattern even at rest
- Unlike ventricular septal defects, uncomplicated ASDs are not associated with high risk of bacterial endocarditis (lower turbulence and velocity of blood flow)
Clinical Features
A patient may be asymptomatic or have any of the following features:
- Dyspnea on Exertion
- CHF
- Palpitations
- Syncope
- Right heart failure
- A. fib
- Stroke (via an embolism)
- Pulmonary hypertension, marker of late disease and increased mortality[6]
- Eisenmenger syndrome
Differential Diagnosis
Congenital Heart Disease Types
- Cyanotic
- Acyanotic
- AV canal defect
- Atrial septal defect (ASD)
- Ventricular septal defect (VSD)
- Cor triatriatum
- Patent ductus arteriosus (PDA)
- Pulmonary/aortic stenosis
- Coarctation of the aorta
- Differentiation by pulmonary vascularity on CXR[7]
- Increased pulmonary vascularity
- Decreased pulmonary vascularity
- Tetralogy of fallot
- Rare heart diseases with pulmonic stenosis
Evaluation
ECG Findings
- An ECG may show the “crochetage” pattern (92% specific)—a notch near the apex of the R wave in inferior limb leads[8]
- Large notches signify a larger shunt
- Other ECG findings
- (Incomplete right bundle branch block, very sensitive
- 1st degree AV block
- Atrial flutter or atrial fibrillation in ~20% of adults with ASDs requiring surgery[9]
- Right axis deviation (pulmonary hypertension)
Echocardiography
.jpg)
Echo in subcostal view. The apex is towards the right, the atria are to the left. ASD secundum seen as a discontinuation of the white band of the atrial septum. The enlarged right atrium is below. The enlarged pulmonary veins are seen entering the left atrium above.
Positive Bubble Test in a pediatric patient demonstrating a Atrial Septal Defect [10]
- Subcostal view preferred window, due to interatrial septum perpendicular to echo signal (apical four-chamber is parallel to ASD echo signal)
- Clues to ASD
- Hypermobile interatrial septum
- Abrupt septal irregularity
- RA and/or RV volume overload
- Pulmonary artery dilation
- High pulmonary artery pressures
- TTE with Doppler can demonstrate most shunting
- Agitated saline with Valsalva maneuver to increase right to left shunting is more diagnostic[11]
Management[12]
- Medical management of complications (Afib, pulmonary HTN, etc.)
- Avoid pregnancy and exertional activity in ASD complicated by pulmonary hypertension
- Indications for ASD closure
- Right heart overload with RA or RV enlargement
- Complicated ASDs
Disposition
- If no acute complications → discharge with outpatient follow-up
See Also
External Links
References
- ↑ Warnes CA, Williams RG, Bashore TM, et al. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease. J Am Coll Cardiol. 2008;52:e143–263.
- ↑ Craig RJ, Selzer A. Natural history and prognosis of atrial septal defect. Circulation. 1968;37:805–15.
- ↑ Fleg JL, Shapiro EP, O’Connor F, Taube J, Goldberg AP, Lakatta EG. Left ventricular diastolic filling performance in older male athletes. JAMA. 1995;273:1371–5.
- ↑ Swinne CJ, Shapiro EP, Lima SD, Fleg JL. Age-associated changes in left ventricular diastolic performance during isometric exercise in normal subjects. Am J Cardiol. 1992;69:823–6.
- ↑ Ward R, Jones D, Haponik EF. Paradoxical embolism. An underrecognized problem. Chest. 1995;108:549–58.
- ↑ Gabriels C, De Meester P, Pasquet A, et al. A different view on predictors of pulmonary hypertension in secundum atrial septal defect. Int J Cardiol. 2014;176:833–40.
- ↑ Knipe K et al. Cyanotic congenital heart diseases. Radiopaedia. http://radiopaedia.org/articles/cyanotic-congenital-heart-disease
- ↑ Heller, J et al. “Crochetage” (Notch) on R wave in inferior limb leads: A new independent electrocardiographic sign of atrial septal defect. J Am Coll Cardiol. 1996;27(4):877-882 full text]
- ↑ Gatzoulis MA, Freeman MA, Siu SC, Webb GD, Harris L. N Engl J Med. 1999 Mar 18; 340(11):839-46.
- ↑ http://www.thepocusatlas.com/echocardiography/
- ↑ Shub C, Dimopoulos IN, Seward JB, et al. Sensitivity of two-dimensional echocardiography in the direct visualization of atrial septal defect utilizing the subcostal approach: experience with 154 patients. J Am Coll Cardiol. 1983;2:127–35.
- ↑ Martin SS et al. Atrial Septal Defects – Clinical Manifestations, Echo Assessment, and Intervention. Clin Med Insights Cardiol. 2014; 8(Suppl 1): 93–98.