Atrial Septal Defect

Atrial Septal Defect (ASD) adalah Penyakit jantung bawaan berupa lubang pada septum interatrial yang terjadi karena kegagalan fusi septum inter atrial semasa janin. Termasuk PJB nonsianotik, 10-15 % dari seluruh PJB dan merupakan PJB pada dewasa paling banyak . Klasifikasi : a. ASD sekundum. Lubang didaerah Fossa Ovalis b. ASD primum. - Lubang di caudal, didaerah perbatasan dgn ventrikel. - Sering disertai kegagalan pertumbuhan endocard cushion tdpt cleft pd katup mitral c. Defek sinus venosus - Letak di muara v.cava superior atau inferior. - Sering disertai transposisi sebagian v.pulmonalis dextra (APVD).

Treating Atrial Septal Defect

Periodic checkups are done to see whether an atrial septal defect (ASD) closes on its own. About half of all ASDs close on their own over time, and about 20 percent close within the first year of life. When treatment of an ASD is required, it involves catheter or surgical procedures to close the hole. Doctors often decide to close an ASD in children who still have medium to large holes by the time they're 2 to 5 years old.

Catheter Procedure
Doctors can use catheter procedures to close secundum ASDs, the most common type of ASD. During the procedure, the doctor inserts a catheter (a thin, flexible tube) into a vein in the groin (upper thigh) and threads it to the heart's septum. The catheter has a tiny umbrella-like device folded up inside it. When the catheter reaches the septum, the device is pushed out of the catheter and positioned so that it plugs the hole between the atria. The device is secured in place and the catheter is withdrawn from the body. Within 6 months, normal tissue grows in and over the device. There is no need to replace the closure device as the child grows. Doctors often use echocardiography (echo) or transesophageal (tranz-ih-sof-uh-JEE-ul) echo (TEE) as well as angiography (an-jee-OG-ra-fee) to guide them in threading the catheter to the heart and closing the defect. TEE is a special type of echo that takes pictures of the heart through the esophagus (the passage leading from the mouth to the stomach). Catheter procedures are much easier on patients than surgery because they involve only a needle puncture in the skin where the catheter is inserted. This means that recovery is faster and easier. The outlook for children having this procedure is excellent. Closures are successful in more than 9 out of 10 patients, with no significant leakage. Rarely, a defect is too large for catheter closure and surgery is needed.

Surgery
Open-heart surgery generally is done to repair primum or sinus venosus ASDs. During the surgery, the cardiac surgeon makes an incision (cut) in the chest to reach the ASD. He or she then repairs the defect with a special patch that covers the hole. Your child is placed on a heartlung bypass machine so that the heart can be opened to do the surgery. The outlook for children after ASD surgery is excellent. On average, children spend 3 to 4 days in the hospital before going home. Complications, such as bleeding and infection, from ASD surgery are very rare. They will talk about preventing blows to the chest as the incision heals, limiting activity while your child recovers, bathing, scheduling followup medical appointments, and determining when your child can go back to his or her regular activities.

Not all children with an atrial septal defect are candidates for surgery, which is only indicated for those children with clinically significant left-to-right shunting. In general, a pulmonary-tosystemic flow ratio of 1.5:1 or more is considered the principal indication for surgical repair. Shunting less than this in children with small defects and in those with existing pulmonary hypertension may be observed. Because cardiac catheterization is rarely necessary, echocardiographic evidence of right atrial and right ventricular enlargement is usually considered evidence of a clinically significant left-to-right shunt and an indication for surgical closure of the atrial septal defect. Surgery is ideally performed in children aged 2-4 years and has a very low mortality rate. However, surgery may be performed earlier than this if the child has evidence of CHF. Newer, minimally invasive surgical techniques have been developed. These improve cosmetic appearances and decrease hospital stays. These techniques are ideally suited for simple closure of a secundum atrial septal defect.[15] The surgical mortality rate is low in patients with uncomplicated atrial septal defects. In an experienced pediatric center, the mortality rate should be less than 1%. Postoperative morbidity in individuals with atrial septal defects is almost exclusively due to accumulation of pericardial fluid (postpericardiotomy syndrome), which occurs in approximately one third of patients. On occasion, tamponade occurs and requires pericardiocentesis. Pericardial effusion should be suspected in any pediatric patient who undergoes postsurgical repair of an atrial septal defect and who presents with chest pain, fever, shortness of breath, or general malaise. In young children, symptoms may be nonspecific and include irritability and decreased appetite. Transcatheter approaches to atrial septal defect closure are well accepted in the pediatric population. Secundum atrial septal defects are currently the only subtype of atrial septal defect that are amenable to this approach. Such techniques require individuals with considerable expertise in the field of interventional pediatric cardiology and cooperation between the interventionalist and the noninvasive imaging specialists. Benefits of the transcatheter approach include its minimal invasiveness, the lack of median sternotomy, the avoidance of cardiopulmonary bypass, and the relatively quick recovery time. Potential drawbacks and concerns include residual shunting around the device, embolization during placement requiring surgical intervention, lack of adequate septal rims to properly seat the device and the need for specific technical expertise and equipment. Long-term safety concerns are noted because device placement in smaller children is still relatively new. Long-term followup studies will provide further information. Overall however, the medium- to long-term outcomes of ASD closure, either surgically or percutaneously, appear very good.[16]