Atrial Septal Defect

(ASD)
Cardiology Division
Department of Child Health
Medical Faculty University of Brawijaya
Saiful Anwar General Hospital
Malang East Java - Indonesia

Abbreviation
ASD
CHD

: atrial septal defect

: congenital heart
disease

FR: flow ratio

HS
: heart sound
IVC
: inferior vena cava
LA: left atrium
LV : left ventricle
L to R : left to right

PH

: pulmonary
hypertension

RA

: right atrium

RV

: right ventricle

PVOD : pulmonary vascular

obstructive disease

Qp : Qs

: Flow to pulmonary :
to systemic

SVC

: superior vena cava

Outlines
1. To know the incidence and anatomy ASD
2. To describe pathophysiology L to R shunt in ASD
3. Able to make prompt diagnosis ASD based on:
- history
- clinical manifestation
- supporting examination
4. To make differential diagnosis of ASD
5. To describe natural course of disease in ASD
6. To know management of ASD

External
Normal
Heart
(Frontal View)

Internal
Normal
Heart
(Frontal
View)

Internal
Normal
Heart
(View from
right side)

Incidence and anatomy

Incidence
+ 5- 10 % from all CHD
30-50% children with CHDs has ASD as part of
cardiac defect
Ratio : = 1 : 2
Anatomy :
Defect on foramen ovale : Secundum ASD
Defect at SVC and RA junction: Sinus venosus ASD
Defect at ostium primum : Primum ASD

Atrial
Septal
Defects
(View from
right side)

Atrial
Septal
Defects

Pathophysiology L to R in ASD

RA

LA

RV

LV

LA

RA

RV

LV

History
Usually
asymptomatic

Clinical manifestation
Body weight maybe less
than 10th percentile
Auscultation :
Normal 1st HS or loud
Wide and fixed split
2nd HS
Ejection systolic
murmur

Normal Split 2nd Heart

Sound
A22 = P22
Exp

RA
RA

LA
LA

RV
RV

LV
LV

A22
RA
RA

Insp

RV
RV

LA
LA
LV
LV

P22

Wide and Fixed Split 2nd Heart

Sound in ASD
A22
Exp

RA
RA
RV
RV

LA
LA

P22

LV
LV

A22
RA
RA

Insp

RV
RV

LA
LA
LV
LV

P22

Chest X
ray
- Right
atrial
enlargeme
nt
- RVH
- Prominenc
e of the
MPA
- Increased
pulmonary
vascular

Electrocardiography

Right axis deviation of +90 to +180 degrees and

mild right ventricular hypertrophy (RVH)
or right bundle branch block (RBBB) with an rsR pattern in V1

Echocardiography

Diagnosis Differential

Partial anomalous pulmonary vein drainage

Pulmonary stenosis
Innocent murmur

Natural course of disease

1. Spontaneous closure
2. Remain asymptomatic
3. Heart failure
4. Pulmonary hypertension Eisenmenger syndrome
5. Arrhytmia (fibrillation or flutter)
6. Cerebrovascular accident (result from paradoxical
embolization)
7. Infective endocarditis (not in isolated ASD)

ASD
Large Shunt

Small Shunt
Observation
Evaluation
At age 5-8 yrs
Cath

Heart
Failure (-)

Children/Adults
PH (-)
Heart
Failure (+)
PVD
(-)
Anti failure

Success

FR<1.5 FR>1.5
Conservative

Infants

Age >1yrs
W >10kg

PH (+)
PVD
(+)
Hyperoxia

Fail

Surgical
Closure

Reactive

Transcatheter closure (Secundum ASD) /

Surgical Closure(other type of ASD)

Non
reactive

Conservative

Management and Timing for definitive treatment

1. Timing for surgery : pre school age
2. Medication
- Heart failure : Diuretics, vasodilator, Inotropes
2. Definitive treatment
- Surgery
- Trancatheter closure of ASD
Indication : Secundum ASD 5 mm-32 mm
Hemodynamic significant L to R
Evidence RV overload (Ratio Qp/Qs > 1.5)

Patch
Repair

Atrial Septal Defect Patch Repair

Occlusion of atrial septal defect

Clockwise from above:

Transcatheter delivery
of Amplatzer device,
which is positioned
across the atrial
septal defect
Left: Device in place

Thank

Amplatzer Septal Occluder

AMPLATZER Septal Occluder

Occlusion of Intracardiac and Vascular

Shunts
Atrial Septal Defect Occlusion

2D echocardiogram of a
secundum atrial septal defect
from the subcostal view

Angiogram of sizing balloon

across an ASD.
(Transesophageal
echocardiogram probe (TEE)
is also seen.)

Atrial septal defect

ASD
ASD before
before occlusion
occlusion

Atrial septal defect

ASD
ASD after
after occluded
occluded
using
using ASO
ASO