case report

Atrial Septal DefectType : SecundumPRESENTED BY :TRI KURNIAWAN (C11111323)

SUPERVISOR : DR. ABDUL HAKIM ALKATIRI, SPJP, FIHA

Cardiology DepartmentFaculty of Medicine, Hasanuddin University2015

Patient’s Identity

Name : Ms J

Age : 22 years old

Gender : Female

Adress : Cilellang Selatan, Kab. Barru

Medical Record No. : 6996xx

Admission : August, 8th 2015

HISTORY TAKING

Chief complaint Palpitation

Guided-Anamnesis Experienced since 3 months ago.

DOE (+), Orthopnea (-), PND (-).

Chest pain was felt intermittently on active state

Epigastric pain (-), cough (-), fever (-)

Fatigue (+)

Headache (-), Nausea and vomiting (-)

Syncope (-), history of syncope (-)

Urination and defecation remains normal

HISTORY TAKING

Previous illness

Goiter (+)

Hypertension (-)

Diabetes Mellitus (-)

Recurrent respiratory tract infection (-)

Risk Factor Modifiable : (-)

Non-Modifiable : History of alcohol, drugs, or illness of mother during pregnancy (-), histoy of family with same disease (-)

Physical Examination General State

Moderate illness/ well-nourished/ compos mentis

Vital sign

BP : 110/80 mmHg

HR : 78 x/minutes, regular,

RR : 22 x/minutes

Temp : 36,5 º C (Axilla)

Head and Neck

Conjungtiva : Anemia (-), Icterus (-)

Lips : Cyanosis (-)

Neck : JVP R+2 cmH20 on 30° supine position

Lymphadenopathy (-)

Tumor Mass (-)

Thyroid enlargement (+), grade IB

Physical Examination Thorax :

Inspection : symmetric left=right, normothorax

Palpation : tenderness (-), tumor (-), vocal fremitus

left=right

Percussion : sonor left=right,

Liver and Lung margin ICS VI dextra

Right Back Lung margin ICS IX dextra

Left Back Lung margin ICS X sinistra

Auscultation : BS : vesicular; Ronchi (-/-), Wheezing -/-

Physical Examination

Heart

Inspection : Ictus cordis isn’t visible

Palpation : Ictus cordis is not palpable, thrill is not palpable

Percussion : Upper border ICS III sinistra

Right border linea parasternalis dextra

Left border medioclavicularis sinistra

Auscultation : HS I/II pure, regular

Sistolic ejection murmur hear on ICS II sinistra

Physical Examination

Abdominal Exam

Inspection : Flat, simetrical, follows breath movement

Auscultation : Peristaltic (+), normal

Palpation : tenderness (-), tumor mass (-), liver and spleen not palpable

Percussion : Tympani (+), Ascites (-)

Extremity

Warm, edema pretibial (-/-), edema dorsum pedis (-/-)

Electrocardiography15/8/2015

Interpretation

Basic rhytm : sinus

QRS rate : 94 x/minutes

Regularity : regular

PR interval : 0,20 second

Axis : right axis deviation

Morphology

Gelombang P : 0,08 second, inverted on V1

Kompleks QRS : 0,12 second, there’s RsR’ configuration on

lead III, rsR’ on V3, wide and notch R wave on lead II, AVF,

and V4, reciprocal morphology RsR’ on AVL,

widening S wave on lead I, and deep S ( 12 mm)

on lead V5 dan V6

ST segmen : Normal on all lead

Gelombang T : Normal on all lead

Conclusion : Sinus Rhtym, Right axis deviation with incomplete

Right Bundle Branch Block

Chest X-Ray PA 6/8/2015

Conclusion :

Cardiomegaly with the sign ofLeft to Right Shunt

Laboratory FIndings 11/8/2015

Parameter Result UNIT

WBC 5,1 (10³/UI)

RBC 4,71 (106/UI)

HGB 12,1 (gr/dL)

HCT 36,2 (%)

PLT 212 (103/uL)

GDS 85 mg/dL

Ureum/Creatinin 19/0,5 mg/dL

SGOT 18 mmol/L

SGPT 19 mg/dL

BT 2,30 minutes

CT 7,00 minutes

PT 11,9 seconds

aPTT 28,4 seconds

INR 1,11

Natrium 142 mmol/L

Kalium 3,9 mmol/L

Klorida 111 mmol/L

Conclusion :

All Parameters are remain in normallimit

Echocardiography transthoracal (21/5/2015)

Conclusion :

Huge ASD Secundum (2,6 cm) with left to the right shuntModerate Pulmonary HypertensionEnlargement of right atrium and right ventricle

Echocardiography transesophageal (13/8/2015)

Conclusion :

Huge ASD Secundum (2,9cm)

Diagnosis

Atrial Septal Defect type : Secundum

Management

ASD Closure with using Percutaneus Catheterization Amplatzer Septal Occluder

Discussion

ATRIAL SEPTAL DEFECT Congenital Heart Disease on Adults

Definition Atrial septal defect (ASD) is one of the more

commonly recognized congenital cardiac anomalies presenting in adulthood. Atrial septal defect is characterized by a defect in the interatrial septum allowing pulmonary venous return from the left atrium to pass directly to the right atrium.

Result Left to Right Shunt, Right to left shunt (worse prognosis)

Classification

Ostium secundum: The most common type of ASD accounting for 75% of all ASD cases, representing approximately 7% of all congenital cardiac defects and 30-40% of all congenital heart disease in patients older than 40 years.

Ostium primum: The second most common type of ASD accounts for 15-20% of all ASDs. Primum ASD is a form of atrioventricular septal defect and is commonly associated with mitral valve abnormalities

Sinus venosus: The least common of the three, sinus venosus (SV) ASD is seen in 5-10% of all ASDs. The defect is located along the superior aspect of the atrial septum. Anomalous connection of the right-sided pulmonary veins is common and should be expected. Alternate imaging is generally required.

Epidemiology

Incidence : ASD occur on 1 by 1500 live birth,

Gender : ASD occurs with a female-to-male ratio of approximately 2:1

Age : Patients with ASD can be asymptomatic through infancy and childhood, though the timing of clinical presentation depends

on the degree of left-to-right shunt. Symptoms become more common with advancing age. By the age of 40 years, 90% of

untreated patients have symptoms of exertional dyspnea, fatigue, palpitation, sustained arrhythmia, or even evidence of

heart failure.

ETIOLOGY

• Holt-Oram syndrome characterized by an autosomal dominant pattern of inheritance and deformities of the upper limbs (most often, absent or hypoplastic radii) has been attributed to a single gene defect in TBX5. The penetrance is nearly 100% for Holt-Oram syndrome.

• Fetal alcohol syndrome – about one in four patients with fetal alcohol syndrome has either an ASD or a VSD.

• Down syndrome – patients with Down Syndrome have higher rates of ASDs, especially a particular type that involve ventricular wall.  As many as one half of Down Syndrome patients have some type of septal defect.

• Idiopathic

Atrial septal defect

(ASD) may occur on a

familial basis.

Risk Factor

Risk factor which predict influencing the incidence of ASD are :

Infection of German Measles (rubella) during pregnancy

Exposure of medicine, cigarettes, alcohol, and existence of lupus and diabetes mellitus during pregnancy

Pathogenesis ASD Secundum

Hyperresorbtion of septum primum during formation of ostium secundum

Disruption of development of septum secundum

ASD PrimumDisruption of closure of ostium primum on septum primum during formation of ostium secundumFailure of fusion between septum primum and endocardial cushion

Sinus venosus

There is abnormality of fusion between embryonal sinus venosus and atrium

Pathophysiology

Pathomechanism of Symptoms Dyspnea

Long Standing L to R shunt

Hypervascularization

of pulmonary circulation

Vascular bed filled with blood

Pulmonary hypertensi

on and Hydrostatic

pressure elevated

Transudation of fluid

from capillary to interstitial

Inhibition of diffusion O2 on lung

Dyspnea

Fatigue

Pathomechanism of Symptoms

L to R shuntVolume

systolic of LV decrease

Blood containing

oxygen decrease

Perfusion decrease

Ischemic and metabolism

disorderFatigue

Pathomechanism of Symptoms Angina

Systemic circulation decrease

Coronary circulation decrease

Right volume

overload

Pulmonary hypertensi

on

Wall-Stress increases

of RV

Oxygen demand increase-Oxygen supply

decrease

Angina

Palpitation

Left to Right Shunt Dilatation of right atrium and right ventricle Prolonged of conduction pathway re-entry current Atrial Fibrillation/ SVT/ MAT Palpitation

Recurrent of respiratory tract infection

Hypervascularization of pulmonary circulation vascular bed filling Hydrostatic pressure increases Edema of lower respiratory tract disruption of immunity system susceptible of infection

Pathomechanism of Symptoms

Physical Examination Inspection

Hard to find abnormalities Palpation

Thrill can be palpated Pulsation of right ventricle can be felt

Percussion Cardiomegaly

Auscultation Wide-fixed split of S2 S2 Louder Systolic ejection murmur on ICS A mid-diastolic murmur at lower left sternal border

Electrocardiography Complete or

incomplete right bundle branch block

Right Axis deviation

Right Ventricle Hypertophy

Abnormality of Q wave

Echocardiography

Findings :Defect on interatrial septumOn color Echocardiography, there is shunt between left and right atrium, following systolic andDiastolyc cycle of heartDilatation of right atrium and right ventriclePulmonary hypertension (conditional)Mitral regurgitation (occasionally on ASD primum)Tricuspid regurgitation secondary caused by dilatation of annulus

Another Examination

Chest X-ray

Not Specific Cardiomegaly

Blood profile

Not specific

Cardiac catheterization

Gold Standar to detect atrial septal defec (invasive, high side effect, takes time) prefer Echocardiography instead of cathetherization

Management Definitif and Symptomatic (Antiarrhytmia, Dorner, Furosemid)

Definitif treatment Interventional and Surgical

Interventional : Percathetherization devices Amplatzer Septal Occluder

Indication for closure with ASO :

ASD Secundum, defect >5 mm

Right-sided heart enlargement with/without symptoms

Presence of Paradoxical embolism

There is left-right shunt proved, pulmonary artery pressure <2/3 systemic pressure

Qp : Qs = <1,5:1

Indication of surgical ASD primum or Sinus VenosusInterventional is a contraindication

Complication

PULMONARY HYPERTENSI

ONARITMIA

RIGHT-SIDED HEART

FAILURE

DISABILITY LIMITATION

EISENMENGER SYNDROME

References

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4. anonim. Risk factor atrial septal defect. USA: Mayo Clinic; 2014 [cited 2015 August 19th]; Available from: http://www.mayoclinic.org/diseases-conditions/atrial-septal-defect/basics/risk-factors/con-20027034.

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