chd - asd

Robosa, DinoRodas, Francis

Rodriguez, ShereenRogelio, Ma. Gracella

Salazar, RiccelSalcedo, Von

Etiology: Congenital Heart Disease Anatomy: atrial septal defect, ostium

secundum, dilated right atrium, markedly dilated and hypertrophied right ventricle, dilated main pulmonary artery, anterior mitral valve prolapse

Physiology: NSR, incomplete right bundle branch block, diffuse ST-T changes, moderate pulmonary hypertension, increased right ventricular pressure and overload

Functional Capacity: Class II Objective Assessment: C

2. How do you explain the auscultatory findings?

a. At the base, S1 is normal followed by a grade 3/6cresendo-decresendo murmur– Increased flow across the pulmonic valve is

responsible for a midsystolic pulmonary outflow murmur

– Grade 2–3 mid-systolic murmur at the mid to upper left sternal border with fixed splitting of S2

• Ostium secundum ASDs are most common

b. S2 is wide with fixed splitting

• Wide splitting– The split becomes wider when there is delayed

activation of contraction or emptying of the right ventricle resulting in a delay in pulmonic closure

• Fixed splitting– This occurs with delayed closure of the pulmonic

valve when output of the right ventricle is greater than that of the left ventricle (such as occurs in large atrial septal defects, a ventricular septal defect with left to right shunting, or right ventricular failure)

c. At the apex, multiple clicks are heard◦ Midsystolic clicks, occurring with or without a

late systolic murmur, often denote prolapse of one or both leaflets of the mitral valve

Results from the chordae tendineae that are functionally unequal in length

Best heard along the lower left sternal border and at the left ventricular apex

◦ Systolic clicks usually occur later than the systolic ejection sound.

Acyanotic Includes:

◦ Ventral septal defect◦ Atrial septal defect◦ Patent ductus arteriosus

Left-to-Right Shunt

Chambers

Enlarged

Prominent

aortic knob

Dilated MPA

Pulmonary

Vascularity

Ventral Septal Defect

LA and LV

No Yes ↑

Atrial Septal Defect

RA and RV

No Yes (convex)

↑

Patent Ductus Arterios

us

LA and LV

Yes Yes ↑

RV Enlargement◦ PA view: lateral upward displacement of the

cardiac apex◦ Lateral view: fullness of retrosternal space

RA Enlargement◦ PA view: increased convexity of the lower right

cardiac border

Normal PA view PA view (ASD)

SVC

RV

IVC

Aortic knob

MPA

LV

Dilated MPA

Increased pulmonary vascularity


Right ventricular enlargement

2/32/31/31/3

Retrosternal space

Retrosternal space

Normal Lateral view

Lateral view (ASD)

Retrosternal space

Retrosternal space

Acyanotic Includes:

◦ Ventral septal defect◦ Atrial septal defect◦ Patent ductus arteriosus

Left-to-Right Shunt

Chambers

Enlarged

Prominent

aortic knob

Dilated MPA

Pulmonary

Vascularity

Ventral Septal Defect

LA and LV

No Yes ↑

Atrial Septal Defect

RA and RV

No Yes (convex)

↑

Patent Ductus Arterios

us

LA and LV

Yes Yes ↑

RV Enlargement◦ PA view: lateral upward displacement of the

cardiac apex◦ Lateral view: fullness of retrosternal space

RA Enlargement◦ PA view: increased convexity of the lower right

cardiac border

Normal PA view PA view (ASD)

SVC

RV

IVC

Aortic knob

MPA

LV

Dilated MPA



Right ventricular enlargement

2/32/31/31/3

Retrosternal space

Retrosternal space

Normal Lateral view

Lateral view (ASD)

Retrosternal space

Retrosternal space

should include treatment of possible complications:◦ Respiratory tract infections◦ Arrhythmias, atrial fibrillation, supraventricular

tachycardia◦ Pulmonary hypertension, coronary artery disease,

heart failure◦ Infective endocarditis

Harrison’s Principles of Internal Medicine 17th ed.

Operative repair – definitive management with a patch of pericardium OR prosthetic material OR percutaneous transcatheter device closure

should be advised for all patients with uncomplicated secundum atrial septal defects with significant left-to-right shunting

Harrison’s Principles of Internal Medicine 17th ed.

The mere presence of an ASD may warrant intervention especially if there is a significant shunt (> 2:1)

symptomatic pulmonary hypertension is present [pulmonary artery pressure

(PAP) > 2/3 systemic arterial blood pressure (SABP) or pulmonary arteriolar resistance > 2/3 systemic arteriolar

resistance net left-to-right shunt (Qp:Qs) of at least 1.5:1• RA or RV enlargement – radiographic, cardiac catheterization or there is evidence of pulmonary artery reactivity when

challenged with a pulmonary vasodilator (e.g. oxygen, nitric oxide and/or prostaglandins)

or lung biopsy evidence shows that pulmonary arterial changes are potentially reversible

Schwartz ‘s Principles of Surgery, 9th ed.http://www.achd-library.com/index.html

Device closure may now be offered as an alternative to surgical closure to patients with secundum ASD of up to 36-38 mm in diameter

Surgical closure may also be offered, and may be especially attractive should the patient prefer the surgical approach, or especially if atrial arrhythmia surgery (atrial maze procedure for atrial fibrillation and radiofrequency or cryoablation for atrial flutter) may be offered concurrently

http://www.achd-library.com/index.html

The following ASD patients require periodic follow up by an ACHD cardiologist

• Those repaired as adults• Elevated pulmonary artery pressures at the time of

repair• Atrial arrhythmias pre- or post-operatively• Ventricular dysfunction pre-operatively• Co-existing heart disease (e.g. coronary artery disease,

valvular heart disease, hypertension) • Those with device closure need follow-up in specialized

centers with serial ECGs and echocardiograms to determine the late outcomes of these new techniques

• Endocarditis prophylaxis and aspirin are recommended for 6 months following device closure

http://www.achd-library.com/index.html

chd - asd

Documents

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