Download CHD - ASD

Robosa, Dino
Rodas, Francis
Rodriguez, Shereen
Rogelio, Ma. Gracella
Salazar, Riccel
Salcedo, Von
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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)
At the apex, multiple clicks are heard
c.
Midsystolic clicks, occurring with or without a late
◦
systolic murmur, often denote prolapse of one or
both leaflets of the mitral valve
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◦
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.
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
Acyanotic
Includes:
◦ Ventral septal defect
◦ Atrial septal defect
◦ Patent ductus arteriosus
Left-to- Chambe Prominen
Right
rs
t aortic
Shunt Enlarged
knob
Ventral
Septal
Defect
Atrial
Septal
Defect
Patent
Ductus
Arterios
Dilated
MPA
Pulmonar
y
Vascularit
y
↑
LA and
LV
No
Yes
RA and
RV
No
Yes
(convex)
↑
LA and
LV
Yes
Yes
↑
Left-to- Chambe Prominen
Right
rs
t aortic
Shunt Enlarged
knob
Ventral
Septal
Defect
Atrial
Septal
Defect
Patent
Ductus
Arterios
Dilated
MPA
Pulmonar
y
Vascularit
y
↑
LA and
LV
No
Yes
RA and
RV
No
Yes
(convex)
↑
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)
Dilated
MPA
SV
C
Aortic
knob
MPA
RV
IVC
LV
Increased pulmonary
vascularity
Normal Lateral view
Lateral view (ASD)
Retrosternal
space
Retrosternal
space
1/3
2/3
Right ventricular
enlargement


Acyanotic
Includes:
◦ Ventral septal defect
◦ Atrial septal defect
◦ Patent ductus arteriosus
Left-to- Chambe Prominen
Right
rs
t aortic
Shunt Enlarged
knob
Ventral
Septal
Defect
Atrial
Septal
Defect
Patent
Ductus
Arterios
Dilated
MPA
Pulmonar
y
Vascularit
y
↑
LA and
LV
No
Yes
RA and
RV
No
Yes
(convex)
↑
LA and
LV
Yes
Yes
↑
Left-to- Chambe Prominen
Right
rs
t aortic
Shunt Enlarged
knob
Ventral
Septal
Defect
Atrial
Septal
Defect
Patent
Ductus
Arterios
Dilated
MPA
Pulmonar
y
Vascularit
y
↑
LA and
LV
No
Yes
RA and
RV
No
Yes
(convex)
↑
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)
Dilated
MPA
SV
C
Aortic
knob
MPA
RV
IVC
LV
Increased pulmonary
vascularity
Normal Lateral view
Lateral view (ASD)
Retrosternal
space
Retrosternal
space
1/3
2/3
Right ventricular
enlargement

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 leftto-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
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The following ASD patients require periodic follow up by an
ACHD cardiologist
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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
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