CHD - ASD

1. CHD - ASD Robosa, Dino Rodas, Francis Rodriguez, Shereen Rogelio, Ma. Gracella Salazar, Riccel Salcedo, Von

2. 2. How do you explain the auscultatory findings?

3. Etiology: Congenital Heart Disease • Anatomy: atrialseptal defect, ostiumsecundum, 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

4. What is your complete diagnosis?

5. 2. How do you explain the auscultatory findings?

8. 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 • Ostiumsecundum ASDs are most common

9. S2 is wide with fixed splitting

10. 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 atrialseptal defects, a ventricular septal defect with left to right shunting, or right ventricular failure)

11. 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.

12. 4a. What are the chest x-ray findings in a left to right shunt?

13. Left-to-right shunts • Acyanotic • Includes: • Ventral septal defect • Atrialseptal defect • Patent ductusarteriosus

14. Left-to-right shunts

15. Left-to-right shunts

16. 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

17. Dilated MPA Aortic knob SVC MPA RV LV IVC Increased pulmonary vascularity Normal PA view PA view (ASD)

18. Normal Lateral view • Lateral view (ASD) Retrosternal space Retrosternal space 2/3 1/3 Right ventricular enlargement

19. 4a. What are the chest x-ray findings in a left to right shunt?

20. Left-to-right shunts • Acyanotic • Includes: • Ventral septal defect • Atrialseptal defect • Patent ductusarteriosus

21. Left-to-right shunts

22. Left-to-right shunts

23. 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

24. Dilated MPA Aortic knob SVC MPA RV LV IVC Increased pulmonary vascularity Normal PA view PA view (ASD)

25. Normal Lateral view • Lateral view (ASD) Retrosternal space Retrosternal space 2/3 1/3 Right ventricular enlargement

26. How do you manage this patient?

27. Medical management • 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.

28. Surgical management • 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.

29. Indications 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

30. 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

31. 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