ASD

Question 1

Name the 3 associated congenital lesions with a SECUNDUM type ASD

Answer 1

1. Pulmonic stenosis
2. Mitral valve prolapse
3. Partial anomalous pulmonary venous return

Question 2

Name the 2 associated congenital lesions with a PRIMUM type ASD

Answer 2

1. Cleft mitral valve

2. Discrete subaortic stenosis

Question 3

Name the congenital lesion associated with a SINUS VENOSUS type ASD

Answer 3

1. Partial anomalous pulmonary venous return

Question 4

Name the 2 congenital lesions associated with a CORONARY SINUS type ASD (aka Coronary sinoseptal defect)

Answer 4

1. Partial anomalous pulmonary venous return

2. Persistent left-sided superior vena cava

Question 5

Order the types of ASDs by most frequently occurring to least.

Answer 5

1. Secundum ASD (in the region of fossa ovalis) - 75%
2. Primum ASD (inferiorly near the crux of the heart) - 15-20%
3. Sinus venosus (superior near the SVC entry or inferior near the IVC entry) - 5-10%
4. Coronary sinus ASD (shunts from the “roof” of the ostium of the CS) -

Question 6

Which ASD is a from of Atrioventricular Septal Defect? Which valve lesion is it nearly always associated with?

Answer 6

Primum ASD. Nearly always associated with a cleft of the anterior mitral valve leaflet.

*Post-operatively, subaortic stenosis may also develop.

Question 7

What mitral valve lesion is frequently seen with ASDs?

Answer 7

Mitral valve prolapse.

-Cleft anterior mitral leaflet is associated with Primum ASD

Question 8

What are hemodynamic consequences of unrepaired ASD with large left to right shunt?

Answer 8

• RV Volume overload and pulmonary overcirculation
• -> Excess pulmonary blood flow, right heart failure and flow-related PAH (typically occurs in adult years, much later than VSD or PDA which are high pressure shunts)

Question 9

What are common arrhythmia consequences of unrepaired ASD with large left to right shunt?

Answer 9

Atrial arrhythmias – flutter, a fib, SSS

Question 10

What are typical adult presenting symptoms of ASDs?

Answer 10

• Dyspnea
• Palpitations
• New onset afib/flutter
• CM on CXR
• Paradoxical embolic event
• Small defects (

Question 11

What exam findings may be found in ASD?

List of 4

Answer 11

• Precordial lift
• Systolic pulmonary flow murmur
• FIXED Splitting of S2
• Diastolic flow rumble across TV (with large shunts)

Question 12

What EKG findings may be found in ASD?

Which are more likely in secundum, primum and SV-type ASDs?

Answer 12

• Right axis deviation
• Right atrial enlargement
• Incomplete RBBB (Secundum ASD)
• Superior left axis deviation (Primum ASD- due to anatomic position of the conduction bundles and should NOT be confused with bifascicular block)
• Abnormal P-wave axis (superior sinus venosus ASD)

Question 13

What may show up on CXR in ASD?

Answer 13

• RV and RA enlargement
• Prominent pulmonary artery segment
• Increased pulmonary vascularity

Question 14

What is a Class I indication for closure of an ASD (either surgically or percutaneously)?

Answer 14

RA and RV enlargement with or without symptoms

Question 15

What types of ASD should ONLY be closed surgically (not percutaneously)?
Class I recommendation

Answer 15

A sinus venosus, coronary sinus, or primum ASD should be

repaired surgically rather than by percutaneous closure.

Question 16

When is surgical closure of secundum ASD reasonable?

Class IIa recommendation

Answer 16

When concomitant surgical repair/replacment of a tricuspid valve is considered OR when the anatomy of the defect precludes the use of a percutaneous device

Question 17

What is a paradoxical embolism?

Answer 17

Paradoxical embolism, or venous thromboembolism transit from right- to left-sided cardiac chambers, may occur via interventricular, interatrial, or pulmonary arteriovenous malformations.

Question 18

Class IIa recommendation – Closure of an ASD, either percutaneously or surgically, is reasonable in the presence of what?

Answer 18

• Paradoxical embolism

- Documented orthodeoxia-platypnea

Question 19

Closure of an ASD, either percutaneously or surgically, may be considered in the presence of net left-to-right shunting, pulmonary artery pressure less than ____ systemic levels, PVR less than ____ systemic vascular resistance, or when responsive to either pulmonary vasodilator therapy or test occlusion of the defect (patients should be treated in conjunction with providers who have expertise in the management of pulmonary hypertensive syndromes).

Answer 19

• two thirds

- two thirds

Question 20

When is it a Class III indication to close an ASD?

Answer 20

Patients with severe irreversible PAH and no evidence of a

left-to-right shunt should not undergo ASD closure.

Question 21

What is a Warden Procedure? When should it be done?

Answer 21

The Warden procedure (translocation of the superior vena cava to the right atrial appendage) may be applied to the sinus venosus ASD when the anomalous pulmonary venous drainage enters the mid or upper superior vena cava.

Question 22

What conditions should be checked annually in patients post-op ASD closure?

Answer 22

• Presence or worsening of PAH
• Atrial arrhythmias
• RV or LV dysfunction
• Coexisting valve or other cardiac lesions
• Device migration or erosion (check 3 months to 1 yr post op and periodically thereafter; usually checked at 24 hours, 1 month, 6 months and 1 yr)

Question 23

Transmission of CHD to offspring of women with sporadic ASD is estimated at ___?

Answer 23

8-10%

Question 24

What genetic syndromes are associated with ASD?

Answer 24

• Heart-hand syndromes (Holt-Oram syndrome is best known)

- Down syndrome (associated with both secundum and primum)