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ACHD > ASD > Flashcards

ASD Flashcards

1
Q

Types of ASD

A

Secundum ASD
Sinus venosus defect (superior or inferior)
Primum ASD
Coronary sinus defect

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2
Q

Secundum ASD anatomic sub-types

A 
Central defect
Deficient aortic rim
Deficient posterior rim
Deficient IVC rim
Multi-fenestrated
Multiple
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3
Q

What is a secundum ASD?

A

Defect of septum premium in the area of the fossa ovalis
Result of deficiency of the flap valve tissue of the oval foramen so the flap valve does not completely cover the oval fossa or there are fenestrations

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4
Q

What percentage of all atrial level defects do secundum ASDs account for?

A

70%

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5
Q

What is a sinus venous ASD?

A

Defect in the posterior atrial septum

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6
Q

What percentage of all atrial level defects do sinus venosus ASDs account for?

A

5-10%

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7
Q

What are sinus venosus defects commonly associated with?

A

Anomalous pulmonary veins

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8
Q

What ECG change do you notice in sinus venosus defects?

A

Abnormal P wave axis (left atrial p waves)

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9
Q

What is a primum ASD?

A

Deficiency in endocardial cushion tissue - inferior atrial septum (just above AV valve)

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10
Q

What percentage of all atrial level defects do primum ASDs account for?

A

5-10%

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11
Q

What is primum ASD associated with?

A

Cleft anterior leaflet of the MV causing MR

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12
Q

What determines shunt magnitude of ASD?

A

Size of defect

Ventricular diastolic compliance

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13
Q

ASD Complications

A

Mortality
Atrial arrhythmias
Pulmonary hypertension

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14
Q

Frequency of atrial arrhythmias in patients with ASD

A

10% unoperated will develop by 40 yrs age

20-50% by 55-60 yrs age

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15
Q

How can prevalence of atrial arrhythmias be reduced?

A

Surgery before 40 yo

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16
Q

What affects your risk of atrial arrhythmias after ASD closure?

A

Male
Age>40
Hx of atrial arrhythmias

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17
Q

Factors that increase risk of pHTN in patients with ASD

A

Type of defect
Size of defect
Shunt magnitude
Age

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18
Q

Post-ASD closure factors that increase risk of pHTN

A 
Type of defect
Size of defect
Shunt magnitude
Age at repair
Patient age
PA pressure
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19
Q

ASD Indications for Closure

A

RA and RV dilatation with 1 or more of the following:
ASD minimum diameter >10 mm on echocardiography
Qp:Qs >1.5:1 by echo or CMR flow assessment or from oxygen saturation runs when cardiac catheterisation is performed (for other reasons)

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20
Q

Management of Sinus venosus defect

A

Patch closure

Re-routing pulmonary veins

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21
Q

Management of primum ASD

A

Patch closure

Repair of cleft in AV valves

22
Q

When should surgery be considered for Secundum ASD?

A

Surgery only for the extremely large >38-40mm
Deficient inferior rim
Device interferes with adjacent cardiac structures

23
Q

Which ASD should be considered for percutaneous device closure?

A

Only secundum ASDs <38mm and sufficient rim of 5mm (except towards the aorta)

24
Q

Effects of ASD device closure

A

Right heart will reduce in size

25
Q

Contraindications to ASD Closure

A

PHTN
- Elevated PVR > 8U
Systemic desaturation at rest or exercise
LV diastolic dysfunction with high LA pressure and left sided heart failure
Eisenmenger physiology

26
Q

When is annual clinic follow-up recommended?

A

Watch for PAH, atrial arrhythmias, valvular disease, device complications or residual shunts.

27
Q

How do you calculate ether Qp:Qs ratio with saturation data?

A

Qp:Qs = (systemic artery saturation (SpO2) - mixed venous saturation (SVC/IVC)) / (PV saturation(SpO2) - PA saturation)

28
Q

What causes ASD murmurs?

A

Increased flow over the pulmonary and tricuspid valves

29
Q

Symptomatic presentation in Adults

A

SOBoE or palpitations usually in 30-40s

30
Q

ASD Examination findings

A

RVH
Pulmonary ESM
Fixed splitting of S2 during all respiration phases
Tricuspid diastolic flow murmur (with large defects)

31
Q

ASD CXR findings

A

Normal or mildly increased CTR with prominent pulmonary vascular markings and enlargement of central pulmonary artery

32
Q

ASD ECG Findings

A

RAD; RVH; RSR in right precordial leads with QRS <120ms (incomplete RBBB)
Ostium primum: LAD with RVH

33
Q

After ASD closure at a young age what happens to the right heart?

A 
RV size and function return to normal and patients do well
Improves left heart filling
Improves functional class
Improves exercise capacity
Improves survival
34
Q

Are there restrictions in physical activities in patients after successful ASD closure?

A

No

35
Q

Is pregnancy well tolerated in patients after ASD Closure?

A

Yes, but contraindicated in patients with severe PAH or Eisenmenger

36
Q

What lesions are associated with ASDs?

A

anomalous PV connection
Persistent left SVC
PV stenosis
MVP

37
Q

What syndrome can secundum ASD be associated with?

A

Holt-oram syndrome

38
Q

What is Holt-oram syndrome?

A

AD disorder that affects bones in the arms and hands and often causes heart problems (ASD/VSD, cardiac conduction disease)

39
Q

What does the ASD shunt volume depend on?

A

RV/LV compliance
Defect size
LA/RA pressure

40
Q

What can increase left to right shunt?

A

Reduction in LV compliance or any condition with elevation of LA pressure (HTN, IHD, Cardiomyopathy, AV or MV disease)

41
Q

What can reduce L-R shunt or cause shunt reversal (leading to cyanosis)?

A

Reduced RV compliance (PS, PAH, other RV disease) or TV disease

42
Q

What is the best imaging modality to diagnose sinus venosus defect?

A

TOE

43
Q

What patients should undergo ASD closure?

A

Significant shunt (Signs of RV volume overload) and PVR <5WU should undergo ASD closure REGARDLESS of symptoms

44
Q

What patients should be considered for ASD closure?

A

All patients with suspicion of paradoxical embolism (regardless of size)
Patients with PVR>/= 5 WU but <2/3 SVR or PAP <2/3 systemic pressure (baseline or when challenged with vasodilators, preferably nO or after targeted PAH therapy) and evidence of net L-R shunt (Qp:Qs >1.5)

45
Q

How long should patients be on anti platelet therapy for post-device closure for secundum ASD?

A

6/12 Aspirin 100mg od

46
Q

What is a modified Maze procedure?

A

Surgical AF ablation (laparoscopic or open heart)

They create scar tissue to direct electrical signals through a controlled path

47
Q

Which patients with repaired ASDs do not require regular follow-up?

A

Repaired <25 yo without relevant sequelae or residual shunt, normal PAP, normal RV, no arrhythmias

48
Q

After device closure, how often is follow-up recommended?

A

Regular during first 2 years and then, depending on results, every 2-4 years

49
Q

When is IE prophylaxis recommended?

A

For 6/12 after device closure

50
Q

What different types of percutaneous ASD devices exist?

A

Figulla

Amplatzer

ACHD (8 decks)

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