Atrial Septal Defect

Question 1

Atrial septal defect presentation

Answer 1

This young woman complains of cough and occasional palpitations. Examine her cardiovascular system.

Question 2

Clinical signs of Atrial septal defect

Answer 2

1. Raised JVP
2. Pulmonary area thrill
3. Auscultation
   - Fixed split-S2 that do not change with respiration.
   - Pulmonary ejection systolic and mid-diastolic flow murmurs with large left-to-right shunts.
   - There is no mumur from the ASD itself.
   * Consider:
4. Pulmonary hypertension:
   - RV heave and loud P2, + cyanosis and clubbing (Eisenmenger’s: right‐to‐left shunt)
5. Congestive cardiac failure

Question 3

Auscultation in ASD

Answer 3

1. Fixed split-second heart sounds that do not change with respiration.
2. Pulmonary ejection systolic and mid-diastolic flow murmurs with large left-to-right shunts.
3. There is no mumur from the ASD itself.

Question 4

Types of Atrial septal defect

Answer 4

1. Primum associated with (Atrioventricular Septal Defect AVSD and cleft mitral valve) seen in Down’s syndrome
2. Secundum (commonest)

Question 5

Complications of Atrial septal defect

Answer 5

1. Paradoxical embolus
2. Atrial arrhythmias
3. RV dilatation

Question 6

Investigation of Atrial septal defect

Answer 6

1. ECG: RBBB + LAD (primum) or + RAD (secundum); atrial fibrillation
2. CXR: small aortic knuckle, pulmonary plethora and double‐heart‐border (enlarged RA)
3. TTE/TOE: site, size and shunt calculation; amenability to closure
4. Right heart catheter shunt calculation (not always necessary)

Question 7

Indications for closure of Atrial septal defect

Answer 7

1. Symptomatic: paradoxical systemic embolism, breathlessness
2. Significant shunt: Qp:Qs>1.5:1, RV dilatation

Qp pulmonary flow, Qs systemic flow

Question 8

Contraindication for closure of Atrial septal defect:

Answer 8

• Severe pulmonary hypertension and Eisenmenger’s syndrome

Question 9

Closure of Atrial septal defect:

Answer 9

1. Percutaneous closure device
   ⚬⚬> Secundum ASD only, no left atrial appendage thrombus or anomalous pulmonary venous drainage, adequate rim to anchor device
2. Surgical patch repair