This document discusses the management of atrial septal defects (ASDs). It covers the history, clinical presentation, diagnosis, and treatment options for ASDs. There are generally three treatment options - watchful waiting for small defects, catheter device closure, or open heart surgical closure. Device closure has largely replaced surgery as it has similar success rates but lower risks of complications. Surgery is usually reserved for defects that are too large for devices or have complex anatomical features making device closure difficult.

1. MANAGEMENT OF ATRIAL SEPTAL DEFECT
BY DR NIKUNJ
(CTS RESIDENT STAR HOSPITAL)
(Coordinator:DR P.SATYENDRANATH PATHURI)
(26/3/19)

2. INTRODUCTION
• ASD is an acyanotic CHD characterized by defect in the interatrial septum causing a left to
right flow between the atria
• ASD constitutes 8-10% of congenital heart defects in children.
• female: male ratio for secundum ASD = 3:1 For sinus venosus ASD= 1:1

3. HISTORICAL CONSIDERATIONS
• The earliest closed approaches included a technique in which a straight needle with suture,
guided by palpation, was passed blindly through the defect and both atria, and the free walls
of the left and right atria were drawn together to obstruct the defect.
• Bailey and colleagues described the “atrio-septo-pexy” consisting of a digital invagination of
the atrial appendage through the defect with external suture attachment of the atrial tissue
to the perimeter of the defect (Fig. 114-1A).

4. • Tyge Søndergaard devised a purse-string external suture closure of ASD by a near
circumferential dissection around the defect in the plane of the interatrial groove and a
plication of its edges (see Fig. 114-1B).

5. • Semiopen techniques used before cardiopulmonary bypass became common practice
included the “atrial well” technique, where a right atriotomy was formed, controlled by
partial atrial clamping. A 15-cm tall, openended rubber cone was then attached to the
atriotomy to produce an open column of blood in continuity with the beating heart. Working
through the atrial well by palpation, the defect was closed by direct suture or patch. Regional
intermittent heparinization prevented blood clotting within the well (see Fig. 114-1C).
• Lewis and Taufic reported the first successful openheart ASD closure under direct
visualization, using surface cooling and circulatory arrest by inflow occlusion in 1953.

6. • The modern era of cardiac surgery was heralded by the introduction of the pump oxygenator
in 1953, and the earliest application of this technology was for ASD closure.

7. CLINICAL PRESENTATION
• A great majority of ASDs are asymptomatic, and palpitations, atrial fibrillation, and
congestive failure are late sequelae, uncommon in patients younger than 40 years of age.
• Occasional dyspnea on extreme exertion is observed even in children.
• Recurrent respiratory infection in the presence of a large ASD is not uncommon.
• In rare cases, ASDs may be associated with cyanosis.

8. DIAGNOSTICS AND EXAMINATION
• A prominent right ventricle impulse is present, with a precordial right ventricular lift, leftward
displacement of the apex, and possible left chest wall prominence.
• AUSCULTATORY FINDINGS include a systolic flow murmur heard over the left upper sternal
border from elevated flow across the pulmonary valve, a split S2, fixed throughout the
respiratory cycle, with a prominent pulmonary valve component.
• An apical mid-diastolic murmur, especially at inspiration, reflects increased flow across the
tricuspid valve.

9. • The right atrium and right ventricle are large.
• pulmonary vascular markings are increased, or plethoric
• Patients with heart failure may have interstitial pulmonary edema and areas of pulmonary consolidation
and atelectasis.
THE CHEST X-RAY demonstrates cardiomegaly

10. • The ELECTROCARDIOGRAM in ASD shows right ventricular hypertrophy, lengthened PR
interval, incomplete right bundle branch block, and an RSR pattern in V1.
• Electrocardiographic criteria for right ventricular enlargement are found in more than 50% of
young patients with a large ASD.
• A traditional teaching is that the secundum ASD is associated with right-axis deviation and
incomplete right bundle branch block (rSR’ pattern in right precordial leads),
• whereas the primum defect exhibits left-axis deviation with incomplete right bundle branch
block.

11. • CARDIAC CATHETERIZATION is similarly seldom used in the diagnosis of ASD, but, when
performed, an SVC to right atrium O2 saturation step-up is reflective of the left-to- right
shunting at the atrial level.
• A pressure gradient, usually less than 25 mm Hg at peak, may be detected across the
pulmonary valve that is physiologic, reflecting the elevated pulmonary blood flow.
• ECHOCARDIOGRAPHY is the most common mode of diagnosis, capable of acquiring
sufficient morphologic and physiologic data to obviate the need for catheterization in a great
majority of cases.
• TRANSTHORACIC ECHOCARDIOGRAPHY WITH COLOR DOPPLER flow mapping is
accepted as the most accurate modality of ASD diagnosis

13. • Small defects and defects in obscure locations, such as coronary sinus defects and some sinus
venosus defects, may remain difficult to image by echocardiogram.
• High-resolution COMPUTED TOMOGRAPHY (CT) and CARDIAC MAGNETIC
RESONANCE IMAGING (MRI) have been used to image some interatrial defects that have
eluded adequate echocardiographic characterization.
• MRI is particularly useful in imaging partial anomalous pulmonary venous structures that
may lie adjacent to the airways and lung, where air interface interferes with the
echocardiographic image resolution

14. Three-dimensional cardiac magnetic resonance image of a heart (posterior view),
showing right upper pulmo- nary veins anomalously entering the superior vena cava
(SVC), cephalad to the atriocaval junction in a patient with superior sinus venosus atrial
septal defect. (Courtesy David Parra, MD, Vanderbilt Children’s Heart Institute.)

15. PATENT FORAMEN OVALE MANAGEMENT
• presently insufficient data to support the medical, surgical, or device treatment of
the incidentally diagnosed, hemodynamically insignificant PFO.
• Adverse events attributed to the presence of a PFO or associated ASA include
• EMBOLIC STROKE OR PERIPHERAL EMBOLUS,
• BRAIN ABSCESS,
• GAS EMBOLIZATION IN DIVER’S DECOMPRESSION ILLNESS
• MIGRAINE HEADACHE
• Indications for PFO closure in these settings are also controversia

16. PATENT FORAMEN OVALE AND STROKE
• The associations of PFO with stroke are complicated, age dependent
• An association between PFO and cryptogenic stroke is accepted in the younger
population, an age group for whom stroke is rare in general.
• An association between cryptogenic stroke and the presence of PFO is strong for
patients younger than 55 years of age, and the association is even stronger if ASA, with
or without PFO, is present

17. PATENT FORAMEN OVALE AND STROKE
• Generally accepted practice guidelines suggest a treatment strategy
as follows:
• 1. Aspirin alone for any asymptomatic patients with PFO or ASA.
Risk of stroke in this population is 1%/yr or less.
• 2. Coumadin for patients with PFO and a hypercoagulable state,
history of stroke, transient ischemic attack (TIA) or deep vein
thrombosis (DVT) pre- ceding stroke. PFO closure for this population
may be indicated.
• 3. PFO closure for patients younger than 60 years old who have
suffered cryptogenic stroke if the PFO is associated with ASA (4%/yr
risk of stroke, even on aspirin)

18. PATENT FORAMEN OVALE AND MIGRAINE
• Although PFO may be present in more migraine sufferers than in the general
population, especially for those with migraine accompanied by an aura, a clear
association is not well established.
• Migraine cure or improvement has been reported in many patients
undergoing closure of PFO, but the association of PFO closure and migraine
improvement may be affected by placebo effect

19. PATENT FORAMEN OVALE AND DIVER’S DECOMPRESSION ILLNESS
• Bubbles in the left heart are documented by echocardiogram to demonstrate
diver’s decompression illness in association with PFO.
• Underwater pressure and its effects on ventilation elevate the pulmonary
resistance, reducing left ventricular preload while increasing right-sided
pressures, and favoring right-to-left shunting across the PFO.
• The overall risk of diver’s decompression illness with PFO is low, with 5 events
per 10,000 divers
Billinger M, Zbinden R, Mordasini R, et al: Patent foramen ovale closure in recreational divers: effect on decompression illness and ischaemic
brain lesions during long-term follow-up. Heart 97(23):
1932–1937, 2011

20. MANAGEMENT OF ATRIAL SEPTAL DEFECT
• Elective closure of ASD is generally recommended when the ratio of pulmonary to
systemic blood flow (Qp : Qs) is 1.5:1 or greater.
• Ideally, ASD closure should be performed at age 2 to 5 years, before exercise
capacity changes, while chest wall compliance is optimal, and before school age

21. INDICATIONS
FOR ATRIAL SEPTAL DEFECT CLOSURE
• A small hemodynamically insignificant ASD, without cardiomegaly, does not
warrant closure
• An echo diagnosis of a significant defect with right ventricular volume overload is
common and is a sufficient indication to close an ASD
• severe pulmonary hypertension, a fenestrated ASD closure may be successfully
performed

22. CONTRAINDICATIONS FOR ATRIAL SEPTAL DEFECT CLOSURE
• Pregnancy is a relative contraindication to closure, with closure safely delayed
until after delivery.
• Severe left ventricular failure is a contraindication to ASD closure.
• Advanced pulmonary hypertension is a contraindication to ASD closure.

23. CATHETER-BASED TREATMENT
• King and Mills reported the first catheter-delivered ASD closure in 1976
• 1983, Rashkind introduced a self-expanding patch device that attached to the
septum with small barbed hooks
• Lock Clamshell device a double disc, self-expanding device that could be delivered
through an 11 Fr delivery sheath. First reported in 1990
• the two devices currently approved by the Food and Drug Administration (FDA) in
the United States are
• THE AMPLATZER SEPTAL OCCLUDER (ST. JUDE MEDICAL, ST. PAUL, MN)
• THE HELEX SEPTAL OCCLUDER (GORE & ASSOCIATES, FLAGSTAFF, AZ)

24. CATHETER-BASED TREATMENT
• Most ASDs today are closed by catheter-based devices. The Amplatzer and Helex
occluders are the most commonly used approved devices at this time.
• The success rate and morbidity are almost equal when comparing device closure
with surgical closure.
• Current published studies comparing the two approaches with anatomically similar
defects show a device success rate of 80% to 95.7% and a surgical closure success
rate of 95% to 100%
• Complications requiring treatment (defined to include anemia, arrhyth- mia
requiring minor treatment, post pericardotomy syndrome, pericardiaal or pleural
effusion, transfusion, fever, wound complication) occur in up to 8% of device clo-
sures and 23% to 24% of surgical closures, and mean length of hospital stay is 1
day in the device group versus 3.4 days in the surgical group.
Du ZD, Hijazi ZM, Kleinman CS, et al: Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and
adults: results of a multicenter nonrandomized trial. J Am Coll Cardiol 39(11):1836–1844, 2002.
Cowley CG, Lloyd TR, Bove EL, et al: Comparison of results of closure of secundum atrial septal defect by surgery versus Amp- latzer septal
occluder. Am J Cardiol 88(5):589–591, 2001.

29. ANATOMIC DETERMINANTS THAT PROHIBIT DEVICE CLOSURE
• failed attempted device closure,
• common atria or those without sufficient septal rim to engage the
device
• sinus venosus defects for which device closure would threaten
obstruction of pulmonary veins, IVC, or SVC.
• Anterior-inferior septal deficiency can result in device interference
with the tricuspid valve, mitral valve, or coronary sinus.
• The largest Amplatzer septal occlusion device presently available in
the United States is 38 mm, and defects exceeding this size require
surgical closure.
• Multiple defects can be closed with multiple devices, although the
cost of multiple device closures may exceed the cost of surgery.

30. COMPLICATION
• EARLY MAJOR PROCEDURAL COMPLICATIONS
• device embolization; cardiac tamponade; stroke or TIA;
• retroperitoneal hematoma;
• thrombosis;
• device erosion;
• obstruction of the IVC, coronary sinus, or pulmonary vein
• tricuspid or mitral insufficiency.
• NON- CARDIAC COMPLICATIONS include iliac vein dissection, retroperitoneal or
groin hematoma, and leg ischemia.
• MINOR COMPLICATIONS include minor vascular complications, arrhythmia,
percutaneously retrieved device embolization, pericardial effusion, device
malposition not requiring surgery, and pulmonary edema.
• LATE COMPLICATIONS include device- related death, cerebrovascular events,
device thrombosis or malposition, embolization, erosion, aortoatrial fistula,
arrhythmia, device fracture, pericardial effusion, endo- carditis, and nickel toxicity

32. • 20-year outcome comparison of device versus surgical treatment of comparable
ASDs shows no significant differences in survival, functional capacity, arrhyth- mia,
or late embolic stroke between methods of closure, supporting a transcatheter
approach for defects amenable to device closure
Kutty S, Hazeem AA, Brown K, et al: Long-term (5-to 20-year) outcomes after transcatheter or surgical treatment of hemody-
namically significant isolated secundum atrial septal defect. Am J Cardiol 109(9):1348–1352, 2012.

33. SURGICAL TREATMENT
• SECUNDUM ATRIAL SEPTAL DEFECT AND PATENT FORAMEN OVALE
• The standard surgical incision for the repair of ASD is partial or complete
median sternotomy.

35. SINUS VENOSUS ATRIAL SEPTAL DEFECT WITH PARTIAL ANOMALOUS
PULMONARY VENOUS RETURN
• The most common variant of sinus venosus ASD is the superior, when the right
upper pulmonary vein drains anomalously to the right atrium or SVC.
• A single intra atrial patch can be positioned to baffle the pulmonary vein through
the septal defect into the left atrium in many cases.
• Care is exercised to place the SVC incision remote from the sinoatrial node.
• The single-patch technique may predispose to SVC narrowing, as the baffle
occupies space within the SVC lumen.
• A two-patch approach enlarges the SVC to accommodate the baffle.

36. • When one or more pulmonary veins connect to the SVC too cephalad to
permit simple baffling, an adjunctive patch plasty of the lateral SVC must be
carried out
• Anticipating such geometry, an atriotomy can be planned at the lateral base
of the SVC, so that septal and caval patch plasties can be placed through a
single atriotomy, extended as far as necessary onto the SVC (Fig. 114-6). ASD
enlargement may also be needed to ensure an unobstructed baffle.

38. • The Warden procedure, described in 1984,97 consists of transection of the SVC
cephalad to the connection of
• the anomalous pulmonary vein, thereby committing the atriocaval junction to
pulmonary venous blood flow exclusively.
• An intra-atrial patch baffles the atriocaval junction to the left atrium, through a
preexistent or created ASD.
• The transected SVC is then reimplanted into the right atrial appendage by direct
anastomosis (Fig. 114-7).
• A tensionless SVC anastomosis is imperative to the success of the SVC
reimplantation, and patch augmentation is sometimes necessary.
• Special care must be taken to resect all trabecular muscle in the atrial append- age
that might impair SVC flow through the reimplantation site.

40. PRIMUM ATRIAL SEPTAL DEFECT
• Characterized by the absence of any septal tissue between the AV valves, the
primum ASD closure requires that the patch be sutured directly to mitral or
tricuspid tissue, avoiding the subjacent ventricular septum and the His bundle, and
sometimes leaving the coronary sinus on the left atrial side to avoid the AV node.
• An examination of the mitral valve and closure of the associated cleft is indicated,
even in the absence of mitral regurgitation.
• Care is taken to avoid creating mitral stenosis.

41. MINIMALLY INVASIVE APPROACHES
• Various alternatives to the median sternotomy have been described for the repair
of ASD.
• An inframammary or axillary incision with thoracotomy provides exposure of the
right atrium with a scar that is more easily concealed than the full median
sternotomy.
• The subxiphoid “ministernotomy” or partial lower sternotomy can be performed
through small vertical or transverse inframammary incisions, and cannulation
through the incision rather than peripherally.
• Experience continues to expand with methods that use even smaller incisions,
femoral cannulation, and video or robotic assistance

44. COMPLICATIONS OF SURGERY
• Early complications following the surgical closure of ASD include
• patch dehiscence,
• thromboembolism, and
• arrhythmia such as heart block, sinus node dysfunction, and atrial fibrillation or
flutter.
• The incidence of residual shunt after surgical closure is negligibly small.

45. THANK YOU