This document discusses the investigation and management of atrial septal defects (ASD). Key points include: ECG, echocardiography, chest x-ray and cardiac catheterization are used to diagnose ASD. Echocardiography can image the interatrial septum from various views and detect flow between the atria with color Doppler. ASDs are often asymptomatic but can cause complications like pulmonary hypertension. Small and moderate ASDs may be treated with percutaneous device closure while larger defects or those with complications may require surgical repair via patch. The take home message is that small ASDs can often be asymptomatic for life while larger defects cause issues in adulthood, and definitive treatment is via device

1. Investigations and
Management

2. Investigations options…..
 ECG
 Chest x-ray
 Echocardiography
 Cardiac catheterization

3. ECG

4. ECG findings……..
 Right axis deviation
 rSr’ or rSR’ in V1
 Predominant s- waves in left
precordial leads(V5- V6)
 Features of arrythmia

5. Echocardiography

8. Echo. Findings…….
 Transthoracic 2D- IAS can be imaged
from apical and subcostal four
chamber view
 Subcostal view is best
 Echo drop out in mid portion for ASD
secundum
 Color doppler imaging shows directly
flow from LA to RA

9. Cardiac catheterization

10. Findings…….
 Now not diagnostic, used for device
closure
 In ASD catheter passes through from
RA to LA
 Small ASD- RA pressure tracing is
normal, oxygen step up more than 10
%
 Large ASD- when RA and LA pressure
tracing same and mean pressure
tracing less than 3 mmHg

11. Continued…..
 When oxygen saturation 15% or more
in RA than SVC or IVC, ASD is
diagnosed
 In absence of ASD , RA oxygen
saturation increase in-
 VSD with TR
 Rupture sinus valsalva aneurysm

12. Chest X-Ray

13. Findings…..
 Normal in small ASD
 Large ASD- cardiomegaly with RA and
RV enlargement
 Lung vascularity increase
 Pulmonary conus full
 In pulmonary hypertension, lungs field
become oligaemic (outer third, pruned
tree like appearance)

14. MANAGEMENT

15. Medical management
 If asymtomatic – no treatment
 If complication developes-
 O2-inhalation
 diuretics
 spironolactone
 ACE inhibitor
 digoxin

16. Interventional procedure
DEVICE CLOSURE
Small and moderate size defect
Closed percutanously through right
heart
Uses different devices
Most recently- Amplatzer device
 anbiotic cover given before procedure
Aspirin and clopidogrel given for 6
month after procedure

17. Continued…..
Must fulfill following criteria-
 ASD less than 40mm diameter,
 clear AV valve and pul.veins and
 rim of atrial septum (<5mm)

18. Continued….
Contraindications…
Ostium primum ASD
Sinus venosus ASD
Anomalous pulmonary venous
drainage
Severe pulmonary HTN

20. SURGICAL CLOSURE
 between age 5 to 10 yrs
To avoid complcation- RV-failure,
arrythmia, pul. HTN
Qp:Qs ratio >2:1
Older pt surgical procedure is still
worthwhile
Surgery by partial sternal split with
minimal skin incision by pericardial or
Teflon patch

22. TAKE HOME MESSAGE……
 Small ASD asymptomatic upto adulthood
 Large ASD symptomatic in adulthood
 Ostium secundum most common variety
 Examination- ESM and wide and fixed
splitting 2nd heart sound
 2-D echo- echo dropout of interatrial
septum with T sign and left to rt color flow
on color doppler
 Percutanous device closure or surgical
patch closure is definitive treatment