RT Book, Section
A1 Higgins, John P.
A1 Ali, Asif
A1 Filsoof, David M.
SR Print(0)
ID 1173757741
T1 Congenital Heart Diseases
T2 Cardiology Clinical Questions, 2e
YR 2016
FD 2016
PB McGraw-Hill Education
PP New York, NY
SN 9781259643330
LK accesscardiology.mhmedical.com/content.aspx?aid=1173757741
RD 2024/04/18
AB Table  Graphic  Jump  Location|Download  (.pdf)|PrintThe  decision  to  close  an  atrial  septal  defect  (ASD)  is  based  upon  the  size,  location,  degree  of  shunting  and  RV  function.HPI:  May  be  asymptomatic.  Dyspnea,  exercise  intolerance,  palpitations.PMH:  Arrhythmias,  pulmonary  hypertension,  stoke,  thromboembolism,  congestive  heart  failure  (CHF).FH:  Family  History  of  congenital  heart  disease.May  have  a  normal  examination.  Prominent  right  ventricular  (RV)  impulse,  wide  fixed  splitting  of  S2,  midsystolic  pulmonary  ejection  murmur.Prolonged  PR  interval.Secundum  ASD  =  Right  axis  deviation  +  right  atrial  enlargement  +  incomplete  right  bundle  branch  block  (IRBBB).Primum  ASD  =  Left  axis  deviation  +  IRBBB.Chest  x-ray:  RV  and  RA  enlargement;  prominent  pulmonary  artery;  increased  pulmonary  vascularity.Echocardiogram:  Direct  visualization  of  ASD  or  shunting  (especially  with  agitated  saline  study),  dilation  of  the  right  atrium/ventricle,  elevated  pulmonary  pressure,  Qp/Qs  (pulmonary  to  systemic  ratio)  to  quantitate  shunt.SYM  =  SYMptomatic  ASD  =  Dyspnea  on  exertion,  fatigue,  palpitations,  evidence  of  atrial  arrhythmias,  orthodeoxia-platypnea.ASYM  =  ASYMptomatic  ASD  (small  shunt  and  normal  RV  size).SIG-SHUNT  =  Significant  left-to-right  shunt  (usually  caught  on  echo),  Qp:Qs  >1.5.STR-CHANGE  =  Evidence  of  STRuctural  CHANGEs  in  the  heart  such  as  elevated  pulmonary  pressure,  right  atrial  or  right  ventricular  enlargement  or  hypertrophy.PxE  =  History  of  a  paradoxical  embolic  event.CLOSURE  =  CLOSURE  of  ASD.  Can  be  performed  percutaneously  or  surgically  depending  on  size  and  location  of  ASD.FOLLOW  =  Clinical  follow-up  and  echocardiogram  every  2–3  years  or  sooner  if  symptoms  develop.END-STAGE  =  The  clinical  picture  from  an  uncorrected  significant  ASD  over  time.  May  have  severe  irreversible  pulmonary  hypertension  or  Eisenmenger  physiology.  Mortality  is  not  improved  with  closure  at  this  point.  Prognosis  is  poor  (pulmonary  artery  pressure  >2/3  systemic  pressure,  pulmonary  vascular  resistance  >2/3  systemic  vascular  resistance).MED-TX  =  Medical  management.  There  is  no  medicine  to  correct  the  anatomical  defect.  Can  give  medicines  to  alleviate  right  heart  failure  and  pulmonary  hypertension.PE  =Paradoxical  Embolism.OP=Orthodeoxia  Platypnea.PAP  <  2/3  SBP  =  Pulmonary  artery  pressure  less  than  two  thirds  systemic  levels.PVR  <  2/3  SVR  =  Pulmonary  vascular  resistance  less  than  two  thirds  systemic  vascular  resistance.SYM  +  (NO  END-STAGE)  =  CLOSUREASYM  +  SIG-SHUNT  =  CLOSUREASYM  +  STR-CHANGE  =  CLOSUREASYM  +  PxE  =  CLOSUREASYM  +  (NO  SIG-SHUNT)  +  (NO  STR-CHANGE)  =  FOLLOWEND-STAGE  =  MED-TXPE  =  ClosureOP  =  ClosurePVR  <  2/3  SVR  =  ClosurePAP<  2/3  SVR  =  ClosureMost  patients  with  ASD  are  asymptomatic  for  decades  and  have  a  relatively  normal  physical  examination  making  ASD  the  most  common  adult  uncorrected  congenital  anomaly.  The  natural  history  for  an  ASD  with  a  significant  shunt  is  to  develop  pulmonary  hypertension  and  right  heart  remodeling  from  pulmonary  vascular  overload.  The  mortality  once  severe  pulmonary  hypertension  has  developed  is  high.  Closure  of  ASD  has  a  very  low  incidence  of  morbidity  and  mortality  from  the  procedure  itself  and  can  be  done  percutaneously  or  surgically.  The  goal  is  to  close  significant  ASDs  early  before  complications  develop.  Very  small  ASDs  without  significant  shunting  rarely  become  clinically  significant  and  oftentimes  close  spontaneously.  Atrial  arrhythmias  should  be  treated  to  restore  and  maintain  sinus  rhythm  if  possible.Closure  is  not  recommended  in  patients  with  severe  irreversible  pulmonary  artery  hypertension  and  no  evidence  of  left-to-right  shunt.–  Most  patients  with  ASD  will  be  asymptomatic  for  decades.–  Mortality  is  ...