Atrial Septic Defect

Neeraj Awasthy, Dinesh Singh Bhist
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Clinical Features And Investigations
Clinical Features ?
1. Incidental findings: Many children with ASD are detected on routine examination-- systolic murmur in pulmonary area or wide fixed split of S3.
2. Failure to thrive – may be seen in large ASDs.
3. Dyspnea on exertion may be present after 4 years age.
4. Arrythmias – adults may present with arrythmias.
5. Recurrent LRTI ? may be seen with large ASD.
Physical findings:
Inspection: Precordial buldge and increased precordial activity may be seen.
Palpitation: Parasternal heave s/o RV volume overload, cardiac enlargement, shift of apex to down & out.
Auscultation: Prominent P2 s/o PAH, wide fixed split, ejection systolic murmur in pulmonary area s/o increased flow across PV, middiastolic murmur in tricuspid area s/o under flow across TV.
III. Investigations:
CXR:- cardiomegaly (Right atrial enlargement + Right ventricular enlargement)
RAE ? > extending upto 3 ribs on right parasternal area.
RVE ? Apex down and out
Increased pulmonary vascular markings.

Figure 1 : Chest x ray ap view I a case of ASD showing dilated right atrium and right ventricle with increased blood flow to the pulmonary vascular bed
Chest x ray ap view I a case of ASD showing dilated right atrium and right ventricle with increased blood flow to the pulmonary vascular bed


ECG:
1. Right axis deviation s/o RVE
Lead I ? decreased QRS
Lead aVF ? increased QRS.
LAD seen in ASD primum.
2. RsR' in V1 s/o RV Volume Overload
Pathognomic of RV Volume Overload

Figure 2 : electrocardiogram in a case of ASD showing features of right sided dilatation. Note the presence of partial RBBB and crochette sign.
electrocardiogram in a case of ASD showing features of right sided dilatation. Note the presence of partial RBBB and crochette sign


ECHO:-
Echo is essential modality to delineate the ASD and its types. Diagnosis confirmed on subcostal view.Echo is essential to look at the site of ASD , to looks for the rims of ASD( to ascertain for suitability for the device closure of ASD), to look for associated features of ASD, to look for the evidence of pulmonary artery hypertension. To look for associated anomalies.

Figure 3 : Echocardiography image in subcoastal view showing the fossa ovalis ASD with atrial rim ( marked by arrow) and AV rim ( marked by star)
Echocardiography image in subcoastal view showing the fossa ovalis ASD with atrial rim ( marked by arrow) and AV rim ( marked by star)



Figure 3a: Echocardiography image in subcoastal view showing the fossa ovalis ASD with SVCl rim ( marked by arrow) and deficient IVC rim . Such ASD are not considered suitable for ASD device closure
Figure 3a: Echocardiography image in subcoastal view showing the fossa ovalis ASD with SVCl rim ( marked by arrow) and deficient IVC rim . Such ASD are not considered suitable for ASD device closure



Transesophageal echocardiography (TEE):-
Usually required in adults in view of poor subcostal window and during device closure in children too.

Cath:
Usually required in adults to r/o under PVR & also during device closure.
RA, RV, PA, PV, LV, Ao pressures and saturations are taken pulmonary vascular resistance is calculated as= PA-PV pressure/Pulmonary flow(Qp), and Qp= O2 consumption/Hbx10x(PV-PA SpO2) .PVR upto 8 woods unit non modifiable on O2 are acceped as treatable.
Angiography may be done to rule out any associated CHDs like PAPVC, PV anomaly.

BNP Levels:
May be elevated in CHF / volume overload.

Figure 4 : Flouroscopy image of the case of ASD , undergoing a ASD device closure in LAO carnail View ( 30/30 degree) showing the ASD device ins situ. Also note the prescence of TEE probe ( marked by arrow).
Flouroscopy image of the case of ASD , undergoing a ASD device closure in LAO carnail View ( 30/30 degree) showing the ASD device ins situ. Also note the prescence of TEE probe ( marked by arrow).



References
Atrial Septic Defect Atrial Septic Defect 04/26/2016
<< Atrial Septic Defect - Presentation Management And Natural History of Treated and Untreated ASD >>
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