Atrial Septic Defect

Neeraj Awasthy, Dinesh Singh Bhist
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Management And Natural History of Treated and Untreated ASD
TREATMENT:
Medial:
Antifailure treatment in the form of diuretics are very rarely required.These may be given if theer is evidence of congestive heart failure. Antiamythics may be given in adults > 40 years if there are associated arrhythmias.IE prophylaxis is not recommended.

Spontaneous closure.
Is seen in ASD < 4mm before 4 years of life.

Surgical closure:-
Indications:
If device closure not possible because of deficient rims then only surgical closure is recommended.

Ideal age of closure: (IAP guidelines)
I. In asymptomatic child (2-4years) class I (for SV ASD surgery may be delayed 4-5 years class IIa).
II. II. Symptomatic ASD in infancy (CHF, severe PAH) seen in 10% cases. Rule out TAPVC, APW, LVOTO- early closure is recommended (class I)).
III. If presenting beyond ideal age ; elective closure irrespective of age as long as there is RV overload and PVR is in operable range (class I).
DEVICE CLOSURE:
ASD occluders are available upto 40mm for device closure.
Atrial, aortic, SVC and IVC rims should be at least 5mm so that the device can sit properly.
The device is made of nitinol wire (nickel & titanium) and Dacron meshwork embedded on it.
The device is advanced under fluoroscopic guidance from IVC ? RA ? ASD ? LA and released across the IAS with the delivery catheter under TEE guidance.



Complication:
1. Device embolisation may occur in to RA, RV / PV if it does not sit properly or if rims are not good. In that case it may be snared back under flouro. Usually surgery is required, so CTVS background is must.
2. Very rarely 1; 1000 it may erode into aortic root.

Surgical closure:
Dacron patch closure of ASD is done under CPB with good results.

Complications:
1. General complications of surgery and CPB.
2. Residual shunt.
Longterm complications (Natural history)
Mean age to death = 37.5 + 4.5 years, 75% die by 50 years, 90% die by 60 years of age.
Spontaneous closure (mean follow up of 14 months).
<3mm – generally all close.
3 to 5mm – 87% close
5 to 8mm 80% close
>8mm – generally none

Pulmonary vascular obstructive disease develops in patients with large left to right shunt. In young adult there is 14% chance of developing PAH.
Arrhythmias – atrial flutter and fibrillation develops in 1% cases < 40 years of age, 40 to 60 years 15% develops arrhythmias, >60 years 61% develops arrhythmias.


References
Atrial Septic Defect Atrial Septic Defect 04/26/2016
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