Atrial Septal Defect

Physical Examination

• General examination:

  • Signs of heart failure (e.g., peripheral edema, elevated jugular venous pressure)

  • Cyanosis (in cases with right-to-left shunt)

  • Clubbing (if associated with cyanotic heart disease)

  • Evidence of underlying syndromes (e.g., Down syndrome)

  • Features of stroke (paradoxical embolus)

• Palpation:

  • Parasternal heave (indicating right ventricular hypertrophy)

• Auscultation:

  • Soft ejection systolic murmur at upper left sternal edge (increased pulmonary blood flow)

  • Pansystolic murmur at tricuspid area (secondary to RV overload)

  • Wide fixed split second heart sound (delayed closure of pulmonary valve)

  • Mid-diastolic rumble at left lower sternal edge (increased flow across tricuspid valve)

• Additional examination:

  • Hepatomegaly (right-sided heart failure)

Investigations

• Laboratory tests:

  • Complete blood count (anemia, infection)

  • Blood gas analysis (hypoxia, acidosis)

  • B-type natriuretic peptide (BNP, heart failure)

• ECG

  • Right axis deviation, incomplete right bundle branch block, right ventricular hypertrophy, P-pulmonale)

• Imaging:

  • Chest X-ray (cardiomegaly, increased pulmonary vascular markings)

  • Echocardiography (confirm diagnosis, assess shunt severity, related complications)

  • Cardiac MRI (evaluate cardiac anatomy, function)

• Invasive tests:

  • Cardiac catheterization (hemodynamic assessment, shunt quantification)

  • Electrophysiology study (if arrhythmias suspected)

Management

• General management:

  • Treat other conditions (e.g., infection)

  • Monitor growth and development

  • Oxygen therapy (if hypoxia)

• Medical management:

  • Diuretics (heart failure)

  • Anticoagulation (if atrial arrhythmias or paradoxical emboli)

• Surgical management:

  • Percutaneous device closure (minimally invasive)

  • Surgical repair (open-heart surgery, if device closure not feasible)

• Other management:

  • Genetic counseling (for families with history of congenital heart disease)

  • Regular follow-ups (assessing growth, development, heart function)

Types of ASD

1. Ostium secundum ASD: most common type (75%)

2. Ostium primum ASD

3. Sinus venosus ASD

4. Coronary sinus ASD

Indications for Surgery

The decision to repair any kind of ASD is based on clinical and echocardiographic information including the size and location of the ASD, the magnitude and hemodynamic impact of the left to right shunt and the presence and degree of pulmonary arterial hypertension.

• All ASDs with evidence of right ventricular overload

• Clinically significant shunt (pulmonary flow [Qp] to systemic flow [Qs] ratio > 1.5