An Atrial Septal Defect (ASD) is a hole in the wall between the two upper chambers of the heart called atrium.
The condition is present from birth (congenital). Small atrial septal defects may close on their own during infancy or early childhood. Large and long-standing atrial septal defects can damage heart and lungs. Small defects may never cause a problem and may be found incidentally. An adult who has had an undetected atrial septal defect for many years may have a shortened life span from heart failure or high blood pressure that affects the arteries in the lungs (pulmonary hypertension). Surgery may be necessary to repair atrial septal defects to prevent complications.
An atrial septal defect allows freshly oxygenated blood to flow from the left upper chamber of the heart (left atrium) into the right upper chamber of the heart (right atrium). There, it mixes with deoxygenated blood and is pumped to the lungs, even though it’s already refreshed with oxygen.
If the atrial septal defect is large, this extra blood volume can overfill the lungs and overwork the heart. If not treated, the right side of the heart eventually enlarges and weakens. If this process continues, the blood pressure in the lungs increases as well, leading to pulmonary hypertension.
Atrial septal defects can be several types, including:
Many babies born with atrial septal defects don’t have associated signs or symptoms. In adults, signs or symptoms usually begin by age 30, but in some cases signs and symptoms may not occur until decades later.
Atrial septal defect signs and symptoms may include:
Hearing a murmur on a physical exam is the most common reason an atrial septal defect is suspected. Echocardiography is the primary method used to confirm the presence of an atrial septal defect.
Echocardiography can show not only the hole and its size, but also any enlargement of the right atrium and ventricle in response to the extra work they are doing.
An electrocardiogram (EKG) may show evidence of thickening of the heart muscle and a chest X-ray may show enlargement of the heart and increased blood flow to the lungs.
In some children, an ASD may close on its own without treatment. With a small atrial septal defect, the rate of spontaneous closure may be as high as 80 percent in the first 18 months of life. An ASD still present by 3 years of age will probably never close on its own.
Although an atrial septal defect may be closed by open-heart surgery, this approach is not as common as it once was now that transcatheter closure devices are readily available. Should open heart surgery be deemed necessary, the surgeon may be able to directly close the hole with sutures or, depending on the size and shape of the hole, may need to close it with a patch. Surgery is very effective and carries a low risk profile.
Transcatheter Device Closure
Depending on the size and the area of the septum involved, many atrial septal defects may be closed by placement of a device during a cardiac catheterization. This device is inserted through a catheter and covers the ASD by attaching to the atrial septum. A catheter is a long thin tube, about the diameter of a piece of spaghetti, which is directed to the heart through the large blood vessels in the groin.
The benefits of being able to close an atrial septal defect with a transcatheter device is that it can be put in place without stopping the patient’s heart or utilizing cardiopulmonary bypass, it doesn’t have the psychological trauma related to open-heart surgery and it doesn’t create a scarring across the chest the way open-heart surgery does.
Surgical closure of atrial septal defects is complication free in more than 99 percent of cases. Although the Amplatzer device has only been utilized for a decade, its success rate also appears to be very high. After ASD closure in childhood, the heart size returns to normal over a period of four to six months.
Every child is born with an opening between the upper heart chambers. It’s a normal fetal opening that allows blood to detour away from the lungs before birth. After birth, the opening is no longer needed and usually closes or becomes very small within several weeks or months.
Sometimes the opening is larger than normal and doesn’t close after birth. In most children the cause isn’t known. Some children can have other heart defects along with ASD.
Normally, the left side of the heart only pumps blood to the body, and the right side of the heart only pumps blood to the lungs. In a child with ASD, blood can travel across the hole from the left upper heart chamber (left atrium) to the right upper chamber (right atrium) and out into the lung arteries.
If the ASD is large, the extra blood being pumped into the lung arteries makes the heart and lungs work harder and the lung arteries can become gradually damaged.
If the hole is small, it may not cause symptoms or problems. Many healthy adults still have a small leftover opening in the wall between the atria, sometimes called a Patent Foramen Ovale (PFO).
Children with an ASD often have no symptoms. If the opening is small, it won’t cause symptoms because the heart and lungs don’t have to work harder. If the opening is large, the only abnormal finding may be a murmur (noise heard with a stethoscope) and other abnormal heart sounds. In children with a large ASD, the main risk is to the blood vessels in the lungs because more blood than normal is being pumped there. Over time, usually many years, this may cause permanent damage to the lung blood vessels.
If the opening is small, it doesn’t make the heart and lungs work harder. Surgery and other treatments may not be needed. Small ASDs that are discovered in infants often close or narrow on their own. There isn’t any medicine that will make the ASD get smaller or close any faster than it might do naturally.
If the ASD is large, it can be closed with open-heart surgery, or by cardiac catheterization using a device inserted into the opening to plug it. Sometimes, if the ASD is an unusual position within the heart, or if there are other heart defects such as abnormal connections of the veins bringing blood from the lungs back to the heart (pulmonary veins), the ASD can’t be closed with the catheter technique. Then surgery is needed.
Closing a large ASD by open-heart surgery usually is done in early childhood, even in patients with few symptoms, to prevent complications later. Many defects can be sewn closed without using a patch.
The child may not need any special precautions and may be able to participate in normal activities without increased risk. After surgery or catheter closure, the child’s paediatric cardiologist may advise some activity changes for a short time. But after successful healing from surgery or catheter closure, no restrictions are usually needed. Sometimes medicines to prevent blood clots and infection are used for a few months after ASD closure.
Depending on the type of ASD, child’s paediatric cardiologist may examine the child periodically to look for uncommon problems. For a short time after surgery to close an ASD, a paediatric cardiologist must regularly examine the child. The long-term outlook is excellent, and usually no medicines and no additional surgery or catheterization are needed.
Most children with an ASD are not at increased risk for developing endocarditis. Your child’s cardiologist may recommend that your child receive antibiotics before certain dental procedures for a period of time after ASD repair.
A large ASD is usually closed in early childhood, even in patients with few symptoms, to prevent complications later. Some defects were closed with a patch of pericardium (the normal lining outside the heart) or synthetic material such as Dacron. However, many defects that required surgery may have been sewn closed without using a patch. The prognosis after ASD closure during childhood is excellent and late complications are uncommon.
If the opening is small, surgery or other treatments may not be needed. Most large atrial septal defects now can be closed either with open-heart surgery or during a cardiac catheterization using a device inserted into the opening to plug it (referred to as interventional or therapeutic catheterization – PDF). However, if the ASD is in an unusual position within the heart, or if there are other heart defects such as abnormal connections of the veins bringing blood from the lungs back to the heart (pulmonary veins), the ASD cannot be closed with the catheter technique. Then surgery is needed. Even when the defect is discovered in adulthood, patients benefit from closure of large defects.
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