Atrial Septal Defect (ASD)
What is an Atrial Septal Defect?
An ASD, or Atrial Septal Defect, is a "hole" or "holes" between the Atria, the upper two chambers of the heart. The "hole" or "holes" may be single or multiple. It can be located anywhere along the atrial septum, the wall dividing the two upper chambers of the heart. The defect may be a residual opening from the Foramen Ovale, or a separate hole in the upper portion, mid-portion or lower portion of the septum. Atrial Septal Defects may be associated with other congenital heart defects.
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What do Atrial Septal Defects do?
In the Normal Heart, the wall (septum) between the atria is meant to separate the "blue" or unoxygenated blood from the "red" or oxygenated blood. When a hole exists in this wall mixing of the "blue" and "red" blood occurs. The "red" blood from the high-pressured Left side of the heart flows across the hole in the septum to the low-pressured right side of the heart and mixes with the "blue" blood. This phenomenon occurs because blood will normally only flow from places of high pressure to places of low pressure.
On occasion the Atrial Septal Defect is associated with Partial Anomalous Pulmonary Venous Return, or PAPVR. This type of ASD is known as a Sinus Venosus Defect.
What happens if the Atrial Septal Defect is left untreated?
Because of the "left to right" Shunt of the blood across the Atrial Septum, the right side of the heart now receives blood from two places and has to pump more blood than normal to the lungs. The normal amount of "blue" or deoxygenated blood returning from the body reaches the right atrium. In addition, the "red" or oxygenated blood returning to the heart from the lungs passing into the left atrium and flows left to right through the ASD into the right atrium. The right heart can become overworked with the extra load, and the lungs can become damaged from the extra blood flow. When the lungs become flooded, breathing comes difficult. Children with flooded lungs are at higher risk for lung infections. Children with Atrial Septal Defects often catch many "colds", sometimes several in one month.
When excessive pulmonary blood flow occurs over an extended period of time the lung blood vessels can become very thick and hard. This condition is called Pulmonary Hypertension, and can occur after many years of having an ASD. In this situation, lung damage is usually irreversible and even repairing the defect may not cure the disease.
In most cases children with Atrial Septal Defects show little to no symptoms. Some small ASD’s close with out any treatment at all, although there is no definite way to predict which defects will go on to require a surgical intervention for closure. If left untreated in young girls, there is a higher risk of complications during a pregnancy. This is due to the possibility of a clot forming in the veins of the pelvis or legs and passing from the right, to the left side of the heart causing a stroke.
Should an Atrial Septal Defect be closed?
Decision making in this area is very complex. The Cardiologists and the Cardio-Thoracic Surgeon take many factors into consideration. These factors include the age of the child, the location and the size of the Atrial Septal Defect, the level of lung involvement, the child’s gender, and the severity of the enlargement of the right side of the heart.
Children with Atrial Septal Defects do not commonly show physical signs of heart failure. Therefore diagnosis of the severity of an Atrial Septal Defect may only be accomplished by having an Echocardiogram and/or a Cardiac Catheterization performed on the child for diagnostic purposes. Children who are not showing signs of right-sided heart failure or enlargement may be followed medically by the Cardiologists, allowing time for the septal defect to possibly close spontaneously.
Small ASD’s lend themselves too much controversy on the idea of closure. The decision to repair these small defects would depend largely on the philosophy of the Cardiologists, and the Surgeons.
When should an Atrial Septal Defect be repaired?
Again this decision is a very complex one. Factors such as the age of a patient, the size of the ASD, the gender of the child, the severity of the lung involvement and the degree of right ventricular enlargement all must be considered.
In small Atrial Septal Defects, with little to no lung involvement and a lack of right ventricular enlargement, the idea of closure becomes more of a controversial subject. Most Cardiologists and surgeons would not close these ASD’s if the child were of the male gender. These children would be followed closely by their Cardiologists into adulthood. With females the risk of stroke associate with pregnancies later on in life becomes a strong argument for closure at around 2-3 years of age.
Moderate to Large sized ASD’ may be followed and managed medically until the child is 2-3 years of age, or until clinical signs of right sided heart failure become apparent. If clinical signs of right-sided enlargement or Congestive Heart Failure became apparent, the recommendation to close the ASD would be made. The recommended age of elective closure is usually 2-3 years of age or prior to the child starting school.
How are Atrial Septal Defects Closed?
In order to close an Atrial Septal Defect the child must undergo an "Open Heart Operation". The defect will be closed through an incision in the right atrium.
If the ASD is small the hole may be closed "primarily", or with stitching the sides of the hole together without the use of a patch. When the defect is of moderate to large size, and /or has multiple holes, it is closed with a patch made of a synthetic material or pericardial tissue (the membrane covering the outside of the heart), stitched into the septum covering up the hole or the holes of the defect.
With a Sinus Venosus Defect, as mentioned earlier, where the Atrial Septal Defect is associated with Partial Anomalous Pulmonary Venous Return, the repair is slightly different. This Defect is patched with a portion of the pericardium (the sack around the heart), so that the "red" blood returning to the right atrium through the anomalous pulmonary vein is redirected back to the left atrium and out to the body.
Is the Atrial Septal Defect closure a safe procedure?
No surgery is ever 100% safe, but the closure of an Atrial Septal Defect is a reasonably safe procedure. The patient has to go through an "Open Heart Operation" and the risks are directly related to this procedure. Some of these risks include bleeding requiring a blood transfusion, infection, and of course the risk of death, although it is very low at 1% for ASD closures. Most surgeons will tell you that the risks later on in life for young women will always outweigh the risks of having the Atrial Defect closed.
One of the most commonly seen complications with the closure of an Atrial Septal Defect is a phenomenon known as Post-Pericardiotomy Syndrome. This complication presents approximately 7 days postoperatively. Fluid accumulates in the pericardium, or the sack around the heart. If too much fluid is allowed to accumulate it can put pressure on the heart causing it to be unable to function properly. If this occurs, it can be a life or death situation for the child. Nobody really understands why this phenomenon occurs more frequently with Atrial Septal Defect repairs, but most cardiologists and surgeons take its chance of occurrence very seriously. All Atrial Septal Defects are kept in the hospital for at least 5 days post-operatively so that an Echocardiogram can be done prior to discharge to check for fluid around the heart. This will be checked again at the follow-up visit with the Cardiologist several days after discharge from the hospital.
Will my child be "normal" after the closure of an Atrial Septal Defect?
Fortunately most children do very well, and most are leading normal lifestyles with no restrictions. For 5-6 weeks post-op there will be some mild physical limitations on the child. Most will not be cleared to return to school for at least two weeks after the operation. The surgeon and the cardiologists will closely monitor the child for a few months after the surgery. Some children may have to be on antibiotics to decrease the risk of infections that may spread to the heart before some minor operations, and/or having their teeth worked on. Other than these minor restrictions, children who have their ASD’s repaired and who have not other illness’ live normal healthy lives.
Contact Information:
John Mark Morales MD, FACS, FAAP
Chief of Cardiothoracic, Director of Perfusion Services
Certified by the American Board of Surgery, American Board of Thoracic SurgeryMark Bielefeld, MD
Driscoll Children's Hospital Chief of Staff
Certified by the American Board of Surgery, American Board of Thoracic SurgeryThoracic surgeons are available for questions and consultations: (361) 854-0201. For appointments, assistance, and physician references in Corpus Christi call: (361) 854-0201 or 800-DCH-LOVE
Fax : 361-855-7572
E-MAIL : jmarkmorales@aol.com
For further information on any surgical procedures you can contact Carol Kaplan, RN, Surgical Nurse Liaison at (361) 694-5150. Consultation and surgery for inpatients is provided in concert with neonatology and pediatric cardiology departments. Complete evaluation and management for infants, children, adolescents and adults with congenital or acquired cardiac, vascular or thoracic anomalies.
Cardiothoracic Associates
3533 S. Alameda, Suite 202
Corpus Christi, Texas 78411
Phone: (361) 694-5150
Fax: (361) 855-7572
Hours: 9am to 6pm
Fri 9am to 5pm
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Corpus Christi, Texas
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