A "hole" in the wall that separates the top two chambers of the heart. This defect allows oxygen-rich blood to leak into the oxygen-poor blood chambers in the heart. ASD is a defect in the septum between the heart's two upper chambers (atria). The septum is a wall that separates the heart's left and right sides

1. ATRIAL SEPTAL DEFECT
3RD MOST COMMON CHD

2. TIME RUNNING OUT FOR RAREST PRIMATE
RESCUE BID LAUNCHED TO SAVE HAINAN GIBBON FROM
BECOMING FIRST APE DRIVEN TO EXTINCTION BY HUMANS
Human runs so much
behind his
achievement, Neither
he is accountable nor
has time to see what
car wheel has
crushed

3. INCIDENCE
• 56 per 100 000 livebirths
• 100 per 100 000 livebirths by Echocardiograghy
• 65—70% :II ASD
• 50% of primum ASD and 40—50% SV ASD are seen in female.

4. CAUSES/ASSOCIATION
• Familial clustering:autosomal dominant
• Mutations in the cardiac transcription factor gene NKX2-5,GATA4 and TBX5 and MYH6
[14q12]
• AV block: NKX2-5
• Fetal alcohol syndrome
• Cigarette consumption
• Antidepressants
• Diabetes
• Maternal age ≥35 years

5. SYNDROME ASSOCIATION
• Holt-Oram:60% cases have ASD
• Ellis van Creveld
• Noonan
• Down:42% have primum and secundum ASD
• Budd-Chiari
• Jarcho-Levine

6. DEVELOPMENT
• Atrial septation is derived from septum primum, septum secundum, septum spurium and the atrioventricular canal
septum
• At 28 days after gestation, septum primum (Sep 1°)—the first septum to appear in the developing atria—develops
as a crescent-shaped structure. Its leading edge is covered by a layer of mesenchymal cells called mesenchymal cap.
The space between the developing septum primum and the developing endocardial cushions is called foramen primum
or ostium primum. Septum secundum (Sep 2°; limbus of the fossa ovalis) is a crescent-shaped muscular infolding of the
atria wall that appears shortly thereafter to the right of septum primum
• At 35 days, both septum primum and septum secundum continue to develop. The openings within septum
primum are called foramina secondi
• At 60 days, the atrial septum is nearly fully formed and the foramina secundi close by way of coalescing
fenestrations within septum primum. The foramen ovale remains patent throughout pregnancy

7. CONTD……
Normal development of the atrial septum results in formation of the fossa
ovalis, which includes two anatomical elements: first, muscular boundaries
contributed by septum secundum; and second, the valve of the fossa
ovalis, which attaches on the left atrial aspect of septum secundum—septum
primum. The atrial component of the atrioventricular canal septum lies anterior
and inferior to the fossa ovalis, separating it from the tricuspid and mitral valve
annuli—the atrioventricular canal septum. The tissue that separates the right
pulmonary veins from the superior vena cava and from the posterior and
inferior aspects of the right atrial free wall is termed sinus venosus. The tissue
that separates the coronary sinus from the left atrium is termed coronary sinus
septum

8. ANATOMY
• PFO:All new born;25-30% adult
• II ASD:Most common after PFO
• PRIMUM ASD:A cleft in the AML and conduction abnormality
• SV ASD:4—11% of all ASD;80-85% at SVC and RUPV junction
• CS ASD:Raghib’ syndrome
• COMMON ATRIUM: Heterotaxy syndrome
• COMPLEX ASD

9. PATHOPHYSIOLOGY
• Left-to-right shunt
• The direction and shunt : Size of the defect and by the relative atrial pressures and
compliances of the left and right ventricles
• Size and the compliances of the ventricles can change over time
• At birth: A transit from high PVRI and low RV compliance to a high compliance
and low resistance
• Shunt works : late ventricular systole,early diastole, increasing during atrial
contraction and expiration
•

10. • Small defects
• Most defects smaller than 10 mm and shunt <1.5
• Larger defects
• changes in the myocardium and in the pulmonary vasculature
• Initially volume overload and later pressure overload on the right heart
• Decreased left ventricular diastolic filling
• Increased pulmonary-to-systemic flow ratio through the defect, and diminished systemic output
• Left ventricular systolic dysfunction develop late in patients with a large atrial septal defect
• Decrease left-to-right flow : valve or vessel stenosis and PVOD

11. NATURAL HISTORY
• Defect size
• Clinical presentation
• Exercise capacity
• Pulmonary hypertension
• Arrhythmia
• Life expectancy

12. DEFECT SIZE
• Anatomical type, size, and patient-specific factors
• SV and primum defects : significant shunt, do not decrease in size, and usually need surgical
closure
• Secundum defects vary widely
• Spontaneous closure occurs frequently in young patients with small defects
• Secundum defect can increase or decrease with age
• 70% of initially small (≤4 mm) defects decrease in size, 12% remain unchanged, and 18%
increase
• defect size greater than 8—12 mm, only 9% decreased in size, 15% remain unchanged, and
76% increased

13. PRESENTATION
• Most asymptomatic in childhood
• Large also lies until adulthood
• Incidental
• Adult + large
• Fatigue, exercise intolerance, palpitations, syncope, shortness of breath,
peripheral oedema, manifestations of thromboembolism, and cyanosis.

14. EXERCISE ABILITY
• Exercise intolerance is uncommon in young children
• Pulmonary function is often impaired in this age
• The frequency of exercise intolerance increases insidiously with age
• Exercise capacity and peak oxygen consumption are decreased in
most adults with unrepaired Secundum defect, often at 50—60% of
predicted values in healthy controls

15. PAH
• Uncommon in children
• PAH increase with age
• High altitude
• Eisenmenger syndrome: 5—10%
• Female-to-male ratio 3

16. ARRYTHMIA
• Uncommon in children
• Most common :atrial flutter and fibrillation
• >20% have by age > 40 yrs
• AV block occassional

17. LIFE EXPECTANCY
Campbell reported a low annualised mortality rate in the first two
decades of life (0·6% and 0·7% per year, respectively), increasing to
4·5% per year in the fourth decade and 7·5% per year in the sixth
decade

18. DIAGNOSIS
• ECHO
• CT/MRI for complex anatomy or doubtful PV venous
drainage/obstruction
• Cardiac catherization for PVRI in doubtful cases

19. CLOSURE OF ASD
• Indications
• Contraindication
• Timing of defect closure
• Strategies :Surgery and Transcathetor closure
• Clinical and haemodynamic results of defect closure

20. INDICATION
• American and European practice guidelines86, 87 state that an atrial
septal defect can be closed if the pulmonary vascular resistance is
lower than two-thirds of the systemic vascular resistance (at baseline
or after pulmonary vasodilator acute challenge or targeted
pretreatment course) and there is evidence of a pulmonary-to-
systemic flow ratio greater than 1·5 (class IIB, level of evidence C)

21. CONTRAINDICATION
• American and European practice guidelines: PVR> 8 Woods units
precludes closure and Eisenmenger syndrome
• Pop-off valve:COPD with corpulmonale
• Balloon occlusion :rise in PAP

22. TIMING OF SURGERY
•Ideally: 3-5 years
•Usually before 25 years
•Elderly: Improves morbidity and mortality

23. STRATEGY
• MM
• DEVICE CLUSRE
• SURGERY:SV ASD,PRIMUM ASD,CS TYPE,>36 MM size and
deficient rims

24. ADULTS WITH ATRIAL SEPTAL DEFECTS
•Unrepaired
•Repaired
•Pregnancy
•

25. UNREPAIRED
• Occasionally go undiagnosed for decades
• 25—30% of of GUCH
• Exercise test discovers subnormal exercise capacity
• Later age: fatigue, exercise intolerance, shortness of breath, palpitations,
and HF
• Age,CAD,HTN and AS add to detriment
• Atrial flutter and fibrillation in 21% of adults older than 40 years with a rising
frequency over time

26. REPAIRED
• By the age of forty
• Irrespective of technique, closure of atrial septal defects after age 40 years confers morbidity and mortality benefits
compared with medical therapy alone
• The risk of atrial flutter and fibrillation, remains high
• In view of the risk of unmasking left ventricular diastolic dysfunction by closing an atrial communication, test
occlusion in the catheterisation laboratory is recommended before closure of the defect
• By the of age 60 years
• symptomatic improvement and increase in 6 min walking distance coupled with a low procedural risk provide the
rationale for defect closure in elderly patients.

27. PREGNANCY
• WITHOUT PAH
• Maternal complications are uncommon
• Arrhythmias (4%) and transient ischaemic attack (1%).
• WITH PAH
• Avoided in severe
• maternal mortality was prohibitively high (28%) in women with congenital heart
disease and pulmonary hypertension, despite use of pulmonary vasodilator therapy
in more than half of the patients
• Maternal deaths tended to occur shortly after delivery and were often caused by
heart failure, thromboembolism, pulmonary hypertensive crisis, and sudden cardiac
death.

28. TAKE HOME
Any kind of closure is safe and effective and when done before age 25
years is associated with normal life expectancy