ATRIAL SEPTAL DEFECT

Prof SOAD SHEDEED

Children Hospital – Zagazig University
 Facts about ASD
• Asymptomatic until
adulthood
• Symptoms beyond the
fourth decade
• Life expectency reduced
• Quality of life decreased
• Eisenmenger rare 5 %
syndromes associated with ASD

Holt-Oram synrome
Noonan syndrome
Trisomy 21 (Down Syndrome)
Budd-Chiari syndrome
Jarcho-Levine
Echocardiographic
Assessment of
ASD
 Types of ASD
1. ASD secundum
2. ASD primum
3. Sinous venosus
4. Unroofed Coronary
sinus
Development of IAS
 Associations of other…
• Secundum ASD: MVP
• Primum ASD: AV canal defect (Down
syndrome)
• Sinus venosus: Partial anomalous
pulmonary venous retrun
• Conornary sinus variety: complete
AV septal defect, absence of
coronary sinus, left SVC that drains
into the left atrium
 Prognosis
• Secundum ASDs <5 mm may close
spontaneously or become smaller in the
first year of life

• Primum ASDs, sinus venosus ASDs or

coronary sinus ASDs almost never
become smaller over time
 Echocardiography in ASD
• Site
• Size
• Associated defects
• Complications
 Echocardiographic modalities
1. Transthoracic echocardiogram
2. Transoesophgeal
echocardiogram
3. Intracardiac echocardiogram

Modes:
2D, M mode, Doppler study ,3D
 Common views in TTE
•Subcostal long axis
•Subcostal short axis
•Left Anterior Oblique
•Apical Four-Chamber
•Parasternal Short-Axis
•High Right Parasternal View
 TTE views for ASD

The subcostal long axis (four-

chamber) view
imaging of the atrial septum
along its anterior–posterior
axis from the SVC to the AV
valves.
ASD osteum secundum
 ASD secundum rims
• SVC or superior margin
• IVC or inferior margin
• Posterior margin
• Anterior or retroaortic
margin
• Mitral rim
• The subcostal short axis view is
acquired by turning the
transducer 90 clockwise from the
frontal view. This view can be
used to:
• -measure the rim from the
defect to the SVC and IVC
• - to image a sinus venosus type
defect
• Apical Four-Chamber :
- RA and RV dilation
- RV pressure using the tricuspid
valve regurgitant jet velocity. This
view is also used to evaluate for
right-to-left shunting with agitated
saline
• Parasternal Short-Axis

This view is ideal to identify the

aortic rim of the defect. It also
highlights the posterior rim (or
lack thereof) in sinus venosus and
posteroinferior secundum defects.
• Left Anterior Oblique.
The left anterior oblique is acquired
by turning the transducer
approximately 45 counterclockwise
from the frontal (four- chamber)
view.
This view allows imaging of
the length of the atrial septum
ideal to identify ostium primum
ASDs
assessment of coronary sinus
dilation
High right sternal view
ideal for diagnosing
sinus venosus
defects, particularly
when the
subxiphoid windows
are inadequate
 ASD secundum rims
• SVC or superior margin
• IVC or inferior margin
• Posterior margin
• Anterior or retroaortic
margin
• Mitral rim
Views to identify the ASD rims
PSAX view
Aortic and Post rim
A4CV:
Mitral Rim
Subcostal view: SVC and
IVC rim
Different ASD rims
 Qp/Qs
• Qp – pulmonary flow
• Qs – systemic flow
• Qp/Qs = 1 in normal
• Qp/Qs > 1.5 significant shunt

• Qp = VTI, RVOT diameter

• Qs = VTI, LVOT diameter
 Pulmonary hypertension
by TR if no RVOT obstruction

Also by PR max velocity or RVOT

acceleration time
 ASD with Eisenmenger
syndrome
• pulmonary hypertension,
• reversal of flow,
• and cyanosis
 ASD secundum Device
CRITERIA:
closure

1.͞Significant͟ ASDs (Qp/Qs >1.5 or ASDs

2.Secundum ASD that has a stretched

diameter of less than 30 mm

3.Adequate rims (5 mm) to enable secure

deployment of the device

4.Anomalous pulmonary venous connection

or proximity of the defect to the AV valves or
coronary sinus or systemic venous drainage,
intracardiac thrombie absent
Device in situ
Device in
situ
 Follow up after device
closure
endocarditis prophylaxis until the device
endothelializes, following which, assuming
that no residual shunt is present require 6
months

6 months of aspirin
echocardiogram taken every year because of
the possibility of late issues, especially
erosion.

Ref: Braunwald
10th ed
 Surgical complications
•Pericardial effusion
●Pleural effusions
●Arrhythmias
●Bleeding
●Pneumothorax
●Wound infection
THANK YOU