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Questions and Answers
What is the primary method for quantifying the degree of a shunt across a defect?
What does the formula for calculating Left Atrial Pressure include?
Which imaging technique is recommended for evaluating persistent SVC?
What does a late appearance of bubbles in the bubble study indicate?
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Which condition does NOT typically require surgical treatment as mentioned?
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Which of the following is NOT a role of transesophageal echo?
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What is the role of a bubble study during evaluation?
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Which type of ASD is associated with partial anomalous pulmonary venous return?
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What is the main advantage of using subcostal imaging?
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What is the main goal of device closure in the treatment of defects?
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What type of atrial septal defect is most commonly associated with mitral valve prolapse?
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Which of the following conditions can lead to increased left to right shunting through an atrial septal defect?
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In which location is the ostium primum atrial septal defect typically found?
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What is the pathophysiological consequence of prolonged large volume shunting in atrial septal defects?
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Which echocardiographic feature is indicative of a significant atrial septal defect?
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Which associated lesion is commonly linked with primum atrial septal defect?
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What is the incidence of atrial septal defects in the general population?
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What type of atrial septal defect is associated with anomalous return of pulmonary veins?
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Which measurement indicates a hemodynamically significant left-to-right shunt?
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Which potential complication arises from atrial septal defects due to persistent left to right shunting?
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Study Notes
Atrial Septal Defects (ASDs)
- ASDs are abnormal openings in the interatrial septum.
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Ostium secundum ASDs are the most common type, located in the mid portion of the septum.
- Associated with hemodynamic mitral valve prolapse.
- More common in women.
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Ostium primum ASDs are located at the inferior portion of the septum.
- Associated with cleft mitral valve.
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Sinus venosus ASDs are located in the posterior and superior portion of the septum near the SVC or inferior and posterior near the IVC.
- Associated with partial or total anomalous pulmonary venous return.
- Usually, a single vein returns blood to the RA instead of the LA.
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Coronary sinus ASDs occur when the roof of the coronary sinus is partially or completely absent, creating a shunt between both atria and the coronary sinus.
- Dilated coronary sinus can affect the mitral valve.
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Common atrium involves the absence of the interatrial septum.
- Associated with situs abnormalities.
- Shunts in ASDs are predominantly left to right, with brief reversal during atrial relaxation.
Pathophysiology of ASDs
- Interatrial communication caused by the ASD results in left to right shunting, initially, due to the lower compliance of the RV compared to the LV.
- Prolonged large volume shunting can lead to right to left shunting with elevated right-sided pressures.
- Eisenmenger's physiology is rare in ASD but can occur when this prolonged large-volume shunting results in right to left flow with increased right-sided pressures.
- Conditions that increase left to right shunting through an ASD:
- LVH
- Cardiomyopathy
- Mitral Stenosis/Regurgitation
- Mitral Valve Atresia
- Cor Triatriatum Sinister
- Aortic Stenosis
- Coarctation of the Aorta
Clinical Presentation of ASDs
- May be asymptomatic for many years, even into mid to late adulthood.
- Dyspnea upon exertion.
- Recurrent respiratory infections.
- Atrial arrhythmias, especially atrial fibrillation.
- Systolic murmur due to increased flow across the pulmonary valve.
- Relative pulmonary valve stenosis
- A diastolic murmur through the tricuspid valve in cases of large shunts.
Associated Lesions
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Secundum ASD and PFO:
- Mitral valve prolapse
- Tricuspid atresia
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Sinus venosus defect:
- Anomalous pulmonary vein return:
- Total or partial
- Right upper and lower pulmonary veins returning to the SVC, RA, or LA.
- Anomalous pulmonary vein return:
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Primum ASD:
- Cleft mitral valve: slit-like hole in a leaflet.
- Atrioventricular valvular regurgitation.
Etiology
- ASDs occur in approximately 1 in 1000 births.
Echocardiographic Features of ASDs
-
2D/M-mode:
- Location and size of the defect:
- Defects greater than 10mm are considered large;
- 2-20mm is an ideal size for closure;
- Greater than 25mm is difficult to close.
- RV function:
- Dilatation,
- RVOT diameter (normal 1.7-2.3 cm),
- Volume and pressure overload (paradoxical septal motion/flattening).
- Right and left atrial dilatation:
- LAE is associated with left heart failure, cleft mitral valve, or mitral valve prolapse.
- Pulmonary artery and branch dilatation.
- Tricuspid and pulmonic valve annulus dilatation over time.
- Tricuspid annulus (RV basal measurement) greater than 42mm.
- Partial or total anomalous venous return.
- Location and size of the defect:
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Doppler:
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Color and PW:
- Demonstrates direction and velocity of the shunt.
- Turbulent flow in the pulmonary artery due to increased volume.
- Presence and severity of valvular regurgitation or stenosis.
- Presence of partial or total anomalous venous return.
- RVOT VTI is increased with large ASDs; LVOT VTI is decreased with large ASDs. (Higher blood volume = higher VTI; Lower blood volume = lower VTI).
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Qp/Qs (pulmonary to systemic flow ratio):
- Hemodynamically significant if greater than or equal to 1.5:1.
- Helps quantify the degree of shunt across a defect, and is used to determine if and when the defect should be closed.
- SPAP, MPAP, PAEDP, PVR: obtained from Doppler.
- Width of the ASD: measured with color Doppler.
- Left atrial pressure: measured with color Doppler.
- Right/Left ventricular function: assessed diastole and systole.
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Color and PW:
Imaging Techniques
- Subcostal imaging is usually optimal for evaluation.
- Pediatric high right parasternal/supraclavicular views may be attempted.
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Crab view:
- Short axis of SSN for pulmonary vein connection.
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Bubble study:
- Detects PFO and ASD.
- Saline injection temporarily increases pressures on the right side, forcing bubbles to appear on the left side of the heart within 3 to 4 cardiac cycles.
- Late appearance indicates intra-pulmonary shunting.
- Evaluates for persistent SVC.
Treatment
- Catheterization
- Antiarrhythmics
- Device closure (PFO/Secundum ASD)
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Surgical:
- Primary (suture) closure for small defects.
- Patch repair.
- Mitral valve repair or replacement if cleft mitral valve is present.
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Description
This quiz covers key concepts related to Atrial Septal Defects (ASDs), including their various types and associations. Learn about ostium secundum, primum, sinus venosus, and coronary sinus ASDs, along with their clinical implications. Test your knowledge on these congenital heart defects and their impact on hemodynamics.
