Atrial Septal Defect: Spectrum of Care

Abstract

Atrial septal defect (ASD) is a common congenital heart defect. Variability in management of this lesion exists among clinicians. A review of the literature reveals that there is lack of standard guidelines for the evaluation and management of patients with different types of ASDs. This survey-based study was conducted to test the uniformity of diagnostic and therapeutic approach to management of children with secundum, sinus venosus, and primum ASDs. Survey questionnaires were prepared to include questions regarding follow-up, diagnosis, and therapeutic intervention of different types and sizes of ASDs. Questions addressed follow-up visitations, type and frequency of investigative studies, pharmacological therapy, and choice of repair method. Surveys were sent out to all pediatric cardiology academic programs in the United States (n=48) and randomly selected international programs from Europe, Asia, and Australia (n=19). A total of 23 programs (34%) responded to the survey (15 from the United States and 8 internationally). A separate questionnaire was prepared for secundum, primum, and sinus venosus ASD. In each questionnaire, lesion types were subdivided into small, moderate, and large defect sizes to address differences of management approaches to each defect type and size. Results indicate that in secundum ASD, most participants use size of the defect and/or evidence of right-sided volume overload as criteria for defining small, moderate, and large defects. Frequency of follow-up does not vary with the type of lesion but is more frequent with larger defects. Most participants see patients with small defects at intervals of 6 months to 1 year and those with large defects at 3- to 6-month intervals. Age of patient and presence of symptoms determined the frequency of follow-up across all defects. Echocardiography was the most frequently used investigative modality in all defect sizes and types during follow-up visits (used by >80% for follow-up), followed by electrocardiography (ECG). There is a striking preference for the use of pharmacological therapy in primum ASD compared with secundum and sinus venosus ASD. The timing of repair was mainly dependent on patient age and symptomatology in different defects, with the presence of associated anomalies contributing to that in primum and sinus venosus ASD. Most participants use percutaneous approach to close secundum ASD (either as a first choice or as one of two choices depending on the presence of certain features). Before repair, participants use MRI or cardiac catheterization to fully evaluate a secundum ASD if it is large. These investigative modalities are not commonly used in primum and sinus venosus ASD. There is agreement on postoperative follow-up in different types of defects, with most participants continuing follow-up indefinitely, especially in larger defects.

The utility of modified Butler-Leggett criteria for right ventricular hypertrophy in detection of clinically significant shunt ratio in ostium secundum–type atrial septal defect in adults

“…17 Moreover, recent literature suggests that ASDs are classified according to size of the defect and/or right-sided volume overload. 18 Once again, the BL criterion can play a role in determining if there is significant right-sided volume overload. Although other noninvasive procedures for determining the Qp/Qs ratio such as phase contrast cine MRI (with a sensitivity and specificity of 0.93 and 1, respectively) are available, the lack of such facilities at many centers warrants investigation into the ECG as a simple procedure to identify those with a significant shunt ratio warranting ASD closure.…”

Surgical repair of combination of Addison’s Disease and secundum type atrial septal defect and our postoperative follow-up principles

“…Assessment of the patient with known or suspected congenital heart defects requires a careful history, physical examination, and noninvasive assessment [ 5 ]. Echocardiography was the most frequently used investigative modality in all defect sizes and types [ 9 ]. The transthoracic approach was successful in capturing sufficient data to create 3-D images, which can provide an accurate assessment of secundum ASD [ 10 ].…”

New pulmonary vein Doppler echocardiographic index predicts significant interatrial shunting in secundum atrial septal defect

“…The former involves radiation and the latter is limited by a lack of availability or clinical contra-indications. Echocardiography understandably remains the first-line imaging option for evaluating ASD patients [30]. While it is often adequate to address the degree of right heart dilatation, the combined 2-dimensional and pulsed Doppler method to assess Qp/Qs ratios remains inaccurate.…”