Atrial septal defects (ASD) are the most commonly recognized congenital cardiac anomalies. This type of cardiac defect is associated with the upper chambers (atrium) of the heart. The wall separating the right and left chambers is partially or completely missing.

There are 4 basic types of classifications: 

  • Ostium Secundum – Most common type of ASD. Can be seen in conjunction with other congenital heart defects as well.
  • Ostium Primum – Also known as an endocardial cushion defect due to sharing the same tissue as nearby atrioventricular valves (mitral and tricuspid valves)
  • Sinus Venosus – Either called superior, if high on the right atrium near the superior vena cava and right atrial junction (most common type), or inferior, if low on the right atrium near the inferior vena cava. Often these are associated with anomalous pulmonary venous defect. (commonly referred to as a partially anomalous pulmonary venous defect).
  • Coronary Sinus – Also known as an unroofed coronary sinus, least common

Symptoms

An atrial septal defect's symptoms depend largely on the amount of blood flow that is traveling from the left side of the heart to the right side of the heart, referred to as a left-to-right shunt. The amount of shunting is related to the size of the defect and the pulmonary vasculature resistance. When too much blood is going to the lungs they can get overworked, often seen a few weeks after birth when pulmonary resistance falls. Children may require medication to help the body remove "extra" fluid on the lungs associated with this over circulation. Additionally, if this connection is not fixed, the lungs can become permanently injured and the child can develop pulmonary hypertension which may prevent any future repair.

Infants may show signs and symptoms of congestive heart failure such as breathing fast, difficulty or working hard to breathe, elevated heart rate, not taking feedings and other babies, not growing well for their age, being tired or sleeping more often than other babies.

Interventional/Surgical Techniques

The most common approach to closing this defect is by a transcatheter approach in the Cardiac Catheterization Lab (Cath Lab). This technique is done by placing a catheter into a vein and guiding the catheter into the heart to deploy a device or "plug". The ASD device has to have enough tissue to anchor on for proper placement. In some instances, if there is not enough tissue to provide this anchor, surgical intervention is warranted.

The surgical approach can vary from a standard midline incision to a small anterior thoracotomy approach. A machine that allows the heart and lungs to rest (cardiopulmonary bypass) is used to allow the surgery team to repair the area of concern. Surgical repair most commonly involves placing a patch of material, either biological or synthetic, on the atrium's septum.

A "Minimal Incision ASD" repair is performed when clinically able and is an advanced operative technique by with the incision is minimized, and the sternum is only partially opened.

Post-Operative Care

Recovery time is dependent on the technique used to repair the atrial septal defect.

Interventional repair in the Cath Lab will routinely require an overnight stay on the Cardiovascular Intermediate Service (Step-Down). The breathing tube (endotracheal tube) inserted for surgery is removed before leaving the Cath Lab. Minimally invasive intravenous lines are placed before the procedure for delivery of medication and hydration. These peripheral intravenous (PIV) catheters are left in place and removed as soon as enough fluids can be taken by mouth. The site where the catheter was placed, usually the groin, will have a pressure bandage applied and require lying flat for approximately 6 hours. Routine monitoring will generally include cardiac rhythm on telemetry, pulse oximetry probe to monitor oxygen saturation, and non-invasive blood pressure measurements. Anticipate discharge home the next day after a few routine exams (electrocardiogram, chest x-ray and echocardiogram).

After a surgical atrial septal defect repair, monitoring in the post-operative period will include invasive lines, such as an arterial line and central venous line, to monitor blood pressure and deliver medications. Medications may be needed to control hemodynamics, provide sedation and maintain hydration during recovery. Perfusion is monitored by pulse oximetry and NIRS (near-infrared spectroscopy) probes. The breathing tube (endotracheal tube) is generally able to be removed before leaving the operating room. A chest tube will be present to remove air, blood and/or fluid from around the heart or lungs. This tube will be removed in the ICU as soon as possible, typically the following day.

The average length of hospital stay is around 3-5 days. 

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