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Atrial Septial Defect
Atrial Septial Defect
• Embryologically, the septum primum separates the two atria first, moving
inferiorly toward the endocardial cushions. The ventricular septum forms by
moving upward from the ventricles to the endocardial cushions at the same
time. If the atrial septum does not make it all the way, the residual defect in
the septum primum (ostium primum) results in the primum ASD.
• If the septum primum makes it all the way, a hole or holes (fenestrations)
form in the middle of the septum (forming the ostium secundum). A second
septum then moves down the right side of the first and normally covers the
ostium secundum hole. If it does not cover the hole, a secundum ASD is
present.
• The septum secundum normally completely covers the right side of the
atrial septum except for an ovale hole in it (the foramen ovale). If the septae
do not fuse, a patent path from the RA to the LA persists (the patent
foramen ovale PFO).
• The most common form of ASD (80% of cases) is persistence of the ostium
secundum in the mid septum; less commonly, the ostium primum (which is
low in the septum) persists
• .
NORMAL PRESSURES
ATRIAL WAVES
• a= atrial contraction
• c= contraction of ventricle and closure of tricuspid valve
• x=x descent
• v=venous filling
• y= y descent due to opening of tricuspid valve
SWAN GANZ CATHETER
RIGHT HEART PRESSURES
Haemodynamic Parameters
Essentials of Diagnosis
• •Often asymptomatic and discovered on routine physical examination.
•RV lift; S2 widely split and fixed.
•Grade IIII/VI systolic ejection murmur at pulmonary area.
•ECG shows RV conduction delay;
•radiograph shows dilated pulmonary arteries and increased vascularity;
echocardiography/Doppler diagnostic.
•A PFO is present in 25% of the population but can lead to paradoxical
emboli and cerebrovascular events. Suspicion should be highest in patients
who had cryptogenic stroke before age 55.
•In all cases, normally oxygenated blood from the higher-pressure LA
passes into the RA, increasing RV output and pulmonary blood flow. In
children, the degree of shunting across these defects may be quite large
(3:1 or so). As the RV diastolic pressure rises from the chronic volume
overload, the RA pressure may rise and the degree of left-to-right shunting
may decrease. Eventually, the shunt may even be right-to-left and cyanosis
appears
ASD
CHAMBER PRESSURES
• S2 is widely split and does not vary with breathing due to the fact
that the left-to-right shunt decreases as the RA pressure increases
with inspiration
EISENMENGER COMPLEX
The pulmonary pressures are
modestly elevated in most patients
with an ASD due to the high
pulmonary blood flow, but severe
pulmonary hypertension
(Eisenmenger's complex) is actually
rare, occurring in only about 15% of
the patients (see illustration).
• Right axis deviation or RVH may be present depending on the size of the RV volume overload
(see ECG); (see ECG). Incomplete or complete right bundle branch block is present in nearly all
cases of ASD, and superior axis deviation is noted in the AV canal defect, where complete heart
block is often seen as well. With sinus venosus defects, the P axis is leftward of +15 due to
abnormal atrial activation with loss of the upper RA tissue from around the sinus node
XRAY IN ASD