Atrial septal defects

Last reviewed: June 2019

Last updated: January 2018

Summary

There are 4 types of atrial septal defect (ASD): ostium secundum, ostium primum, sinus venosus, and unroofed coronary sinus. Secundum defects are the most common.

Most patients are asymptomatic. Untreated defects can produce right atrial enlargement, cardiac arrhythmias, and heart failure over time.

Secundum, primum, and coronary sinus defects with small shunts (ratio of pulmonary flow to systemic flow, Qp:Qs, <1.5) do not require treatment. Corrective closure is required if the shunt is larger (Qp:Qs ratio ≥1.5), there is right atrial enlargement, or the patient has a sinus venosus defect.

Corrective closure, if required, is usually performed at 2 to 4 years of age but can be performed at a younger age in symptomatic patients.

Percutaneous device closure is the preferred treatment for secundum defects, and surgical closure is reserved for larger secundum defects, technically challenging cases, and other defects.

If right-to-left shunting (Eisenmenger syndrome) occurs, the ASD is operable if the shunt is reversible with pulmonary vasodilators. If the shunt is irreversible, the treatment is largely supportive.

Definition

An atrial septal defect (ASD) is an opening in the atrial septum, excluding a patent foramen ovale. [1] There are 4 types of ASD: ostium secundum, ostium primum, sinus venosus, and unroofed coronary sinus.

History and exam

Key diagnostic factors

systolic ejection murmur
fixed splitting of the second heart sound

Full details

Other diagnostic factors

mid-diastolic murmur
congestive cardiac failure
failure to thrive
symptoms of atrial arrhythmias
cyanosis
finger clubbing

Full details

Risk factors

female gender
maternal alcohol consumption
positive FHx

Full details

Diagnostic investigations

1st investigations to order

echocardiogram
ECG
chest x-ray

Full details

Investigations to consider

chest CT/MRI
cardiac catheterization

Full details

Treatment algorithm

ACUTE

left-to-right shunt

right-to-left shunt

Contributors

Authors VIEW ALL 

Sachin Khambadkone, MD, DCH, DNB

Consultant in Paediatric and Adolescent Cardiology

Interventional Cardiologist

Honorary Senior Lecturer

Paediatric and Adolescent Cardiology

Great Ormond Street Hospital and Institute of Child Health

London

Disclosures

SK declares that he has no competing interests.

Acknowledgements

Dr Sachin Khambadkone would like to gratefully acknowledge Dr Brandon Lane Phillips, Dr Frank Cetta, and Dr David J. Driscoll, previous contributors of this monograph. BLP, FC, and DJD declare that they have no competing interests.

Peer reviewers VIEW ALL 

Alexander Opotowsky, MD, MPH

Senior Fellow

Adult Congenital Heart Disease and Pulmonary Hypertension

Department of Cardiology

Children's Hospital Boston

Department of Medicine

Division of Cardiology

Brigham and Women's Hospital

Boston

Disclosures

AO declares that he has no competing interests.

Gianluca Rigatelli, MD, FACP, FACC, FESC, FSCAI

Director

Section of Transcatheter Treatment of Congenital Heart Disease in the Adult

Rovigo General Hospital

Rovigo

Italy

Disclosures

GR declares that he has no competing interests.

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Atrial septal defects

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

left-to-right shunt

right-to-left shunt

Contributors

Authors VIEW ALL 

Sachin Khambadkone, MD, DCH, DNB

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Alexander Opotowsky, MD, MPH

Disclosures

Gianluca Rigatelli, MD, FACP, FACC, FESC, FSCAI

Disclosures

Differentials

Guidelines

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