eMedicine Specialties > Cardiology > Congenital Heart Disease in the Adult

Atrial Septal Defect: Workup

Author: Bekir Hasan Melek, MD, Assistant Professor of Clinical Medicine, Department of Medicine, Section of Cardiology, Tulane University School of Medicine
Coauthor(s): James V Talano, MD, MM, FACC, Director of Cardiovascular Medicine, SWICFT Institute; Jeffrey C Milliken, MD, Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California at Irvine School of Medicine; Peter B Smulowitz, BA, University of California at Irvine School of Medicine
Contributor Information and Disclosures

Updated: Jul 11, 2006

Workup

Laboratory Studies

  • No specific laboratory blood tests are indicated in the workup of ASDs.
  • The following routine laboratory studies should be performed in patients undergoing surgical correction of ASD under general anesthesia:
    • CBC count
    • Determination of electrolyte levels
    • Coagulation studies (prothrombin time [PT], activated partial thromboplastin time [aPTT])
    • Routine urinalysis

Imaging Studies

  • Chest radiography
    • In the presence of a clinically significant left-to-right shunt, chest radiographs most often show cardiomegaly because of dilatation of the right atrium and right ventricular chamber.
    • The pulmonary artery is prominent, and pulmonary vascular markings are increased in the lung fields.
    • Left atrial enlargement is rare only if clinically significant mitral regurgitation or atrial fibrillation is present. On occasion, proximal dilatation of the superior vena cava can be seen in sinus venosus defect.
  • Transthoracic echocardiography
    • Transthoracic echocardiography has been suggested as the initial investigation in patients thought to have an ASD. An uncertain diagnosis can be clarified with transthoracic 2-dimensional echocardiography, which provides direct noninvasive visualization of most types of ASDs, especially from the subcostal view. One exception is the diagnosis of sinus venosus defects, for which transesophageal echocardiography (TEE) is the procedure of choice.
    • Two-dimensional echocardiography is also useful in demonstrating enlargement of the right atrium, right ventricle, and pulmonary arteries, as well as other associated abnormalities (eg, single papillary muscle, left ventricular hypoplasia and aortic coarctation).
    • In young patients with good echocardiographic windows, anomalies of systemic venous connection should be sought. These can be clearly identified by 2-dimensional imaging.
    • Real-time echocardiography is helpful for identifying additional abnormalities, such as mitral valve prolapse and a double-orifice mitral valve (seen in 3% of patients with ostium primum defect).
    • Doppler echocardiography may be helpful in demonstrating flow across the atrial septum. It typically shows biphasic (systolic and diastolic) pattern with a small right-to-left shunt at the beginning of systole. Largest shunt flow occurs in late systole.
    • Two-dimensional color Doppler studies are usually required for a reliable assessment of pulmonary venous connections.
    • Transthoracic echocardiography may be suboptimal in some patients with poor echocardiographic windows. In such patients, TEE can provide excellent definition of the atrial septum. TEE is also useful in guiding device placement during catheter ASD occlusion procedures and in providing immediate intraoperative assurance that defect closure is accomplished.
    • Continuous-wave Doppler echocardiography is valuable for estimating right ventricular–pulmonary arterial systolic pressure when a tricuspid regurgitant jet is present. This technique is also useful in estimating the pressure gradient across the atrial septum in patients with left atrial hypertension and restrictive atrial septal effects and in evaluating patients for obstruction to pulmonary venous return.
    • Contrast echocardiography can provide additional confirmation. A right-to-left shunt can be detected by visualizing microcavitation bubbles in the left atrium and the left ventricle. A left-to-right shunt can be detected as a negative contrast washout effect in the right atrium.
  • MRI: MRI has successfully been used to identify the size and position of ASDs, facilitating appropriate referral for catheter occlusion or surgery.

Other Tests

  • Electrocardiography
    • ECG usually shows a normal sinus rhythm unless an atrial arrhythmia has developed. Characteristic findings in patients with secundum ASD are right-axis deviation and an rSR' pattern in V1 or a right bundle-branch block (which represents delayed posterobasal activation of the ventricular septum and enlargement of the right ventricular outflow tract).
    • Left-axis deviation and an rSR' pattern in V1 or a right bundle-branch block suggest an ostium primum defect or an ostium secundum defect with associated mitral valve prolapse.
    • Left-axis deviation and negative P wave in lead III suggest sinus venosus defect.
    • Increasing pulmonary hypertension can cause loss of the rSR' pattern in V1 and a tall monophasic R wave with a deeply inverted T wave.
  • A prolonged P-R interval is most common in ostium primum and is due to left atrial enlargement and an increased distance for internodal conduction produced by the defect itself. Displacement of the AV node in a posteroinferior direction in some patients or an enlarged right atrium has also been reported.

Diagnostic Procedures

  • When noninvasive techniques demonstrate the presence of an uncomplicated ASD in a child, routine cardiac catheterization is unnecessary.
  • Cardiac catheterization may be useful if the clinical data are inconsistent, if clinically significant pulmonary hypertension or associated malformations are suspected, or if concurrent CAD must be assessed in patients older than 40 years.
  • The diagnosis of ASD may be confirmed by directly passing the catheter through the defect.
    • Serial oxygen saturation measurements may be used to estimate the magnitude of the shunt
    • In young patients, right heart pressures are often normal despite a large shunt.
    • If high oxygen saturation is present in the superior vena cava or if the catheter enters pulmonary vein directly from the right atrium, sinus venosus type is likely.
    • Partial anomalous pulmonary venous return is usually associated with sinus venosus defect, but it may also accompany the ostium secundum type.

More on Atrial Septal Defect

Overview: Atrial Septal Defect
Workup: Atrial Septal Defect
Treatment: Atrial Septal Defect
Follow-up: Atrial Septal Defect
References
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References

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Further Reading

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Keywords

atrial septal defect, atrial septum, ASD, ostium secundum ASD, sinus venosus defect, ostium primum defect, ostium secundum defect, congenital heart disease, congenital cardiac disorder, ventricular dilatation, thoracic surgery, pulmonary hypertension, Eisenmenger syndrome, Holt-Oram syndrome, transcatheter occlusion devices, dyspnea, fatigue, palpitations, syncope, congestive heart failure, CHF

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Contributor Information and Disclosures

Author

Bekir Hasan Melek, MD, Assistant Professor of Clinical Medicine, Department of Medicine, Section of Cardiology, Tulane University School of Medicine
Bekir Hasan Melek, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Society of Echocardiography, and Louisiana State Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

James V Talano, MD, MM, FACC, Director of Cardiovascular Medicine, SWICFT Institute
James V Talano, MD, MM, FACC is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Physician Executives, American College of Physicians, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, and Society of Geriatric Cardiology
Disclosure: Nothing to disclose.

Jeffrey C Milliken, MD, Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California at Irvine School of Medicine
Jeffrey C Milliken, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs, California Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Kappa, Society of Thoracic Surgeons, Southwestern Oncology Group, and Western Surgical Association
Disclosure: Nothing to disclose.

Peter B Smulowitz, BA, University of California at Irvine School of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Park W Willis IV, MD, Sarah Graham Distinguished Professor of Medicine and Pediatrics, University of North Carolina at Chapel Hill School of Medicine
Park W Willis IV, MD is a member of the following medical societies: American Society of Echocardiography
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Steven J Compton, MD, FACC, FACP, Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals
Steven J Compton, MD, FACC, FACP is a member of the following medical societies: Alaska State Medical Association, American College of Cardiology, American College of Physicians, and Heart Rhythm Society
Disclosure: Nothing to disclose.

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Michael E Zevitz, MD, Assistant Professor of Medicine, Finch University of the Health Sciences, The Chicago Medical School; Consulting Staff, Private Practice
Michael E Zevitz, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Medical Association, and Michigan State Medical Society
Disclosure: Nothing to disclose.

 
 
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