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Atrial Septal Defect Workup

  • Author: David H Adler, MD, FACC; Chief Editor: Park W Willis IV, MD  more...
 
Updated: Dec 06, 2015
 

Laboratory Studies

See the list below:

  • No specific laboratory blood tests are indicated in the workup of atrial septal defects (ASDs).
  • Routine laboratory studies should be performed in patients undergoing intervention for ASD:
    • Complete blood count
    • Type and screen
    • Metabolic profile or chemistry
    • Coagulation studies (prothrombin time [PT] and activated partial thromboplastin time [aPTT])
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Imaging Studies

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  • 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. On occasion, proximal dilatation of the superior vena cava can be seen in sinus venosus defect.
  • Transthoracic echocardiography[1]
    • An uncertain diagnosis can be clarified with transthoracic 2-dimensional echocardiography, which provides direct noninvasive visualization of most types of ASDs, including evaluation of the right atrium, right ventricle, and pulmonary arteries, as well as other associated abnormalities. The view most beneficial is often the subcostal view. One exception is the diagnosis of a sinus venosus defect, for which transesophageal echocardiography (TEE) may be needed to image the defect, but this still may not be able to visualize the pulmonary venous return. TEEs and an echocardiogram are shown below:
      Parasternal short axis: RV dilation with RV pressuParasternal short axis: RV dilation with RV pressure overload as evidenced by flattening of the interventricular septum in systole.
      Transesophageal echocardiogram: Moderate-large ASDTransesophageal echocardiogram: Moderate-large ASD with left-to-right shunt across the interatrial septum.
      Apical 4-chamber view. Apical 4-chamber view.
    • In any patient with an ASD, particularly a sinus venosus defect, anomalies of systemic venous connection should be sought. These can be clearly identified by 2-dimensional imaging. Right atrial and right ventricular enlargement without identification of the cause should prompt consideration for a TEE.
    • Doppler echocardiography may be helpful in demonstrating flow across the atrial septum. It typically shows a biphasic (systolic and diastolic) pattern with a small right-to-left shunt at the beginning of systole.
    • 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 (and pulmonary arterial when there is no associated right ventricular outflow tract obstruction) systolic pressure when a tricuspid regurgitant jet is present. This technique is also useful 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 ASD. However, utility is limited for small defects. A major advantage of MRI is the ability to quantify right ventricular size, volume, and function along with the ability to identify the systemic and pulmonary venous return.
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Other Tests

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  • Electrocardiography
    • Characteristic findings in patients with secundum ASD are a normal sinus rhythm, right-axis deviation, and an rSR' pattern in V1, an interventricular conduction delay or 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, an interventricular conduction delay or right bundle branch block suggests an ostium primum defect.
    • 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 can be seen in familial ASD or ostium primum secondary 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.
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Diagnostic Procedures

See the list below:

  • When noninvasive techniques demonstrate the presence of an uncomplicated ASD in a child, routine cardiac catheterization for diagnosis is unnecessary.
  • However, cardiac catheterization may be useful if the clinical data are inconsistent, if clinically significant pulmonary arterial hypertension is suspected, or if concurrent coronary artery disease must be assessed in patients older than 40 years. Catheterization is also a viable alternative for intervention for secundum ASD.
  • The diagnosis of ASD may be confirmed by directly passing the catheter through the defect.
    • Serial oxygen saturation measurements can 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 a 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.
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Contributor Information and Disclosures
Author

David H Adler, MD, FACC Assistant Professor of Medicine, Eastern Virginia Medical School; Cardiologist, Cardiovascular Associates, Ltd

David H Adler, MD, FACC is a member of the following medical societies: American College of Cardiology, American Heart Association

Disclosure: Nothing to disclose.

Coauthor(s)

Alexander R Ellis, MD, MSc, FAAP, FACC Assistant Professor of Internal Medicine and Pediatrics, Eastern Virginia Medical School; Co-Director, Pediatric Echocardiography Laboratory, Division of Pediatric Cardiology, Director, Adult Congenital Heart Disease Program, Children’s Hospital of the King’s Daughters; Director of Resident and Medical Student Education, Division of Cardiology, Children’s Hospital of the King’s Daughters and Eastern Virginia Medical School

Alexander R Ellis, MD, MSc, FAAP, FACC is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steven J Compton, MD, FACC, FACP, FHRS Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals

Steven J Compton, MD, FACC, FACP, FHRS is a member of the following medical societies: American College of Physicians, American Heart Association, American Medical Association, Heart Rhythm Society, Alaska State Medical Association, American College of Cardiology

Disclosure: Nothing to disclose.

Chief 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.

Additional Contributors

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.

Acknowledgements

Marc G Cribbs, MD Fellow, Department of Pediatric Cardiology, Vanderbilt University Medical Center

Marc G Cribbs, MD is a member of the following medical societies: American Heart Association, American Medical Association, and Christian Medical & Dental Society

Disclosure: Nothing to disclose.

Larry W Markham, MD Assistant Professor of Pediatrics and Medicine, Vanderbilt University School of Medicine

Larry W Markham, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Bekir Hasan Melek, MD Assistant Professor of Clinical Medicine, Department of Medicine, Section of Cardiology, Tulane University School of Medicine

Bekir Hasan Melek 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.

Jeffrey C Milliken, MD Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California, 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, Southwest Oncology Group, and Western Surgical Association

Disclosure: Nothing to disclose.

Peter B Smulowitz University of California, Irvine, School of Medicine

Disclosure: Nothing to disclose.

James V Talano, MD, MBA, MM, FACC, FAHA Director of Cardiovascular Medicine, SWICFT Institute

James V Talano, MD, MBA, MM, FACC, FAHA 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.

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Parasternal short axis: RV dilation with RV pressure overload as evidenced by flattening of the interventricular septum in systole.
Transesophageal echocardiogram: Moderate-large ASD with left-to-right shunt across the interatrial septum.
Apical 4-chamber view.
 
 
 
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