Pediatric Atrial Septal Defects Follow-up
- Author: Michael R Carr, MD; Chief Editor: P Syamasundar Rao, MD more...
Further Outpatient Care
Provide routine medical care with special attention to signs of congestive heart failure (CHF) or increased pulmonary vascular resistance (PVR). Most patients with an atrial septal defect are asymptomatic and require only routine well-child care until they undergo elective surgical repair or transcatheter device placement for their defects.
Most children with uncomplicated atrial septal defects are followed up by their primary care provider and receive follow-up with a pediatric cardiologist every year or every other year. Children who require medical intervention or who have other comorbidities are seen by a cardiologist more frequently than this.
Further Inpatient Care
Please refer to the sections regarding the specific subtypes of atrial septal defect (ASD) for potential inpatient issues.
An isolated atrial septal defect almost never causes clinically significant problems in the neonatal period or in infancy. Refer a child who is to have elective atrial septal defect surgical repair or transcatheter intervention to a pediatric center with experience in performing cardiopulmonary bypass and surgical atrial septal defect closure or catheter based procedures in young children.
A patient with an ostium primum atrial septal defect may have associated clinically significant AV valve insufficiency and may require earlier surgical intervention. Refer this patient to a center with experience in the evaluation and repair of this problem.
Any attempt at closure with a transcatheter device should be performed at a center with experience in pediatric interventional cardiology with surgical support. Additionally, since some atrial septal defects are detected outside of childhood, transcatheter interventions in adults are often performed by adult interventionalists with the assistance of a pediatric interventionalist. Adult interventionalists may be very comfortable with transcatheter patent foramen ovale closure, but not as familiar with the nuances of true atrial septal defectdevice closure, especially larger defects.
Atrial septal defect is usually an asymptomatic disease. However, children with atrial septal defects are at increased risk for several complications, such as endocarditis (if associated mitral valve insufficiency is present) and respiratory tract infections, which are less well tolerated in children with atrial septal defects than in children without atrial septal defects. Any individual with an atrial level shunt is at risk for a paradoxical embolus from a venous thrombus, but in children, this is exceedingly rare, unless there is an underlying hypercoagulable state.
Children with clinically significant and untreated atrial septal defects are at risk for various cardiac complications, including CHF, pulmonary hypertension, and arrhythmias. However, these cardiac complications generally manifest in adulthood.
The prognosis for a child with an atrial septal defect is good; the rate of surgical mortality is less than 1%. Many children are candidates for catheter-based device implantation, which also carries a very low procedural morbidity and mortality and avoids the risks associated with a median sternotomy and cardiopulmonary bypass.
Ostium secundum defects may spontaneously close. A wide range of spontaneous closure rates have been reported among different studies, ranging from 4-87%. The likelihood of spontaneous closure appears to be closely related to the initial size of the defect. One study demonstrated a 56% spontaneous closure rate and 30% regression to a diameter of less than 3 mm for defects 4-5 mm in diameter. Conversely, none of the defects more than 10 mm in diameter closed spontaneously, and 77% of those required intervention. The general thought is that spontaneous closure does not occur with ostium primum, sinus venosus, or coronary sinus defects.[19, 20]
Certain patients with ostium primum atrial septal defects and an abnormal mitral valves may require a second operation for mitral valve dysfunction later in their lives.
The repair of sinus venosus atrial septal defects can be more complex and often involves baffling of the right upper pulmonary vein to the left atrium and anastomosis of the superior vena cava to the right atrial appendage. Stenosis of the right upper pulmonary vein baffle or superior vena cava/atrial appendage anastomotic site may require further catheter-based or surgical intervention.
Endocarditis of catheter-placed devices has been reported and may necessitate removal of the hardware and surgical repair.
Surgical or catheter-based intervention of atrial septal defects in individuals outside of childhood is generally feasible, even in the face of pulmonary vascular changes and evidence of pulmonary hypertension. This is distinctly different from similar aged individuals with moderate-to-large post-tricuspid shunts (ventricular septal defect, aortopulmonary window, patent ductus arteriosus, or major aortopulmonary collateral vessels), who often have markedly elevated pulmonary vascular resistance and Eisenmenger physiology. However, when compared with earlier timing of intervention, some evidence suggests that patients repaired later in life have higher longer-term morbidity.
Focus patient education on ensuring that the family and caregivers understand potentially serious symptoms so that they seek prompt medical attention when necessary. However, parents also require consistent education regarding long-term prognosis, which is generally quite good, as well as the expected signs and symptoms that can be seen with the defect, which are usually minimal.
Reassurance is often needed due to the stigmata associated with the diagnosis of congenital heart disease (CHD). Some children may be unnecessarily restricted from activity by well-meaning medical personnel or by over-cautious parents.
Education regarding care of an atrial septal defect and its complications should also include input from the cardiologist and cardiac surgeon.
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