eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology

Atrial Septal Defect, General Concepts: Follow-up

Author: Michael R Carr, MD, Pediatric Cardiologist, Naval Medical Center Portsmouth
Coauthor(s): Brent R King, MD, Associate Professor of Emergency Medicine and Pediatrics, University of Texas Health Science Center at Houston; Chair, Department of Emergency Medicine, Memorial Hermann Hospital, Lyndon B Johnson General Hospital
Contributor Information and Disclosures

Updated: Oct 30, 2008

Follow-up

Further Inpatient Care

  • Please refer to the sections regarding the specific subtypes of atrial septal defect (ASD) for potential inpatient issues.

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 ASD 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 ASDs 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 are seen by a cardiologist more frequently than this.

Transfer

  • An isolated ASD almost never causes clinically significant problems in the neonatal period or in infancy.
  • Refer a child who is to have elective ASD surgical repair to a pediatric center with experience in performing cardiopulmonary bypass and surgical ASD closure in young children.
  • A patient with an ostium primum ASD may have associated severe 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.

Complications

  • ASD is usually an asymptomatic disease. However, children with ASDs 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 ASDs than in children without ASDs.
  • Children with clinically significant and untreated ASDs are at risk for various cardiac complications, including CHF, pulmonary hypertension, and arrhythmias. However, these cardiac complications generally manifest in adulthood.

Prognosis

  • The prognosis for a child with an ASD 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.
  • Ostium secundum defects may spontaneously close. The likelihood of spontaneous closure appears to be closely related to the initial size of the defect. Some studies show that defects do not occur with ostium primum, sinus venosus, or coronary sinus defects.
  • Certain patients with ostium primum ASDs and an abnormal mitral valves may require a second operation for mitral valve dysfunction later in their lives.

Patient Education

  • Focus patient education on ensuring that the family and caregivers understand potentially serious symptoms so that they seek prompt medical attention when necessary.
  • In addition, reassurance is often needed because of the stigmata associated with the diagnosis of congestive heart disease (CHD).
  • Children may be unnecessarily restricted from activity.
  • Education regarding care of an ASD and its complications also should include input from the cardiologist and cardiac surgeon.

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose an atrial septal defect (ASD) in a child referred for evaluation of a murmur is a pitfall. A second examination is often necessary at a later time, especially if the initial examination is difficult in a young child or infant. However, in such circumstances, the family must be reliable regarding follow-up. In such circumstances, if findings on the repeat examination are still equivocal, echocardiography is warranted.
  • Recommending closure of an ASD in a patient with pulmonary hypertension and advanced pulmonary vascular disease in whom repair of the defect is unlikely to yield benefit or likely to worsen the patient's condition is another pitfall.
  • Recommending a transcatheter approach in a patient with a primum, sinus venosus, or coronary sinus ASD is a pitfall.

Special Concerns

  • In the rare instance that a child has a hemodynamically significant ASD and ECG evidence of Wolff-Parkinson-White Syndrome, consideration should be given to performing an electrophysiologic study to evaluate the accessory pathway prior to closure of the ASD, either percutaneously or surgically. This is due to the possibility of a left-sided accessory pathway, which may be difficult to access after closure of the ASD.
 


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References
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References

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Further Reading

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Keywords

atrial septal defect, ASD, congenital heart defect, ostium primum defect, ostium secundum defect, sinus venosus defect, coronary sinus septal defect, malalignment-type ASD, hypoplastic left heart syndrome, hypoplastic left heart syndrome, partial anomalous pulmonary venous connection, unroofed coronary sinus, congenital heart disease, atrial fibrillation, pulmonary hypertension, congestive heart failure, CHF, stroke, upper respiratory tract infection, pulmonary vascular obstructive disease, pulmonary artery hypertension, right ventricular hypertrophy, heart block, Down syndrome, hypertrophic cardiomyopathy

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Contributor Information and Disclosures

Author

Michael R Carr, MD, Pediatric Cardiologist, Naval Medical Center Portsmouth
Michael R Carr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Cardiology, American Heart Association, and American Society of Echocardiography
Disclosure: Nothing to disclose.

Coauthor(s)

Brent R King, MD, Associate Professor of Emergency Medicine and Pediatrics, University of Texas Health Science Center at Houston; Chair, Department of Emergency Medicine, Memorial Hermann Hospital, Lyndon B Johnson General Hospital
Brent R King, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, American College of Physician Executives, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Paul M Seib, MD, Associate Professor of Pediatrics, University of Arkansas for Medical Sciences; Medical Director, Cardiac Catheterization Laboratory, Co-Medical Director, Cardiovascular Intensive Care Unit, Arkansas Children's Hospital
Paul M Seib, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, Arkansas Medical Society, International Society for Heart and Lung Transplantation, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Alvin J Chin, MD, Professor of Pediatrics, Division of Cardiology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine
Alvin J Chin, MD is a member of the following medical societies: American Association for the Advancement of Science and American Heart Association
Disclosure: Nothing to disclose.

CME Editor

Gilbert Herzberg, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College
Gilbert Herzberg, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Chief Editor

Steven R Neish, MD, SM, Director of Pediatric Cardiology Fellowship Program, Associate Professor, Department of Pediatrics, Baylor College of Medicine
Steven R Neish, MD, SM is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and American Heart Association
Disclosure: Nothing to disclose.

 
 
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