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

Atrial Septal Defect, General Concepts: Treatment & Medication

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

Treatment

Medical Care

Medical therapy is of no benefit in children with asymptomatic atrial septal defects (ASDs).

  • With the exception of ostium secundum types, ASDs are structural defects that do not spontaneously close. Surgical closure is ultimately required for most ASDs, other than ostium secundum ASDs. An ostium secundum ASD that measures 6 mm in diameter or smaller in the patient's first year of life is likely to spontaneously close; however, such closure is substantially slower than that of a typical small, muscular ventricular septal defect.
  • Infants who are severely affected with an ASD and who develop congestive heart failure (CHF) may be treated as any other child with CHF from a left-to-right shunt. This treatment, which includes diuretics, digoxin, and afterload reduction, is covered in other articles.
  • Arrhythmias associated with ASD are similarly uncommon in childhood but have become increasingly common with age. In fact, the development of atrial fibrillation may trigger CHF in adults with ASD who are younger than 40 years. Arrhythmias may result from atrial distention, and these individuals may require antiarrhythmic therapy until the ASD is repaired.
  • Some children with an ASD develop recurrent respiratory tract infections, which may be poorly tolerated.
  • Bacterial endocarditis prophylaxis is not necessary for the typical patient with an isolated ASD, regardless of the type of ASD. Prophylaxis is recommended prior to surgical repair if the ASD is part of complex cyanotic congenital heart disease (CHD).  Endocarditis prophylaxis is recommended for 6 months following either surgical or percutaneous repair of ASDs and, in some instances, may be recommended for longer in patients with residual mitral valve abnormalities after surgical repair of primum ASDs. For more information see Antibiotic Prophylactic Regimens for Endocarditis.5

Surgical Care

Definitive therapy for an ASD has historically been limited to surgical closure. However, with the advent of transcatheter techniques, many children undergo successful treatment in the cardiac catheterization laboratory.

  • The most common surgical approach to the defect is primary repair with suture closure or with patch repair (generally with glutaraldehyde treated autologous pericardium or fabric made of polyester fiber [Dacron]).
  • Not all children with an ASD are candidates for surgery, which is only indicated for those children with clinically significant left-to-right shunting.
    • In general, a pulmonary-to-systemic flow ratio of 1.5:1 or more is considered the principal indication for surgical repair. Shunting less than this in children with small defects and in those with existing pulmonary hypertension may be observed.
    • Because cardiac catheterization is rarely necessary, echocardiographic evidence of right atrial and right ventricular enlargement is usually considered evidence of a clinically significant left-to-right shunt and an indication for surgical closure of the ASD.
  • Surgery is ideally performed in children aged 2-4 years and has a low mortality rate. However, surgery may be performed earlier than this if the child has evidence of CHF.
  • Newer, minimally-invasive surgical techniques have been developed. These improve cosmetic appearances and decrease hospital stays. These techniques are ideally suited for simple closure of a secundum ASD.
  • The surgical mortality rate is low in patients with uncomplicated ASDs. In an experienced pediatric center, the mortality rate should be less than 1%.
  • Postoperative morbidity in individuals with ASDs is almost exclusively due to accumulation of pericardial fluid (postpericardiotomy syndrome), which occurs in approximately one third of patients. On occasion, tamponade occurs and requires pericardiocentesis. Pericardial effusion should be suspected in any pediatric patient who undergoes postsurgical repair of an ASD and who presents with chest pain, fever, shortness of breath, or general malaise. In young children, symptoms may be nonspecific and include irritability and decreased appetite.
  • Transcatheter approaches to ASD closure have gained acceptance in the pediatric population.
    • Secundum ASDs are currently the only subtype of ASD that are amenable to this approach.
    • Such techniques require individuals with considerable expertise in the field of interventional pediatric cardiology and cooperation between the interventionalist and the noninvasive imaging specialists.
    • Benefits of the transcatheter approach include its minimal invasiveness, the lack of median sternotomy, the avoidance of cardiopulmonary bypass, and the relatively quick recovery time. Potential drawbacks and concerns include residual shunting around the device, embolization during placement requiring surgical intervention, lack of adequate septal rims to properly seat the device, long-term safety concerns, and the need for specific technical expertise and equipment. Although relatively new, transcatheter approaches for ASD closure are becoming prevalent, and studies are showing a high success rate.

Consultations

  • Diagnosis of an ASD in a newborn or an older child should prompt consultation with a pediatric cardiologist.
  • Almost all newborns have a small left-to-right shunt at the foramen ovale, as detected during echocardiography in the neonatal period. In the absence of a murmur or other signs of a true ASD on subsequent well-child care visits, consultation with a cardiologist is probably not necessary, although review of the initial echocardiogram report is prudent to verify the description of the defect.

Activity

  • Children with ASDs generally have no restrictions on their activity.
  • Children with compensated CHF with an ASD are candidates for surgical or catheter-based intervention and should be able to resume normal activity after the defect is corrected.

Medication

Medication is not currently a component of care for this condition. See Treatment.

More on Atrial Septal Defect, General Concepts

Overview: Atrial Septal Defect, General Concepts
Differential Diagnoses & Workup: Atrial Septal Defect, General Concepts
Treatment & Medication: Atrial Septal Defect, General Concepts
Follow-up: Atrial Septal Defect, General Concepts
Multimedia: Atrial Septal Defect, General Concepts
References
[ CLOSE WINDOW ]

References

  1. Van Praagh R, Corsini I. Cor triatriatum: pathologic anatomy and a consideration of morphogenesis based on 13 postmortem cases and a study of normal development of the pulmonary vein and atrial septum in 83 human embryos. Am Heart J. Sep 1969;78(3):379-405. [Medline].

  2. Weinberg PM, Chin AJ, Murphy JD, et al. Postmortem echocardiography and tomographic anatomy of hypoplastic left heart syndrome after palliative surgery. Am J Cardiol. Dec 1 1986;58(13):1228-32. [Medline].

  3. Basson CT, Bachinsky DR, Lin RC, et al. Mutations in human TBX5 [corrected] cause limb and cardiac malformation in Holt-Oram syndrome. Nat Genet. Jan 1997;15(1):30-5. [Medline].

  4. Hirayama-Yamada K, Kamisago M, Akimoto K, et al. Phenotypes with GATA4 or NKX2.5 mutations in familial atrial septal defect. Am J Med Genet A. 2005;135(1):47-52. [Medline].

  5. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. Oct 9 2007;116(15):1736-54. [Medline].

  6. Alexi-Meskishvili VV, Konstantinov IE. Surgery for atrial septal defect: from the first experiments to clinical practice. Ann Thorac Surg. Jul 2003;76(1):322-7. [Medline].

  7. Bierman FZ, Williams RG. Subxiphoid two-dimensional imaging of the interatrial septum in infants and neonates with congenital heart disease. Circulation. Jul 1979;60(1):80-90. [Medline].

  8. Bruneau BG. The developmental genetics of congenital heart disease. Nature. Febuary 2008;451(7178):943-8. [Medline].

  9. Butera G, Carminati M, Chessa M, et al. Percutaneous versus surgical closure of secundum atrial septal defect: comparison of early results and complications. Am Heart J. 2006;151(1):228-34. [Medline].

  10. Chin AJ, Murphy JD. Identification of coronary sinus septal defect (unroofed coronary sinus) by color Doppler echocardiography. Am Heart J. Dec 1992;124(6):1655-7. [Medline].

  11. Chin AJ, Weinberg PM, Barber G. Subcostal two-dimensional echocardiographic identification of anomalous attachment of septum primum in patients with left atrioventricular valve underdevelopment. J Am Coll Cardiol. Mar 1 1990;15(3):678-81. [Medline].

  12. Driscoll DJ. Left-to-right shunt lesions. Pediatr Clin North Am. Apr 1999;46(2):355-68, x. [Medline].

  13. Friedman WF. Congenital heart disease in infancy and childhood. In: Braunwald ed. Heart Disease: A Textbook of Cardiovascular Medicine. 5th ed. 1997:896-910.

  14. Fukazawa M, Fukushige J, Ueda K. Atrial septal defects in neonates with reference to spontaneous closure. Am Heart J. Jul 1988;116(1 Pt 1):123-7. [Medline].

  15. Hanslik A, Pospisil U, Salzer-Muhar U, Greber-Platzer S, Male C. Predictors of spontaneous closure of isolated secundum atrial septal defect in children: a longitudinal study. Pediatrics. Oct 2006;118(4):1560-5. [Medline].

  16. Helgason H, Jonsdottir G. Spontaneous closure of atrial septal defects. Pediatr Cardiol. 1999;20(3):195-9. [Medline].

  17. Jonas RA. Atrial septal defect. In: Comprehensive Surgical Management of Congenital Heart Disease. 2004:225-41.

  18. Mahoney LT, Truesdell SC, Krzmarzick TR, Lauer RM. Atrial septal defects that present in infancy. Am J Dis Child. Nov 1986;140(11):1115-8. [Medline].

  19. Mas MS, Bricker JT. Clinical physiology of left-to-right shunts. In: The Science and Practice of Pediatric Cardiology. Vol 2. 1990:999-1001.

  20. Murphy JG, Gersh BJ, McGoon MD, et al. Long-term outcome after surgical repair of isolated atrial septal defect. Follow-up at 27 to 32 years. N Engl J Med. Dec 13 1990;323(24):1645-50. [Medline].

  21. Patel HT, Hijazi ZM. Pediatric catheter interventions: a year in review 2004-2005. Curr Opin Pediatr. 2005;17(5):568-73. [Medline].

  22. Porter CJ, Feldt RH, Edwards WD, et al. Atrial septal defects. In: Heart Disease in Infants, Children, and Adolescents. Vol 1. 6th ed. 2001:603-17.

  23. Radzik D, Davignon A, van Doesburg N, et al. Predictive factors for spontaneous closure of atrial septal defects diagnosed in the first 3 months of life. J Am Coll Cardiol. Sep 1993;22(3):851-3. [Medline].

  24. Yeager SB, Chin AJ, Sanders SP. Subxiphoid two-dimensional echocardiographic diagnosis of coronary sinus septal defects. Am J Cardiol. Sep 1 1984;54(6):686-7. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

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

[ CLOSE WINDOW ]

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.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.