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

Atrial Septal Defect, Ostium Secundum: Treatment & Medication

Author: Ira H Gessner, MD, Professor Emeritus, Pediatric Cardiology
Contributor Information and Disclosures

Updated: Nov 10, 2008

Treatment

Medical Care

Small-to-moderate–sized ostium secundum atrial septal defects diagnosed in the infant demonstrate significant likelihood of either spontaneous closure or reduction in size to the point that medical intervention no longer is indicated. Such patients should be followed until age 3-4 years before considering either device use or surgical closure.5,15

Surgical Care

  • Minimally invasive cardiac surgery techniques allow closure without the use of blood or blood products in appropriately sized patients.16,17
    • The skin incision is short because complete vertical division of the sternum is not necessary.
    • If the defect is moderate in size and oval in shape, direct suture closure may be appropriate. Larger or rounder defects require patch closure. The patch can be fashioned from the patient's pericardium or made from Dacron.
    • Results of surgery are excellent; a 100% closure rate should be achieved. Risk of mortality does not exceed that of general anesthesia.18,19
    • Inpatient hospital stay now averages 2-3 days. Perform postoperative echocardiography to confirm closure.
    • Postoperative care includes bacterial endocarditis precautions for 6 months if a patch was placed.
  • Catheter intervention may be indicated.
    • Transcatheter device closure of secundum atrial septal defect now represents a standard of care for this abnormality.20 Experience at centers throughout the world is extensive; the success rate has been high, and the risk of complications has been low.21,22,23 Indication for closure in the pediatric age range is a shunt of sufficient size to be clinically apparent. The reason for closure is to prevent development of complications (eg, atrial dysrhythmia, right heart dysfunction) that may appear in the adult. Small defects in children that are detectable only by echocardiography do not require closure.
    • In adult patients who experience a suspected thrombotic stroke and who manifest a patent foramen ovale (15-20% of all adults demonstrate a patent foramen ovale on echocardiography), concern arises that the stroke may have been caused by a paradoxical embolus.24 In these patients, device closure of the communication is often recommended and accomplished. Studies remain controversial regarding the appropriateness of this treatment.
    • Transcatheter device occlusion of a secundum atrial septal defect should be accomplished only by physicians properly trained and experienced in the procedure. Proper sizing of the defect and anatomic evaluation to assure reliable seating of the device is essential.
    • The device is placed in the atrial septum via a catheter introduced into a femoral vein. Most operators advise monitoring the procedure with transesophageal echocardiography. Multiple studies indicate a high degree of success, with complete closure rates only slightly less than those obtained by surgery.
    • Studies comparing device closure with surgery establish that hospital stay is shorter in patients undergoing device closure. Total costs of the 2 techniques do not significantly differ, apparently because of the cost of the device.25
    • Complications of device occlusion include hemorrhage, vascular disruption, pain, nausea and vomiting, and arterial or venous obstruction from thrombosis or spasm. Other complications include rupture of blood vessel, tachyarrhythmias, bradyarrhythmias, and vascular occlusion. Embolization of the device during placement rarely occurs but can result in emergency surgery for removal. The most common complication is incomplete closure of the defect.26

Consultations

Patients should be evaluated by a pediatric cardiologist. Patients with defects considered appropriate for transcatheter device closure should be evaluated by an interventional pediatric cardiologist experienced in the procedure. If surgery is contemplated, the patient should be evaluated by a cardiovascular surgeon experienced in surgery of congenital heart defects. Ideally, decisions regarding therapy should result from simultaneous evaluation of patient data at a group meeting that includes all of these physicians.

Diet

No special diet is required.

Activity

No activity restrictions are required except for a few weeks following either device closure or heart surgery.

Medication

Drug therapy is not currently a component of the standard of care for this condition. No specific medications are indicated for patients with a secundum atrial septal defect. Bacterial endocarditis prophylaxis is required for the first 6 months following device closure or surgical closure with a patch (see Endocarditis, Bacterial for further information). Preoperatively, antibiotic prophylaxis is not required in an isolated ostium secundum atrial septal defect. For information regarding antibiotics used for endocarditis prophylaxis, see Antibiotic Prophylactic Regimens for Endocarditis.

More on Atrial Septal Defect, Ostium Secundum

Overview: Atrial Septal Defect, Ostium Secundum
Differential Diagnoses & Workup: Atrial Septal Defect, Ostium Secundum
Treatment & Medication: Atrial Septal Defect, Ostium Secundum
Follow-up: Atrial Septal Defect, Ostium Secundum
References
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References

  1. Gessner IH. Atrial septal defect. In: Surgery of Congenital Heart Disease: Pediatric Care Consortium 1984-1995. Armonk, NY: Futura Publishing Co.; 1998:31-44.

  2. Vick GW, Titus JL. Defects of the atrial septum, including the atrioventricular canal. In: Garson A, Bricker JT, Fisher, DJ, Neish, SR eds. The Science and Practice of Pediatric Cardiology. Vol 2. Baltimore, MD: Lippincott Williams & Wilkins; 1998.

  3. Azhari N, Shihata MS, Al-Fatani A. Spontaneous closure of atrial septal defects within the oval fossa. Cardiol Young. Apr 2004;14(2):148-55. [Medline].

  4. Saxena A, Divekar A, Soni NR. Natural history of secundum atrial septal defect revisited in the era of transcatheter closure. Indian Heart J. Jan-Feb 2005;57(1):35-8. [Medline].

  5. 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]. [Full Text].

  6. McMahon CJ, Feltes TF, Fraley JK, et al. Natural history of growth of secundum atrial septal defects and implications for transcatheter closure. Heart. Mar 2002;87(3):256-9. [Medline].

  7. Sachweh JS, Daebritz SH, Hermanns B, et al. Hypertensive pulmonary vascular disease in adults with secundum or sinus venosus atrial septal defect. Ann Thorac Surg. Jan 2006;81(1):207-13. [Medline].

  8. Caputo S, Capozzi G, Russo MG, et al. Familial recurrence of congenital heart disease in patients with ostium secundum atrial septal defect. Eur Heart J. Oct 2005;26(20):2179-84. [Medline].

  9. Sznajer Y, Keren B, Baumann C, et al. The spectrum of cardiac anomalies in Noonan syndrome as a result of mutations in the PTPN11 gene. Pediatrics. Jun 2007;119(6):e1325-31. [Medline]. [Full Text].

  10. Godwin KA, Sibbald B, Bedard T, Kuzeljevic B, Lowry RB, Arbour L. Changes in frequencies of select congenital anomalies since the onset of folic acid fortification in a Canadian birth defect registry. Can J Public Health. Jul-Aug 2008;99(4):271-5. [Medline].

  11. Wu ET, Akagi T, Taniguchi M, et al. Differences in right and left ventricular remodeling after transcatheter closure of atrial septal defect among adults. Catheter Cardiovasc Interv. May 1 2007;69(6):866-71. [Medline].

  12. Walker RE, Moran AM, Gauvreau K, Colan SD. Evidence of adverse ventricular interdependence in patients with atrial septal defects. Am J Cardiol. Jun 1 2004;93(11):1374-7, A6. [Medline].

  13. Giardini A, Donti A, Formigari R, et al. Determinants of cardiopulmonary functional improvement after transcatheter atrial septal defect closure in asymptomatic adults. J Am Coll Cardiol. May 19 2004;43(10):1886-91. [Medline].

  14. Arrington CB, Tani LY, Minich LL, Bradley DJ. An assessment of the electrocardiogram as a screening test for large atrial septal defects in children. J Electrocardiol. Nov-Dec 2007;40(6):484-8. [Medline].

  15. Brassard M, Fouron JC, van Doesburg NH, Mercier LA, De Guise P. Outcome of children with atrial septal defect considered too small for surgical closure. Am J Cardiol. Jun 1 1999;83(11):1552-5. [Medline].

  16. Doll N, Walther T, Falk V, et al. Secundum ASD closure using a right lateral minithoracotomy: five-year experience in 122 patients. Ann Thorac Surg. May 2003;75(5):1527-30; discussion 1530-1. [Medline].

  17. Argenziano M, Oz MC, Kohmoto T, et al. Totally endoscopic atrial septal defect repair with robotic assistance. Circulation. Sep 9 2003;108 Suppl 1:II191-4. [Medline]. [Full Text].

  18. Shah D, Azhar M, Oakley CM, et al. Natural history of secundum atrial septal defect in adults after medical or surgical treatment: a historical prospective study. Br Heart J. Mar 1994;71(3):224-7; discussion 228. [Medline].

  19. Bolz D, Lacina T, Buser P, et al. Long-term outcome after surgical closure of atrial septal defect in childhood with extensive assessment including MRI measurement of the ventricles. Pediatr Cardiol. Sep-Oct 2005;26(5):614-21. [Medline].

  20. Lock JE, Cockerham JT, Keane JF, et al. Transcatheter umbrella closure of congenital heart defects. Circulation. Mar 1987;75(3):593-9. [Medline].

  21. Jones TK, Latson LA, Zahn E, et al. Results of the U.S. multicenter pivotal study of the HELEX septal occluder for percutaneous closure of secundum atrial septal defects. J Am Coll Cardiol. Jun 5 2007;49(22):2215-21. [Medline].

  22. Patel A, Lopez K, Banerjee A, Joseph A, Cao QL, Hijazi ZM. Transcatheter closure of atrial septal defects in adults > or =40 years of age: immediate and follow-up results. J Interv Cardiol. Feb 2007;20(1):82-8. [Medline].

  23. Post MC, Suttorp MJ, Jaarsma W, Plokker HW. Comparison of outcome and complications using different types of devices for percutaneous closure of a secundum atrial septal defect in adults: a single-center experience. Catheter Cardiovasc Interv. Mar 2006;67(3):438-43. [Medline].

  24. Handke M, Harloff A, Olschewski M, Hetzel A, Geibel A. Patent foramen ovale and cryptogenic stroke in older patients. N Engl J Med. Nov 29 2007;357(22):2262-8. [Medline].

  25. Vida VL, Barnoya J, O'Connell M, et al. Surgical versus percutaneous occlusion of ostium secundum atrial septal defects: results and cost-effective considerations in a low-income country. J Am Coll Cardiol. Jan 17 2006;47(2):326-31. [Medline].

  26. 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. Jan 2006;151(1):228-34. [Medline].

  27. Giardini A, Donti A, Specchia S, Formigari R, Oppido G, Picchio FM. Long-term impact of transcatheter atrial septal defect closure in adults on cardiac function and exercise capacity. Int J Cardiol. Feb 29 2008;124(2):179-82. [Medline].

  28. Brochu MC, Baril JF, Dore A, et al. Improvement in exercise capacity in asymptomatic and mildly symptomatic adults after atrial septal defect percutaneous closure. Circulation. Oct 1 2002;106(14):1821-6. [Medline]. [Full Text].

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Further Reading

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Keywords

ostium secundum atrial septal defect, ASD, fossa ovalis defect, secundum atrial septal defect, atrial dysrhythmia, right heart dysfunction, patent foramen ovale, chronic right atrial dilation, heart failure, atrial fibrillation, atrial flutter, atrial dysrhythmia, stroke, obstructive pulmonary vascular disease, failure to thrive, bacterial endocarditis, primary pulmonary hypertension, pulmonary valve stenosis, Holt-Oram syndrome

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Contributor Information and Disclosures

Author

Ira H Gessner, MD, Professor Emeritus, Pediatric Cardiology
Ira H Gessner, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Pediatric Society, and Society for Pediatric Research
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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