Atrial septal defect indications for surgical repair in adults
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Priyamvada Singh, M.B.B.S. [[2]]; Cafer Zorkun, M.D., Ph.D. [3]; Assistant Editor-In-Chief: Kristin Feeney, B.S. [[4]]
Overview
The decision for surgical closure in atrial septal defects depends on many contributing factors like type of defect, size of defect, amount of left-to-right shunting, development or worsening of symptoms, presence of pulmonary hypertension and presence of any associated anomalies. Once an individual is diagnosed with an atrial septal defect, a determination of whether it should be corrected has to be made.
Indications for atrial septal defect in adults
1) Amount of blood shunting across the defect
Size and amount of blood shunting across the defect serve as a good indicator of the progression and worsening of the disease. The pulmonary-to-systemic flow ratio Qp/Qs gives a good idea of the shunting. Cardiac catheterization gives more accurate diagnosis of Qp/Qs, however echocardiography and doppler ultrasound is more commonly used as it is convenient, non-invasive and cheap.
- Qp/Qs is calculated as Qp/Qs = [PA diameter(2) x VTI-PA] ÷ [LVOT diameter(2) x VTI-LVOT] where PA = pulmonary artery, VTI-PA = velocity time of the Doppler flow signal, LVOT = left ventricular outflow tract, and VIT-LVOT = maximum Doppler flow velocity apical to the aortic valve.
- If the pulmonary arterial pressure is more than 2/3 the systemic systolic pressure, there should be a net left-to-right shunt of at least 1.5:1 or evidence of reversibility of the shunt when given pulmonary artery vasodilators prior to surgery. If Eisenmenger's syndrome has developed, it must be demonstrated that the right-to-left shunt is reversible with pulmonary artery vasodilators prior to surgery.
- The American Heart Association has recommended a threshold Qp/Qs ≥1.5:1 for patients 21 years of age or older. [1]
- The Canadian Cardiac Society recommended a threshold Qp/Qs >2:1, or >1.5:1 in the presence of reversible pulmonary hypertension [2].
- The Qp/Qs ratio can change as the disease progresses. Due to this it has been recommended to have a echocardiography every 2-3 years in asymptomatic patients.
2) Development of symptoms
- Development and worsening of symptoms such as shortness of breath, exercise intolerance, fatigue, swelling of feet and ankle or abdomen (suggesting right sided heart failure), recurrent respiratory infections along with echocardiographic abnormalities are an indication for repair.
- Arrrhythmias as an isolated symptom can occur in 1 out of 5 adults patients with atrial septal defects. The surgical closure for patients presenting only with arrhythmia is controversial as not much benefit could be derived even after surgery.
3) Size of defect
- Secundum ASDs <6 mm diameter in infants may close spontaneously by the end of two years of life. Thus, in asymptomatic patients with small defects early closure is not indicated.
- Defects of moderate size (6 to 8 mm) have fewer chances to close spontaneously. Despite this surgical closure of these defects are not indicated before two years of age, in case these are asymptomatic
4) Age
- Closure of an ASD in individuals under age 25 has been shown to have a low risk of complications, and individuals have a normal lifespan (comparable to a healthy age-matched population).
- Closure of an ASD in individuals between the ages of 25 and 40 who are asymptomatic but have a clinically significant shunt is controversial. Those that perform the procedure believe that they are preventing long-term deterioration in cardiac function and preventing progression of pulmonary hypertension.
Trial supportive data
In a study done by Konstantinides et al. it was found that the surgical repair of an atrial septal defect in patients over 40 years of age, decreases all causes mortality, increases long-term survival and decreases complications like heart failure when compared with medical therapy. However, surgically treated patients may have an increased risk of arrhythmias and thromboembolic episodes and therefore should be closely watched for it.[3]
Special conditions
Pregnancy
Migraine
- Migraine could be a complication seen with patent foramen ovale and atrial septal defect. There exists a controversy on the surgical repair to close these defects to prevent migraine.
See also
References
- ↑ Driscoll D, Allen HD, Atkins DL, Brenner J, Dunnigan A, Franklin W; et al. (1994). "Guidelines for evaluation and management of common congenital cardiac problems in infants, children, and adolescents. A statement for healthcare professionals from the Committee on Congenital Cardiac Defects of the Council on Cardiovascular Disease in the Young, American Heart Association". Circulation. 90 (4): 2180–8. PMID 7923709.
- ↑ Therrien J, Dore A, Gersony W, Iserin L, Liberthson R, Meijboom F; et al. (2001). "CCS Consensus Conference 2001 update: recommendations for the management of adults with congenital heart disease. Part I.". Can J Cardiol. 17 (9): 940–59. PMID 11586386.
- ↑ Konstantinides S, Geibel A, Olschewski M, Görnandt L, Roskamm H, Spillner G; et al. (1995). "A comparison of surgical and medical therapy for atrial septal defect in adults". N Engl J Med. 333 (8): 469–73. doi:10.1056/NEJM199508243330801. PMID 7623878.