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Showing posts with label Atrial septal defect. Show all posts
Showing posts with label Atrial septal defect. Show all posts

Is prophylaxis against infective endocarditis recommended in atrial septal defect ?

Is prophylaxis against infective endocarditis recommended in atrial septal defect ? 


Prophylaxis against infective endocarditis is not recommended for patients with atrial septal defects (repaired or unrepaired) unless a concomitant valvular abnor-mality (e.g. mitral valve cleft or prolapse) is present.

Leonardo da Vinci's description in 1513 of a 'perforating channel' in the atrial septum is believed to be the first recorded account of a congenital malformation of the human heart.

Rene Lutembacher, a French physician, described the Lutembacher syndrome in 1916. Mary Holt, cardiologist, King% Culluge Hu~pltdI, London. Samuel Oram, cardiologist, King's College Hospital, London.
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How would you manage an uncomplicated atrial septal defect ?

How would you manage an uncomplicated atrial septal defect ?
 

Early childhood
 

If the defect is detected in early childhood, surgical closure is recommended between the ages of 5 and 10 years to prevent the late onset of either right ven-tricular failure, atrial arrhythmias or right heart failure.
 

In adults
 

• Small ASDs can be left alone, although many believe that all ASDs must be closed. Those operated on before the age of 25 years have an excellent prognosis and one may anticipate normal long-term survival, but older patients require regular supervision. In a recent study, surgical repair of atrial septal defects in middle-aged and elderly patients was found to improve longevity and reduce functional limitation due to heart failure, and is therefore superior to medical treatment. However, the risk of atrial arrhythmias, especially fibrillation and flutter, and the attendant risk of thromboembolic events was not reduced by closure of the defect.
 

• Left-to-right shunt saturations of 1.5:1 or more require surgical closure to prevent right ventricular dysfunction.
 

• Closure in adults results in a reduction in right ventricular size and improves symptoms.
More recently, ASDs are being occluded by transcatheter button or 'clam-shell devices'.
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How is pregnancy tolerated in a woman with atrial septal defect ?

How is pregnancy tolerated in a woman with atrial septal defect ?

 Pregnancy is usually well tolerated in uncomplicated atrial septal defects; however, when the defect is complicated by significant pulmonary hypertension there is increased maternal and fetal morbidity and mortality and hence pregnancy should be avoided in Eisenmenger syndrome. Rapidly progressive pulmonary vascular disease may develop during pregnancy, therefore routine closure of atrial septal defect is recommended before pregnancy.
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What are the complications of atrial septal defect ?

What are the complications of atrial septal defect ? 

• Atrial arrhythmias: atrial fibrillation is most common. Atrial fibrillation is often accompanied by the appearance of tricuspid regurgitation. Patients are usually in normal sinus rhythm in the first three decades of life, alter which atrial arrhythmias including atrial fibrillation and supraventricular tachycardia may appear.

• Pulmonary hypertension with the development of right ventricular disease.

• Eisenmenger syndrome with reversal of shunt.

• Paradoxical embolus.

• Infective endocarditis in patients with ostium primum defects only.

 • Recurrent pulmonary infections.
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How would you investigate a patient with atrial septal defect ?

How would you investigate a patient with atrial septal defect ?

 ECG

 • Often has right axis deviation and incomplete right bundle branch block.

• In ostium primum defects left axis deviation also occurs, whereas a junctional or low atrial rhythm (inverted P waves in inferior leads) occurs in sinus venosus defects.


Chest radiography 

• Prominent pulmonary arteries (large pulmonary conus).

• A peripheral pulmonary vascular pattern of 'shunt vascularity' (in which the small pulmonary arteries are especially well visualized in the periphery of both lungs).

• Small aortic knob. • Enlarged right ventricle and right atrium.

• 'Hilar dance' on fluoroscopy.

Echocardiography

 • Transthoracic echocardiography visualizes ostium secundum and primum defects but usually does not identify sinus venosus defects. • Sensitivity can be enhanced by injecting microbubbles into a peripheral vein. after which the movement across the defect can be seen.

• Trans-oesophageal and Doppler colour-flow echocardiography is useful in detecting and determining the location of atrial septal defects and also in identifying anomalous venous drainage and sinus venosus defects.

Cardiac catheterization Often unnecessary in diagnosis but is useful in determining the magnitude and direction of shunting and to determine the severity and reversibility of pulmonary hypertension.
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What do you know about the embryology of atrial septal defect ?

What do you know about the embryology of atrial septal defect ? 

There are seven septa involved in the partitioning of the heart.

Three form passively (i.e. when an area of tissue forms a septum because of the rapid growth of con-tiguous tissue); these include the septum secundum at the atrial septum, the mus-cular portion of the ventricular septum and the aorticopulmonary septum.

The actively formed portions of the septa of the heart include the septum of the atrio-ventricular canal, the conal septum and the truncal septum.

The atrial septum begins as a passively formed septum; however, active growth from the endocardial cushions completes the septum.
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What are the types of atrial septal defect (ASD) ?

What are the types of atrial septal defect (ASD) ? 

• Ostium secundum detect accounts for 70% of the cases. The defect is in the middle portion of the atrial septum and is usually 24 cm in diameter (incomplete right bundle branch block pattern, QRS axis rightward).

• Sinus venosus type is a defect in the septum just below the entrance of the superior vena cava into the right atrium (leftward P wave axis so that P waves are inverted in at least one inferior lead).

• Ostium primum type is a defect in the lower part of the septum, and clefts may occur in the mitral and tricuspid valves (QRS axis leftward). A junctional or low atrial rhythm (inverted P waves in the inferior leads) occurs with sinus venosus defects.
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