Acyanotic Congenital Heart Disease - ASD (Dr. Gunasekaran)

1. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
ACYANOTIC CONGENITAL HEART DISEASE

2. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD

3. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Sinus venous
defect – near
the entry of
SVC, IVC
Coronory sinus
Ostium primum-
lower part of
septum
Down Syn(MVPS)
Ostium Secondum – in
the upper part of septum
(Most common)

4. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD

5. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
RATV RVPV  PALungsPVLALVAorta
Other parts of the body
What organic murmur? Why?
What flow murmurs? Why?
Which chamber gets enlarged? Position of AI? Type of AI?
Why recurrent RTI?

6. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Size: Defect of what size of ASD , usually cause symptoms in
infancy?
2 cm

7. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Symptoms in ASD
Small ASD:
Asymptomatic; growth is normal;
Murmur & Change in HS - routine clinical examination.
Large ASD:
Breathlessness on exertion
Exercise intolerance
Feeding difficulties
Failure to thrive
Frequent RTI (in all RTIs)
Forehead sweating (if failure)
Chest pain, palpitation, syncope ???

8. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Vitals in ASD
Pulse: Volume? Rate? Character? Rhythm?
Blood pressure?

9. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Examination of heart
Inspection:
Precordial bulge (Cardiomegaly – Pliable chest)
Harrison sulcus +/-
Respiratory distress (LRTI)

10. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Examination of heart
Palpation:
Apical position:
Shifted out (RV enlarge)
Apical impulse type:
Normal
Palpate in the para-sternal area:
Para-sternal lift due to volume overload to RV

11. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Examination of heart
Auscultation:
Heart sounds: what is the change in S2
S2 wide & fixed split; do not vary with respiration.
Murmurs: what murmur is common? Why it occurs?
ESM – Pulmonary area - grade 2 0r 3
(Remember, shunt remains silent)
Other possible murmurs: Flow murmurs –MDM at TA
Inspn: A2 P2
Expn: A2 P2

12. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Differential diagnosis of Wide S2
Late Pulmonary Valve closure:
Electrical:
RBBB (Delayed excitation & hence, delayed emptying of RV)
WPW
Mechanical:
PS: Systolic overload
ASD , TAPVC: Diastolic overload
RVF: Combined Systolic & Diastolic overload
Early Aortic Valve closure:
MR

13. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Complications
Frequent LRTI
Failure to thrive
Congestive Cardiac Failure – Very rare (only in 3rd or 4th decade)
Pulmonary Hypertension- Very rare
Eisenmenger’s syndrome – Very rare
Infective Endocarditis-Unknown in OS type

14. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Natural History
Spontaneous closure : based on size & age
< 3 mm: 100% close, by 1 ½ years of age
>8 mm / > 2 years: rarely, close

15. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Investigations
Chest X Ray: Cardiomegaly, Increased PBF, Lung Infn.
ECG: Chamber enlargement
ECHO:

16. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Management
Medical:
Diet: High calorie & high protein
Anemia correction

17. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Management - Surgical
Closure: Simple suture
Patch of Pericardium or Teflon
Decision based on
Size of defect
Age: surgery is usually delayed until 2-4 years of age

18. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Management - Surgical
Contraindications for surgery: severe PHT
PVR > 8 wood units/m2 BSA not responding to isoproterenol infusion
> 12 wood units / m2 BSA

19. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD
Syndromes associated with ASD
1. Chromosomal anomalies: Trisomies 21 (Down synd)
Trisomy 18 (Edward synd)
Trisomy 13 (Patau synd)
2. Syndromes:
Holt - Oram syndrome (Thumb with extra phalanx &
deformities of radius and ulna)
TAR syndrome: Thrombocytopenia & Absent Radius
3. Maternal conditions: Phenytoin, Congenital Rubella

20. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASDOS ASD OP ASD
More common Less common
Defect is high in the septum Defect is low in septum
Not connected with Down Often associated with
Down’s
No Valve defects MVPS is seen in 8-37%
PHT is very rare PHT is possible
ECG: RAD (+60-90) (N:
+40-60)
ECG: LAD (0-30)

21. Dr. D. Gunasekaran D, MD., Dept., o f Paediatrics, MGMCRI.
Acyanotic Congenital Heart Disease - ASD