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Posts Tagged ‘ostium primum’

Atrial  septal defects  are one of the commonest forms of congenital heart disease.

  • The commonest being the ositum secundum ASD     ( Which is in fact is a defect in the development of septum primum)
  • The next common is ostium primum defect which is a part of AV canal or atrio ventricular septal defect.

Other forms of ASD include

  • SVC type /Also  called sinus venosus type of ASD .
  • IVC type
  • Coronary sinus defect -Also called partial or complete forms of unroofed coronary sinus

asd svc asd sinus venosus

SVC type ASDs

They are in the strict sense can not be called as ASD. This is because there is no defect in  any of the  embryological  inter atrial septal component.

There is no direct communication between RA and LA, instead   a window  or passage of communication   between pulmonary vein and SVC. Right upper lobe pulmonary vein  is usually the culprit .Some times more than one PV  communicates with SVC.

The exact area of this PV-SVC window occur between anterior surface of right upper lobe PV with postero lateral surface of SVC.

PAPVC partial anomalous pulmonary venous drainage can be considered an integral part of this defect as RUPV is linked with SVC.

Can we have a combination of SVC ASD and OS ASD ?

This is possible .But two embryological errors need to occur. This is often seen as a large OS ASD with deficient or absent superior rim. So whenever superior rim of IAS is deficient a PAPVC and a SVC ASD should be looked for.

Clinical features

  • SVC type ASDs  generally shunt lesser blood than OS ASDs. (Often<2:1) .This is because it is not the LA that is communicating with RA instead only a
  • It is usually a single PV (some times 2) that shunts from left to right.

There is a distinct possibility of missing this lesion in routine echo.Minimal RA,RV enlargement may give us a clue.The classical subcostal or  4 chamber  view in echocardiography may not visualise  these defects.

So, whenever one encounters mild dilatation  of RA and RV and the IAS appears  intact, a meticulous search and a focused echo in the superior aspect of IAS is warranted. Angled  superior views may pick up this defect.A transesophageal echocardiogram (TEE) is often required to  confirm it.

Therapeutic issues

  • Device closure is not possible
  • Surgery involves little more technicality than ASD OS.
  • Small defects can be patch closed.
  • Some times the SVC has to be disconnected from the PV and anastamosed separately on right atrial appendage. SVC resection  will  aid the surgeon in proper patch closure.
  • Post operative follow up is necessary as SVC obstruction or PV obstruction may be a delayed consequence

References

svc asd sinus venosus

http://ats.ctsnetjournals.org/cgi/content/full/59/6/1588?ijkey=4f42649bc5805f3cf7d60f5728ec7f871356277b

http://asianannals.ctsnetjournals.org/cgi/content/full/10/3/231

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Atrial septal defect is one among the commonest congenital heart disease .After years of controversy, there is consensus  now , all significant ASDs  need to be closed ,  at whatever age it is detected.

This rule does not apply to small ASDs without chamber  right atrial and right ventricular dilatation. These defects and PFOs need not be closed .

Over the years , the  controversy  has shifted  from   Should we close ?  to  How to close ?

There are two options available : Device closure , Surgical closure

asd closure device www.drsvenkatesan.com

asd closure www.drsvenkatesan.com

The following table compares the both treatment  modalities

( Personal perspective )

asd device closure 4

Final message

Device closure is a complex, costly, often  difficult  and  error prone   cardiac procedure .It needs long term follow up and may  carry a life long risk of major cardiac complication.It is useful only in selected subset of ASD patients. Surgical closure prevails over device closure in most situations.

Is this article  has biased view against this  emerging pediatric  interventional procedure of ASD closure ?

It may appear so . But that is the reality as on 2009 !.May we hope technology evolves further and take our surgeons head on .

2012 update on ASD device closure .

The   hard-ware  as well as the  expertise has   improved a lot and it is on right track to become a real challenge to surgery.

The only issue again is the availability of  rims to mount the device . Another  realistic and sensitive issue  which  have I come across is  , many interventionist cardiologist do feel awkward  when they experience  unexpected rim shortage on table.  They should realise it is not their  fault.

Always be ready to abandon the procedure and refer to the surgeon , according to your  true conscience 

After all , improperly delivered device is  a life long pain for the patient .He has come to you with a  great belief  isn’t !

2014 update

Device closure for most ASDs in both children and adult is  now possible with high degree of success. We have crossed about 50 patient experience. And  I am truly amazed  , how within a short period the device closure is about to conquer the crown from the surgeons ! (Exciting new data are coming from   my colleague Dr Gnanavelu from  the new Super specialty hospital of Government of Tamil Nadu Chennai. )

 

Reference

Aortic erosion following ASD closure

http://content.onlinejacc.org/cgi/content/full/45/8/1213

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