Transcript How do you manage this patient?

How do you manage this
patient?
Medical management
• should include treatment of possible
complications:
– Respiratory tract infections
– Arrhythmias, atrial fibrillation, supraventricular
tachycardia
– Pulmonary hypertension, coronary artery disease,
heart failure
– Infective endocarditis
Harrison’s Principles of Internal Medicine 17th ed.
Surgical management
• Operative repair – definitive management
• with a patch of pericardium OR
• prosthetic material OR
• percutaneous transcatheter device closure
should be advised for all patients with
uncomplicated secundum atrial septal
defects with significant left-to-right
shunting
Harrison’s Principles of Internal Medicine 17th ed.
Indications
The mere presence of an ASD may warrant intervention especially if there
is a significant shunt (> 2:1)
• symptomatic
• pulmonary hypertension is present [pulmonary artery pressure (PAP) >
2/3 systemic arterial blood pressure (SABP) or
• pulmonary arteriolar resistance > 2/3 systemic arteriolar resistance
• net left-to-right shunt (Qp:Qs) of at least 1.5:1
• RA or RV enlargement – radiographic, cardiac catheterization
• or there is evidence of pulmonary artery reactivity when challenged
with a pulmonary vasodilator (e.g. oxygen, nitric oxide and/or
prostaglandins)
• or lung biopsy evidence shows that pulmonary arterial changes are
potentially reversible
Schwartz ‘s Principles of Surgery, 9th ed.
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Device closure may now be offered as an alternative to
surgical closure to patients with secundum ASD of up
to 36-38 mm in diameter
Surgical closure may also be offered, and may be
especially attractive should the patient prefer the
surgical approach, or especially if atrial arrhythmia
surgery (atrial maze procedure for atrial fibrillation
and radiofrequency or cryoablation for atrial flutter)
may be offered concurrently
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The following ASD patients require periodic follow up by an ACHD
cardiologist
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Those repaired as adults
Elevated pulmonary artery pressures at the time of repair
Atrial arrhythmias pre- or post-operatively
Ventricular dysfunction pre-operatively
Co-existing heart disease (e.g. coronary artery disease, valvular
heart disease, hypertension)
• Those with device closure need follow-up in specialized centers
with serial ECGs and echocardiograms to determine the late
outcomes of these new techniques
• Endocarditis prophylaxis and aspirin are recommended for 6
months following device closure
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