Atrial Septal Defect
vidence ree Sinus Venosus ASD Patent Foramen Ovale = ASD post/sup to FO (o5en w anom R pulm vn) See Anomalous Pulmonary Venous Return Algorithm, though some evidence here may apply. “What is the chance this will close without surgery?” “Why go to = failure of FO to seal closed when LAP >RAP postnatally surgery if the child doesn’t have symptoms?” = ASD anterior to the FO to a PFO? Should we close it?” Small & ASx Moderate Large & Sx c/s Cath Closure Long Term NHx -­‐2nd ASD might spont close, but also get biggerR1 -­‐Up to 20% close spont’ly, most by 4yoR1, w up to 66% of small ASDs closing in other studiesR7 refs, mainly d/o age at Dx -­‐in pt Dx at <3mo if <3mm, nearly all close by 18mo, if 3-­‐5mm 87% close by 12mo, if 5-­‐8mm, 80% by 15moR10 -­‐One studyR7 of 104 pt w 2nd ASD >3mm at Dx, avg 4 yrs old at Dx w 3yr f/u: -­‐of 34 small (3-­‐6mm), at 3yr f/u 3 closed, 6 got signif bigger (to 6 to >12mm); of 40 mod (6-­‐12mm) at 3yr f/u 3 descr to <6mm & 8 incr to >12mm; of 30 large (>12mm), at 3yr f/u, all remained large -­‐overall, 65% incr in size, avg by 0.8mm/yr; 14% decr in size, no change in growth rate by Dx age, ini\al size correlates w final size (r2 = 0.6) -­‐Similar results in diff study 56% close if 4-­‐5mmR11 -­‐Up to 24% of newborns had an ASD of some sort, and 92% closed by 1yo-­‐ more likely if <7-­‐8mm diam, and younger at DxR1 Long Term Px -­‐benign unless very largeR1 -­‐may be ASx through >50s w a moderate ASDR1 -­‐CHF uncommon early on, but by >40yo.R1 -­‐Atrial Aryth are about 10% by 40yo, 20% overallR2 -­‐Afib/fluaer – 13% at 40, 50% at 60yoR1 -­‐If untreated, 5-­‐10% of pt (F>M) get pulm vasc dz usually at age >20yoR1 Mod-­‐Large & +Sx ASx & <3mm Symptoma\c ASD is an indica\on to close, though Rx can stall & treat Sx -­‐Diure\cs (Lasix) Only follow up if symptoms occur or exam changesR1, R10 “What will ASx & >3mm happen without surgery for a large ASD?” Follow Up at 12 & 15 months old or if Sx startR1, R10 Adult with Asx ASD (any type, not PFO): Closure will reduce risk of arrhythmia in medium term (<5yr), but not long term (>5yr) per Meta data: -­‐Σ OR0.66 overall, 0.47 in med term (CI95 0.36-­‐0.62), but long term OR 0.7 (CI95 0.65-­‐1.07), but limited high quality long term data -­‐Of high quality studies OR 0.7 (CI95 0.51-­‐0.97) -­‐for afib/fluaer OR 0.77 (CI95 0.63-­‐0.95) àc/s closure, knowing no proven long term effect “Can we close it via cath?” Indica\on to close at pre-­‐
school age (by 4yo) (Qp by exam, echo, cath) Older Adult with ASDR3 & R12 Surgical Indica\ons: -­‐wait \ll 4yo for elec\ve repair (pre-­‐school, big enough to make it easier) -­‐if an adult, might have earlier mortality (but uncertain bc healthy ppl w ASD might be lost to f/u in the study) Asx ASD w Qp:Qs >1.5:1 by cath/echo Asx but murmur/fixed split S2 or orther signs/sx of Qp:Qs >1.5 Sx of FTT, CHF uncontrolled with meds -­‐about 98-­‐99% successful outcome (adult/
peds mixed data)R1, R24, with subsequent improved RV dila\on etcR24 Cath Risks: -­‐Erosion causing tamponade, Ao fistula, aaributed to over or under sized which can incr contact w Ao root. Incidence unknown but 0.2-­‐0.3% reported.R22 -­‐Safer than Surg-­‐ One study wkids & adults 4x less risk of major xx-­‐ HF, AVB needing temp pacer, arryth needing cardioversion, bleeding needing reop, PTx, etcR23 -­‐14/751 Cath pts needed opera\on for malposi\on/embolizn -­‐trivial/small resid shunt more common w cath (8% vs 3%) but mainly w Cardioseal and not Amplazter -­‐One study (adult/peds) showed 2/176 pts needed surg for resid ASD or device malposi\on, 7% w arrhyth (SVT/VT), no mortality -­‐One study: 1% postop xx needing surgR25 -­‐RCT 473 Mexicans 40-­‐70yo w any ASD type, NYHA 1-­‐2 -­‐all with Qp:Qs >1.7, PAP <70; 7yr f/u avg à Surgery be^er than Rx Tx EndPt: ΣCV death, worsen HF, syst/pulm emboli, recur pulm infec\on, SVT, incr phtn >20% baseline HR 1.99 (CI95 1.23-­‐3.22), p MVA 1.85 (1.08-­‐3.17) w R/F for worse outcome = incr age at Dx, PAP >35mmHg, or RxTx -­‐2y endpt death: signif diff in MVA analysis only w HR 4, if adjust for age, PAP>35, prev afib/fluaer, CI <3.5 -­‐One StudyR12, retro non random Surg vs Rx in pt Dx at >40yr w Qp:Qs >1.5 à surg improves NYHA (RR0.2) and survival (95% vs 84% 10yr f/u, but no change in arrhyth or CVA, but Rx pts were older, and 20% Rx pt went to Surg, and 27% had systemic/suprasyst RVP… -­‐Another studyR13, of NYHA I&II pt >25yo Qp:Qs>1.5, did not show that surg improves Sx-­‐ no diff in survival, stroke, HF Pre-­‐Op Ques\ons -­‐Echo Eval:Lai Text Median Sternotomy -­‐preferred by Mavroudis groupR21 Minimally Invasive SurgeryR19 -­‐5-­‐7mm scar only, but limited exposure -­‐One study of 23 pts show good outcome “What are the risks to Cath & Surgery?” child need surgery?” Thoracotomy -­‐7.4% get ipsi breast maldvp, w periareolar numpness/hypoesthesia in 39%, low but present risk of atalectasis, R phrenic palsy, rib fxR9 -­‐incr risk of R phrenic n injury & air embolusR21 Surgical Risk: -­‐0.04% mortality for 2nd & sinus venosus ASD -­‐see Cath Risk for comparison “What are the risks to adults with ASD?” [ ] Defect loca\on & size [ ] Rela\on to neighboring structures-­‐ MV, RV, Syst/P Vns [ ] Measure defect margins for ?transcatheter closure [ ] Hemodynamics [ ] flow direc\on, transseptal pressure gradient-­‐ check mean gradient [ ] check for HD load-­‐ RA, RV enlargement, diastolic septal flaaening fr RV OD [ ] RV syst P by TR jet and systolic ventric septum configura\on [ ] biventric fx [ ] assoc lesions “Does my Surgical Closure Cath Closure -­‐Amplatzer-­‐ ideally 12-­‐14mm rims, ideally for defects w 18-­‐38mm diamR25 -­‐Ao rim must be at least 5mmR26 -­‐CardioSEAL -­‐Helex septal occluder Long Term Px & NHxR1 -­‐R heart volume ODà dilated RA & RV -­‐mural thrombi uncommon -­‐Sev RV dila\on can à RV forming apex, IVS straightens so both ventricles are D shaped -­‐TV and PV dila\on, w TR & PR, mildly thick -­‐Central Pulm Art Dila\on -­‐LV size/mass remains Nl -­‐Ch Vol OD to Lungsà medial hypertrophy of arts/vnsà pulm htn, plexiform & thrombo\c obst lesions; may worsen other dz pt may have (COPD etc) ASx & Qp:Qs >1.5 ASx & Qp:Qs <1.5 Con\nue to monitor serially ASx & Arrhythmia in AdultsR2 Cath Requirements: -­‐Pa\ent size & age -­‐Atrial Septal Rims: R25 (details xx by rim defic) 1. AV vlv rim |4. (RUPV rim) |7. CS rim 2. Ao rim |5. Post rim 3. SVC rim |6. IVC rim = ASD via unroofed CS in LA, o5en w an LSVC See Atrioventricular Septal Defect Algorithm, though some evidence here may apply. = ASD of the septum primum “Is there risk Coronary Sinus ASD Secundum ASD -­‐Present in 15-­‐25% of people.R4 -­‐No Need to Intervene as always ASx. -­‐Only indica\on to close is 2 strokes (but insufic data per AHA 2011 Guidlns) -­‐CLOSURE I RCT-­‐ PFO closure in pt w stroke doesn’t reduce risk of 2nd stroke (differs from many obsv studies)R13, R14 -­‐Doesn’t reduce Migraines in MIST RCT R16 though did w obs studiesR15. R17 -­‐Might decr atr arrhyth risk per meta.R20 Risks of PFOR4, R5 -­‐?if assoc w atrial septal aneurysm (1-­‐2% prevalence) -­‐PFO & AS Anyrsm + Incr risk stroke for pt <55y-­‐ OR 3(CI95 2.3-­‐4.2). If >55yo, OR is only 1.27 (CI95 0.8-­‐2) for PFO. Incr risk if PFO & AS An; -­‐No proven incr risk of strokeR17, R18 -­‐If pt had a stroke, no incr risk for 2nd stroke at 2yr f/u -­‐Eu study of pts <55yo, risk of 2nd stroke was incr w PFO Other studies differ, No RCTs -­‐See R17 for detail on xx evidence Primum ASD “If you close it, will my child be cured?” Long Term Px 97% survival at 5yrs postopR1 -­‐90% survival at 10yrs postopR1 -­‐74% at 30yrs post upR1 (Ctrl pts had 99%, 98%, 85% survival) R1 -­‐57% of pts >24yo had late CVAs compared to 15% if <24yo at surgical correc\onR1 -­‐One study of pts w surgery for 2nd or Sn Vn ASD at Mayo in 1950-­‐60s, no diff in 27yr survival if <25yo at surg, but if >25-­‐41 then only 84% vs 91% in ctrl, and if >41 then 40% survival vs 59% in ctrl w more late CHF, stroke, a-­‐fib. 75% of all the pts were +Sx at surgery. R6