MY APPROACH to the adult patient with newly identified atrial septal defect

Abstract

1016/j.tcm.2015.05.017 blished by Elsevier Inc. n PracticeUpdate on January 21, 2015. Republishe Secundum ASD is the most common type. Less common ASDs include sinus venosus, coronary sinus, and primum. There are other rare ASD subtypes, but these four are the ones seen most frequently. If you suspect that your patient has an ASD, the first test to establish the diagnosis is echocardiography, either transthoracic or transesophageal. The sensitivity of transthoracic echocardiography in detecting ASD varies by the size of the defect, and specific patient factors, such as body habitus, which may limit the ability to obtain diagnostic transthoracic views. After you identify the defect, you have to look for any associated congenital heart disease that can occur alongside an ASD; this is the second step. For example, sinus venosus ASD is commonly associated with a partial anomalous pulmonary venous connection. The latter can happen with secundum ASD as well, but not as commonly. So, whenever you are diagnosing someone with an ASD, you have to look for a partial anomalous pulmonary venous connection. Whenever you see a partial anomalous pulmonary vein, you have to look for an ASD. They often go together. The reason why it's important to define the anatomic type of ASD and the presence of an associated defect is that it can affect your management plan. For example, a secundum ASD is almost always treated with a device closure, but when a sinus venosus ASD, primum ASD, or coronary sinus ASD is present, device closure is not an option. If you go to surgery and the patient has an anomalous pulmonary venous connection plus an ASD, the surgery is different because you have to consider doing what is called a Warden procedure, whereby you channel the anomalous vein back into the left atrium through the atrial septum. Primum ASDs are commonly associated with cleft of the anterior mitral valve defects and mitral regurgitation, and they are commonly associated with left anterior hemiblock on EKG. Associated defects can usually be determined by EKGs or echocardiography. Occasionally, cardiac MR or CT is required to assess the pulmonary venous connections.