Clinical manifestations and diagnosis of atrial septal defects in adults
- Martin G St. John Sutton, MBBS, FRCP, FACC, FASE
Martin G St. John Sutton, MBBS, FRCP, FACC, FASE
- John Bryfogle Professor of Medicine
- University of Pennsylvania School of Medicine
Atrial septal defect (ASD) is the most common congenital heart lesion in adults after bicuspid aortic valve. The defect is often asymptomatic until adulthood, with potential presenting complications of atrial arrhythmias and paradoxical embolization. Late complications of larger defects include right ventricular dilatation, tricuspid regurgitation, right heart failure and pulmonary hypertension that can become irreversible and lead to right-to-left shunting (Eisenmenger syndrome).
The pathophysiology, anatomy, natural history, and clinical features of ASDs in adults will be reviewed here. The identification and assessment of ASDs, methods for treatment, and issues related to ASDs in children are discussed separately. (See "Identification and assessment of atrial septal defects in adults" and "Indications for closure and medical management of atrial septal defects in adults" and "Classification of atrial septal defects (ASDs), and clinical features and diagnosis of isolated ASDs in children" and "Management and outcome of isolated atrial septal defects in children".)
Atrial septation begins as early as the fifth week of gestation. The septum primum arises from the superior portion of the common atrium and grows caudally to the endocardial cushions located between the atria and ventricles, eventually closing the orifice (ostium primum) between the atria (figure 1).
A second orifice (the ostium secundum) develops in the septum primum; this orifice is covered by another septum (the septum secundum) that arises on the right atrial side of the septum primum. The septum secundum grows caudally and covers the ostium secundum. However, the septum secundum does not completely divide the atria, but leaves an oval orifice (the foramen ovale) that is covered but not sealed on the left side by the flexible flap of the septum primum (figure 1).
In the fetus, the foramen ovale is held open by the pressure gradient between the right and left atria; the right atrial pressure is higher than that of the left and pushes the flexible septum primum aside. At birth, expansion of the lungs lowers right heart pressures at the same time that systemic vascular resistance rises, causing reversal of the inter-atrial gradient. The septum primum is then held against the septum secundum and the interatrial shunt is abolished. (See "Classification of atrial septal defects (ASDs), and clinical features and diagnosis of isolated ASDs in children", section on 'Perinatal physiology'.)
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- Secundum ASD
- Primum ASD
- Sinus venosus ASD
- Unroofed coronary sinus
- Patent foramen ovale
- NATURAL HISTORY
- CLINICAL MANIFESTATIONS
- Atrial arrhythmias
- Stroke due to paradoxical embolization
- Migraine headache
- Pulmonary hypertension and Eisenmenger syndrome
- PHYSICAL FINDINGS
- Precordial palpation
- Heart sounds
- Heart murmurs
- Pulmonary hypertension
- Eisenmenger syndrome
- INITIAL TESTS
- Chest radiograph
- SUMMARY AND RECOMMENDATIONS