Identification and assessment 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 defects (ASDs) are the most common congenital lesion in adults after bicuspid aortic valves. Although persons with ASDs are often asymptomatic until adulthood, potential complications of an undetected lesion include irreversible pulmonary hypertension, right ventricular failure, progressive tricuspid valve regurgitation from annular dilatation, atrial arrhythmias, paradoxical embolization, and cerebral abscess. (See "Clinical manifestations and diagnosis of atrial septal defects in adults".)
This topic will review the methods used for diagnosis and assessment of ASDs, including identification of the precise anatomy of the defect and associated anomalies, evaluation of right ventricular overload, evaluation of pulmonary artery pressures, and estimation of the pulmonary-to-systemic flow ratio [1,2]. In most cases, echocardiography provides all the required information. Other modalities such as cardiovascular magnetic resonance and cardiac computed tomography may be helpful in selected cases, especially when echocardiography is technically suboptimal or inconclusive. Cardiac catheterization is rarely required to diagnose and assess an ASD because the requisite information including hemodynamics can be obtained noninvasively in the majority of individuals.
The pathophysiology, clinical features, and management of ASDs in adults and issues related to ASD in children are discussed separately. (See "Clinical manifestations and diagnosis 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".)
IDENTIFICATION OF ASD AND ASSOCIATED ANOMALIES
Overview — Patients with unexplained right ventricular volume overload should be referred for evaluation of possible atrial communication, partial anomalous venous connection, or unroofed coronary sinus/coronary sinus atrial septal defect (ASD) . Imaging of an ASD should include demonstration of the presence and direction of shunting across the defect and evaluation of associated anomalies .
In most patients, echocardiography identifies the ASD, its size and direction of flow, associated abnormalities, and complications. Partial anomalous pulmonary venous drainage of the right upper and middle pulmonary veins frequently accompanies superior sinus venosus defects and less frequently occurs with secundum ASDs. Primum ASDs are generally accompanied by cleft anterior mitral valve leaflet. Since the sensitivity of echocardiography varies with technology, acoustic windows, and operator/patient factors, prior negative suboptimal echocardiograms do not definitively exclude an ASD.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- IDENTIFICATION OF ASD AND ASSOCIATED ANOMALIES
- - Transthoracic echocardiography
- Two-dimensional TTE
- - Agitated saline contrast
- - TEE
- - Three-dimensional
- CMR and CT
- Cardiac catheterization
- EVALUATION FOR RV OVERLOAD
- EVALUATION OF PULMONARY ARTERY PRESSURES
- ESTIMATION OF THE Qp/Qs
- Doppler echocardiography
- Cardiac catheterization
- SUMMARY AND RECOMMENDATIONS