Atrial septal defect: symptoms and treatment. Atrial septal defect

Many factors influence the health of the unborn baby. Improper intrauterine development can cause congenital malformation of internal organs. One of the disorders is a ventricular septal defect (VSD), which occurs in a third of cases.

Peculiarities

Dmzhp is a congenital heart disease (CHD). As a result of pathology, a hole is formed connecting the lower chambers of the heart: its ventricles. The pressure level in them is different, because of which, when the heart muscle contracts, a little blood from the more powerful left part enters the right. As a result, its wall is stretched and enlarged, the blood flow of the small circle, for which the right ventricle is responsible, is disturbed. Due to the increase in pressure, the venous vessels are overloaded, spasms and seals occur.

The left ventricle is responsible for blood flow in a large circle, so it is more powerful and has a higher pressure. With the pathological flow of arterial blood into the right ventricle, the required level of pressure decreases. To maintain normal performance, the ventricle begins to work with greater force, which further adds to the load on the right side of the heart and leads to its increase.

The amount of blood in the small circle increases and the right ventricle has to increase the pressure in order to ensure the normal speed of passage through the vessels. This is how the reverse process occurs - the pressure in the small circle now becomes higher and the blood from the right ventricle flows into the left. Oxygen-enriched blood is diluted with venous (depleted) blood, and there is a lack of oxygen in organs and tissues.

This condition is observed with large holes and is accompanied by a violation of breathing and heart rhythm. Often, the diagnosis is made in the first few days of the baby's life, and doctors begin immediate treatment, prepare for surgery, and, if it is possible to avoid surgery, conduct regular monitoring.

Small VSD may not immediately appear, or is not diagnosed due to mild symptoms. Therefore, it is important to be aware of the possible signs of the presence of this type of CHD in order to take timely measures and treat the child.

Blood flow in newborns

Communication between the ventricles is not always a pathological abnormality. In the fetus during intrauterine development, the lungs do not participate in the enrichment of blood with oxygen, therefore, there is an open oval window (ooo) in the heart, through which blood flows from the right side of the heart to the left.

In newborns, the lungs begin to work and ooo gradually overgrows. The window completely closes at the age of about 3 months; in some cases, overgrowth is not considered a pathology by 2 years. With some deviations, ooo can be observed in children aged 5-6 years and older.

Normally, in newborns, ooo is not more than 5 mm; in the absence of signs of cardiovascular diseases and other pathologies, this should not cause concern. Dr. Komarovsky recommends constantly monitoring the baby's condition, regularly visiting a pediatric cardiologist.

If the size of the hole is 6-10 mm, this may be a sign of vmjp, surgical treatment is required.

Types of defect

The cardiac septum may contain one or more pathological holes of different diameters (for example, 2 and 6 mm) - the more there are, the more difficult the degree of the disease. Their size varies from 0.5 to 30 mm. Wherein:

• A defect up to 10 mm in size is considered small;
• Holes from 10 to 20 mm - medium;
• A defect larger than 20 mm is considered to be large.

According to the anatomical division, there are three types of DMH in a newborn and differs in the place of localization:

1. In the membranous (upper part of the heart septum), a hole occurs in more than 80% of cases. Defects in the form of a circle or oval reach 3 cm, if they are small (about 2 mm), they are able to spontaneously close in the process of growing up a child. In some cases, defects of 6 mm are overgrown, whether an operation is needed, the doctor decides, focusing on the general condition of the child, the features of the course of the disease.
2. Muscle jump in the middle part of the septum is less common (about 20%), in most cases round in shape, with a size of 2–3 mm, it can close with the age of the child.
3. At the border of the excretory vessels of the ventricles, a supracrestal septal defect is formed - the rarest (about 2%), and almost does not stop on its own.

In rare cases, there is a combination of several types of jmp. The defect can be an independent disease, or accompany other severe abnormalities in the development of the heart: atrial septal defect (ASD), problems with arterial blood flow, aortic coarctation, stenosis of the aorta and pulmonary artery.

Reasons for development

The defect is formed in the fetus from 3 weeks to 2.5 months of intrauterine development. With an unfavorable course of pregnancy, pathologies in the structure of internal organs can occur. Factors that increase the risk of VSD include:

1. Heredity. A predisposition to VSD can be genetically transmitted. If any of the close relatives had defects in various organs, including the heart, there is a high probability of abnormalities in the child;
2. Viral diseases of an infectious nature (flu, rubella), which a woman suffered in the first 2.5 months of pregnancy. Herpes and measles are also dangerous;
3. Taking medications - many of them can cause intoxication of the embryo and lead to the formation of various defects. Particularly dangerous are antibacterial, hormonal, anti-epilepsy and CNS drugs;
4. Bad habits in the mother - alcohol, smoking. This factor, especially at the beginning of pregnancy, increases the risk of abnormalities in the fetus several times;
5. The presence of chronic diseases in a pregnant woman - diabetes mellitus, problems of the nervous, cardiac system, and the like can provoke pathologies in the baby;
6. Avitaminosis, deficiency of essential nutrients and trace elements, strict diets during pregnancy increase the risk of birth defects;
7. Severe toxicosis in early pregnancy;
8. External factors - dangerous environmental conditions, harmful working conditions, increased fatigue, overstrain and stress.

The presence of these factors does not always cause the occurrence of severe diseases, but increases this likelihood. To reduce it, you need to limit their impact as much as possible. Timely measures taken to prevent problems in the development of the fetus are a good prevention of congenital diseases in the unborn child.

Possible complications

Small defects (up to 2 mm) in the normal state of the baby are not a threat to his life. Regular examination, observation by a specialist is necessary and are able to stop spontaneously over time.

Large holes cause disruption of the heart, which manifests itself in the first days of a baby's life. Children with VSD have a hard time with colds and infectious diseases, often with complications in the lungs, pneumonia. They can develop worse than their peers, they are hard to tolerate physical exertion. With age, shortness of breath occurs even at rest, problems with internal organs appear due to oxygen starvation.

An interventricular defect can cause serious complications:

• Pulmonary hypertension - an increase in resistance in the vessels of the lungs, which causes right ventricular failure and the development of Eisenmenger's syndrome;
• Violation of the heart in an acute form;
• Inflammation of the inner heart membrane of an infectious nature (endocarditis);
• Thrombosis, the threat of a stroke;
• Malfunctions of the heart valves, the formation of valvular heart defects.

To minimize the consequences detrimental to the health of the baby, timely qualified assistance is needed.

Symptoms

Clinical manifestations of the disease are due to the size and location of the pathological openings. Small defects in the membranous part of the cardiac septum (up to 5 mm) occur in some cases without symptoms, sometimes the first signs occur in children from 1 to 2 years old.

In the first days after birth, the baby can hear heart murmurs caused by blood flowing between the ventricles. Sometimes you can feel a slight vibration if you put your hand on the baby's chest. Subsequently, the noise may weaken when the child is in an upright position or has experienced physical activity. This is caused by compression of the muscle tissue in the region of the opening.

Large defects can be found in the fetus even before or in the first time after birth. Due to the peculiarities of blood flow during intrauterine development, newborns have a normal weight. After birth, the system is rebuilt to the usual one and the deviation begins to manifest itself.

Especially dangerous are small defects located in the lower region of the cardiac septum. They may not show symptoms in the first few days of a child's life, but for some time breathing and heart problems develop. With careful attention to the child, you can notice the symptoms of the disease in time and consult a specialist.

Signs of a possible pathology, which must be reported to the pediatrician:

1. Paleness of the skin, blue lips, skin around the nose, arms, legs during exercise (crying, screaming, overexertion);
2. The baby loses appetite, gets tired, often throws the breast during feeding, slowly gains weight;
3. During physical exertion, crying, shortness of breath appears in babies;
4. increased sweating;
5. A baby older than 2 months is lethargic, drowsy, it has reduced motor activity, there is a developmental delay;
6. Frequent colds that are difficult to treat and flow into pneumonia.

If such signs are identified, an examination of the baby is carried out to identify the causes.

Diagnostics

The following research methods allow you to check the condition and work of the heart, to identify the disease:

• Electrocardiogram (ECG). Allows you to determine the congestion of the heart ventricles, to identify the presence and degree of pulmonary hypertension;
• Phonocardiography (FCG). As a result of the study, it is possible to identify heart murmurs;
• Echocardiography (EchoCG). Able to detect blood flow disorders and helps to suspect VSD;
• Ultrasound procedure. Helps to assess the work of the myocardium, the pressure level of the artery of the lung, the amount of blood discharged;
• Radiography. According to the pictures of the chest, it is possible to determine changes in the pulmonary pattern, an increase in the size of the heart;
• Probing of the heart. Allows you to determine the level of pressure in the arteries of the lungs and the ventricle of the heart, the increased oxygen content in the venous blood;
• Pulse oximetry. Helps to find out the level of oxygen in the blood - a lack indicates disorders in the cardiovascular system;
• Cardiac catheterization. It helps to assess the state of the structure of the heart, to determine the level of pressure in the heart ventricles.

Treatment

Vmzhp 4 mm, sometimes up to 6 mm - a small size - in the absence of a violation of the respiratory, cardiac rhythm and the normal development of the child allows in some cases not to use surgical treatment.

With the deterioration of the overall clinical picture, the appearance of complications, it is possible to prescribe an operation in 2-3 years.

Surgical intervention is performed with the patient connected to a heart-lung machine. If the defect is less than 5 mm, it is tightened with P-shaped sutures. If the hole is larger than 5 mm, it is covered with patches made of artificial or specially prepared bio-material, which subsequently overgrows with the body's own cells.

If surgical treatment is necessary for a child in the first weeks of life, but it is impossible for some indicators of the health and condition of the baby, a temporary cuff is placed on the pulmonary artery. It helps to equalize the pressure in the ventricles of the heart and alleviates the patient's condition. A few months later, the cuff is removed and an operation is performed to close the defects.

In children with congenital heart defects, in about 6-10% of cases, there are single or multiple holes on the septum, which is located between the two atria of the heart. This disease is called "atrial septal defect", and it leads to an abnormal shunt of blood to the left, the gradual development of hemodynamic disturbances and the development of heart failure and pulmonary hypertension.

Features of the disease

The atrial septum is formed in the fetus during its intrauterine development. It is laid out of two ridges, one of which grows upward from the atrioventricular junction (the primary part of the septum is its lower third), the second one grows downward from the base of the heart. Approximately in the middle of the septum there is an oval fossa, which is not closed in the fetus and is a window - a natural component of blood circulation during the intrauterine development of the child. In newborns, the oval window closes in the first weeks after birth. If closure does not occur, the diagnosis is an atrial septal defect.

Up to 10% of all CHDs belong to atrial septal defects (ASD), and this defect is independent (isolated). As for the combined, complex CHD, in such cases, ASD coexists with other disorders of the heart structure in 30-35% of children with defects. In most cases, it is associated with such CHD and other congenital diseases of the cardiovascular system:

• stenosis of the pulmonary artery;
• insufficiency of the mitral or tricuspid valve;
• anomalies in the development of the pulmonary veins;
• coarctation of the aorta;
• open ductus arteriosus;
• ventricular septal defect;

Unclosed holes in the atrial septum may also represent variants of underdevelopment of one of its parts. In any case, one or multiple defects cause hemodynamic disturbances inside the heart. The blood pressure in the left atrium is higher than the pressure in the right atrium by 8-10 mm Hg. If there is a defect, it can even out, or approach equal. Blood is thrown through the shunt from left to right, which provokes an increase in pulmonary blood flow and overload of the right ventricle, while the severity of pathological changes directly depends on the size of the defect in the atrial septum and ventricular compliance.

Since at the first time of life the thickness of the walls of the ventricles is the same, during the period of diastole they stretch evenly, the pathological reset is small. With age, the decrease in vascular resistance also increases, and an increasingly significant amount of blood is discharged through the shunt.

The right parts of the heart increase in size due to chronic overload, but even at this stage there may be no symptoms of pathology. Only the appearance of signs of pulmonary hypertension (usually by 2-3 years and older), as well as heart failure, causes the development of symptoms (the larger the defect, the earlier pathological signs are observed in the child).

Many ASDs spontaneously close in the first years of life (we are talking about small defects - up to 2-5 mm.). In addition to the division by size, holes in the interatrial septum are classified as follows:

1. Primary defect located in the lower third of the septum. Such holes are localized near the atrioventricular valves, which are deformed, or their dysfunction is observed. Primary defects are abnormalities in the development of the endocardial pads. Occasionally, adults develop Lutembashe's syndrome - a combination of ASD with acquired mitral valve stenosis, which occurs against the background of previous rheumatism.
2. A secondary defect located in the upper part of the septum or the zone of the oval fossa (up to 80% of all ASDs). Such defects should not be confused with foramen ovale non-closure disease, which, if small, does not affect life expectancy and hemodynamics at all. Secondary defects are most often combined with other heart defects, with aneurysms. The group of secondary ASD also includes a rare defect of the venous sinus.

Causes of an atrial septal defect

The formation of ASD is associated with various disorders in the development of the fetus in the embryonic period. These violations relate to the underdevelopment of parts of the interatrial septum and endocardial ridges. Despite the fact that many cases of defects are sporadic, there are numerous data on the hereditary transmission of pathology in those families where the mother, father or immediate family already had CHD. Often ASD as family cases appear in combination with atrioventricular blockade, or with underdevelopment of the bones of the hands (Holt-Oram syndrome).

The influence of teratogenic factors on the fetus can also lead to the development of pathology. These include:

• infections in a pregnant woman that she suffered in the first trimester of pregnancy - rubella, chickenpox, cytomegalovirus, influenza, herpes, syphilis and many others;
• acute febrile conditions;
• the presence of uncorrected endocrinopathies, especially diabetes mellitus;
• taking drugs that have a toxic effect on the fetus;
• x-ray examination of the mother, exposure to ionizing radiation;
• early toxicosis up to the threat of miscarriage;
• mother's work in hazardous production;
• taking alcohol, drugs;
• unfavorable environment in the place of residence.

Chromosomal mutations that occur during conception can lead to the appearance of multiple heart defects, as well as anomalies in the development of this organ, together with other disorders in the body. So, an atrial septal defect can become part of severe genetic diseases - Goldenhar syndrome, Williams syndrome, Ellis-Van Creveld syndrome and many others.

Symptoms of the disease

This heart disease is present in a child from birth. However, its symptoms appear much later - after several weeks, months, or even years. When listening to the heart in the maternity hospital, as a rule, no abnormalities are detected. Only later does a characteristic murmur appear in the heart, which, however, can be very weak or not heard at all. The absence of symptoms often leads to late recognition of the defect, when the child already has serious complications.

The larger the hole in the atrial septum and the smaller the resistance of the pulmonary artery, the faster the clinical picture of ASD appears. Usually, until a certain age, a child grows and develops along with peers, but then the first signs become noticeable - faster fatigue and intolerance to high physical exertion. But when this heart disease is combined with other congenital heart diseases, and hemodynamic disturbances are more significant, the symptoms can be both early and more obvious. In general, the following components of the clinic of the disease are possible:

• tachycardia;
• feeling of heartbeat;
• shortness of breath on exertion;
• the formation of a "heart hump";
• increased pulsation of the right ventricle and pulmonary artery;
• murmurs in the heart;
• cyanosis (usually mild);
• persistent pallor of the skin;
• coldness of the extremities;
• weakness;
• dizziness, tendency to faint;
• enlargement of the liver.

In 5% of children with secondary atrial septal defect, severe heart failure occurs by the age of one, which is usually associated with the presence of a large defect in the venous sinus. Such patients always have a lag in physical development, and sometimes concomitant defects and anomalies of other organs due to the existence of genetic syndromes. In the absence of heart surgery, most of these patients die at an early age. Another unfavorable outcome of the disease is possible when it is asymptomatic for many years and manifests itself as an embolic stroke in a patient, which often happens during pregnancy in women with congenital heart disease.

Possible complications

As a rule, without eliminating the defect against the background of hypervolemia of the pulmonary circulation, respiratory diseases often occur - bronchitis, pneumonia, which are not treatable for a long time, accompanied by a strong cough with wet rales and shortness of breath. Rarely, hemoptysis may occur. As a rule, by the age of 20, the patient begins to experience complications:

1. pulmonary hypertension - an overload of the right side of the heart, the occurrence of stagnation in the pulmonary circle and an increase in pressure in it;
2. heart failure - a violation of the heart in terms of its pumping function, as a result of which the body cannot cope with providing tissues with oxygen;
3. arrhythmias - changes in the heart rhythm up to those that threaten sudden cardiac arrest;
4. Eisenmenger's syndrome - irreversible changes in the lungs against the background of pulmonary hypertension;
5. paradoxical embolization - the passage of blood clots from the veins through the existing defect in the atrial septum;
6. thromboembolism - the formation and separation of blood clots from the walls of blood vessels and blockage of vital arteries - pulmonary, cerebral. More about the diagnosis and signs of thromboembolism on the ECG

Only timely surgical intervention can prevent these consequences and the subsequent disability and death.

Carrying out diagnostics

Methods for diagnosing the disease in children and adults are as follows:

1. ECG. There are signs of an increase in the right atrium and right ventricle, their overload, if the patient already has pulmonary hypertension. There may be a sharp deviation of the electrical axis to the left due to the displacement of the reduced branch of the left leg of the bundle of His. With complications on the cardiogram, there are signs of atrioventricular blockade, weakness of the sinus node. With a defect in the venous sinus, a lower atrial rhythm appears.
2. Chest X-ray. There is an increase in the pulmonary pattern, expansion of the roots of the lungs, bulging of the right atrium, a more pronounced pulsation of the pulmonary roots.
3. Ultrasound of the heart with dopplerography (in adults - transesophageal echocardiography). Hypertrophy, dilatation of the left sections are found, with pulmonary hypertension - also of the right sections of the heart. The atrial septal defect itself may be visually noticeable (at this stage, it is differentiated with an open oval window). An analysis of the presence of concomitant defects and anomalies is carried out, the degree of blood discharge is assessed.
4. Catheterization of the heart (probing its cavities). It is indicated before surgery for the elimination of heart disease, as well as for suspected pulmonary hypertension with conflicting data from other examinations. During catheterization, a test with oxygen inhalation and a test with aminophylline are performed, which will assess the degree of reversibility of pulmonary hypertension.
5. Angiography, MRI angiography. As a rule, these methods are required to detect abnormal pulmonary venous drainage and ventricular dysfunction as concomitant ASD pathologies.

ASD should be differentiated from ventricular septal defect, Fallot's triad, abnormal pulmonary venous drainage, patent ductus arteriosus, and other heart defects, as well as their combination. Secondary atrial septal defects should also be distinguished from a functional systolic murmur in the heart, non-closure of the foramen ovale.

When to see a doctor urgently

In the event that ASD was not diagnosed at an early age, parents may not be aware of its existence at all. Doctors often recommend postponing the operation until a certain age of the baby (as a rule, interventions are done after 3-4 years), and he continues to live and grow with the existing defect in the atrial septum. In any case, you should immediately consult a doctor if the following symptoms appear in a child:

• blue skin;
• a sharp increase in fatigue, weakness;
• dyspnea;
• swelling of the arms and legs;
• abnormal heartbeat;
• pulse disorders;
• pain in the region of the heart.

These signs reflect the development of varying degrees of heart failure, and therefore the operation may have to be performed ahead of schedule.

Treatment methods

Defects less than 3 mm. in diameter often close on their own. This usually happens by the age of 1.5 years of the child. With regard to primary defects, as well as defects of the venous sinus, they never close spontaneously. Usually, without surgery, pulmonary hypertension and heart failure occur by the age of 20-30, but this can occur much earlier. Therefore, the operation is indicated for all patients with ASD, but not earlier than at 3-5 years. Indications for a faster intervention are as follows:

• hyperplasia of the heart;
• recurrent pneumonia;
• enlargement of the walls of the pulmonary artery;
• severe delay in physical development;
• progression of heart failure;
• the presence of concomitant heart defects.

Before surgery, children are shown regular monitoring by a cardiologist and the implementation of courses of drug treatment:

1. diuretics for edema, symptoms of impaired pulmonary circulation;
2. beta-blockers to reduce pressure, eliminate heart rhythm disturbances;
3. thrombolytics to reduce blood clotting to prevent the threat of thrombosis;
4. cardiac glycosides to dilate blood vessels and increase the volume of blood pumped out by the heart.

There are several types of operations that are currently used in ASD. The choice of a specific technique depends on the size of the defect and its type. There are two main types of operations and many of their varieties:

1. plastic surgery (a patch of pericardium or synthetic fabric) or suturing of a defect when creating conditions for cardiopulmonary bypass;
2. occlusion of the defect with the Amplatzer device and other devices (usually used when the hole is small and has a regular shape).

Usually, with early surgery in childhood, complications occur in no more than 1-4% of cases (thrombosis, perforation of the vessel wall, AV block, etc.), mortality does not exceed 0.1%. As a rule, the dilatation of the chambers of the heart undergoes a reverse development after the defect is eliminated. In adulthood, even after surgery, existing complications may persist - pulmonary hypertension, arrhythmias.

Lifestyle with this pathology

After the operation and before it is performed, the child cannot go in for professional sports, physical overload, hard work are strictly prohibited. In the first weeks after the intervention, you should wear a special bandage that will not allow the seams to disperse, observe bed rest, and then you need to start moving a little, breathing deeper. You can not take a shower and a bath until the seams are completely overgrown, but only gently wipe the body with a damp sponge.

With heart defects, it is imperative to adhere to a healthy lifestyle, eat right. It is necessary, if possible, to prevent respiratory pathologies in the first year after the intervention, as well as before its implementation. Moderate physical activity is indicated for all operated patients - gymnastics, walking, swimming, etc. After the operation, it is advisable to see a cardiologist once a year until the end of life. We must not forget to take all the therapeutic and prophylactic drugs prescribed by the doctor.

Pregnancy and childbirth

The small size of an ASD in a woman usually allows her to endure and give birth to a child without problems. But with existing complications in the form of pulmonary hypertension, heart failure, arrhythmias, with a large defect, a life-threatening condition for the mother and fetus can occur during gestation, because the load on the heart during this period increases significantly. That is why cardiologists strongly recommend surgical treatment in childhood or adolescence, or planning a pregnancy after undergoing a course of conservative therapy. In any case, it is necessary to be observed by a specialist, as well as to perform an ultrasound of the fetal heart at an early stage to detect life-incompatible or combined defects that may be due to aggravated heredity.

Pathology prognosis

The prognostic calculation is based on the timing of the operation and the presence of complications that arose before it was performed. Without surgery in early childhood, the course of the disease in 95% of cases is benign. Severe circulatory disorders and death in the first year of life are rare. Without treatment, the average life expectancy is 40 years, 15% of patients die before the age of 30. About 7% live to be 70 years old, but by the age of 45-50 they become disabled.

When the defect is eliminated in childhood, the risk of complications is low, patients, as a rule, live a full life.

In some cases, it is still possible to develop various types of arrhythmia at the age of 45-60 years. With surgical closure of the defect after 20-25 years, there is a high risk of shortening life expectancy due to the presence of irreversible pulmonary hypertension and heart failure.

An atrial septal defect (ASD) is a hole in the wall between the right and left atrium. This is a congenital heart defect. An ASD that is small enough may close on its own in early childhood.

If the atrial septal defect is large enough, it cannot heal itself, and without surgical treatment leads to the development of heart failure, due to the reflux of blood from the left sections to the right and overload of the pulmonary circulation and the right sections of the heart.

Symptoms of ASD

In most cases, newborns with ASD do not have any symptoms of this heart disease. In adults, signs of an atrial septal defect usually appear by the age of 30, but in some cases, manifestations of ASD may not be observed until older age.

Symptoms of an atrial septal defect include:

• Heart murmurs (on auscultation)
• Shortness of breath, especially on exertion
• Fatigue
• Swelling of the legs, feet and abdomen
• heartbeat
• Frequent lung infections
• Stroke
• Blueness of the skin (cyanosis)

When to See a Doctor

You should see a doctor if any of the following symptoms occur:

• Blueness of the skin
• Dyspnea
• Fatigue, especially after exercise
• Swelling of the legs, feet, abdomen
• palpitations

All these symptoms indicate the presence of heart failure and other complications of an atrial septal defect.

Causes of ASD

The exact and clear causes of heart defects are unknown. Heart defects themselves, including ASD, arise due to a violation of the development of the heart in the early stages of fetal formation. An important role is played by external environmental factors and genetic factors.

With an atrial septal defect, blood, due to the fact that the myocardium of the left heart is "stronger" than the myocardium of the right heart, enters through the opening of the defect from the left atrium to the right. This blood is just from the lungs, that is, it is enriched with oxygen. In the right atrium, it mixes with oxygen-poor blood and enters the lungs again. With a significant size of the defect, the lungs and right sections of the heart are overloaded with blood. In the absence of treatment, the right parts of the heart expand, hypertrophy of the myocardium of the right atrium and ventricle occurs, with its gradual weakening. In some cases, this can lead to pulmonary congestion and pulmonary hypertension.

Comparison of atrial septal defect with non-closure of the foramen ovale

The foramen ovale is a natural opening in the atrial septum, which is necessary for the blood flow of the fetus in the womb. This is due to the peculiarities of fetal circulation. After birth, this hole usually closes up. With its non-closure, they speak of such a defect as non-closure of the oval window. Depending on the size of this hole, there will be manifestations of this defect.

Risk factors for ASD

There are no exact causes of an ASD, like most other congenital heart defects, but researchers have identified a number of key risk factors that can lead to an ASD in a child. These can be, for example, genetic factors, so if you or someone in your family has a congenital heart disease, you should undergo genetic counseling to determine the risk of the defect in your unborn child.

Among the risk factors that play a role in the occurrence of ASD during pregnancy, the following are distinguished:

• Rubella.

  This is a viral disease. If a woman had rubella during pregnancy, especially at an early stage, then there is a risk of congenital heart defects, including ASD, as well as other developmental anomalies in the newborn.

• Taking certain drugs and alcohol during pregnancy.

  Some drugs, especially if they are taken in early pregnancy, when the main organs of the fetus are being laid, as well as alcohol intake, can increase the risk of developmental anomalies, including ASD.

Complications of ASD

With a small ASD, a person may never notice any problems at all. Small atrial septal defects may close on their own during infancy.

With a larger size of this heart disease, there can be life-threatening complications:

• Pulmonary hypertension.

  If a large atrial septal defect is left without surgical correction, there is an overload of blood in the right heart with the development of stagnation in the pulmonary circulation and pulmonary hypertension (increased blood pressure in the pulmonary circulation).

• Eisenmenger syndrome.

  In rare cases, pulmonary hypertension can lead to irreversible changes in the lungs. This complication, called Eisenmenger's syndrome, usually develops after a long period of time in only a small number of ASD patients.

Other complications of atrial septal defect

Other complications of ASD, in the absence of surgical treatment, include:

• Right heart failure
• Heart rhythm disorders
• Low life expectancy
• Increased risk of stroke

Timely surgical treatment can help prevent all these complications.

Atrial septal defect and pregnancy

Most women with an ASD, in which the size of the defect is small, can get pregnant without any problems. However, if the size of the atrial septal defect is large, or the woman has complications of this defect such as heart failure, arrhythmias, or pulmonary hypertension, then the risk of complications during pregnancy increases. Women with Eisenmenger's syndrome are strongly advised by doctors to refrain from pregnancy, as it can be life-threatening.

In addition, the risk of congenital heart defects in children if the mother or father of the child has a congenital heart disease, including ASD, is higher than in others. Patients with heart disease, whether operated on or not, are advised to consult their doctor before deciding to become pregnant. In addition, before deciding on pregnancy, you should stop taking certain drugs that can be risk factors for ASD, so in this case, you should also consult a doctor.

Diagnosis of ASD

An atrial septal defect may be suspected at regular physical examinations. Usually, the doctor first learns about the possibility of an ASD during auscultation, when heart murmurs are heard. In addition, ASD can also be detected by ultrasound of the heart (echocardiography), which is performed for any other reason.

If the doctor detects heart murmurs during auscultation, special research methods are required to clarify the type of heart disease:

• Echocardiography (ultrasound of the heart).

  It is also a non-invasive and safe research method that allows you to evaluate the work of the heart muscle, its condition, as well as the conduction of the heart.

• Chest X-ray.

  A chest x-ray can look for enlarged heart or extra fluid in the lungs. This may be a sign of heart failure.

• Pulse oximetry.

  This method of research allows you to determine the saturation of the blood with oxygen. A special sensor is placed on the tip of the finger, which records the level of oxygen in the blood. Low blood oxygen saturation indicates heart problems.

• Cardiac catheterization.

  This is an x-ray method, which consists in the fact that using a thin catheter, which is inserted through the femoral artery, a special contrast agent is injected into the bloodstream, after which a series of x-rays is taken. This allows the doctor to assess the condition of the structures of the heart. In addition, this method allows you to determine the pressure in the chambers of the heart, on the basis of which you can indirectly judge the pathology of the heart.

• Magnetic resonance imaging (MRI).

  MRI is a method that allows you to get a layered structure of organs and tissues, while without x-ray radiation. This is an expensive diagnostic method, and is usually used in cases where echocardiography does not give an accurate answer.

Treatment of ASD

An atrial septal defect does not require urgent surgical treatment (except when its complications have a risk of threatening the patient's life). If an ASD has been identified in a child, then the doctor may first suggest monitoring his condition, since often the atrial septal defect can heal itself. In some cases, when an ASD does not heal itself, but the hole is small enough, it may not interfere with the patient's normal life, in which case surgical correction may not be required. But most often, ASD requires surgical treatment.

The timing of surgical correction of this heart defect depends on the health of the child and the presence of other congenital heart defects.

Medical treatment of ASD

It should be immediately noted that no drug leads to the fusion of an atrial septal defect. But conservative treatment can reduce the manifestation of ASD, as well as the risk of complications after surgery. Among the drugs that can be used in patients with ASD, we can note:

• Drugs that regulate the rhythm of the heart.

  Among them are beta-blockers (inderal, anaprilin) ​​and digoxin.

• Drugs that reduce blood clotting.

  This is the so-called. Anticoagulants, which reduce blood clotting, reduce the risk of a complication of ASD such as a stroke. These drugs include, most commonly, warfarin and aspirin.

Surgical treatment of ASD

Many cardiac surgeons recommend surgical treatment of ASD in childhood to prevent possible complications in adulthood. In both children and adults, surgical treatment consists in closing the defect by applying a "patch" that prevents blood from flowing from the left side of the heart to the right side. To do this, one of the methods of intervention can be carried out:

• Cardiac catheterization.

  This is a minimally invasive method of treatment, which consists in inserting a thin probe through the femoral vein under X-ray control, the end of which is brought to the defect site. Further, a mesh patch is installed through it, which closes the defect in the septum. After some time, this mesh grows into tissue, and the defect is completely closed. Such an intervention has a number of advantages - a shorter postoperative period and a lower complication rate. In addition, this method of treatment is easier to tolerate by the patient, as it is less traumatic. Among the complications of this method of treatment can be identified:
  • Bleeding, pain, or infection at the site of the catheter.
  • Damage to a blood vessel (rare complication)
  • Allergic reaction to the radiopaque substance that is used during catheterization.

• Open surgery.

  This type of surgical treatment of heart defects is performed under general anesthesia and consists of a traditional chest incision, connecting the patient to a heart-lung machine. In this case, a heart incision is made and a patch of synthetic material is sewn in. The disadvantage of this method is a longer postoperative period and a greater risk of complications.

Among all heart defects, an atrial septal defect is most often determined. Such an anomaly is often combined with damage to the interventricular septum. Up to 80% of this defect overgrows in the first years of a child's life, therefore, in terms of the frequency of distribution among CHD, it is ASD that occupies the leading place.

An atrial septal defect (ASD) is a violation of the wall structure between the two upper chambers of the heart (atria), most often presented as a hole. The condition is often detected at birth, so this anomaly is considered congenital. It can manifest itself both in childhood (in newborns) and in adults. In each individual case, the most appropriate treatment tactics or monitoring of the patient's condition is considered.

The disease may not require surgical treatment, but surgery is often recommended, as otherwise the risk of developing complications that threaten with a fatal outcome increases.

Before surgery, patients must undergo a comprehensive examination. The location of the defect is carefully studied, other violations and their severity are determined. Equally important after the operation is the rehabilitation period. With the correct implementation of all actions, the prognostic conclusion is most often favorable.

Video ASD or atrial septal defect: causes, symptoms, diagnosis and treatment of ASD

What is DMPP?

Among congenital heart defects, the most common type is atrial septal defect. Close attention to the disease began to be paid from 1900, when Bedford created a detailed description of the disease. Additions were made by Papp and Parkinson in 1941, and then - physical, electrocardiographic, radiological diagnostics.

ASD is often associated with other congenital lesions such as patent ductus arteriosus, anomaly of the interventricular septum, pulmonary valve stenosis, and transposition of large artery trunks. Often combined with defects of the ventricular septum, ductus arteriosus, rare venous anomalies when emptying the pulmonary veins. Thus, an atrial septal defect can accompany almost any congenital lesion, but it often appears in an isolated form.

Some statistics:

• The interatrial septum is completely absent in 3% of cases.
• Ostium secundum defect: the most common type of ASD and accounts for 75% of all cases of pathology, it is approximately 7% of all congenital heart defects and 30-40% of such anomalies in patients older than 40 years.
• Defect of the ostium primum type: the second most common type of defect and accounts for 15-20% of all cases.
• Sinus venosus defect: the least common of the three types of ASD and is observed in 5-10% of all developmental anomalies.
• The ratio of occurrence of ASD between women and men is approximately 2:1.
• By age 40, 90% of untreated patients have symptoms of shortness of breath, fatigue, palpitations, prolonged arrhythmias, or even signs of heart failure.

Pathogenesis

In a normal state, the heart is divided into four hollow chambers: two on the right and two on the left. To pump blood throughout the body, the heart uses the left and right sides to perform various tasks. The right half moves blood towards the lungs via the pulmonary arteries. In the alveoli, blood is saturated with oxygen, after which it returns to the left half of the heart through the pulmonary veins. The left atrium and ventricle pump blood through the aorta, directing it to the rest of the organ and tissues.

When an atrial septal defect is present, oxygenated blood flows from the left upper chamber of the heart (left atrium) to the upper right chamber of the heart (right atrium). There it mixes with oxygen-free blood and is pumped back into the lungs, although it had already been oxygenated before.

In a large atrial septal defect, this extra volume of blood can overwhelm the lungs and overload the right side of the heart. Therefore, in the absence of disease, the right side of the heart eventually hypertrophies and weakens. If this process continues further, arterial pressure in the lungs increases markedly, which immediately leads to pulmonary hypertension.

The reasons

Basically, all predisposing risk factors and causes of ASD are associated with intrauterine development of the fetus. Under certain circumstances, the probability of having a child with a congenital heart disease is especially high.

• Rubella (infectious disease). Rubella virus infection during the first few months of pregnancy may increase the risk of fetal heart defects, including ASDs.
• Drug addiction, smoking or alcoholism, and exposure to certain substances. The use of certain medications, tobacco, alcohol, or drugs such as cocaine during pregnancy can harm the developing fetus.
• Diabetes mellitus or systemic lupus erythematosus. If such diseases are noted (especially in a pregnant woman), then the chances of having a child with heart disease increase.
• Obesity. Obesity overweight may play a role in increasing the risk of having a child with an atrial septal defect.
• Phenylketonuria (PKU). If a woman has this condition, she may be more likely to have a child with a severe defect.

Clinic

Many children born with atrial septal defects do not have characteristic signs. In adults, symptoms may appear around the age of 30 or older.

Symptoms of an atrial septal defect may include:

• shortness of breath, especially during exercise;
• fatigue;
• frequent or irregular heartbeat;
• stroke.

When should you see a doctor?

You should not delay visiting a doctor if a child or adult has any of the following signs:

• intermittent breathing;
• swelling of the legs, arms, or abdomen;
• fatigue, especially after exercise;
• palpitations or extrasystoles.

Most often, this indicates the presence of heart failure or other complications that have arisen with congenital heart disease.

Complications

A minor atrial septal defect most often does not lead to serious hemodynamic disturbances. Small ASDs usually close on their own during infancy.

Large MPP defects often cause serious violations:

• Right sided heart failure
• Heart rhythm disorders (arrhythmias)
• Increased risk of stroke
• Premature wear of the heart muscle

Less common serious complications:

• Pulmonary hypertension. If a large atrial septal defect is not treated, increased blood flow to the lungs increases blood pressure in the pulmonary arteries, resulting in a complication like pulmonary hypertension.
• Eisenmenger syndrome. Long-term pulmonary hypertension can cause permanent lung damage. This complication usually develops over many years and occurs in people with large atrial septal anomalies.

Early treatment can prevent or help manage many of these complications.

ASD and pregnancy

Most women with an atrial septal defect can carry a pregnancy without any problems. But in the presence of a large defect or concomitant diseases such as heart failure, arrhythmia or pulmonary hypertension, the risk of complications during pregnancy increases significantly.

Doctors strongly advise women with Eisenmenger syndrome not to conceive a child because it could put both lives at risk.

The risk of congenital heart disease is higher in children whose parents have congenital heart defects, whether father or mother. Any person with a congenital heart disease, repaired or not, who is considering starting a family should discuss this carefully in advance with their doctor. Some medications may be taken off the prescription list or adjusted before pregnancy occurs because there may be serious problems for the developing fetus.

Video Living well! Atrial septal defect

Diagnostics

If the ASD is large, the doctor may hear an abnormal heart murmur during auscultation of the patient's heart. With small defects, it may be faintly audible. Since many people with an uncorrected ASD do not have significant symptoms, the disorder may be detected during adolescence or as an adult.

The most common diagnostic test used to confirm an ASD is an echocardiogram (echoCG), or ultrasound of the heart.

Other studies that the doctor may prescribe to the patient are as follows:

• Chest radiograph
• Electrocardiogram (ECG)
• Magnetic resonance imaging of the heart (MRI)
• Transesophageal echocardiography
• Cardiac catheterization

Treatment

If a small ASD is identified, closure is usually not recommended. However, if the patient has symptoms such as fatigue, shortness of breath, pre-stroke, atrial fibrillation, or if the right ventricle is enlarged, then reconstructive plasty is considered.

If a patient has severe pulmonary hypertension due to Eisenmenger's syndrome, plastic reconstruction of the defect is not recommended.

In 1953, Dr. John H. Gibbon successfully closed the MPP defect using open heart surgery and a cardiopulmonary control device. Since then, ASDs have been restored using various materials and surgical methods. Until the early 1990s, all ASDs were closed by open heart surgery. Today, the method of choice is to close the hole through cardiac catheterization. If the size of the defect is too large or the patient has any other types of congenital malformations, open surgery is recommended.

With early diagnosis and recovery of an ASD, the outcome is usually excellent. In such cases, a good long-term outcome is expected, especially if the defect was diagnosed early and closed in adulthood, or the patient has normal pulmonary artery pressure. However, there is often a risk of developing atrial arrhythmias due to scarring in the area of ​​the closure. In a small number of cases, a second operation may be required. Other risks that may arise later include the possibility of developing heart failure or hypertension.

Depending on whether the ASD patient underwent specific treatment or not, the following recommendations are given:

1. All adults who have an unrepaired ASD should be followed up regularly throughout their lives by a congenital heart disease specialist.
2. Patients whose defect was closed in childhood or adulthood need periodic heart checks; which should be taken at least once a year in a specialized medical center. This is necessary for correct diagnosis and evaluation of the effectiveness of previous treatment.
3. Further follow-up needs will be determined by the treating congenital heart disease cardiologist.

Forecast

Adults with small ASDs that do not affect heart function usually do not require treatment. In such cases, it is still important to see a doctor at least once a year to make sure nothing has changed. On the other hand, if the hole is too large and blood flows from the left side of the heart to the right side, then the prognosis worsens. This is because excess blood flows to the lungs, causing the heart and lungs to work harder and less efficiently. When this happens, there is a great risk of developing other diseases of the heart, lungs and circulatory system.

The prognosis for ASD worsens if the following complications are identified:

• The right side of the heart is enlarged, which can cause heart failure
• Irregular and rapid heartbeats such as fibrillation, especially those located in the atria
• Stroke
• Damage to the pulmonary arteries
• Eisenmenger syndrome
• Tricuspid and mitral valve disease

Prevention

Most often, the development of an atrial septal defect cannot be prevented. If pregnancy is planned, then you should first consult with your doctor. This visit should include:

• Examination for the presence of immunity to rubella. If susceptibility to the virus is determined, then vaccination is carried out.
• Analysis of general health and determination of medications taken. If necessary, certain health problems during pregnancy will need to be closely monitored. Your doctor may also recommend dose adjustments or avoidance of certain medications that can harm your pregnancy.
• Analysis of heredity. If the family history is burdened with heart defects or other genetic disorders, consideration should be given to consulting a geneticist, which will determine the risks regarding future pregnancy.

Video Ventricular septal defect

Atrial septal defect (abbreviated ASD) is one of the varieties of congenital heart disease. It consists in the presence of an opening between the right and left atrium. If the ASD is small, there is a chance that it will close on its own in the first years of life. But if the hole is large, it will not disappear without surgery. Approximately 7-12% of newborns have ASD, which can be combined with other diseases of the cardiovascular system, sometimes symptoms are detected immediately, sometimes in childhood, and sometimes even in adults.

Over time, an ASD can lead to rhythm disturbances, the heart muscle becomes thinner due to the nature of the work, and there is a risk of blood clots that can lead to heart attacks and strokes. Based on the foregoing, the elimination of ASD is a mandatory measure for a child with heart disease, because according to statistics, people with a hole between the right and left atrium, at best, live up to 40-50 years.

In newborns, ASD does not manifest itself in any way, so the defect is often detected either during routine diagnostics or when specific symptoms appear. ASD is characterized by:

Attention: if your child has any of the above symptoms, you should urgently go to the doctor for an appointment. Because shortness of breath, fatigue, edema and accelerated heart rate indicate, first of all, the presence of a complication of RTD (heart failure and other characteristic diseases).

The reasons ASD in children

Until this moment, the exact causes of the formation of heart disease, including ASD, have not been established. If we talk about the mechanism of the occurrence of pathologies, then all of them are the result of impaired fetal development in the early stages. Causes are called genetic failures and environmental factors.

Doctors focus on the fact that ASD and other pathologies arise as a result of the negative influence of an external or internal nature. The course of ASD in children is due to the fact that the myocardium of the left sections experiences less stress than the right ones, respectively, the enriched blood in the right atrium mixes with blood, which practically does not contain oxygen. As it then re-enters the lungs, there is an overload that affects the right side of the heart muscle and the lungs.

Over time, due to constant and significant loads, the right sections expand, hypertrophy occurs, and this leads to the weakening of the heart muscle, which we mentioned above. One of the complications at this stage of ASD can be fluid stagnation in the pulmonary circulation.

Video - ASD or atrial septal defect

ASD and non-closure of the oval window: we distinguish pathologies

When we talk about ASD, we mean the presence of an opening between the right and left atrium, which is not anatomically incorporated; the oval window, on the contrary, is a natural opening intended for the implementation of the blood flow of the fetus in the womb. After the birth of the child, the oval window should be overgrown. If this does not happen, we are talking about a minor pathology (MARS syndrome), the manifestations of which directly depend on the size of the window. In addition, the window may close during the first five years of life.

Risk factors for developing an ASD

As we said earlier, doctors cannot name the exact reasons for the formation of heart defects. However, research continues to be carried out and doctors have managed to identify risk factors that, under certain conditions, lead to the onset of pathology.

First, this genetic predisposition, if one of the relatives was diagnosed with ASD, then you have a burdened heredity. It is advisable to consult a geneticist to find out the risk of this disease in an unborn child.

Secondly, risk factors are diseases that a woman has had in the process of bearing a fetus. For example, rubella is a viral disease, especially dangerous for the fetus in early pregnancy.

It is during this period that the main organs are formed and anomalies are possible, for example, ASD.

Thirdly, the development of a child in the womb can be affected taking certain medications, smoking, drinking alcohol and a poor environmental situation, stress, malnutrition.

The main complications of ASD

If the hole is small, the child may not feel any discomfort, besides, small defects may close themselves in the first years of life. But if we are talking about a significant hole, then the first complications soon appear. Most often, patients with ASD are diagnosed with pulmonary hypertension (due to excessive load, the right sections stretch, weaken and increase in size), congestion occurs.

In exceptional cases, hypertension contributes to the development of Eisenmenger's syndrome (irreversible changes in the lungs).

Among the complications, arrhythmia occurs, with prolonged absence of treatment, heart failure develops.

Diagnosis of cardiac pathologies

A septal defect can also be detected during a routine medical examination. As a rule, the first suspicions of ASD arise after auscultation (heart murmurs are heard). It makes it possible to detect pathology and ultrasound of the heart (echocardiogram).

If your doctor suspects the above deviation in the functioning of the heart, specific research methods will be needed to confirm the diagnosis:

• the above-mentioned echocardiogram (evaluates the work of the heart muscle and its condition);
• chest x-ray (makes it possible to detect the expansion of individual departments. If the image shows the expansion of the right departments, most likely the patient has an ASD pathology);
• pulse oximetry (a method of studying blood for oxygen content. The procedure is absolutely painless for a child, it is performed using a sensor, it calculates the amount of oxygen);
• cardiac catheterization (a contrast agent is injected through an artery using a catheter into the bloodstream system, with the help of images its path is fixed. This allows drawing conclusions about the functional state of the heart and identifying pathology);
• MRI (magnetic resonance imaging) makes it possible to assess the state of the structural elements of the heart without exposing the child to x-rays. Usually, MRI is used as an additional method of making a diagnosis, if the results of previous studies did not give an unequivocal answer about the presence of pathology.

Treatment ASD in children

Children with a hole in the interatrial septum need surgical intervention. If the hole is small, the doctor may decide to observe the child's condition for a while. It happens that the pathology does not cause tangible harm and the heart functions normally. But in most cases, the presence of a hole poses a direct threat to life and surgery cannot be avoided. The risks of surgical intervention depend on the patient's state of health, the presence of functional pathologies, and the state of the heart muscle.

Medical support

No existing drug can stimulate the elimination of pathology.

Conservative treatment is aimed primarily at reducing the negative effects of the defect and eliminating the risk of deterioration. Patients are prescribed drugs that can regulate the rhythm of the heart, as well as anticoagulants to prevent the formation of blood clots. Drug therapy is also carried out before surgery to correct the patient's condition.

Surgery

It is advisable to perform an operation to eliminate an ASD immediately after its discovery, when the body has not yet suffered so much from the pathology. The operation involves closing the hole with a “patch” or sewing it together. Due to this, it is possible to prevent mixing of fluid in the right atrium. The operation is performed by catheterization or on the open heart (the patient is connected to a heart-lung machine and a patch is sewn on the basis of synthetic non-allergenic materials). The second option of surgical intervention is more dangerous because of the risk of complications.

Endovascular closure pathology

Since open heart surgeries are very dangerous, require the patient to be connected to life support devices and are fraught with consequences or, at least, long-term rehabilitation, doctors were actively looking for a less dangerous and traumatic method for eliminating heart defects. When it comes to ASD, the operation is performed with the help of an occluder. This is a device that, when folded, is placed in a thin catheter tube and inserted into the patient. Visually, the occluder looks like two discs and has a shape memory effect. created from nitinol, completely biocompatible, do not cause allergies and do not have magnetic properties.

Before the operation, the patient must undergo an ultrasound examination of the heart (transesophageal), thanks to which doctors receive accurate information about the structural features of the organ and the anatomy of the defect.

This research method allows you to determine the indications and contraindications of this type of treatment. Although endovascular surgery does not require incisions, most patients undergo the procedure under anesthesia (the transducer causes discomfort). Information about the size of the defect is measured through echocardiography, then the occluder (folded) is inserted through the femoral vein and positioned so that the discs are in the right and left atrium. If the operation is successful, the patch closes the lumen and the blood no longer mixes.

If the occluder has shifted, it is pulled into the catheter and the process is repeated. After the patch is installed, the device is removed from the outside. The procedure takes no more than an hour (with the preparation of the patient). For another day, the patient must remain under the supervision of doctors and undergo an examination.

According to statistics, approximately 90% of patients with atrial septal defect can be treated in this way. Contraindications to the procedure are defects without edges, as well as the presence of some cardiovascular anomalies (the doctor should decide on the possibility of endovascular surgery).

The rehabilitation course usually takes six months. At this time, the patient should refrain from physical activity, vaccination and pregnancy. And also take a number of drugs prescribed by the doctor.

If the size of the defect does not exceed 1.2 (according to some sources, up to 3) centimeters, it is sutured. If the hole is larger, then it is closed with a patch. The second option to eliminate the pathology is preferable, because it contributes to the formation of blood clots at the surgical site to a lesser extent.

In the future, the patient should be regularly observed by a cardiac surgeon, rehabilitation therapy lasts a year. Only after this time the patient is allowed physical activity.

Video - Atrial septal defect plasty

Forecast

The prognosis depends primarily on when the operation was performed. If the defect was corrected in childhood or adolescence, there is a good chance that complications can be avoided. The functional state of the heart muscle is also important: how much pathology has affected its work and what damage has been done. Arrhythmia is the most common postoperative complication. If at the time of the operation the child has developed heart failure, it is, alas, impossible to eliminate the disease even with the help of an operation. In this case, surgical intervention is necessary primarily in order to prevent the deterioration of the patient's condition. With timely treatment, the child can completely recover from DMPP.