2013-01-09

← Older revision

Revision as of 21:42, 9 January 2013

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OR

OR



2. There is 1.5 times more pulmonary flow than systemic flow
'''
(i.e. the pulmonary flow [Qp] : systemic flow [Qs] ratio is >1.5).

+

2. There is 1.5 times more pulmonary flow than systemic flow (i.e. the pulmonary flow [Qp] : systemic flow [Qs] ratio is >1.5).

If the patient meets these criteria, and has no symptoms, this is not a contraindication for repair.

If the patient meets these criteria, and has no symptoms, this is not a contraindication for repair.

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* VIT-LVOT = Maximum doppler flow velocity apical to the aortic valve

* VIT-LVOT = Maximum doppler flow velocity apical to the aortic valve



6) In case the
[[
pulmonary arterial pressure
]]
is more than 2/3rd of the systemic systolic pressure, it could cause a net [[left-to-right shunt]] of at least
'''
1.5:1
'''
or evidence of reversibility of the shunt when given
[[
pulmonary artery
]] [[
vasodilators
]]
prior to surgery.

+

6) In case the pulmonary arterial pressure is more than 2/3rd of the systemic systolic pressure, it could cause a net [[left-to-right shunt]] of at least 1.5:1 or evidence of reversibility of the shunt when given pulmonary artery vasodilators prior to surgery.



7) If [[Eisenmenger's syndrome]] has developed, it must be demonstrated that the right-to-left shunt is reversible with [[pulmonary artery]] [[vasodilators]] prior to surgery.

+

7) If [[Eisenmenger's syndrome]] has developed, it must be demonstrated that the right-to-left shunt is reversible with [[pulmonary artery]] [[vasodilators]]prior to surgery.



8) The [[American Heart Association]] has recommended a threshold
'''
Qp/Qs ≥1.5:1
'''
for patients
'''
21
'''
years of age or older.
{{cite journal| author=Driscoll D, Allen HD, Atkins DL, Brenner J, Dunnigan A, Franklin W et al.| title=Guidelines for evaluation and management of common congenital cardiac problems in infants, children, and adolescents. A statement for healthcare professionals from the Committee on Congenital Cardiac Defects of the Council on Cardiovascular Disease in the Young, American Heart Association. | journal=Circulation | year= 1994 | volume= 90 | issue= 4 | pages= 2180-8 | pmid=7923709 | doi= | pmc= | url= }}

+

8) The [[American Heart Association]] has recommended a threshold Qp/Qs ≥1.5:1 for patients 21 years of age or older.
{{cite journal|author=Driscoll D, Allen HD, Atkins DL, Brenner J, Dunnigan A, Franklin W et al.| title=Guidelines for evaluation and management of common congenital cardiac problems in infants, children, and adolescents. A statement for healthcare professionals from the Committee on Congenital Cardiac Defects of the Council on Cardiovascular Disease in the Young, American Heart Association. | journal=Circulation | year= 1994 | volume= 90 | issue= 4 | pages= 2180-8 | pmid=7923709 | doi=| pmc= | url= }}



9) The Canadian Cardiac Society recommended a threshold
'''
Qp/Qs >2:1, or >1.5:
1''' in
the presence of reversible [[pulmonary hypertension]]
{{cite journal| author=Therrien J, Dore A, Gersony W, Iserin L, Liberthson R, Meijboom F et al.| title=CCS Consensus Conference 2001 update: recommendations for the management of adults with congenital heart disease. Part I. | journal=Can J Cardiol | year= 2001 | volume= 17 | issue= 9 | pages= 940-59 | pmid=11586386 | doi= | pmc= | url= }}
.

+

9) The Canadian Cardiac Society recommended a threshold

Qp/Qs >2:1, or >1.5:
1in
the presence of reversible [[pulmonary hypertension]]
{{cite journal| author=Therrien J, Dore A, Gersony W, Iserin L, Liberthson R, Meijboom F et al.| title=CCS Consensus Conference 2001 update: recommendations for the management of adults with congenital heart disease. Part I. | journal=Can J Cardiol | year= 2001 | volume= 17 | issue= 9 | pages= 940-59| pmid=11586386 | doi= | pmc= | url= }}
.

10) The Qp/Qs ratio can change as the disease progresses. Due to this it has been recommended that asymptomatic patients undergo [[echocardiography]] every 2-3 years.

10) The Qp/Qs ratio can change as the disease progresses. Due to this it has been recommended that asymptomatic patients undergo [[echocardiography]] every 2-3 years.

====Symptoms====

====Symptoms====



1) Development and worsening of symptoms such as [[shortness of breath]], [[exercise intolerance]], [[fatigue]], [[pedal edema|swelling of feet]] and ankle or [[abdomen]] (suggesting [[right sided heart failure]]), recurrent [[respiratory infections]] along with [[echocardiographic]] abnormalities are an indication for repair.

+

1) Development and worsening of symptoms such as [[shortness of breath]], [[exercise intolerance]], [[fatigue]], [[pedal edema|swelling of feet]] and ankle or[[abdomen]] (suggesting [[right sided heart failure]]), recurrent [[respiratory infections]] along with [[echocardiographic]] abnormalities are an indication for repair.

2) [[Arrhythmia]]s as an isolated symptom can occur in 1 out of 5 adults patients with [[atrial septal defect]]s.  The surgical closure for patients presenting only with arrhythmia is controversial as not much benefit could be derived even after surgery.

2) [[Arrhythmia]]s as an isolated symptom can occur in 1 out of 5 adults patients with [[atrial septal defect]]s.  The surgical closure for patients presenting only with arrhythmia is controversial as not much benefit could be derived even after surgery.

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====Size of Defect====

====Size of Defect====



1)Secundum ASD
'''

'''
in infants may close spontaneously by the end of two years of life.  Thus, in asymptomatic patients with small defects early closure is not indicated.

+

1)Secundum ASD



2) Defects of moderate size
'''
(6 to 8 mm)
'''
are less likely to close spontaneously. Despite this [[Atrial septal defect surgical closure | surgical closure]] of these defects are not indicated before two years of age, in case these are asymptomatic.

+

2) Defects of moderate size (6 to 8 mm) are less likely to close spontaneously. Despite this [[Atrial septal defect surgical closure | surgical closure]] of these defects are not indicated before two years of age, in case these are asymptomatic.

====Age====

====Age====



1) Closure of an [[ASD]] in individuals
'''
under age 25
'''
has been shown to be associated with a low risk of complications, and individuals have a normal lifespan (comparable to a healthy age-matched population).

+

1) Closure of an [[ASD]] in individuals under age 25 has been shown to be associated with a low risk of complications, and individuals have a normal lifespan (comparable to a healthy age-matched population).

2) Closure of an [[ASD]] in individuals between the ages of 25 and 40 who are asymptomatic but have a clinically significant shunt is controversial. Those that perform the procedure believe that they are preventing long-term deterioration in cardiac function and preventing progression of [[pulmonary hypertension]].

2) Closure of an [[ASD]] in individuals between the ages of 25 and 40 who are asymptomatic but have a clinically significant shunt is controversial. Those that perform the procedure believe that they are preventing long-term deterioration in cardiac function and preventing progression of [[pulmonary hypertension]].

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===Percutaneous Versus Surgical Closure===

===Percutaneous Versus Surgical Closure===



The ACC/AHA guidelines recommend different interventional and [[Atrial septal defect surgical closure | surgical closure]] techiques in patients with [[atrial septal defect]] depending on the associated lesions, presence and absence of atrial and ventricular hypertrophy and amount of shunting across the lesions.  [[Atrial septal defect percutaneous closure | Percutaneous closure]] is commonly performed for ostium secundum atrial septal defect.  This procedure is still not [[FDA]] approved for the treatment of other types of atrial septal defects like [[Atrial septal defect sinus venosus|sinus venosus ASD]], [[Atrial septal defect coronary sinus|coronary sinus ASD]], or [[atrial septal defect ostium primum|primum ASD]]. With appropriate patient selection, percutaneous closure has been demonstrated to be as successful, safe and effective as surgical closure. Additionally, [[Atrial septal defect percutaneous closure | percutaneous closure]] has been associated with fewer complications and a reduced average length of hospital stay compared to surgical care. Surgical closure of ostium ostium secundum atrial septal defect can be done when a concomitant tricuspid valve repair is considered or when the anatomy of the defect doesn't favor a percutaneous device.

+

The ACC/AHA guidelines recommend different interventional and [[Atrial septal defect surgical closure | surgical closure]] techiques in patients with [[atrial septal defect]] depending on the associated lesions, presence and absence of atrial and ventricular hypertrophy and amount of shunting across the lesions.  [[Atrial septal defect percutaneous closure | Percutaneous closure]] is commonly performed for ostium secundum atrial septal defect.  This procedure is still not [[FDA]] approved for the treatment of other types of atrial septal defects like [[Atrial septal defect sinus venosus|sinus venosus ASD]], [[Atrial septal defect coronary sinus|coronary sinus ASD]], or [[atrial septal defect ostium primum|primum ASD]]. With appropriate patient selection, percutaneous closure has been demonstrated to be as successful, safe and effective as surgical closure. Additionally, [[Atrial septal defect percutaneous closure | percutaneous closure]]has been associated with fewer complications and a reduced average length of hospital stay compared to surgical care. Surgical closure of ostium ostium secundum atrial septal defect can be done when a concomitant tricuspid valve repair is considered or when the anatomy of the defect doesn't favor a percutaneous device.



==2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)
{{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 23 | pages= e1-121 | pmid=19038677 | doi=10.1016/j.jacc.2008.10.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038677  }}
==

+

==2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)
{{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 23 | pages= e1-121 | pmid=19038677 | doi=10.1016/j.jacc.2008.10.001 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038677  }}
==



===Recommendations for Interventional and Surgical Therapy (DO NOT EDIT)
{{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 23 | pages= e1-121 | pmid=19038677 | doi=10.1016/j.jacc.2008.10.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038677  }}
===

+

===Recommendations for Interventional and Surgical Therapy (DO NOT EDIT)
{{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 |issue= 23 | pages= e1-121 | pmid=19038677 | doi=10.1016/j.jacc.2008.10.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038677  }}
===

{|class="wikitable"

{|class="wikitable"

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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]

| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]

|-

|-



|bgcolor="LemonChiffon"|
"
'''1.''' Closure of an ASD, either percutaneously or surgically, may be considered in the presence of net [[left-to-right shunt]]ing, pulmonary artery pressure less than two thirds systemic levels, PVR less than two thirds systemic vascular resistance, or when responsive to either pulmonary [[vasodilator]] therapy or test occlusion of the defect (patients should be treated in conjunction with providers who have expertise in the management of pulmonary hypertensive syndromes). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
"

+

|bgcolor="LemonChiffon"|
"
'''1.''' Closure of an ASD, either percutaneously or surgically, may be considered in the presence of net[[left-to-right shunt]]ing, pulmonary artery pressure less than two thirds systemic levels, PVR less than two thirds systemic vascular resistance, or when responsive to either pulmonary [[vasodilator]] therapy or test occlusion of the defect (patients should be treated in conjunction with providers who have expertise in the management of pulmonary hypertensive syndromes). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
"

|-

|-

|bgcolor="LemonChiffon"|
"
'''2.''' Concomitant Maze procedure may be considered for intermittent or chronic atrial [[tachyarrhythmias]] in adults with ASDs. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
"

|bgcolor="LemonChiffon"|
"
'''2.''' Concomitant Maze procedure may be considered for intermittent or chronic atrial [[tachyarrhythmias]] in adults with ASDs. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
"

|}

|}



==References==

==References==

{{reflist|2}}

{{reflist|2}}

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