Cardiac Surgery – Atrial Septal Defect

Posted: Published on August 6th, 2018

This post was added by Rebecca Evans

What Are Holes in the Heart?

Holes in the heart are simple congenital (kon-JEN-ih-tal) heart defects. Congenital heart defects are problems with the heart's structure that are present at birth. These defects change the normal flow of blood through the heart.

Your heart has two sides, separated by an inner wall called the septum. With each heartbeat, the right side of your heart receives oxygen-poor blood from your body and pumps it to your lungs. The left side of your heart receives oxygen-rich blood from your lungs and pumps it to your body.

The septum prevents mixing of blood between the two sides of the heart. However, some babies are born with holes in the upper or lower septum.

A hole in the septum between the heart's two upper chambers is called an atrial septal defect (ASD). A hole in the septum between the heart's two lower chambers is called a ventricular septal defect (VSD).

ASDs and VSDs allow blood to pass from the left side of the heart to the right side. This means that oxygen-rich blood can mix with oxygen-poor blood. As a result, some oxygen-rich blood is pumped to the lungs instead of out to the body.

Over the past few decades, the diagnosis and treatment of ASDs and VSDs have greatly improved. Children who have simple congenital heart defects can survive to adulthood and live normal, active, and productive lives because their heart defects close on their own or have been repaired.

To understand holes in the heart, it's helpful to know how a healthy heart works. Your child's heart is a muscle about the size of his or her fist. The heart works like a pump and beats 100,000 times a day.

The heart has two sides, separated by an inner wall called the septum. The right side of the heart pumps blood to the lungs to pick up oxygen. Then, oxygen-rich blood returns from the lungs to the left side of the heart, and the left side pumps it to the body.

The heart has four chambers and four valves and is connected to various blood vessels. Veins are the blood vessels that carry blood from the body to the heart. Arteries are the blood vessels that carry blood away from the heart to the body.

The illustration shows a cross-section of a healthy heart and its inside structures. The blue arrow shows the direction in which oxygen-poor blood flows from the body to the lungs. The red arrow shows the direction in which oxygen-rich blood flows from the lungs to the rest of the body.

The heart has four chambers or "rooms."

Four valves control the flow of blood from the atria to the ventricles and from the ventricles into the two large arteries connected to the heart.

Valves are like doors that open and close. They open to allow blood to flow through to the next chamber or to one of the arteries, and then they shut to keep blood from flowing backward.

When the heart's valves open and close, they make a "lub-DUB" sound that a doctor can hear using a stethoscope.

The arteries are major blood vessels connected to your heart.

The veins also are major blood vessels connected to your heart.

For more information on how a healthy heart works, go to the Diseases and Conditions Index How the Heart Works article. This article contains animations that show how your heart pumps blood and how your heart's electrical system works.

An atrial septal defect (ASD) is a hole in the part of the septum that separates the atria (the upper chambers of the heart). This hole allows oxygen-rich blood from the left atrium to flow into the right atrium instead of flowing into the left ventricle as it should.

This means that oxygen-rich blood gets pumped back to the lungs, where it has just been, instead of going to the body.

Figure A shows the normal structure and blood flow in the interior of the heart. Figure B shows a heart with an atrial septal defect. The hole allows oxygen-rich blood from the left atrium to mix with oxygen-poor blood from the right atrium.

An ASD can be small or large. Small ASDs allow only a little blood to flow from one atrium to the other. Small ASDs don't affect the way the heart works and don't need any special treatment. Many small ASDs close on their own as the heart grows during childhood.

Medium to large ASDs allow more blood to leak from one atrium to the other, and they're less likely to close on their own. Most children who have ASDs have no symptoms, even if they have large ASDs.

The three major types of ASDs are:

Over time, if an ASD isn't repaired, the extra blood flow to the right side of the heart and lungs may cause heart problems. Usually, most of these problems don't show up until adulthood, often around age 30 or later. Complications are rare in infants and children.

Possible complications include:

These problems develop over many years and don't occur in children. They also are rare in adults because most ASDs either close on their own or are repaired in early childhood.

A ventricular septal defect (VSD) is a hole in the part of the septum that separates the ventricles (the lower chambers of the heart). The hole allows oxygen-rich blood to flow from the left ventricle into the right ventricle instead of flowing into the aorta and out to the body as it should.

Figure A shows the normal structure and blood flow in the interior of the heart. Figure B shows two common locations for a ventricular septal defect. The defect allows oxygen-rich blood from the left ventricle to mix with oxygen-poor blood in the right ventricle.

An infant who is born with a VSD may have a single hole or more than one hole in the wall that separates the two ventricles. The defect also may occur by itself or with other congenital heart defects.

Doctors classify VSDs based on the:

VSDs can be small or large. Small VSDs don't cause problems and often may close on their own. Because small VSDs allow only a small amount of blood to flow between the ventricles, they're sometimes called restrictive VSDs. Small VSDs don't cause any symptoms.

Medium VSDs are less likely to close on their own. They may require surgery to close and may cause symptoms during infancy and childhood.

Large VSDs allow a large amount of blood to flow from the left ventricle to the right ventricle. They're sometimes called nonrestrictive VSDs. A large VSD is less likely to close completely on its own, but it may get smaller over time. Large VSDs often cause symptoms in infants and children, and surgery usually is needed to close them.

VSDs are found in different parts of the septum.

Over time, if a VSD isn't repaired, it may cause heart problems. A moderate to large VSD can cause:

Mothers of children who are born with atrial septal defects (ASDs), ventricular septal defects (VSDs), or other types of heart defects often think that they did something wrong during the pregnancy to cause the problems. However, most of the time, doctors don't know why congenital heart defects develop.

Heredity may play a role in some heart defects. For example, a parent who has a congenital heart defect is slightly more likely than other people to have a child with the problem. Very rarely, more than one child in a family is born with a heart defect.

Children who have genetic disorders, such as Down syndrome, often have congenital heart defects. Half of all babies who have Down syndrome have congenital heart defects.

Smoking during pregnancy also has been linked to several congenital heart defects, including septal defects.

Scientists continue to search for the causes of congenital heart defects.

Many babies who are born with atrial septal defects (ASDs) have no signs or symptoms. When signs and symptoms do occur, heart murmur is the most common. A heart murmur is an extra or unusual sound heard during a heartbeat.

Often, a heart murmur is the only sign of an ASD. However, not all murmurs are signs of congenital heart defects. Many healthy children have heart murmurs. Doctors can listen to heart murmurs and tell whether they're harmless or signs of heart problems.

Over time, if a large ASD isn't repaired, the extra blood flow to the right side of the heart can damage the heart and lungs and cause heart failure. This doesn't occur until adulthood. Signs and symptoms of heart failure include:

A heart murmur usually is present in ventricular septal defect (VSD), and it may be the first and only sign of this defect. Heart murmurs often are present right after birth in many infants. However, the murmurs may not be heard until the babies are 6 to 8 weeks old.

Most newborns who have VSDs don't have heart-related symptoms. However, babies who have medium or large VSDs can develop heart failure. Signs and symptoms of heart failure usually occur during the baby's first 2 months of life.

The signs and symptoms of heart failure from VSD are similar to those listed above for ASD, but they occur in infancy.

A major sign of heart failure in infancy is difficulty feeding and poor growth. VSD signs and symptoms are rare after infancy because the defect either decreases in size on its own or is repaired.

Doctors usually diagnose holes in the heart based on results from a physical exam and tests and procedures. The exam findings for an atrial septal defect (ASD) often aren't obvious, so the diagnosis sometimes isn't made until later childhood or even adulthood.

Ventricular septal defects (VSDs) have a very distinct heart murmur, so a diagnosis usually is made in infancy.

Doctors who specialize in diagnosing and treating heart problems are called cardiologists. Pediatric cardiologists take care of babies and children who have heart problems. Cardiac surgeons repair heart defects using surgery.

During a physical exam, your child's doctor will listen to your child's heart and lungs with a stethoscope. The doctor also will look for signs of a heart defect, such as a heart murmur or signs of heart failure.

Your child's doctor may recommend several tests to diagnose an ASD or VSD. These tests also will help the doctor determine the location and size of the defect.

Echocardiography (echo) is a painless test that uses sound waves to create a moving picture of the heart. During the test, the sound waves (called ultrasound) bounce off the structures of the heart. A computer converts the sound waves into pictures on a screen.

Echo allows the doctor to clearly see any problem with the way the heart is formed or the way it's working.

Echo is an important test for both diagnosing a hole in the heart and following the problem over time. Echo can show problems with the heart's structure and how the heart is reacting to the problems. Echo will help your child's cardiologist decide whether and when treatment is needed.

An EKG is a simple, painless test that records the heart's electrical activity. The test shows how fast the heart is beating and its rhythm (steady or irregular). It also records the strength and timing of electrical signals as they pass through each part of the heart.

An EKG can detect whether one of the heart's chambers is enlarged, which can help diagnose a heart problem.

A chest x ray is a painless test that creates pictures of the structures in the chest, such as the heart and lungs. This test can show whether the heart is enlarged or whether the lungs have extra blood flow or extra fluid, a sign of heart failure.

Pulse oximetry shows how much oxygen is in the blood. For this test, a small sensor is attached to a finger or toe (like an adhesive bandage). The sensor gives an estimate of how much oxygen is in the blood.

During cardiac catheterization (KATH-e-ter-i-ZA-shun), a thin, flexible tube called a catheter is put into a vein in the arm, groin (upper thigh), or neck and threaded to the heart.

Special dye is injected through the catheter into a blood vessel or a chamber of the heart. The dye allows the doctor to see the flow of blood through the heart and blood vessels on an x-ray image.

The doctor also can use cardiac catheterization to measure the pressure inside the heart chambers and blood vessels. This can help the doctor determine whether blood is mixing between the two sides of the heart.

Cardiac catheterization also is used to repair some heart defects. For more information, go to "How Are Holes in the Heart Treated?"

Many holes in the heart don't need treatment, but some do. Most holes in the heart that need treatment are repaired in infancy or early childhood. Sometimes, adults are treated for holes in the heart if problems develop.

The treatment your child receives depends on the type, location, and size of the hole. Other factors include your child's age, size, and general health.

Periodic checkups are done to see whether an atrial septal defect (ASD) closes on its own. About half of all ASDs close on their own over time, and about 20 percent close within the first year of life.

Your child's doctor will let you know how often your child should have checkups. For an ASD, frequent checkups aren't needed.

When treatment of an ASD is required, it involves catheter or surgical procedures to close the hole. Doctors often decide to close an ASD in children who still have medium to large holes by the time they're 2 to 5 years old.

Until the early 1990s, surgery was the usual method for closing all ASDs. Now, thanks to medical advances, doctors can use catheter procedures to close secundum ASDs, the most common type of ASD. For this procedure, your child is given medicine so he or she will sleep through it and not feel any pain.

During the procedure, the doctor inserts a catheter (a thin, flexible tube) into a vein in the groin (upper thigh) and threads it to the heart's septum. The catheter has a tiny umbrella-like device folded up inside it.

When the catheter reaches the septum, the device is pushed out of the catheter and positioned so that it plugs the hole between the atria. The device is secured in place and the catheter is withdrawn from the body.

Within 6 months, normal tissue grows in and over the device. There is no need to replace the closure device as the child grows.

Doctors often use echocardiography (echo) or transesophageal (tranz-ih-sof-uh-JEE-ul) echo (TEE) as well as angiography (an-jee-OG-ra-fee) to guide them in threading the catheter to the heart and closing the defect. TEE is a special type of echo that takes pictures of the heart through the esophagus (the passage leading from the mouth to the stomach).

Catheter procedures are much easier on patients than surgery because they involve only a needle puncture in the skin where the catheter is inserted. This means that recovery is faster and easier.

The outlook for children having this procedure is excellent. Closures are successful in more than 9 out of 10 patients, with no significant leakage. Rarely, a defect is too large for catheter closure and surgery is needed.

Open-heart surgery generally is done to repair primum or sinus venosus ASDs. Your child is given medicine so that he or she will sleep through the surgery and not feel any pain.

During the surgery, the cardiac surgeon makes an incision (cut) in the chest to reach the ASD. He or she then repairs the defect with a special patch that covers the hole. Your child is placed on a heart-lung bypass machine so that the heart can be opened to do the surgery.

The outlook for children after ASD surgery is excellent. On average, children spend 3 to 4 days in the hospital before going home. Complications, such as bleeding and infection, from ASD surgery are very rare.

Some children may develop inflammation of the outer lining of the heart, a condition called pericarditis (PER-i-kar-DI-tis). This causes fluid to collect around the heart in the weeks after surgery. This complication of heart surgery usually resolves with medicine.

While in the hospital, your child will be given medicines as needed to reduce pain or anxiety. The doctors and nurses at the hospital will teach you how to care for your child at home.

They will talk about preventing blows to the chest as the incision heals, limiting activity while your child recovers, bathing, scheduling followup medical appointments, and determining when your child can go back to his or her regular activities.

Doctors may choose to monitor and observe children who have ventricular septal defects (VSDs) but don't have symptoms of heart failure. This means regular checkups and tests to see whether the defect closes on its own or gets smaller.

More than half of VSDs eventually close, usually by the time a child is in preschool. Your child's doctor will let you know how often your child should be checked. Checkups may range from once a month to once every 1 or 2 years.

When treatment for a VSD is required, options include extra nutrition and surgery to close the VSD.

The doctor may recommend surgery if your child's VSD:

Some infants who have VSDs don't grow and develop or gain weight as they should. These infants usually:

Doctors usually recommend extra nutrition or special feedings for these infants. These feedings are high-calorie formulas or breast milk supplements that give babies extra nourishment.

In some cases, tube feeding is needed. Food is given through a small tube that's placed through the nose and into the stomach. Tube feeding can add to or take the place of bottle feeding. This treatment usually is temporary because a VSD that causes symptoms will likely need surgery.

Most doctors recommend surgery to close large VSDs that are causing symptoms or haven't closed by the time children are 1 year old. Surgery may be needed earlier if:

Rarely, medium-sized VSDs that are causing enlarged heart chambers are treated with surgery after infancy. However, most VSDs that need surgery are repaired in the first year of life.

The outlook for children who have atrial septal defects (ASDs) or ventricular septal defects (VSDs) is excellent. Advances in treatment allow most children who have these heart defects to live normal, active, and productive lives with no decrease in lifespan.

Many children who have these defects need no special care or only occasional checkups with a cardiologist (a heart specialist) as they go through life.

Small ASDs often close on their own and don't cause complications or require treatment. Children and adults who have small ASDs that don't close and don't cause symptoms are healthy and don't need treatment.

Many others who have ASDs that don't close have catheter procedures or surgery to close the holes and prevent possible long-term complications. Children recover well from these procedures and lead normal, healthy lives. Adults also do well after closure procedures.

Arrhythmias. The risk of arrhythmias (irregular heartbeats) increases before and after surgery. Adults who have ASDs and are older than 40 are especially likely to have arrhythmias. People who had arrhythmias before surgery are more likely to have them after surgery.

Followup care. Regular followup care into adult life is advised for people who have had:

Antibiotics. Children who have severe heart defects may be at slightly increased risk for infective endocarditis (IE). IE is a serious infection of the inner lining of your heart chambers and valves.

ASDs aren't associated with a risk of IE, except in the 6 months after repair (for both catheter procedures and surgery).

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Cardiac Surgery - Atrial Septal Defect

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