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Indications for
intervention of ASDand VSD
Ri
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ASD
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Morphology 4 Types of ASD:
* ostium primum
* ostium secundum* sinus venosus
* coronary sinus defects
Left to right shunt:
* left ventricular compliance
* left atrial pressure
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Clinical feature Large ASD(Qp/Qs > 2): CHF, pulmonary
HTN or failure to thrive
Undetective ACD with a significant shunt
(Qp/Qs > 1.5): symptoms with aging
80% spontaneous closure occur < 1 y/o
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Indications for intervention Asymptomatic children: Right heart
dilation + a significant
ASD (>5 mm) without spontaneous closure
Significant ASD (Qp/Qs > 1.5)
ASD associated with RV volume overload To prevent paradoxical
emboli in stroke patients
Pulmonary HTN:
* Resistance < 8.0 Wood units/m2
* Net left-to-right shunt of at least 1.5
* Pulmonary artery reactive to vasodilator (e.g., O2 or NO)*
Lung biopsy revealed pulmonary arterial changes are potentially
reversible
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Intervention Device closure
* For secundum ASD with stretched diameter < 36 mm + adequate
rims
* Exception:
1) Anomalous pulmonary venous connection2) Proximity to the AV
valves / coronary sinus / systemic
venous drainage
Surgery
* For sinus venosus or ostium primum defects or with secundum
defects
with unsuitable anatomy
* primary suture closure or using a pericardial or synthetic
patch
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VSD
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Morphology 4 components of Septum:
Membranous, inlet, trabecular, outlet (conal,
infundibular) part 3 Types of VSD
* Muscular VSD
* Membranous VSD
* Doubly committed subarterial VSD
(juxta-arterial/supracristal/outlet/conal defects)
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PathophysiologyShunt Qp/Qs P/A systolic
pressure ratio
RestrictiveVSD
Small 1~1.4 2.2 >0.66
Eisenmenger
VSD
Right to
left
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Indications for intervention Significant VSD: symptomatic
without irreversible pulmonaryHTN* Qp/Qs > 1.5
* PA systolic pressure > 50 mm Hg
* Increased LV and LA size
* Deteriorating LV function
Perimembranous VSD with more than mild AR +
recurrentendocarditis.
Subarterial VSD
Children without irreversible pulmonary HTN
* significant symptoms failing to respond to medication
* elective surgery (performed between 3 ~ 9 m/o)
Pulmonary HTN
* PA resistance < 7 Wood units
* Net left-to-right shunt of at least 1.5
* Irreversible
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Intervention Surgery: direct suture or with a patch
* Single-stage closure: large defect,CHF s/s, failure to
thrive
* Perimembranous and muscular defects + normal PAP + no s/s
delayed op up to 1 year or more* Patient >10 y/o with a small
defect (Qp:Qs < 1.5; normal PAP)
controversial
Device closure:
* Trabecular VSDs have proven more amenable
* Perimembranous VSDs is technically more challenging
