ATRIAL SEPTAL DEFEK

ATRIAL SEPTAL DEFECT

BAGIAN KARDIOLOGI DAN VASKULER FAKULTAS KEDOKTERAN UNIVERSITAS HASANUDDIN MAKASSARDisusun Oleh :Ainil Fatima ZainodinC111 10 878Supervisor :dr. Julius Patimang Sp.A, Sp.JPDIBAWAKAN DALAM RANGKA TUGAS KEPANITERAAN KLINIKBAGIAN KARDIOLOGI DAN KEDOKTERAN VASKULERFAKULTAS KEDOKTERANUNIVERSITAS HASANUDDINMAKASSAR2015PATIENTS IDENTITYNAME: Mr. MSBIRTH DATE : 21-09-1982 (33 years old)ADDRESS: Sudiang RayaMEDICAL RECORD : 534907DATE OF ADMISSION : 22nd June 2014HISTORY TAKINGChief Complaint : PalpitationPresent Ilness History : He has been suffering from palpitation since 3 months ago and getting worst 4 hours before entering hospital. Palpitation is not influence by activities. But palpitation increase when he felt anxious. The patient also complain mild chest pain. Described as stab pain and not radiating. The pain always resolved with rest. Absence of shortness of breath, nausea and cough. No history of bluish discoloration of the skin and mucous membranesHISTORY TAKINGPast Ilness History :He was diagnosed with Atrial Septal Defect (ASD) on 2012 but does not control frequently with cardiologist because he thought he was fine.

PHYSICAL EXAMINATIONGeneral StatusModerate illness/ well nourished / Compos MentisWeight: 62 kgHeight: 168 cmBMI: 22,1 kg/m2Vital StatusBlood pressure : 120/80 mmHgHeart rate : 101 bpmRespiratory rate : 20 bpmTemperature : 36,5 oC

ELECTROCARDIOGRAM

Sinus rhythmHeart rate : 75 bpmAxis : NormoaxisP Wave : P normal PR interval : 0,12 secondsQRS Complex: 0,08 seconds, morphology normalST segment : NormalT wave: Inverted T4-T6, II,III,AVFConclusion : Sinus rhythm, Ischemic anterolateral and inferior

RADIOLOGY (CXR)Cardiomegaly with increased pulmonary vascular markingDilatation, elongation et atherosclerosis aortae

LABORATORY FINDINGSHemoglobin14.3 gr/dlLeucocyte7.5 x 103/uLThrombocyte348 x 103/uLRed blood cells5.03 x 10 03/uLGDS100 mg/dlElectrolyte Sodium (Na) : 139 mmol/lPotassium (K) : 4.3 mmol/lChloride (Cl) : 104 mmol/l Ureum21 mg/dlCreatinine0.79 mg/dlSGOT14 U/LSGPT9U/LPT12,5 detikAPTT42,7 detikINR1,20Conclusion: With normal RangeECHOCARDIOGRAPHY Trans Thoracal Echocardiography (TTE)

Conclusion :ASD sekundum with Left to Right ShuntRA dan RV dilatationMild Hypertension Pulmonal

ECHOCARDIOGRAPHY Trans Esophageal Echocardiography (TEE)

Conclusion :ASD sekundum 15-20mmPosition 20 ; Rim Posterior 20mm, Rim Aorta 4mmPosition 110 ; Rim IVC 15mm, Rim SVC 17mm

CATHETERISATION Conclusion :ASD Sekundum with Low Flow, High ResistanceDIAGNOSISAtrial Septal Defect Type SecundumMANAGEMENTInfuse NaCl 0.9% 500cc/24jamBisoprolol 2,5mg/24jam/oralAlprazolam 0,5mg/24jam/oralCeftriaxone 2gr/24jam/intravena16DISCUSSION

Lets discuss togetherCONGENITAL HEART DISEASEASIANOSISSIANOSISTetralogy of FallotTotal anomalous pulmonaru venous returnTransposition of the great vesselsTricuspid atresiaTrunchus arteriosusPulmonary atresiaEbsteins anomalyHypoplastic left heart

INTRODUCTIONAtrial Septal Defect (ASD)Ventricular septal defect (VSD)Patent Ductus Arteriosus (PDA)Coarctation of AortaAtrioventricular canal (endocardial cushion defect)Pulmonic stenosisAortic stenosisDefinitiion of asd

An atrial septal defect (ASD) is a persistent opening in the interatrial septum after birth that allows direct communication between the left and right atria.Classification of asdASD secundumASD primumASD sinus venoususASD sinus coronarius

High O2 saturationFrom umbilical arteryBlood shunt from R-L atriumForamen OvaleAscending aorta9% Coronary Artery 62% Carotid & Subclavia vessels29% Desending aorta MyocardiumBrainRest of fetal bodyPATHOPHYSIOLOGY of asdBefore birth

PATHOPHYSIOLOGY of asd

Diagrammatic depiction of the flap-type valve of the foramen ovale. Before birth, the valve permits only right-to-left flow of blood from the higher pressured right atrium (RA) to the lower-pressured left atrium (LA).

Following birth, the pressure in the LA becomes greater than that in the RA, causing the septum primum to close fi rmly against the septum secundum.Before birthFollowing birth

Persistant opening interatrial septum Shunt Left Right atriumVolume overload & enlargement of the RA and RVAtrial Septal DefectEnlargement of pulmonary arteryUncomplicated ASDAtrial Septal DefectComplicated ASD : Eisenmenger syndrome.

Clinical manifestationAsymptomaticSymptomatic- Fatigue- Dyspnea on Exertion- Recurrent lower respiratory tract infection- Decrease of stamina (adult)- Palpitation

Palpitation due to atrial tachyarrytmia resulting from right atrial enlargement 25PHYSICAL eXAMINATIONA prominent systolic impulse may be palpated along the lower-left sternal border,

Heart Sound : second heart sound (S2) a widened, fixed splitting pattern

Systolic murmur at the upper-left sternal border.

A mid-diastolic murmur may also be present at the lower-left sternal border

- A prominent systolic impulse may be palpated along the lower-left sternal border, representing contraction of the dilated RV (termed an RV heave). The second heart sound (S2) demonstrates a widened, fi xed splitting pattern, because the normal respiratory variation in systemic venous return is countered by reciprocal changes in the volume of blood shunted across the ASD. The increased volume of blood fl owing across the pulmonary valve often creates a systolic murmur at the upper-left sternal border. A mid-diastolic murmur may also be present at the lower-left sternal border owing to the increased fl ow across the tricuspid valve.Blood traversing the ASD itself does not produce a murmur because of the absence of a signifi - cant pressure gradient between the two atria.26ADDITIONAL EXAMINATIONOn chest radiographs, the heart is usually enlarged because of right atrial and right ventricular dilatation, and the pulmonary artery is prominent with increased pulmonary vascular markings. Diagnostic studiesThe electrocardiogram (ECG) shows - Rght ventricular hypertrophy, - often with Right atrial enlargement and - incomplete or complete Right bundle branch block. - Patients with the ostium primum type of ASD, left axis deviation is common and is thought to be a result of displacement and hypoplasia of the left bundle branchs anterior fascicle.

The echocardiography Trans Thoracal Echocardiography (TTE)Trans Esofageal Echocardiography (TEE)

TTETEE

Cardiac catheterization To confirm the presence of an ASD. Useful to assess pulmonary vascular resistance and to diagnose concurrent coronary artery disease in older adults. In a normal person undergoing cardiac catheterization, the oxygen saturation measured in the right atrium is similar to that in the superior vena cava. However, an ASD with left-to right shunting of well-oxygenated blood causes the saturation in the right atrium to be much greater than that of the superior vena cava28TREATMENTElective surgical repair To prevent the development of heart failure or pulmonary vascular disease. Defect is repaired by direct suture closure or with a pericardial or synthetic patch.Percutaneous ASD repair, using a closure device deployed via an intravenous catheter, is a less invasive alternative to surgery in selected patients with secundum ASDs.

Amplatzer septal occlude (ASO).