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My Child Has:
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Atrial Septal Defect
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Normal Heart
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The normal heart has two sides, the left and the right, which are separated by a muscular wall called the septum. Each side of the heart also has two parts -- an upper chamber called an atrium, and a lower chamber called a ventricle. Atrial septal defect (ASD), a congenital (present at birth) defect, occurs when there is an opening in the atrial septum, or dividing wall between the two upper chambers of the heart, known as the right and left atria.
Normally, oxygen-poor (blue) blood returns to the right atrium from the body, travels to the right ventricle, then is pumped into the lungs where it receives oxygen. Oxygen-rich (red) blood returns to the left atrium from the lungs, passes into the left ventricle, then is pumped out to the body through the aorta. See About the Heart and Blood Vessels and Anatomy and Function of the Heart
Valves for more information on how the heart normally works.
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An atrial septal defect allows oxygen-rich (red) blood to pass from the left atrium through the opening in the septum, and then mix with oxygen-poor (blue) blood in the right atrium. An ostium secundum, an opening in the middle of the atrial septum, is the most common type of ASD.
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Atrial septal defects occur in 5 to 10 percent of all children born with congenital heart disease. For unknown reasons, girls have atrial septal defects twice as often as boys.
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For in-depth visual and audio information on this condition, visit the Children's Hospital Boston Multimedia Library.
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Atrial septal defect (ASD)
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The heart is forming during the first eight weeks of fetal development. It begins as a hollow tube, then partitions develop within the tube that eventually become the septa (or walls) dividing the right side of the heart from the left. Atrial septal defects occur when the partitioning process does not occur completely, leaving an opening in the atrial septum.
Some congenital heart defects may have a genetic link, either occurring due to a defect in a gene, a chromosome abnormality or environmental exposure, causing heart problems to occur more often in certain families. Most atrial septal defects occur sporadically (by chance), with no clear reason for their development.
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This heart defect can cause lung problems if not repaired. When blood passes through the ASD from the left atrium to the right atrium, a larger volume of blood than normal must be handled by the right side of the heart, causing the right side to become overworked and enlarged. Extra blood then passes through the pulmonary artery into the lungs, causing higher pressure than normal in the blood vessels in the lungs, a condition known as pulmonary hypertension.
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A small opening in the atrial septum allows a small amount of blood to pass through from the left atrium to the right atrium. A large opening allows more blood to pass through and mix with the normal blood flow in the right heart. The larger the volume of blood that goes to the lungs, the higher the pressure.
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The lungs are able to cope with this extra pressure for a while, depending on how high the pressure is. After a while, however, the blood vessels in the lungs become diseased by the extra pressure. If this combination of lung disease and damage to the right side of the heart is severe, it could lead to an inability of the heart to pump effectively, called congestive heart failure.
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Many children have no symptoms and seem healthy. If the ASD is large and permits a large amount of blood to pass through to the right side of the heart, however, the right atrium, right ventricle and lungs will become overworked, and symptoms may be noted. The following are the most common symptoms of atrial septal defect. Each child may experience symptoms differently. Symptoms may include:
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- child tires easily when playing
- fatigue
- sweating
- rapid breathing
- shortness of breath
- poor growth
- frequent respiratory infections
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The symptoms of an atrial septal defect may resemble other medical conditions or heart problems. Always consult your child's physician for a diagnosis.
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Your child's physician may have heard a heart murmur during a physical examination, and referred your child to a pediatric cardiologist for a diagnosis. A heart murmur is simply a noise caused by the turbulence of blood flowing through the opening from the left side of the heart to the right.
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A pediatric cardiologist specializes in the diagnosis and medical management of congenital heart defects, as well as heart problems that may develop later in childhood. The cardiologist will perform a physical examination, listening to the heart and lungs, and make other observations that help in the diagnosis. The location within the chest that the murmur is heard best, as well as the loudness and quality of the murmur (harsh, blowing, etc.) will give the cardiologist an initial idea of which heart problem your child may have. Other tests are needed to help with the diagnosis, and may include the following:
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- Chest X-ray — A diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones and organs onto film. With an ASD, the heart may be enlarged because the right atrium and ventricle have to handle larger amounts of blood flow than normal. Also, there may be changes that take place in the lungs due to extra blood flow that can be seen on an X-ray.
- Electrocardiogram (ECG or EKG) — A test that records the electrical activity of the heart, shows abnormal rhythms (arrhythmias or dysrhythmias) and detects heart muscle stress.
- Echocardiogram (echo) — A procedure that evaluates the structure and function of the heart by using sound waves, recorded on an electronic sensor, that produce a moving picture of the heart and heart valves. An echo can show the pattern of blood flow through the septal opening and determine how large the opening is, as well as how much blood is passing through it.
- Cardiac Catheterization — A procedure that gives very detailed information about the structures inside the heart. Under sedation, a small, thin, flexible tube (catheter) is inserted into a blood vessel in the groin and guided to the inside of the heart. Blood pressure and oxygen measurements are taken in the four chambers of the heart, as well as in the pulmonary artery and aorta. Contrast dye is injected to more clearly visualize the structures inside the heart. If the echocardiogram has provided enough information, this procedure is often not needed to evaluate ASD.
- Cardiac Magnetic Resonance Imaging (MRI) — A non-invasive test that uses three-dimensional imaging technology produced by magnets to accurately determine blood flow and functioning of the heart as it is working.
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Specific treatment for ASD will be determined by your child's physician based on:
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- your child's age, overall health and medical history
- extent of the disease
- your child's tolerance for specific medications, procedures or therapies
- how your child's doctor expects the disease to progress
- your opinion or preference
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Ostium secundum atrial septal defects may close spontaneously as a child grows. Once an atrial septal defect is diagnosed, your child's cardiologist will evaluate your child periodically to see if it is closing on its own. Usually, an ASD will be repaired if it has not closed on its own by the time your child starts school, to prevent lung problems that will develop from long-term exposure to extra blood flow. The decision to close the ASD also may depend on the size of the defect. Treatment may include:
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- Medical Management -- Many children have no symptoms and require no medications, however some children may need to take medications to help the heart work better, since the right side is under strain from the extra blood passing through the ASD. Medication that may be prescribed includes the following:
- Digoxin - a medication that helps strengthen the heart muscle, enabling it to pump more efficiently.
- Diuretics - the body's water balance can be affected when the heart is not working as well as it could. These medications help the kidneys remove excess fluid from the body.
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- Infection Control — Children with certain heart defects are at risk for developing an infection of the inner surfaces of the heart known as bacterial endocarditis. It is important that you inform all medical personnel that your child has an ASD so they may determine if the antibiotics are necessary before a procedure.
- Cardiac Catheterization — If the defect is large and your child develops severe symptoms, or the defect seems to be causing injury to the aortic valve, your child's cardiologist may recommend cardiac catheterization treatment or surgery immediately. One recent development allows treatment through cardiac catheterization. A patch shaped like an umbrella is closed (like a closed umbrella) and inserted into the damaged area through a small tube, called a catheter. The umbrella patch is then opened to cover the hole. This method requires a small incision, avoiding the need for open-heart surgery.
- Surgical Repair — The surgical closure of an ASD is carried out through an incision in the middle of the chest. A heart-lung machine is used to do the work of the heart while the heart is cooled, stopped, emptied and opened through the right atrium. The hole in the wall between the right and left atrium is closed with stitches if it is small, or, if too large, with a patch of thin leather-like material called pericardium, which makes up the sac covering the heart. The right atrium is then closed and the heart is restarted as the heart-lung machine is withdrawn. Advancements in cardiovascular surgical repair include minimally invasive cardiac surgery.
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The majority of children who have had atrial septal defect surgical repair will live healthy lives. Your child's cardiologist may recommend that your child take antibiotics to prevent bacterial endocarditis for a specific time period after discharge from the hospital.
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Consult your child's physician regarding specific outlook for your child.
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Complementing the Cardiovascular Program of Children's Hospital Boston is the nation's most intensive clinical and basic research program focused on pediatric heart disease. Children's is a world leader in opening new avenues of "translational research," bringing laboratory advances to the bedside and doctor's office as quickly as possible. All senior medical staff members of the Cardiovascular Program participate in clinical research activities.
Children's Hospital Boston has pioneered interventional catheterization repair of many types of congenital heart defects, including atrial septal defect. In many cases, this eliminates the need for open-heart surgery, allowing less pain, reduced chance of infection and shorter recovery time.
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Contact Children's Hospital Boston Cardiovascular Program physicians for a second opinion.
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