BAGIAN KARDIOLOGI DAN VASKULER

FAKULTAS KEDOKTERAN UNIVERSITAS

HASANUDDIN MAKASSAR

ATRIAL SEPTAL DEFECT

Disusun Oleh :
Ainil Fatima Zainodin
C111 10 878
Supervisor :
dr. Julius Patimang Sp.A, Sp.JP

DIBAWAKAN DALAM RANGKA TUGAS KEPANITERAAN KLINIK

BAGIAN KARDIOLOGI DAN KEDOKTERAN VASKULER
FAKULTAS KEDOKTERAN
UNIVERSITAS HASANUDDIN
MAKASSAR
2015

PATIENTS IDENTITY
NAME: Mr. MS
BIRTH DATE : 21-09-1982 (33 years
old)
ADDRESS : Sudiang Raya
MEDICAL RECORD : 534907
DATE OF ADMISSION : 22nd June 2014

HISTORY TAKING

Chief Complaint : Palpitation

Present 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

HISTORY TAKING
Past 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 EXAMINATION
General Status
Moderate illness/ well nourished / Compos Mentis
Weight : 62 kg
Height : 168 cm
BMI : 22,1 kg/m2

Vital Status
Blood pressure
Heart rate

: 120/80 mmHg
: 101 bpm

Respiratory rate : 20 bpm

Temperature

: 36,5 oC

HEAD AND NECK

No anemic, no icteric
No cyanosis
JVP R+3cmH20

LUNG

Inspection : Symmetry left=right

Palpation : Mass (-), no tenderness
Percussion : Sonor
Auscultation : Vesikuler
Wheezing -/-

Ronchi -/-,

HEART
Inspection
: Ictus cordis not visible
Palpation
: Ictus cordis not palpable, thrill (-)
Percussion :
Upper border 2nd ICS sinistra
Right border 4th ICS linea parasternalis dextra
Left border 5th ICS linea axillaris anterior sinistra
Auscultation
: Heart sound S1 Single sound/S2 wide fixed splitting,
Murmur Sistolik 2/6 at upper left sternal border

ABDOMEN
Inspection :
Auscultation :
Palpation
:
Percussion :

EXTREMITIES
No edema

flat, follows breath movement

peristaltic (+), normal
liver and spleen not palpable
Tympani

ELECTROCARDIOGRAM

Sinus rhythm
Heart rate
: 75 bpm
Axis
: Normoaxis
P Wave
: P normal
PR interval
: 0,12 seconds
QRS Complex : 0,08 seconds, morphology normal
ST segment
: Normal
T wave
: Inverted T4-T6, II,III,AVF
Conclusion
: Sinus rhythm, Ischemic
anterolateral and
inferior

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

LABORATORY FINDINGS
Hemoglobin

14.3 gr/dl

Leucocyte

7.5 x 103/uL

Thrombocyte

348 x 103/uL

Red blood cells

5.03 x 10 03/uL

GDS

100 mg/dl

Electrolyte

Sodium (Na) : 139

mmol/l
Potassium (K) : 4.3
mmol/l
Chloride (Cl) : 104
mmol/l

Ureum

21 mg/dl

Creatinine

0.79 mg/dl

SGOT

14 U/L

SGPT

9U/L

PT

12,5 detik

APTT

42,7 detik

ECHOCARDIOGRAPHY
Trans Thoracal Echocardiography (TTE)

Conclusion :
- ASD sekundum
with Left to
Right Shunt
- RA dan RV
dilatation
- Mild
Hypertension
Pulmonal

ECHOCARDIOGRAPHY
Trans Esophageal Echocardiography (TEE)

Conclusion :
-

ASD sekundum 15-20mm

Position 20 ; Rim Posterior

20mm,

Rim Aorta 4mm

Position 110 ; Rim IVC 15mm,

Rim SVC 17mm

CATHETERISATION

Conclusion :
-

ASD Sekundum with

Low

Flow,

Resistance

High

DIAGNOSIS

Atrial Septal Defect

Type Secundum

MANAGEMENT

Infuse NaCl 0.9% 500cc/24jam

Bisoprolol 2,5mg/24jam/oral
Alprazolam 0,5mg/24jam/oral
Ceftriaxone 2gr/24jam/intravena

Lets discuss together

DISCUSSION

INTRODUCTION
CONGENITAL
HEART DISEASE
ASIANOSIS

Atrial Septal Defect (ASD)

Ventricular septal defect
(VSD)
Patent Ductus Arteriosus
(PDA)
Coarctation of Aorta
Atrioventricular canal
(endocardial cushion defect)
Pulmonic stenosis
Aortic stenosis

SIANOSIS

Tetralogy of Fallot
Total anomalous pulmonaru
venous return
Transposition of the great
vessels
Tricuspid atresia
Trunchus arteriosus
Pulmonary atresia
Ebsteins anomaly
Hypoplastic left heart

DEFINITIION 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
ASD
ASD secundum

ASD primum

ASD sinus coronarius

ASD sinus venousus

PATHOPHYSIOLOGY
Before
High O2
birth
OF ASD
saturation
From umbilical
artery Foramen
Ovale
Blood shunt
from R-L
atrium
Ascending aorta
9%
Coronary
Artery

29%
Desending
aorta
62%
Carotid &
Subclavia
vessels

Myocardiu
m

Brain

Rest of fetal
body

PATHOPHYSIOLOGY
OF
ASD
Before
birth

Following birth

Diagrammatic depiction of the flap-type valve of the

foramen ovale.
A. Before birth, the valve permits only right-to-left flow of blood
from the higher pressured right atrium (RA) to the lowerpressured left atrium (LA).
B. 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.

Atrial Septal
Defect

Uncomplicated
ASD

Persistant opening interatrial

septum
Shunt Left Right atrium
Volume overload &
enlargement of the RA and
RV
Enlargement of pulmonary
artery

Atrial Septal
Defect

Complicated ASD : Eisenmenger syndrome.

CLINICAL
MANIFESTATION
Asymptomatic
Symptomatic
- Fatigue
- Dyspnea on Exertion
- Recurrent lower respiratory tract infection
- Decrease of stamina (adult)
- Palpitation

PHYSICAL
EXAMINATION
A 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

ADDITIONAL
Diagnostic studies
EXAMINATION
On 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.

The 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
1. Trans Thoracal Echocardiography (TTE)
2. Trans Esofageal Echocardiography (TEE)

TTE

TEE

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.

TREATMENT
Elective 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