atrial septal defect (hole in the heart)
A hole in the wall (septum) that separates the two upper chambers (atria)
of the heart. An atrial septal defect (ASD),
or "hole in the heart," allows
blood to flow from one atrium to the other,
usually from the left side to the right side. This causes extra blood flow
in the right atrium, in the right ventricle,
and to the lungs.
|Figure A shows the normal anatomy and blood flow
of the interior of the heart. Figure B shows a heart with an atrial
septal defect, which allows oxygen-rich blood from the left atrium
to mix with oxygen-poor blood from the right atrium.
In a normal heart, oxygen-poor (blue) blood
returns from the body to the right atrium. From the right atrium, the blue
blood flows to the right ventricle – one of the two lower chambers
of the heart – and is pumped to the lungs to pick up oxygen. After
traveling through the lungs, the blood is now oxygen-rich and red. The red
blood returns from the lungs to the left atrium and goes to the left ventricle,
where it is pumped to the body. The right and left sides of the heart are
normally completely separated by the septum. The septum keeps the blue blood
from mixing with the red blood. ASD is the second most common congenital
- More than 3,000 babies are born with ASD each year in the United States.
- ASD occurs twice as often in girls as in boys.
Effects of atrial septal defect
Over time, the extra blood flow to the right side of the heart and the lungs
Usually, most of these effects don't show up until adulthood, often around
age 30 or later. They are rare in infants and children.
- Enlargement of the right atrium and the right ventricle.
- Right heart overload. The right side of the heart
has to work harder to pump extra blood to the lungs, especially as resistance
in the pulmonary artery increases.
Over time, the heart may become overworked, and function may become
impaired. This is exceedingly rare with modern methods of diagnosis
- Arrhythmias (irregular
heartbeats or rhythms). Extra blood flowing into the right atrium through
the ASD can cause the atrium to stretch and enlarge. When this occurs,
a fast heartbeat can develop with symptoms such as dizziness, fainting,
or chest discomfort.
- Stroke. Occasionally
a blood clot in a vein or in the right side of the heart can pass through
the ASD and enter the blood stream, where it can block an artery
supplying the brain and cause a stroke.
arterial hypertension. This is when high
blood pressure exists in the arteries that carry blood to the lungs.
The extra blood being pumped to the lungs can increase the pressure
in the pulmonary arteries. Over time, high pressure can damage the arteries
and the small blood vessels in the lungs. They thicken and become stiff,
making it harder for blood to flow through them (pulmonary vascular
An ASD is classified by its size and location.
The size of an ASD can range from small to large.
- Most small defects close on their own as the heart grows during childhood.
They usually allow only a small amount of blood to flow between the
- Moderate to large defects are much less likely to close on their own.
They allow two or more times the normal amount of blood to flow through
the right side of the heart. Large holes sometimes cause symptoms during
infancy or childhood.
Three major types of ASD exist, based on the location of the defect on the
- Secundum. This defect is in the middle of the septum.
It is the most common form of ASD. About 7 out of every 10 babies born
with ASD have this type. This type often closes on its own, unless it
- Primum. This defect is in the lower part of the septum.
It also involves an incomplete or partial atrioventricular septal defect,
and the valves that separate the upper and lower heart chambers are
not normal. About 2 out of every 10 babies born with ASD have primum
defects. This type of defect does not close on its own.
- Sinus venosus. This defect is in the upper part of
the septum near where a large vein (the superior
vena cava) brings blue blood from the upper body to the right atrium.
It is rare, accounting for only about 1 out of every 10 cases of ASD.
Children with sinus venosus defects usually have an associated condition
called partial anomalous pulmonary venous return, in which one or more
of the veins carrying red blood from the lungs return to the wrong chamber
of the heart. This type of defect does not close on its own.
Half of all ASDs close without treatment. When treatment is necessary, it
is usually successful. Once the defect has closed or has been repaired,
- Don't need additional treatment or medicine
- Can live normal, healthy lives
What causes atrial septal defect?
There is no single, known cause of atrial septal defect (ASD).
Heredity (genetics) may play a role in ASD. In some cases, it may be due
to a difference in one or more genes.
What are the signs
and symptoms of atrial septal defect?
The major signs and symptoms of atrial septal defect (ASD) are:
A heart murmur is the most common sign
of ASD. Often, it is the only sign. Sometimes, the heart murmur is the sound
from a delay in the closing of the pulmonary
- Heart murmur
- Change in heart sounds that represent valve closure
Most children with ASD don't have symptoms, even with a large ASD. However,
some children and adults with ASD may develop symptoms which include:
In most people with ASD who develop symptoms, the symptoms don't develop
- Fatigue or tiring easily
- Shortness of breath
- Fast breathing
- Slow growth
How is atrial septal defect diagnosed?
Atrial septal defect (ASD) is diagnosed using a medical history, a physical
exam, and tests. ASD is usually found in infants or children during a routine
physical exam. However, some people with ASD are not diagnosed until adulthood.
Medical and family history
Your child's doctor will ask you about:
- Family history of congenital heart disease
- Your child's symptoms
- Your child's feeding and growth
The doctor will listen to your child's heart with a stethoscope for a heart
murmur. The doctor will also check for signs of increased blood flow to
Your child's doctor may order one or more tests to diagnose ASD. These tests
also help the doctor decide the type and size of the defect:
- Echocardiogram. This
test, which is harmless and painless, uses sound waves to create a moving
picture of your child's heart. During an echocardiogram, reflected sound
waves outline the heart's structure completely. The test allows the
doctor to clearly see any problem with the way the heart is formed or
the way it's working. An echocardiogram is the most important test available
to your child's cardiologist to both diagnose a heart problem and follow
the problem over time. In children with ASD, the echocardiogram shows
exactly where the hole is located in the wall between the two upper
chambers of the heart, how big the hole is, and how the heart is responding
to the defect. The test will also help your child's cardiologist to
know if and when the hole should be closed.
- Chest X-ray. A chest X-ray
takes a picture of the heart and lungs. It can show if the heart is
enlarged or if there is fluid in the lungs.
- EKG (electrocardiogram).
An EKG test measures the rate and regularity of your child's heartbeat.
It provides an estimate of enlargement of the heart chambers and shows
abnormal heart rhythms (arrhythmias).
- Cardiac catheterization.
In cardiac catheterization, a thin flexible tube (catheter) is passed
through a blood vessel (artery or vein) to the heart. With the assistance
of X-rays, the doctor can see the child's blood vessels and heart. During
the procedure, the doctor can measure blood pressure in the heart and
arteries connected to the heart and see how much blood is mixing between
the two sides of the heart. Cardiac catheterization is rarely used for
diagnosis of ASD, unless the echocardiogram does not provide enough
information or if other defects or problems are suspected.
How is atrial septal defect treated?
The goals of treating atrial septal defect (ASD) include:
- Monitoring the defect to see if it closes by itself (secundum defects
- Closing or repairing the ASD to prevent pulmonary vascular disease
and other complications
- Treating symptoms of heart failure,
- Preventing abnormal heart rhythms
Types of treatment include:
Your child's doctor will discuss treatment options with you and will consider
your family's preferences when making treatment decisions.
- Monitoring and observation (periodic checkups)
- Closure of the ASD through surgery or a procedure using a catheter
Monitoring and observation
Periodic checkups are done to see if the defect closes on its own. About
half of all ASDs close on their own, and many close within the first year
of life. Your child's doctor will recommend how often your child should
be checked, ranging from weekly checkups to checkups every 1 or 2 years.
Children with no symptoms usually don't need any medicines. Children who
develop symptoms usually are referred for closure of the defect. They may
need medicines to control the symptoms until the defect can be closed. Medicines
Antibiotics may be given to prevent bacterial
endocarditis, an infection of the inner
lining and valves of the heart. The antibiotic is given in a single dose
1 hour before a dental visit or surgical procedure. This treatment is usually
needed for only 6 months after ASD surgery or a catheter procedure. The
antibiotics are used only to prevent infection and not to treat the ASD.
- Digoxin to improve heart function
and keep the heartbeat regular
- Diuretics to treat fluid buildup
Closure of the atrial septal defect
Closure may be recommended for infants and children who develop symptoms
such as fast breathing or slow growth. Closure is also commonly performed
for children with moderate to large ASDs that remain at 3 to 5 years of
age. Sometimes, doctors recommend closure of smaller defects found in older
children and adults.
Until recently, surgery was the usual method for closing an ASD. General
anesthesia is used so the child will
sleep through the procedure and not feel any discomfort.
Complications, such as bleeding and infection, from ASD surgery are rare
and short term. Some people may develop swelling of the outer lining of
the heart, causing fluid to collect around the heart. This usually resolves
- The surgeon makes an incision down the center of the chest to reach
- The child is placed on a heart/lung bypass machine during surgery.
- The heart is stopped, and the heart/lung bypass machine takes over
for the heart, pumping red blood throughout the body.
- The heart/lung machine also brings blue blood back to the machine,
where it picks up oxygen.
- The surgeon uses a special patch or stitches to close the ASD.
- The surgeon puts the patch over the ASD and sews it into place.
- Once the repair is completed, the heart is restarted.
- The child is taken off the heart/lung bypass machine.
- The surgeon then closes the skin incision.
Your child may need to take medicine temporarily to help with discomfort.
After ASD surgery, your child will spend a few days in the intensive care
unit or in a regular hospital room. Most children go home within 4 days
after the surgery.
While in the hospital, your child will be given medicines to reduce pain
or anxiety as needed. The doctors and nurses at the hospital will teach
you how to care for your child at home. They will talk to you about:
The outlook for children after surgery is usually excellent. Your child
will most likely have little pain or discomfort from the incision. After
recovering, your child should be able to take part in normal activities.
- Avoiding blows to the chest incision as it heals
- Limiting activity for your child while he or she recovers
- Returning to school
- Scheduling followup appointments with your child's doctors
- Administering medicine to your child at home, if needed
Procedures using catheters
A procedure that uses a catheter to close the ASD with a special closure
device (septal occluder) is a recent but increasingly used option. Catheters
are thin, flexible tubes used in cardiac catheterization.
The advantages of such procedures are that they:
Closure with a catheter can't be done for every type of ASD. A catheter
can be used with secundum defects (that is, those located near the middle
of the septum). It can't be used with defects so large that there is not
enough surrounding tissue to anchor the device.
- Don't require the child's chest to be opened
- Usually require no more than an overnight stay in hospital
- Let the child recover quickly
The catheter procedure is done under general anesthesia, so your child will
sleep through the procedure and not feel any discomfort. During the procedure,
Within 6 to 8 weeks, normal tissue grows in and over the device. There is
no need to replace the closure device as the child grows.
- Inserts a catheter into a blood vessel in the groin
- Threads the catheter to the heart
- Measures pressure and oxygen levels for all four heart chambers
- Injects dye and takes pictures (angiogram) of the heart
- Uses a balloon catheter (under ultrasound
guidance) to estimate the size of the ASD
- Threads a special fabric-covered wire frame to the heart
- Positions half of the device on the left side of the atrial septum
- Positions the other half of the device on the right side of the atrial
- Wedges ASD between the two parts of the device
The outlook for children having this procedure is excellent. Closures are
successful in more than 9 out of 10 patients, with no significant leakage.
Because the device is relatively new, what is not known is whether there
are any long-term problems with the device compared to surgery.
Living with atrial septal defect
Smaller atrial septal defects (ASDs) often close on their own, and children
don't have any problems or need treatment. Children and adults with small
ASDs that cause no symptoms may be healthy and feel well with no treatment.
However, many others undergo closure procedures to prevent potential long-term
complications. Most children recover well from closure procedures and live
normal, healthy lives. Adults also usually do well after closure procedures.
Arrhythmias. The risk of arrhythmias (irregular heartbeats)
increases before and after surgery. Adults older than 40 years are especially
likely to have arrhythmias. People who had arrhythmias before surgery are
more likely to have them after surgery.
Regular followup care is advised for those who had:
- ASD repaired as an adult
- Arrhythmias before and after surgery
- ASD repaired with a procedure using catheters instead of surgery
- High blood pressure in the pulmonary artery at the time of surgery
Special needs for children
Activity. Children with a repaired or closed ASD have no
restrictions on their activity. Children who are being monitored and treated
with medicines may have some restrictions. Consult your child's doctor for
Growth and development.
Children with ASD have very few growth and development problems. If your
child has slow growth, he or she will catch up after the ASD has closed
or been repaired.
Antibiotics before dental care.
Children with just ASD don't need antibiotics for dental care. The doctor
may recommend antibiotics for dental care for the first 6 months after a
closure procedure. The antibiotic is given in a single dose 1 hour before
the dental visit. The antibiotic is given to prevent bacteria from entering
the bloodstream and causing an infection called endocarditis.
Regular health care. Your child should see his or her regular
doctor for routine health care.
Special needs for adults
Some adults have their ASDs closed to prevent or minimize symptoms and complications.
After ASD closure, full recovery takes longer for adults than for children.
You may benefit from a cardiac rehabilitation program as you recover from
your ASD closure. Talk with your doctor about when it is all right for you
to drive, return to work, resume exercising, and do other activities.
• hole in the heart
Source: U.S. National
Heart, Lung and Blood Institute