Cardiology DepartmentFaculty of Medicine, Hasanuddin University 2015 case report Atrial Septal Defect Type : Secundum PRESENTED BY :TRI KURNIAWAN (C11111323) SUPERVISOR : DR. ABDUL HAKIM ALKATIRI, SPJP, FIHA Patient’s Identity Name : Ms J Age : 22 years old Gender : Female Adress : Cilellang Selatan, Kab. Barru Medical Record No. : 6996xx Admission : August, 8th 2015 HISTORY TAKING Chief complaint Palpitation Guided-Anamnesis Experienced since 3 months ago. DOE (+), Orthopnea (-), PND (-). Chest pain was felt intermittently on active state Epigastric pain (-), cough (-), fever (-) Fatigue (+) Headache (-), Nausea and vomiting (-) Syncope (-), history of syncope (-) Urination and defecation remains normal or illness of mother during pregnancy (-). drugs. histoy of family with same disease (-) .HISTORY TAKING Previous illness Goiter (+) Hypertension (-) Diabetes Mellitus (-) Recurrent respiratory tract infection (-) Risk Factor Modifiable : (-) Non-Modifiable : History of alcohol. RR : 22 x/minutes Temp : 36.5 º C (Axilla) Head and Neck Conjungtiva Lips Neck : Anemia (-). Icterus (-) : Cyanosis (-) : JVP R+2 cmH20 on 30° supine position Lymphadenopathy (-) Tumor Mass (-) Thyroid enlargement (+). regular. grade IB .Physical Examination General State Moderate illness/ well-nourished/ compos mentis Vital sign BP : 110/80 mmHg HR : 78 x/minutes. Liver and Lung margin ICS VI dextra Right Back Lung margin ICS IX dextra Left Back Lung margin ICS X sinistra Auscultation : BS : vesicular.Physical Examination Thorax : Inspection : symmetric left=right. vocal fremitus left=right Percussion: sonor left=right. Ronchi (-/-). normothorax Palpation : tenderness (-). tumor (-). Wheezing -/- . Physical Examination Heart Inspection : Ictus cordis isn’t visible Palpation : Ictus cordis is not palpable. thrill is not palpable Percussion : Upper border ICS III sinistra Right border linea parasternalis dextra Left border medioclavicularis sinistra Auscultation : HS I/II pure. regular Sistolic ejection murmur hear on ICS II sinistra . normal Palpation palpable : tenderness (-). edema dorsum pedis (-/-) . edema pretibial (-/-).Physical Examination Abdominal Exam Inspection : Flat. tumor mass (-). simetrical. follows breath movement Auscultation : Peristaltic (+). liver and spleen not Percussion : Tympani (+). Ascites (-) Extremity Warm. AVF.12 second.20 second right axis deviation Gelombang P : Kompleks QRS 0. rsR’ on V3. Right axis deviation with incomplete Right Bundle Branch Block . and deep S ( 12 mm) on lead V5 dan V6 ST segmen : Normal on all lead Gelombang T : Normal on all lead Conclusion : Sinus Rhtym.08 second. and V4. reciprocal morphology RsR’ on AVL.Electrocardiography Interpretation Basic rhytm : QRS rate : 94 x/minutes Regularity : regular PR interval : Axis Morphology : 15/8/2015 sinus 0. widening S wave on lead I. there’s RsR’ configuration on lead III. wide and notch R wave on lead II. inverted on V1 : 0. Chest X-Ray PA 6/8/2015 Conclusion : Cardiomegaly with the sign of Left to Right Shunt . 9 mmol/L Klorida 111 mmol/L 11/8/2015 Conclusion : All Parameters are remain in normal limit .00 minutes PT 11.5 mg/dL SGOT 18 mmol/L SGPT 19 mg/dL BT 2.71 (106/UI) HGB 12.9 seconds aPTT 28.1 (gr/dL) HCT 36.30 minutes CT 7.4 seconds INR 1.Laboratory FIndings Parameter Result UNIT WBC 5.11 Natrium 142 mmol/L Kalium 3.1 (10³/UI) RBC 4.2 (%) PLT 212 (103/uL) GDS 85 mg/dL Ureum/Creatinin 19/0. 6 cm) with left to the right shunt Moderate Pulmonary Hypertension Enlargement of right atrium and right ventricle .Echocardiography transthoracal (21/5/2015) Conclusion : Huge ASD Secundum (2. 9cm) .Echocardiography transesophageal (13/8/2015) Conclusion : Huge ASD Secundum (2. Diagnosis Atrial Septal Defect type : Secundum . Management ASD Closure with using Percutaneus Catheterization Amplatzer Septal Occluder . Discussion ATRIAL SEPTAL DEFECT Congenital Heart Disease on Adults . Result Left to Right Shunt.Definition Atrial septal defect (ASD) is one of the more commonly recognized congenital cardiac anomalies presenting in adulthood. Atrial septal defect is characterized by a defect in the interatrial septum allowing pulmonary venous return from the left atrium to pass directly to the right atrium. Right to left shunt (worse prognosis) . sinus venosus (SV) ASD is seen in 510% of all ASDs. The defect is located along the superior aspect of the atrial septum. Anomalous connection of the right-sided pulmonary veins is common and should be expected. Ostium primum: The second most common type of ASD accounts for 15-20% of all ASDs.Classification Ostium secundum: The most common type of ASD accounting for 75% of all ASD cases. Alternate imaging is generally required. . representing approximately 7% of all congenital cardiac defects and 30-40% of all congenital heart disease in patients older than 40 years. Primum ASD is a form of atrioventricular septal defect and is commonly associated with mitral valve abnormalities Sinus venosus: The least common of the three. fatigue.Epidemiology Incidence : ASD occur on 1 by 1500 live birth. or even evidence of heart failure. sustained arrhythmia. Symptoms become more common with advancing age. Gender : ASD occurs with a female-to-male ratio of approximately 2:1 Age : Patients with ASD can be asymptomatic through infancy and childhood. 90% of untreated patients have symptoms of exertional dyspnea. By the age of 40 years. though the timing of clinical presentation depends on the degree of left-to-right shunt. . palpitation. ETIOLOGY Atrial septal defect (ASD) may occur on a familial basis. • Holt-Oram syndrome characterized by an autosomal dominant pattern of inheritance and deformities of the upper limbs (most often. especially a particular type that involve ventricular wall. The penetrance is nearly 100% for Holt-Oram syndrome. • Idiopathic . absent or hypoplastic radii) has been attributed to a single gene defect in TBX5. • Down syndrome – patients with Down Syndrome have higher rates of ASDs. • Fetal alcohol syndrome – about one in four patients with fetal alcohol syndrome has either an ASD or a VSD. As many as one half of Down Syndrome patients have some type of septal defect. and existence of lupus and diabetes mellitus during pregnancy . alcohol. cigarettes.Risk Factor Risk factor which predict influencing the incidence of ASD are : Infection of German Measles (rubella) during pregnancy Exposure of medicine. Pathogenesis ASD Secundum Sinus venosus Hyperresorbtion of septum There isduring abnormality primum formation of of fusion ostiumbetween secundum embryonal sinus Disruption of development of venosus and atrium septum secundum ASD Primum Disruption of closure of ostium primum on septum primum during formation of ostium secundum Failure of fusion between septum primum and endocardial cushion . Pathophysiology . Pathomechanism of Symptoms Dyspnea Long Standing L to R shunt Hypervasc ularization of pulmonary circulation Vascular bed filled with blood Pulmonary hypertensi on and Hydrostatic pressure elevated Transudati on of fluid from capillary to interstitial Inhibition of diffusion O2 on lung Dyspnea . Pathomechanism of Symptoms Fatigue L to R shunt Volume systolic of LV decrease Blood containing oxygen decrease Perfusion decrease Ischemic and metabolism disorder Fatigue . Pathomechanism of Symptoms Angina Systemic circulation decrease Coronary circulation decrease Right volume overload Pulmonary hypertensi on Wall-Stress increases of RV Oxygen demand increaseOxygen supply decrease Angina . Pathomechanism of Symptoms Palpitation Left to Right Shunt Dilatation of right atrium and right ventricle Prolonged of conduction pathway re-entry current Atrial Fibrillation/ SVT/ MAT Palpitation Recurrent of respiratory tract infection Hypervascularization of pulmonary circulation vascular bed filling Hydrostatic pressure increases Edema of lower respiratory tract disruption of immunity system susceptible of infection . Physical Examination Inspection Hard to find abnormalities Palpation Thrill can be palpated Pulsation of right ventricle can be felt Percussion Cardiomegaly Auscultation Wide-fixed S2 Louder Systolic A split of S2 ejection murmur on ICS mid-diastolic murmur at lower left sternal border . Electrocardiography Complete or incomplete right bundle branch block Right Axis deviation Right Ventricle Hypertophy Abnormality of Q wave . there is shunt between left and right atrium. following systolic and Diastolyc cycle of heart Dilatation of right atrium and right ventricle Pulmonary hypertension (conditional) Mitral regurgitation (occasionally on ASD primum) Tricuspid regurgitation secondary caused by dilatation of annulus .Echocardiography Findings : Defect on interatrial septum On color Echocardiography. high side effect. takes time) prefer Echocardiography instead of cathetherization .Another Examination Chest X-ray Not Specific Cardiomegaly Blood profile Not specific Cardiac catheterization Gold Standar to detect atrial septal defec (invasive. Dorner. Furosemid) Definitif treatment Interventional and Surgical Interventional : Percathetherization devices Amplatzer Septal Occluder Indication for closure with ASO : ASD Secundum. defect >5 mm Right-sided heart enlargement with/without symptoms Presence of Paradoxical embolism There is left-right shunt proved.5:1 Indication of surgical ASD primum or Sinus Venosus Interventional is a contraindication .Management Definitif and Symptomatic (Antiarrhytmia. pulmonary artery pressure <2/3 systemic pressure Qp : Qs = <1. Complication PULMONARY HYPERTENSI ON ARITMIA RIGHT-SIDED HEART FAILURE DISABILITY LIMITATION EISENMENGER SYNDROME . 41(11): 633–8. Congenital Heart Disease in the Adult. 2008. Rhodes Jr. 2008. Setiyohadi. 6. 17th ed.References 1. editor. 7. anonim. Choi JY. Child J. Robert J.mayoclinic. editor. 5.. 2008. 2. BD. Ghanie A. Harrison's Principle of Internal Medicine. Available from: http://www.org/diseases-conditions/atrial-septal-defect/basics/risk-factors/con-20027034 . Jakarta: Interna Publishing. Medscape. 2009. S. John F. B. USA: Mayo Clinic. Berg D. Penyakit Jantung Kongenital pada Dewasa. Transcatheter Closure of Atrial Septal Defect: Does Age Matter? Korean Circ J. 19th].medscape. USA: MC-Graw Hill. MD. ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease: Executive Summary. Ilmu Penyakit Dalam. 5th edition ed. In: Sudoyo A. Lily Lea. 3. Kim NK PS.com/article/162914-overview#a6 . Alwi. I. MPH. 2011. In: Fauci ea. Pathophysiology of Congenital Heart Disease in the Adult. 8. Risk factor atrial septal defect. 4. Simadibrata. USA: Lippincott williams and wilkins. Patophysiology of Heart Disease. 2011. Atler DH ea. Atrial Septal Defect. Warnes C. Setiati. AHA Journals. 2014 [cited 2015 August. Available from: http://emedicine. M. editor.117:1090-9.. MD. . V ed. et al. 2014 [cited 2015 August 19th].. Sommer MZMH. AHA Journals.