Echocardiography can suggest the presence of an atrial septal defect by identifying an attenuated or absent atrial septum, associated atrial and/or right ventricular enlargement, or pulmonary hypertension from right-to-left shunting. Doppler studies may localize a high-velocity flow pattern across the atrial septum. Contrast echocardiography may be diagnostic of an atrial septal defect, especially with right-to-left shunting. Injections of saline microbubbles into a peripheral vein can demonstrate transit of the contrast from right to left at the atrial level. In patients with left-to-right shunting, a negative image of contrast-free blood may be seen in the right atrium due to washout from contrast-free left atrial blood.
Should atrial septal defects be surgically repaired?
Symptomatic atrial septal defects should be fixed whether symptoms are due to left-to-right or to right-to-left shunting. In asymptomatic patients, recommendations for closure of the defect are intended to prevent the development of pulmonary hypertension, which can develop from persistently increased pulmonary blood flow from left-to-right shunting. Closure is recommended for patients with pulmonary-to-systemic blood flow ratios of 1.5:1.0 or greater. In patients 45 years of age, surgical risk is 1%.
What is a coarctation of the aorta?
Coarctation of the aorta is a congenital narrowing of the descending thoracic or abdominal aorta. It usually occurs just distal to the origin of the left subclavian artery. Coarctation occurs 5 times more commonly in males. There is a significant association with bicuspid aortic valve and Turner’s syndrome (gonadal dysgenesis).
Does aortic coarctation have any âœclassicâ findings?
The physical clue to coarctation is differential pulses in the arms (strong) versus the legs (weak and delayed). There is often a systolic murmur from the coarctation best heard in the posterior left thorax. Chest x-ray may show notching of the ribs due to enlargement of the intercostal arteries. Coarctation is one of the causes of surgically correctable hypertension in the adult. Later symptoms include heart failure and endocarditis.
Which congenital heart lesions are at increased risk of endocarditis?
Bicuspid aortic valve Aortic coarctation Ventricular septal defect Tetralogy of Fallot
Pulmonic stenosis (moderate or severe)
Severe mitral or tricuspid regurgitation
Patients with surgically corrected congenital heart disease involving placement of a prosthetic valve or prosthetic conduit are at even higher risk. Antibiotic prophylaxis is recommended for these patients. Unfortunately, 20% of endocarditis cases in patients with congenital heart disease are associated with identifiable events or medical procedures.