5 Clinical featureLarge ASD(Qp/Qs > 2): CHF, pulmonary HTN or failure to thriveUndetective ACD with a significant shunt (Qp/Qs > 1.5): symptoms ↑with aging80% spontaneous closure occur < 1 y/o
6 Indications for intervention Asymptomatic children: Right heart dilation + a significantASD (>5 mm) without spontaneous closureSignificant ASD (Qp/Qs > 1.5)ASD associated with RV volume overloadTo prevent paradoxical emboli in stroke patientsPulmonary HTN:* Resistance < 8.0 Wood units/m2* Net left-to-right shunt of at least 1.5* Pulmonary artery reactive to vasodilator (e.g., O2 or NO)* Lung biopsy revealed pulmonary arterial changes are potentiallyreversible
7 Intervention Device closure * For secundum ASD with stretched diameter < 36 mm + adequate rims* Exception:1) Anomalous pulmonary venous connection2) Proximity to the AV valves / coronary sinus / systemicvenous drainageSurgery* For sinus venosus or ostium primum defects or with secundum defectswith unsuitable anatomy* primary suture closure or using a pericardial or synthetic patch
13 Pathophysiology Shunt Qp/Qs P/A systolic pressure ratio Restrictive VSDSmall1~1.4<0.3Moderately restrictive VSDModerate1.4~2.20.3~0.66Nonrestrictive VSDLarge>2.2>0.66Eisenmenger VSDRight to left<11
14 Indications for intervention Significant VSD: symptomatic without irreversible pulmonary HTN* Qp/Qs > 1.5* PA systolic pressure > 50 mm Hg* Increased LV and LA size* Deteriorating LV functionPerimembranous VSD with more than mild AR + recurrent endocarditis.Subarterial VSDChildren without irreversible pulmonary HTN* significant symptoms failing to respond to medication* elective surgery (performed between 3 ~ 9 m/o)Pulmonary HTN* PA resistance < 7 Wood units* Net left-to-right shunt of at least 1.5* Irreversible
15 Intervention Surgery: direct suture or with a patch * Single-stage closure: large defect, CHF s/s, failure to thrive* Perimembranous and muscular defects + normal PAP + no s/sdelayed op up to 1 year or more* Patient >10 y/o with a small defect (Qp:Qs < 1.5; normal PAP) controversialDevice closure:* Trabecular VSDs have proven more amenable* Perimembranous VSDs is technically more challenging
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