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Indications for intervention of ASD and VSD Ri 張智銘.

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Presentation on theme: "Indications for intervention of ASD and VSD Ri 張智銘."— Presentation transcript:

1 Indications for intervention of ASD and VSD Ri 張智銘

2 ASD

3 Morphology 4 Types of ASD: * ostium primum * ostium secundum * sinus venosus * coronary sinus defects ↑Left to right shunt: * left ventricular compliance↓ * left atrial pressure ↑

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5 Clinical feature Large ASD(Qp/Qs > 2): CHF, pulmonary HTN or failure to thrive Undetective ACD with a significant shunt (Qp/Qs > 1.5): symptoms ↑with aging 80% spontaneous closure occur < 1 y/o

6 Indications for intervention Asymptomatic children: Right heart dilation + a significant ASD (>5 mm) without spontaneous closure Significant ASD (Qp/Qs > 1.5) ASD associated with RV volume overload To prevent paradoxical emboli in stroke patients Pulmonary 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 potentially reversible

7 Intervention Device closure * For secundum ASD with stretched diameter < 36 mm + adequate rims * Exception: 1) Anomalous pulmonary venous connection 2) Proximity to the AV valves / coronary sinus / systemic venous drainage Surgery * For sinus venosus or ostium primum defects or with secundum defects with unsuitable anatomy * primary suture closure or using a pericardial or synthetic patch

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9 VSD

10 Morphology 4 components of Septum: Membranous, inlet, trabecular, outlet (conal, infundibular) part 3 Types of VSD * Muscular VSD * Membranous VSD * Doubly committed subarterial VSD (juxta-arterial/supracristal/outlet/conal defects)

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13 Pathophysiology ShuntQp/QsP/A systolic pressure ratio Restrictive VSD Small1~1.4<0.3 Moderately restrictive VSD Moderate1.4~2.20.3~0.66 Nonrestrictive VSD Large>2.2>0.66 Eisenmenger VSD Right 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 function Perimembranous VSD with more than mild AR + recurrent endocarditis. Subarterial VSD Children 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/s  delayed op up to 1 year or more * Patient >10 y/o with a small defect (Qp:Qs < 1.5; normal PAP)  controversial Device closure: * Trabecular VSDs have proven more amenable * Perimembranous VSDs is technically more challenging


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