1. Indications for intervention of ASD and VSD

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 ↑

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

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)

13. Pathophysiology Shunt Qp/Qs P/A systolic pressure ratio
Restrictive VSD
Small
1~1.4
<0.3
Moderately restrictive VSD
Moderate
1.4~2.2
0.3~0.66
Nonrestrictive VSD
Large
>2.2
>0.66
Eisenmenger VSD
Right to left
<1 1

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