Definition & Overview

Atrial septal defect repair is the procedure used to close a hole located in the wall of the heart, between the right and left atria. This condition is congenital and most patients who have it need to undergo the repair procedure before reaching the age of 25.

In its normal flow, blood enters the right side of the heart and gets pumped into the lungs to be oxygenated. It then flows back into the heart from the left atrium and gets pumped out to be distributed to the rest of the body. The two sides of the heart are separated by the septum. The wall dividing the left and right atria is called the interatrial septum while the interventricular septum divides the left and right ventricles. During foetal development, there is an opening between the atria that normally closes before childbirth. Atrial septal defect occurs when this opening fails to close and oxygenated blood goes back into the right atrium and into the lungs instead of being pumped to other parts of the body. There are several major types of atrial septal defects, classified according to location. Secundum is the defect located in the middle of the interatrial septum while primum is located in the lower part. The third type, the sinus venosus, is a defect found in the upper part of the septum, near the large superior vena cava. In some cases, this condition resolves itself as the baby grows older, needing no further intervention.

Who Should Undergo and Expected Results

Babies who are diagnosed with atrial septal defect do not automatically undergo repair procedures. Factors that are considered include the size and location of the defect, manifestation of pulmonary arterial hypertension, and the impact of the condition on the overall cardiovascular function of the body.

Most patients are monitored for a certain period to see if the condition resolves itself, especially for those with small-sized holes in the septum. An exception to this rule are infants and small children who have a high risk of developing congestive heart failure if immediate treatment is not provided. If the condition persists over time, there could be a significant impact on the heart and lungs. Atrial septal defect repair is offered to patients exhibiting symptoms of dyspnea or difficulty in breathing, palpitations, shortness of breath during activities, and recurring respiratory infections especially among children. Children with unresolved atrial septal defect typically exhibit poor appetite and growth.

The procedure has high success and low morbidity rate, especially among younger patients. In fact, most survive well into adulthood with little or no complications, and no activity restrictions. However, they need to maintain regular check-up sessions with their physicians to ensure the overall health of their heart.

How is the Procedure Performed?

Atrial septal defect repair can be performed using either open-heart surgical procedure or percutaneous transcatheter closure technique.

The open-heart surgical approach involves making an incision in the chest area, splitting the sternum in the midline in the process. Cardiopulmonary bypass is then performed, using a heart-lung machine to arrest the heart movement and proceed with the opening the organ. The surgeon then exposes the right atrium and locates the hole. For those with secundum defects, a continuous suture can be used to close the hole. When treating primum and sinus venosus defects, the procedure becomes more complex. Primary defects are addressed by placing a special patch to the septum hole, taking care not to damage or injure the nearby mitral valve. The patch is made out of synthetic polyester polymer or polytetrafluoroethylene. During the repair of a sinus venosus defect, the surgeon has to redirect the flow of blood from the pulmonary veins into the left atrium instead of going to its right counterpart. A special patch is also used to repair the defect.

Before removing the heart-lung machine, the surgeon has to make sure that no debris or trapped air remains in the atria and nearby ventricles. Pacing wires are then left in place temporarily before the surgeon closes the incision.

Meanwhile, percutaneous transcatheter closure technique for atrial septal defect repair involves inserting a catheter into the femoral vein in the groin area. Using imaging technology, the surgeon guides the catheter as it travels to the septum. It carries a small device that unfolds like an umbrella when it reaches its destination. It is secured to the hole and acts as a plug to prevent the leaking of blood back into the right atrium. The catheter is then withdrawn and no suture is needed.

Possible Risks and Complications

Undergoing open-heart surgery carries the risk of adverse reaction to anaesthesia, bleeding, and infection in the surgical site.

There is also a small risk of developing blood clots, especially in cases where a closure device is used. Most patients are prescribed long-term medications to prevent this episode.

Patients also have a higher risk of developing infective endocarditis following this procedure.

Reference:

  • Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, et al. ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease: Executive Summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines for the management of adults with congenital heart disease). Circulation. 2008 Dec 2. 118(23):2395-451.
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