13 Feb 2013
Isolated atrial septal defect (ASD) is the
second most common congenital heart defect.
Atrial flutter and fibrillations are the
commenest atrial arrhythmias encountered in patient with ASDs.
Sinus node dysfunction has been reported in
22–65% in adults with unrepaired ASDs .
Almost all patients have ECG evidence of right
ventricular conduction delay.
ď ź
Larger defects are associated with substantial shunting, which may lead to volume overload of the right atrium, right ventricle, and pulmonary arteries.
ď ź If left unrepaired into adulthood, chronic left
to right shunting with consequent right atrial and right ventricular dilatation leads to an increased incidence of .
ď ź For
presentation.
, are
at
ď ź Atrial flutter and/or atrial fibrillation is seen in
patients who present over patients who present over
.
and
of
of
ď ź Usually, no symptoms are related to an ASD
in the pediatric age group.
ď ź Symptoms become more common in the
fourth or fifth decade and include:
1. Dyspnea on exertion 2. Easy fatigability 3. Congestive heart failure (CHF) 4. Atrial arrhythmias
Arrhythmia documentations on ECG. Holter. Event monitor. Electrophysiology study.
Typical atrial flutter. Intra-atrial reentry tachycardia (IART) /
Atypical atrial flutter.
Atrial fibrillation. Ectopic atrial tachycardia (EAT) Paroxysmal SVT.
ď ź Surgical repair or device closure beyond
early adulthood does not appear to decrease the risk for atrial flutter or atrial fibrillation.
ď ź In contrast, only 4% of children will
experience an atrial tachyarrhythmia if they undergo ASD repair under age 11.
ď ź In these procedures, transient AV block has been
reported in 6% with permanent AV block requiring pacemaker placement in only 1% .
ď ź These numbers vary greatly depending on the
device (Amplatzer, Helex, Cardioseal). Although the device-related risk of arrhythmia is very low
ď ź Catheter ablation of atrial flutter and other
macroreentrant atrial tachycardias is effective in nearly all cases with low recurrence rates.
ď ź Pulmonary vein isolation for paroxysmal AF
must be attempted prior to ASD closure.
ď ź 23-year-old man with dyspnea and
palpitation while playing sport.
•
A characteristic
on the R
•
From Heller J, Hagege AA, Besse B, et al.: J Am Coll Cardiol 27(4):880, 1996.)
wave of leads II, III, and aVF has been reported.
“
1-I 6-aVF
200 mm/s
100 ms
7-V1 29-RF ds 30-RF px 31-HALO 1 32-HALO 2 33-HALO 3
34-HALO 4 35-HALO 5 36-HALO 6 37-HALO 7 38-HALO 8 39-HALO 9 40-HALO 10
244 ms
Ablation in the tricuspid isthmus creates a line of block that interrupts the flutter circuit. Subsequent pacing from the coronary sinus demonstrates bidirectional block along the line of ablation.
Atriotomy SVC
Kalman: Circ 93:502, 1996
This is a 45 year old male patient, previously healthy with progressive SOB and palpitation, Echo showed large ASD.
12 LEAD ECG SINUS RHYTHM
12 LEAD EKG OF AFLU
CCW FLU: RATE ; 225 msec.
SUCCESSFUL TERM.OF AFLU WITH RF APPLICATION
Ablation in the tricuspid isthmus creates a line of block that interrupts the flutter circuit. Subsequent pacing from the coronary sinus demonstrates bidirectional block along the line of ablation.
A.FIB
CARTO Map and pulmonary vein isolation
Digoxin
Propaferone.
Propanolol
Amiodarone.
Atenolol Nadolol
Sotalol Disopyramide Procainamide
Verapamil Flecainide
Atrial Flutter and Fibrillations are the
commonest atrial arrhythmias encountered in patients with ASD.
Catheter ablation of atrial flutter and other
macroreentrant atrial tachycardias is effective in nearly all cases with low recurrence rates.
Pulmonary vein isolation for symptomatic
paroxysmal AF must be attempted prior to ASD closure.
ď ź
prior to surgery: atrial flutter alone in 5%, atrial flutter and fibrillation in 2.8%, and atrial fibrillation alone in 11% [30]. Over a post-surgical follow-up of 3.8 years, atrial arrhythmias persisted or recurred in 60% of patients diagnosed preoperatively, and 2.3% developed new- onset arrhythmias. All patients with post-surgical atrial arrhythmias were over 40 years of age at time of repair. In a subsequent study that randomized 521 adults over 40 years of age with a secundum or sinus venosus ASD to surgical closure versus medical therapy, no difference in atrial tachyarrhythmias were noted at a median of 7 years post-operatively [31]. The impact of transcatheter ASD closure on atrial arrhythmias is less clear. In one series, all patients with persistent arrhythmias remained in atrial fibrillation or flutter after closure [32].
Sinus rhythm is usual Right QRS axis deviation (+95 to +170째) Incomplete right bundle branch block pattern: in V1 (consistent with right ventricular overload) Tall and peaked P waves may be present (right atrial enlargement)
••
Right axis deviation and incomplete RBBB pattern. Ectopic atrial rhythm, junctional rhythm or wandering atrial pacemaker reflecting sinus node dysfunction