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Case Report ATRIAL SEPTAL DEFECT Presented by: ANDI DEWI PRATIWI C111 11 153 Supervisor: dr. Akhtar Fajar M, Sp.JP, FIHA Cardiology and Vascular Medicine Department Medical Faculty of Hasanuddin University Makassar 2015

Atrial Septal Defect

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Atrial Septal Defect is a congenital heart disease

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Page 1: Atrial Septal Defect

Case ReportATRIAL SEPTAL

DEFECTPresented by:

ANDI DEWI PRATIWIC111 11 153

Supervisor:dr. Akhtar Fajar M, Sp.JP, FIHA

Cardiology and Vascular Medicine DepartmentMedical Faculty of Hasanuddin University

Makassar2015

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PATIENT’S IDENTITY

Name : Ms. JAge : 22 years oldSex : FemaleAdmission date : August 8th, 2015Medical record : 699600

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HISTORY TAKING

Chief complaint: shortness of breath

• Suffered since 3 months before admission• Orthopneu (-), dyspneu on effort (+), paroxysmal nocturnal

dyspneu (-)• Palpitation (+)• Chest pain (+), intermittently, not radiating down the arm• Fatigue (+)• Fever (-) cough (-) headache (-) epigastric pain (-) nausea &

vomiting (-)• Urination & defecation normal

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HISTORY TAKING

• History of outpatient in Wahidin Sudirohusodo Hospital 3 months ago because of goiter

• History of previous shortness of breath (-)• History of chest pain (-)• History of hypertension (-)• History of diabetes mellitus (-)• History of smoking (-)• History of heart disease in family (-)

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RISK FACTOR

Modifiable

-

Non modifiable

Gender : female

History of alcohol, drugs, or illness of

mother during pregnancy (-)

history of family with

same disease (-)

Histrry of family with other

kongenital disease (-)

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PHYSICAL EXAMINATION

• Moderate illness• Under-nourished• Compos mentis

General

state• BP: 110/80 mmHg• HR: 78/i• RR: 22x/i• Temp: 36,5oC

Vital signs

• Anemic (-) icterus (-) cyanotic (-)

• DVS R+2 cmH2o• Thyroid enlargement , grade

IB

Head & neck

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PHYSICAL EXAMINATION

THORAX

• I: symmetric, normochest

• P: tumor mass (-) tenderness (-)

• P: sonor, pulmo-hepar border : 6th ICS ant. dextra

• A: vesicular, ronkhi (-) wheezing (-)

COR

• I : apex cordis not seen

• P: apex cordis not palpable

• P : dull, left border : ICS V linea midclavicularis sinistra

• A : S1/S2 regular, systolic ejection murmur in ICS II sinitra

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PHYSICAL EXAMINATION

ABDOMEN

• I: convex, symmetric, following breath movement

• A: peristaltic (+), normal

• P: tenderness (-), tumor mass (-), hepar and spleen not palpable

• P: tympani(+), ascites(-)

EXTREMITIES

• Edema -/-

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ELECTROCRADIOGRAPHY (15/8/2015)

INTERPRETATION• Rhytm : Sinus• Heart rate : 94x/i• Regularity :

regular• Axis : Right

Axis Deviation• P wave : 0,08 sec• PR interval : 0,20

sec• QRS complex : RsR’

morphology in lead V1, III, V3, AVL, R wave is taller than S wave in lead V1

• ST segment : normal

• T wave : normalCONCLUSION:Sinus rhytm, HR 94 x/min, right axis deviation with incomplete

RBBB, right ventricle hipertrophy/dilatation

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CHEST X-RAY (6/8/2015)

- Lung bronchovascular marking increased.

- Cor difficult to assess, the impression enlarged. Heart waist prominent, elevated apex (RVE), normal aorta

- Both sinus and diaphragm well

- The bones intact

Conclusion :Cardiomegaly with signs L to R shunt

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Lab Value Unit

WBC 5,1 (10³/UI)

RBC 4,71 (106/UI)

HGB 12,1 (gr/dL)

HCT 36,2 %

PLT 212 (103/uL)

PT 11,9 Second

APTT 28,4 Second

INR 1,11 -

FT4 2,71 ng/dl

TSHS <0,05 mlU/ml

Lab Value Unit

GDS 85 mg/dL

Ureum 19 mg/dL

Creatinin 0,5 mg/dL

SGOT 18 u/L

SGPT 19 u/L

Natrium 142 mmol/L

Kalium 3,9 mmol/L

Klorida 111 mmol/L

LABORATORY RESULT (1/8/2015)

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TRANSTHORACIC ECHOCARDIOGRAM

(21/5/2015)

CONCLUSION

• ASD secundum enlarged with left to the right shunt

• Moderate Pulmonary hypertension

• Dilatation the right atrium and right ventricle

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TRANSESOPHAGEAL ECHOCARDIOGRAPHY

(21/5/2015)

CONCLUSION

secundum ASD

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SECUNDUM ATRIAL SEPTAL DEFECT WITH MODERATE PULMONARY HYPERTENSION

DIAGNOSIS

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ATRIAL SEPTAL DEFECT CLOSURE WITH AMPLATZER SEPTAL OCCLUDER

TREATMENT

SYMPTOMATIC TREATMENT (DIURETIC, BERAPROST SODIUM)

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ATRIAL SEPTAL DEFECT

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DEFINITION

Atrial septal defect (ASD) is a congenital heart defect in which

persistentopening in the interatrial septum

allows direct communication between the left and right atria.

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EPIDEMIOLOGY

Incidence : ASD occur on 1 by 1500 live birth.

ASD occurs with a female-to-male ratio of approximately 2:1

Secundum ASD account for75% of all ASDsand 30% to 40% of congenital disease seen in patients older than 40 years

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CLASSIFICATION

Type ASD

Secundum ASD

Sinus Venosus

ASD

Primum ASD

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• mutation in gen cardiac transcription factor NKX2.5

Etiology

• Prenatal factor• Genetic factor

Risk Factor

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PATOPHYSIOLOGY

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CLINICAL MANIFESTATION

palpitation

dyspnea on exertion

fatigue

Chest pain

recurrent lower respiratory tractinfections

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Pathomechanism of Symptoms Dyspnea

Long Standing L to R shunt

Hypervascularization of pulmonary circulation

Vascular bed filled with blood

Pulmonary hypertension

and Hydrostatic

pressure elevated

Transudation of fluid from capillary to interstitial

Inhibition of diffusion O2 on lung

Dyspnea

Page 24: Atrial Septal Defect

Fatigue

Pathomechanism of Symptoms

L to R shunt

Volume systolic

of LV decreas

e

Blood containi

ng oxygen decreas

e

Perfusion

decrease

Ischemic and

metabolism

disorder

Fatigue

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Pathomechanism of Symptoms

Angina

Systemic circulation decrease

Coronary circulation decrease

Right volume overload

Pulmonary hypertension

Wall-Stress increases of RV

Oxygen demand increase-Oxygen supply decrease

Angina

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Pathomechanism of Symptoms

Palpitation

Left to Right Shunt

Dilatation of right atrium

and right ventricle

Prolonged of conduction pathway

re-entry current

Atrial Fibrillation/ SVT/ PAT

Palpitation

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Pathomechanism of Symptoms Recurrent of respiratory tract infection

Hypervascularization of pulmonary

circulation vascular bed filling

Hydrostatic pressure increases

Edema of lower respiratory tract

disruption of immunity system

susceptible of infection

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DIAGNOSIS

Cardiac

catheterizatio

n

Echocardiography

Chest X-

Ray

ECG

Physical exa

mination

History taking

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EXAMINATION

PHYSICAL EXAMINATION

• Thrill can be palpated• Cardiomegaly in percussion• The second heart sound (S

2) demonstrates a widened (wide fixed splitting)• systolic murmur at the upper-left

sternal border• A mid-diastolic murmur may also

be present at the lower-left sternal border

ECG

• Right atrial deviation• RBBB• RVH• Abnormal P wave

ECHOCARDIOGRAPH

• septal defect location• the direction of the shunt• the size of the atrium and right ventricle• mitral valve involvement

CXR

• Cardiomegaly• Right atrial dilatation• Bronchovascular marking prominent

CARDIAC CATHETERIZATION

• see the oxygen saturation in the right atrium, measuring the magnitude ratio of pulmonary flow and systemic• set the pressure and pulmonary artery resistance• evaluating pulmonary artery anomaly

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COMPLICATION

PULMONARY

HIPERTENSION

ARITMIA RIGHT-SIDED HEART FAILURE

EISENMENGER SYNDROME

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TREATMENT

SYMPTOMATICDEFINITIVE

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DEFINITIVE TREATMENT

SURGERYINTERVENTIONAL

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INTERVENTIONAL

AMPLATZER SEPTAL OCCLUDER

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REFERENCES

1. Manurung D. Defek Septum Atrial. In: Sudoyo A, Setiyohadi B, Alwi I, Simadibrata M, Setiati S, editors. Buku Ajar Ilmu Penyakit Dalam. V ed. Jakarta: Interna Publishing; 2009. p. 2. Braunwald, Eugene et al. Braunwald's Heart Disease A Textbook Of Cardiovascular Medicine. Elsevier. 2015.3. Lilly Leonard S. Pathophysiology of Heart Disease. Wolters Kluwer. 5th edition. 2011. 4. Rilantono, Lily Ismudiati. Buku Ajar Kardiologi. Jakarta : Fakultas Kedokteran Universitas Indonesia. 2004.5. Topol Eric J. Textbook of Cardiovascular Medicine. Lippincott Williams & Wilkins. 2nd Edition. 2002.

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THANK YOU

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SIRKULASI DARAH JANIN

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Patent Foramen Ovale VS ASD