“All you need to know about Paediatric cardiac procedures – ASD/VSD”
— Get Well in India
A hole in the wall between the two upper collecting chambers (ASD) or between the two bottom pumping chambers (VSD) can change the normal flow of blood through heart.
A baby with one or more heart defects since birth has Congenital heart diseases. The complexity of the disease depends on the size and the location of the defect, it may have no symptom or even lead to a heart failure. Possible reason for a heart failure in a baby could be complications during the time of pregnancy or due to inadequate feeding and inadequate weight gain.
Heart has two sides which are separated by an inner wall called the septum. With each heartbeat, the right side of your heart receives oxygen-poor blood from your body and pumps it to your lungs. The left side of your heart receives oxygen-rich blood from your lungs and pumps it to your body. The septum, which is the inner wall, prevents mixing of blood between the two sides of the heart. However, some babies are born with holes in the upper or lower septum.
A hole in the septum between the heart’s two upper chambers is called an atrial septal defect (ASD). A hole in the septum between the heart’s two lower chambers is called a ventricular septal defect (VSD).
ASDs and VSDs allow blood to pass from the left side of the heart to the right side. This means that oxygen-rich blood can mix with oxygen-poor blood. As a result, some oxygen-rich blood is pumped to the lungs instead of out to the body.
Over the past few decades, the diagnosis and treatment of ASDs and VSDs have greatly improved. Children with these defects can survive to adulthood and live a normal life because sometimes their heart defects close on their own or might have been repaired.
Dr. Suresh Rao
Paediatric - ASD/VSD
Dr. Krishnan Iyer
Paediatric - ASD/VSD
In a healthy child’s heart, there is a muscle about the size of his or her fist. The heart works like a pump and beats 1,00,000 times a day.
There are four chambers and four valves which are connected to various blood vessels. Veins are blood vessels that carry blood from the body to the heart. Arteries are blood vessels that carry blood away from the heart to the body.
A healthy heart has:
Heart Chambers: The heart has four chambers:
- The atria are the two upper chambers that collect blood as it flows into the heart.
- The ventricles are the two lower chambers that pump blood out of the heart to the lungs or other parts of the body.
Heart Valves: There are four valves which control the flow of blood from the atria to the ventricles and from the ventricles into the two large arteries connected to the heart.
- The tricuspid valve is in the right side of the heart, between the right atrium and the right ventricle.
- The pulmonary valve is in the right side of the heart, between the right ventricle and the entrance to the pulmonary artery. This artery carries blood from the heart to the lungs.
- The mitral valve is in the left side of the heart, between the left atrium and the left ventricle.
- The aortic valve is in the left side of the heart, between the left ventricle and the entrance to the aorta. This artery carries blood from the heart to the body.
Valves are like doors that open and close. They open to allow blood to flow through to the next chamber or to one of the arteries. Then they shut to keep blood from flowing backward. When the heart’s valves open and close, they make a “lub-dub” sound that a doctor can hear using a stethoscope.
Arteries: The arteries are major blood vessels connected to your heart.
- The pulmonary artery carries blood from the right side of the heart to the lungs to pick up a fresh supply of oxygen.
- The aorta is the main artery that carries oxygen-rich blood from the left side of the heart to the body.
- The coronary arteries are the other important arteries attached to the heart. They carry oxygen-rich blood from the aorta to the heart muscle, which must have its own blood supply to function.
Veins: The veins also are major blood vessels connected to your heart.
- The pulmonary veins carry oxygen-rich blood from the lungs to the left side of the heart so it can be pumped to the body.
- The superior and inferior vena cavae are large veins that carry oxygen-poor blood from the body back to the heart.
Types of Holes in Heart
Atrial Septal Defect: An atrial septal defect (ASD) is a hole in the part of the septum that separates the atria (the upper chambers of the heart). This hole allows oxygen-rich blood from the left atrium to flow into the right atrium instead of flowing into the left ventricle as it should. This means that oxygen-rich blood goes back to the lungs, instead of going to the body.
The size of ASD can be small, medium, or large. Small ASDs means little blood to flow from one atrium to the other, they don’t need any major treatment and close on their own as the heart grows during childhood. Medium and large ASD’s allow more blood to leak from one atrium to the other. They might need treatment as they’re less likely to close on their own.
Most children with ASD’s have no symptoms, whatever be the size of ASD’s.
The three major types of ASDs are:
- Secundum: This defect is in the middle of the atrial septum and is the most common form of ASD. They close on their own.
- Primum: This defect is in the lower part of the atrial septum. Primum defects often occur with heart valve problems. This is not a common defect and it does’nt close on its own and might need treatment.
- Sinus venosus: This defect is in the upper part of the atrial septum. This is a rare occurrence and doesn’t close on their own.
ASD Complications: If an ASD isn’t repaired, the extra blood flow to the right side of the heart and lungs may cause heart problems. Most of these problems occur at the age 30 or post that.
Complications such as:
- Right heart failure
- Arrhythmias or irregular heartbeats
- Pulmonary hypertension
Ventricular Septal Defect: A ventricular septal defect (VSD) is a hole in the part of the septum that separates the ventricles. A VSD allows oxygen-rich blood to flow from the left ventricle into the right ventricle, instead of flowing into the aorta as it should. So, instead of going to the body, the oxygen-rich blood goes back to the lungs.
The size of VSDs can be small, medium, or large. Small VSDs may close on their own. Medium VSDs are less likely to close on their own. Large VSDs likely won’t close completely on their own. Surgery usually is needed to close large VSDs.
VSD Complications: If a medium or large VSD isn’t repaired, it may cause heart problems.
- Heart failure
- Growth failure
- Arrhythmias or irregular heartbeats.
- Pulmonary hypertension
Causes of ASD and VSD: Complications during pregnancies is the major cause of ASDs or VSDs. It could also be hereditary. Children with down syndrome, often have congenital heart defects. Smoking or alcohol during pregnancy also leads to these heart defects.
The diagnosis of the hole is based on a physical exam and the results from tests.
- Physical Exam: This will be carried out to listen to your child’s heart and lungs with a stethoscope to monitor the heart murmur.
- Diagnostic Tests and Procedures: Your child’s doctor may recommend several tests to diagnose an ASD or VSD, such as:
- Echocardiography: It uses sound waves to create a moving picture of the heart. The computer converts the sound waves into pictures on a screen. It is an important test for both diagnosing a hole in the heart. This test will help your child’s cardiologist decide whether and when treatment is needed.
- Electrocardiogram: This test shows how fast the heart is beating and monitor its rhythm, whether steady or irregular. It also records the strength and timing of electrical signals as they pass through the heart. An EKG can detect whether one of the heart’s chambers is enlarged, which can help diagnose a heart problem.
- Chest X Ray: This test creates pictures of the structures in the chest, such as the heart, lungs, and blood vessels. This test can show whether the heart is enlarged.
- Pulse Oximetry: This test helps recognize the level of oxygen in the blood. A small sensor is attached to a finger or ear. The sensor uses light to estimate how much oxygen is in the blood.
Cardiac Catheterization: A thin, flexible tube called a catheter is put into a vein in the arm, groin, or neck. The tube is threaded to the heart. Special dye is injected through the catheter into a blood vessel or one of the heart’s chambers. The dye allows the doctor to see the flow of blood through the heart and blood vessels on an x-ray image. This test is also used to measure the pressure inside the heart chambers and blood vessels.
The treatment of hole in the child’s heart depends on the type, location, and size of the hole, child’s age and overall health.
Treating ASD: Periodic checkups are done to see whether an atrial septal defect (ASD) closes on its own. If it doesn’t, then treatment of an ASD is required which involves catheter or surgical procedures to close the hole.
During Catheter Procedure, a catheter, which is a thin, flexible tube is entered into a vein in the groin till heart’s septum. When the catheter reaches the septum, the device is pushed out of the catheter and positioned so that it plugs the hole between the atria. The device is placed and the catheter is withdrawn from the body. Within 6 months, normal tissue grows in and over the device. There is no need to replace the closure device as the child grows.
Catheter procedures are easy as they involve only a needle puncture in the skin where the catheter is inserted. Recovery is faster and easier.
The other option is ‘Open-heart surgery’, which is done to repair primum or sinus venosus ASDs. Anesthesia is given, an incision is made in the chest to reach the ASD. The defect is repaired with a special patch that covers the hole.
Treating VSD: Regular checkups and tests are conducted time to time to see whether the defect closes on its own or the size reduces.
More than half of VSDs eventually close, usually by the time a child is in preschool. Treatment for a VSD include extra nutrition and surgery to close the VSD.
The doctor may recommend surgery if your child’s VSD Is large, causing symptoms, causing enlarged heart chamber or affecting the aortic valve
Good nutrition or special feedings is recommended for kids. These feedings are high-calorie formulas or breast milk supplements that give babies extra nourishment. In some cases, tube feeding is needed. This treatment usually is temporary because a VSD that causes symptoms will likely need surgery.
Surgery: It is recommend to close large VSDs that are causing symptoms or haven’t closed by the time children are 1 year old. Surgery may be needed earlier if:
- The child fails to gain weight
- Medicines are needed to control the symptoms of heart failure
One way to close a VSD hole is to use cardiac catheterization. In this procedure, doctors use a small, flexible tube called a catheter and another tool called a septal occluder. Catheter will be pushed through your baby’s blood vessels all the way into your child’s heart. Then, septal occluder will be used to close up the hole in your baby’s heart. This procedure is very safe.
Your child will need at least 3 or 4 more weeks at home to recover. Your child’s doctor will tell you when your child can resume school, daycare, or play.
Pain after surgery is normal. There may be more pain after closed-heart surgery than after open-heart surgery. The pain will likely decrease over time and with the help of antibiotics.
Behaviour of a child may vary after heart surgery. They may be clingy, irritable. Support your child through this time. Take utmost care when lifting your child, support both the child’s head and bottom for the first 4 to 6 weeks. Toddlers and older children will often stop any activity if they become tired.
Your child should not do any activity that could result in a fall or a blow to the chest. Your child should also avoid bicycle or skateboard riding, roller skating, swimming. Do not pull or lift the child by the arms or from their armpit area. Good nutrition is very important.
Look at the wound for signs of infection, such as redness, swelling, tenderness, warmth, or drainage.
Avoid extreme temperatures. Hot bath and then cold bath. Till the surgical wound looks pink, make sure it is covered with clothing or a bandage when your child is in the sun. Avoid direct sun.
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