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         Hole in the heart

THERE ARE TWO COMMON TYPES OF HOLE IN THE HEART:

  1. ASD (ATRIAL SEPTAL DEFECT)
  2. VSD (VENTRICULAR SEPTAL DEFECT)

WHAT IS ASD?
An atrial septal defect (ASD) is a type of congenital heart disease in which there is a hole in the wall (septum) of the heart between the right atrium and the left atrium.

Basic Facts
A hole in the wall between the right and left atria is called an atrial septal defect.  Atrial septal defects, also referred to as ASDs, are common.  They may be diagnosed in childhood or adulthood.  The impact of the ASD on the heart depends on the size of the hole and whether there are other congenital heart abnormalities.

Who Gets an ASD?
Anyone can be born with an ASD, but they run in some families.  There are also rare syndromes that may be associated with ASD.  ASD may also be one part of more complex congenital heart disease.

What Happens Because of an ASD?
An ASD allows blood coming back to the left atrium to go into the right atrium.  (The reason blood flows from left to right instead of right to left through an ASD is because the pressures in the left side of the heart are usually higher than the pressures on the right).  This means that there is extra blood in the right atrium that will end up in the right ventricle.  The right ventricle has to work harder to pump the extra blood.  Eventually the right atrium and right ventricle become enlarged to deal with the extra blood. 

What Symptoms Does an ASD Cause?
An ASD may cause no symptoms at all.  Infants and children rarely have symptoms due to an ASD.  In those infants with large ASDs, they may not grow normally or may have heart failure.  Heart failure in babies usually causes problems when the baby eats or cries.  They may breathe rapidly, grunt or sweat when eating or crying. 

Adolescents or adults with symptoms often have fatigue and shortness of breath, especially with exercise.   Some have chest pain and some have swelling in their legs.  Some patients will have abnormal heart rhythms (arrhythmias) that cause symptoms.   Rarely an ASD can allow blood clots from the veins in the body to pass into the left side of the heart, causing a stroke, heart attack or other clot related problem.  Clots going from the right side of the heart to the left side are called paradoxic emboli. This is uncommon, but for some people with excessive clotting, the ASD may need to be fixed to prevent paradoxic emboli.

How Is an ASD Diagnosed?
Most often, an ASD is diagnosed because a doctor hears a heart murmur and gets an echocardiogram (heart ultrasound).  The heart murmur is often faint, and is difficult to diagnose by just listening. 

The echocardiogram can show the hole, as well as any abnormalities of the right heart caused by the hole.  Sometimes, doctors get the echocardiogram because of symptoms.  Other times tests done for other reasons might be abnormal, like a chest x-ray or electrocardiogram (ECG).  The abnormality leads the doctors to suspect a heart condition, so they order an echocardiogram.  Other tests, like CT scans, cardiac MRIs and cardiac catheterizations may also be used to diagnose an ASD.

How is an ASD Treated?
An ASD may be so small that it doesn’t need treatment. 
Medium and larger ASDs usually need to be fixed.  The treatment is closure of the hole, which can be done with open heart surgery.  In some cases, the ASD can be closed with a device placed through a catheter that is moved to the heart through a vein in the groin or neck.

What are the Long-Term Problems with an ASD?
A small ASD may cause no heart problems.  If an ASD is larger and isn’t fixed, it can eventually cause abnormal heart rhythms, failure of the right side of the heart or high pressures in the lungs.  Some of these symptoms can be managed with medications if fixing the ASD isn’t an option. 

Once an ASD is fixed, the right side of the heart will often return to normal size and any symptoms will get better.  Sometimes the right heart doesn’t return to normal or there are still symptoms.  Those patients need regular lifelong care from a cardiologist specializing in congenital heart defects.

                                    VSD (VENTRICULAR SEPTAL DEFECT)
WHAT IS IT?
A ventricular septal defect (VSD) is a type of congenital heart disease in which there is a hole in the wall (septum) of the heart between the right ventricle and the left ventricle.

Basic Facts
A ventricular septal defect (VSD) is a type of congenital heart disease in which there is a hole in the wall (septum) of the heart between the right ventricle and the left ventricle.

Who Gets a VSD?
Anyone can be born with a VSD, but patients with Down syndrome are more likely to have a VSD.  Mothers with uncontrolled diabetes are more likely to have a baby with a VSD.  VSD may also be one part of more complex congenital heart disease.

What Happens Because of a VSD?
A VSD allows blood to go between the left and right ventricles.  Normally, the pressure in the left ventricle is higher than the pressure in the right ventricle.  So with a VSD, “red” blood goes from the left ventricle to the right ventricle through the hole where it mixes in with the “blue” blood.  This means there is extra blood being squeezed out to the lungs.  This blood comes back from the lungs to the left atrium and left ventricle.  The extra blood means the left ventricle has to work harder to pump the right amount of blood to the body.  Eventually the left ventricle will enlarge to cope with the extra work load. 

Because there is extra blood going into the lungs, the arteries in the lungs may tighten to control the blood flow.  This can eventually cause the pressures in the lungs to rise, called pulmonary hypertension.  The high pressure in the lungs causes extra work for the right ventricle.  If the pressure in the lungs becomes too high, the pressure needed for the right ventricle to squeeze blood to the lungs may be higher than the pressure needed for the left ventricle to squeeze blood to the body.  This causes the blood flow through the VSD to “reverse”.  The blue blood now goes from the right ventricle into the left ventricle.  This can make the patient “blue”, also known as cyanosis.  The “reversal” of blood flow between the ventricles is called Eisenmenger syndrome.
For an explanation of how a normal heart is structured and functions, please read the article on congenital heart disease.

What Symptoms Does a VSD Cause?
A small VSD may cause no symptoms at all.  If there are symptoms due to a VSD, they  usually develop shortly after birth.

Infants with larger VSDs may not grow normally or may have heart failure.  Heart failure in babies often causes problems when the baby eats.  The baby may tire easily, breathe rapidly, grunt or sweat when eating.  Babies with heart failure often sleep more than other babies and may not grow normally.

Some children with moderate sized VSD may have exercise limitations, fatigue or shortness of breath.  It is rare for patients with VSD to develop symptoms for the first time in adulthood. 

Patients who develop Eisenmenger syndrome will be “cyanotic”, which refers to a blue coloration due to the oxygen-poor blood being pumped out to the body.  The blueness is usually best seen in the fingers and toes or around the mouth.  Patients with Eisenmenger syndrome can have shortness of breath, especially with exercise.  They may also have fatigue, chest pain or dizziness. 

How Is a VSD Diagnosed?
A VSD may be diagnosed with an echocardiogram.  Reasons to get an echocardiogram may be to evaluate symptoms or because the doctor hears a murmur.  VSDs often cause loud murmurs, and can be suspected just by listening, especially in babies. 

Sometimes other tests done might be abnormal, like a  chest x-ray or  electrocardiogram (ECG) .  The abnormality leads the doctors to suspect a VSD, so they order an echocardiogram.  Other tests, like CT scans ,  cardiac MRIs and  cardiac catheterizations may also be used to diagnose an ASD. 

How Is a VSD Treated?
A small VSD may go away on it’s own during childhood. Other small VSDs may still be present in late childhood or adulthood, but may be so small treatment is not needed. 
Medium and larger VSDs usually need to be fixed.  The treatment is closure of the hole, which can be done with open heart surgery.  Medications are often needed before surgery to improve symptoms in babies and children.  The medications can usually be stopped after surgery is done to fix the hole.

Patients with Eisenmenger syndrome should not have the hole closed because it is too dangerous once the pressures in the lungs are that high.  These patients may need medications to try to decrease the pressures in the lungs.  They may also need other medications to help with symptoms. 

What are the Long-Term Problems with a VSD?
A small VSD may cause no heart problems.  There is a small risk of an infection of the hole, called endocarditis.  Once a VSD is fixed, the left side of the heart will often return to normal size and symptoms will get better.  If the pressures in the lungs were high, they may return to normal.  Sometimes the left heart doesn’t return to normal or the lung pressures remain high. Those patients need regular lifelong care from a cardiologist specializing in congenital heart defects.  Patients with Eisenmenger syndrome need lifelong specialized care. 

 
      Doctor Tips
Angina is an uncomfortable feeling or pain in the chest.
   
It usually feels like a heaviness or tightness.
      For healthcare professional
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