Hostname: page-component-cd9895bd7-p9bg8 Total loading time: 0 Render date: 2024-12-27T21:50:45.642Z Has data issue: false hasContentIssue false

Atrial shunts: presentation, investigation, and management, including recent advances in magnetic resonance imaging

Published online by Cambridge University Press:  07 January 2014

Cheryl G. Zvaigzne
Affiliation:
Stephenson Cardiovascular Magnetic Resonance Imaging Centre, Department of Cardiology, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada Department of Paediatric Cardiology, Alberta Children’s Hospital, Calgary, AB, Canada
Andrew G. Howarth
Affiliation:
Stephenson Cardiovascular Magnetic Resonance Imaging Centre, Department of Cardiology, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
David J. Patton*
Affiliation:
Stephenson Cardiovascular Magnetic Resonance Imaging Centre, Department of Cardiology, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada Department of Paediatric Cardiology, Alberta Children’s Hospital, Calgary, AB, Canada
*
Correspondence to: D. J. Patton, Department of Paediatric Cardiology, Alberta Children’s Hospital, 2888 Shaganappi Trail NW, Calgary, Canada AB T3B 6A8. Tel: +1 (403) 955 7858; Fax: +1 (403) 955 7621; E-mail: David.Patton@albertahealthservices.ca

Abstract

Atrial shunts are a common finding in both paediatric and adult populations. Recent developments in advanced imaging have widened the options for diagnosis and evaluation of such shunts. This paper reviews the various types of interatrial communications, discusses the features of clinical presentation in adults and children, and provides an overview of the clinical assessment including physical examination, electrocardiography, echocardiography, cardiac catheterisation, computed tomography, and magnetic resonance imaging. Focus will be placed on recent developments in magnetic resonance imaging that may improve the non-invasive evaluation of atrial shunts.

Type
Review Articles
Copyright
© Cambridge University Press 2014 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Porter, CEW. Atrial septal defects. In: Allen HD, Clark EB, Gutgesell HP, Driscoll DJ (eds). Moss and Adams’ Heart Disease in Infants, Children, and Adolescents: Including the Fetus and Young Adults, 7th edn. Lippincott Williams & Wilkins, Philadelphia, PA, 2008, pp 632645.Google Scholar
2. English, R, Anderson, R, Ettedgui, J. Interatrial communications. In: Anderson RH, Baker EJ, Penny DJ, Redington AN, Rigby ML, Wernovsky G (eds). Pediatric Cardiology, 3rd edn. Churchill Livingstone, Elsevier, Philadelphia, PA, 2010, pp 523546.Google Scholar
3. Veldtman, GR, Freedom, RM, Benson, LN. Atrial septal defect. In: Freedom R, Yoo S, Mikailian H, Williams WG (eds). The natural and modified history of congenital heart disease. Wiley-Blackwell, Elmsford, NY, 2003, pp 3143.Google Scholar
4. Webb, G, Gatzoulis, MA. Atrial septal defects in the adult: recent progress and overview. Circulation 2006; 114: 16451653.Google Scholar
5. Piaw, CS, Kiam, OT, Rapaee, A, et al. Use of non-invasive phase contrast magnetic resonance imaging for estimation of atrial septal defect size and morphology: a comparison with transesophageal echo. Cardiovasc Intervent Radiol 2006; 29: 230234.Google Scholar
6. Whitaker, KB. Embryologic development of the cardiopulmonary system. In: Whitaker KB (ed). Comprehensive Perinatal and Pediatric Respiratory Care. Delmar, Thompson Learning, Albany, NY, 2001, pp 1820.Google Scholar
7. Anderson, RH, Brown, NA, Webb, S. Development and structure of the atrial septum. Heart 2002; 88: 104110.CrossRefGoogle ScholarPubMed
8. Hagen, PT, Scholz, DG, Edwards, WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984; 59: 1720.Google Scholar
9. Hoffman, JI, Kaplan, S. The incidence of congenital heart disease. J Am Coll Cardiol 2002; 39: 18901900.Google Scholar
10. Ho, SY, Rigby, ML, Anderson, RH. Interatrial communications. In: Ho SY, Rigby ML, Anderson RH (eds). Echocardiography in Congenital Heart Disease Made Simple, 1st edn. Imperial College Press, London, 2005, pp 6775.Google Scholar
11. Vogel, M, Berger, F, Kramer, A, Alexi-Meshkishvili, V, Lange, PE. Incidence of secondary pulmonary hypertension in adults with atrial septal or sinus venosus defects. Heart 1999; 82: 3033.CrossRefGoogle ScholarPubMed
12. Joy, J, Kartha, CC, Balakrishnan, KG. Structural basis for mitral valve dysfunction associated with ostium secundum atrial septal defects. Cardiology 1993; 82: 409414.Google Scholar
13. Hoey, ET, Gopalan, D, Ganesh, V, Agrawal, SK, Screaton, NJ. Atrial septal defects: magnetic resonance and computed tomography appearances. J Med Imaging Radiat Oncol 2009; 53: 261270.Google Scholar
14. Vick, GW. Defects of the atrial septum including atrioventricular septal defects. In: Garson A, Bricker JT, Fisher DJ, Neish SR (eds). The Science and Practice of Pediatric Cardiology, 2nd edn. Williams & Wilkins, Baltimore, Maryland, 1998, pp 11421177.Google Scholar
15. Bustin, D. Hemodynamic Monitoring for Critical Care. Appleton-Century-Crofts, Norwalk, Connecticut, 1986.Google Scholar
16. Sanders, SP, Yeager, S, Williams, RG. Measurement of systemic and pulmonary blood flow and QP/QS ratio using Doppler and two-dimensional echocardiography. Am J Cardiol 1983; 51: 952956.CrossRefGoogle ScholarPubMed
17. Colan, SD. Ventricular function in volume overload lesions. In: Fogel M (ed.). Ventricular Function and Blood Flow in Congenital Heart Disease. Blackwell, Malder, MA, 2005, pp 205221.Google Scholar
18. Gatzoulis, MA, Freeman, MA, Siu, SC, Webb, GD, Harris, L. Atrial arrhythmia after surgical closure of atrial septal defects in adults. N Engl J Med 1999; 340: 839846.Google Scholar
19. Meijboom, F, Hess, J, Szatmari, A, et al. Long-term follow-up (9 to 20 years) after surgical closure of atrial septal defect at a young age. Am J Cardiol 1993; 72: 14311434.Google Scholar
20. Haworth, SG, Rabinovitch, M. Pulmonary circulation. In: Anderson RH, Baker EJ, Penny DJ, Redington AN, Rigby ML, Wernovsky G (eds). Paediatric Cardiology, 3rd edn. Churchill Livingstone, Elsevier, Philadelphia, PA, 2010, pp 117141.Google Scholar
21. Craig, RJ, Selzer, A. Natural history and prognosis of atrial septal defect. Circulation 1968; 37: 805815.Google Scholar
22. Cherian, G, Uthaman, CB, Durairaj, M, et al. Pulmonary hypertension in isolated secundum atrial septal defect: high frequency in young patients. Am Heart J 1983; 105: 952957.Google Scholar
23. Tavel, ME, Stewart, J. Usefulness and limitations of precordial phonocardiography and external pulse recordings. Cardiovasc Clin 1975; 6: 4155.Google ScholarPubMed
24. Parikh, DN, Fisher, J, Moses, JW, et al. Determinants and importance of atrial pressure morphology in atrial septal defect. Br Heart J 1984; 51: 473479.Google Scholar
25. Rees, A, Farru, O, Rodriguez, R. Phonocardiographic radiological, and haemodynamic correlation in atrial septal defect. Br Heart J 1972; 34: 781786.Google Scholar
26. Cohen, JS, Patton, DJ, Giuffre, RM. The crochetage pattern in electrocardiograms of pediatric atrial septal defect patients. Can J Cardiol 2000; 16: 12411247.Google Scholar
27. Giardini, A, Donti, A, Formigari, R, et al. Determinants of cardiopulmonary functional improvement after transcatheter atrial septal defect closure in asymptomatic adults. J Am Coll Cardiol 2004; 43: 18861891.Google Scholar
28. Suchon, E, Podolec, P, Tomkiewicz-Pajak, L, et al. Cardiopulmonary exercise capacity in adult patients with atrial septal defect. Przegl Lek 2002; 59: 747751.Google Scholar
29. Radojevic, J, Rigby, M. Atrial septal defect, Chapter 25. In: Gatzoulis MA, Webb GD, Daubeney PEF (eds). Diagnosis and Management of Adult Congenital Heart Disease, 2nd edn. Elsevier Saunders, Philadelphia, 2011, pp 183184.Google Scholar
30. Baumgartner, H, Bonhoeffer, P, De Groot, NM, et al. Task Force on the Management of Grown-up Congenital Heart Disease of the European Society of Cardiology (ESC); Association for European Paediatric Cardiology (AEPC); ESC Committee for Practice Guidelines (CPG). ESC Guidelines for the management of grown-up congenital heart disease (new version 2010). Eur Heart J 2010; 31: 29152957.Google Scholar
31. Gnanapragasam, JP, Houston, AB, Northridge, DB, Jamieson, MP, Pollock, JC. Transoesophageal echocardiographic assessment of primum, secundum and sinus venosus atrial septal defects. Int J Cardiol 1991; 31: 167174.CrossRefGoogle ScholarPubMed
32. Fischer, G, Stieh, J, Uebing, A, Hoffmann, U, Morf, G, Kramer, HH. Experience with transcatheter closure of secundum atrial septal defects using the Amplatzer septal occluder: a single centre study in 236 consecutive patients. Heart 2003; 89: 199204.Google Scholar
33. Lerakis, S, Babaliaros, VC. Transesophageal echocardiography guided percutaneous closure of secundum atrial septal defects. Echocardiography 2010; 27: 724727.Google Scholar
34. Saric, M, Perk, G, Purgess, JR, Kronzon, I. Imaging atrial septal defects by real-time three-dimensional transesophageal echocardiography: step-by-step approach. J Am Soc Echocardiogr 2010; 23: 11281135.Google Scholar
35. Lodato, JA, Cao, QL, Weinert, L, et al. Feasibility of real-time three-dimensional transoesophageal echocardiography for guidance of percutaneous atrial septal defect closure. Eur J Echocardiogr 2009; 10: 543548.Google Scholar
36. Durongpisitkul, K, Tang, NL, Soongswang, J, Laohaprasitiporn, D, Nanal, A. Predictors of successful transcatheter closure of atrial septal defect by cardiac magnetic resonance imaging. Pediatr Cardiol 2004; 25: 124130.Google Scholar
37. Zanchetta, M, Rigatelli, G, Pedon, L, Zennaro, M, Carrozza, A, Onorato, E. Catheter closure of perforated secundum atrial septal defect under intracardiac echocardiographic guidance using a single Amplatzer device: feasibility of a new method. J Invasive Cardiol 2005; 17: 262265.Google ScholarPubMed
38. Hernandez, F, Garcia-Tejada, J, Velazquez, M, Albarran, A, Andreu, J, Tascon, J. Intracardiac echocardiography and percutaneous closure of atrial septal defects in adults. Rev Esp Cardiol 2008; 61: 465470.Google Scholar
39. Onorato, E, Casilli, F, Zanchetta, M. Intracardiac echocardiography by ultra ICE. In: Sievert H, Qureshi S, Wilson N, Hijazi Z (eds). Percutaneous Interventions for Congenital Heart Disease. Informa Healthcare, United Kingdom, 2007, pp 4959.Google Scholar
40. Hundley, WG, Li, HF, Lange, RA, et al. Assessment of left-to-right intracardiac shunting by velocity-encoded, phase-difference magnetic resonance imaging. A comparison with oximetric and indicator dilution techniques. Circulation 1995; 91: 29552960.Google Scholar
41. Levin, AR, Spach, MS, Boineau, JP, Canent, RV Jr, Capp, MP, Jewett, PH. Atrial pressure-flow dynamics in atrial septal defects (secundum type). Circulation 1968; 37: 476488.Google Scholar
42. Boehrer, JD, Lange, RA, Willard, JE, Grayburn, PA, Hillis, LD. Advantages and limitations of methods to detect, localize, and quantitate intracardiac left-to-right shunting. Am Heart J 1992; 124: 448455.Google Scholar
43. Jarmakani, JM. Cardiac catheterization. In: Moss AJ, Adams FH, Emmanouilides GC (eds). Heart disease in infants, children and adolescents, 2nd edn. Williams & Wilkins, Baltimore, 1977, pp 116117.Google Scholar
44. Williamson, EE, Kirsch, J, Araoz, PA, et al. ECG-gated cardiac CT angiography using 64-MDCT for detection of patent foramen ovale. AJR Am J Roentgenol 2008; 190: 929933.CrossRefGoogle ScholarPubMed
45. American College of Cardiology Foundation Task Force on Expert Consensus Documents, Hundley, WG, Bluemke, DA, et al. ACCF/ACR/AHA/NASCI/SCMR 2010 expert consensus document on cardiovascular magnetic resonance: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Cardiol 2010; 55: 26142662.Google Scholar
46. Pennell, DJ, Sechtem, UP, Higgins, CB, et al. Clinical indications for cardiovascular magnetic resonance (CMR): consensus panel report. J Cardiovasc Magn Reson 2004; 6: 727765.CrossRefGoogle ScholarPubMed
47. Teo, KS, Disney, PJ, Dundon, BK, et al. Assessment of atrial septal defects in adults comparing cardiovascular magnetic resonance with transoesophageal echocardiography. J Cardiovasc Magn Reson 2010; 12: 4449.CrossRefGoogle ScholarPubMed
48. Lamb, HL, Kozerke, S, Doornbos, J, Bax, JJ, de Roos, A. Clinical approach to cardiovascular magnetic resonance techniques. In: Higgins CB, de Roos A (eds). MRI and CT of the Cardiovascular System. Lippincott Williams & Wilkins, Philadelphia, PA, 2006, pp 58.Google Scholar
49. Sandner, TA, Theisen, D, Bauner, KU, Picciolo, M, Reiser, MF, Wintersperger, BJ. Cardiac functional analysis with MRI. Radiologe 2010; 50: 514522.Google Scholar
50. Colletti, PM. Evaluation of intracardiac shunts with cardiac magnetic resonance. Curr Cardiol Rep 2005; 7: 5258.Google Scholar
51. Hamilton-Craig, C, Sestito, A, Natale, L, et al. Contrast transoesophageal echocardiography remains superior to contrast-enhanced cardiac magnetic resonance imaging for the diagnosis of patent foramen ovale. Eur J Echocardiogr 2011; 12: 222227.Google Scholar
52. Johnson, TR, Fogel, MA. Abnormalities of the atria and systemic veins. In: Fogel MA (ed.). Principles and Practice of Cardiac Magnetic Resonance in Congenital Heart Disease. Wiley-Blackwell, United Kingdom, 2010, pp 110119.Google Scholar
53. Thomson, LE, Crowley, AL, Heitner, JF, et al. Direct en face imaging of secundum atrial septal defects by velocity-encoded cardiovascular magnetic resonance in patients evaluated for possible transcatheter closure. Circ Cardiovasc Imaging 2008; 1: 3140.Google Scholar
54. Beerbaum, P, Korperich, H, Barth, P, Esdorn, H, Gieseke, J, Meyer, H. Noninvasive quantification of left-to-right shunt in pediatric patients: phase-contrast cine magnetic resonance imaging compared with invasive oximetry. Circulation 2001; 103: 24762482.Google Scholar
55. Fratz, S, Chung, T, Greil, G, et al. Guidelines and protocols for cardiovascular magnetic resonance in children and adults with congenital heart disease: SCMR expert consensus group on congenital heart disease. J Cardiovascu Magn Reson 2013; 15: 5176.CrossRefGoogle Scholar
56. Gatehouse, PD, Rolf, MP, Graves, MJ, et al. Flow measurement by cardiovascular magnetic resonance: a multi-centre multi-vendor study of background phase offset errors that can compromise the accuracy of derived regurgitant or shunt flow measurements. J Cardiovasc Magn Reson 2010; 12: 5.Google Scholar
57. Beerbaum, P, Parish, V, Bell, A, Gieseke, J, Korperich, H, Sarikouch, S. Atypical atrial septal defects in children: noninvasive evaluation by cardiac MRI. Pediatr Radiol 2008; 38: 11881194.Google Scholar
58. Beerbaum, P, Korperich, H, Esdorn, H, et al. Atrial septal defects in pediatric patients: noninvasive sizing with cardiovascular MR imaging. Radiology 2003; 228: 361369.Google Scholar
59. Holmvang, G, Palacios, IF, Vlahakes, GJ, et al. Imaging and sizing of atrial septal defects by magnetic resonance. Circulation 1995; 92: 34733480.Google Scholar
60. Valverde, I, Simpson, J, Schaeffter, T, Beerbaum, P. 4D phase-contrast flow cardiovascular magnetic resonance: comprehensive quantification and visualization of flow dynamics in atrial septal defect and partial anomalous pulmonary venous return. Pediatr Cardiol 2010; 31: 12441248.Google Scholar
61. Wang, ZJ, Reddy, GP, Gotway, MB, Yeh, BM, Higgins, CB. Cardiovascular shunts: MR imaging evaluation. Radiographics 2003; 23 (Spec No): S181S194.Google Scholar
62. Prasad, SK, Soukias, N, Hornung, T, et al. Role of magnetic resonance angiography in the diagnosis of major aortopulmonary collateral arteries and partial anomalous pulmonary venous drainage. Circulation 2004; 109: 207214.Google Scholar
63. Fogel, MA. Assessment of ventricular function and flow. In: Fogel MA (ed.). Principles and Practice of Cardiac Magnetic Resonance in Congenital Heart Disease: Form, Function, and Flow. Wiley-Blackwell, United Kingdom, 2010, pp 6372.Google Scholar
64. Juluru, K, Vogel-Claussen, J, Macura, KJ, Kamel, IR, Steever, A, Bluemke, DA. MR imaging in patients at risk for developing nephrogenic systemic fibrosis: protocols, practices, and imaging techniques to maximize patient safety. Radiographics 2009; 29: 922.Google Scholar
65. Ain, DL, Narula, J, Sengupta, PP. Cardiovascular imaging and diagnostic procedures in pregnancy. Cardiol Clin 2012; 30: 331341.Google Scholar
66. Marinskis, G, Bongiorni, MG, Dagres, N, et al. Performing magnetic resonance imaging in patients with implantable pacemakers and defibrillators: results of a European Heart Rhythm Association survey. Europace 2012; 14: 18071809.Google Scholar
67. Therrien, J, Warnes, C, Daliento, L, et al. Canadian cardiovascular society consensus conference 2001 update: recommendations for the management of adults with congenital heart disease part III. Can J Cardiol 2001; 17: 11351158.Google Scholar
68. Daniel, WC, Lange, RA, Willard, JE, Landau, C, Hillis, LD. Oximetric versus indicator dilution techniques for quantitating intracardiac left-to-right shunting in adults. Am J Cardiol 1995; 75: 199200.Google Scholar
69. Fu, Y, Cao, Q, Hijazi, Z. Closure of secundum atrial septal defect using the Amplatzer septal occluder. In: Sievert H, Qureshi S, Wilson N, Hijazi Z (eds). Percutaneous Interventions for Congenital Heart Disease. Informa Healthcare, United Kingdom, 2007, pp 265288.Google Scholar
70. Oliver, JM, Gallego, P, Gonzalez, AE, et al. Surgical closure of atrial septal defect before or after the age of 25 years. comparison with the natural history of unoperated patients. Rev Esp Cardiol 2002; 55: 953961.Google Scholar
71. King, TD, Thompson, SL, Steiner, C, Mills, NL. Secundum atrial septal defect. nonoperative closure during cardiac catheterization. JAMA 1976; 235: 25062509.CrossRefGoogle ScholarPubMed
72. Gervasi, L, Basu, S. Atrial septal defect devices used in the cardiac catheterization laboratory. Prog Cardiovasc Nurs 2009; 24: 8689.Google Scholar
73. Bjornstad, PG. The role of devices in the closure of atrial septal defects in the oval fossa. Cardiol Young 1998; 8: 285286.Google Scholar
74. Alexi-Meskishvili, VV, Konstantinov, IE. Surgery for atrial septal defect: from the first experiments to clinical practice. Ann Thorac Surg 2003; 76: 322327.Google Scholar
75. Luermans, JG, Post, MC, Yilmaz, A. Late device thrombosis after atrial septal defect closure. Eur Heart J 2010; 31: 142.Google Scholar