An atrial septal defect (ASD) is the second most common congenital heart defect after VSD and the

most common to become symptomatic in adulthood. It is characterised by an abnormal opening in the atrial septum allowing communication of blood between the right and left atria. Due to the low pressures of the atria the lesion is typically asymptomatic until adulthood despite 2 - 4 times the normal pulmonary blood flow. A gradual congestive cardiac failure (high output) eventually develops, becoming symptomatic usually around the age of 30. There may be greater female predilection. Pathology
Classification

There are four major types of ASDs , distinguished according to their location within the septum. They are:

secundum ASD o ~ 60 - 90% of all ASDs o usually an isolated abnormality primum ASD o 5 - 20% o associated with cleft anterior mitral valve leaflet (partial atrioventricular septal defect) sinus venosus o 5% o associated with anomalous right pulmonary venous return to the superior vena cava or right atrium coronary sinus type ASD o < 1%

Patients with ASD usually are asymptomatic early in life, although occasional reports exist of congestive heart failure (CHF) and recurrent pneumonia in infancy. Common findings include a prominent right ventricular cardiac impulse and palpable pulmonary artery pulsation. The first heart sound is normal or split, with accentuation of the tricuspid valve closure sound. Twodimensional echocardiography, supplemented by conventional or color-coded Doppler flow and/or contrast echocardiography, has superseded cardiac catheterization as the confirmatory test for ASD. In contrast to adults, children with the sinus venosus or secundum types of ASD rarely require treatment for CHF, atrial fibrillation, or supraventricular tachycardia. Although the risk of infective subacute bacterial endocarditis is low, antibiotics should be administered prophylactically before dental procedures. Operative repair is recommended for all patients with uncomplicated ASD in whom significant left-to-right shunting exists (ie, in patients with pulmonary flow/systemic flow ratios exceeding approximately 1.5:1). Ideally, the repair should be performed early (ie, by age 2-4 years). Surgical mortality is less than 1%, and results generally are excellent.

Chest radiographs usually reveal the following findings:

Enlargement of the right atrium and ventricle may be demonstrated. Dilatation of the pulmonary artery and its branches may be demonstrated. Increased pulmonary vascular markings may be demonstrated. In general pulmonary arterial overcirculation is almost always noted when at least a 2:1 shunt is present. The vascular pedicle (ascending aorta and arch and SVC shadow) is small. Dilatation of the proximal portion of the SVC occasionally is noted in patients with a sinus venosus defect. Left atrial dilatation is extremely rare (the left atrium is decompressed by the ASD) but may be observed when significant mitral regurgitation exists. The left ventricle is normal.

The degree of confidence is reasonably good if there are typical radiographic findings, but confirmation with echocardiography is usually necessary. An ASD should be differentiated from other etiologies of acyanotic heart disease with increased pulmonary vascularity. Left atrial enlargement is seen in ventricular septal defects and patent ductus arteriosus, not in ASDs.
http://emedicine.medscape.com/article/348121-overview#a01

http://radiopaedia.org/articles/atrial-septal-defect-2

A. Posteroanterior (PA) chest radiograph demonstrates a slight increase in pulmonary arterial markings with a normal sized heart. The main pulmonary artery segment is convex.

http://www.bcm.edu/radiology/cases/pediatric/text/2aA.htm

http://www.learningradiology.com/archives/COW%20010-ASD/asdcorrectpage.htm