Rubrik Kongenital

ASD
Kasus : Wanita 35 tahun datang ke Poli Klinik Jantung karena sesak napas

NO Assesment Deskripsi

Perkenalan dan anamnesis terarah

1 Profesionalisme dan
komunikasi
Anamnesa (terarah)
- Perkenalan diri dan perilaku profesional
- Mencuci tangan dan memakai APD yang sesuai
Riwayat Keluhan sekarang (OLDChARTS)
 Onset : sesak napas dirasakan sejak 2 tahun belakangan.
 Lokasi (-)
 Durasi : intermittent
 Character : Pada sesak ditanya keluhan terkait  PND (-)
orthopnea (+) exercise intolerance (+), palpitation (+)
 Aggravating: Memberat dengan aktifitas fisik
 Alleviating : membaik dengan istirahat.
 Radiating (-)
 Timing/ Triggering: Sesak dipicu oleh aktifitas sedang dan
berat.
 Severity : (-)
 Related symptoms : exercise intolerance? palpitasi?
Syncope?
Kondisi terkait lain : demam (-), malaise (-), hamil (-)  Pasien
perempuan usia produktif WAJIB ditanya HAMIL/tidak
Riwayat penyakit dahulu (terarah) :
Riwayat sesak saat aktifitas, exercise intolerance saat kecil-remaja
 tidak ada.
Riwayat nyeri telan (-), nyeri sendi (-) subcutaneous nodule (-)
Riwayat growth and development (failure thrive)
 Apakah pertumbuhan dan perkembangan terlambat
(dibandingkan teman sebaya/saudara kandung bila ada )
 lebih kurus, perawakan lebih kecil, lebih terlambat
berjalan atau bicara. Etc
Riwayat feeding difficulty saat bayi  heteroanamnesa : saat
kecil tidak kuat menyusu, menyusus sedikit-sedikit, saat menyusu
tampak terengah-engah, volume minum susu sedikit.
Riwayat Infeksi saluran napas berulang  waktu kecil hingga
remaja sering batuk pilek panas
Riwayat prenatal/natal  pasien lahir dibidan, riwayta kehmilan
pada ibu tidak diketahui.

Family History PJB : tidak ada

Risk Factors : tidak ada
Social History : IRT. Mempunyai 1 anak.

Pemeriksaan fisik
2 Pemeriksaan fisik
- Meminta data Keadaan Umum pasien :
- KU : tampak sakit sedang
- BB : 43 kg
- TB: 165 cm

CRT <2, warm acrals, clubbing finger (-), strong pulse in all
extrimities
Pemeriksaan penunjang
3 Permintaan
pemeriksaan penunjang
dan interpretasi
Rubrik Kongenital
ASD
- Meminta data pemeriksaan vital sign
(BP 103/61, HR 98x/m regular, RR 20x, saturasi 96% RA )
- Meminta data pemeriksaan Kepala leher
- Conj anemis (-), icteric (-)
- JVP R+4
- Cyanosis (-)
- Meminta data pemeriksaan Thorax
COR:
- Inspeksi : normal
- Palpasi : RV heaves (+), hyperdynamic pulse in apex
area (-).
- Perkusi : pelebaran batas jantung kanan
- Auskultasi : S1 normal, S2 widely fixed split(+), murmus
systolic ejection ICS 2 parasternal S , murmur systolic
at LLSB louder with inspiration
PULMO : Rh +/+ minimal at the base. Wh (-) others within
normal limit.
- Meminta data pemeriksaan Abdomen  dbn
- Meminta pemeriksaan extrimitas :
- Meminta pemeriksaan ECG :
- RSR′ pattern in lead V1
- incomplete right bundle branch block  sign of
RV volume overload
- Right-axis deviation
- RV hypertrophy
- RA enlargement (about 50%) with a prominent P-wave
in lead II
- Meminta data CXR :
- Cardiomegaly with upward apex
- Increase pulmonary markings (phletora)
- When PH  reduced PVM, prominent Pulmonary
segment
 Rubrik Kongenital

ASD

ASD-PH  RAE RVH Conus pulmonalis menonjol + Inverted

comma sign + pruning

- Meminta data Lab : dalam batas normal

- Meminta data Echocardiografi :
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ASD
- Subsifoid view : IAS GAP (+)
- RA and RV enlargement
- TR moderate
- Flow pattern : L to R shunt
Meminta data TEE  tidak
dilakukan
 Rubrik Kongenital

ASD
ASD

Penegakan Diagnosis
4 Menyebutkan diagnosis - Diagnosis utama : ASD secundum sedang L to R shunt
secara lengkap - Diagnosis penyerta : HF stg C fc II dt Congenital Heart Disease
- Diagnosis banding : VSD, PDA, AVSD

Tatalaksana awal
5 Planning Diagnosa - TEE  menentukan Rim-rim
Lanjutan - Kateterisasi Jantung Kanan :
- menilai resiko dan kontraindikasi penutupan ASD
- Menilai Kontraindikasi Penutupan ASD
- Dilakukan sebelum ASD mau ditutup dengan transkateter
- Yang dinilai : PARI, PVR/SVR Ratio (R-R Ratio), FR

Tatalaksana lanjutan
6
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ASD
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ASD

a
RV enlargement with
increased stroke volume.
b
Providing there is no PAH
or LV disease.
c
In elderly patients not
suitable for device closure,
carefully weigh surgical risk
vs. potential benefit of ASD
closure.
d
Carefully weigh the
benefit of eliminating L–R
shunt against the potential
negative impact of ASD
closure on outcome due to
an increase in filling
pressure (taking closure,
fenestrated closure, and no
closure into consideration).

©ESC
www.escardio.org/guidelines

2020 ESC Guidelines for the management of adult congenital heart disease (ACHD)
(European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa554)

Indikasi Penutupan ASD :

1. PARi < 8 dan rasio PVR/SVR < 0.3
2. PARi ≥ 8 dan rasio PVR/SVR ≥ 0.3 tetapi dengan tes
vasodilator paru PARi turun < 8 dan rasio PVR/SVR < 0.3
3. Flow ratio ≥ 1.5
Kontra Indikasi Penutupan ASD:
1. Bila sdh terjadi PVD atau sindroma eisenmenger
2. Tidak reaktif vasodilator tes yaitu PARi > 8 dan
rasio PVR/SVR ratio > 0.3

Penutupan ASD : surgical , non surgical (transkateter)

Kriteria Penutupan ASD transketer :

1. Pada anak, sebaiknya BB > 6 kg
2. Diameter ASD >= 5 mm dan <=40 mm (seusai
occlude yang tersedia)
3. Rim-rim adekuat >=5
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ASD
4. Rim yang mutlak harus ada : rim posterior, rim IVC dan
rim SVC. Untuk rim aorta bila minimal/tidak ada 
masih bisa ditutup dgn occlude
5. Bila sudah timbul PH tapi belum PVD dengan hasil
tes vasodilator PARI < 8 WU, dan PVR/SVR <= 0.3
6. Bila hasil tes vasodilator PVR/SVR 0.3-0.5 
tutup dengan fenestrated occluder

Recommendations for intervention in atrial septal defect

(native and residual) (1)
Recommendations Class Level
*
In patients with evidence of RV volume overload and no PAH (no non-
invasive signs of PAP elevation or invasive confirmation of PVR <3 WU in case
I B
of such signs) or LV disease, ASD closure is recommended regardless of

©ESC
symptoms.
Device closure is recommended as the method of choice for secundum ASD
I C
closure when technically suitable.
In elderly patients not suitable for device closure, it is recommended to
I C
carefully weigh the surgical risk against the potential benefit of ASD closure.
In patients with non-invasive signs of PAP elevation, invasive measurement
I C
of PVR is mandatory.
*
RV enlargement with increased stroke volume.

2020 ESC Guidelines for the management of adult congenital heart disease (ACHD)
www.escardio.org/guidelines (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa554)
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ASD

Recommendations for intervention in atrial septal defect

(native and residual) (3)
Recommendations Class Level
In patients with PVR ≥5 WU, fenestrated ASD closure may be considered
when PVR falls below 5 WU after targeted PAH treatment and significant L–R IIb C
shunt is present (Qp:Qs >1.5).
ASD closure is not recommended in patients with Eisenmenger physiology,
patients with PAH and PVR ≥5 WU despite targeted PAH treatment, or III C

©ESC
desaturation on exercise.*
*
There are limited data available for a precise cut-off, but by clinical experience, this would definitely be given by a fall of arterial oxygen saturation
below 90%.

2020 ESC Guidelines for the management of adult congenital heart disease (ACHD)
www.escardio.org/guidelines (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa554)

Recommendations for intervention in atrial septal defect

(native and residual) (2)
Recommendations Class Level
In patients with LV disease, it is recommended to perform balloon testing
and carefully weigh the benefit of eliminating L–R shunt against the potential
negative impact of ASD closure on outcome due to an increase in filling I C
pressure (taking closure, fenestrated closure, and no closure into
consideration).
In patients with suspicion of paradoxical embolism (exclusion of other
causes), ASD closure should be considered regardless of size providing there IIa C
is absence of PAH and LV disease.
In patients with PVR 3–5 WU, ASD closure should be considered when
IIa C
©ESC

significant L–R shunt is present (Qp:Qs >1.5).

2020 ESC Guidelines for the management of adult congenital heart disease (ACHD)
www.escardio.org/guidelines (European Heart Journal 2020 - doi/10.1093/eurheartj/ehaa554)

Tambahan:
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ASD
Agitated Saline Contrast/Bubble Test

Bubble Test TTE

No Prosedur
1 Sebutkan indikasi:
- Deteksi shunt (PFO, ASD, pulmonary, persistent left SVC)
- Intensifikasi TR signal saat estimasi fungsi sistolik RV sulit
- Meningkatkan pencitraan trunkus pulmonaris terutama dalam
deteksi trombus
- Delianisasi jantung kanan termasuk massa
- Membantu pericardiosintesis
- Kontrol jalur vena dalam

2 Sebutkan kontraindikasi
- Terdapat R to L shunt, bidirectional atau transient R to L shunt
yang beresiko menyebabkan oklusi mikrovaskular dan iskemia.
- Hipertensi pulmonal
- Kondisi kardiovaskular tidak stabil seperti aritmia, sindroma
koroner akut, dan gagal jantung akut

3 Profesionalisme (memperkenalkan diri, menjelaskan prosedur tindakan

dan meminta persetujuan)
4 Persiapan pasien
- Pasien berbaring lurus dengan posisi supinasi
- Menggunakan baju tindakan

5 Persiapan alat
- Elektroda EKG
- Three-way stopcock
- NaCl 0.9%
- Abocath 20G
- 2 buah Spuit 10 cc
- Contrast saline (80% NaCl, 10% darah, 10% udara bebas)

6 Persiapan diri
- Cuci tangan 6 langkah
- Gunakan handschoen

7 Prosedur
- Dapatkan akses intravena lengan kanan pasien hubungkan
abocath dengan three-way stopcock.
- Siapkan contrast saline.
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ASD
- Lakukan agitasi three-way stopcock sebelum injeksi.
- Pengambilan view dasar echocardiography 4 chamber.
- Injeksi contrast saline yang sudah diagitasi saat pasien strain
phase valsava minimal selama 10 detik.
- Lepaskan valsava saat bubble mulai memasuki RA.
- Optimalisasi view echocardiography dengan:
- Four shortening apical 4 chamber/ subxiphoid
- Tissue harmonic imaging dan
- Durasi acquisition panjang.

8 Interpretasi bubble test TTE

- View dasar: kesan tampak echo gap pada IAS, tidak tampak IAS
hipermobile/ Atrial Septal Aneurysm (ASA).
- Bubble menyebrang IAS dalam 3 beat pertama.
- Large PFO (> 20 microbubble).

Interpretasi bubble TEE

- Bubble menyebrang IAS dalam 3 beat pertama.
- Mobilitas IAS, visualisasi ASA.
- Ukuran tunnel > 10 mm.
- Large PFO (> 20 microbubble).

Kesimpulan: High risk PFO (contoh)