Brief Answer:
Please upload full ECHO report

Detailed Answer:
Hello, Madam.

I understand your concern.

ASD is actually well tolerated in pregnancy.The complication rate is also very minimal.

Sir, I can guide you better if you upload the FULL report of ECHO.

I want to clarify if associated structural defects are are noted since this type is associated with abnormal venous communication in the heart.

I want to know the size of the ASD and whether Coronary sinus ASD an isolated defect or not?

Further she(your wife)being asymptomatic is a good sign.

I would like to know what medicines she has been prescribed.

Once I receive the follow-up, I will clearly confirm the outcome on pregnancy.

Thank you.

---

Brief Answer:
Possible SVD type ASD. A high degree of monitoring is warranted.

Detailed Answer:
Hello, Sir.

I understand your concern.

I apologise for the delayed response owing to hectic work schedule.

I have gone through your uploaded images and reports in detail.

The diagnosis goes in favour of Sinus Venous type ASD based on the characteristic findings and images on the TEE.

SVD type of ASD is associated with anomalous RUPV(right upper pulmonary vein) in many cases.

Sinus venosus atrial septal defects (ASDs), like most ASDs, are diagnosed upon detection of a murmur, a fixed split second heart sound, and/or right heart enlargement on chest x-ray or ECG or Echo in the usually asymptomatic patient.

Coronary sinus ASD is very rare typically associated with abnormalities in the roof of the coronary sinus.The CS in her case is normal but dilated.

In many cases, there can be confusion in differentiating the two conditions due to false drop puts in the interatrial septum morphology

The best investigation which can differentiate the two conditions is Cineangiography and Cardiac Catheterisation.These investigations are required in complicated cases where both TTE and TEE scan reports are inconclusive.

But in my view, I do not find the need for further investigations as clinically the patients of SVD of ASD are asymptomatic whereas those with CS typed ASD are associated with frequent respiratory insults.

There is elevated RVSP noted on both echo scans of the two doctors.

Any value greater to 35mm of Hg is an indicator of PAH.(53 vs 44).You have misunderstood that there is no PAH on 2nd echo by your Paediatric Cardiologist opinion.It was clearly mentioned on the report of TTE as 44+ m of Hg.

Also, Left to right shunt is evident on both echo scans of the two doctors.This indicates shunt several and a propensity to develop or worsen PAH.

PAH(pulmonary arterial hypertension) is a strong possibility in your wife's case considering echo parameters.

1.Dilated RA and RV.(enlarged right sided chambers)
2.Left to right shunt(>2:1).

But she currently is asymptomatic for PAH.But scan wise, there is mild pericardial effusion which could be an important reflection of underlying PAH progression.

Now coming to the course of Pregnancy-One has to monitor the L->R shunting periodically on Echo, since once this process becomes irreversible a condition Eissemenger Syndrome may develop, which strongly warrants termination of pregnancy.This is the only major complication that is expected and that which be closely followed.The prime duty should be to lower L->R shunt and subsequent PAH.

Considering the echo parameters, there is a strong possibility of PAH progression in her case.Hence, an early prophylactic therapy to lower PAH may be considered to avoid complications during pregnancy and labour.

The definitive management in her case is surgical correction which can be taken up after delivery.

The risk of ASD and other congenital lesions in the baby is high as many cases of ASD have a familial basis.Regular anomaly scan of the foetus can detect the same.Hence, periodic tracking has to be done in the child.

To conclude-
1.This is SVD of ASD.

2.Opinion of Pediatric Cardiologist is scientific and reasonable.

3.The possibility of PAH-Need for pulmonary antihypertensive therapy ?

4.Only Surgical correction offers Cure.

5.PAH tracking should be done at least on a monthly basis through TTE(transthoracic echocardiography).In the presence of controlled PAH/Normal RVSP(< 35 mm of Hg) and the absence of symptoms - a good obstetric outcome can be expected.

6.Keep a watch on symptoms like breathlessness and heart rhythm disturbances.Hence, a periodical ECG is advisable to detect SINUS NODE DYSFUNCTION which is quite common in SVD type ASD.

7.No further medical opinions needed.

Post your further queries if any.
Thank you.

---

Brief Answer:
Relevant facts and Referral Doctor details provided.

Detailed Answer:
Hello, Sir.

I understand your concern.

I apologise for the delayed response owing to my hectic work schedule.

I am thankful to you for kindly bearing with me.

The pregnancy is your case can be termed High-risk considering

1.Intracardiac shunt- a risk factor for paradoxical emboli formation.
2.Developing L->R shunt.
3.Evolving PAH-risk factor for Eisenmenger syndrome.
3.Rising RVSP-which can lead to RVS dysfunction.

Pregnancy is usually well tolerated in the absence of significant right ventricular systolic dysfunction or pulmonary hypertension and In women after a surgical or interventional closure of an ASD, and those with a small unrepaired ASD.

The risk of transmission of congenital heart disease is approximately 5-10%, compared to a background risk of approximately 1% of having a baby with congenital heart disease.

However, rarely, ASD may be associated with genetic syndromes in baby such as the Holt-Oram syndrome. Genetic counselling is recommended for women in all such cases.

In your case, the decision to terminate the pregnancy is not always justified.Termination is warranted only if Eisenmenger syndrome develops(The previous left-to-right shunt is converted into a right-to-left shunt secondary to elevated pulmonary artery pressures and associated pulmonary vascular disease).

Hence, a series of blood tests and blood gas analysis have to be carried out to detect this complication.

If special precautions are carried out in your case then pregnancy can be carried to a successful outcome.They include the following

In women with a large unrepaired ASD or high-risk features (significant right ventricular systolic dysfunction or pulmonary hypertension), antenatal care should be provided by a dedicated multidisciplinary team of experienced cardiologists, obstetricians, and anesthetists at a high-risk pregnancy center.

Women are at risk for paradoxical embolism. Therefore prophylaxis of deep vein thrombosis with low molecular heparin at times of increased risk (i.e. when a patient is bedbound for obstetric reasons) should be considered.

Women should be offered fetal echocardiography at approximately 20 weeks gestation.

During Labour and Delivery -

1.In women with high-risk features, labour and delivery should be planned carefully with a multidisciplinary team well in advance. It is important to communicate the delivery plan to the woman as well as other physicians involved in her care.

2.Vaginal delivery is preferred. Women with large unrepaired ASD with significant right ventricular systolic dysfunction or pulmonary hypertension (complex ASD) are at higher risk for complications.Therefore by decreasing maternal expulsive efforts during the second stage of labour, forceps or vacuum delivery is often utilized to minimize such complications.

3.In women with an ASD, air-particulate filters (bubble trap filters) are recommended for intravenous lines to decrease the risk of paradoxical air embolism.

4.Prophylaxis against Endocarditis?

Future possibility of conceiving can be predicted only after surgical correction of ASD. Almost all women who are successfully repaired for ASD have normal conception and pregnancy outcome rates.You need not worry about this.

Hence, you can make the choice of GO vs NO-GO by consulting an expert Obstetrician.I recommend the following doctor to you.

Dr XXXXXXX Anagani
HOD, Chief Gynaecologist, Obstetrician, Infertility Speciality & Laparoscopic Surgeon at Maxcure Hospitals, Madhapur, XXXXXXX

I advise you to consult her for the final decision making.

Post your further queries if any.
Thank you.

---