Pediatric Cardiology

Atrial Septal Defect (ASD) in Children: Symptoms and Treatment Options

Posted on by Prof. Dr. İbrahim Cansaran TANIDIR

Atrial Septal Defect (ASD) in children is the presence of a congenital opening in the wall that separates the right and left atria, the upper chambers of the heart, or as it is commonly known, a “hole in the heart.” This anatomical difference causes some of the oxygen-rich clean blood on the left side of the heart to leak through the hole in the wall to the right side, increasing the volume of blood going to the lungs above normal. When this condition, which affects the heart’s natural pumping order, is diagnosed in time, it is a structural issue that can be completely corrected with modern methods by specialist physicians without leaving a permanent negative impact on the child’s development and future quality of life.

What Is ASD (Hole in the Heart) in Children and How Does It Form?

The human heart is a remarkable structure consisting of four different chambers. There are two atria at the top and two ventricles at the bottom. While the right side of the heart collects oxygen-depleted blood returning from the body, the left side contains oxygen-rich, clean blood coming from the lungs. Between the right and left atria at the top, there is a wall that separates these two different blood pools from each other. Since the baby in the womb does not yet breathe or use the lungs, the presence of a natural opening in this wall is completely necessary for life in the womb. Clean blood coming from the mother passes through this natural opening and circulates throughout the baby’s body.

When birth takes place and the baby fills the lungs with air with the first cry, the pressure balances inside the heart change completely within seconds. This new pressure balance allows that natural valve, which was life-saving in the womb, to close tightly like a room door. Over time, this valve fuses with the surrounding tissues and becomes a smooth, leak-proof wall. However, in the very early stages of pregnancy, a small pause during the growth and development of these very thin membranes causes the wall not to fuse completely. As a result, a permanent hole remains between the right and left atria. The condition in which this door, which should close after the baby is born, remains open is called Atrial Septal Defect. This condition, which is quite common among congenital heart differences, is one of the anatomical conditions most frequently followed and successfully treated by heart specialists in childhood.

What Are the Different Types of ASD (Atrial Septal Defect) Openings in the Heart?

These openings in the heart are named differently according to where they are located in that wall. The location of the hole is the most important factor determining the type of treatment that will be applied later. Specialists make this distinction very carefully during evaluation.

The main types of openings seen in the wall between the atria are:

  • Ostium secundum
  • Ostium primum
  • Sinus venosus
  • Coronary sinus

The most common of these types is ostium secundum defects. This group accounts for almost eighty percent of cases and is known for being located in the middle of the wall separating the two chambers. Being exactly in the middle of the wall ensures that there is strong tissue around it, which is a major advantage for the non-surgical closure method we will discuss later.

Ostium primum defects are located at the lowest part of the wall, very close to the valves that act as passageways to the lower chambers of the heart. This type may often be accompanied by some minor leaks or structural differences in the valves. These types of defects are treated surgically.

Sinus venosus type openings are located at the far end points where the large veins bringing deoxygenated blood from the body connect to the heart. These types of defects are treated surgically.

Coronary sinus defects are the rarest type and mean the absence of the wall between the heart’s own venous drainage system and the left atrium. These types of defects, which could previously be treated surgically, can also be treated transcatheter/angiographically in selected and suitable patients.

How Does ASD (Hole in the Heart) Affect the Child’s Heart and Lungs Over Time?

Since the left side of the heart is responsible for sending clean blood from the tips of the toes to the brain throughout the entire body, it has very strong muscles and high pressure. The right side, on the other hand, has a lower-pressure, softer structure because it only pushes blood to the nearby lungs. When there is an opening between the atria, just as water always flows from high to low, clean blood begins to leak from the high-pressure left side to the low-pressure right side.

As a natural result of this leakage, the right side of the heart is left with much more blood than it normally should carry. Both the usual deoxygenated blood returning from the body and the clean blood leaking through the hole accumulate in the right atrium. Since the right side of the heart has an incredibly flexible structure, it initially carries this extra load without complaint by expanding slightly and working harder. However, as the years pass, this continuously ongoing extra work causes the right side of the heart to enlarge and become fatigued. In addition, the amount of blood pumped from the right side of the heart to the lungs also increases greatly. When the lung vessels are continuously washed with this high blood volume, hardening may occur in the vessel walls over time. Therefore, it is vitally important to detect and manage this opening in the heart before it creates permanent strain in the lung vessels.

What Are the Symptoms Indicating That Your Child Has ASD (Hole in the Heart)?

Most of the time, this condition progresses very silently for years without giving any clues. Babies usually breastfeed comfortably, grow very well, and begin walking at the same time as their peers. However, if the hole is large or as the child grows and physical activities increase, some small signals begin to appear.

Symptoms that may be observed externally in children include:

  • Easy fatigue
  • Rapid breathing
  • Palpitations
  • Dizziness
  • Fainting
  • Growth retardation
  • Loss of appetite
  • Frequent lung infections

If the child needs to move aside and rest earlier than peers while running and playing in the park, this is an important sign. During exercise, the heart must send more oxygen to the muscles, but because some of the blood leaks to the right side due to the hole, the body cannot receive enough oxygen and the child tires early. In addition, since there is constantly extra blood accumulation in the lungs, the lungs become more sensitive than normal to germs and viruses. This may cause the child to frequently develop bronchitis or pneumonia, especially during winter months, and to recover from illnesses more slowly and with more difficulty than other children. In older children, fluttering sensations in the chest, namely palpitations caused by the heart working too much, may be seen. Sometimes in very large openings, slowing or stagnation in weight gain may also draw families’ attention due to the extra energy spent by the body.

How Do Doctors Detect ASD (Hole in the Heart) During Physical Examination?

The first detection of this condition in a child who has no symptoms and appears completely healthy usually occurs during a routine well-child examination by pediatricians. The stethoscope, the instrument used to listen to the heart, is like a translator that explains the fluid movements inside the heart in the hands of an experienced physician.

When a normal heart works, the closing sounds of the valves are heard very clearly and synchronously. However, in a child with an opening in the heart, because the amount of blood accumulated in the right side of the heart is excessive, the closing of the pulmonary valve on the right side is always later than the aortic valve on the left side. This delay is fixed regardless of breathing. When the specialist doctor places the stethoscope on the child’s chest, these valve sounds are heard very distinctly as a double rhythm. In addition, that enormous blood flow moving from the right side of the heart toward the lungs creates a soft blowing sound as it passes through the pulmonary valve, similar to the sound a river makes while passing through a narrow strait. This sound, called a murmur, is the greatest evidence that the child’s heart is doing extra work and directs the physician to the next step.

Which Methods Are Used for the Definitive Diagnosis of ASD (Hole in the Heart)?

When such a suspicion related to the heart arises during physical examination, painless and highly comfortable tests are used to clarify the condition, measure the size of the hole, and determine the degree of enlargement it has caused in the heart.

Diagnostic tools frequently used in clinics (for ASD diagnosis, follow-up, and evaluation) include:

  • Echocardiography
  • Electrocardiography
  • 24-hour rhythm Holter
  • Cardiac CT or MRI

Echocardiography, namely heart ultrasound, is indisputably the most valuable tool in this process. With a small device touched to the chest together with warm gel, the internal structure of the heart, the movement of the valves, and the wall between the chambers appear on the screen within seconds. Thanks to the color ultrasound feature, how fast and how much clean blood passes through the hole to the right side becomes visible. In addition, the lengths of the strong wall around the hole are measured millimetrically. Electrocardiography maps the electrical activity of the heart; changes in the electrical signals of the overworked right heart are recorded. Chest X-ray shows how much space the heart occupies in the rib cage and the excess blood density in the lung vessels. The 24-hour rhythm Holter monitor is used in older children when heart rhythm needs to be recorded at home over twenty-four hours. As a result of all these examinations, a complete map of the child’s heart is obtained.

Must Every ASD (Hole in the Heart) Be Closed and Can It Close Spontaneously?

The issue that families most wonder about and place hope in at the time of diagnosis is whether this opening will close on its own. Openings that are discovered incidentally within the first few months of life and are especially very small in diameter have a fairly high chance of closing spontaneously as the child grows and the surrounding tissues thicken with the development of the heart muscle.

For children who have these small openings and do not have any enlargement on the right side of the heart or increased lung pressure, specialists do not perform any medical intervention. During this process, no restriction is placed on the child’s daily life, play, or nutrition. They only prefer to wait by monitoring the heart’s condition with ultrasound at specific months. However, if the hole has still not closed by the time the child reaches two or three years of age, if its size is relatively large, and most importantly, if the right chambers of the heart have begun to enlarge from becoming fatigued by carrying this excess blood, this opening is no longer expected to close on its own. At this stage, before any permanent sign of fatigue occurs in the heart and before the child reaches school age, the process of closing the hole with external assistance begins to be planned.

How Is ASD (Hole in the Heart) Closure Performed With the Non-Surgical Method?

Thanks to advances in medicine, the vast majority of these openings can now be closed in the angiography laboratory with a highly elegant method, without making any incision in the child’s chest. Secundum type openings located exactly in the middle of the wall are the most suitable candidates for this method.

In this procedure, which is performed without the need for an operating room environment, a very thin and flexible tube is inserted through the vein in the groin area of the sleeping child. Through this tube, a closure device made of a special memory metal is advanced. When this device is inside the tube, it is in the form of a long, thin wire. When the hole in the heart is reached, one end of the device opens on the left side of the hole and takes the shape of a small umbrella. Then the other end of the device opens on the right side of the hole, forming a second umbrella. The hole becomes trapped like a sandwich between these two umbrella discs and is completely closed. During the procedure, specialists confirm the position of the device millimetrically with ultrasound, and after making sure everything is perfect, they detach the device from the wire and leave it in the heart. The child feels no pain after this procedure, returns to the room with a small bandage on the groin, and is discharged the next day walking. Leaving no aesthetic scar and causing no psychological trauma are the greatest advantages of this method.

In Which Situations Is Open Heart Surgery Required for ASD (Hole in the Heart)?

Although the umbrella method is very comfortable, not every opening in the heart is suitable for this procedure due to its structure. If the type of the hole is ostium primum or sinus venosus, or if the hole is in the middle of the wall but there is not enough strong tissue margin for the device to hold firmly on both sides, surgical treatment is the only and most appropriate option for safety.

Pediatric cardiac surgeons perform this procedure under general anesthesia. If the hole is very small, the opening is approximated and sutured using special cardiac stitches. However, if the hole is large, a patch is needed to close the hole. This patch is usually obtained from the child’s own outer heart membrane or from specially produced synthetic fabrics. The patch is carefully sewn over the hole, and leakage is completely prevented. Today, these surgical procedures can also be performed through small aesthetic incisions under the arm without fully opening the breastbone. The success of the surgical method is complete; the hole is closed definitively and permanently. The hospital stay may last approximately one week, and a recovery period of several weeks is needed for the body to regain its previous form.

What Should Be Expected During the Recovery Process After ASD (Hole in the Heart) Treatment?

Whether the opening is closed with the umbrella method or surgically, the heart needs a certain amount of time to adapt to the new situation and achieve complete healing. The device or patch placed there is initially a new object within the bloodstream. The body’s wonderful healing system covers this new patch with the heart’s own natural inner layer within months, making it an inseparable part of the heart.

Routine follow-up periods after the procedure are:

  • First month
  • Third month
  • Sixth month
  • Twelfth month

Until this covering process is completed, that is, for an average of six months, children need to use a certain daily dose of blood thinner to prevent clot formation in the blood. Again, during this sensitive first six-month period, in cases of tooth extraction or any febrile procedure, preventive antibiotics must be taken under physician supervision to prevent bacteria from settling in the patch area of the heart. In monthly follow-ups, the position of the device is checked with ultrasound, and the most pleasing development is observed: the right side of the heart, which had enlarged and become tired before the hole was closed, rapidly recovers and returns to completely normal size because it is relieved of the excess blood load.

When Can Children Return to Sports After ASD (Hole in the Heart) Treatment?

One of the issues families worry about most for children who have completed treatment is their future physical capacity and freedom of movement. The quality of life, heart health, and lifespan of successfully treated children are completely no different from those of children who have never had a hole in their heart.

Only during the first few months after the procedure, children are asked to avoid hard contact sports that may cause severe impacts to the chest area, as the patch or device placed in the heart is expected to fuse and stabilize well with the tissues. However, after the sixth-month check-up confirms that everything is going well, life returns completely to normal for children. These children can run freely in physical education classes at school, swim, and actively participate in any competitive sports branches they want. Specialists even specifically encourage children who have completed treatment to do sports so that they can have a strong cardiovascular system, maintain weight control, and improve their self-confidence.

Güncellenme Tarihi: 13.10.2026

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