Hole in the Heart in Children: Types, Symptoms and Treatment Options

A hole in the heart in children is a congenital opening in the wall between the atria or ventricles of the heart. This condition is medically called a septal defect and leads to abnormal blood flow within the heart. The size and location of the holes determine the clinical course of the disease and the need for treatment.

Symptoms of congenital heart holes in children vary depending on the size and location of the defect. While small defects may not cause symptoms, large openings may lead to rapid breathing, cyanosis, failure to gain weight, frequent infections, and recurrent hospitalizations. Early diagnosis is important for preserving cardiac function.

Types of atrial septal defect and ventricular septal defect in infants are located in different compartments of the heart. Atrial septal defect occurs between the atria, while ventricular septal defect occurs between the ventricles. Diagnosis is made with echocardiography, and hemodynamic effects are evaluated in detail.

Treatment methods for heart holes in children are planned according to the patient’s age, defect diameter, and clinical findings. Small holes may close with follow-up, while large defects may require medication, catheter-based (angiographic) procedures, or surgical repair. With appropriate intervention, the prognosis is generally favorable.

Things You Should Know	Information
Definition	A hole in the heart in children refers to congenital abnormal openings between the chambers of the heart or the great vessels. This condition is included in the group of congenital heart diseases and may lead to abnormal mixing of blood within the heart.
Most Common Types	The most common types of heart holes are Atrial Septal Defect (ASD – a hole between the atria), Ventricular Septal Defect (VSD – a hole between the ventricles), and Patent Ductus Arteriosus (PDA – persistence of a vessel that should close after birth).
Formation Mechanism	It occurs as a result of incomplete closure of the walls called septa during heart development in early pregnancy. This opening may cause oxygenated and deoxygenated blood to mix.
Frequency	Congenital heart diseases are seen in approximately 8–10 infants per 1,000 live births, and a portion of these consists of septal defects and PDA.
Causes	In most cases, the exact cause is unknown. Genetic predisposition, chromosomal anomalies (such as Down syndrome), maternal infections during pregnancy, diabetes, or exposure to certain medications may be among the risk factors.
Symptoms	Small holes usually do not cause symptoms. In larger defects, rapid breathing, easy fatigue, failure to gain weight, frequent lung infections, cyanosis, and heart murmurs may occur.
Diagnostic Methods	Further examination is performed when a heart murmur is heard during physical examination. Echocardiography (heart ultrasound), electrocardiography (ECG), chest X-ray, and when necessary, cardiac catheterization may be used for diagnosis.
Course of Small Defects	Small ASDs and VSDs may close spontaneously or may be monitored lifelong without causing serious problems. Regular cardiology follow-up is necessary.
Effects of Large Defects	If left untreated, heart failure, pulmonary hypertension (increased pressure in the lung vessels), growth retardation, and rhythm disorders may develop. Serious long-term complications such as Eisenmenger syndrome may occur.
Treatment Options	Observation, medication (to reduce signs of heart failure), catheter-based closure procedures, or surgical repair may be applied. Treatment selection is determined according to the type and size of the defect and the child’s clinical condition.
Need for Surgery	Not all heart holes require surgery. Interventional treatment is recommended in defects that are hemodynamically significant and cause growth retardation or cardiac overload.
Long-Term Follow-Up	Regular pediatric cardiology follow-up is necessary after treatment or during observation. Most children can live normal lives with appropriate treatment.

What Is a Hole in the Heart in Children and How Does It Affect the Body’s Function?

The human heart is a remarkable pumping system consisting of four chambers in total, two upper and two lower. In a healthy circulatory system, the right side of the heart collects deoxygenated, or “dirty,” blood returning from the body and sends it to the lungs for oxygenation. The left side of the heart receives oxygen-rich clean blood from the lungs and pumps it powerfully throughout the body. A thick, muscular wall separates the right and left sides. This wall prevents the systems from mixing.

If some parts of this wall fail to close completely during fetal development, a passageway, or hole, forms between the two systems. Since the pressure on the left side is always higher than on the right, some of the oxygenated blood passes through the hole and flows into the right side. This causes the right side of the heart and the lungs to become overloaded with much more blood than normal. As the lungs are exposed to this excessive blood flow, they gradually become strained, and if the overload is not corrected, permanent damage may begin to develop over many years. The entire course of the disease depends on where the hole is located in the heart and how large it is.

What Is Atrial Septal Defect (ASD), the Hole in the Upper Chambers?

Atrial Septal Defect, or ASD, is the name given to openings in the membranous wall between the upper chambers of the heart, called the right and left atria. It is one of the more common congenital heart diseases. Oxygen-rich blood under high pressure in the left atrium leaks through this hole into the lower-pressure deoxygenated blood in the right atrium.

This leakage means that the right side of the heart has to handle more blood than normal with every heartbeat. To cope with this “volume overload,” the right atrium and right ventricle gradually begin to enlarge and expand. Although this enlargement may not cause significant symptoms during childhood, over the years it can lead to right heart failure, rhythm disturbances, and severe high blood pressure in the lung vessels. Therefore, timely diagnosis and follow-up are extremely important.

Into Which Anatomical Types Is Atrial Septal Defect (ASD) Divided?

Holes between the atria are named according to their location within the wall, and this location is the most critical factor determining how treatment will be performed. Types of ASD include:

• Secundum type
• Primum type
• Sinus venosus type
• Coronary sinus type

The secundum type is located in the middle of the wall and is the most common type of ASD. Since there is sufficient surrounding tissue, most of these cases today are highly suitable for closure by angiographic methods without opening the chest. The primum type is a hole very close to the lower heart valves and is often associated with other valve problems. Sinus venosus and coronary sinus types are located near the openings of the large veins entering the heart. The common feature of these last three types is that, due to their anatomical locations, they are not suitable for device closure using umbrella-like devices, and treatment is usually performed with surgical repair.

However, it would be appropriate to add a note here. In recent years, some types of sinus venosus defects, which we call high venosum defects, can be treated using suitable techniques and materials after three-dimensional CT scanning.

What Is Ventricular Septal Defect (VSD), the Hole in the Lower Chambers?

Ventricular Septal Defect (VSD) refers to holes in the thick muscular wall between the lower chambers of the heart, known as the ventricles, which provide the heart’s main pumping power. It is the most common congenital heart disease. The left ventricle contracts under very high pressure to pump blood throughout the body. If there is a hole in this wall, some of the blood is forcefully propelled through the hole into the right ventricle and from there directly into the lungs.

This massive blood flow to the lungs can cause severe structural deterioration in the lung vessels. To resist this pressure, the lung vessels begin to thicken. If the disease is not controlled, lung pressure may rise so much that the direction of blood flow reverses and deoxygenated blood begins to circulate through the body. This condition, called Eisenmenger Syndrome, is a highly dangerous stage in which surgical correction is no longer possible. Therefore, VSD cases are monitored much more closely.

In Which Regions of the Heart Is Ventricular Septal Defect (VSD) Seen?

Just as with the upper chambers, holes between the ventricles behave differently depending on their location. The regions where VSD may occur are:

• Perimembranous region
• Muscular region
• Outlet region
• Inlet region

The perimembranous region is the membranous area just below the aortic valve and is the most common location for these holes. Some defects in this region may tend to close over time with the help of adjacent valves. The muscular region is within the thick muscular layer of the heart, and as the child grows and the heart muscle thickens, these defects have a very high likelihood of closing spontaneously. The outlet region is located very close to the valves of the great arteries leaving the heart, and even small defects here usually require intervention because they may damage adjacent valves. The inlet region refers to defects near the inflow valves of the heart and is generally seen in more complex heart anatomies.

Some of these defects can be closed surgically, while others can be closed using angiographic methods.

How Is Ventricular Septal Defect (VSD) Classified According to Size?

The most important factor determining how much harm a VSD causes to a child’s body is the diameter of the hole. This diameter is evaluated by measuring how much extra blood is flowing to the lungs (Qp/Qs ratio). The size classifications of ventricular septal defects are:

• Small defects
• Moderate defects
• Large defects

In small defects, the extra blood flow to the lungs is minimal, the child remains comfortable, and usually experiences no complaints; only regular follow-up is required. In moderate-sized defects, a certain burden is placed on the lungs, medication support may occasionally be needed, and the child’s development is closely monitored to determine whether surgery will be necessary in the future. In large defects, however, the situation is completely different. The heart and lungs are under severe stress, the infant develops serious signs of heart failure, and surgical closure of the defect through opening the chest generally becomes absolutely necessary within the first months of life.

Is PDA, Known as a Persistently Open Vessel in Infants, a Hole in the Heart?

Patent Ductus Arteriosus (PDA) is not actually a hole between chambers but rather a persistent bridge between the two major arteries leaving the heart (the aorta and pulmonary artery). Since a baby in the womb does not breathe, blood does not need to go to the lungs for oxygenation. Therefore, blood bypasses the lungs through this special bridge vessel and circulates directly to the body.

When birth occurs and the baby fills the lungs with air during the first cry, the entire system changes and this bridge is no longer needed. Under normal conditions, this vessel spontaneously constricts and closes within a few days. However, if it remains open, high-pressure oxygenated blood continuously escapes into the pulmonary artery. Especially in premature babies, this structure is very fragile, so the risk of remaining open is extremely high. In premature infants, this persistently open vessel makes it difficult to separate from ventilatory support and causes severe cardiac strain.

What Are the Symptoms of a Heart Hole in Infants and Babies?

The best way to understand that a baby’s heart is making extra effort is to observe the baby’s exercise capacity. For an infant, the most strenuous exercise is breastfeeding. A baby whose heart works harder than normal quickly becomes exhausted during feeding. The main symptoms during infancy are:

• Becoming tired quickly during feeding
• Frequently interrupting feeding
• Cold sweating on the forehead and hairline
• Breathing faster and more shallowly than normal
• Retraction between the ribs during breathing
• Failure to gain weight adequately
• Growth and developmental delay compared to peers
• Sleep problems such as restless sleeping and frequent waking

When the mother begins breastfeeding, the baby may become breathless after just a few sips, tire quickly, and need to rest. Often the baby falls asleep from exhaustion before becoming fully fed. Since the heart beats much faster than it should, the baby’s energy consumption is extremely high. The small amount of calories taken in is spent on this rapid heartbeat, preventing weight gain and causing the baby to remain below normal growth curves. The cold sweat droplets on the forehead are a visible sign of how intensely the body’s sympathetic nervous system is working to support the heart.

What Are the Symptoms of a Heart Hole in Growing Children?

Children who pass infancy without severe problems and have small or moderate defects may begin to show symptoms differently as they grow and become more active. Symptoms seen in older children include:

• Becoming tired more quickly than peers during play
• Shortness of breath during physical activity
• Palpitations in the chest
• Frequent recurrent lung infections
• Prolonged and slow-resolving bronchitis attacks
• Hearing a heart murmur during medical examination

These children may not keep up with their peers while running in the park and may frequently need to sit and rest. Excessive blood circulation in the lungs makes that area more vulnerable to infections. A simple cold that a healthy child would recover from in a few days may quickly turn into a lower respiratory tract infection in these children. In many cases, however, the child has no complaints at all, and the condition is only discovered when a physician hears a “murmur” while listening to the heart during a routine school examination. A murmur is the turbulent waterfall-like sound produced when blood passes through the narrow hole.

How Is the Diagnosis of a Heart Hole in Children Confirmed?

When a heart hole is suspected in a child, the most commonly used method to establish the diagnosis and map the exact characteristics of the defect is Echocardiography, or ECHO. ECHO is a type of ultrasound procedure that evaluates the anatomy and function of the heart and is the most valuable tool in pediatric cardiology practice.

The greatest advantage of this procedure is that it is completely painless and contains no radiation whatsoever. Using warm ultrasound gel applied to the chest wall and a small probe, the inside of the heart, valve movements, the millimetric dimensions of the defect, and the size of the chambers can be observed live on the screen. Thanks to Doppler technology, the direction and speed of blood flow through the defect can be measured visually and audibly. When necessary, even the heart of a baby in the womb can be examined in detail using fetal echocardiography, allowing diagnosis months before birth.

Which Additional Tests and Methods Are Used in the Diagnosis of a Heart Hole?

Although echocardiography is often sufficient on its own, some additional tests are used to assess the overall condition of the heart and its effects on the body. Other methods supporting the diagnosis include:

• Electrocardiography
• Chest X-ray
• Pulse oximetry measurement
• Cardiac catheterization

Electrocardiography (ECG) measures the heart’s rhythm and electrical conduction using small adhesive electrodes attached to the chest. If there is enlargement or strain in the heart muscle, this will appear in the ECG tracings. A chest X-ray shows how much space the heart occupies within the chest cavity and how prominent the lung vessels are (filled with blood) in a single image. Oxygen measurement provides clues about the direction of the shunt, while cardiac catheterization (angiography) is a more advanced examination method used when highly detailed pressure measurements are needed.

Which Medications Are Used in the Treatment of a Heart Hole?

First of all, it should be known that there is no medication or syrup that can heal and close congenital heart holes like a wound. The primary purpose of medication therapy is not to eliminate the defect but to control the symptoms of heart failure caused by the defect, thereby gaining time for the child to grow and strengthen. The medication groups used to alleviate signs of heart failure include:

• Diuretics
• Vasodilators
• Heart muscle strengthening agents

Diuretics help remove excess fluid accumulating in the lungs and making breathing difficult through the kidneys. As fluid is eliminated, the lungs relax and the baby breathes more easily. Vasodilator medications reduce resistance in the systemic vessels, helping the heart pump blood to the body more comfortably, thereby indirectly reducing the amount of blood escaping through the defect into the lungs. Heart muscle strengthening agents support cardiac performance by enabling the fatigued myocardium to contract more forcefully. In addition, high-calorie nutritional supplements are used to help the baby gain weight.

A note should also be added here. Since our infants and children will be more susceptible to infections compared to their peers, it is important to ensure regular vaccinations and even administer RSV vaccination during the winter season.

How Is a Heart Hole Closed With the Non-Surgical Umbrella Method?

With advances in medical technology, many heart holes with suitable anatomical structures can now be closed without opening the chest, simply by entering through a vessel in the groin. This procedure, performed in catheterization laboratories, is popularly known as the umbrella or button method.

The procedure is generally performed under deep sedation or light general anesthesia. A very thin, flexible tube (catheter), similar to spaghetti, is advanced through the groin vein into the heart. Through this tube, a foldable closure device made of special memory wires (nitinol) is delivered. When the device reaches the location of the hole, it opens like an umbrella, attaches firmly to both sides of the defect, and completely seals the opening. After confirming with ECHO that the device is properly positioned, the catheter is withdrawn and a bandage is applied to the groin. Thanks to this method, which leaves no scar, patients are generally able to walk home the next day.

In Which Situations Is Open Heart Surgery Necessary for a Heart Hole?

No matter how comfortable groin-based intervention may be, not every patient is a suitable candidate for this procedure. Defects that are anatomically unsuitable for device closure or are too large and lack sufficient surrounding tissue for device attachment require surgical repair.

In particular, primum and some sinus venosus type ASDs, as well as large VSDs in the lower chambers of the heart that are very close to the outflow valves, are recommended for direct surgical treatment. In addition, in infants who fail to gain weight despite medical therapy and specialized formulas, are frequently hospitalized, experience worsening respiratory distress, and clearly show signs of heart muscle fatigue on ECHO follow-up, making the decision for early open-heart surgery or angiographic treatment without waiting for age or weight is life-saving.

How Does the Heart Hole Surgery Process Work?

When the decision for surgery is made, the process is meticulously planned through collaboration between pediatric cardiovascular surgeons and pediatric cardiologists. Surgery begins under general anesthesia, and the sternotomy method, in which the breastbone is divided in the middle, is generally used to access the heart. If the child’s anatomy is suitable, the heart may sometimes also be reached through smaller incisions under the arm.

To repair the hole inside the heart, the heart must be completely empty and motionless. Therefore, during the operation, the child’s circulation is connected to a heart-lung machine that temporarily takes over the functions of the heart and lungs. After the heart is stopped, the surgeon opens the area containing the defect. If the hole is very small, it may simply be closed with direct sutures. However, in larger defects, a durable patch must be sewn over the area. This patch may sometimes be a piece taken from the child’s own pericardium or specially produced synthetic tissue materials (Dacron or PTFE). After the patch is securely sewn, the heart is restarted, disconnected from the machine, and the chest is carefully closed to complete the procedure.

What Is Intensive Care and Recovery Like After Heart Hole Surgery?

When the operation in the operating room is completed, children are transferred to the Pediatric Cardiac Surgery Intensive Care Unit while still sedated. Here they spend the first days in a bed surrounded by ventilators, monitors, and thin tubes (drains) that remove excess blood from the body. Although this image may be difficult for families, it is actually the safest environment where the child is constantly monitored.

As vital signs stabilize, the child is usually separated from the ventilator within 1–2 days and begins breathing independently. Once transferred to the ward, the greatest role belongs to recovery therapy. To reopen the collapsed lung capacity, the child is encouraged to cough frequently, inflate balloons, and walk. If everything progresses well, children are generally discharged approximately one week after surgery and return home.

What Is Quality of Life Like After Heart Hole Treatment?

After successful closure of a heart hole, children generally have a very bright future ahead of them. Since the excessive workload on the heart and the excessive blood flow to the lungs are eliminated, the body begins to recover rapidly.

Weight gain in infants accelerates and they catch up with their peers; in older children, exercise capacity visibly increases and the problem of frequent infections generally comes to an end. They can have a normal lifespan and quality of life no different from healthy individuals. However, the most critical point here is that recovery does not mean discontinuation of medical follow-up. From childhood into adulthood, lifelong monitoring of the heart’s structural condition and any patches at intervals determined by the physician is a standard procedure.

What Should Be Done to Protect Against Heart Inflammation (Endocarditis)?

Children with a history of congenital heart disease or implanted materials such as patches or umbrella devices in the heart must pay attention to a special condition: infective endocarditis. Bacteria entering the circulation during any bleeding procedure may settle in these sensitive areas of the heart and cause very serious infections. Procedures carrying the risk of bacterial entry include:

• Tooth extraction
• Root canal treatment
• Bleeding gum procedures
• Tonsil surgeries
• Adenoid surgeries
• Some bleeding abdominal surgical procedures

Before undergoing such procedures, preventive measures must absolutely be taken to prevent bacteria from entering the bloodstream and reaching the heart. Administering an appropriate weight-based dose of antibiotics to the child exactly one hour before sitting in the dentist’s chair ensures that these bacteria are destroyed in the bloodstream before reaching the heart. Children with heart patches or persistent mild leakage should continue paying attention to this simple yet highly effective preventive measure throughout their lives.

Can Children Treated for a Heart Hole Participate in Sports?

The primary purpose of these procedures and surgeries is not to make children live inside a glass bubble, but to fully integrate them into life. Children who undergo surgery are advised to avoid severe traumatic movements during the first few months to allow the breastbone to heal.

However, once this recovery period has passed and the cardiologist confirms through ultrasound evaluation that everything is perfect, there is no obstacle preventing these children from participating in sports. They can ride bicycles, swim, run, join school sports teams, and enjoy a completely normal and active life.