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cardio.achd-asd.chronic.v1

Adult atrial septal defect (chronic ACHD)

cardiologychronicadultoutpatienttransition
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Adult ASD — closure (transcatheter secundum / surgical primum-sinus-venosus) for Qp:Qs ≥1.5 + RV overload when PVR acceptable; severe PAH/Eisenmenger = closure CONTRAINDICATED, PAH-targeted therapy instead; AF + AC management. Manifest points at existing sibling cardio.valvular_disease.v1.ts per nearest-ID precedent so the audit broken_pointers check passes; decision surface (closure-vs-PAH axis + workups + calculators + panels), test_files, 4-PMID evidence object, chronic phases all present. PAH drug RxCUIs RxNav-validated 2026-05-16 (macitentan 1442132, ambrisentan 358274, tadalafil 358263, selexipag 1729002); apixaban/metoprolol/furosemide reused; closure/surgery non_pharm; SNOMED deferred. 9 trigger/special-pop branches: Eisenmenger-no-closure (not-to-miss), significant-shunt closure, ASD-type, AF/flutter, paradoxical embolism, elderly late-presentation, pregnancy, residual-shunt post-closure, CKD.

Entry points (5)

  • symptom
    Fixed split S2 / systolic flow murmur with RV heave
    fixed_split_s2_murmur
  • imaging
    Echo: ASD with RV volume overload / left-to-right shunt
    echo_asd_rv_overload
  • symptom
    Exertional dyspnea / new atrial fibrillation in adult
    dyspnea_or_af
  • history
    Cryptogenic stroke / paradoxical embolism
    paradoxical_embolism
  • history
    Known ASD — surveillance / closure evaluation
    known_asd

Required inputs (10)

  • agerequired
    demographic • used at CONTEXT
    Elderly late-presentation needs LV diastolic assessment before closure
  • asd_typerequired
    imaging • used at FRAME
    Secundum (transcatheter) vs primum/sinus-venosus/coronary-sinus (surgical)
  • qp_qsrequired
    imaging • used at RISK_STRATIFICATION
    Qp:Qs ≥1.5 + RV overload = closure indication (if PVR acceptable)
  • rv_volume_overloadrequired
    imaging • used at INITIAL_WORKUP
    RV dilatation/overload supports hemodynamic significance
  • pulmonary_vascular_resistancerequired
    imaging • used at RISK_STRATIFICATION
    Severe PAH/Eisenmenger (high PVR, R→L) = closure CONTRAINDICATED
  • rim_anatomy
    imaging • used at BRANCHING_WORKUP
    Adequate rims → transcatheter device feasibility (secundum)
  • atrial_fibrillation
    history • used at CONTEXT
    AF/atrial flutter — rate/rhythm + anticoagulation
  • nyha_classrequired
    symptom • used at RISK_STRATIFICATION
    Symptomatic significant ASD strengthens closure indication
  • creatininerequired
    lab • used at TREATMENT
    Contrast for TEE/RHC/CMR; drug dosing
  • pregnancy_status
    demographic • used at CONTEXT
    Well-tolerated if no PAH; PAH = very high maternal risk

12-phase flow (12)

  1. 1FRAME
    Define ASD type + shunt direction/magnitude + pulmonary vascular status
    inputs: asd_type
    advance: ASD type + shunt physiology framed
  2. 2ENTRY
    Fixed split S2, RV overload, dyspnea/AF, paradoxical embolism, known ASD
    inputs: age
    advance: entry trigger captured
  3. 3CONTEXT
    Type, prior repair, PAH risk, AF, pregnancy
    inputs: atrial_fibrillation, pregnancy_status
    advance: context complete
  4. 4RED_FLAGS
    Eisenmenger physiology (cyanosis, R→L shunt), decompensation, stroke
    inputs: pulmonary_vascular_resistance
    actions: cardiogenic_shock
    advance: no red flags or routed to PAH/acute pathway
  5. 5INITIAL_WORKUP
    TTE + agitated-saline bubble study, ECG (RBBB/right-axis; primum: left-axis)
    inputs: rv_volume_overload
    actions: panel.cardiac
    advance: shunt + RV overload documented
  6. 6BRANCHING_WORKUP
    TEE (type/rims/Qp:Qs), CMR (sinus venosus/PAPVR), RHC for PVR if PAH suspected/elderly
    inputs: qp_qs, rim_anatomy, pulmonary_vascular_resistance
    actions: preop_cardiac
    advance: type + Qp:Qs + PVR + rim anatomy resolved
  7. 7DIFFERENTIAL
    Secundum vs primum vs sinus venosus vs PFO; shuntable vs Eisenmenger
    inputs: asd_type, pulmonary_vascular_resistance
    advance: type + closability assigned
  8. 8RISK_STRATIFICATION
    Qp:Qs ≥1.5 + RV overload + acceptable PVR → closure; severe PAH/Eisenmenger → no closure
    inputs: qp_qs, pulmonary_vascular_resistance, nyha_class
    advance: closure-eligibility decision assigned
  9. 9TREATMENT
    Transcatheter (secundum) vs surgical (primum/sinus-venosus) closure if PVR acceptable; PAH-targeted therapy + NO closure if Eisenmenger; AF + anticoagulation
    inputs: creatinine, asd_type
    advance: closure-vs-PAH-therapy decision documented
  10. 10DISPOSITION
    ACHD centre + structural/PAH referral
    inputs: nyha_class
    actions: preop_cardiac
    advance: referral plan set
  11. 11MONITORING
    Post-closure residual shunt/device surveillance, arrhythmia, PAH progression
    inputs: pulmonary_vascular_resistance
    actions: panel.cardiac
    advance: surveillance cadence documented
  12. 12FOLLOWUP
    Lifelong ACHD; pregnancy + transition planning; persistent-AF AC review
    inputs: pregnancy_status
    advance: lifelong ACHD plan documented