Doppler Atrial Shunt Flow Patterns in Patients with Secundum Atrial Septal Defect: Determinants, Limitations, and Pitfalls

Fifteen patients with uncomplicated secundum atrial septal defect underwent studies with real-time color-coded two dimensional flow imaging, pulsed Doppler echocardiographic examination, and simultaneous pressure recordings from the left and right atrium to determine the flow-pressure dynamics of the atrial shunt flow. In all 15 patients both the color flow mapping and pulsed Doppler studies revealed that the shunt flow was mainly from left to right, occurring both during ventricular systole and diastole. It started in early systole, reached a peak in late systole to early diastole, and lasted throughout diastole with an accentuation in late diastole during atrial contraction. The amplitude of the flow velocity, the direction, and the magnitude of the shunt flow, however, changed from phase to phase during the cardiac cycle. It correlated well with the phasic variation of the interatrial pressure difference, which usually revealed a peak pressure gradient that occurred in early systole between the x descent and v wave and during the period of v wave and a wave of the left atrial pressure tracing. Right to left shunt was not detected in any of the 15 patients by color flow mapping studies. A minor reversal of the shunt flow, however, was frequently detected at the beginning of ventricular systole and sometimes also in the middle of diastole by pulsed Doppler echocardiography. The reversal of shunt flow correlated with the minor reversal of pressure gradient that occurred during the z point, x descent, and y descent of the left atrial pressure tracing. In conclusion, left to right shunt flow occurs both during ventricular systole and diastole in uncomplicated secundum atrial septal defect. The amplitude of flow velocity, the magnitude, and the direction of the shunt flow changes from phase to phase and reflects the phasic variation of the interatrial pressure difference during the cardiac cycle.