Occult Atrial Septal Defect in Adults* U. R. Shettigar, M.B., B.S.; Herbert N. Hultgren, M.D. ; Theodore Berndt, M.D .; and Richard D . Wasnich, M.D .
Two patients are described who presented with congestive heart failure and were found to have an atrial septal defect with a pulmonary blood flow approximately twice the systemic blood flow. Most of the usual clinical signs of atrial septal defect were absent, and the diagnosis was established by right heart catheterization and radioisotopic angiography. Both patients had hypertension and coronary artery disease. Atrial septal defect in the aduH
Q f the various congenital cardiac lesions produc-
ing symptoms in the adult, atrial septal defect is the most common. 1-4 This is largely due to the fact that signs and symptoms of atrial septal defect are usually not prominent until the adult years. The lesion may be a cause of cardiac symptoms even in very elderly patients.'•-• The diagnosis of atrial septal defect in the older adult may be difficult when associated cardiac or pulmonary disease is present. Even in such patients, correct diagnosis is important for proper management. \Vhile surgical closure of atrial septal defect may be associated with symptomatic improvement and prevention of late complications in some selected elderly patients, 8 - 10 it may be associated with higher operative mortality and a lesser degree of symptomatic relief in others.4. 11 . 12 It is the purpose of this paper to present the findings in two patients in whom the clinical diagnosis of atrial septal defect was obscured by the presence of associated hypertension, coronary artery disease, and left ventricular dysfunction. The diagnostic value of radionuclidic angiography and right heart catheterization in the patients is documented. CASE REPORTS CAsE 1
A 57 -year-old white man entered the Palo Alto Veterans Administration Hospital in May 1973 for evaluation of congestive heart failure. He had noted exertional chest pain for 20 years and had experienced a myocardial infarction four °From the Veteran.~ Administration Hospital, Palo Alto, Calif., and the Deparbnent of Radiology, Division of Nuclear Medicine, Stanford University School of Medicine, Stanford, Calif. Manuscript received December 23; revision accepted February 4. Reprint requests: Dr. Shettigar, VA Hospital, Palo Alto, California 94304
CHEST, 68: 3, SEPTEMBER, 1975
patient may not be recognized because of associated cardiac disease, including coronary artery disease and hypertension, or pulmonary disease which may obscure the usual clinical signs of a septal defect. Radioisotopic angiography and right heart catheterization should be considered in any patient with heart disease or congestive failure of obscure cause even if the usual diagnostic signs of atrial septal defect are absent.
months prior to admission. A heart munnur had been present for seven years. Mild hypertension was noted three years prior to admission. The blood pressure was 150/100 mm Hg. The heart rate was 72 beats per minute with an irregular rhythm. Mild hypertensive changes were present in the fundi. The jugular veins were distended. The anteroposterior chest diameter was increased, and bilateral basilar rales were audible. A diffuse left ventricular apical heave was present, and a grade 3/6 systolic ejection munnur was heard at the upper left sternal border and the apex. The first and second heart sounds were nonnal. Atrial fibrillation, old anteroseptal myocardial infarction, left axis deviation, and incomplete right bundle-branch block were noted on the electrocardiogram (Fig 1 ) . Biventricular enlargement, a prominent ascending aorta, and a moderately enlarged pulmonary artery were. present on the chest roentgenograms (Fig 2). Paradoxic septal motion, and biventricular and left atrial enlargement were noted on the echocardiogram. A closely split second sound with nonnal order of valve closure was noted on phonocardiogram. Mild elevation of pulmonary artery pressure at rest, an abnonnal increase of venous oxygen saturation low in the right atrium, and a pulmonary-to-systemic flow ratio of 2.1/1.0 were demonstrated by right heart catheterization studies (Table 1) . Three-vessel disease with a total occlusion of the left anterior descending coronary artery was noted on coronary arteriogram. Surgery was perfonned on July 17, 1973. During the operation, a typical ostium secundum atrial septal defect measuring 2 em in dian1eter was found. No aberrant pulmonary veins were noted. An old healed anterior myocardial infarction was present. The septal defect was closed, and aortocoronary saphenous-vein bypass grafts were placed to the right main coronary and the circumflex coronary arteries. One week postoperatively, right heart catheterization was perfonned, which revealed no residual left-toright shunt (Table 1). Left ventricle function was abnormal, as evidenced by a mean left ventricular diastolic pressure of 10 mm Hg and a left ventricular stroke work index of 27 units. Prior to surgery the mean left ventricular diastolic pressure was 8 mm Hg, and the left ventricular stroke work index was 78 units. On August 3, 1973, an acute anterior myocardial infarction occurred, complicated by pulmonary edema and ventricular arrhythmias. The patient was hospital-
OCCULT ATRIAL SEPTAL DEFECT IN ADULTS 307
FrGURE 1. Electrocardiogram reveals atrial fibrillation, incomplete right bundle-branch block, left axis deviation, and old anteroseptal myocardial infarction (case 1) .
ized for three weeks. On January hospitalized with congt>stive heart January 30, 1974. Autopsy study papillary musde infarction. Both grafts were patent, and the surgical defect was intact. CAsE
25, 1974, he was again failure and expired on revealed acute anterior saphenous-vein bypass repair of the atrial septal
2
A '5H-year-old . white man entered the Palo Alto (Calif) VA Hospital in April W73 for evaluation of congestive heart failure and hypertension. A heart munnur had nevt>r been noted in the pars. Ont> year prior to admission, he sustained a myocardial infarction, at which time hypertension was noted. The blood pressure was 180/120 mm Hg, the heart rate was HO heats per minute, and the cardiac rhythm was regular. The patient had prominent jugular venous distension and an incred antt>roposterior chest diameter. Bilateral hasilar rales were heard. There were no ahnom1al precordial impulses. The first sound was normal, and the sely split. There were no murmurs or gallop sounds ( Sa or S4 ) • The liver edge was palpated 10 em below the right costal margin. An old inferior-wall myocardial infarction was noted on elt>drocardiogram (Fig 3). Biventricular enlargement and mild pulmonary vascular congestion were noted on the chest roentgt>nognun taken at admission. Marked reduction in heart
308 SHETTIGAR ET AL
FIGURE 2. Chest x-ray film reveals generalized cardiomegaly. Prominent pulmonary artery and as~ending aorta are also evident ( case I ) .
CHEST, 68: 3, SEPTEMBER, 1975
Table 1-Right Heart Catheteri:zation Data Prl'opt'rativt'
Pressure* Right atrium Right ventricle Pulmonar~· artery Pulmonar~· artry \\"
Two patients are described who presented with congestive heart failure and were found to have an atrial septal defect with a pulmonary blood flow approximately twice the systemic blood flow. Most of the usual clinical signs of atrial septal defect were absent, and the diagnosis was established by right heart catheterization and radioisotopic angiography. Both patients had hypertension and coronary artery disease. Atrial septal defect in the aduH
Q f the various congenital cardiac lesions produc-
ing symptoms in the adult, atrial septal defect is the most common. 1-4 This is largely due to the fact that signs and symptoms of atrial septal defect are usually not prominent until the adult years. The lesion may be a cause of cardiac symptoms even in very elderly patients.'•-• The diagnosis of atrial septal defect in the older adult may be difficult when associated cardiac or pulmonary disease is present. Even in such patients, correct diagnosis is important for proper management. \Vhile surgical closure of atrial septal defect may be associated with symptomatic improvement and prevention of late complications in some selected elderly patients, 8 - 10 it may be associated with higher operative mortality and a lesser degree of symptomatic relief in others.4. 11 . 12 It is the purpose of this paper to present the findings in two patients in whom the clinical diagnosis of atrial septal defect was obscured by the presence of associated hypertension, coronary artery disease, and left ventricular dysfunction. The diagnostic value of radionuclidic angiography and right heart catheterization in the patients is documented. CASE REPORTS CAsE 1
A 57 -year-old white man entered the Palo Alto Veterans Administration Hospital in May 1973 for evaluation of congestive heart failure. He had noted exertional chest pain for 20 years and had experienced a myocardial infarction four °From the Veteran.~ Administration Hospital, Palo Alto, Calif., and the Deparbnent of Radiology, Division of Nuclear Medicine, Stanford University School of Medicine, Stanford, Calif. Manuscript received December 23; revision accepted February 4. Reprint requests: Dr. Shettigar, VA Hospital, Palo Alto, California 94304
CHEST, 68: 3, SEPTEMBER, 1975
patient may not be recognized because of associated cardiac disease, including coronary artery disease and hypertension, or pulmonary disease which may obscure the usual clinical signs of a septal defect. Radioisotopic angiography and right heart catheterization should be considered in any patient with heart disease or congestive failure of obscure cause even if the usual diagnostic signs of atrial septal defect are absent.
months prior to admission. A heart munnur had been present for seven years. Mild hypertension was noted three years prior to admission. The blood pressure was 150/100 mm Hg. The heart rate was 72 beats per minute with an irregular rhythm. Mild hypertensive changes were present in the fundi. The jugular veins were distended. The anteroposterior chest diameter was increased, and bilateral basilar rales were audible. A diffuse left ventricular apical heave was present, and a grade 3/6 systolic ejection munnur was heard at the upper left sternal border and the apex. The first and second heart sounds were nonnal. Atrial fibrillation, old anteroseptal myocardial infarction, left axis deviation, and incomplete right bundle-branch block were noted on the electrocardiogram (Fig 1 ) . Biventricular enlargement, a prominent ascending aorta, and a moderately enlarged pulmonary artery were. present on the chest roentgenograms (Fig 2). Paradoxic septal motion, and biventricular and left atrial enlargement were noted on the echocardiogram. A closely split second sound with nonnal order of valve closure was noted on phonocardiogram. Mild elevation of pulmonary artery pressure at rest, an abnonnal increase of venous oxygen saturation low in the right atrium, and a pulmonary-to-systemic flow ratio of 2.1/1.0 were demonstrated by right heart catheterization studies (Table 1) . Three-vessel disease with a total occlusion of the left anterior descending coronary artery was noted on coronary arteriogram. Surgery was perfonned on July 17, 1973. During the operation, a typical ostium secundum atrial septal defect measuring 2 em in dian1eter was found. No aberrant pulmonary veins were noted. An old healed anterior myocardial infarction was present. The septal defect was closed, and aortocoronary saphenous-vein bypass grafts were placed to the right main coronary and the circumflex coronary arteries. One week postoperatively, right heart catheterization was perfonned, which revealed no residual left-toright shunt (Table 1). Left ventricle function was abnormal, as evidenced by a mean left ventricular diastolic pressure of 10 mm Hg and a left ventricular stroke work index of 27 units. Prior to surgery the mean left ventricular diastolic pressure was 8 mm Hg, and the left ventricular stroke work index was 78 units. On August 3, 1973, an acute anterior myocardial infarction occurred, complicated by pulmonary edema and ventricular arrhythmias. The patient was hospital-
OCCULT ATRIAL SEPTAL DEFECT IN ADULTS 307
FrGURE 1. Electrocardiogram reveals atrial fibrillation, incomplete right bundle-branch block, left axis deviation, and old anteroseptal myocardial infarction (case 1) .
ized for three weeks. On January hospitalized with congt>stive heart January 30, 1974. Autopsy study papillary musde infarction. Both grafts were patent, and the surgical defect was intact. CAsE
25, 1974, he was again failure and expired on revealed acute anterior saphenous-vein bypass repair of the atrial septal
2
A '5H-year-old . white man entered the Palo Alto (Calif) VA Hospital in April W73 for evaluation of congestive heart failure and hypertension. A heart munnur had nevt>r been noted in the pars. Ont> year prior to admission, he sustained a myocardial infarction, at which time hypertension was noted. The blood pressure was 180/120 mm Hg, the heart rate was HO heats per minute, and the cardiac rhythm was regular. The patient had prominent jugular venous distension and an incred antt>roposterior chest diameter. Bilateral hasilar rales were heard. There were no ahnom1al precordial impulses. The first sound was normal, and the sely split. There were no murmurs or gallop sounds ( Sa or S4 ) • The liver edge was palpated 10 em below the right costal margin. An old inferior-wall myocardial infarction was noted on elt>drocardiogram (Fig 3). Biventricular enlargement and mild pulmonary vascular congestion were noted on the chest roentgt>nognun taken at admission. Marked reduction in heart
308 SHETTIGAR ET AL
FIGURE 2. Chest x-ray film reveals generalized cardiomegaly. Prominent pulmonary artery and as~ending aorta are also evident ( case I ) .
CHEST, 68: 3, SEPTEMBER, 1975
Table 1-Right Heart Catheteri:zation Data Prl'opt'rativt'
Pressure* Right atrium Right ventricle Pulmonar~· artery Pulmonar~· artry \\"
