An 11 year old boy is brought to your OPD by his father at 11 o clock in the morning.
According to his dad , he is having chest pain since 8 am.
On detailed history , his father tells that he gets attacks of chest pain that last upto 15 – 30 minutes and tend to go away.
Sometimes he wakes up from sleep and grabs left side of his chest with his hand in agony.
You examine the boy and he seems to be in distress.
On examination :
He has a lean built.
Blood pressure is 100/70 mmHg
Afebrile .
Pulse : 120 beats per minute , regular.
Oxygen saturation 92 %
Chest is clear.
You decide to send him for an ECG which is given below :
1. What are the findings on ECG ?
2. What further investigations would you like to perform?
3. What is the most likely Diagnosis ?
4. What are the symptoms of this disease?
5. What will be findings on auscultation of the heart ?
6. How will you manage this patient ?
7. What are the complications of this disease if left untreated?
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1. What are the findings on ECG :
Tachycardia ( Heart rate upto 130/ bpm).
RSR Pattern in Lead V 1 and T wave inversion (Discordant changes )suggestive of Right Bundle Branch Block.
T wave inversions in leand II , II , avF ( inferior leads ) and V1 ,V2 (septal ).
2. What further investigations would you like to perform?
A . Echocardiogram
To evaluate any problems with function of the heart including ejection fraction and septal defects or valvular abnormanlities.
B .Full Blood count to evaluate Haemoglobin levels and exclude Anemia as it can cause Tachycardia and Cardiac Iscahemia as well.
3. What is the most likely Diagnosis ?
Ostium secundum Atrial Septal Defect.
An ostium secundum ASD is a hole in the center of the atrial septum. Normally, the right side of the heart pumps oxygen-poor blood to the lungs, while the left side pumps oxygen-rich blood to the body. An ASD allows blood from both sides to mix, causing the heart to work less efficiently.
Secundum ASD occurs in the middle part of the atrial septum. Primum ASD occurs in the lower part of the atrial septum close to the tricuspid and mitral valves.
An ostium secundum defect can be identified on an echocardiogram in many ways. A subcostal 4 chamber view serves as the best plane to visualize the anatomy of the ostium secundum. Can be visualized by examination of the middle of the septum in the area of the fossa ovalis where it occurs.
4. What are the symptoms of this disease?
A larger hole can eventually cause symptoms such as shortness of breath, respiratory infections, fainting, irregular heart rhythms or fatigue after mild activity. Larger ASDs can also ultimately lead to pulmonary artery hypertension, right ventricular hypertrophy (enlargement); SVT, or heart failure.
5. What will be findings on auscultation of the heart ?
A soft midsystolic murmur at the upper left sternal border with wide and fixed splitting of the 2nd heart sound (S2) is common.
6. How will you manage this patient ?
The most common type of ASD may close on its own as the child grows. Once an ASD is diagnosed, the child's cardiologist will check your child to see if the defect is closing on its own. An ASD will usually be fixed if it has not closed by the time a child starts school.
An ASD that isn't treated in childhood can lead to health problems later, including an abnormal heart rhythm (an atrial arrhythmia) and problems in how well the heart pumps blood.
When treatment of an ASD is required, it involves catheter or surgical procedures to close the hole. Doctors often decide to close an ASD in children who still have medium to large holes by the time they're 2 to 5 years old.
In the past, atrial septal defect (ASD) closure required open-heart surgery through an incision in the chest using a heart-lung bypass machine. This procedure would require three to five days in the hospital for recovery. It is now possible to close ASDs without surgery.
This is done during a heart procedure called a cardiac catheterization using a "patch" or special septal repair device that is placed permanently in the heart to cover the hole.
A septal repair device consists of two connected patches that are permanently placed in the hole to cover both the left and right atrial sides. After placement, within the first three months, the lining of the heart wall grows over the patch and seals the hole completely. There are several devices currently available for closure. The type and size of device is chosen after X-ray and echocardiogram movie pictures determine the size and location of the hole. Sometimes more than one device is needed to completely close the hole.
7. What are the complications of this disease if left untreated?
ASD Complications :
If ostium secudum defect is not repaired by age of 24 years, Mitral regurgitation and Mitral valve prolapse are common.
