Medical Mystery of the Week

While participating in a teleconference you are asked to make a diagnosis in a 38-year-old man who is complaining of recent onset exertional dyspnea by listening to a recording of his heart taken over the pulmonic area and by reviewing his chest x-ray.

chest film  echo echocardiogram

 Click here to listen to the heart over the pulmonic area..

DIAGNOSIS: Atrial Septal Defect (ASD). The clue to the diagnosis in this patient is the fixed split of the second heart sound (S2) heard best over the pulmonic area. The patient has developed pulmonary hypertension (note prominent pulmonary artery segment) and is starting to reverse the shunt.The diagnosis was confirmed by a bubble echocardiogram (see above), which shows flow of the bubbles through the defect during both systole and diastole, confirming shunt reversal.

Patients with ASD often become symptomatic in their third or forth decade of life, the diagnosis having been missed in childhood and adolescence. An initial diagnosis of ASD or patent ductus arteriosus (PDA) has even been made as late as the eighth and ninth decade of life.

This patient underwent surgical repair of his ASD with a good outcome..

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