An overlooked ostium secundum atrial septal defect in a patient presenting with atrial fibrillation and heart failure

    Authors

    Keywords

    atrial septal defect, transthoracic echocardiography, atrial fibrillation, heart failure

    DOI

    https://doi.org/10.15836/ccar2024.451

    Full Text

    **Introduction**: Atrial septal defects (ASDs) represent the most common congenital heart defect diagnosed in adulthood. There are several types of ASD and the most common one is ostium secundum defect type (80%). The heterogeneity in anatomy and the progression of complications over time, including arrhythmias, thromboembolism, right heart failure, and pulmonary arterial hypertension, pose significant challenges to finding optimal diagnostic and treatment solutions. (1) **Case report**: 70-year-old woman was hospitalized due to acute heart failure presumably precipitated with new-onset atrial fibrillation (AF). Transthoracic echocardiography found right ventricular volume overload (right ventricular dilatation resulting in tricuspid annular dilatation and moderate tricuspid regurgitation) with also dilatated both atrium (more right than left) and abnormal motion of the interventricular septum (towards the left atrium). There was also a high probability of pulmonary hypertension. All of these features initially raised suspicion of pulmonary embolism, later ruled out by CT angiography. Afterwards, transesophageal echocardiography (TEE) was performed to exclude left atrium thrombus. In the end, a successful cardioversion was performed and she was then discharged home with a prescription for optimal medical therapy. On hospital readmission in three months, control TTE was made, but now we detected an ASD (16-20mm) with L-D shunt (Qp/Qs 2,5:1) later confirmed with TEE. She was then scheduled to undergo coronarography and right heart catheterization. **Conclusion**: This case illustrates the importance of a systematic protocol for transthoracic and transesophageal echocardiography rather than a targeted approach. Another important message is not to jump to conclusion that heart failure is caused by an obvious pathology (in this case atrial fibrillation), but to think about congenital heart defect, even in older patients.

    Literature

    1. Brida M, Chessa M, Celermajer D, Li W, Geva T, Khairy P, et al. Atrial septal defect in adulthood: a new paradigm for congenital heart disease. Eur Heart J. 2022 July 21;43(28):2660–71. https://doi.org/10.1093/eurheartj/ehab646
    Cardiologia Croatica
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    An overlooked ostium secundum atrial septal defect in a patient presenting with atrial fibrillation and heart failure

    Extended Abstract
    Issue11-12
    Published
    Pages451
    PDF via DOIhttps://doi.org/10.15836/ccar2024.451
    atrial septal defect
    transthoracic echocardiography
    atrial fibrillation
    heart failure

    Authors

    Iva Zec*ORCIDZabok General Hospital and Croatian Veterans Hospital, Zabok, Croatia
    Tereza KnaflecORCIDZabok General Hospital and Croatian Veterans Hospital, Zabok, Croatia
    Nikolina Mijač MikačićORCIDZabok General Hospital and Croatian Veterans Hospital, Zabok, Croatia
    Martina RoginićORCIDZabok General Hospital and Croatian Veterans Hospital, Zabok, Croatia
    Siniša RoginićORCIDZabok General Hospital and Croatian Veterans Hospital, Zabok, Croatia

    *Correspondence email: ivatokic2612@gmail.com

    Full Text

    Introduction: Atrial septal defects (ASDs) represent the most common congenital heart defect diagnosed in adulthood. There are several types of ASD and the most common one is ostium secundum defect type (80%). The heterogeneity in anatomy and the progression of complications over time, including arrhythmias, thromboembolism, right heart failure, and pulmonary arterial hypertension, pose significant challenges to finding optimal diagnostic and treatment solutions. (1)

    Case report: 70-year-old woman was hospitalized due to acute heart failure presumably precipitated with new-onset atrial fibrillation (AF). Transthoracic echocardiography found right ventricular volume overload (right ventricular dilatation resulting in tricuspid annular dilatation and moderate tricuspid regurgitation) with also dilatated both atrium (more right than left) and abnormal motion of the interventricular septum (towards the left atrium). There was also a high probability of pulmonary hypertension. All of these features initially raised suspicion of pulmonary embolism, later ruled out by CT angiography. Afterwards, transesophageal echocardiography (TEE) was performed to exclude left atrium thrombus. In the end, a successful cardioversion was performed and she was then discharged home with a prescription for optimal medical therapy. On hospital readmission in three months, control TTE was made, but now we detected an ASD (16-20mm) with L-D shunt (Qp/Qs 2,5:1) later confirmed with TEE. She was then scheduled to undergo coronarography and right heart catheterization.

    Conclusion: This case illustrates the importance of a systematic protocol for transthoracic and transesophageal echocardiography rather than a targeted approach. Another important message is not to jump to conclusion that heart failure is caused by an obvious pathology (in this case atrial fibrillation), but to think about congenital heart defect, even in older patients.

    Literature

    1. 1.
      Brida M, Chessa M, Celermajer D, Li W, Geva T, Khairy P, et al. Atrial septal defect in adulthood: a new paradigm for congenital heart disease. Eur Heart J. 2022 July 21;43(28):2660–71.DOI