Presentation of atrial septal defect in the pediatric population

Our recent experience indicates that patients with a hemodynamically significant atrial septal defect secundum (ASD2) do not necessarily present with classic physical and electrocardiographic (ECG) findings. The purpose of the study was to review the records of patients either receiving a catheter device or undergoing surgical repair for the closure of ASD2 to determine their initial physical and ECG findings. Therefore, we did a retrospective review of 47 consecutive patients who had echocardiographic evidence of a hemodynamically significant isolated ASD2 and who underwent ASD2 closure. Of these 47 patients, the presenting complaints were murmur (n = 36), chest pain (n = 6), seizure (n = 1), stroke (n = 1), syncope (n = 1), Kawasaki's disease (n = 1), and cardiomegaly (n = 1). Charts were reviewed for the evaluation of four abnormal physical findings: hyperactive right ventricular impulse, split fixed second heart sound, systolic and diastolic flow murmurs; and three ECG abnormalities: right axis deviation, right atrial enlargement, and evidence of right ventricular hypertrophy. In all, 30% of patients had either one or no typical physical findings, 18% had normal ECG findings, and 7% had no physical or ECG findings. On physical examination and ECG, the abnormalities due to ASD2 may be too subtle to detect. Although it is well known that variations can occur in the clinical signs and symptoms typical of ASD2, dependence on classical physical and or ECG findings may result in the underdiagnosis of a significant number of patients.