Benazir Bhutto Hospital

“Late Presentation of ASD” Case Presentation “Late Presentation of ASD” By Cardiology Department, Benazir Bhutto Hospital, Rawalpindi.

Case History PERSONAL PROFILE: PRESENTING COMPLAINTS: Mr. NS 60 years male Resident of Rawalpindi. DOA: 03-02-2016 PRESENTING COMPLAINTS: Chest Pain ------------------ Last 3 Hours Shortness of Breath ----- Last 24 Hours Cough with sputum ------ Last 24 Hours Apprehension with profused sweating ----- Last 3 Hours Vertigo ----- Last 3 Hours

Premorbid history HTNo Dmo IHDo Smokero No Family history DM, HTN, IHD, Stroke

History of Present Illness Recently diagnosed DM type-II Presented with complaint of chest pain, shortness of breath, apprehension and cough with sputum. Chest pain was central, mild in intesity, diffuse, not relieved by change in posture,rest or lying down, no radiation to left arm Jaw or back, unrelated to exertion. Shortness of breath from last 24 hours of class NYHA II.

Systemic Enquiry CVS: History of Palpitation No history of PND, orthopnoea, Dizziness, Syncopal Attacks History of ankle swelling in the past GIT: No History of Diarrhea, Constipation, Hemetemsis ,Malena R. System: History of cough with sputum No History of Fever CNS: No history of numbness paresthesias No history of Transient Ischemic Attack No history of Transient Weakness of Muscles of Limbs No history of Transient Visual Loss

Systemic Enquiry UGS: No history of polyuria, dysuria, oliguria MSK System: History of generalized body aches No history of Joint Swelling No history of Rash

Past Medical History Previous History of fever with cough and sputum. Previous history of palpitation and shortness of breath off and on

Socioeconomic History Belongs to lower middle class

Clinical Examination

General Physical Examination A gentle man 60 years old, well-oriented in time, place & person. With respiratory rate of 20/min. Pulse 116/min, irregular in rhythm, normal volume, no specific character, no radio-radial or radio-femoral delay. All the peripheral pulses are bilateral symmetrically present BP --- 120/80mm Hg in both arms No postural drop Temp 98.4 °F O2 SATURATION ROOM AIR 98%

General Physical Examination Mild ankle edema JVP not raised Thyroid not palpable No Lymph nodes palpable

Systemic Examination CVS: Chest contour shows prominent left hemithorax, no visible pulsation Visible scar marks on the back. Apex beat in left 5th intercostals space in mid clavicular line. normal First & second heart sounds are audible, loud P2 with 2/6 systolic murmur on Lower left parasternal area. Fixed splitting of second heart sound,apparent when restored to sinus rhythm,initially was not detected

Systemic Examination Respiratory System: Normal vesicular breathing with no other significant findings.

Systemic Examination CNS: Higher Motor Function Intact No sensory or motor deficit Planters bilateral down going No Focal neurological deficit Fundoscopic examination normal

Investigations BLOOD CP HB 15.7 g/dl PCV 47.3/I MCV 97.8fl MCH 29.1 pg MCHC 33.41/dl TLC 7700/cmm Platelet Count 156000/cmm ESR 13 LFTs BILIRUBIN 1.2 mg/dl ALT 93u/L ALK. PHOSPHATASE 128 u/l USG Abdomen Normal RFTs Urea 38mg/dl Creatinine 1.1mg/dl Uric Acid 5 mg/dl BSF 166 mg/dl Na 140 mmol/L K 4 mmol /L Serum Cholesterol 156 Serum triglycerides175 Urine R/E Albumin – nil Sugar – + Pus cells --- 3-4 Coagulation Profile PT --- 13 sec APTT --- 32 sec INR --- 1.0

Investigaton Trop I=0.92 ng/ml (N=<0.50) BNP not raised

ECG Finding Rhythm: Irregular Heart Rate: 120/min ECG Shows : Broad QRS complexes in all leads RSR pattern in V1, V2, V3 with flutter waves

Imaging Studies

X-Ray Images

Echocardiography TTE TEE

Echocardiography Large ASD secundum with size of 3.4cm Left to right shunt No LAA clot seen Spontaneous echo contrast in RA

PRESSURE DATA RA RV PA PCW LA LV AO a=14 v=10 mean=9(2-6) 45/10 (15-30/1-7) PA 45/12 (15-30/4-12) PCW Mean 14 (4-12) LA A=16 V=12 LV 120/10 AO 120/80

Saturations Data SVC Mid RA IVC RV PA LA LV Conclusion: 78% Mid RA 95% IVC 82% RV 92% PA LA 100% LV Conclusion: Step up in Mid RA, signifying shunt from left to right at atrial level

CATH DATA

CATH DATA ASD with Lt. To Rt. Shunt Qp/Qs =1.8

Angiography

Preliminary Diagnosis LVF ACS ,NSTEMI

Final DIAGNOSIS ASD Ostium Secundum

Management

Management Plan Patient was initially managed as NSTEMI,on ACS protocol and atrial flutter. Patient was put on anticoagulants therapy.pharmacological cardioversion with amiodarone was attempted,sinus rhythm not restored During stay in CCU he was cardioverted with 50J for atrial flutter,as he devolped fast ventricular response and patient was hemodynamically compromised.

Follow up Patient has been accepted for ASD repair, still admitted in CCU of Benazir Bhutto Hospital, Rawalpindi.

Thank You!

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