1. Benazir Bhutto Hospital

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

3. Case History PERSONAL PROFILE: PRESENTING COMPLAINTS: Mr. NS
60 years male
Resident of Rawalpindi.
DOA:
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

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

5. 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.

6. 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

7. 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

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

9. Socioeconomic History
Belongs to lower middle class

10. Clinical Examination

11. 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 /80mm Hg in both arms
No postural drop
Temp 98.4 °F
O2 SATURATION ROOM AIR 98%

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

13. 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

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

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

16. 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 /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
Coagulation Profile
PT sec APTT sec
INR

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

25. 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

26. Imaging Studies

27. X-Ray Images

30. Echocardiography TTE TEE

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

32. 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

33. 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

34. CATH DATA

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

36. Angiography

38. Preliminary Diagnosis
LVF
ACS ,NSTEMI

39. Final DIAGNOSIS
ASD Ostium Secundum

40. Management

41. 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.

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

43. Thank You!

44. Discussion