Caso 5/2007: criança de cinco anos com comunicação interatrial

Abstract

A five-year-old white female child had been diagnosed with a heart murmur in a routine examination when she was 18 months old, remaining asymptomatic and quite active. However, since birth she had shown difficulty in gaining weight. On physical examination she was eupneic, with normal pulses and a good skin color. She weighed 14.2 kg and was 110 cm tall. Her blood pressure was 90/60 mm Hg and her heart rate, 96 bpm. The aorta was not palpable in the suprasternal notch. Chest examination showed mild systolic impulses along the left sternal border and a valve and muscular apical impulse located at the 4 th left intercostal space limited by one finger breadth. Heart sounds were very loud, and the second sound was split, with both components of equal intensity. There was an early systolic click ++ at the left sternal border. A harsh, early, systolic murmur + was heard at the 2 nd and 1 st left intercostal spaces. The liver was not palpable.The ECG showed sinus rhythm and signs of right ventricular overload with polyphasic QRS complexes in V1 and V2 and wide S waves from V4 to V6. QRS duration was 0.08 seconds. Radiographic examinationRadiographic findings included an enlarged cardiac silhouette secondary to right atrial and right ventricular dilation, a bulged mid-arch, and increased pulmonary vascularity (Figure 1). Diagnostic impressionThis image suggests the diagnosis of atrial septal defect. Differential diagnosisOther abnormalities may share similar features, such as partial atrioventricular septal defect with ostium primum ASD, associated with a cleft in the mitral valve causing mild mitral regurgitation; partial anomalous pulmonary venous drainage into the right atrium; and coronary artery-to-cardiac chamber arteriovenous fistulas, also into the right atrium. Diagnostic confirmationClinical findings are consistent with the diagnosis of atrial septal defect, considering the split second heart sound, the soft murmur in the pulmonary area, the right ventricular systolic ManagementThe 30-mm interatrial communication was closed via a trans-sternal minithoracotomy using a pericardial patch, and the patient evolved satisfactorily.