MKSAP Quiz: Evaluation for exertional dyspnea
A 35-year-old man is evaluated for exertional dyspnea. His history is otherwise unremarkable. Following a physical exam and other testing, what is the most appropriate management?
A 35-year-old man is evaluated for exertional dyspnea. His history is otherwise unremarkable.
On physical examination, vital signs and oxygen saturation are normal. Central venous pressure is elevated. A left parasternal impulse is present. A grade 2/6 systolic murmur is heard at the second left intercostal space, and a diastolic flow rumble is heard at the left sternal border. Fixed splitting of the S2 is present. The remainder of the physical examination is normal.
An ECG demonstrates sinus rhythm with right axis deviation and incomplete right bundle branch block. A transthoracic echocardiogram demonstrates a 1.5-cm ostium secundum atrial septal defect, with moderate right heart enlargement. Left ventricular cavity size and function are normal. The estimated right ventricular systolic pressure is 30 mm Hg.
Which of the following is the most appropriate management?
A. Atrial septal defect closure
B. Cardiopulmonary exercise testing
C. Coronary angiography
D. Echocardiographic surveillance
MKSAP Answer and Critique
The correct answer is A. Atrial septal defect closure. This content is available to MKSAP subscribers as Question 56 in the Cardiovascular Medicine section. More information about MKSAP is available online.
Atrial septal defect (ASD) closure (Option A) is indicated in this patient with a 1.5-cm ASD associated with right heart enlargement, symptoms, and no pulmonary hypertension. An ASD is a defect in the atrial septum resulting in a left-to-right shunt with eventual right-sided cardiac chamber dilatation in most patients. Ostium secundum defects, the most common type of ASD (75% of cases), are typically located in the mid portion of the atrial septum and are usually isolated anomalies. In asymptomatic patients with a small ASD and no right heart enlargement, periodic clinical monitoring and echocardiographic imaging are recommended. The main indications for ASD closure include right-sided cardiac chamber enlargement, dyspnea, or paradoxical embolization. Most patients with ostium secundum ASD are candidates for device closure of the ASD, a procedure performed in the cardiac catheterization laboratory.
Cardiopulmonary exercise testing (Option B) may be helpful in evaluating dyspnea if the initial evaluation is unrevealing, deconditioning is a possibility, or several problems may be contributing to dyspnea. This patient's dyspnea and right heart enlargement are caused by the ASD, and cardiopulmonary testing is not necessary.
Coronary angiography (Option C) is considered before cardiac surgery or intervention for noncoronary cardiac issues in patients with symptoms of angina, evidence of coronary ischemia, decreased left ventricular systolic function, a history of coronary artery disease, or risk factors for coronary artery disease. This patient's symptoms and evaluation are consistent with ASD, not cardiac ischemia, and coronary angiography is not required.
Echocardiographic surveillance (Option D) is considered for patients with an ASD if there is no associated right heart enlargement, if severe pulmonary hypertension is present, or if there are no severe comorbid conditions that may adversely affect outcome. Transesophageal echocardiography may be needed to confirm the presence of an ASD if transthoracic echocardiography is nondiagnostic or for the purposes of procedure planning. ASD closure, not serial surveillance with echocardiography, is recommended for this patient with a symptomatic ASD and right heart enlargement.
Key Points
- Atrial septal defect closure is indicated in patients with symptoms or evidence of right-sided cardiac chamber enlargement and without severe pulmonary hypertension.
- Most patients with ostium secundum atrial septal defect are candidates for device closure performed in the cardiac catheterization laboratory.