Dyspnea, atrial fibrillation and ejection systolic murmur (106/1700)

A 45yo lady has 10m hx of SOB. She is found to have irregularly irregular pulse and loud P2 with
fixed splitting and ejection systolic murmur in left 2nd ICS. What is the probable dx?

a. TOF
b. ASD
c. VSD
d. PDA
e. CoA


























causes of ejection systolic murmur
aortic stenosis
ASD if there is splitting
Pulmonary stenosis if no splitting

The atrial septal defect (ASD) malformation can go undiagnosed for decades due to subtle physical examination findings and a lack of symptoms. Even isolated defects of moderate-to-large size may not cause symptoms in childhood. However, some may have symptoms of easy fatigability, recurrent respiratory infections, or exertional dyspnea. In childhood, the diagnosis is often considered after a heart murmur is detected on routine physical examination or after an abnormal finding is observed on chest radiographs or electrocardiogram (ECG).
If undetected in childhood, symptoms can develop gradually over decades and are largely the result of changing compliance with age, pulmonary arterial hypertension, atrial arrhythmias, and, sometimes, those associated with mitral valve disease in a primum ASD. Virtually all patients with ASD who survive beyond the sixth decade are symptomatic.
Clinical deterioration in older patients occurs by means of several mechanisms, such as the following:

• First, an age-related decrease in left ventricular compliance augments the left-to-right shunt.
• Second, atrial arrhythmias, especially atrial fibrillation, but also atrial flutter or paroxysmal atrial tachycardia, increase in frequency after the fourth decade and can precipitate right ventricular failure.
• Third, most symptomatic adults older than 40 years have mild-to-moderate pulmonary arterial hypertension in the presence of a persistent large left-to-right shunt; therefore, the aging right ventricle is burdened by both pressure and volume overload.
• Another mechanism for symptoms particularly associated with primum ASD is related to clinically significant mitral regurgitation. Its incidence, extent, and degree of dysfunction increases with age. Mitral valve insufficiency leads to further increase in left atrial pressure and a higher degree of left-to-right shunt.

Overall, the most common presenting symptoms include dyspnea, easy fatigability, palpitations, sustained atrial arrhythmia, syncope, stroke, and/or heart failure. In adults, one of the most common symptoms is the development of palpitations related to atrial arrhythmias.