Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging

: 2022  |  Volume : 6  |  Issue : 1  |  Page : 82--83

A Humongous Atrial Septal Defect

Tarun Bansal1, Antara Banerji2, Ajay Bahadur1, Anupam Mehrotra1, Pradyot Tiwari1,  
1 Department of Cardiology, Apollomedics Super Speciality Hospitals, Lucknow, Uttar Pradesh, India
2 Department of Anesthesia, P. D. Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India

Correspondence Address:
Dr. Pradyot Tiwari
Apollomedics Hospital, Lucknow, Uttar Pradesh

How to cite this article:
Bansal T, Banerji A, Bahadur A, Mehrotra A, Tiwari P. A Humongous Atrial Septal Defect.J Indian Acad Echocardiogr Cardiovasc Imaging 2022;6:82-83

How to cite this URL:
Bansal T, Banerji A, Bahadur A, Mehrotra A, Tiwari P. A Humongous Atrial Septal Defect. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2022 [cited 2023 Oct 4 ];6:82-83
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Full Text

Our patient was a 74-year-old male who presented to the emergency department as a case of obstructed inguinal hernia and was planned for urgent surgery. He was evaluated by the department of cardiology as a part of presurgical workup.

He had a history of mild breathlessness on exertion for the last 10–15 years which he attributed to his chronic smoking status and was never worked up for this. On examination, he had a wide-fixed split-second heart sound with a loud P2 component. Electrocardiogram revealed right bundle branch block pattern with left anterior hemiblock [Figure 1]a. Chest X-ray was suggestive of cardiomegaly with pulmonary plethora and prominent proximal pulmonary arteries [Figure 1]b. Peripheral arterial saturation was 97%.{Figure 1}

Two-dimensional echocardiography demonstrated a humungous 76 mm ostium secundum atrial septal defect (ASD) [Figure 1]c, with left-to-right shunt [Figure 1]d and resultant dilatation of the right atrium and ventricle. There was a moderate-grade tricuspid regurgitation with a pulmonary artery systolic pressure of 77 mm of Hg + right atrial pressure [Figure 1]e, indicating severe pulmonary artery hypertension. There was moderate-to-severe mitral regurgitation with mitral valve prolapse [Figure 1]f. The right and left ventricular functions were normal.

This is a rare case with a triad of unusual findings. First, according to our review, this is the largest ASD ever reported. This humungous ASD is postulated to be due to concomitant stretching of the ASD margins by the enlarging atria. Atrial size is enlarged due to the combination of severe mitral regurgitation (left atrium), left-to-right shunt (right atrium), and atrial fibrillation (both atria).[1] Second, it is a large ASD presenting unusually late.[2] Third, mitral regurgitation leading to the elevation of left-sided pressures is postulated to contribute to persistent left-to-right shunt despite severe pulmonary artery hypertension.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


1Sanfilippo AJ, Abascal VM, Sheehan M, Oertel LB, Harrigan P, Hughes RA, et al. Atrial enlargement as a consequence of atrial fibrillation. A prospective echocardiographic study. Circulation 1990;82:792-7.
2Campbell M. Natural history of atrial septal defect. Br Heart J 1970;32:820-6.