Functional Closure of Atrial Septal Defects | Spontaneous Remission Database

Abstract

Four infants with spontaneous closure of a hemodynamically significant ventricular septal defect are presented. Repeat catheterizations showed completely normal oxygen saturations in the right side of the heart in 2 patients and only a small left-to-right shunt in the other 2. Previously elevated pressures in the right ventricle and pulmonary artery were found to be normal. These cases are presented as a contribution to the natural history of ventricular septal defect and as an argument in favor of a more cautious approach to the surgical indications to operative closure of these lesions.

Case Details

Personal Characteristics

This girl was admitted for cardiac studies at age 9 months. A murmur was noted at birth. Birth weight was 4.1 kilograms. At age 9 months weight was only 7.3 kilograms (tenth percentile), and the baby was not sitting or crawling.

Clinical Characteristics

There were no specific cardiac symptoms. The cardiac impulse suggested right ventricular enlargement. The second heart sound was widely split and the split did not vary with respiration. There was a systolic ejection click and a grade 3/6 systolic murmur at the second left intercostal space. The electrocardiogram showed an rsr in lead v3 with the r wave measuring 23 millimeters. Chest roentgenogram showed a cardiothoracic ratio of 8/14 with some accentuation of lung markings.

Remission Characteristics

At age 6 she was readmitted for further studies. At this time the second heart sound was normally split, the roentgenogram showed a normal heart size with normal lung vascularity, and the murmur was reduced to a soft grade 2/6 short systolic ejection murmur at the pulmonary area. The electrocardiogram still showed an incomplete right bundle branch block with an r wave of 8 millimeters. Repeat catheterization studies showed normal hemodynamics. No shunt was demonstrated by oxygen saturations, indicator curves, or angiographic studies.

Treatment & Mechanisms

Proposed Remission Mechanisms

Not discussed

Clinical Treatment

Heart catheterization studies confirmed the clinical diagnosis of atrial septal defect with a large left to right shunt at the atrial level. Right ventricular pressure was elevated to 46 mmhg. The catheter easily entered the left atrium, and the mean pressure differential between left and right atria was only 1 mmhg.

Additional Notes

The patient remained asymptomatic, and eventually reached normal levels in her development. The catheter, introduced from a saphenous vein, could not be inserted through a patent foramen ovale.