Ann Thorac Surg 2002;74:1694-1695
© 2002 The Society of Thoracic Surgeons
Case report
Atrial septal defect and myocardial infarct
Nicholas C. Cavarocchi, MDa*
a Section of Cardiothoracic Surgery, Mercy Hospital Wilkes-Barre, Wilkes-Barre, Pennsylvania, USA
Accepted for publication June 20, 2002.
* Address reprint requests to Dr Cavarocchi, Department of Cardiothoracic Surgery, Mercy Hospital Wilkes-Barre, 166 Hanover St, Suite 303, Wilkes-Barre, PA 18702-3545, USA
e-mail: ncc717{at}aol.com
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Abstract
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The etiology for an acute myocardial infarction with normal coronary arteriography should rule in and rule out the presence of an atrial septal defect. Acute increases in left to right shunting with an atrial septal defect may lead to episodes of myocardial necrosis and right ventricular dysfunction. This case report describes such a scenario.
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Introduction
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Myocardial infarction with normal coronary arteriography remains a dilemma for clinicians [1]. Elevated cardiac enzymes without electrocardiogram or echocardiogram abnormalities necessitates the search for other causes. Recently, a case report of heavy resistant, exercise-induced cardiac enzyme elevation in a patient with atrial septal defect (ASD) was reported by Auer and colleagues [2].
A 47-year-old Caucasian woman was admitted to a community hospital with a history of atypical chest pain and new onset of congestive heart failure. Vital signs were stable. A significant clinical finding was that the second heart sound was widely split without widening during inspiration; a pulmonary systolic ejection murmur was present. Electrocardiogram showed no acute process. Echocardiogram showed dilatation of the right atrium and right ventricle, dilated pulmonary artery, and the presence of an ostium secundum defect.
Symptoms improved rapidly after initiation of oxygen and diuretics. Past medical history was significant for hypertension, moderate obesity, history of ASD, and positive family history of coronary artery disease. Laboratory examination revealed elevated serum concentration of cardiac troponin I (7.9 ng/ml; normal less than 1.6 ng/ml). Repeat troponins on day 2 was 3.5 ng/ml. Coronary angiography revealed normal epicardial coronary vessels; ciniangiocardiography revealed no wall motion abnormalities. Right heart catheterization demonstrated elevated right atrial (16), right ventricle (62/16), and pulmonary artery (62/26) pressures; shunt fraction was 2.6 to 1.
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Comment
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Other causes of elevated concentrations of cardiac troponins have been reported in patients with primary and secondary cardiomyopathies, acute right ventricular dysfunction, and pulmonary embolus [3, 4]. It is doubtful that coronary disease caused the elevated cardiac enzymes in this case, in light of the normal coronary angiography and lack of any wall motion abnormalities on echocardiogram. In theory, increases in left to right shunting may cause subacute onset of right ventricular dysfunction with myocardial necrosis. This etiology explains the elevated troponins in this case.
Clinical trials have demonstrated conflicting data on the management of ASD in older patients [5]. If the present theory persists, subacute myocardial necrosis can occur secondarily on multiple occasions leading to right ventricular dysfunction in patients with an ASD. This suggests another strong indication for ASD repair. The ASD was repaired during the hospital admission and the patient recovered uneventfully.
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References
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- Michaelson S.P., Karsh D.L., Wolfson S., et al. Recurrent myocardial infarction with normal coronary arteriography. N Engl J Med 1977;297:916-917.[Medline]
- Auer J., Punzengruber C., Berent R., et al. Elevated cardiac troponin I following heavy-resistance exercise in ostium secundum type-atrial septal defect. Chest 2001;120:1752-1753.[Free Full Text]
- Sato Y., Yamada T., Taniguchi R., et al. Serum concentration of cardiac troponin T in patients with cardiomyopathy: a possible mechanism of acute heart failure. Heart 1998;80:209-210.[Free Full Text]
- Mayer T., Binder L., Hruska N., et al. Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction. J Am Coll Cardiol 2000;36:1632-1101636.[Abstract/Free Full Text]
- Shah D., Azhar M., Oakley C.M., et al. Natural history of secundum atrial septal defect in adults after medical or surgical treatment: a historical prospective study. Br Heart J 1994;71:224-227.[Abstract/Free Full Text]
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Abstract
Introduction
