An unusual cause of dyspnea, hypoxemia, and pedal edema in an 85-year-old woman

Atrial septal defect (ASD) is 1 of the most common causes of congenital heart disease manifested in adulthood. Among the 3 kinds of ASD, the clinical features of secundum-type ASD have been well-characterized in patients less than 40 years of age, and account for two-thirds of all such defects (sinus venosis and ostium primum are the second- and third-type defects, respectively). More than 90% of patients with a secundum ASD die before the age of 60. However, a subgroup of patients may or may not develop symptoms until late adulthood, presenting with atrial fibrillation, dyspnea and heart failure as the first manifestation of secundum ASD. In the last 30 years, 6 octogenarians presenting similarly with ASD have been described in the literature. The diagnosis requires a high index of clinical suspicion combined with careful inspection of the electrocardiogram and chest radiograph for signs of right ventricular volume overload. Transthoracic echocardiography and color Doppler interrogation of the atrial septum combined with bubble contrast should confirm the presence of secundum ASD in the majority of elderly patients presenting with this unusual clinical entity.