ATRIAL SEPTAL DEFECT WITH UNUSUAL

CLINICAL PRESENTATION: MASSIVE

PLEURAL EFFUSION AND ASCITES
Anindita Setyoningrum , Anggoro Budi Hartopo , Vita Yanti Anggraeni ,
1 1,2 1,2

Dyah Wulan Anggrahini2, Lucia Kris Dinarti 1,2

1Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada
– Dr. Sardjito Hospital, Yogyakarta, Indonesia
2Department of Cardiology and Vascular Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada
– Dr. Sardjito Hospital, Yogyakarta, Indonesia

Background
Atrial septal defect (ASD) is congenital heart disease which mostly found in adult patients with 10% incidence. ASD
causes left-to-right intracardiac shortcuts with right ventricular (RV) volume overload, increased pulmonary blood flow,
pulmonary artery hypertension (PAH), RV hypertrophy and right heart failure (RHF). We here report a case of ASD with
massive pleural effusion and ascites which were unusual clinical presentation.

Case Presentation
A 32 years old female presented to the emergency room with exertional dyspnea, ortopnea, paroxysmal
nocturnal dyspnea, abdominal distension and swollen legs. On physical examination, we found elevated
jugular venous pressure, cardiomegaly, pleural effusion, ascites and splenomegaly. Chest X-ray revealed
cardiomegaly and bilateral pleural effusion. The electrocardiogram showed right axis deviation and right
ventricle hypertrophy. No specific findings were found in investigations to unravel the cause of massive
pleural effusion and ascites. Transthoracic echocardiogram showed normal left ventricular function with
a left-to-right shunt secundum ASD and high probability pulmonary hypertension (PH). The right atrium
and ventricle were dilated with severe tricuspid regurgitation. The RV systolic pressure was 50.65
mmHg. The RV function was reduced (TAPSE was 11 mm). NTproBNP level was elevated, i.e. 19033.0
pg/mL. Intravenous diuretics and sildenafil were administered and resulted in gradual clinical Figure. Chest Radiographing Imaging of the
improvement. patient showing bilateral pleural effusion with
pneumonia

Discussion
Pleural effusion and ascites is an unusual presentation of ASD. Previous report showed ASD patient with pleural effusion and ascites
related to constrictive pericarditis. Right sided heart chamber overload and pulmonary over circulation can lead to sign and symptoms
of heart failure. Ultimately, ASD patients will suffer from RHF, with manifestation of ascites, pleural effusion and peripheral edema. The
PAH appears to be an aggravating factor. Treatment with diuretics and PAH-targeted therapy subsided pleural effusion and ascites,
supporting the underlying cause of PAH and RHF.

Conclusion
ASD with massive pleural effusion and ascites is rarely found. ASD contribute to development
of PAH and RHF, resulted in this unusual clinical presentation.
Keywords: ASD, ascites, massive pleural effusion, right ventricle dysfunction, right heart failure