Alteration of Pulmonary Venous Flow Doppler Post Transcatheter Closure of Atrial Septal Defect

Background: Atrial septal defect is a common congenital heart anomaly results in hemodynamically significant right ventriclular volume overload and an increase in the pulmonary venous flow. Aim: Evaluate changes of pulmonary venous flow parameters after transcatheter closure of secundum atrial septal defect. Patients and Methods: 50 patients with atrial septal defect aged from 3.5 to 31 years were included in the study. Pulmonary venous flow Doppler and right ventricular function were evaluated before and after successful transcatheter closure by transthoracic and transesophageal echocardiography. Results: The defect size ranged from 15 to 37mm with a mean (24.96 ±7.52), Normal systolic and diastolic waves of pulmonary venous flow Doppler were replaced by a continuous antegrade wave (mean 60±13.6 cm/s) in all atrial septal defect patients. Post-closure, the normal pulmonary venous flow pattern was regained, two separate waves, with a significant decrease in mean peak Systolic wave velocity (44.54±8.12 cm/sec vs 69.61±12.37, P=0.000), the mean peak Diastolic Wave velocity (55.85±9.81 cm/sec vs 72.65±10.38, P=0.000) and a significant increase in the mean peak atrial reversal wave velocity (28.75±4.63cm/sec vs 21.18±3.64, P=0.000). In multivariate regression analysis, significant predictors of haemodynamic significant ASD were ASD size,(odds ratio 1.508, P=0.007, 95% CI 1.153,2.671) and ASD/IAS ratio (odds ratio 2.313, P=0.001, 95% CI 1.064,3.104). Conclusions: Atrial septal defect patients have characteristic pulmonary venous flow pattern: continuous antegrade wave with systolic predominance and decrease in atrial reversal wave, which return to normal after closure. These changes could be helpful echocardiographic tool in prediction of successful closure of the defect.

Role of cardiac rehabilitation in patient with pulmonary hypertension on functional capacity and quality of life

Patients with pulmonary hypertension (PH) continue to develop significant exertional symptoms and reduced quality of life despite receiving pharmacological therapy. Guidelines highlighted the importance of rehabilitation as part of management in PH. However, the cardiac rehabilitation program is still underused. We present a case of functional capacity improvement in patients with surgically corrected secundum atrial septal defect (ASD) with PH who underwent cardiac rehabilitation program. A 30-year-old female with a previous history of surgically corrected ASD went to our rehabilitation program in our hospital. She had a 3-weeks program of rehabilitation, and there were improvements in symptoms, clinical parameters, and quality of life after completion of the cardiac rehabilitation program. Rehabilitation can be an adjuvant for pharmacological therapy for PH that has been proven to improve the quality of life in patients with PH.

Prevalence of Mitral Valve Regurge with or without Prolapse and Left Atrial Volume among Patients with Secundum Type Atrial Septal Defect

Background: An atrial septal defect (ASD) is a persistent interatrial communication. It is distinct from a patent foramen ovale wherein there is a flap with intermittent communication. The aim of this work was to assess prevalence of mitral valve regurge or prolapse and left atrial volume in patients with secundum type ASD. Methods: This prospective study was carried out at the cardiovascular department, Tanta University Hospitals on 140 patients either adult or children who were diagnosed as atrial septal defect by 2-D echocardiography. They were subjected to detailed history, detailed clinical examination, chest x-ray and echocardiography (2-D echo & Doppler). Results: 95% of patients were trivial or mild mitral regurgitation, 3.6% were moderate and 1.4% were severe. Cause of mitral valve regurgitation was 2.86% prolapse, 1.43% rheumatic and 0.71 dysplastic. Left atrial enlargement was found in 2.1% of patients. Mean LA diameter was 34.68 ± 3.9 mm, mean LA volume was 45.75 ± 3.44 ml and mean LA volume index was 24.14 ± 2.97 ml/m2. 1.43% of patients have history of rheumatic fever. 51.4% of patients presented with fatigue, 45.7% presented with palpitation, 41.4% of the patients presented with exertional dyspnea and 22.8% presented with tachypnea. Conclusions: The prevalence of mitral regurgitation is low in secundum ASD. Mitral regurgitation associated with secundum atrial septal defect could exist as a coexistent lesion, its recognition is important and most of them could be repaired with satisfactory results. Also, the left atrial volume was not affected except in sever mitral regurgitation.

Repair of Atrial Septal Defect Using Pedicled Right Atrial Wall Flap — A Retrospective Observational Study of a Novel Surgical Technique in a Tertiary Care Hospital in Eastern India

Introduction : In our institute, we have used the pedicled right atrial wall flap as an alternative to a free patch to close Atrial Septal Defect (ASD) in a series of patients. We hereby, report its results. Methods : Between January, 2016 and September, 2018, 24 patients (mean age 25.2 ± 12.43 years; range 5 years to 51 years), underwent closure of ASD with pedicled right atrial wall flap. All the patients who underwent this procedure had ostium secundum type of ASD without any other Intra-cardiac anomaly. Results : The intraoperative and postoperative period was uneventful in all the patients. The mean aortic crossclamp (X- clamp) time was 13 ± 2.99 minutes (Mean ± SD) and the mean duration for Cardiopulmonary Bypass (CPB) was 46.5 ± 10.23 minutes (Mean ± SD). There was no mortality. All the patients were discharged either on 3rd or 4th postoperative day. The pre-discharge and latest follow-up Transthoracic Echocardiographic Evaluation was found satisfactory in all the patients. None of them revealed any residual shunt, peri-flap Thrombosis, Flap dehiscence or shrinkage, or Cardiac Dysfunction. Conclusions : The Pedicled Right Atrial Wall Flap can be safely used as an alternative for pericardial patch for ASD closure. It is a novel technique with several advantages.

Changes of Cardiac Rhythm after Closure of Secundum Atrial Septal Defect in Children

Background: Arrhythmias may complicate congenital heart diseases, such as secundum atrial septal defects. We aimed at following up the rhythm changes in children after closure of ostiumsecundum atrial septal defects. Methods: The current study was conducted in the Pediatric Cardiology Unit, Tanta University, on 60 pediatric patients who had undergone either trans-catheter or surgical closure of secundum atrial septal defects. Complete history taking and full clinical assessment were done. Echocardiographic assessment was performed to detect any residual defects, and assess chamber dimensions, and cardiac functions. Electrocardiographic assessment including Holter monitoring was performed within two months afterthe procedure, after six months, and after one year. Arrhythmias were classified into major and minor types. All results were statistically analyzed and tabulated.Results: There were no significant differences between the pre-closure rhythm and the rhythm after closure of the defects throughout the follow-up. The percentage of patients with major arrhythmias has increased from 6.7% of the total sample to 13.3%, 11.6%, and 11.6% in the early, midterm and late follow up respectively. The significant risk factors for postoperative arrhythmias were; pre-closure arrhythmia, right atrial dilatation, and serious hemodynamic instability in the early follow up. Conclusions: We concluded that arrhythmiaswere common before and after atrial septal defect closure, without significant differences. Pre-closure arrhythmia, right atrial dilatation, and serious hemodynamic instability are considered important risk factors of arrhythmias after secundum atrial septal defect’s closure in pediatric patients

Mid-term Safety and Efficacy of Transcatheter Closure of Ostium Secundum Atrial Septal Defect under Transthoracic Echocardiographic Guidance in Children Weighing Less than 15 Kg

Background: Transcatheter device closure of ostium secundum atrial septal defect is a safe & effective intervention in older children, & is usually done under transesophageal echocardiography guidance. However, the procedure under transthoracic echocardiography guidance, especially in smaller children, is done only at few centers, the data of which is scarce. Methods: A prospective study was undertaken to assess the mid-term efficacy and outcome of transcatheter device closure of ostium secundum atrial septal defect under transthoracic echocardiographic guidance, in children <15 Kg. Results: Eighty three children with ostium secundum atrial septal defect were included in the study. Median age of the study population was 3.5 years (1.9-5.6 years), and median weight of 11.6 Kg (7.6 - 14.9 Kg). The primary and secondary procedural success rates were 94% and 96.4% respectively. Post procedure patients were followed up for 12-30 months. Device related major complications were encountered in 4 (4.8%) cases. The total occlusion rates of the defect at 24 hours, 1 month and 3 months post procedure were 94%, 98.8% and 100% respectively. Conclusion: The transcatheter device closure of ostium secundum atrial septal defect under transthoracic echocardiography guidance, in children <15 Kg, has a high short and mid-term safety and efficacy.

Functional and clinical importance of a large sized ostium secundum defect in a middle aged female cadaver: a case report / 대한해부학회지

Atrial septal defect (ASD) is one of the common congenital anomalies of the heart in humans. Its complications depend on the size of the defect and can manifest at any age. The common symptoms of ASD include dyspnea and fatigue. Most of the ASDs are associated with morbidity and mortality, Earlier the treatment, it is better to the patient. I saw a large ostium secundum defect in the heart of an adult female cadaver during dissection classes for undergraduate medical students. The interatrial septum had large defect at the region where fossa ovalis should have been located. It was about 1.25 inches in diameter and oval in shape. This type of large septal defect might result in cyanosis, stroke or death of the patient at any age.

Tromboembolismo pulmonar y comunicación interauricular tipo osteum secundum / Pulmonary embolism and interatrial osteum secundum

Se presenta el caso de una paciente de 45 años, de edad con antecedente de Cardiopatía Congénita Acianógena: comunicación interauricular (CIA) tipo Osteum Secundum (OS), quien de manera ambulatoria consultó para la realización de la evaluación Cardiovascular en preoperatorio de colecistectomía. En Rayos X y Angiotomografia de tórax, se evidenció tromboembolismo pulmonar (TEP). Paciente refiere disnea leve, inspiratoria, habitualmente asociada a leves esfuerzos por más de tres meses, negando otro síntoma pertinente. La ausencia de Enfermedad Tromboembólica venosa (ETV) del tipo Trombosis venosa profunda(TVP) y de factores de riesgo para un Síndrome de Hipercoagulabilidad, excepto el hábito tabáquico, aunado al antecedente de CIA tipo Osteum secundum y la falta de correlación clínica-imagenológica convergen para que la presentación de este caso clínico pudiendo ser mortal sea una condición rara, dado que durante la hospitalización se confirmaron los diagnósticos de TEP Crónico, Hipertensión pulmonar severa (HPS), en ausencia de criterios para Embolismo paradójico (EP), complicación descrita en este tipo de cardiopatía cuando hay hipertensión pulmonar asociada. Los métodos de imagen fueron esenciales para el correcto diagnóstico y el manejo terapéutico de la paciente, la cual evoluciona satisfactoriamente(AU)

A 45-year-old woman came to the office with mild shortness of breath for the past 3 months and the chest X-ray (CXR) and CT showed chronic pulmonary embolism (PE). She had a past medical history of non-cyanotic congenital ostium secundum atrial septal defect, severe pulmonary hypertension and active smoking status. The uncommon clinical presentation in this patient could have been fatal without the appropriate diagnose and treatment(AU)

Clinical evaluation of ostium secundum ASD treatment via one -stop hybrid and classical surgical procedures / 中国基层医药

Objective To investigate clinical effect and safety of ostium secundum atrial septal defect(ASD) treatment via one -stop hybrid and classical surgical procedures.Methods 45 patients were diagnosed ostium secun-dum simple ASD by ultrasound cardiogram and clinical manifestation,they were divided into one -stop hybrid proce-dure group (n =20)and classical surgical procedure (n =25).Age,gender,weight,post operation hospital day,on -pump time,blood transfusion amount,drainage flow,incision length and incidence of complication between the two groups were compared.Results Age and weight had no difference between the two groups(t =0.40 and 1.64,P >0.05),but the proportion of female cases in one -stop hybrid procedure group was higher than post operation(χ2 =9.45,P 0.05).And one -stop hybrid procedure group was off -pump without blood transfusion.Conclusion One -stop hybrid procedure was simple,could make a quick recovery post operation and was an ideal method for ostium secundum ASD treatment.

Clinical comparison of robotic minimally invasive surgery and transcatheter interventional occlusion for adult secundum atrial septal defect / 解放军医学杂志

Objective To assess the safety and efficiency of robotic minimally invasive surgery and transcatheter interventional occlusion for treatment of adult secundum atrial septal defect (ASD) by comparing the early and recent postoperative follow-up results of the two minimally invasive surgery. Methods Thirty adult patients with secundum ASD, who admitted to the General Hospital of PLA from Jan. 2008 to Dec. 2014 and received treatment of da Vinci Surgical System, were recruited as TEASD-R group, meanwhile, another 30 adult patients who received transcatheter interventional occlusion were recruited under the strict 1:1 criterion as TIASD-O group. The early postoperative complications, in-hospital conditions, recent postoperative follow-up results and the quality of life 30d and 6 months after operation were compared and retrospectively analyzed between the two groups. Results The success rates of surgery were 100% in the both groups, no early and recent postoperative complications (residual shunt, pericardial effusion, cerebral infarction, peripheral vascular embolism, new arrhythmia, etc.) were found in TEASD-R group. While some of corresponding complications existed in TISAD-O group, and the differences were of statistical significance (P<0.05) between the two groups in the incidence of postoperative new arrhythmia, tricuspid incompetence and pulmonary hypertension, as well as in the early size of right atrium and in-hospital time. SF-36 quality of life questionnaire showed that the difference of somatic pain 30d after operation was of statistical significance (P<0.05) between the two groups, but the difference disappeared 6 months after operation. Conclusion Robotic minimally invasive surgery for adult secundum ASD is feasible, safe and efficacious since no postoperative complications occurred such as tricuspid incompetence and pulmonary hypertension, but the longer operative and inhosptial time are the shortages of the operation.

Platypnea-Orthodeoxia Syndrome Two Decades after Definitive Surgical Repair of Pulmonary Atresia with Intact Ventricular Septum

A 20-year-old female had undergone definitive surgical repair for pulmonary atresia with intact ventricular septum soon after birth. She was referred to our institution with the chief complaint of clubbing fingers. A thorough examination revealed platypnea-orthodeoxia syndrome due to an interatrial right-to-left shunt through a secundum atrial septal defect. Percutaneous closure with an Amplatzer Septal Occluder resulted in resolution of the syndrome.

Association of mean platelet volume with pulmonary artery hypertension associated with secundum atrial septal defect / 中国介入心脏病学杂志

Objective To observe changes in mean platelet volume ( MPV) and investigate its possibility as a predictor and influence in patients with pulmonary artery hypertension associated with secundum atrial septal defect (ASD-PAH) . Methods 627 patients who suffered from secundum ASD were included in the study from the First Affiliated Hospital of Xinjiang Medical University Heart Center between January 2010 and March 2014. Patients were divided into two groups based on whether they had PAH or not (PAH group, n = 420 and non-PAH group, n = 207) . We also included 690 healthy people as a control group who received routine body check up at the same time. Examinations including complete blood count, serum biochemistry and ECG were done. Right heart catheterization examination was performed in patients who suffered from secundum ASD. Results The MPV was significantly higher in secundum ASD patients than in the control group [ (9. 4 ± 1. 6) fl vs. (8. 9 ± 1. 5) fl, P ﹤ 0. 001] . No significant difference was observed in MPV between PAH group and non-PAH group (P = 0. 268) . In univariate and multivariate logistic regression analysis, age ( OR 1. 401, 95% CI 1. 087 to 1. 806, P = 0. 009), RV diameter (OR 1. 101, 95% CI 1. 026 - 1. 181, P = 0. 008) and ASD defect diameter (OR 1. 064, 95% CI 1. 013 - 1. 118, P = 0. 013) were associated with ASD-PAH. Conclusions Our study demonstrated that age, RV diameter and ASD defect diameter were associated with ASD-PAH. Platelet activation exists in ASD-PAH, but this may not be the precipitating cause that contribute to the pathogenesis of ASD-PAH. MPV at admission does not predict the risk of PAH in patients with secundum ASD.

A survey of the indications for early closure of ostium secundum atrial septal defects and subsequent progress of children in whom this has been undertaken.

Objectives: Closure of isolated secundum atrial septal defect (ASD) is generally recommended at the age of 4 to 5 years. However, there are children with isolated secundum ASDs in whom early closure is performed. The aim of this study is to describe the conditions that led to the decision for early closure and to determine whether these conditions were resolved by means of closure of the defect. Methods: The records of 16 patients who underwent surgical closure of isolated ASD before 24 month of life from 2001 to 2010 at Southampton University Hospital were scrutinised to collect data. Results: There were eight patients with recurrent respiratory tract infections and failure to thrive, three with only recurrent respiratory tract infection, two with evidence of high pulmonary pressures and one with heart failure. Two patients were asymptomatic but had large defects with significant right sided volume overloading. All patients survived surgery and most of them had an uneventful postoperative period. All patients showed clear improvement of their symptoms during the follow up period. Two patients continued to fail to thrive despite closure of ASD but both had other problems to account for the failure to thrive. Conclusion: All symptomatic patients with ostium secundum ASD improved following closure of the ASD before two years of age. Co-existing chromosomal or non cardiac anomalies can be associated with a continued tendency to a poor weight gain after ASD closure.

Bronchial compression in an infant with isolated secundum atrial septal defect associated with severe pulmonary arterial hypertension / 소아과

Symptomatic pulmonary arterial hypertension (PAH) in patients with isolated atrial septal defect (ASD) is rare during infancy. We report a case of isolated ASD with severe PAH in an infant who developed airway obstruction as cardiomegaly progressed. The patient presented with recurrent severe respiratory insufficiency and failure to thrive before the repair of the ASD. Echocardiography confirmed volume overload on the right side of heart and severe PAH (tricuspid regurgitation [TR] with a peak pressure gradient of 55 to 60 mmHg). The chest radiographs demonstrated severe collapse of both lung fields, and a computed tomography scan showed narrowing of the main bronchus because of an intrinsic cause, as well as a dilated pulmonary artery compressing the main bronchus on the left and the intermediate bronchus on the right. ASD patch closure was performed when the infant was 8 months old. After the repair of the ASD, echocardiography showed improvement of PAH (TR with a peak pressure gradient of 22 to 26 mmHg), and the patient has not developed recurrent respiratory infections while showing successful catch-up growth. In infants with symptomatic isolated ASD, especially in those with respiratory insufficiency associated with severe PAH, extrinsic airway compression should be considered. Correcting any congenital heart diseases in these patients may improve their symptoms.

" Lutembacher's Syndrome " - A Case Report.

Lutembacher's Syndrome is a rare heart disease comprises ASD (congenital) secundum with Mitral stenosis (Rheumatic origin). The patient Md. Mosharraf Hossain, 72 years old man, non diabetic, non hypertensive, smoker admitted in FMCH on 10.10.2010 with the complaints of respiratory distress and chest pain for 10 days. He had a previous history of Rheumatic fever in early childhood. There was history of recurrent attack of Rheumatic fever. Subsequently he developed MS from Rheumatic carditis. ASD was congenital in origin. If diagnosis could be done earlier, surgical closure of ASD with replacement of mitral valve bears a good prognostic value. Our patient is in elderly age and already developed pulmonary hypertension, operative procedure is not suitable. So the patient should be kept in conservative treatment.

The role of transthoracal echocardiography in closing secundum atrial septal defects with Amplatzer Septal Occluder.

Transesophageal echocardiography (TEE) under general anesthesia has become a routine procedure as guidance in implanting Amplatzer septal occluder (ASO) for closing secundum atrial septal defects (ASDs) together with fluoroscopy in cardiac catheterization laboratory. To simplify the procedure and reduce the cost, recently we used transthoracal echocardiography (TTE) in guiding the ASO implantation. Aim of this study is to evaluate accuracy and performance of ASO procedure guided by TTE compared to ASO procedure guided by TEE. This is a comparative study. Ninety-one patients with ASDs referred for transcatheter closure with ASO in National Cardiovascular Center Harapan Kita Hospital Jakarta were reviewed. In the 22 patients, TTE were used as guidance instead of TEE. Patients selection were performed in the outpatient clinic by TEE. The stretched diameter was measured by TEE or TTE and fluoroscopy. Patients were divided into two groups, TEE group consisted of procedures guided by TEE, and TTE group guided by TTE. From 91 patients, 83 can be evaluated. It consisted of 61 patients in TEE group and 22 in TTE group. Measurement of defects sizes with TTE and TEE have a high correlation with fluoroscopic measurements (r=0.837 and r=0.853, respectively). There were no significant differences between the accuracy of TTE and TEE sizes measurement (p=0.085) compared to fluoroscopy. Fluoroscopy time in ASO procedures guided by TEE was significantly longer than those guided by TTE (33.2 ± 21.3 min vs. 22.8 ± 19.3 min, P=0.014). There was also no significant differences in the failure of devices implantation between TEE and TTE guidance. All patients were in good condition at follow-up. ASO procedures guided by TTE have similar accuracy to those guided by TEE, with shorter fluoroscopy time. TTE guidance also has no difference in failure rate compared to TEE guidance.

The Natural Course and Size Change of Atrial Septal Defect Secundum

PURPOSE: This study was performed to follow the natural course and size change of isolated atrial septal defect(ASD) secundum. METHODS: Among the newly diagnosed with ASD secundum at the division of pediatric cardiology in Yonsei cardiovascular hospital from January 1996 to December 2000, 89 patients with pure ASD secundum were checked by the serial echocardiographic evaluation to measure the size change. RESULTS: There was a statistical difference(P8 mm) and the group of smaller defect (< or = 8 mm). There was also a statistical difference(P<0.05) in the rate of spontaneous closure and size change of the defect between the group of younger than three years of age and the group of older than three years of age. The initial size of the defect and change of size were the significant influencing factors in the rate of spontaneous closing of ASD. In the group of patients who have persistent ASD, the size of defect showed a tendency of increasing size of defect with the age(P<0.005); however in the correction of these values by the body surface area of each patients, there was no statistical difference. CONCLUSION: The possibility of spontaneous closure of pure ASD secundum was higher in the group of patients who have smaller defect and who were younger. The ASD secundum that did not have spontaneous closure showed an increase in size with the growth of the patients; however when this size was corrected by the body surface area, there was no statistical difference. The closure of the defect was at 26.2 months of age so close follow-up of the patients is important.

Persistent Left Superior Vena Cava with Absent Right Superior Vena Cava and Large Atrial Septal Defect in Visceroatrial Situs solitus

Abscence of right superior vena cava(SVC) in visceroatrial situs solitus is a rare(0.07% to 0.13%) congenital cardiovascular malformation, and little is known about the type and frequency of additional heart defects and arrhythmias. We reviewed previous publications and report the case of 8 month old male infant with absent right superior vena cava and persistent left superior vena cava and large secundum atrial septal defect, mild pulmonary valvular stenosis.

Clinical Course of the Ostium Secundum Atrial Septal Defect(ASD) and Its Rate of Spontaneous Closure

PURPOSE: To know the natural course of the ostium secundum ASD including its rate of spontaneous closure. METHODS: We studied 259 cases who were diagnosed as ostium secundum ASD by 2D-echocardiography at Department of Pediatrics, Kyungpook National University Hospital between Jan. 1985 and Dec. 1994. According to the age at diagnosis, we divided them into two groups, group I (those diagnosed before 1 month of age: 59 cases) and group II (those diagnosed after 1 month of age: 200 cases) RESULTS: Mean age at first diagnosis was 2.6+/-4.6 years and mean defect size(diameter by 2D-echocardiography) was 9.9+/-8.0 mm. Cardiac murmur was the main reason to refer the patients to hospital, being in 50 cases(87%) in group I, 179 cases(90%) in group II. Defect sizes were significantly small in group I compared with group II (5.3+/-3.4 mm vs 11.1+/-6.9 mm, p<0.05). Symptoms corresponding to congestive heart failure were present in 16 cases of group I (27%)( isolated ASD: 8 cases, ASD accompanying with PDA: 5 cases, ASD accompanying with VSD: 2 cases, ASD accompanying both PDA and VSD : 1 case) and in 27 cases of group II(13.5%) (isolated ASD: 17 cases, ASD accompanying with VSD: 4 cases, ASD accompanying with PDA: 4 cases, ASD accompanying both PDA and VSD: 2 cases). Of total 139 cases, spontaneous closure of ostium secundum ASD was documented in 14 cases(10.1%) by follow up 2D-echocardiography. The rate of spontaneous closure was significantly high in group I compared with group II (6 cases: 37.5% vs 8 cases: 6.5%, p<0.05) Comparing with those cases without closure, there were no significant differences in defect size in group I but significant differences in group II(p<0.05), being 5.63 2.62 mm in cases with spontaneous closure and 12.82 7.09 mm in those cases without closure. Of the 9 cases with atrial septal septal aneurysm, 2D- echocardiographic follow ups were possible in 5 cases with spontaneous closure in 2 (40%). CONCLUSIONS: Spontaneous closure was documented in 10.1% of all the patients with ostium secundum ASD. Especially the closure rate was significantly high in those cases their diagnosis was made before 1 month of age and with atrial septal aneurysm.