Not a feature of atrial septal defect:

Ans. d (Paradoxical pulse). (Ref OP Ghai 6th ed. 402; Nelson Paediatrics, 18th/1883)ATRIAL SEPTAL DEFECT (ASD):# This is a common cardiac anomaly that may be first encountered in the adult and occurs more frequently in females.# Can be divided into 3 types:- Ostium primum atrial septal defect (ASD)- Ostium secundum ASD, the more common type.- Sinus venosus defect (less common).- Coronary sinus atrial septal defect# Its most common form is osteum secundum defect.# The most common ostium secundum type atrial septal defect involves the fossa ovalis and is midseptal in location. This type of defect should not be confused with a patent foramen ovale. True atrial septal defects, that is, defects within the confines of the fossa ovalis.# Child is usually asymptomatic.# Physical signs include- Mild left precordial bulge,- Loud S1,- Wide and fixed S2 split, - Systolic ejection murmur due to increasing flow across RV outflow into pulmonary artery.- Short rumbling mid diastolic murmur proved increasing volume of blood across tricuspid V.# Left atrial enlargement does not occur early in the disease.# Right bundle branch block is common# CXR:- The heart in ASD is sometimes displaced to left (Bedford sign).- Ascending aorta and arch tend to appear smaller than normal, probably due to rotation of ascending aorta by enlarged RA-RV, causing saggital alignment of arch (Small knuckle).- The central pulmonary arteries are enlarged and there is a variable degree of pulmonary plethora, depending on the size of shunt.- Septal lines (Kerley B lines) in a patient of ASD should always suggest an associated mitral valve abnormality (ECD or Lutembacher syndrome).# The "great hilar dance" sign characterizes ASD on fluoroscopy.# The "Goose-neck" deformity is seen in ASD on cardioangiography."Hilar dance sign" is seen on fluroscopyTreatment of Atrial septal defect:# Most ostium secundum defects should be closed.# Optimal time for closure is a debated issue, however 2-5 yrs age is considered ideal for surgery.# A large percentage of isolated secundum defects are now closed using transluminal percutaneous devices especially in children who have attained 10 kg or more weight.# For the child in whom device closure is not an option, repair can easily be done on cardiopulmonary bypass using a patch of pericardium, polytetrafluoroethylene (Gore-Tex), or Dacron if primary closure is not feasible.Indications for surgery in ASD:# For secundum atrial ventricular defects (which contributes to approximately 70% of ASDs) that fail to spontaneously close and primum AV defects (which contributes to approximately 20% of ASDs), treatment is aimed at closing the defect if a LR shunt of 1.5:2 or more is present.# Closure is performed during the first decade, even in absence of symptoms to avoid late-onset RVF, endocarditis, and paradoxical emboli.# Without surgery, 50-60% of infants with complete AV canal defect die from CCF secondary to large L=> R shunting and/or AV valve incompetency by 1 year of age.