case_images: PMC10830150_01
case_images: Phonocardiography. A high-pitched murmur during early to mid systole (asterisk) is seen at the third left sternal border (3LSB). The pulmonary component of the second sound (S2) is louder than the aortic component (arrow); the pulmonary component is also noted at the apex. ECG denotes electrocardiography; H, high frequency; L, low frequency; M1, lower-middle frequency: M2, higher-middle frequency; S1, the first sound.
case_images: cureus-0016-00000051479-i01.jpg
case_images: PMC10830150_01_cureus-0016-00000051479-i01.jpg
case_images: FIG1
case_images: There was a right ventricular heave, and chest auscultation revealed a split-second sound with an increased pulmonary component and a systolic ejection murmur in the pulmonary region (Figure 1), findings consistent with pulmonary artery hypertension due to ASD.
case_images: Echocardiography. Transthoracic echocardiographic four-chamber images before (A) and after agitated saline contrast (B) show not only contrast-enhanced right atrium (RA) and right ventricle (RV) but also numerous bubbles in the left atrium (LA) and left ventricle (LV). Transesophageal echocardiography (C) shows a wall defect between the superior vena cava (SVC) and LA (arrow) with direct blood flow from LA to SVC on color Doppler.
case_images: cureus-0016-00000051479-i02.jpg
case_images: PMC10830150_01_cureus-0016-00000051479-i02.jpg
case_images: FIG2
case_images: Physical findings suggestive of ASD and unexplained right heart enlargement compatible with ASD were further evaluated with an agitated saline contrast study, which was positive with numerous bubbles in the left atrium almost simultaneously with the right atrium filled with bubble contrast (Figure 2). Transesophageal echocardiography showed a superior sinus venosus ASD and direct flow between the left atrium and superior vena cava (Figure 2) without anomalous pulmonary venous connection, which was confirmed by computed tomography of the chest.