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Med J Indones

Madiyono et al.

Ctinical Features and Management of Secundum Atrial Septal Defect in Infants and Children Bambang Madiyono, Jumiety Achmad, Sudigdo Sastroasmoro, Ismet N. Oesman, Sukman Tulus Putra

Abstrak Dalan penelitian retrospekûfini dilakukan evaluasi terhadap penampilan Hinis dan tata laksana pasien defek septum atriun yang berobat di Subbagian Kardiologi, Bagian llnw Kesehatan Anak RS. Cipto Mangunkusunto, Jakarta, antara I Januari 1983 sanpai dengan 3 1 Desember 1992. Sebelun tersedia alat ekokardiografi, diagnosis defek septwn atriurn sernata-nata didasarkan pada riwayat penyakit, petneriksaanfisis, elektrokardiogram, danfoto rontgen dada- Setelah tersedia alnt ekokardiografi (Januari 1987), diagnosis kelainan ini dipastikan dengan ekokardiografi (keuudianjuga Doppler dan Doppler berwarna). Seri ini nenunjukkan: (1) Defekseptunt atriun sekundun lebih sering ditenukan pada anak perentpuan, dengan rasio perentpuan : lelaki : 1,5 : 1,2; (2) Jwnlah pasien yang didiagnosis sebagai defek septurn atrium lebih banyak setelah tersedia alat ekol
Abstract This retrospective study aitned to review the clinicalfeatures and nanagement o;fpatients with secunduu atrial septal defect (ASD 2")- The subjecrs studied were 9O boys (39.8%) and 136 girls (60.2%), treated at the Ourpatient Clinic, Cardiology Division, Deparrnent of Child Health, Cipto Mangunkusumo Hospital, Jakarta, Indonesia, frotn January 1, 1983 to December 31, 1992. Clinical ossessilrcnt and nnnagetnent were evaluated by one ofthe authors. Electrocardiographic, radiographic, and henodynanùc findings were analyzed b), the etperîs. The diagnostic procedure was contpleted u'ith echocardiographic exanination since January 1987. This study discloses severalfindings: (1)ASD20 affectedgirls ntorethanboys, the sex ratiowas 1,5:1; (2)The diagnosis ofASD 2" in infants was increased after the advent of echocardiographl,; p) While rypical auscultatory findings could be heard in older ASD ccrses, the clinical features were not specirtc in young infunts; (4) Growth retardation, cardiouegaly and right bundle branch block were coutttton in large ASD 2"; (5) Simple closure ofASD 2" was the procedure ofchoice. Key w ords : at r i al s ep

tal

defe ct,

e

cho car d i o gr aphy,

c Ii

ni

c

al n anife stat i o ns

2) is the third or olsease ln disease in congenital congenrtal neart heart fourth most common lourth 7. of childhood, accounting for approximalely percent all children with congenital heart disease.'-' Most infants with this defect are asymptomatic, and frequently their condition goes undetected until school age. Most patients with a moderate left-to-right usually complain only of mild fatigue and dyspnea.* The frequency of fatigue and dyspnea increases in infants with large shunt, and cardiac failure occasionally o""*r.5 Secundum atrial septal defect (ASD

second heart sound and soft eiection systolic mutmur at the upper left sternal bordËr.a'6'7 In young infants nical findings are usually not ographic examination is usually diagnosis.l3-16

The purpose of this study was to review the physical

as well as electrocardiographic, radiographic, and echocardiographic findings of patients with ASD 2o treated at our Outpatient Pediatric Cardiology Clinic during the last l0 years.

ASD 2" is easily recognized in older patients by the typical auscultatory findings consisting of widely fixed METHODS Depart,nent of Child Health, Medical School, Universiq, sf Indonesia, Jakarra, Indonesia Paper presented at the 9th Indonesian Congress of Pediatrics, June 13-17, 1993, Senarang, Indonesia.

This retrospective study reviewed the clinical findings and management of patients with ASD 2() treated at the Outpatient Clinic, Cardiology Division, Department of Child Health, Cipto Mangunkusumo Hospital, Jakarta,

VoI 5, No 1, January -

March 1996

Indonesia, from January

l,

Atrial Septal Defect

1983 to December 31,

43

RESULTS

1992.

Before echocardiographic machine was available in our department, the diagnosis of ASD was based on typical clinical symptoms and signs, electrocardiogram, and chest X-ray examinations. Since January 1, 1987, when electrocardiograhic machine was avail-

able, the diagnosis was confirnred by echocardiographic examination. Cardiac catheterization was only performed on certain indications prior to surgical closure.

Suggestive diagnosis

of ASD by the referring

physicians was noted. Clinical symptoms such as recurrent respiratory tract infections (more than 4 episodes per year), easy fatigability (as reported by the parents), dyspnea on exertion, and growth retardation (weight per age, NCHS standard) were recorded.

Two hundred and twenty six patients were enrolled in the study. They were 90 boys (39.8To) and 136 girls (60.2%). The female to male ratio thus being 1.5:1, so ASD 20 affected girls more than boys as is generally the case. l-4

The diagnosis of ASD had already been suggested by the referring physicians in 62 cases (27.4%), most of them aged 3 years or more. This relatively small percentage indicates that ASD 2o could be recognized by the referring physicians in some older cases. The distribution of patients studied based on the age group at the first evaluation showed binrodal pattern (Table 1), the two peaks were at the age group of less than I year (3O.57o) and 3-6 years (29.2%), respective-

ly.

Physical examination was thoroughly carried out by an

experienced staff. Signs of typical auscultatory findings of ASD 2o, i.e., widely fixed second heart sound and ejection systolic murmur were noted by one of the authors. Complete electrocardiogram was recorded in all cases, i.e., standard leads, unipolar limb leads and chest leads V3R, V1-V6. All electrocardiograhic tracings were reviewed and assessed by the authors. Heart size was evaluated roentgenographycally by measuring the

cardio-thoracic ratio, i.e., the ratio of the maximum width of the heart to the body thorax at the level of the right diaphragm in antero-posterior view. M-mode and two dimensional echocardiograms were performed in

all patients seen after January l, 1987 using ALOKA SSD 720. The echocardiographic examination was completed by color Doppler echocardiography using ALOKA SSD 870. Cardiac catheterization was performed prior to surgery in some special cases with suggestive pulmonary hypertension. The patients were arbitrarily divided into two groups; Group A consisted of patients admitted during the first

four-year period (from January

l,

Table 1. Sex and age distribution of 226 ASD 20 patients Age (years)

Number of Cases

0-

69

l-

5l

3-

66

7>

40

Percentage

(3o.s%) (22.6%)

(2e2%) (t7.7%)

Total

(too.o%)

Table 2 depicts the number of patients by age, based on 5 year-period of study. It is clear that the number of patients with ASD 2o increased in the last 5 years (144 cases or 25 cases per year), compared with the number ofpatients in the second 5-year period (g2 patients, or

17 cases per year). This table also shows that the proportion of ASD patients less than 3 years of age increased from 41.5% in the first 5-year period to 59.7% in the second 5-year period.

19g3 to December

31, 1986), where echocardiography was not available, while Group B comprised the rest of patients admitted afterward.

Table 2. Age distribution of 226 patients based on 5_year period of diagnosis Age

For statistical analysis numerical results are given as mean (standard deviation of the nrean). euantitative data were comparedby Student's t A value of p < 0,05 was considered statistically significant.

(years) 1983-1987

<3 3 or more

34 (4t.s%) 48 (58.57o') 82

(100.0%)

lgïB-tgg2 86 s8

(s9.77o) (40.3%)

t2O (53.5Vo) 106 (46.s%)

144

(Ioo.o%)

226 (Loo.oVo)

-I

44

Med J Indones

Madiyono et al.

Further interesting result is seen if the age distribution of patients studied was related with the availability of echocardiographic machine. The number of patients with ASD 2o in this series was increased significantly, i.e.,49 patients in the first 4 years (12 cases per year) compared with 177 patients in the last six years (30 cases per year). See Table 3. The proportion of ASD patients diagnosed before the age of 3 years increased from28.6% during 1983-1986 to as high as 599% in the period of 1987-1992.

patients aged less than 3 years. Marked differences was

found in dyspnea on exertion (36.8% in group of patients 3 years old or more vs 15.57o in group of patients less than 3 years), growth retardation (43.37o v s 26.7 %), palpable thrill (L7 .O7o v s O%), widely fixed second heart sound (96.2% vs 43.37o),ejection systolic murmur (IOO% vs 57.57o), and diastolic flow murmur (26.4% vsOTo), The results of supporting examinations are presented in Table 5. In this table patients were also arbitrarily divided into 2 groups, i.e., those aged 3 years or more, and those aged less than 3 years old. Similar to those of the clinical findings, we also noted that typical findings for ASD were more commonly found in older patient group when compared with those in younger patients. Notable difference was noted in the prolongation of P-R interval (56.67o in group of patients 3 years of age or more vs 3.3% in those aged less than 3 years), incomplete bundle branch block (90.67o vs

Table 3. Age distribution of 226 patients based on echocardiographic availability Age

$ears)

1983-1986

1987-1992

(without echo)

(with echo)

<3

t4 (28.670)

3 or more

3s (71.4%)

Total

4e (too%)

tO6

'tr

(59.9Vo)

(40.r%)

r77 (roo%)

Total

l2O (53.57o) 106 (46.5%)

30.870), right ventricular hypertrophy (89.6% vs 33.37o). Cardiothoracicratio ofl more than 55% and increased vascular markings were 2 times as much in the group of patients aged 3 years or more as in the

226 (rOO.O7o)

The clinical symptoms and signs of the 226 patients with ASD 2o are shown in Table 4. The patients were arbitrarily divided into 2 groups, i.e., those aged less than 3 years and those aged 3 years or more. The division was based on the assumption that at the age of 3 years the clinical presentations of ASD, if any, usually have manifested. It is seen that the percentage of the clinical manifestations in group of patients aged 3 years or more was consistently higher than that of

younger age group. With echocardiograms, the atrial septal defect could be seen in all subjects examined (106 patients in group less than 3 years of age andTl patients in the older group). Right atrial and ventricular dilatations were also noted more frequently in the older age group. Of particular interest was that we did not find a clear paradoxical septal motion in the M-mode of patients less than 3 years of age, but did so in 32.1% of patients aged 3 years or more.

Table 4. Physical hndings of the226 patients studied Age < 3 yrs (N=120)

3 years or

Percent

Dyspnea on exertion Recurrent respiratory tract infection Tachycardia Growth retardation Right precordial bulging Right precordial heaving

Thrill Pulmonary tapping Accentuated first heart sound Widely fixed split 2nd heart sound Accentuated P2 Ejection systolic murmur Mid diastolic tricuspid flow murmur

2T

14.5

46

38.3 56;7 26.7 10.0 6.7 0 0

68 32

more (N=106)

39 99 59 46 33 20

60

26.6

r45

s5.7

119

78 45 28

64.2 52.8 34.5 19.9

0

3

52 0

43.3

t02

0

l0

69 0

57.5

r06

0

28

26.4

8

0 0 0

l8 10

Percent

36.8 93.3 43.3 31.3 18.9 17.0 9.4 2.8 96.2 9.4 100

l2

Total (N=226)

Percent

18

10

t2.4 8.0 4.4

J

1.3

157

t75

69.5 4.4 77.4

28

12.45

10

Vol 5, No 1, January -

March

1996

Atrial Sepral

Defed

45

Table 5' Results of ECG, chest X-ray, and echocardiohraphic examination in 226 patients studied

Ag"

<3yrs ECG Right axis deviation - Prolonged PR interval -

-IRBBB - Right atrial enlargement -

Right ventricular dilatation

cxR - cTR > 0,5570 - Increased vasc markings

Echocardiogram - Visualized defect - Right atrial enlargement - Right ventric. hypertrophy - Paradoxical septal motion

Percent

No

30.0

57 60

(n= 120)

36 4 37 8 40 24 38

3t.7

(n=106) 60 64 34

66.0 0.0

Table 6. Invasive diagnostic procedure and snrgical cases 36 (ts.e%) 47 (2O.8Vo) 4 ( 8.s%)

47

89.6

135

66.0

94 106

(N=226) 64.2

71

41.4 28.5 58.9 20.8 59.7

133

36.8

(n=71) 100.0 61.3

8.5%. See Table 6.

93 64

(n=106) 70 68

Percenl

(N=226) 56.6 90.6

39 95

20.0

monary hypertension. Surgical closure of the ASD was perfomed in 47 patients, with the mortatity of

No

53.8

96

(n-120)

106 65 70 0

Total

Percent (n= 106)

3.3 30.8 6.7 33.3

We performed cardiac catheterization in 36 out of the total 226 patients. Most of them (27) are performed before echocardiography was available, AftËr echocar_ diographic examination was available, we did cardiac catheter only in patients who showed evidence of pul_

Cardiac catheterization Simple ASD closure Surgical mortality

3 yrs or more

100.0 84.5 90.1 47.8

4t.4 47.4

I

180

80.

t77

100.0

125

69.1

134

74.O

34

15.0

Hospital in Boston reflecting the recent increase in atrial septal defects, probably related to local interests in closing these defects with devices introduced during cardiac catheterization.3 We can say with confidence

tha dia clo

n the number of patients 20 in the last 5 years is

bility of echocardiographic examination. Similarly, the incerased number of patients aged less than 3 years in our series must have been related to echocardiography.

Our data also support previous knowledge that ASD patients aged less than 3 years of age are usually

asympetomatic, and also give only non_specific clinical

signs."- '' Typical auscultatory findings ior ASD which are consisted of widely fixed second heart sound and

DISCUSSION

soft ejection systolic murmur are usually noted when the patients becoming older, so that prior to echocar_ diography era, the diagnosis of ASD is usually estab_ lished in the preschool age group (3_5 years). The wide

problem constitute one group, whereas older children contribute to the second peak.3 The inceras patients dia

period,

has

rank.order

more

.ii: ren's

split of the second heart sound resulis front delayed emptying of rhe overload right ventricle; the fixed split is the consequence of unlintited conrntunication be_ tween the two atria, allowing for equalization of the influence of respiratory variation on the right and left

ventricular output.3

Other non-specific findings in ASD include right

precordial bulging and righr precordial heaving, Thèse are correlated with right ventricular volume overload

with large left to right shunt at atrial level. This abnor_

mality is usually found when the overload become

46

Madiyono et al.

chronic; in the case of ASD, older children have the higher probability to have this sign, as seen in our series.

Med J Indones

atrial pathway which conducted faster than surrounding atrial muscle; and (2) the right atrial enlargement required to accommodate the hemodynamic volume overload increases the distance ofthe SA node and the

Mid-diastolic murmur at the lower left sternal border, whis is considered to be associated with relative tricuspid stenosis was detected only in 28 cases (12.4%). This relatively small percentage of mid-diastolic murmur wâs due to the absence of such sign in the younger age group. From the clinical point of view, the presence of this murmur usually indicates that there

is a large left to right shunt.3i'7

Atrial septal defect rarely results in congestive heart failure in infancy. Congestive heart failure was suspected on the basis of tachypnea, tachycardia, and cardiomegaly. Early changes in right ventricular compliance combined with ASD can lead to early diastolic overloading of the right ventricle causing cardiomegaly and congestive heart failure at an early age.'u History of frequent respiratory infections was reported in most patients. lo We did not diagnose a single ASD patient with frank congestive heart failure; however, a substantial number of patients, especially those aged 3 yeils or older, showed growth retâTdâtion. This indicated that the left to right shunt had disturbed the normal hemodynamic, w-hich caused in decreased intake of the nutrients. 17-20 Patients with complicated ASD showed marked retardation in both height and weight; whereas those with isolated ASD 20 showed only slight retardation in height, but moderate retarda-

tion in weight./

AV node.7'lo Chest x-ray in ASD showed moderate to marked cardiomegaly with increased pulmonary vascular markings, proportionate to the amount of shunt.3'7'22 In most ca_se^s, the pulmonary artery segment was prominent.lrtt'zz In this series, cardiothoracic ratio of greater than 0,55 and increased vascular marking were seen in 94 cases (41.4%) and 106 cases (47.4%), respectively. When we divided the patients into 2 group wi th a cutoff point of 3 years (see Table 5), it became apparent that those abnormalities were mainly seen in older patients. Hoffman rqlorted that large shunt might have no car-

diomegaly.e The echocardiographic diagnosis of ASD has evolved to the point where it can be made with virtual certain-

ty.r Combined normal findings by x-ray film

and

echocardiography appeared adequate for exclusion of ASD.14 ASD are best visualized using a subxiphoid view. In this series the defect could be visualized in all 177 cases (Table 5).

Supporting evidence for a shunt should always be sought. Reversal septal motion on the M-mode as manifestation of right ventricular dilatation could be detected in 34 cases (15.O% of all cases). It is interest-

Pulmonary hypertension as a.consequence of ASD 20 develops rarely in chilhood.'' Pulmonary tapping and accentuated P2 as signs of pulmonary hypertension that may develop in untreated patients were found in l0 cases (4.4%), all of them belonged to the older age group. These findings were confirmed on cardiac catheterization.

ing to note that no single patient aged less than 3 years showed reversal septal motion. Right atrial enlargement and dilatation of the right ventricle that indicated volume loading due to the left-to-right shunt was found in 125 cases and 134 cases, respectively. Value of respiratory variations dimension by echocardi ographi c study in the identification of small ASD2 not requiring 15 surgery had been reported. A normal right ventri-

Abnormal electrocardiogram are usually seen in ASD 2o.l-3 Ho*ever, this abnormality is more commonly

septal motion is very sensitive and moderately

seen in older patients, as also seen in our series. In this series incomplete right bundle branch block was found

in

133 cases (58.9%) (Table 7). Incomplete right bundle branch block was mostly not seen in infants. Right axis deviation was found in 93 cases (41.1%). Prolonged PR-interval was found in 64 (28.5%). Fyler had also noted prolonged PR-interval in l0 per cent of, ASD 2() cases. There are two factors that contribute the prolongation of the PR-interval: (i) any large atrial septal defect altered a large segment of the anatomy of the atrial septum that might affect the three specific

cular end-diastolic dimension during expiration (RVDDE) is very specific but not sensitive, a normal specific, and normal variation in right ventricular diastolic with respiration (RVDVR) is both very sensitive and specific.ls Doppler color flow mapping is especially useful in detecting shunt flow across an atrial defect.3

Transesophageal echocardiography has overcome some of the limitations of the transthoracic approach. Tiansesophageal Doppler color flow imaging is extremely sensitive not only in detecting ASD but also in evaluaiing the size and the shunt flow volunr".16

Vol 5, No 1, January -

March 1996

Atrial Septal Defect

regurgitation is a determinant of rhe right to left shunt in patients with ASD even in the absence of the reversal of pressure gradient between the left and right atrium.'o

fr-ilsnid

Cardiac catheterization and surgical closure were per_ formed in 36 patients (t5.9 %) and 47 parients (20.8 %), respectively (Table 6). Most of the cardiac catheteriza_ ,iol *gl"ryrformed before rhe advent of echocardiog_ laphy.t'zs'z+ The pulmonary-systemic flow ratio > 2.5 was found in most casas, and had a good correlation with the presence of mid diastolic tricuspid flow mur_ mur. Pulmonary vascular resistance was normal in most cases. As has been practiced in most centers, the surgical closure was performed in last I I cases without cardiac catheterization. To day the risk of cardiac surgery for ASD 20 is virtually zero,but unfortunately mortality rate in this series was still higir !!"_1*gt"ul (8.5%) (Table 8). Four patients died, consisred of one

patient died on table of profuse bleeding and the 3 others deceased less than 24 hours afteisurgery of

respiratory and congestive heart failure.

In view of high rate of spontaneous closure even of

a

symptomatic infants who fail to respond to intensive medical therapy the defect is best clôsed immediately, both to improve the clinical condition and to prevent

the development of further pulmonary vascular

damf8-e. Though pulmonary hypertension develops rarely in childhood, closure of the defect should not be

postponed if there is any doubt that pulnronary arterial is normal.2l Double-umbrella devices that are inserted

with a cardiac catheter are now used to close many ASDs. The desirability of avoiding intrathoracic dis_

i,

"Uiio*.i-'-

The following features can be summarized from our

data:

20 affected

was 1.5:1.

2. Typical

girls more than boys, the sex ratio

auscultatory findings could be heard in

most older cases.

usually needed to confirm the diag_

nosis.

4. Growth

retardation, cardiomegaly, right bundle branch block, right ventriculai hypertrophy,

5.

paradoxical ventricular septal motion, were com_ mon in large ASD 20. Simple closure of ASD 2o was the procedure of

choice.

REFERENCES

l.

Feld RH, Edwards WD, puga FI, Seward JB, Weilman WH.

Atrial septal defects and atrioventriculap canal, In: Adams FH, Emmanouilides GC, eds. Moss. Heart disease in in_

fants, children and adolescent; 3rd ed. Baltimore: Williarns Wilkins, 1983; 1lB-34. 2. Berman LB, Zuberbuhler JR. Atrial septal defect. In: Ander_ son RH, Shinebourn EA, Macartney FJ, Tynan M, eds. and

Pediatric Cardiology, lst ed. New Livingstone, l9B7 ; 541-62.

yoÀ:

Churchill

DC. Nadas' pediarric cardiology. Singapore: Hanley Belfus, 1992;513-24. 4. PerloffJK. The clinjcal recognition ofcongenital heart dis_ ease; 3rd ed. Philadelphia: Saunders, l9g7 27 2_349 ; 5. Baum D, Beck R, Kodama A, Brown B. Early heart failure as cause of growth and tissue disorder in children with congenital heart disease. Circulation 1990; 62:1145_51. 6. Sastroasmoro S, Oesman IN, Macliyono B. Auskultasi jan_ tung dan fonokardiografi, Naskah Lengkap pendidikan Tambahan Berkala Ilmu liesehatan AnaÈke-XI. hal. 5_20 (Fakultas Kedokteran Universitas Indonesia, Jakarta l9g5). 7. Madiyono B, Oesman IN, Sastroasmoro S, Sukman Tp, Soelaiman EI, Rachmad KB. Secundurn atrial septal defect and aftersurgery. pediatrlndones l9g9;29 :, 199_20g. - lfore 8. Hunt CE, Lucas RV Jr. Symptomatic atrial septal defect in infancy. Circulation 197 2; 47 : l}42_g.

9. Hoffman JIE, Rudolph AM, Danilowicz D. Left to right atrial shunt in infants. Am J Cardiol 1972;3}:g6g_75. 10. Dimich I, Sreinfeld L, park SC. Symptomaric atrial septal defect in infants. Am Heart I 1973; g5:601_4. I l. Tandon R, Edward JE. Atrial septal defect in infancy. Com_ mon association with other anomalies. Circulation 1974; 49:1005-10.

12. Mahoney

LT, Truesdell SC, Krzmarzick TR, huer RM. Atrial septal defects that present in infancy. Am J Dis Child 1986; 140: l l l5-8.

13. Madiyono

SUMMARY

1. ASD

s with ASD 20 rhe clinical findings ot specific, echocardiographic ex_

:. fflgr

large ASD, it seems advisable to defer elective surgical closure until after 2-3 years of age if successful medi_ cal rnanagement can be ac tieved.3'8 Most infants with symptomatic ASD may be managed medically, allow_ ing sufficient time to observe *h.th", spontaneous closure will occur. 12 Vigorous medical mànagement, including digitalis, diuretics, and antibiotics, were suf_ ficient to maintain these infants during this critical first year permitting elective surgical repair later. l0 In

section and opening the heart

3.

B,

Oesman

IN,

Sastroasmoro S. pemeriksaan

ekokardiografi pada beberapa penyakit jantung bawaan. Naskah Lengkap pendidikan Tambahan Berkala Ilmu Kesehatan Anak ke-XI, hal. 43_70 (Fakultas Kedokteran

Universitas Indonesia, Iakarra l9g5) 14. Egelblad H, Heming J, Efsen F, Wennevold A. Non_invasive diagnosis in clinically suspected atrial septal defect ofsecun_ dum or sinus venosus type. Value ofcombining chest x_ray,

ptronocardiography, and M-mode echocardtgarphy. Ér Heart

f 980;44:lt7-21.

48 15.

Madiyono et aI.

Mauran P, Fouron JC, Carceller AM, et al. Value of respiratory variations of right ventricular dimension in the identification of small atrial septal defects (secundum type) not requiring surgery: An echocardiographic study. Am

Heart J 1986; 112:548-53. Kai H, Koyanagi S, Hirooka Y, et al. Right{o-left shunt across atrial septal defect related to tricuspid regurgitation: Assessment by transesophageal Doppler echocardiogarphy. Am Heart I 1994;127:578-84. 17. Mehrizi A, Drash A. Growth disturbance in congenital heart disease. J Pediatr 1962;67: 418-29. 18. Feidt RH, Stricler GB, Wiedman WH. Growth of children with congenital heart disease. Am J Dis Child 1969; ll7:. 573-9. 19. Suoninen P. Physical growth of children with congenital heart disease, pre and post operative study of355 cases. Acta Paediatr Scand 1971; Suppl 255:1-45. 20. Chan KY, Tay JSH, Yip WCL, Wong HB. Growth retardation in children with congenital heart disease. J Singapore Paediatr Soc 1987; 29:185-193.

16.

Med J lrtdones

21. Haworth SG. Pulmonary vascular disease in secundum atrial septal defect in childhood. Am J Cardiol 1982;5I:265-12, 22.'lamaela LA. Penilaian X-foto polos pada penyakit jantung bawaan, Naskah I-engkap Pendidikan Tambahan Berkala Ilmu Kesehatan Anak ke XI, hal. 5-20 (Fakultas Kedokteran Universitas Indonesia, Jakarta 1985). 23. Madiyono B, Trisnohadi HB, Affandi MB. His bundle electrocardiogram in children with secundum atrial septal defect. Paediatr Indones 1981; 21:1-10. 24. Oesman IN, Madiyono B, Sastroasmoro S. Kateterisasi jantung dan angiokardiografi pada penyakit jântung bawaan,

Naskah Lengkap Pendidikan Tambahan Berkala Ilmu Kesehatan Anak ke XI, hal. 71-84 (Fakultas Kedokteran Universitas Indonesia, Jakarta I 985). 25. Rachmad KB. Tindakan pembedahanjantung pada penyakit jantung bawaan; Naskah tengkap Pendidikan Tambahan Berkala Ilmu Kesehatan Anak ke XI, Hal. 88-96 (Fakultas Kedokteran Uni versitas Indonesia, Iakarta 1 985 ) 26. Graham TD. When to operate on a child with congenital heart disease. Pediatr Clin N Am 1984;3121275-9t.

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