Patients with an isolated atrial septal defect remain asymptomatic throughout childhood and adolescence. Typical physical findings reflect right ventricular volume overload and include equal jugular venous "a" and "v" waves, prominent right sided precordial impulses of both the pulmonary artery and right ventricle, a systolic ejection murmur at the upper left sternal edge, wide, fixed splitting of the second heart sound and a mid diastolic murmur at the lower left sternal edge due to enhanced right ventricular filling.