The aortic root and the upper part of the ventricular septum moves anteriorly in early systole, while the lower part moves posteriorly. The hinge of the counterpart motion of the ventricular septum is called pivot point. Using Doppler tissue imaging (DTI), we attempted to clarify the location of the pivot point of the ventricular septum in children with normal heart and with atrial septal defect (ASD), and to investigate the relation between the degree of the downward shift of the pivot point and that of volume overload of the right ventricle in patients with ASD. Study subjects consisted of 20 healthy children and 36 patients with ASD, aged from 1 to 15 years (mean 5.7+/-3.4) in the normal group and 6 months to 12 years (mean 4.4+/-3.2) in the ASD group, respectively. The pivot point was designated as a border of the color signal of DTI of the ventricular septum in early systole. Measurements were then obtained on cross-sectional echocardiography and DTI: septal length in the parasternal long-axis view, distance from aortic valve to pivot point in early systole, diastolic left ventricular internal dimension, and diastolic right ventricular internal dimension. In the normal group, the ratio of distance from aortic valve to pivot point/septal length was 0.13+/-0.049, whereas it was 0.26+/-0.168 in the group with ASD (p <0.001). In the ASD group, the distance from aortic valve to pivot point normalized by body surface area (mm/m2) correlated with the ratio of diastolic right/left ventricular internal dimension and with the ratio of pulmonary to systemic flow (Qp/Qs) (r = 0.63 and 0.50, respectively). The ratio of the distance from aortic valve to pivot point/septal length correlated with the ratio of diastolic right/left ventricular internal dimension and Qp/Qs (r = 0.56 and 0.44, respectively). By DTI, the pivot point was located at the upper 13+/-5% of the total length of the ventricular septum in normal children, and was located at 26+/-17% in patients with ASD (p < 0.001). The degree of this displacement in ASD correlated with that of volume overload of the right ventricle. The paradoxic motion of the ventricular septum shown in the ASD could be explained by this downward shift of the pivot point.