Prevalence of atrial septal aneurysm in patients with mitral valve prolapse

Surgical management of a giant atrial septal aneurysm

We experienced a very rare case of surgical management of a giant atrial septal aneurysm. It is an interesting case and is supported by preoperative, intraoperative, and pathology images.

Effect of atrial septal aneurysm on risk of cerebrovascular events in Japanese patients

BACKGROUND

The aim of the present study was to determine whether atrial septal aneurysm (ASA) detected by transthoracic echocardiography (TTE) is an independent risk factor of cerebrovascular events for Japanese people.

METHODS

A control study was conducted with 178 patients with ASA (follow-up rate, 96.7%; median follow-up period, 5.6 years) and 176 control patients (follow-up rate, 97.8%; median follow-up period, 5.4 years), selected from 42,528 consecutive patients who underwent TTE in the Omiya Medical Center, Jichi Medical School, from April 1991 to March 2001. Data were collected by structured review of patient charts and a subsequent telephone survey. Long-term cerebrovascular risk factors were evaluated by logistic regression analysis.

RESULTS

A previous episode of cerebral infarction had occurred in nine ASA patients (5.1%) and 11 control patients (6.3%). During the follow-up period, new cerebral infarction occurred in 12 ASA patients (6.7%) and six control patients (3.4%). Only atrial fibrillation was found to be an independent risk factor of new cerebral infarction (OR, 5.06; 95% CI, 1.32-19.46; P=0.04).

CONCLUSIONS

ASA is not an independent risk factor of cerebrovascular events for Japanese patients. Thus, aggressive strategies such as anticoagulation are not essential for ASA patients without embolic episodes.

Atrial septal aneurysm: a new classification in two hundred five adults

Atrial septal aneurysm is a localized "saccular" deformity, generally at the level of the fossa ovalis, which protrudes to the right or the left atrium or both. For 39 months we prospectively analyzed 205 consecutive patients in whom atrial septal aneurysm was diagnosed echocardiographically. The direction and movement of atrial septal aneurysms were carefully studied in multiple views, and, according to our findings, we now propose a new classification: type 1R if the bulging is in the right atrium only, type 2L if the bulging is in the left atrium only, type 3RL if the major excursion bulges to the right atrium and the lesser excursion bulges toward the left, type 4LR if the maximal excursion of the atrial septal aneurysm is toward the left atrium with a lesser excursion toward the right atrium, type 5 if the atrial septal aneurysm movement is bidirectional and equidistant to both atria during the cardiorespiratory cycle. We found an incidence of 1.9%, a mean age of 63 years (25 to 97 years), a female/male ratio of 2:1, valvular regurgitation 74%, hypertension 64%, left ventricular hypertrophy 38%, coronary heart disease 32%, patent foramen ovale 32%, pulmonary hypertension 31%, stroke 20%, dysrhythmias 16%, valvular prolapse 15%, and atrial septal defect 3%. No differences were found between mobile and motionless types of atrial septal aneurysm. However, differences were found between predominantly left bulging or right bulging atrial septal aneurysm (134 versus 57 patients), as well as other variables. All types of atrial septal aneurysm have particular clinical or echocardiographic characteristics. The new classification is a complete, simple, and practical form. Atrial septal aneurysm is associated with congenital and acquired heart diseases but also can present as an isolated abnormality.

Atrial Septal Aneurysm and Dilated Sinus of Valsalva in a Patient with Wolff-Parkinson-White Syndrome

Atrial septal aneurysm and a dilated sinus of Valsalva were noted on echocardiography in a 30-year-old male with Wolff-Parkinson-White syndrome. The relative low probability of all three coexisting by chance alone suggests the possibility of a common developmental origin. (ECHOCARDIOGRAPHY, Volume 13, January 1996)

Morphologic features of fossa ovalis membrane aneurysm in the adult and its clinical significance

OBJECTIVES

This study evaluated morphologic features of fossa ovalis membrane aneurysm and associated cardiac abnormalities that may predispose to systemic embolism.

BACKGROUND

An increasing number of fossa ovalis membrane aneurysms are diagnosed by echocardiography. Higher frequencies of such aneurysms have been reported in patients with embolic stroke.

METHODS

The hearts of 20 adults with fossa ovalis membrane aneurysms (mean [ +/- SD] age 62 +/- 19 years, range 24 to 87; 12 women [60%], 8 men [40%]) were examined. The areas of excised atrial septum, fossa ovalis membrane and fossa ovalis were measured. An aneurysm was defined as the ratio of the fossa ovalis membrane to fossa ovalis area > or = 1.5.

RESULTS

Compared with a control group of 20 adults (mean age 58 +/- 21 years, range 18 to 86; 12 women [60%], 8 men [40%]), the 20 patients with fossa ovalis membrane aneurysm had larger (711 +/- 240 vs. 203 +/- 105 mm2, p < 0.0001) and thinner fossa ovalis membranes (0.6 +/- 0.1 vs. 1.9 +/- 0.9 mm2, p < 0.0001). The mean ratio of the fossa ovalis membrane to fossa ovalis area was 2.1 +/- 0.4 in patients with and 1.2 +/- 0.1 in those without fossa ovalis membrane aneurysm. Patent foramen ovale was seen in 14 (70%) of 20 patients with fossa ovalis membrane aneurysm and in 4 (20%) of 20 control subjects (p = 0.0005).

CONCLUSIONS

Fossa ovalis membrane aneurysm is characterized by thinning and marked redundancy without adherent thrombi or fibrin tags. Mitral valve prolapse, dilated atria, intracardiac thrombi and patent foramen ovale are frequently seen in association with fossa ovalis membrane aneurysm and may explain the increased frequency of embolic stroke in patients with such aneurysms.

Atrial septal aneurysm and cardiac arrhythmias

Atrial septal aneurysm has been associated with thromboembolic events, interatrial shunting, mitral valve prolapse, and systolic click. An association between atrial septal aneurysm and cardiac arrhythmias has been also described. Twenty patients with atrial septal aneurysm and 19 control subjects performed 24-h Holter monitoring. Frequent (> 10/h) atrial premature beats were observed in seven patients vs. none of the controls (P = 0.008). The mean number of episodes of supraventricular tachycardia and the prevalence of ventricular tachycardia were also higher in the atrial septal aneurysm group (P = 0.044 and P = 0.046, respectively). Left atrial enlargement, mitral valve prolapse and left ventricular hypertrophy were more frequent than in the normal subjects. In conclusion, atrial and ventricular 'complex' arrhythmias occurred more frequently in patients with atrial septal aneurysm than in normal subjects. Further studies in patients with atrial septal aneurysm without other associated echocardiographic abnormalities need to be done to ascertain a potential arrhythmogenicity of this condition.

Prolapsing large aneurysm of the atrial septum simulating a right atrial mass

An unusual case of a large, prolapsing atrial septal aneurysm in a patient with an otherwise normal heart is described. The aneurysm caused right atrial obstruction and resulted in a "tumor effect." The patient experienced debilitating symptoms for years before receiving an appropriate diagnosis and curative surgical treatment.

Atrial fibrillation and interatrial septal aneurysm in a patient with Marfan's syndrome

A 25-year-old male, with Marfan's syndrome, had asymptomatic atrial fibrillation. Echocardiography revealed an interatrial septal aneurysm. Electrical cardioversion restored sinus rhythm. Relevant aspects of interatrial septal aneurysm are reviewed.

Diagnostic value of transesophageal echocardiography in atrial septal aneurysm

Transthoracic and transesophageal echocardiography was performed in 40 consecutive adult patients with an atrial septal aneurysm. In 11 (27%) of 40 patients transthoracic echocardiography failed to demonstrate the lesion and the diagnosis was established by the transesophageal approach only. Interatrial shunting, assessed by echocardiographic contrast study and/or color flow mapping, was detected in 13 (54%) of 24 patients on transthoracic imaging and in 29 (76%) of 38 patients during transesophageal echocardiography. Identification of multiple fenestrations (n = 9) and thrombi within the aneurysm (n = 2) could be achieved only by transesophageal ultrasound. A cerebrovascular event of suspected embolic origin occurred in 20 (50%) of 40 patients; 11 (55%) of the 20 patients had repeated cerebral events. Except for mitral valve prolapse in 2 patients and spontaneous left atrial contrast phenomenon in 1 patient no other potential cardiac source of embolism could be identified by transesophageal echocardiography. A marked thickening of the aneurysm was present in 14 (70%) of 20 patients with a cerebrovascular event versus only 4 (20%) of 20 patients without a cerebrovascular event (p less than 0.01). The mechanism of embolization may be both primary thrombus formation within the aneurysm and paradoxical embolization through an interatrial communication as suggested by the findings on transesophageal ultrasound in 2 patients. Although the patients of this study represent a highly selected group it may be concluded that atrial septal aneurysm is a cardiac abnormality with embolic potential. Transesophageal echocardiography has to be regarded the imaging method of choice for evaluation of this lesion.

Improved morphologic characterization of atrial septal aneurysm by transesophageal echocardiography: relation to cerebrovascular events

Transthoracic and transesophageal echocardiography was performed in 23 consecutive adult patients with an atrial septal aneurysm. In three patients with a cerebrovascular event the diagnosis was established by the transesophageal approach only. Interatrial shunting on transthoracic imaging with use of echocardiographic contrast imaging or Doppler color mapping, or both, was detected in 7 (41%) of 17 patients. On performing contrast imaging in combination with color flow mapping during transesophageal echocardiography, positive shunting was demonstrated in 15 (83%) of 18 patients. Echocardiographic identification of multiple fenestrations (n = 4) and thrombus within the aneurysm (n = 2) could be achieved for the first time by transesophageal ultrasound application. Cerebrovascular events occurred in 12 (52%) of 23 patients and were regarded as being definitely thromboembolic in 10 (43%); 8 (67%) of the 12 patients had repeated cerebral events. Except for mitral valve prolapse in one patient, no other potential cardiac source of embolism could be identified despite the use of transesophageal echocardiography. A thickening of the aneurysmal membrane greater than or equal to 5 mm was found in 9 (75%) of 12 patients with versus 3 (27%) of 11 patients without a cerebrovascular event (p less than 0.05); this proved to be the only significant difference between the two patient groups. The mechanism of embolization may be both primary thrombus formation within the aneurysm and paradoxic embolization through an interatrial communication as demonstrated by the findings in two patients. It is concluded that atrial septal aneurysm is a cardiac abnormality with thromboembolic potential. In patients with this lesion and a history of an embolic event, long-term anticoagulant therapy is indicated.