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

The Role of Trans-Oesophageal Echocardiography in the Interventional Cardiology of Adult Congenital Heart Diseases

Advances in interventional cardiology have significantly broadened the range of congenital heart diseases (CHDs) amenable to trans-catheter interventions. Trans-oesophageal echocardiography (TOE) plays a pivotal role as a procedural guide in several percutaneous treatments. Enhanced imaging modalities and technological innovations in echocardiography have refined the precision and applicability of these approaches. This review explores the role, impact, and advancements of TOE in trans-catheter treatments for adult CHDs, including both common procedures (e.g., atrial septal defect closure, ventricular septal defect closure) and less frequent interventions (e.g., Mustard/Senning baffle leak closure, Fontan conduit fenestration, ruptured sinus of Valsalva embolization).

Could Pulsed Wave Tissue Doppler Imaging Solve the Diagnostic Dilemma of Right Atrial Masses and Pseudomasses? A Case Series and Literature Review

Even if rarely detected, right atrial (RA) masses represent a diagnostic challenge due to their heterogeneous presentation. Para-physiological RA structures, such as a prominent Eustachian valve, Chiari's network, and lipomatous atrial hypertrophy, may easily be misinterpreted as pathological RA masses, including thrombi, myxomas, and vegetations. Each pathological mass should always be correlated with adequate clinical, anamnestic, and laboratory data. However, the differential diagnosis between pathological RA masses may be challenging due to common constitutional symptoms, as in the case of vegetations and myxoma, which present with fever and analogous complications such as systemic embolism. The implementation of transthoracic echocardiography (TTE) with pulsed wave (PW) tissue Doppler imaging (TDI) may improve the visualization and differentiation of intracardiac masses through different color coding of the pathological structure compared to surrounding tissue. More remarkably, PW-TDI can provide a detailed assessment of the specific pattern of motion of each intracardiac mass, with important clinical implications. Specifically, a TDI-derived pattern of incoherent motion is typical of right-sided thrombi, myxomas, and vegetations, whereas right-sided pseudomasses are generally associated with a TDI pattern of concordant motion synchronous with the cardiac cycle. An increased TDI-derived mass peak antegrade velocity may represent an innovative marker of the embolic potential of mobile right-sided pathological masses. During the last two decades, only a few authors have used TTE implemented with PW-TDI for the characterization of intra-cardiac masses' morphology and mobility. Herein, we report two clinical cases of totally different right-sided cardiac masses diagnosed using a multimodality imaging approach, including PW-TDI, followed at our institution. The prevalence and physiopathological characteristics of the most relevant RA masses and pseudomasses encountered in clinical practice are described in the present narrative review. In addition, we will discuss the principal clinical applications of PW-TDI and its potential value in improving the differential diagnosis of pathological and para-physiological right-sided cardiac masses.

Right Atrial Septal In Situ Microthrombus: A Potential Novel Cause of Patent Foramen Ovale-Associated Stroke

BACKGROUND

Patent foramen ovale (PFO)-associated stroke has a complex and diverse pathogenesis. It mainly results from a paradoxical embolism caused by venous thrombosis. However, few studies have investigated the presence of an in situ thrombus in the right atrium. Transesophageal echocardiography can effectively detect right atrial septal in situ microthrombus. Therefore, we aimed to explore the relationship between a right atrial septal in situ microthrombus and PFO-associated stroke and further dissect the pathophysiological basis of microthrombus formation.

METHODS AND RESULTS

Between April 2022 and October 2023, we prospectively investigated 466 patients who visited our hospital for transesophageal echocardiography with a high clinical suspicion of PFO. Right atrial septal in situ microthrombus was detected in 34 patients (7%), and 23 of them were examined. The microthrombus disappeared in 13 patients and decreased in 7; PFO recanalization and anatomical variations were observed in 2 and 1 patient, respectively. The incidence of index stroke was higher in the microthrombus group than in the nonmicrothrombus group (76.47% versus 61.11%). Univariate and multivariable (adjusted) analyses revealed PFO as an independent risk factor for right atrial septal in situ microthrombus formation (odds ratio, 3.29 [95% CI, 1.49-7.26]; P=0.003).

CONCLUSIONS

Transesophageal echocardiography effectively detects right atrial septal in situ microthrombus. A PFO may promote the formation of right atrial septal in situ microthrombus. Right atrial septal in situ microthrombus significantly increases the risk of PFO-associated stroke. This finding may be crucial in disease management strategies for patients with PFO.

Age-dependent association between aneurysmal and isolated redundant inter-atrial septum with patent foramen ovale

BACKGROUND

Interatrial septum (IAS) could be redundant by abnormal movement with or without aneurysmal bulging. We aimed to determine the prevalence of isolated redundant and aneurysmal IAS motion and their probable relationship with age and presence of patent foramen ovale (PFO) in a large-scale referral center.

METHOD

A total of 15,288 patients who underwent transthoracic echocardiography (TTE) at Tehran Heart Center were included From March 2019 to March 2021. Contrast echocardiography was conducted on patients with suspected PFO. Data were retrospectively analyzed from our previously established database. The prevalence of aneurysmal and redundant IAS and their relationship with age and PFO presence was evaluated.

RESULTS

Aneurysmal and isolated redundant IAS were present in 4% and 12.4% of the participants, respectively. The aneurysmal group was older, more frequently female and had higher frequency of PFO. The frequency of PFO among patients with aneurysmal IAS was about 14.4% and 5.3% in isolated redundant IAS patients. In both groups, the prevalence of abnormal IAS motion increased across age groups from the youngest to the oldest, while the prevalence of PFO decreased.

CONCLUSION

In conclusion, the frequency of PFO among patients with aneurysmal IAS was about 2.5 times more than that among patients with isolated redundant IAS and 24 times more than the normal population. The increasing trend observed across the aging group proposes a potential role for age in the pathophysiology of abnormal IAS. Furthermore, the decreasing prevalence of PFO among patients underlies its clinical significance as an important risk factor.

Long-term impact of transcatheter closure interatrial shunts on disabling migraine

BACKGROUNDS

Effectiveness of patent foramen ovale (PFO) closure on relief of migraine, is still unclear. We sought to analyse the long-term (>10 years) effects of interatrial septal shunt repair on disabling migraine performing a retrospective non-randomised study.

METHODS

Clinical records of patients with disabling, medication-refractory migraine and PFO or significant ASD referred to our centre for closure from 2006 to 2018, were analysed.

RESULTS

Forty -six patients (38 female, mean age 40.0 ± 3.7 years) with PFO and 32 patients with significant ASD (28 female, mean age 38.0 ± 4.1 years) submitted to transcatheter closure had a pre-existing disabling migraine with mean Migraine Disability Assessment Score (MIDAS) of 35.8 ± 4.7. After a mean follow-up of 118.2 ± 19.1 months (range 96 to 144), 72 out of 78 patients were still followed-up: in all subjects, aura was abolished, and migraine improved also in patients without aura. The mean MIDAS significantly decreased from baseline value (p < 0.01). Complete migraine resolution was associated in PFO patients with a shorter history of migraine, a more severe thrombophilic profile, a more severe Right-to-Left Shunt (RLS) and larger left atrial diameter and volume, and in ASD patients with bidirectional shunt.

CONCLUSIONS

Device-based repair of PFO/ASD in patients with migraine was associated with abolition of aura and symptoms reduction in the long-term period.

Navigating the Complexities: Addressing the Challenges of Aneurysmal Atrial Septal Defects

Aneurysmal atrial septal defects (ASDs) represent a rare subset of congenital cardiac anomalies, characterized by bulging of the interatrial septum. This condition poses unique challenges in diagnosis, management, and outcomes due to its variable clinical presentation and associated complications. While echocardiography remains the cornerstone of diagnosis, advanced imaging modalities such as cardiac magnetic resonance imaging (MRI) and computed tomography (CT) may provide additional insights. Optimal management strategies for aneurysmal ASDs require careful consideration of patient-specific factors, including the size and location of the defect, associated cardiovascular abnormalities, and the presence of pulmonary hypertension. Surgical repair, whether through conventional open-heart techniques or transcatheter interventions, remains the primary treatment modality; however, the approach may vary based on individual patient characteristics. Anesthetic considerations, including hemodynamic monitoring and perioperative care, are crucial in optimizing outcomes and reducing the risk of complications during surgical interventions. Long-term follow-up is essential to monitor potential complications such as residual shunting, arrhythmias, and the development of pulmonary vascular disease. Collaborative efforts among cardiologists, cardiothoracic surgeons, anesthesiologists, and other multidisciplinary specialists are paramount in providing comprehensive care for patients with aneurysmal ASDs.

Association between Covid-19 infection and platypnea-orthodeoxia syndrome

Introduction and importance

Platypnea-orthodeoxia syndrome is defined as dyspnoea and deoxygenation when changing from a recumbent to an upright position. Post-Covid-19 sequelae can induce or exacerbate pulmonary hypertension and thereby render a previously mild and asymptomatic platypnea-orthodeoxia syndrome to manifest with new or worsening symptoms.

Case presentation

The authors present the case of an 80-year-old man who following an episode of moderate-severe Covid-19 infection developed type I respiratory failure that required hospital discharge with long-term oxygen therapy. He had a background history of postural paroxysmal hypoxaemia which had previously raised the suspicion of a right-to-left shunt through either a patent foramen ovale, atrial septal defect or an intrapulmonary arteriovenous malformation. However, given the low burden of symptoms this was not explored further. Following recovery from Covid-19 infection, the patient experienced marked dyspnoea and oxygen desaturation in an upright position that was relieved by a return to a supine position.

Discussion and conclusion

Persistent dyspnoea and hypoxia are common symptoms in patients who experience post-Covid-19 syndrome. However, when patients with prior moderate-to-severe Covid-19 illness present with new onset breathlessness and/or desaturation that is worsened in an upright position, platypnea-orthodeoxia syndrome should be considered.

Atrial Transseptal Catheterisation: Challenging Scenarios and Techniques to Overcome Them

Atrial transseptal catheterisation is a fundamental skill of any interventional electrophysiologist. In this review, various scenarios that pose unique challenges to atrial transseptal catheterisation are discussed. These scenarios include post-surgical or congenital malformations of the interatrial septum, presence of interatrial septal closure devices, absent or obstructed inferior vena cava and complex congenital heart disease after palliative surgery. Transseptal catheterisation in all of the above situations is feasible and can be performed safely with the aid of dedicated tools and specific techniques.

Evaluation of causal heart diseases in cardioembolic stroke by cardiac computed tomography

Cardioembolic stroke is a potentially devastating condition and tends to have a poor prognosis compared with other ischemic stroke subtypes. Therefore, it is important for proper therapeutic management to identify a cardiac source of embolism in stroke patients. Cardiac computed tomography (CCT) can detect the detailed visualization of various cardiac pathologies in the cardiac chambers, interatrial and interventricular septum, valves, and myocardium with few motion artifacts and few dead angles. Multiphase reconstruction images of the entire cardiac cycle make it possible to demonstrate cardiac structures in a dynamic manner. Consequently, CCT has the ability to provide high-quality information about causal heart disease in cardioembolic stroke. In addition, CCT can simultaneously evaluate obstructive coronary artery disease, which may be helpful in surgical planning in patients who need urgent surgery, such as cardiac tumors or infective endocarditis. This review will introduce the potential clinical applications of CCT in an ischemic stroke population, with a focus on diagnosing cardioembolic sources using CCT.

Interatrial septal aneurysm associated with patent foramen ovale in a dog - case report

ABSTRACT Atrial septal aneurysm (ASA) is a rare congenital deformity of variable clinical relevance, often reported in association with patent foramen ovale (PFO). Transthoracic Doppler echocardiography (TTE) is the first choice for diagnosis, but complementary techniques, such as microbubble contrast, should be used. Despite its importance, in Veterinary Medicine, there is little information related to the subject, and the present study is the second report of this condition in dogs. The objective was to report a case of ASA type IV LR associated with PFO in a Shar Pei bitch, diagnosed by a combined approach of transthoracic echocardiography backed by agitated saline solution (microbubbles). During clinical care, the owners reported episodes of seizures as their main complaint. Echocardiographic examination revealed a type 4 LR atrial septal aneurysm and left ventricular systolic dysfunction. The use of microbubble contrast showed right-to-left shunt, confirming PFO. The recommended treatment was medication. It was concluded that the rarity of ASA in dogs may be due to incomplete diagnoses and the transthoracic echocardiographic examination allows its analysis and classification. Furthermore, ASA can be found in animals with or without evidence of heart disease and it should be investigated in patients with neurological alterations.

[Detection of secondary atrial fibrillation following percutaneous foramen ovale closure for cryptogenic stroke using an insertable cardiac monitor: a case report]

A 61-year-old man presented with transient dysarthria and left upper extremity numbness. Head MRI showed an acute infarct in the left temporal lobe and multiple old infarcts in the bilateral cortices. A transesophageal echocardiogram revealed a patent foramen ovale with a large shunt. No deep vein thrombosis was found. He suffered a recurrent cerebral infarction while taking antiplatelet therapy. An insertable cardiac monitor was implanted on the 41st day, and the antiplatelet treatment was changed to warfarin. The insertable cardiac monitor did not detect atrial fibrillation, even when the patient had a recurrent transient ischemic attack on the 57th day under warfarin therapy. The patient underwent percutaneous foramen ovale closure on the 63rd day. On postoperative days 18-25, an insertable cardiac monitor detected brief atrial fibrillation, and he took rivaroxaban for three months. Atrial fibrillation may occur secondary to percutaneous patent foramen ovale closure for cryptogenic stroke. The insertable cardiac monitor may help diagnose the pathogenesis of secondary atrial fibrillation and determine the optimal antithrombotic therapy.

Advances in Percutaneous Patent Foramen Ovale Closure: From the Procedure to the Echocardiographic Guidance

Percutaneous patent foramen ovale (PFO) closure by traditional, double disc occluder devices was shown to be safe for patients with PFO, and more effective than prolonged medical therapy in preventing recurrent thromboembolic events. The novel suture-mediated “deviceless” PFO closure system overcomes most of the risks and limitations associated with the traditional PFO occluders, appearing to be feasible in most interatrial septum anatomies, even if data about its long-term effectiveness and safety are still lacking. The aim of the present review was to provide to the reader the state of the art about the traditional and newer techniques of PFO closure, focusing both on the procedural aspects and on the pivotal role of transesophageal echocardiography (TEE) in patient’s selection, peri-procedural guidance, and post-interventional follow-up.

Large Atrial Septal Aneurysm Associated with Secundum Atrial Septal Defect

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A structured multimodality approach is imperative in evaluating interatrial anatomy.

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Secundum ASDs may be associated with ASA.

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Interatrial shunts may be missed, especially when aneurysms are large.

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Three-dimensional TEE allows careful interrogation of concomitant septal defects.

Transcatheter closure of fenestrated atrial septal aneurysm in children: Feasibility and long-term results

BACKGROUND

To date, extensive experience in transcatheter closure of fenestrated atrial septal aneurysm (ASA) in the pediatric population is limited.

METHODS

To report on procedural feasibility, efficacy, and long-term outcome, we enrolled all children submitted to an attempt of transcatheter closure of fenestrated ASA at two, large volume, pediatric cardiology units (Naples and Massa, Italy) between April 2000 to May 2020.

RESULTS

This retrospective study included 139 patients (median age 9 years [range 2-18] and weight 36 kg [range 10-102]); 19 (13.7%) children were ≤20 kg (range 10-20) and 14 (10.1%) were ≤5 years old. Single perforation was observed in 28 patients (20.1%), while 111 patients (79.9%) had multifenestrated ASA. The median size of the main defect was 15 mm (range 6-34) and 25 patients (18%) had a defect ≥20 mm. The procedural success rate was 99% (95% confidence interval [CI]: 94.9-99.8) using a single device in 75 (69%), two devices in 31 (28%), and three devices in 3 (3%) cases. Early minor adverse events (AEs) occurred in four patients (2.8%). Late minor AEs were recorded in one patient (0.7%) over a median follow-up of 5 years ([range 0-18 years; total 890.2 person-years, and with 30 patients (22%) followed ≥10 years). Neither mortality nor major AEs were recorded. Freedom from AEs was 99.1% at 10-15 years (95% CI: 93.5-99.8%), without any difference according to atrial septum anatomy or patient age and weight.

CONCLUSION

Transcatheter closure of fenestrated ASA is technically feasible and effective in children with excellent long-term outcomes.

Transcatheter closure of fenestrated atrial septal aneurysm: feasibility and long-term results

AIM

To report on the feasibility, efficacy and long-term outcome of transcatheter closure of fenestrated Atrial Septal Aneurysm (ASA).

METHODS

Between April 2000 and May 2020, 568 patients with fenestrated ASA underwent transcatheter closure at two large-volume Pediatric Cardiology and GUCH Units (Naples and Massa, Italy). Procedural indications were cardiac volume overload in 223 patients (39%) or prophylaxis of paradoxical embolization in 345 patients (61%). Patients' median age and weight were 42 years (range 19-52) and 66 kg (range 54-79), respectively. One-hundred and thirty-nine patients (25%) were younger than 18 years.

RESULTS

Single fenestration was found in 311 patients (55%) (Group 1), whereas 257 patients (45%) had multifenestrated ASA (Group 2). The procedure was successful in all but seven patients (1.2%). In Group 1, closure was achieved with a single device. In Group 2, one device was used in 168 patients (67%), two devices in 74 patients (28%), three devices in 12 patients (5%), and four devices in 1 patient (0.3%). The early complication rate was 3%, without any difference according to anatomy or patient's age. At discharge, complete shunt closure was higher in Group 1 (92% vs. 72%, P < 0.0001), without any difference between groups at the last follow-up evaluation (100% vs. 99%, P = 0.12). Procedural safety was persistent during the long-term follow-up (mean 7.2 ± 5.4, range 0-19 years): freedom from adverse events was 97% at 10-15 years. Seventeen patients (3%) were submitted to reintervention, mostly as prophylaxis of paradoxical embolization.

CONCLUSION

Transcatheter closure of perforated ASA is technically feasible in a high percentage of cases, with excellent long-term outcomes.

Atrial Septal Aneurysms - A Clinically Relevant Enigma?

Atrial septal aneurysms (ASAs) are often seen during routine cardiac imaging, though their clinical relevance has been poorly defined. The aneurysmal, and often mobile, inter-atrial septum is frequently associated with other clinically relevant structural cardiac abnormalities, particularly patent foramen ovale (PFO). Whilst ASAs have previously been considered an incidental finding, a well-endowed atrial septum provides more than visual interest, including insights into atrial function and intra-atrial pressures, and has important clinical implications in PFO-associated stroke, migraines, and arrhythmias. This review outlines diagnostic challenges when assessing ASAs using all imaging modalities and the clinical implications of this common anatomical variant.

Multiple paradoxical embolisms revealing a patent foramen ovale in a patient with deep venous thrombosis: A case report

Introduction

Paradoxical embolism is a rare medical phenomenon. Depending on the site of embolisation, it can cause different symptoms. Although rare, mesenteric ischemia can reveal paradoxical embolism, and the embolisation of two different sites is rarely described in the literature.

Case presentation

We report the observation of a patient with a table associating an acute mesenteric ischemia and an acute ischemia of the upper limb; whose the etiological assessment revealed a deep venous thrombosis of the lower limbs complicated by pulmonary embolism.

Clinical discussion

These paradoxical embolisms occurred through a patent foramen ovale. The diagnosis of the patent foramen ovale in this patient was revealed by transthoracic echocardiography, with bubble test. The patient benefited from an embolectomy of the superior mesenteric artery and an embolectomy using fogarty catheter by approching humeral artery at the elbow crease with good postoperative evolution. The patient was put on long-term anticoagulation with Acenocoumarol (because of low socio-economic level of our patient). We didn't recommended the closure of the PFO because of the small size of the shunt and especially because the patient refuses that procedure.

Conclusion

Paradoxical embolism remains a pathology rarely mentioned by clinicians, although it can engage the functional and vital prognosis of the patient, hence the interest of a good cardiac evaluation in any patient with embolic ischemia.

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PFO is most often asymptomatic but it can cause manifestations with variable degrees of severity.

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If it is not earyl diagnosed, or negligated, it can be life-threatining

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Paradoxical embolism is a pathological condition that requires a multidiscplinary management.

GENDER DIFFERENCES IN COMPLICATIONS FOLLOWING CATHETER ABLATION OF ATRIAL FIBRILLATION

AIM

Population studies that provide unbiased estimates of gender differences in risk of complications following catheter ablation of atrial fibrillation (AF) are sparse. We sought to evaluate the association of female gender and risk of complications following AF ablation in a nation-wide cohort.

METHODS AND RESULTS

We identified 35,211 patients (29.5% females) undergoing AF ablations from 2008-17 using national hospitalization data from Australia and New Zealand. The primary outcome was any procedural complication occurring up to 30-days after discharge. Logistic regression was used to adjust for differences in baseline characteristics between sexes. Compared with males, females were older (mean age 64.9 vs. 61.2 years), had higher rates of hypertension (14.0% vs. 11.6%) and hematological disorders (5.3% vs. 3.8%) and experienced a higher rate of procedural complications (6.96% vs. 5.41%) (all p<0.001). This gender disparity remained significant after adjustment (OR 1.25 [95%CI 1.14-1.38], p<0.001) and was driven by an increased risk of vascular injury (OR 1.86 [1.23-2.82], p=0.003), pericarditis (OR 1.86 [1.16-2.67], p=0.008), pericardial effusion (OR 1.71 [1.35-2.17], p< 0.001), and bleeding (OR 1.30 [1.15-1.46], p<0.001). Notably, the gender difference persisted over time (OR for the most recent period 1.19 [1.003-1.422], p=0.046) despite a declining complication rate in both men and women.

CONCLUSION

Females undergoing AF ablations experienced a 25% higher risk of procedural complications compared with males, a disparity that has persisted over time despite a falling complication rate. Efforts to reduce this gender disparity should focus on reducing the incidence of pericardial effusion, pericarditis, vascular injury, and bleeding.

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.

Individualized Experience With Percutaneous Transcatheter Closure of Multiple Atrial Septal Defects: A Single-Center Study

Multiple atrial septal defects (ASDs) are one type of secundum ASD, most of which have an atrial septal aneurysm or long interdefect distance. In our retrospective single-center study, we reviewed different closure strategies for multiple ASDs. We analyzed 50 patients who underwent percutaneous transcatheter closure from May 2011 to July 2019. Information on the patients' characteristics, operation procedure, occluder selection, and complications was collected. According to the feature of the defects and device choice, multiple ASDs were divided into five groups. A successful operation was achieved in every patient. A total of 50 patients were implanted with 58 devices, with 26 patients implanted with a single standard ASD occluder (ASDO); six patients were implanted with double standard ASDOs, and only one patient was implanted with three standard ASDOs. There were 17 patients whose closure was made using the small-waist–big-edge ASDO. Seventy-six percent of the patients (38/50) had an immediate residual shunt. During the mean follow-up of 25.76 ± 22.53 months, the complete closure rate was 92%. Except for two patients with a transient atrioventricular block, individualized experience with percutaneous transcatheter closure for multiple ASDs was effective in a single-center study. After a mid- to long-term follow-up, the multiple ASDOs and small-waist–big-edge ASDO had no serious adverse events or complications.

Agitated Saline Contrast Echocardiography in the Identification of Intra- and Extracardiac Shunts: Connecting the Dots

Agitated saline contrast studies are an essential component of contemporary echocardiography. Agitated saline contrast plays a critical role in the elucidation of intracardiac versus intrapulmonary shunting and can have major therapeutic implications, particularly in light of the evolution of percutaneous treatment options for atrial septal defects or a patent foramen ovale. Despite their perceived simplicity, however, there are numerous pitfalls of these investigations that can occur during their performance and interpretation. As such, the authors review the "bubble study" in identifying intracardiac and extracardiac shunts, including the history of its development, the physics and physiology of contrast enhancement, how to optimally perform and interpret an agitated saline contrast study, and its safety in unique populations.

A giant atrial septal aneurysm causing tricuspid valvular obstruction

Atrial septal aneurysm (ASA) is a rare congenital malformation consisting of redundant atrial septal tissue that bulges into either the right or the left atrium. Here, we report the case of a 45-year-old man with a giant ASA prolapsing into the tricuspid orifice and leading to tricuspid valvular obstruction. He was treated successfully by resection of the ASA and repair of the resulting atrial septal defect. Our case indicates the utility of transthoracic, contrast, and transesophageal echocardiography to characterize a huge ASA causing tricuspid valvular obstruction.

Comparison of Intracardiac Echocardiography and Transesophageal Echocardiography for Image Guidance in Percutaneous Patent Foramen Ovale Closure

Background and Objectives: Transesophageal echocardiography (TEE) guidance is the current gold standard for catheter-based procedures in the treatment of structural heart diseases. Intracardiac echocardiography (ICE), which can be performed under local anesthesia, has been recently introduced and is becoming more widely used. We aimed to compare the efficacy and safety of ICE and TEE in patent foramen ovale (PFO) device closure. Materials and Methods: All 74 patients with a history of cryptogenic stroke undergoing PFO closure for secondary prophylaxis were selected from our registry. Intraprocedural TEE was performed by echocardiographer-cardiologists with the patient under general anesthesia. Conversely, ICE was performed with the patient under local anesthesia. Baseline characteristics, procedural details, and immediate outcomes were compared between the TEE and ICE groups (n = 49 and n = 25, respectively). Results: Although patients in the ICE group were older (47 ± 10 vs. 57 ± 7 years, p < 0.001), sex and comorbidity variables were similar between the two groups. The degree of inducible right-to-left shunt via the PFO, assessed using preprocedural TEE, was also comparable. Notably, fluoroscopy time (22 ± 18 vs. 16 ± 7 min, p = 0.030), radiation dose (498 ± 880 vs. 196 ± 111 mGy, p = 0.022), and total procedural time in the catheter laboratory (99 ± 30 vs. 67 ± 12 min, p < 0.001) were significantly lower in the ICE group than those in the TEE group. The entire hospital stay was similar between groups (3.8 ± 2.2 vs. 3.4 ± 1.3 days, p = 0.433). No procedural complications, such as device embolization, pericardial hemorrhage, major bleeding, mortality, or access-related vascular injury were reported in either group. Conclusions: ICE-guided PFO device closure is quicker and less hazardous in terms of radiation exposure than the TEE-guided procedure, with similar procedural outcomes and duration of hospital stay.

[Utility of transesophageal echocardiography for etiologic diagnosis of centrum ovale infarcts]

A small centrum ovale infarct in the territory of the white matter medullary artery can be caused not only by embolism but also small-vessel disease. In our study, thorough screening for emboligenic diseases was performed, including the modality of transesophageal echocardiography (TEE), in patients with an acute, isolated, small (less than 1.5 cm) infarct in the centrum ovale. Of 79 patients enrolled in this study, 45 had emboligenic diseases, in whom a patent foramen ovale was detected in 29 patients, complicated aortic arch lesion in 15, atrial fibrillation in 6, occlusive carotid disease in 2, and others in 2. The majority (80%) of the emboligenic diseases were diagnosed by TEE. Therefore, TEE may be mandatory for the etiologic diagnosis of centrum ovale infarcts.

Dramatic Aneurysmal Atrial Septum Identified with Intracardiac Echo Complicating Transseptal Puncture

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Atrial septal aneurysm is a largely underdiagnosed phenomenon.

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Septal anatomy is best delineated using intracardiac echocardiography.

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Septal anatomy is clinically relevant with procedures involving transseptal puncture.

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Atrial septal aneurysms may be associated with supraventricular tachycardias.

Correlations between serum homocysteine levels and RoPE score in patients with patent foramen ovale

The pathophysiological relationship between elevated serum homocysteine (Hcy) levels and patent foramen ovale (PFO) has not yet been completely clarified. In the present study, we assess the correlation between serum homocysteine levels and the RoPE score in PFO patients. We retrospectively reviewed clinical and instrumental data of 244 subjects referred to a single tertiary center for PFO evaluation and/or treatment between January 2010 and January 2018,stratified as closure and control group, respectively. Patients in the closure group had an higher serum Hcy levels compared to the control group (28.5 ± 8.5 vs 10.2 ± 6.6 μg/dL, p < 0.0001). A significant direct correlation was observed between serum Hcy levels and the RoPE Score in the entire population. A positive significant correlation continued to exist also in the closure and control groups (r = 0.472, p < 0.0001 and r = 0.378, p < 0.0001, respectively). A receiver operating characteristics curve identified the optimal cutoff value of homocysteinemia as a predictor of RoPE score > 7 in the closure group (AUC 0.90, 95% CI 0.81-0.94, p < 0.0001) when 19.5 μg/dL. Multivariate logistic regression analysis demonstrated that an Hcy serum level ≥ 19.5 μg/dL predict an RoPE score > 7 (OR 3.21, 95% CI 2.82-3.26, p < 0.0001) in closed patients independently from the presence of permanent right-to-left (RLS) (OR 2.28, 95% CI 2.01-2.43, p = 0.001) and atrial septal aneurysm (ASA) (OR 3.04, 95% CI 2.64-3.51, p < 0.0001). Serum homocysteine levels in PFO patients are positively correlated with the RoPE score. Moreover, a homocysteinemia ≥ 19.5 μg/dL predicts an RoPE score > 7 independently from the presence of a permanent RLS and a concomitant ASA.

Cardiac Masses in Echocardiography: A Pragmatic Review

Transthoracic echocardiography is a useful diagnostic technique for the identification of intracardiac and extracardiac masses, which can evaluate morphologic properties of the masses such as their location, attachment, shape, size, mobility, and possible hemodynamic-related implications. Apart from physiological variants and structural normal mimickers, echocardiography can detect principal intracardiac masses such as neoplasms, thrombi, vegetation, and extracardiac masses such as metastatic lesions. Moreover, transesophageal echocardiography can provide further details and provide higher accuracy in case a deeper examination of the mass is needed. This review will focus on the systematic evaluation of intra-/extracardiac masses including epidemiology and morphological and echocardiographic features, providing practical and technical tips to health-care professionals to achieve correct identification of the masses. General data on cardiac masses were extracted via PubMed/MEDLINE search engine from indexed reviews, original studies, and clinical case reports. The echocardiographic features of cardiac masses were reviewed according to the most relevant international cardiology and echocardiography scientific societies' position statements.

Light anti-thrombotic regimen for prevention of device thrombosis and/or thrombotic complications after interatrial shunts device-based closure

AIMS

The optimal antiplatelet therapy after atrial septal defect (ASD) or patent foramen ovale device closure (PFO) remain to be established. We evaluated the safety and effectiveness of 6-month 100 mg Aspirin (ASA) regimen in the very long-term follow up after intracardiac echocardiography (ICE) -aided interatrial shunt closure in a large retrospective cohort.

METHODS

Single-center retrospective analysis which included medical and instrumental data of 789 consecutive patients referred to our institution over a 15 years period due interatrial shunt catheter-based closure.

RESULTS

Finally, 734 patients were included in the analysis (mean age 46.1 ± 14.6 years, 398 females): ASD and PFO closure were successfully performed in 281 and 453 patients, respectively. Over the follow-up period, no major bleeding events were observed while the rate of minor bleeding events was 0.9%. Tolerance problems were detected in 3.4% of cases (n==28). In 11 patients (1.5%) an abnormal complete blood count was detected and monitored up to normalization. On a mean follow -up of 10.3 ± 3.0 years (range 1-15), 10 patients (1.36%) had a persistent moderate shunt 12 months after closure and maintained Aspirin 100 mg life-long, whereas the remaining 724 suspended the treatment after 6 months. Device thrombosis in ASD and PFO groups were 0% and 0.2%, respectively. A cerebral ischemic event occurred in 0.4% of the entire cohort.

CONCLUSIONS

A regimen of 100 mg of ASA for six months after ASD/PFO closure appeared to be both safe and effective in preventing device thrombosis and major bleedings.

Left atrial enlargement as a maker of significant high-risk patent foramen ovale

Left atrial (LA) enlargement is a marker of LA cardiopathy and, in patients with patent foramen ovale (PFO), is associated with an increased risk of ischemic stroke. The primary study outcome was the comparison of LA diameter between patients undergoing percutaneous PFO closure versus those treated conservatively. The secondary endpoints were the association of LA diameter with the Risk of Paradoxical Emboli (ROPE) score and the presence of Atrial septal aneurysm (ASA) and Right-To-Left Shunt (RLS). Retrospective analysis of clinical and instrumental data of 1040 subjects referred to a single tertiary center for PFO evaluation and treatment. Seven hundred and nineteen patients were enrolled: 495 patients (closure group, mean RoPE score 7.6 ± 0.8) underwent PFO closure while 224 patients (control group, mean RoPE score 4.1 ± 0.9. p < 0.001) were left to medical therapy. Preoperative LA diameter was significantly larger in closure group and reduced from 44.3 ± 9.1 to 37.3 ± 4.1 mm (p = 0.01) 1 year after the procedure to the size of controls. A larger LA diameter was associated with permanent RLS, RLS curtain pattern, ASA presence and multiple ischemic brain lesions pattern at neuroimaging. A LA diameter ≥ 43 mm was a predictor a RoPEscore > 7. In our patients' cohort, LA diameter was associated with the clinic severity of PFO and RLS. The reversal of LA enlargement after PFO closure suggests a role for RLS to induce LA cardiopathy. LA enlargement has the potential to be considered per se as an indication to transcatheter PFO repair.

An atrial septal aneurysm with an organized thrombus in an asymptomatic patient: A case report

INTRODUCTION

An atrial septal aneurysm (ASA) is a rare congenital cardiac deformity characterized by interatrial septum protruding into atria forming a saccular structure.

PATIENT CONCERNS

In our case, a 42-year-old female patient presented to our hospital complained of palpitation.

DIAGNOSIS

Transthoracic echocardiography detected a 3.4 × 3.4 cm circular mass attached to the interatrial septum in right atrium complicated with a 6 mm secundum atrial septal defects (ASD).

INTERVENTIONS

The patient received a cardiopulmonary bypass surgery to remove the mass and close the ASD.

OUTCOMES

The mass turned out to be an organized thrombus with calcium deposition and fibrinoid necrosis.

CONCLUSION

ASA is a potential location of atrial thrombus because of the stagnation of blood. Systemic embolism events are the main complications of ASA. Surgery or anticoagulation is both recommended in patients with ASA with thrombus.

Association between atrial septal aneurysm and arrhythmias

Objective. This study aimed to assess the association of atrial septal aneurysm (ASA) with cardiac arrhythmias by comparing patients with ASA with a control group with non-ASA, matched for age and gender. Methods. 641 patients with ASA who fulfilled the inclusion criteria were enrolled into the study. The control group consisted of 641 patients without ASA. Patients underwent physical, electrocardiographic and transthoracic echocardiographic examinations. Additional examinations such as transesophageal echocardiography, 24-h rhythm Holter monitoring, and electrophysiological study were performed when clinically needed. Results. There were no differences between the groups in respect to baseline demographic, clinical parameters and echocardiographic parameters except ischemic stroke and smoking status. Percentages of patients suffering from atrial premature complex (APC), ventricular premature complex (VPC), supraventricular tachycardia (SVT) and paroxysmal atrial fibrillation (AF) were higher in ASA patients compared to non-ASA patients. In addition, these parameters were independently associated with the presence of ASA in logistic regression analysis. Conclusions. Certain types of arrhythmias such as APC, VPC, SVT and paroxysmal AF have been shown to be independently associated with the presence of ASA.

Role of 3D transesophageal echocardiography in transcatheter closure of atrial septal aneurysms

BACKGROUND

Three dimensional transesophageal echocardiography (3DTEE) is superior to two dimensional transesophageal echocardiography (2DTEE) as it provides all atrial septal information from a single view.

AIM

To evaluate 3DTEE role in analysis of atrial septal aneurysm (ASA) and in device closure guiding.

METHODS

Three dimensional transesophageal echocardiography were recorded with Vivid*E9,GE system over 14 months. ASAs were classified into 4 types (A: with PFO, B: with one ASD, C: with 2 ASDs, and D: with multiple fenestrations). Each aneurysm was assessed according to its type, shape, dimensions, orientation, aneurysmal tissue, and the surrounding rims. All patients passed to transcatheter aneurysm closure.

RESULTS

A total of 26 patients with ASAs were assessed (7 imperforated aneurysms excluded). The remaining 19 patients' age was 12.84 ± 5.82years. Four patients had type A aneurysms, 6 had type B, 4 had type C, and 5 had type D. 3DTEE demonstrated oval aneurysms in 17 patients. The orientation was oblique in 8 patients, vertical in 7, and horizontal in 4. The ASAs dimensions were 23.5 ± 5.1, 23.2 ± 5.1, and 22.0 ± 4.0 mm for oblique, vertical, and horizontal axes. Percutaneous closure succeeded in 18 patients. Balloon sizing was used in 4 patients. Devices used were: In type A:PFO devices, in type B:ASO devices, in type C:two patients required two ASO devices in each patient and two patients required one cribriform device, and in type D:Cribriform devices used for three patients, PFO for one and ASO for one. LA, LUPV, and RUPV approaches were used. Aspirin was received for 6 months.

CONCLUSION

Three dimensional transesophageal echocardiography helps to select aneurysms suitable for transcatheter closure, select the suitable devices, and guide the transcatheter procedure.

Is there any association between rs1303 (Pi*M3) variant of alpha-1 antitrypsin gene and atrial septal aneurysm development?

AIM

Atrial septal aneurysm (ASA) is one of the congenital heart defects. The underlying pathophysiology of ASA has not been fully understood yet. Alpha-1 antitrypsin (A1AT) is a serine protease inhibitor glycoprotein, which is held responsible from tissue wall proteolysis if it is deficient in the body. The aim of this study was to investigate A1AT serum levels and the rs1303 (Pi*M3) variant in A1AT gene in patients with ASA.

MATERIAL AND METHODS

Thirty patients (7 male and 23 female) with isolated ASA and 33 patients (11 male and 22 female) with normal atrial septum on echocardiography were included in this study. A1AT serum levels of study patients were measured quantitatively by the enzyme-linked immune sorbent assay (ELISA) method. The A1AT gene mutation rs1303 was analyzed by genotyping, which is performed on genomic DNA extracted from circulating mononuclear blood cells. Single-nucleotide polymorphism was evaluated on polymerase chain reaction using commercial kits.

RESULTS

A1AT serum levels were not statistically different among patients with and without ASA (9.52 ± 4.33 µg/mL vs 9.83 ± 5.27 µg/mL, respectively, P = .80). A1AT homozygote mutation (PiM3M3) was significantly higher in the ASA group than the control group (21 vs 11, OR (95% CI): 6.68 [2.09-21.40], P = .001). A1AT serum levels were similar among patients with normal A1AT allele (PiMM), homozygote variant (PiM3M3), and heterozygote variant (PiMM3) (P = .79).

CONCLUSION

This preliminary study revealed that homozygote A1AT rs1303 (PiM3M3) variant is significantly higher in patients with isolated ASA and may be associated with ASA development. Large scale comprehensive studies are needed to validate these results.

The Study of the Fixed Dose Combination of Lisinopril with Prolonged Indopamide (FIXLINDA) with Daily Blood Pressure Monitoring and Diuresis in Hypertensive Patients

Аim. To study the efficacy, tolerability and safety of using a fixed dose combination of an ACE inhibitor lisinopril with a prolonged-action diuretic indapamide in patients with degree 1-2 hypertension.

Material and methods. Patients (n = 32) with uncontrolled 1-2 degrees hypertension, moderate or high cardiovascular risk, without severe comorbid diseases, who were prescribed a fixed dose combination of lisinopril (5, 10 or 20 mg) and indapamide (1.5 mg) were included in the observational study. All patients had home monitoring of blood pressure and diuresis, as well as assessment of subjective tolerance of treatment and registration of adverse events within 3 months of observation. Assessment of changes in circadian fluctuations in blood pressure and diuresis, the frequency of achieving the target blood pressure at the outpatient stage, as well as the subjective tolerance of treatment and adverse events during a three-month follow-up.

Results. Target blood pressure was achieved in 44.5% of patients taking the fixed dose combination of lisinopril 5 mg + prolonged-acting indapamide1.5 mg; 76.9% – in patients taking the combination of lisinopril 10 mg + indapamide 1.5 mg; 78,6% – in patients taking the combination of lisinopril 20 mg + indapamide 1.5 mg. The achieved antihypertensive effect was characterized by daily circadian stability, accompanied by an improvement in the initially impaired day and night diuretic profile (increase in the share of daytime diuresis by 29.6% and 22.3% with a decrease in the share of nighttime diuresis by 35% and 49% when using a combination with lisinopril 5 and 10 mg, respectively). The treatment was well tolerated by patients and did not cause the development of serious adverse events. Reported adverse events (non-intense dry cough, headache, general weakness) were transient and did not require correction or withdrawal of treatment.

Conclusion. The fixed dose combination of the ACE inhibitor lisinopril (5, 10 or 20 mg) and the long-acting thiazide-like diuretic indapamide (1.5 mg) had good antihypertensive efficacy with improved circadian blood pressure and diuresis profiles, acceptable tolerance and safety of treatment, as well as a simple choice of doses of the drug components.

Atrial Septal Aneurysm in Adult Patients of Therapeutic Hospital

Aim. To study detection of atrial septal aneurysm (ASA) by transthoracic echocardiography in patients of the older age group of the therapeutic hospital, as well as combinations with other structural disorders of the heart and blood vessels, as well as other signs of congenital connective tissue dysplasia (CCTD) of other localization.

Material and methods. Identification of ASA as well as other signs of CCTD was performed in patients ≥40 years hospitalized due to exacerbation of therapeutic diseases (n=1119), which had transthoracic echocardiography.

Results. ASA was found in 1.34% of patients (n=15). Undifferentiated connective tissue dysplasia was diagnosed in 14 (93.3%) ASA patients. Prolapse of mitral (60%), tricuspid (33.3%) or both atrio-ventricular valves of the heart (6.7%), patent foramen ovale (33.3%), rudimentary Eustachian valve (6.7%), additional ventricle chords (13.3%), Valsalva sinus dilation (6.7%) was found in ASA patients. 14 (93.3%) patients had electrocardiography signs of cardiac rhythm and conduction disorders. Chronic venous insufficiency (100%), disorders of the musculoskeletal system (100%), hiatal hernia (40%), anterior abdominal wall hernia (46.7%), nephroptosis (46.7%), kidney cysts (33.3%) intestinal diverticula and dolichosigma (26.7%), bronchiectasis (6.7%) were also found.

Conclusion. ASA was found in 1.34% of patients in a therapeutic hospital ≥40 years. Clinically significant and prognostically unfavorable CCTDs were not found in ASA patients in this study. However, physicians should consider the possibility of the presence of other abnormalities of the heart and large vessels, as well as other systems and organs that can lead to fatal events, in these patients.

Very long-term outcomes of transcatheter secundum atrial septal defect closure using intracardiac echocardiography without balloon sizing

AIM

To assess the long-term outcomes of device-based closure of atrial septal defects (ASDs) with no sizing balloon.

MATERIAL AND METHODS

Two hundred and eighty-one consecutive patients (mean age 34±13 years, 178 women) underwent intracardiac echocardiography (ICE)-aided transcatheter closure of secundum ASDs over a 15-year period (September 2002 to March 2017). Sizing of the ASDs was calculated under ICE guidance (UltraICE, EP Technologies, Boston Scientific Corporation, San Jose, CA, USA) using the concept of "supportive rim" for ASDs without the aid of a sizing balloon. Follow-up was conducted by transoesophageal and transthoracic echocardiography.

RESULTS

The procedure was carried out successfully in all patients with 0% related mortality and 5.7% procedural complications. The Amplatzer ASD Occluder was implanted in 251 patients (89.3%, mean size 26.4±10.2 mm) whereas the Gore Cardioform was used in 30 patients (10.6%). Over 10.3±3 years of follow-up (range 1-15) 100% of patients were alive. The complete occlusion rate was 97.8%. No aortic or atrial free wall erosions, device thrombosis, or device frame fractures were detected during the follow-up period.

CONCLUSION

The present study suggested that ICE-guided closure of ASDs with current devices without sizing balloons is safe and effective with very low procedural and late complications even in the very long-term follow-up.

Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome (SECRETO): echocardiography performance protocol

BACKGROUND

The incidence of ischemic stroke in young patients is increasing and associated with unfavorable prognosis due to high risk of recurrent cardiovascular events. In many young patients the cause of stroke remains unknown, referred to as cryptogenic stroke. Neuroimaging frequently suggests a proximal source of embolism in these strokes. We developed a comprehensive step-by-step echocardiography protocol for a prospective study with centralized reading to characterize preclinical cardiac changes associated with cryptogenic stroke.

METHODS AND STUDY DESIGN

SECRETO (Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome; NCT01934725) is an ongoing multicenter case-control study enrolling patients (target n = 600) aged 18-49 years hospitalized due to first-ever ischemic stroke of undetermined etiology and age- and sex-matched controls (target n = 600). A comprehensive assessment of cardiovascular risk factors and extensive cardiac imaging with transthoracic and transesophageal echocardiography, electrocardiography and neurovascular imaging is performed. Transthoracic and transesophageal echocardiograms will be centrally read, following an extensive protocol particularly emphasizing the characteristics of left atrium, left atrial appendage and interatrial septum.

CONCLUSIONS

A detailed assessment of both conventional and unconventional vascular risk factors and cardiac imaging with transthoracic and transesophageal echocardiography are implemented in SECRETO, aiming to establish indirect and direct risk factors and causes for cryptogenic stroke and novel pathophysiological brain-heart pathways. This may ultimately enable more personalized therapeutic options for these patients.

Atrial septal defect and patent foramen ovale: early and long-term effects on endothelial function after percutaneous occlusion procedure

Percutaneous closure of atrial septal defect (ASD)/patent foramen ovale (PFO) can influence systemic hemodynamics. The aim of this research was to evaluate the influence of the closure procedure on morphological and functional characteristics of systemic vascular walls. Fourteen ASD (mean age 40 ± 16 years) and 14 PFO (45 ± 8 years) patients were enrolled in this retrospective study. All underwent percutaneous closure procedure; physical, clinical and biochemical evaluations; echocardiography; carotid evaluation; and brachial artery flow-mediated vasodilatation (FMD). All the evaluations were performed at the time of enrollment, 24 h post-procedure, at 1-6-12-month follow-up. FMD at enrollment was higher in PFO patients as compared to ASD (8.5% [7.6-10.7%] versus 6.5% [5.6-7.6%], p < 0.0001). FMD values in ASD patients significantly increased during follow-up (enrollment: 6.5% [5.6-7.6%], 12-month follow-up: 8.8% [7.2-10.3%], p < 0.01). PFO patients showed reduced FMD values 24 h after the procedure (enrollment: 8.5% [7.6-10.7%], 24 h post-procedure: 7% [6.3-9%], p < 0.001), while recovering endothelial function during follow-up period to baseline values (FMD at 12-month follow-up: 8.2% [7.6-10.5%]). At one-year follow-up, FMD remained inversely related to systolic pulmonary arterial pressure and right and left atrial/ventricle chambers dimensions (RV proximal diameter efflux tract, right atrium [RA] longitudinal diameter, RA transverse diameter, RA area, left ventricle [LV] end-diastolic diameter, left atrium [LA] anteroposterior diameter, LA area; p < 0.01) in ASD patients. Endothelial function improved after percutaneous closure of ASD, while remaining stable after PFO closure. Therefore, ASD patients seem to improve their cardiovascular risk profile after percutaneous closure of their defect.

Atrial septal aneurysm with rare comorbid pulmonary arteriovenous malformation as aetiology for cryptogenic stroke

Atrial septal aneurysms have two mechanisms for cardioembolic events. One is the aneurysm itself can act as a nidus for thrombus formation in the left atrium. The aneurysm creates an area of low turbulence leading to haemostasis allowing fibrin-platelet adhesions to form. If the clot is on the left atrial wall, it may be dislodged by oscillations of the septum and travel into the systemic circulation. The second mechanism is via, an often comorbid, interatrial shunt such as a Patent Foramen Ovale or Atrial Septal Defect. We report a unique case where the associated right to left shunt leading to the cryptogenic stroke is a pulmonary arteriovenous malformation.

Echocardiographic Findings in Patients with Atrial Septal Aneurysm: A Prospective Case-Control Study

Background

Atrial septal aneurysm (ASA) is a congenital deformity of the interatrial septum with a prevalence of 1-2% in the adult population. Although ASA has been supposed to be an incidental finding in echocardiographic examination, its structural and clinical associations have gained an increasing interest.

Aim

To investigate and compare the clinical features and echocardiographic parameters between ASA patients and age- and gender-matched control group patients.

Methods

410 patients with ASA were enrolled in the study, prospectively. After the exclusion of 33 patients, the remaining 377 patients comprised the study group. The control group consisted of 377 age- and gender-matched patients without ASA.

Results

Aortic valve regurgitation and mitral valve regurgitation were more often observed in patients with ASA, and percentages of patients with ascending aortic aneurysm (AAA), patent foramen ovale (PFO), and atrial septal defect (ASD) were higher in ASA patients compared to control group patients. Aortic root diameter was larger in ASA patients compared to control group patients (29.2 ± 3.9, 28.6 ± 3.1, p=0.05, respectively). Ascending aorta diameter was higher in ASA patients compared to patients without ASA (44 ± 0.3, 41.5 ± 0.2, p=0.02). Logistic regression analysis revealed that mitral valve regurgitation (OR: 2.05, 95% CI : 1.44–2.92, p < 0.001) and PFO (OR: 11.62, 95% CI : 2.64–51.02, p=0.001) were positively and independently associated with the presence of ASA. AAA tended to be statistically and independently associated with ASA (OR: 2.69, 95% CI : 0.97–7.47, p=0.05).

Conclusions

We have demonstrated a higher incidence of mitral/aortic valvular regurgitations, AAA, PFO, and ASD in ASA patients compared to age- and gender-matched control group patients. In addition, we have shown that ASA is significantly and positively associated with mild mitral regurgitation and PFO.

Percutaneous transcatheter closure of high-risk patent foramen ovale in the elderly

The efficacy of percutaneous transcatheter closure for preventing recurrent cerebrovascular events in elderly patients with high-risk patent foramen ovale (PFO) remains unclear, whereas in young patients, it has been shown to effectively prevent the recurrence of embolic stroke. The aim of this study was to investigate the safety and efficacy of percutaneous PFO closure in elderly patients with high-risk PFO. Between September 2012 and October 2018, 14 patients ≥ 60 years old with high-risk PFO underwent percutaneous closure to prevent recurrence of cerebrovascular events. The primary end point was recurrence of cerebrovascular events after closure in elderly patients with high-risk PFO, and the secondary end points were occurrence of device-related complications, cerebral hemorrhage, and new-onset atrial fibrillation (AF). The mean patient age and number of cerebrovascular events before closure were 75.2 ± 6.5 years and 1.7 ± 0.7, respectively. All procedures were successfully performed under general anesthesia by transesophageal echocardiography and using a 25-mm Amplatzer Cribriform device. No procedure-related complications occurred. Patients were followed up for a mean 2.6 ± 1.8 years. No patients experienced device-related complications or recurrent cerebrovascular events. However, one patient had AF-related device closure complications at 1 month postoperatively. In addition, other patient had a cerebral hemorrhage with unknown relationship to PFO closure 3 years postoperatively. Percutaneous closure of high-risk PFO in elderly patients may be as effective and safe as in younger patients. It is crucial to evaluate PFO morphology regardless of age in cases of paradoxical embolism.

A Proposed Etiology for Atrial Tachyarrhythmia in Neonates with Atrial Septal Aneurysms

An atrial septal aneurysm (ASA) is an increasingly recognized entity that involves septal tissue significantly bulging into either atria instead of remaining in a relatively neutral position. ASAs may be described based on the length of the segment of atrial septal tissue involved as well as the distance and direction of excursion into the atria throughout the cardiac cycle. Complications associated with ASA include arrhythmias and thromboembolic events with the latter usually in the context of atrial shunting. While the presence of an ASA has been implicated in the development of atrial tachyarrhythmias, no clear mechanism has been elucidated to-date. In this case, we document one of the previously proposed mechanisms of atrial arrhythmia using echocardiography imaging.

Echocardiographic features of PFOs and paradoxical embolism: a complicated puzzle

Patent foramen ovale (PFO) is a residual, oblique, slit or tunnel like communication in the atrial septum that persists into adulthood. It is usually an incidental finding with no clinical repercussions. Nevertheless, recent evidence supports the association between the presence of a PFO and a number of clinical conditions, most notably cryptogenic stroke (CS). There is enough evidence that paradoxical embolism is a mechanism which can explain this association. Patient characteristics and certain echocardiography-derived anatomical and hemodynamic features of PFO provide great assistance in estimating the probability of paradoxical embolism. In this review, we initially describe PFO embryology and anatomy. We extensively present the available data on clinical, anatomical and hemodynamic features of PFOs which have been correlated with increased likelihood of paradoxical embolism and recent evidence of therapeutic management.

Dilating Vascular Diseases: Pathophysiology and Clinical Aspects

Atherosclerotic disease of the vessels is a significant problem affecting mortality and morbidity all over the world. However, dilatation of the vessels either in the arterial system or in the venous territory is another vessel disease. Varicocele, pelvic, and peripheral varicose veins and hemorrhoids are aneurysms of the venous vascular regions and have been defined as dilating venous disease, recently. Coronary artery ectasia, intracranial aneurysm, and abdominal aortic aneurysm are examples of arterial dilating vascular diseases. Mostly, they have been defined as variants of atherosclerosis. Although there are some similarities in terms of pathogenesis, they are distinct from atherosclerotic disease of the vessels. In addition, pathophysiological and histological similarities and clinical coexistence of these diseases have been demonstrated both in the arterial and in the venous system. This situation underlies the thought that dilatation of the vessels in any vascular territory should be considered as a systemic vessel wall disease rather than being a local disease of any vessel. These patients should be evaluated for other dilating vascular diseases in a systematic manner.

Multiperforated atrial septal "aneurysm in aneurysm": Percutaneous closure guided by real-time three-dimensional transesophageal echocardiography

Atrial septal aneurysm (ASA) is a localized deformity of the interatrial septum, which protrudes into the right and/or left atrium. ASA with defects is a source of cardiac embolism. Although transcatheter closure is now a common procedure, it is still challenging in patients with complicated ASA. We describe a case of giant atypical multiperforated ASA with irregular mobility, which showed a rare "aneurysm in aneurysm" structure. Real-time three-dimensional transesophageal echocardiography showed vivid images, which clearly demonstrated these irregular shaped defects mimicking the atriotomy view, and played a crucial role in guiding the transcatheter closure.

Acute Pulmonary Embolism: Focus on the Clinical Picture

Acute pulmonary embolism (APE) is characterized by numerous clinical manifestations which are the result of a complex interplay between different organs; the symptoms are therefore various and part of a complex clinical picture. For this reason, it may not be easy to make an immediate diagnosis. This is a comprehensive review of the literature on all the various clinical pictures in order to help physicians to promptly recognize this clinical condition, remembering that our leading role as cardiologists depends on and is influenced by our knowledge and working methods.

Computational Flow Dynamic Analysis of Right and Left Atria in Patent Foramen Ovale: Potential Links with Atrial Fibrillation

BACKGROUND

An impairment of the left atrial function similar to that usually observed in atrial fibrillation (AF) has been observed also in patients with patent foramen ovale (PFO) and permanent right-to-left shunting (RLS).

METHODS

We reconstructed the geometrical model of right atrium (RA), PFO, left atrium (LA) and left atrial appendage (LAA) of 65 patients with mild (36 patients mean age 45.5±6.8 years, 24 females) or permanent (29 patients, mean age 45.1±5.3 years, 21 females) RLS using anatomical data obtained by transoesophageal echocardiography (TEE) and cardiac MRI, performed as a part of our institutional screening protocol for paradoxical embolism. Using computational fluid dynamic analysis (CFD) we assessed the vorticity magnitude in both the LA and LAA to analyse a possible rheological relationship between PFO and AF.

RESULTS

The anatomical models, in terms of dimensions, were comparable among the patients with mild and permanent RLS. A higher vorticity magnitude was observed in the mild shunt both in the LA (101.12±21.3 vs 88.3±22.6, p=0.02) and LAA (62±14.4 vs 32.4±12.3, p<0.01) when compared to the permanent R-L shunting.

CONCLUSION

The lower vorticity magnitude across the LA and LAA in patients with permanent RLS suggests a possible higher stagnation of the blood in these anatomical sites, similarly as previously observed in patients with AF.

Gender-related Difference in Clinical Outcome of the Patient with Atrial Fibrillation after Radiofrequency Catheter Ablation

Background and Objectives

Previous studies provided controversial result about gender differences in the clinical outcome after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF). We assessed pure difference after adjustment of referral bias.

Methods

The clinical outcomes including freedom from AF/atrial tachycardia (AT) recurrence after RFCA were compared between women and men in 1:1 confounding factor matching with age, AF type, periods since diagnosis (±12 months), and procedure era (±12 months). Subgroup analysis was performed in categories defined by AF type and age of 55 (mean menopausal age of Asian women).

Results

Total 1,875 patients with AF underwent 2,307 RFCA between January 1998 and May 2014 in a single center. Total 367 women (19.6%, 59±10 years) who had undergone first ablation were included. Women had larger left atrial diameter index (26±4 vs. 23±4 mm/m²; p<0.001) and higher peri-procedural complications (9.2% vs. 4.9%; p=0.030) compared to men. The freedom from AF/AT recurrence after RFCA was not different between both groups (71% vs. 76%; log-rank p=0.131, mean follow-up of 55 months). Women with non-paroxysmal AF (PAF) had significantly worse outcome (54% vs. 69%; p=0.014), especially in subgroup with age ≤55 (48% vs. 71%; p=0.010). In multivariate analysis, female gender was an independent predictor of recurrence in subgroup with non-PAF and age ≤55 (hazard ratio [HR], 2.539; 95% confidence interval [CI], 1.112–5.801; p=0.027).

Conclusions

The clinical outcome after RFCA was not different between both genders regardless of referral bias. However, the gender difference became evident in patients under 55 years with non-PAF.