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

Abstract

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.

Practice Parameter: Recurrent stroke with patent foramen ovale and atrial septal aneurysm: [RETIRED]

“…1 The reported prevalence of ASA has also varied tremendously although the population-based TEE study reported a prevalence of 2.2%. 4 Up to 83% of patients with ASA also have a right-to-left shunt, 5 and in patients with PFO, the presence of an ASA has been associated with a larger separation between the septum primum and secundum, a prominent eustachian valve, presence of a Chiari network, and a larger right-to-left shunt. [6][7][8][9] Among patients younger than 55 years, as many as 40% of strokes are described as cryptogenic, with no identified cardioembolic or large vessel source, and in a distribution that is not consistent with small vessel disease.…”

“…While paradoxical embolism is the most commonly ascribed mechanism, there is some evidence to support alternative etiologies such as cardiac in situ thrombus formation and atrial arrhythmias. 5,14,16,[23][24][25] These alternative etiologies may have implications for management of these patients, as atrial arrhythmias are unlikely to resolve following closure procedures.…”

Impairment of Venous Drainage Due to Atrial Septal Aneurysm During Open-Heart Surgery

“…3,4 A recent study based on TEE put its prevalence at 4.3% 5 and suggests that it is a more sensitive diagnostic tool than TTE. 5,6 Although 3D TEE clearly showed the aneurysm in this case, 2D TEE is sufficient to make a diagnosis of ASA. Several studies have classified ASA based on morphology and movement of the aneurysm.…”

“…5,9,10 Although not definitively proven, mechanism is presumed to be due to paradoxical interatrial shunting of thrombus since a high percentage of patients with ASA has PFO. 5,6 Presence of spontaneous echo contrast in the aneurismal cavity has been previously reported and thought to be a precursor to thrombus formation. 8 In a patient who presented for routine coronary artery bypass graft surgery, massive thrombus was noted within the aneurismal cavity that subsequently caused intraoperative embolic stroke.…”

Atrial septal defect with interatrial aneurysm and Axenfeld‐Rieger syndrome

“…None of them were associated with interatrial aneurysm which may lead to cerebral embolism, a cause of focal discrete neurological deficits (Schneider et al 1990). …”