Ridges and Pouches: A Case Series of Anomalous Atrial Septal Fusion

Zisa, David; Faletra, Francesco F.; Wessler, Benjamin S.; Halin, Neil J.; Reddy, Pranitha P; Patel, Ayan R.; Pandian, Natesa G.

doi:10.1016/j.case.2019.10.009

Cited by 7 publications

(8 citation statements)

References 13 publications

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“…Regarding the presence of a prominent ridge along the FO, this was described with a prevalence of 18.7% in pig hearts, 15% in ovine hearts [14], and in humans by Shizukuda et al [15] in one case and by Zisa et al [16] in five human hearts on three-dimensional transesophageal echocardiography and may represent a challenge in the transseptal puncture. Zisa et al [16] discussed that these anomalous ridges of the left side of the interatrial septum may depend on an irregular fusion between the septum primum and the septum secundum and is different from a prominent rim of a PFO.…”

Section: Discussionmentioning

confidence: 95%

Morphological Study of Fossa Ovalis in Formalin-Fixed Human Hearts and Its Clinical Importance

et al. 2021

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Background and Objectives: Our study aimed to investigate the gross anatomy aspects of the fossa ovalis (FO) and the presence of some anatomical variation resulting from the incomplete fusion of septum primum and septum secundum, such as an atrial septal pouch (SP) and left atrial septal ridge. Materials and Methods: Thirty-one adult human hearts removed from formalin-fixed specimens were examined to provide information about the morphology of the FO. The organs were free of any gross anatomically visible pathological conditions. Results: The most common variants were the FO located in the inferior part of the interatrial septum (64.51%), circular (61.3%), with a net-like structure (51.62%), prominent limbus (93.55%), and patent foramen ovale (PFO) (25.8%). The right SP was observed in 9.67% of specimens, the left SP was observed in 29.03% of cases, and in 51.61% of cases, a double SP was observed. One sample presented a right SP and a double left SP, and one case showed a triple left SP, which was not reported previously to our knowledge. Conclusions: Knowledge of the interatrial septal anatomy becomes important for interventional cardiologists and should be documented before transeptal puncture.

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Section: Discussionmentioning

confidence: 95%

Morphological Study of Fossa Ovalis in Formalin-Fixed Human Hearts and Its Clinical Importance

et al. 2021

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“…Today, it is understood that not all patients with an LASP have an increased risk of embolic events [ 10 , 11 ]. The laminar blood flow coming from the right pulmonary veins is a protective mechanism against thrombus formation along the interatrial septum.…”

Section: Discussionmentioning

confidence: 99%

“…The laminar blood flow coming from the right pulmonary veins is a protective mechanism against thrombus formation along the interatrial septum. This protection can be lost in the setting of conditions such as atrial fibrillation (AF), mitral stenosis, high ventricular pressure, heart failure, and anomalies in pulmonary vein confluence, leading to risk of blood stasis and thrombus formation [ 3 , 11 ]. Thrombotic masses emerging from an LASP have been described in a patient who had significant risk factors for blood stasis [ 12 ].…”

Section: Discussionmentioning

confidence: 99%

Left Atrial Septal Pouch and Acute Thromboembolic Ischemia of the Upper Limb

et al. 2021

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Patient: Male, 60-year-old Final Diagnosis: Thromboembolic ischemia of the upper limb Symptoms: Pain and paresthesia in the right arm Medication: — Clinical Procedure: — Specialty: Cardiology Objective: Rare coexistence of disease or pathology Background: A left atrial septal pouch (LASP) was first described in 2010 as a new anatomical entity with potential for embolic events. The prevalences of left, right, and double septal pouches are 40.8%, 5.1%, and 3.7%, respectively. There is a concern about the risk of embolic events due to formation of thrombi in a LASP (especially stroke). Case Report: A 60-year-old man presented with sudden onset of right arm pain associated with sweating and neck pain radiating to his left upper extremity. On physical examination, his right arm was cyanotic and he had pain, pares-thesia, and no radial pulse. The patient was diagnosed with acute arterial occlusion of his right upper extremity. An arterial embolectomy was performed with a Fogarty catheter at the level of the brachial artery, which resulted in immediate reperfusion. The patient had an embolic event and after efforts to identify the possible etiology, only an LASP was found. Therefore, we hypothesized that he experienced an embolic event in which a thrombus had formed at the site of the LASP. Conclusions: The present case report is designed to raise awareness of the thrombogenic potential of LASP and the possibility of an embolic event to the upper limb of patients with it. LASP can be the source of a thrombus in a patient with a non-stroke embolic event.

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“…A 3D TEE provided further comprehensive evaluation of the interatrial septum with further confirmation of the presence of thrombus. 2D and 3D TEE are superior to TTE for identifying anatomic anomalies of the interatrial septum, since TEE may not adequately visualize the anatomy [19]. Atrial septal pouches can also be identified by CT imaging, and physician must be able to recognize it.…”

Section: Discussionmentioning

confidence: 99%

Blue toe syndrome caused by emboli from anomalous left atrial septal pouch thrombus: a case report

et al. 2020

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Background: Left atrial septal pouches (LASPs) are a relatively newly described but common anatomical cardiac variant thought to be associated with atrial fibrillation (AF) and cardio-embolic stroke. Blue toe syndrome (BTS) describes ischemic changes in the toes due to microembolisation of the digital arteries. Establishing the etiology of BTS is vital so that the underlying cause can be treated. Here we describe the first case of BTS arising due to emboli from LASP thrombus arising on a background of new-onset AF. Case presentation: A 65-year-old man presented with a two-day history of progressive painful swelling and bluishpurple discoloration of the second and fourth toes of his left foot and new-onset AF. Tests for hypercoagulability disorders were negative. Duplex ultrasound and CT angiography excluded deep venous thrombosis and an absence of embolus, thrombus, or occlusion in the arterial tree in the lower extremities bilaterally, so BTS was diagnosed. While transthoracic echocardiography and chest CT initially showed no cardiac abnormalities or mural thrombus, subsequent transesophageal echocardiography revealed a LASP with an associated pedunculated thrombus. The affected toes were amputated due to wet gangrene, but the patient recovered well with thrombus resolution after anticoagulation. Conclusion: The presence of a LASP in the absence of any other identifiable cause of BTS should trigger careful investigation of the interatrial septum, preferably using a multimodality imaging approach. The possibility that LASPs may not merely be an innocent bystander but a causative mechanism for peripheral ischemia must be considered.

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Ridges and Pouches: A Case Series of Anomalous Atrial Septal Fusion

Cited by 7 publications

References 13 publications

Morphological Study of Fossa Ovalis in Formalin-Fixed Human Hearts and Its Clinical Importance

Morphological Study of Fossa Ovalis in Formalin-Fixed Human Hearts and Its Clinical Importance

Left Atrial Septal Pouch and Acute Thromboembolic Ischemia of the Upper Limb

Blue toe syndrome caused by emboli from anomalous left atrial septal pouch thrombus: a case report

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