Small left atrium and change in contour of the ventricular septum in total anomalous pulmonary venous connection: a morphometric analysis of 22 infant hearts

Morphometric measurements of 22 hearts with total anomalous pulmonary venous connection (TAPVC) were compared with measurements of 8 matched control specimens without heart disease. Each of the TAPVC specimens had a shorter left atrium, smaller left atrial surface area and larger diameter of the fossa ovalis. In addition to increased length of the right ventricle and larger circumferences for tricuspid and pulmonary valve anuli, the left ventricular contour of the ventricular septum was flat or convex in 18 of the 22 hearts; the septum was significantly longer than normal in these specimens and wider at its midportion. Because mitral and aortic valve anuli were normal in circumference, the data suggest that left ventricular volume is not decreased despite change in ventricular shape.     

An Atrial Septal Ridge Diagnosed by Transesophageal Echocardiography

A left atrial ridge is an anomaly of irregular fusion between the septum primum and septum secundum.1 Aberrant fusion of the septa results in thickened and fibrotic tissue along the region of the fossa ovalis that will occasionally protrude into the left atrium.2 The presence of a left atrial ridge has multiple clinical implications due to its close proximity to the fossa ovalis. The location of this uncommon incongruence may make transseptal catheter-based approaches more challenging, underscoring the importance of imaging guidance to determine the ideal transseptal puncture site.Figure 1 shows cardiac images of a 64-year-old female with a history of severe mitral regurgitation, atrial fibrillation, sick sinus syndrome status post pacemaker implantation, pulmonary hypertension, systemic lupus erythematosus, and chronic kidney disease. She was seen by the valve team and underwent a transesophageal echocardiogram (TEE) to determine candidacy for transcatheter edge-to-edge repair of the mitral valve. Two-dimensional biplane imaging of the interatrial septum (IAS) shows a linear structure on the left atrial side of the fossa ovalis. Three-dimensional imaging of the IAS revealed that the structure was consistent with an atrial septal ridge.Open in a separate windowFigure 1(A) Transesophageal echocardiogram (TEE) 2-dimensional (2D) imaging of the interatrial septum with the atrial septal ridge shown by the yellow arrows. (B) 3D TEE rotated view of the interatrial septum with the fossa ovalis shown in plane with the ridge (yellow arrow). (C) Cardiac magnetic resonance cine SSFP 4-chamber image demonstrating the atrial septal ridge (yellow arrow). (D) The MitraClip transcatheter mitral valve delivery system safely traversed across the interatrial septum (red arrow) with the yellow arrow pointing towards the atrial septal ridge. RA: right atrium; LA: left atrium; AV: aortic valve; IAS: interatrial septum; FO: fossa ovalis; MV: mitral valve     

The normal anatomy of the atrial septum in the human heart.

The atrial septum is a blade-shaped structure with a concave anterior margin that reflects the curve of the ascending aorta, a convex posterior margin, and an inferior margin along the mitral annulus. The fossa ovalis comprises an average of 28 per cent of the total septal area, or 43 mm.2 in infants and 240 mm.2 in adults. The channel that persists between the fossa ovalis and the muscular atrial septum is patent except at the limbus, providing a useful explanation for the success of blunt transseptal atrial catheterization and right-to-left shunts in individuals with elevated right atrial pressure.     

Full-color direct visualization of the atrial septum to guide transseptal puncture

Introduction: Transseptal puncture is required for many interventional procedures but has a serious complication rate of ～1%—primarily related to misidentification of the fossa ovalis resulting in inadvertent puncture of other cardiac structures. We investigated the utility of a full color visualization catheter to correctly position and guide transseptal puncture of the fossa ovalis. Methods and Results: Transseptal puncture and left atrial cannulation were performed after visualization of the atrial septum and fossa ovalis with the visualization catheter (IRIS, Voyage Medical Inc.) on six swine. For each animal, the transseptal puncture was performed twice and the catheter was examined for clot after each puncture. The 12 transseptal punctures required 6.8 ± 3.6 minutes procedural time and 300 ± 94 mL of fluid administered per procedure (i.e., two punctures). IRIS visualization of the atrial septum correlated well with postmortem examination of the atrial septum. In the three animals in which a patent foramen ovale was present (as confirmed by pathological examination), it was also correctly identified by in vivo visualization using the IRIS catheter. Conclusion: The IRIS catheter allows direct in vivo visualization of the interatrial septum to guide transseptal puncture of previous punctures.     

The anatomy of the interatrial septum: a transesophageal echocardiographic study

Transesophageal echocardiography provides a unique view of the IAS. We reviewed results of 119 transesophageal studies (1) to study the detailed anatomy of the IAS, and (2) to determine the thickness of the IAS at different times during the cardiac cycle, (3) the effect of age, and (4) the thickness of the IAS in relation to various disease states. From the transesophageal view the IAS extends from the right posteriorly toward the left and anteriorly. The more inferior aspect of the septum courses in a more direct posteroanterior direction and is more difficult to accurately visualize. The IAS is thickest peripherally and gradually narrows toward the more centrally located fossa ovalis. A region of constant thickness is frequently present between the most peripheral aspect of the IAS and the fossa ovalis. We standardized the measurement of the thickness of the septum by measuring it only at this region of constant thickness in the plane that visualized the fossa ovalis. The mean thickness at this point was 6 +/- 2 mm. The thickness correlated weakly with the age of the patient. These results agree with previously published autopsy findings. Thickness was not affected by the presence of significant disease of the atrioventricular valves, atrial fibrillation, or an atrial septal defect. However, the thickness increased to 7 +/- 2 mm with atrial contraction during sinus rhythm (p less than 0.0001). The mean thickness of the septum primum covering the fossa ovalis was 1.8 +/- 0.7 mm.(ABSTRACT TRUNCATED AT 250 WORDS)     

Diagnosis and classification of atrial septal aneurysm by two-dimensional echocardiography: report of 80 consecutive cases

Atrial septal aneurysms have been related (either by association or as potential causes) to systolic clicks, atrial arrhythmias, systemic and pulmonary embolism, atrioventricular valve prolapse and atrial septal defect. To study these associations and the incidence of atrial septal aneurysm, we reviewed 80 consecutive patients (female to male ratio 1.9:1, mean age 47 years, range 1 day to 89 years) who had been identified prospectively as having an atrial septal aneurysm. These were found in 36,200 two-dimensional echocardiographic studies (incidence: 0.22% overall; 0.29% in the last year of the study done between 1978 and 1984). Three types of fossa ovalis aneurysm and one type of aneurysm involving the entire atrial septum were observed; a fossa ovalis aneurysm with leftward projection and excursion of less than 5 mm or an aneurysm involving the entire atrial septum with rightward projection was not observed. Atrial septal aneurysm occurred more often as an isolated abnormality than in association with other cardiac malformations, although all patients with an aneurysm involving the entire atrial septum had complex congenital cardiac anomalies of the hypoplastic right heart type. The reported associations between atrial septal aneurysms and atrial septal defect, atrioventricular valve prolapse, midsystolic clicks, atrial arrhythmias and cerebral ischemic events were examined. A hypothesis based on interatrial pressure gradients is proposed to explain the different motions and configurational characteristics of fossa ovalis aneurysms observed in these patients. All patients in whom atrial septal aneurysm is demonstrated should undergo examination for atrial septal defect. Atrial septal aneurysm should be specifically looked for in patients who have these associations and who undergo two-dimensional echocardiography, especially if these abnormalities are unexplained.     

Pseudotumor of the right atrium caused by hernia of the valve of Vieussens]

A round swelling was on the substraction films of the right side of the heart taken during angiocardiographic examination of a patient with mitral valve disease; this suggested a mass attached to the inter-atrial septum, and prolapsing into the auricle of the right atrium. Initial diagnsosi was of atrial thrombosis, but this was disproved at operation. An aneurysm of the membrane of the fossa ovalis was found, being caused by overstretching of the auricle of the left atrium under the increased pressure of the valve defect. The aneurysm was resected and the septum simply repositioned as part of the mitral valve replacement. A search of the literature shows how rare this disorder is, and that it should be reclassified with the abnormalities of the inter-atrial septum which are found only rarely in cases of mitral valve disease.     

Intracardiac echocardiography to guide transseptal left heart catheterization for radiofrequency catheter ablation

INTRODUCTION: The purpose of this study was to assess the feasibility and safety of intracardiac echocardiography to guide transseptal puncture for radiofrequency catheter ablation. METHODS AND RESULTS: Transcatheter intracardiac echocardiography (9 MHz) was utilized to guide transseptal puncture in 53 patients undergoing radiofrequency catheter ablation. The anatomy and relationship of intra- and extracardiac structures were visualized with the ultrasound transducer positioned at the fossa ovalis. The tip of the transseptal dilator and tenting of the fossa ovalis and the left atrial wall were simultaneously visualized in a single ultrasound image in all patients. With maximum tenting of the fossa ovalis, the mean distance from the fossa to the left atrial wall was 11.9 +/- 5.8 mm (range: 1.8 to 25.6 mm). In four patients (8%), the tented fossa ovalis abutted the left atrial wall and the transseptal dilator was redirected with ultrasound guidance. Puncture of the interatrial septum was achieved through the fossa ovalis in each patient and required a single attempt in 51 patients (96%). The mean number of punctures per patient was 1.1 +/- 0.4. The mean time to perform transseptal catheterization was 18.2 +/- 6.8 minutes. There were no complications. CONCLUSION: Intracardiac echocardiography delineated the anatomy of intra- and extracardiac structures not identified with fluoroscopy and simplified correct positioning of the transseptal dilator, puncture of the fossa ovalis, and cannulation of the left atrium in a timely and uncomplicated fashion.     

Transseptal left heart catheterization: Usefulness of the intracavitary electrocardiogram in the localization of the fossa ovalis

One of the major difficulties in left heart Catheterization through the interatrial septum is to ensure that the Brockenbrough needle tip is correctly laid on the fossa ovalis floor (FOF), which is the only area where the puncture must be done. The difficulties may be enhanced in patients with atrial enlargement and subsequent distortion of the anatomical structures. In order to reduce the hazards of the septal puncture, an electrocardiographic mapping of the right atrial endocardium was performed using the Brockenbrough needle as an exploratory electrode in a group of 20 patients. When the tip of the needle was laid against the FOF, the endoatrial electrocardiogram (EAE) registered a slight or no injury curve, even when the pressure was tight enough to perforate the septum. On the contrary, the pressure on any other area of the muscular septum or atrial walls elicited a bizarre monophasic injury curve. The peculiar electrocardiographic response of the FOF to the pressure exerted by the Brockenbrough needle tip was a valuable aid to identify the area where the transseptal puncture must be done. In addition, the sudden changes in the P wave morphology immediately after the septal perforation, provided the first clue that the left atrium has been reached.     

Transseptal left heart catheterization: usefulness of the intracavitary electrocardiogram in the localization of the fossa ovalis.

One of the major difficulties in left heart catheterization through the interatrial septum is to ensure that the Brockenbrough needle tip is correctly laid on the fossa ovalis floor (FOF), which is the only area where the puncture must be done. The difficulties may be enhanced in patients with atrial enlargement and subsequent distortion of the anatomical structures. In order to reduce the hazards of the septal puncture, an electrocardiographic mapping of the right atrial endocardium was performed using the Brockenbrough needle as an exploratory electrode in a group of 20 patients. When the tip of the needle was laid against the FOF, the endoatrial electrocardiogram (EAE) registered a slight or no injury curve, even when the pressure was tight enough to perforate the septum. On the contrary, the pressure on any other area of the muscular septum or atrial walls elicited a bizarre monophasic injury curve. The peculiar electrocardiographic response of the FOF to the pressure exerted by the Brockenbrough needle tip was a valuable aid to identify the area where the transseptal puncture must be done. In addition, the sudden changes in the P wave morphology immediately after the septal perforation, provided the first clue that the left atrium has been reached.     

上腔静脉引流入左心房手术矫正成功一例

本文报道1例上腔静脉引流入左心房的手术矫正方法。先切开上腔静脉和右房上部,再切开房间隔,显露左房内的上腔静脉开口。补片上缘和腔静脉开口后缘相缝合,其他边缘和房间隔的切口缘相缝合,这样就将上腔静脉开口隔入右房。用猪心包补片加宽上腔静脉和右心房,以防上腔静脉开口堵塞。术后恢复满意。文中还讨论该病的诊断问题。     

A novel method for transcatheter closure of atrial septal defect within an aneurysm of the fossa ovalis: double sheath technique

An aneurysm of the fossa ovalis is frequently associated with an atrial septal defect. Intervention with transcatheter closure of such defects may be difficult since it bears the risk of inadvertent deployment of the device with both umbrellas in the right or left atrium. A novel technique for the closure of such multiperforated aneurysms of the fossa ovalis, which allows central positioning and controlled deployment of the device, is reported.


Keywords: fossa ovalis; aneurysm; atrial septal defect; transcatheter closure     

Aneurysm of the interatrial septum occurring as an isolated anomaly

We report a case of aneurysm of the atrial septum occurring as an isolated abnormality in a patient with atypical chest pain. Apical two-dimensional echocardiography demonstrated phasic bulging of the fossa ovalis region of the atrial septum into the right atrium. Biplane cineangiography confirmed the presence of a large septal aneurysm in an otherwise normal heart. The incidence, pathogenesis, and complications of this unusual anomaly are briefly discussed.     

Interventricular septal wall motion abnormality in left bundle branch block

An experimental study was performed to clarify the mechanism of perfusion defects in the interventricular septum on T1-201 scintigraphy, as seen in patients with left bundle branch block (LBBB) having normal coronary arteries. In anesthetized open-chest dogs, the following parameters were assessed during right atrial pacing as a control, left ventricular pacing to produce right bundle branch block (RBBB), and right ventricular pacing for LBBB; 1. intramuscular pressure in the interventricular septum, 2. blood flow of the left anterior descending coronary artery (LAD) measured by an electromagnetic flowmeter; 3. regional myocardial blood flow (MBF) determined at three sites, including the interventricular septum, LAD area, and left circumflex coronary artery (LCx) area using the H2-washout method. Aortic pressure, left ventricular pressure, and M-mode echocardiograms were recorded during the procedures. During right ventricular pacing, LAD flow remained unchanged; whereas MBF at the interventricular septum decreased from 99.6 +/- 23.4 to 79.2 +/- 17.6 ml/min/100 g, but MBF at the LCx area increased from 103.2 +/- 19.8 to 122 +/- 18.4 ml/min/100 g. In contrast, there were no significant changes in regional flow in any sites during left ventricular pacing. During right ventricular pacing, an early systolic dip was observed in the septal wall concomitantly with the onset of rise in intramuscular pressure in the interventricular septum. However, the beginning of the rise in left ventricular pressure was delayed 33 +/- 4 msec after that of the septal intramuscular pressure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Atrial defect size after Blalock-Hanlon atrioseptectomy

In transposition of the great arteries, a Blalock-Hanlon closed atrial septectomy is performed to improve intracardiac mixing at the atrial level. Although the Blalock-Hanlon septectomy is a common surgical procedure in cyanotic congenital heart disease, it has not been adequately assessed pathologically. In 14 heart specimens from patients (aged 3 days to 19 years) with transposition of the great arteries and Blalock-Hanlon septectomy, the margins of the septectomy, fossa ovalis and atrial septum were identified. The total area of the septum and its defects was calculated using planimetry. The ratio of defect size to atrial septal area was expressed as percent communication, which ranged from 5 to 39 (mean 18) percent in eight specimens with intact limbus of the foramen ovale and 26 to 57 (mean 42) percent in six specimens in which the limbus had been excised. The finding that specimens in which the Blalock-Hanlon defect extended into the fossa ovalis had the largest total communication emphasizes that to obtain optimal bidirectional atrial mixing the surgeon should extend the Blalock-Hanlon procedure across the limbus into the foramen ovale.     

Balloon Atrial Septostomy by a Right Internal Jugular Venous Approach in a Newborn with Hypoplastic Left Heart Syndrome with a Restrictive Atrial Septum

Hypoplastic left heart syndrome with an intact or highly restrictive atrial septum requires urgent decompression of the left atrium. Catheter‐based interventions from the femoral or umbilical veins represent the standard method of atrial decompression. Restrictive atrial septal defects located at the superior portion of the fossa ovalis can be difficult to cross from these access sites. Here, we describe a successful Rashkind balloon atrial septostomy performed from an internal jugular approach.     

Lipomatous hypertrophy of the interatrial septum versus lipomatous hypertrophy of the intervenous tubercle]

The lipomatous hypertrophy of the interatrial septum is a clinicopathological entity characterized by an accumulation of fat, not encapsulated but circumscribed in the atrial septum, over the fossa ovalis, and protruding into the right atrium; its thickness exceeding 15 mm. It is clinically associated with atrial electric abnormalities such as disorders of the atrial conduction and supraventricular arrhythmias, difficulty of the venous return and sudden death. In 1669 Lower described at the entrance to the right atrium, between the venae cavae, there is a tubercle formed by an accumulation of fat, covered over with muscular fibres that protrudes into the right atrium, which be called intervenous tubercle. The aim of this work is to find out the normal morphology of the intervenous tubercle and to find out whether or not lipomatous hypertrophy of interatrial septum is related to it in some way, because both coincides anatomically.     

Contracted form of primary endocardial fibroelastosis in a young adult without congestive heart failure

A case of a 24-year-old man with the contracted form of primary endocardial fibroelastosis diagnosed by left ventricular endomyocardial biopsy showing a markedly thickened endocardium with fibroelastic proliferation is reported. He had no evident symptoms of congestive heart failure except for shortness of breath on moderate exertion. Echocardiogram showed thickened and dense echoes from the left side of the septum and from the posterior left ventricular endocardium. Hemodynamic and angiographic studies revealed marked elevation of right and left ventricular end-diastolic pressures with dip and plateau pressure contours, moderate pulmonary hypertension, left atrial enlargement and mild mitral regurgitation. Further elevation of right and left ventricular diastolic pressures and pulmonary artery pressure was observed at the second evaluation after 5 years. Our patient suggests that primary endocardial fibroelastosis should be included in the differential diagnosis of adult patients with obscure types of cardiac disease.     

An echocardiographic index for separation of right ventricular volume and pressure overload

Abnormal motion of the interventricular septum has been described as an echocardiographic feature of both right ventricular volume and pressure overload. To determine if two-dimensional echocardiography can separate these two entities and distinguish them from normal, geometry and motion of the interventricular septum in short-axis views of the left ventricle were evaluated in 12 normal subjects and 35 patients undergoing cardiac catheterization. Thirteen of the 35 patients had uncomplicated atrial septal defect with associated right ventricular volume overload, but no elevation in pulmonary artery pressure. The 22 remaining patients had a pulmonary artery systolic pressure greater than 40 mm Hg and, thus, constituted the group with right ventricular pressure overload. An eccentricity index, defined as the ratio of the length of two perpendicular minor-axis diameters, one of which bisected and was perpendicular to the interventricular septum, was obtained at end-systole and end-diastole. In all normal subjects, the eccentricity index at both end-systole and end-diastole was essentially 1.0, as would be expected if the left ventricular cavity was circular in the short-axis view. In patients with right ventricular volume overload, the eccentricity index was approximately 1.0 at end-systole, but was significantly increased at end-diastole (mean eccentricity index = 1.26 +/- 0.12) (p less than 0.001). In patients with right ventricular pressure overload, the eccentricity index was significantly greater than 1.0 at both end-systole and end-diastole (1.44 +/- 0.16 and 1.26 +/- 0.11, respectively) (p less than 0.001). These results suggest that an index of eccentric left ventricular shape which reflects abnormal motion of the interventricular septum can be defined.(ABSTRACT TRUNCATED AT 250 WORDS)     

Recurrence of a left atrial myxoma

A fatal recurrence of a left atrial myxoma was observed despite resection of the original tumor complete with its stalk and a portion of atrial septum. The evidence suggests that this recurrent tumor developed from “pre-tumor” cells in the region of the fossa ovalis. The rate of growth of the second tumor was faster than would have been predicted. Clinical manifestations were similar to those with the initial tumor. Wide excision of the atrial septum with the stalk of such tumors should offer the best chance for operative cure, but prolonged postoperative observation is important if signs of recurrence are to be detected at a time when operative removal can be carried out with minimal risk to the patient.