Diagnosis of atrial septal aneurysm by two-dimensional echocardiography--a case report.

A patient who was evaluated for a syncopal episode was found by two-dimensional (2D) echocardiography to have an aneurysm of the atrial septum. The atrial septal aneurysm appeared as a localized outpouching of the atrial septum that protruded into the left atrium during systole and into the right atrium during early diastole. The 2D echocardiography permits the definitive diagnosis of this condition by a noninvasive technique.     

Giant interatrial septal aneurysm mimicking a right atrial tumor

We report the case of a patient with a giant interatrial septum aneurysm who was admitted to our hospital for analysis of palpitations. Transthoracic echocardiography was not contributive and cardiac magnetic resonance imaging demonstrated a small interatrial septal aneurysm. In our study, only transesophageal echocardiography provided the correct diagnosis, showing a giant interatrial septal aneurysm protruding far away into the right atrium and mimicking a right atrial cystic tumor.     

Atrial wall hematoma after mitral valvuloplasty and maze procedure: a case report

A 66-year-old male patient with mitral regurgitation and atrial fibrillation underwent mitral valvuloplasty with a modified maze procedure. Follow-up echocardiography performed on the 4th postoperative day revealed a high echoic mass of 6.7 x 3.0 cm which appeared continuous to the left atrial wall and protruded into the left atrial cavity. The irregular surface of the mass echo was not compatible with atrial wall hematoma, so computed tomography (CT) was performed for the differential diagnosis. CT showed extension of the mass from the left atrium to the interatrial septum and right atrium, which lead to a conclusive diagnosis of atrial wall hematoma. Echocardiography showed the hematoma was diminished and eventually disappeared after simply reducing the warfarinization level. This rare case of atrial wall hematoma, especially after the maze procedure, required differential diagnosis from intraatrial thrombus and atrial wall dissection.     

Atrial septal aneurysm--a potential cause of systemic embolism. An echocardiographic study

Atrial septal aneurysm is an uncommon condition. Between 1981 and 1984 10 cases of atrial septal aneurysm were diagnosed by real time cross sectional echocardiography performed in 4840 patients. The aneurysm was associated either with mitral valve prolapse (three patients) or with atrial septal defect (three patients) or occurred in isolation (four patients, two of whom had had a previous embolic event leading to the diagnosis of atrial septal aneurysm by cross sectional echocardiography). During cross sectional echocardiography the aneurysm appeared as a localised bulging of the interatrial septum, which was best seen in the subcostal four chamber view and in the parasternal short axis view at the level of the aortic root. The aneurysm either protruded into only the right atrium (five patients) or moved backwards and forwards between the right and the left atria during the cardiac cycle (five patients). This motion pattern might be related to changes in the interatrial pressure gradient. The two patients who had had a systemic embolism were given anticoagulant treatment, but none underwent surgery. It is concluded that the true prevalence of atrial septal aneurysm might have been underestimated before the routine use of cross sectional echocardiography, that cross sectional echocardiography enables definitive diagnosis of this condition by a non-invasive technique, and that an atrial septal aneurysm should be suspected and looked for by cross sectional echocardiography after an unexplained systemic embolism.     

Atrial septal aneurysm--a potential cause of systemic embolism. An echocardiographic study.

Atrial septal aneurysm is an uncommon condition. Between 1981 and 1984 10 cases of atrial septal aneurysm were diagnosed by real time cross sectional echocardiography performed in 4840 patients. The aneurysm was associated either with mitral valve prolapse (three patients) or with atrial septal defect (three patients) or occurred in isolation (four patients, two of whom had had a previous embolic event leading to the diagnosis of atrial septal aneurysm by cross sectional echocardiography). During cross sectional echocardiography the aneurysm appeared as a localised bulging of the interatrial septum, which was best seen in the subcostal four chamber view and in the parasternal short axis view at the level of the aortic root. The aneurysm either protruded into only the right atrium (five patients) or moved backwards and forwards between the right and the left atria during the cardiac cycle (five patients). This motion pattern might be related to changes in the interatrial pressure gradient. The two patients who had had a systemic embolism were given anticoagulant treatment, but none underwent surgery. It is concluded that the true prevalence of atrial septal aneurysm might have been underestimated before the routine use of cross sectional echocardiography, that cross sectional echocardiography enables definitive diagnosis of this condition by a non-invasive technique, and that an atrial septal aneurysm should be suspected and looked for by cross sectional echocardiography after an unexplained systemic embolism.     

Identification of atrial septal defects by cross-sectional contrast echocardiography.

Cross-sectional echocardiography, combined with injections of contrast into peripheral arm veins, has been used to study 15 patients with atrial septal defects and 10 patients with an intact interatrial septum. Of 11 patients with ostium secundum or sinus venosus atrial septal defects and left-to-right shunts a defect could be visualised in all, and in eight some degree of transfer of contrast from right atrium to left atrium was seen. In three of four patients with a dominant right-to-left shunt a defect was seen and in all there was free transfer of contrast from right atrium to left atrium. Though there may be variable loss of echoes in the septal image in patients with an intact interatrial septum, in general no fixed defect is seen an there is no transfer of contrast from right atrium to left atrium. This is a potentially valuable technique in the assessment of patients in whom an atrial septal defect is suspected.     

Partial resection of atrial septal aneurysm with multiple fenestrations--a case report

Aneurysms of the interatrial septum are uncommon lesions that are often accompanied by other cardiac anomalies or systemic thrombosis. The authors report 1 case of atrial septum aneurysm that was diagnosed by two-dimensional contrast echocardiography. At surgery a membrane-like, fenestrated aneurysmal protrusion to the right atrium without thrombosis was seen. The atrial septum was closed without using an artificial patch after some of the aneurysm with fenestrations was resected.     

Single and two dimensional echocardiographic features of the interatrial septum in normal subjects and patients with an atrial septal defect.

The interatrial septum is one of the least studied structures in M mode echocardiography. Two dimensional echocardiography has made it possible to record simultaneous M mode and two dimensional echocardiograms. Such studies were performed in 10 normal subjects and in 9 patients with a secundum atrial septal defect. In the short axis view of the base of the heart, the interatrial septum was visualized in the two dimensional studies as a linear echo running from the posterior aortic wall to the posterior atrial wall and in the M mode records as a series of dense echoes posterior to the aorta. The great variability in echo dropout of the interatrial septum made it impossible to distinguish the normal subjects from the patients with atrial septal defect. The dense echoes of the interial septum in the M mode records gave the false impression that they were filling the left atrium. These data indicate that (1) a secundum atrial septal defect cannot be reliably differentiated from a normal septum using these echocardiographic methods, and (2) the medial location of the interatrial septum should be appreciated so that it will not be confused with a left atrial mass.     

Role of intracardiac echocardiography in atrial septal abnormalities

The purpose of this review is to outline the feasibility of performing a comprehensive atrial septal examination from the internal confine of the right atrium and to evaluate the advantages resulting by intracardiac echocardiography (ICE) evaluation of atrial septal morphology as well as pathophysiology. In this setting, ICE indications have not yet been established because ICE is a relatively new technique that is still evolving. Notwithstanding, during catheter-based secundum atrial septal defect and patent foramen ovale closure, ICE seems useful for diagnosing cardiac abnormalities instantly, guiding and monitoring all stages of the procedures, and assessing proper selection and optimal device placement. Moreover, ICE provides solid anatomical criteria to diagnose fenestrated atrial septal aneurysm, interatrial communications such as ostium primum and sinus venosus defects, partial anomalous pulmonary venous connection, and lipomatous hypertrophy of atrial septum.     

Prognostic implications of right atrial ischemic dysfunction in patients with biventricular inferior infarction: transesophageal echocardiographic analysis

In order to determine the effect of right atrial dysfunction on clinical outcome, six patients with inferior myocardial infarction with extension to right ventricle and right atrium involving only obstructions of the right coronary artery were examined with transesophageal echocardiography (TEE) at the time of the event. Five of the patients were reexamined 15 to 55 months later. Two patients underwent thrombolysis and maintained ratios of right-to-left ventricular diameters of less than 1, as well as normal convexity of the interatrial septum. One patient had spontaneous reperfusion of the right coronary artery, reduction in right ventricular diameter, and normalization of interatrial septum. Another patient underwent delayed angioplasty and manifested a diminished wall movement score (WMS) in the follow-up echocardiogram. One patient died during his first hospitalization with significant right ventricular dilatation, inverted convexity of the interatrial septum, and right atrial thrombosis. The last patient died during follow-up with right ventricular dilatation, increased WMS, right atrial akinesis, and inverted interatrial convexity. Serial TEE examination of patients with infarction of the left ventricular inferior wall is a safe technique for determining the degree of the extension of the ischemic process to the right chambers.     

Echography in aneurysm of the interatrial septum

Atrial septal aneurysm can be detected by subcostal echocardiography as a bulge of the intermediate interatrial septum, ballooning toward the right atrium. We retrospectively revised 5412 echo examinations, consecutively performed in our laboratory, and we found 14 cases of atrial septal aneurysm (0.26%), mean age 36 +/- 15 years, 9 males and 5 females. In 7 patients atrial septal aneurysm was wide, including the whole atrial septum; in 5, only cranial two-thirds of the septum were involved and in 2, it regarded only the intermediate septum. No patients referred to arrhythmias, syncope, embolism, endocarditis or transient ischemic neurologic disorders. Cardiac abnormalities or defects were associated to atrial septal aneurysm in 12/14 patients: they consisted of atrial septal defect, mitral valve prolapse, false ventricular tendons or persistent Chiari network. Atrial left-to-right shunt was detected in all 6 cases with atrial communication. Considering each single associated cardiac abnormality, the prevalence of atrial septal aneurysm was 7% in patients with atrial septal defect, 1.7% in those with mitral valve prolapse, 6.6% in persistent Chiari network and 0.9% in false ventricular tendons. In conclusion, echocardiography is the first-choice technique to detect atrial septal aneurysm and other related cardiac defects.     

Atrial septal hematogenous cyst with calcification mimicking myxoma: A rare case

A 61-year-old female presented with right atrial mass during physical examination. Contrast-enhanced left heart echocardiography revealed a mass with the size of 32*23 mm in the right atrium, attached to the atrial septum; there was a certain degree of activity and deformation. MRI showed a mass of about 35*22 mm in the right atrium adjacent to the atrial septum, which was diagnosed with right atrial myxoma. Intraoperative TEE showed that the mass was located in the atrial septum close to the inferior vena cava and spontaneous echo contrast with hyperechoic images within the mass. The lesion was resected under cardiopulmonary bypass. Pathological examination revealed that the filling defect was an atrial septal hematogenous cyst with calcification.     

Anévrysme isolé du septum interauriculaire : cause exceptionnelle d’ischémie digitale

An atrial septal aneurysm (ASA) is a rare but well recognized entity characterized by saccular deformity of the atrial septum that bulges into the right or left atrium. Diagnosis can be established using transthoracic and transesophageal echocardiography. Although this abnormality is considered clinically benign, it has been independently associated with systemic or cerebral embolism. We present a unique case of isolated atrial septal aneurysm complicated by digital ischemia in a 51 years old woman.     

Echocardiographic appearances of right atrial thrombus

A 17-year-old male presented with a four-day history of increasing shortness of breath and right basal pleuritic chest pain. Physical examination revealed central and peripheral cyanosis, sinus tachycardia, elevation of central venous pressure, hypotension, and added third heart sound. Echocardiography (M-mode and two-dimensional) showed a highly mobile mass in the right atrium apparently attached to the interatrial septum. A diagnosis of right atrial myxoma with pulmonary embolization was made and urgent surgery advised. At operation a string of thrombus in the right atrium (presumed from peripheral venous site) occluding a patent foramen ovale was found. The usefulness of echocardiography in diagnosing atrial thrombus and in differentiating clot from tumor is discussed.     

Drainage of the inferior vena cava to the left atrium

Drainage of the inferior vena cava to the left atrium is an extremely unusual congenital heart disease. We describe a 54-year-old woman, in whom the diagnosis was suggested by transthoracic echocardiography, and then confirmed by a transesophageal exam and magnetic resonance imaging, which also revealed an associated secundum atrial septal defect. Surgical management involved reconstruction of the interatrial septum to include the inferior vena cava in the right atrium. The few previously reported cases in the literature are reviewed.     

A coronary artery fistula with saccular aneurysm mimicking a right atrial cystic mass

A 16 year-old Korean girl with cardiomegaly was found to have a "right atrial cystic mass" on transthoracic echocardiography. An unusual cystic structure made the diagnosis difficult. However, transesophageal echocardiography and multidetector computed tomography revealed a coronary artery fistula with a distal saccular aneurysm involving the interatrial septum and draining into the right atrium. Multidetector computed tomography provided clear anatomic visualization that fully delineated the abnormal structures. Multidetector computed tomography may be considered as a good alternative for transesophageal echocardiography in assessing a tortuous coronary artery fistula and aneurysm with complex anatomy.     

Transesophageal color Doppler flow mapping of iatrogenic left-to-right interatrial shunting after percutaneous transluminal mitral valvotomy

Characteristics of transesophageal color Doppler flow mapping of iatrogenic left-to-right interatrial shunts were assessed in 58 patients, 1 to 994 days after percutaneous transluminal mitral valvotomy. Transesophageal color Doppler flow mapping detected 22 cases of interatrial shunt whereas transthoracic two-dimensional echocardiography visualized only five interatrial septal defects. Five types of color Doppler flow patterns of interatrial shunts were found: type 1, a bluish jet passing through the interatrial septum into the right atrium with a small bluish proximal flow in the left atrium (50%); type 2, a bluish jet passing through the interatrial septum into the right atrium without a proximal flow (13.6%); type 3, a predominant bluish proximal flow in the left atrium passing through the interatrial septum with minimal flow entering into the right atrium (18.2%); type 4, an "en face" bluish jet in the right atrium (4.5%); and type 5, a "wall jet" with proximal flow adhering to and entering into the interatrial septum (13.6%). Oximetry demonstrated increased pulmonary-to-systemic flow ratio (range 1.07 to 3.32) in 11 patients (50%), which was significantly correlated with the maximal jet area derived from color Doppler flow mapping (r = 0.80, P = 0.001). Thus, transesophageal color Doppler flow mapping is useful in detection of left-to-right interatrial shunts after percutaneous transluminal mitral valvotomy, and recognition of the variable types of color flow mapping may further help identify these atypical interatrial shunts.     

Aneurysm of atrial septum associated with rheumatic mitral stenosis simulating tumour of right atrium

We present a case of aneurysm of interatrial septum associated with rheumatic mitral stenosis, which supports the theory that claims that the pressure gradient between the atriums plays an important part in its aetiology. The angiographic image of a filling defect in the right atrium may cause an erroneous diagnosis of atrial tumour. The levophase of right angiography and cross-sectional echocardiography confirmed the diagnosis of aneurysm of interatrial septum.     

Transseptal puncture: use of an angioplasty guidewire for enhanced safety.

During transseptal puncture, once the needle tip has successfully accessed the left atrium, advancement of the needle, dilator and sheath into the left atrium can risk left atrial free wall perforation, particularly if the interatrial septum is aneurysmal and tents far into the left atrial cavity during puncture. We have modified our transseptal technique such that once the left atrium is accessed with the needle tip, a 0.014' angioplasty guidewire is advanced down the Brockenbrough needle. This is guided into the left upper pulmonary vein, and the needle, dilator and sheath advanced over this wire towards the left upper pulmonary vein. In this way, the risk of perforation of the left atrial free wall is negated. We have since used this technique in 30 cases without difficulties.     

Right-left shunt caused by sarcoma of the right atrium

A 70 year old woman was admitted for right ventricular failure and cyanosis of recent onset. Echocardiography showed a very large, homogenous, immobile, smooth-contoured mass filling the right atrium. Right atrial pressures were raised but the other intracardiac pressures were normal at catheterisation. Right heart angiography confirmed the voluminous right atrial mass and dilatation of the hepatic veins and showed early opacification of the left heart chambers. A right-to-left shunt was confirmed by oximetry which showed significant desaturation of the blood in the left atrium and ventricle (saturation 78% in the left ventricle). The tumour was also documented by a thoracic CT scan. At surgery, a very large, malignant right atrial tumour was resected which histological examination showed to be an angiosarcoma. The interatrial septum seemed to be intact: there was no true atrial septal defect but a persistent foramen ovale was found. After resection of the tumour the right atrium was reconstructed. The initial postoperative period was uncomplicated but the patient died nine months later of metastatic disease particularly affecting the liver and brain. The clinical presentation of malignant cardiac tumour is very variable but a right-to-left interatrial shunt through a patent foramen ovale has only been reported previously in 2 cases of primary malignant tumours (a rhabdomyosarcoma and an angiosarcoma) and in 1 case of a secondary cardiac metastasis.