Ultrasonic examination and management of adult atrial septal aneurysm / 中华健康管理学杂志

Objective:To explore the ultrasonography and classification management strategy for adult atrial septal aneurysm (ASA).Methods:Of 138 patients diagnosed with ASA by the transthoracic echocardiography (TTE), in No.83 Army Hospital and No.988 Hospital of Joint Logistic Support Force from January 2015 to October 2019, 103 underwent the transesophageal echocardiography (TEE), and all were examined by the right heart contrast transthoracic echocardiography (cTTE). According to the semi-quantitative method, the shunt was graded, classified, and managed through follow-up or surgical treatment.Results:In the resting state, among 138 patients, 26 cases were detected by TTE as ASA with patent foramen ovale (PFO), showing left-to-right shunt. Among 112 patients with no shunt detected by TTE, 103 cases underwent TEE, of whom 44 cases had PFO and left-to-right shunt. The detection rate of PFO shunt by TEE was significantly higher than that of TTE (42.72% vs 18.84%, P<0.001). Out of the 138 patients who underwent cTTE, 96 cases had different degrees of right-to-left shunt. According to the semi-quantitative standard, there were 15 cases of grade Ⅰ, 28 cases of grade Ⅱ, and 53 cases of grade Ⅲ. The detection rate of cTTE was significantly higher than that of TTE and TEE (69.56% vs 18.84% and 42.72%, both P<0.001). Among these 96 patients with right-to-left shunt detected by cTTE, 52 cases (54.17%) were clinically diagnosed as cryptogenic stroke, with right-to-left shunt in 6 cases of grade Ⅰ, 12 cases of grade Ⅱ, and 34 cases of grade Ⅲ. The number of new infarcts in patients with grade Ⅱ or Ⅲ shunts who received PFO closure via catheter was significantly lower than that of patients who did not receive closure therapy (0 vs 27.27%, P=0.011). Conclusion:ASA combined with PFO and right-to-left shunts were detected more frequently by ultrasonography combined with cTTE in adults, this helps to formulate a reasonable management strategy.

Surgical Treatment for the Annulo-Aortic Ectasia Concomitant with Membranous Ventricular Septal Aneurysm / 日本心臓血管外科学会雑誌

A 60-year-old man complained of palpitation due to transitory atrial fibrillation. The annulo-aortic ectasia was recognized, and was getting enlarged to 52 mm. After an additional examination, membranous ventricular septal aneurysm was revealed. There was no evidence of thrombus, shunt, or infection in the membranous ventricular septal aneurysm. The valve-sparing aortic root replacement (reimplantation) and the patch-closure of the membranous ventricular septal aneurysm were performed. Stabilizing the subannular tissue by a Dacron patch made the reimplantation technique feasible. To secure a subannular suture line, 3 mattress stitches were passed inside-out through the Dacron patch, the fibrous rim of the membranous septum and the prosthetic graft again. He was discharged without any complication 12 days after the operation.

Correlation between the interauricular septum diseases and cryptogenic ischemic stroke on double source CT / 实用放射学杂志

Objective To investigate the association and difference between patent foramen ovale(PFO), atrial septal aneurysm(ASA), atrial septal defect(ASD) in normal controls and cryptogenic ischemic stroke(CS) in youth diagnosed by double source CT.Methods A total of 168 CS patients and 180 controls matched age and gender were included in the present study.The two groups were diagnosed by double source CT and clinical materials.The incident rate of PFO, ASA, ASD, the degrees of PFO, ASD,the lengths of PFO and difference between CS in two groups were analysed.Results The incident rates of PFO, ASA, ASD were 40.6%,10.7%,6.5% and 15.6%,3.3%,2.2% in CS groups and controls respectively(P0.001).Conclusion PFO,ASA and ASD are important to CS.While PFO,ASA and ASD can accurately be diagnosed by double source CT.

Windsock deformity of interatrial septum.

Classical “Windsock deformity” is associated with ruptured aneurysmal sinus of Valsalva. The echocardiographic definition for Atrial septal aneurysm (ASA) in children based on dimensions is lacking. Rupture of an ASA, though uncommon, may lead to cardiac failure due to acute RV volume overload. An untreated ASA may be complicated with thrombus formation.

Accidente vascular de circulación posterior en pacientes con foramen oval permeable y/o aneurisma del septo auricular: dos casos clínicos y una puesta al día / Posterior circulation stroke patients with patent foramen oval and/or atrial septal aneurysm: Presentation of two cases and an update

3% of the cerebrovascular accidents (CVA) compromise the cerebellum. The area most commonly affected in unilateral cerebellar stroke is the posterior inferior cerebellar artery (PICA). Atherosclerotic disease is the first cause, however, in patients with patent foramen ovale (PFO), it is important to consider a paradoxical embolism (PE) within the possibilities. Two cases of patients with posterior cerebellar stroke associated with PFO territory and inter atrial septal aneurysm (ASA) and a review of the literature is presented. Clinical cases: 87 year old woman with a history of stroke in 2012, PFO and ASA. Presented with dizziness, gait abnormality and vomiting. CT shows ischemic brain injury PICA territory. The echocardiogram evidenced ASA + FOP. Holter rhythm analysis evidenced a paroxysmal atrial fibrillation. 72-year-old man presented with dizziness, blurred vision and postural instability. TC showed ischemic brain injury in the territory of PICA and superior cerebellar artery (SCA). Echocardiogram evidenced ASA and PFO. The rest of the study embolic source was negative. Conclusión: There is an association between PFO and cryptogenic stroke. The most studied etiological factor is the paradoxical embolism, which could affect the posterior territory, as seen in the two clinical cases exposed. The best treatment option is notyet clarified and depends on the clinical context of each patient.

Un 3% de los accidentes vasculares encefálicos (ACV) son de cerebelo. El territorio más comúnmente afectado en ACV cerebelosos unilaterales es el de la arteria cerebelosa postero-inferior (PICA). La enfermedad ateroesclerótica es la primera causa, sin embargo, en pacientes con foramen oval permeable (FOP), es importante considerar una embolia paradojal (EP) dentro de las posibilidades. Se presentarán dos casos clínicos de pacientes con ACV cerebeloso de territorio posterior asociado a FOP y aneurisma del septum inter atrial (ASA) y una revisión de la literatura. Casos clínicos: Mujer de 87 años con antecedentes mórbidos de ACV isquémico el 2012, FOP y ASA. Consulta por cuadro de vértigo, alteración de la marcha y vómitos. TC de cerebro muestra lesión isquémica en territorio PICA. Al ecocardiograma se confirma el antecedente. El resto de los estudios de fuente embólica resultaron negativos, sólo destaca en Holter de ritmo fibrilación auricular paroxística. Al alta con anticoagulación y rehabilitación. Hombre de 72 años, hipertenso. Consulta por 24 h de evolución de vértigo, visión borrosa e inestabilidad postural. TC de cerebro muestra lesiones isquémicas en territorio de PICA y de arteria cerebelosa superior (SCA) a izquierda. Al ecocardiograma se evidencia ASA y FOP. Resto del estudio de fuente embólica resulta negativo. Al alta con tratamiento anticoagulante y cierre percutáneo de defecto en forma ambulatoria. Conclusión: Existe una asociación entre FOP y ACV criptogénico. El factor etiológico más estudiado es la embolia paradojal, que podría afectar al territorio posterior a través de la circulación vertebral, tal como se aprecia en los dos casos clínicos expuestos. La mejor opción de tratamiento aún no está aclarada y dependerá del contexto clínico de cada paciente.

Aneurisma del tabique interauricular asociado a ictus / Atrial septal aneurysm associated with stroke

El aneurisma del tabique interauricular es una deformación de tipo sacular del tejido delgado situado en la zona del foramen oval, que se mueve libremente hacia la aurícula derecha, hacia la izquierda o ambas inclusive, con una excursión mayor de 10 mm. Se trata de una enfermedad rara, que cuenta con una fuerte asociación con el ictus. Se presentó una paciente que ingresó al centro con diagnóstico de ictus isquémico cardioembólico, en ausencia de factores de riesgo vascular relevantes y la ausencia de fibrilación auricular. El ecocardiograma transtorácico y transesofágico confirmaron el aneurisma del tabique interauricular asociado a foramen oval permeable. Se reconoció la asociación de esta entidad con el ictus cardioembólico, se explicaron los posibles mecanismos implicados en su génesis. Se recomienda tener en cuenta este diagnóstico en todo ictus criptogénico por las opciones terapéuticas de las que se dispone.

Atrial septal aneurysm is a sac-type deformation of thin tissue located in the area of the foramen ovale, which is free to move into the right atrium, left or inclusive, with greater excursion of 10 mm. It is a rare disease, which has a strong association with stroke. A patient who was admitted with a diagnosis of cardioembolic ischemic stroke, in the absence of relevant vascular risk factors and the absence of atrial fibrillation was presented. Transthoracic and transesophageal echocardiogram confirmed atrial septal aneurysm associated with patent foramen ovale. The association of this entity with cardioembolic stroke is recognized, the possible mechanisms involved in its genesis is explained. It is recommended to consider this diagnosis in all cryptogenic stroke by therapeutic options available.

A Case of Perimembranous Ventricular Septal Defect Associated with Sinus of Valsalva Aneurysm Mimicking Membranous Septal Aneurysm

Sinus of Valsalva aneurysms are rare. Sinus of Valsalva aneurysms are frequently associated with ventricular septal defect (VSD) and aortic regurgitation. They often remain asymptomatic until abruptly presenting with acute chest pain and heart failure secondary to rupture. Here, we describe a case of 20-year-old man who presented with chest pain with a history of VSD. Initial work-up concluded that the patient had VSD associated membranous septal aneurysm. Four years later, the patient presented with symptoms of heart failure. Work-up showed that the ruptured sinus of Valsalva aneurysm was the cause of symptoms. Due to its close proximity to the aortic annulus, sinus of Valsalva aneurysm should be differentiated from membranous septal aneurysm.

Atrial septal aneurysm in adult patients: spectrum of clinical, echocardiographic presentation and to propose a new classification on the basis of trans-thoracic-two-dimensional echocardiography.

An atrial septal aneurysm is a rare but well recognized cardiac abnormality of uncertain clinical relevance. ASA is definitively associated with congenital and acquired heart diseases but also can be presented as an isolated and totally asymptomatic entity. On the basis of our TTE finding we are proposing a new classification of ASA. We have classified ASA in to two major types: (A) Localized, and (B) Generalized. Both major types are further Sub-classified into 5 possible types on the basis of movements of ASA. New classification of ASA is as follows (1) A/B Type 1R: if the bulging is in the RA only (2) A/B Type 2L: if the bulging is in the LA only (3) A / B Type 3RL : if the major excursion bulges to the RA and lesser excursion bulges toward LA (4) A/B Type 4LR: if the maximal excursion of the atrial septal aneurysm is toward the LA with a lesser excursion toward the RA (5) A / B Type 5: if the atrial septal aneurysm movement is bidirectional and equidistant to both atria during the cardiorespiratory cycle. We found higher prevalence (2.24%) of ASA. A/B Type 2L and A/B Type 4LR were most common types. All type of ASA had particular clinical and echocardiographic characteristics. Mobile ASA and ASA with >10 mm excursion are associated with a higher risk of stroke.

Spontaneous rupture of an aneurysm of the sinus of Valsalva into the right atrium, associated with an atrial septal aneurysm / Ruptura espontánea de un aneurisma del seno de Valsalva a la aurícula derecha en una paciente con aneurisma del septum interatrial

Aneurysms of the sinus of Valsalva (SV) and the atrial septum are a rare association. We report the case of a 28-year-old woman, who was admitted to our department complaining of progressive dyspnea of 10 days of evolution, five hours previous to her admission to the hospital; she presented sudden oppressive anterior chest pain, accompanied by palpitations. The presence of rupture of the right SV to the right atrium was clinically confirmed, by echocardiography and hemodynamic studies. In addition, an associated atrial septal aneurysm was found. She underwent surgical correction through sinusplasty without requiring aortic valve replacement. The patient presented persistent postoperative atrioventricular block, which required a permanent pacemaker. Clinical evolution was satisfactory. To our knowledge, this case is a rare combination of two isolated malformations, without previous events that could explain the rupture of the right SV.

Los aneurismas del seno de Valsalva y del septum interauricular son una asociación rara. Informamos el caso de una mujer de 28 años de edad con un cuadro de disnea progresiva en los últimos 10 días, al cual se agregó dolor precordial opresivo, cinco horas previas a su ingreso. Se comprobó clínicamente, por ecocardiografía y hemodinamia la presencia de ruptura del seno de Valsalva derecho hacia el atrio derecho. Un hallazgo interesante fue la presencia de un aneurisma del septum interauricular asociado. La paciente fue sometida a corrección quirúrgica con plastía del seno de Valsalva, sin requerir reemplazo valvular aórtico. En el postoperatorio presentó bloqueo aurículo-ventricular persistente, requiriendo implante de marcapaso definitivo. Su evolución fue satisfactoria. Este es un caso de una rara asociación de dos malformaciones aisladas.

Echocardiographic evaluation and its clinical significance of atrial septal aneurysm / 中华超声影像学杂志

Objective To investigate the clinical significance of atrial septal aneurysm(ASA)and the value of echocardiography in detecting ASA. Methods One hundred and fifty-one patients with ASA diagnosed by transthoracic echocardiography(TTE) or transesophageal echocardiography(TEE) were analyzed retrospectively.The patients were divided into two groups:group Ⅰ included 57 patients who had experience of transient ischaemic attack(TIA)or cerebral shock and group Ⅱ included 94 age-and sexmatched patients without those cerebral ischemic event who underwent echocardiography during the same period of time. The following parameters of the ASA were measured:maximal excursion or protrusionbeyond the plane of the atrial septum,direction of protrusion,thickness of the wall,presence of theombi attaching to the wall and other structural abnormalities associated with ASA. Results One hundred and thirty-two of 151 cases(87.42%) located at fossa ovalis of atrial septum. The wall thickness of ASA increased with depth.The extent of bulging and thinkness of wall in group Ⅰ were greater than those in group Ⅱ and more patent foramen ovale(PFO)were observed in group Ⅰ. However,no difference was found in direction of protrusion and incidence of oscillations between the two groups. As to the performance of the two techniques in the evaluation of ASA,TEE showed better result than TTE. Conclusions Echocardiography is a reliable means to detect ASA and its complications. Greater maximal excursion and thicker aneurysm wall of ASA is associated with a higher risk of cerebral ischaemic event.

Echocardiometric evaluation of cardiovascular abnormalities in Marfan syndrome / Valoración ecocardiométrica de las anomalías cardiovasculares en el síndrome de marfán

Marfan syndrome is an inherited disorder of connective tissue with manifestations in various organ-systems including cardiovascular system. The aim of this study was to characterize and determine the frequency of cardiovascular alterations by echocardiography in 2 age cohorts of Mexican patients with Marfan syndrome and their comparisons with control groups. Material and methods: Sixty six with Marfan syndrome and 33 control patients were evaluated by echocardiography. Segments of the aorta and pulmonary artery were measured at different levels, cardiac valves were examined for prolapse and the interatrial septum was assessed for septal aneurysm. Numeric values were corrected forthe body surface area and compared with the control group. Results: Mean significant values between group I (children) and Group II (adults) were as follows: aortic annulus 16.62 ± 4.57 mm/m² vs 12.81 ± 1.95 (p< 0.001), aortic root 23.30 ±7.49 mm/m²vs 18.36 ± 2.97 (p < 0.001), sinuses of Valsalva 24.14 ± 7.29 mm/m² vs 19.84 ± 3.59 (p < 0.001), ascending aorta 18.43 ± 5.90 mm/m² vs 17.02 ± 4.79 (p < 0.001), aortic arch 16.12 ± 4.73 mm/m² vs 14.20 ± 2.68 (p < 0.001). Pulmonary valve prolapse was seen in 10/22 (45.5%) vs 7/44 (15.9%), p < 0.03. Interatrial septal aneurysm was found in 3/22 (13.6%) vs 20/44 (45.5%), p < 0.03. There was a significative diference in the presence of atrial septal aneurysm between the adult group and control group (p < 0.001). Conclusions: The incidence of cardiovascular abnormalities in our series is similar to that in the literature with the exception of the very high incidence of pulmonary valve prolapse vs control groups, then it suggests that the clinical manifestations of MFS are strikingly severe in the Mexican population. Also a high incidence of interatrial septal aneurysm (34.9%) in comparison to control groups (18.2%) was found.

El síndrome de Marfán es una enfermedad hereditaria del tejido conectivo con manifestaciones en varios órganos incluyendo el sistema cardiovascular. El objetivo del estudio fue caracterizar y determinar la frecuencia de las alteraciones cardiovasculares mediante ecocardiografía en 2 grupos de pacientes mexicanos con síndrome de Marfán en comparación con los grupos controles. Material y métodos: Se estudiaron mediante ecocardiografía a 66 pacientes con síndrome de Marfán y 33 pacientes del grupo control. Se midieron los segmentos de la aorta y de la arteria pulmonar a diferentes niveles, se valoró prolapso valvular y presencia de aneurisma del septum interatrial. Los valores numéricos fueron corregidos por área de superficie corporal y comparados con el grupo control. Resultados: Los variables con valor significativo entre el grupo I (niños) y el grupo II (adultos) fueron: Anillo aórtico: 16.62 ± 4.57 mm/m² vs 12.81 ± 1.95 (p< 0.001), raíz aórtica 23.30 ±7.49 mm/m²vs 18.36 ± 2.97 (p < 0.001), senos de Valsalva 24.14 ± 7.29 mm/m² vs 19.84 ± 3.59 (p < 0.001), aorta ascendente 18.43 ± 5.90 mm/m² vs 17.02 ± 4.79 (p < 0.001), arco aórtico 16.12 ± 4.73 mm/m² vs 14.20 ± 2.68 (p < 0.001). Se encontró prolapso valvular pulmonar en 10/22 (45.5%) vs 7/44 (15.9%), p < 0.03. Aneurisma del septum interatrial en 3/22 (13.6%) vs 20/44 (45.5%), p < 0.03. Hubo diferencia significativa para la presencia de aneurisma del septum interatrial entre el grupo de adultos y el grupo control (p < 0.001). Conclusiones: La incidencia de anormalidades cardiovasculares en nuestra serie es similar a la reportada en la literatura excepto la alta incidencia de prolapso valvular pulmonar en relación al grupo control, lo que sugiere que las manifestaciones clínicas cardiovasculares del síndrome de Marfán son más severas en la población mexicana. Se encontró también una alta incidencia de aneurisma del septum interatrial (34.9%) en comparación al grupo control (18.2%). (Arch Cardiol Mex 2005; 75: 133-140).

A Case of Atrial Septal Aneurysm Associated with Multiple Renal Infarction

Atrial septal aneurysm (ASA) was reported as a cause of unknown origin of central or peripheral thromboembolism with patent foramen ovale, aortic debris and spontaneous echo contrast. Especially the paradoxical right to left shunt via micro-fenestration on this sac may be the important cause of this embolism. We report a case of 39 year-old female patient who had atrial septal aneurysm with multiple renal infarction. Symptom was improved with aneurysmectomy and patch closure, then long term anticoagulation has been continued.

A Case of Atrial Septal Aneurysm with Recurrent Atrial Fibrillation and Cerebellar Infarction

An atrial septal aneurysm is well recognized abnormality of uncertain clinical relevance. An intraatrial aneurysm was demonstrated in the fossa ovalis of a 41-year-old woman who suffered an episode of cerebellar infarction with recurrent atrial fibrillation. The disorder is rarely treated surgically. Most patients with this condition are given life-long anticoagulation, a treatment that may have serious complications. We report a rare case of atrial septal aneurysm with recurrent atrial fibrillation and cerebellar infarction which receiving an appropriate diagnosis and curative treatment.

Spontaneous Closure of Ventricular Septal Defect: A Clinical Study of 42 Cases

During a period of 5 years and 3 months, from January, 1980 to march, 1985, 42 cases of ventricular septal defects were observed to be closed spontaneously during their follow up period and were evaluated at pediatric department, hanyang University hospital. 1) Sex incidence shows female preponderance with male to female ration of 1:2. 2) The mean age when they were diagnosed as ventricular septal defect was 5.0+/-6.4 months, and that of VSD murmur last noted was 13.3+/-11.5 months. The mean age when typical VSD murmur disappeared due to spontaneous closure of the defects was 21.1+/-18.7 months. Spontaneous closure of ventricular septal defects disclosed under one year in 22 cases (52.4%). Of those 22 cases, ventricular septal defects were spontaneously closed under 6 months of age in 16 cases(38.8% of whole study population). From the whole study population 90.5%(38 cases) were spontaneously closed under the age of 5 years. 3) Major clinical and physical characteristics before spontaneous closure of ventricular septal defects were typical pansystolic murmur with maximum intensity at left lower sternal border in all cases, palpable thrill in 5 cases(12.8%), ventricular heaves in 4 cases(10.2%) and frequent respiratory infection histories in 27 cases(64.3%). 4) Electrocardiographic findings when they were initially presented as ventricular septal defects revealed normal axis in 28 cases(84.8%), left axis deviation in 3 cases(9.1%), right axis deviation in 2 cases(6.1%) as frontal QRS axis and left ventricular hypertrophy in 8 cases(24.2%), right ventricular hypertrophy in 5 cases(15.6%) and biventricular hypertrophy in 3 cases(8.7%). Other electrocardiographic abnormalities when they had ventricular septal defects were left atrial enlargement in 12 cases(36.4%) and intraventricular conduction delay in 12 cases(36.4%). After spontaneous closure of ventricular septal defects, the electrocardiographic findings revealed normal axis in 36 cases(92.3%), left axis deviation in 3 cases(7.7%) and left ventricular hypertrophy in one case(2.6%). The remaining abnormalities after spontaneous closure of ventricular septal defect were intraventricular conduction delay in 14 cases(35.9%), deep SV6 in 4 cases(10.3%), tall RV6 in 5 cases(12.8%) and long QTc in 1 case(2.6%). Thirty-eight cases(97.4%) do not show ventricular hypertrophy pattern in EKG after spontaneous closure of their defects. 5) When we analyse their frontal plain chest X-ray films after spontaneous closure of ventricular septal defects, cardiomegaly(cardiothoracic ratio)55%) noted in 7 cases(17.9%) and pulmonary plethora in 5 cases(12.8%);while those before the defect were closed spontaneously were 67.6% and 64.7%, respectively. 6) Among 26 cases who underwent follow up 2 dimensional echocardiographic study so-called septal aneurysm were noted with the process of spontaneous closure of ventricular septal defects in 15 cases(57.7%) and the remaining 11 cases do not have any evidence of 'septal aneurysm' even after the completion of spontaneous closure of their defects. In the patient group with so-called 'septal aneurysm' the proportion of female sex was 60% and early systolic clicky sound were heard in 9 patients from 15 cases(60.0%), while those without 'septal aneurysm'were 55% and 18.2%, respectively.