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Diagnostic value of transesophageal echocardiography in atrial septal aneurysm
B Schneider1, T Hofmann, T Meinertz
1II. Medizinische Abteilung, Allgemeines Krankenhaus St. Georg, Hamburg, Germany.
Insights
Atrial septal aneurysms are linked to stroke. Transesophageal echocardiography is superior to transthoracic echocardiography for diagnosing these aneurysms and identifying embolic sources.
Area of Science:
- Cardiology
- Medical Imaging
- Neurology
Background:
- Atrial septal aneurysm (ASA) is a rare cardiac anomaly.
- The association between ASA and cerebrovascular events (CVEs) is not fully understood.
- Diagnostic challenges exist for identifying ASA and associated embolic risks.
Purpose of the Study:
- To evaluate the diagnostic utility of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) in patients with ASA.
- To investigate the prevalence of interatrial shunting and thrombus formation within ASAs.
- To determine the association between ASA characteristics and the occurrence of CVEs.
Main Methods:
- Transthoracic and transesophageal echocardiography were performed in 40 adult patients with ASA.
- Echocardiographic contrast studies and color flow mapping assessed interatrial shunting.
- Patient history and imaging findings were correlated with CVE occurrence.
Main Results:
- TEE diagnosed ASA in 11 patients (27%) missed by TTE.
- Interatrial shunting was detected in 76% of patients by TEE versus 54% by TTE.
- Thrombi within the aneurysm were identified solely by TEE in 2 patients.
- ASA thickening was significantly associated with CVEs (70% vs 20%, p<0.01).
- 50% of patients experienced CVEs, with 55% of those having recurrent events.
Conclusions:
- Atrial septal aneurysm is an embolic source, posing a risk for cerebrovascular events.
- Transesophageal echocardiography is the preferred imaging modality for evaluating ASAs and associated embolic potential.
- Mechanisms for embolization include in-situ thrombus formation and paradoxical embolism through interatrial communications.
Abstract:
Transthoracic and transesophageal echocardiography was performed in 40 consecutive adult patients with an atrial septal aneurysm. In 11 (27%) of 40 patients transthoracic echocardiography failed to demonstrate the lesion and the diagnosis was established by the transesophageal approach only. Interatrial shunting, assessed by echocardiographic contrast study and/or color flow mapping, was detected in 13 (54%) of 24 patients on transthoracic imaging and in 29 (76%) of 38 patients during transesophageal echocardiography. Identification of multiple fenestrations (n = 9) and thrombi within the aneurysm (n = 2) could be achieved only by transesophageal ultrasound. A cerebrovascular event of suspected embolic origin occurred in 20 (50%) of 40 patients; 11 (55%) of the 20 patients had repeated cerebral events. Except for mitral valve prolapse in 2 patients and spontaneous left atrial contrast phenomenon in 1 patient no other potential cardiac source of embolism could be identified by transesophageal echocardiography. A marked thickening of the aneurysm was present in 14 (70%) of 20 patients with a cerebrovascular event versus only 4 (20%) of 20 patients without a cerebrovascular event (p less than 0.01). The mechanism of embolization may be both primary thrombus formation within the aneurysm and paradoxical embolization through an interatrial communication as suggested by the findings on transesophageal ultrasound in 2 patients. Although the patients of this study represent a highly selected group it may be concluded that atrial septal aneurysm is a cardiac abnormality with embolic potential. Transesophageal echocardiography has to be regarded the imaging method of choice for evaluation of this lesion.