Natural course of atrial septal aneurysm in children and the potential for spontaneous closure of associated septal defect

Atrial septal aneurysm: Prevalence and covariates in adults

BACKGROUND

Atrial septal aneurysm is a localized deformity of interatrial septum, generally at the level of fossa ovalis which protrudes into right or left atrium or both. The purpose of this study was to assess the frequency and covariates of atrial septal aneurysm in adult patients undergoing transthoracic echocardiography in our outpatient clinic.

MATERIALS AND METHODS

From December 2011 to May 2016, 16,570 patients were included in the study. Records of patients were retrospectively analyzed from our previously established database. All cardiovascular examinations and echocardiographical examinations had been done during this period. Briefly, protrusion of interatrial septum more than 15mm into the right or left atrium with an at least 15mm diameter base of interatrial septum confirmed the diagnosis of atrial septal aneurysm.

RESULTS

Atrial septal aneurysm has been documented in 393 patients (2.4%) in our study population. Mild to moderate mitral and aortic valve regurgitation have been demonstrated in 153 (39%) patients and in 61(16%) patients respectively. Sixty one (16%) of patients had the diagnosis of supraventricular arrhythmia of whom 52% underwent radiofrequency ablation procedure.

CONCLUSION

In conclusion we have documented that valvular regurgitation and supraventricular arrhythmias are common concurrent pathologies with atrial septal aneurysm.

Mutations in mammalian tolloid-like 1 gene detected in adult patients with ASD

Atrial septal defect (ASD) is an incomplete septation of atria in human heart causing circulatory problems. Its frequency is estimated at one per 10 000. Actions of numerous genes have been linked to heart development. However, no single gene defect causing ASD has yet been identified. Incomplete heart septation similar to ASD was reported in transgenic mice with both inactive alleles of gene encoding mammalian zinc metalloprotease a mammalian tolloid-like 1 (tll1). Here, we have screened 19 ASD patients and 15 healthy age-matched individuals for mutations in TLL1 gene. All 22 exons were analyzed exon by exon for heteroduplex formation. Subsequently, DNA fragments forming heteroduplexes were sequenced. In four nonrelated patients, three missense mutations in coding sequence, and one single base change in the 5'UTR have been detected. Two mutations (Met182Leu, and Ala238Val) were detected in ASD patients with the same clinical phenotype. As the second mutation locates immediately upstream of the catalytic zinc-binding signature, it might change the enzyme substrate specificity. The third change, Leu627Val in the CUB3 domain, has been found in an ASD patient with interatrial septum aneurysm in addition to ASD. The CUB3 domain is important for substrate-specific recognition. In the remaining 15 patients as well as in 15 reference samples numerous base substitutions, deletions, and insertions have been detected, but no mutations changing the coding sequence have been found. Lack of mutations in relation to ASD of these patients could possibly be because of genetic heterogeneity of the syndrome.

Outcome for patients with isolated atrial septal defects in the oval fossa diagnosed in infancy

OBJECTIVE

Our aim was to investigate the change in diameter of holes within the oval fossa, and the role of aneurismal formation in reducing the size of the hole, in patients diagnosed during infancy with isolated defects in the floor of the fossa.

PATIENTS

In a retrospective study, we included 100 patients diagnosed during the first year of life with an isolated defect in the floor of the oval fossa who had subsequently been observed for at least 5 years. There were 56 females and 44 males. They had been admitted to hospital because of a murmur in 65, heart failure in 9, and other reasons in 17. The remaining 9 patients were referred from other institutions with an established diagnosis of defects within the oval fossa. Patients were grouped according to the size of the deficiency in the floor of the fossa. Defects of diameter less than 5 mm were considered to be small, and 20 patients had such defects. Medium sized defects were judged to be between 5 and 8 mm, with 26 patients fulfilling this criterion, with the other 54 patients having large defects with diameters greater than 8 mm.

RESULTS

The overall spontaneous rate of closure was 27%. Of those with medium defects, half closed spontaneously, but only 7.5% of those with large defects showed such closure. Of the patients who were diagnosed with heart failure, 9 had defects measuring 7 mm, and of these, 6 required surgical closure, 1 patient had spontaneous closure, while the defect became smaller in the remaining 2. On the other hand, in 9 out of 10 patients who had aneurysms, the diameter of the defect was between 7 and 15 mm. Amongst these patients, the defect closed spontaneously in 3, and reduced in size in the others.

CONCLUSION

When holes within the oval fossa measure 8 mm or below, the majority of patients with experience either spontaneous closure or show decrease in size of the defect. In those with larger defects, the size usually increases, and surgery is needed for closure. If there is aneurismal formation, however, even when the defect measures more than 8 mm, the defect usually closes on its own or gets smaller.

Factors associated with development of atrial septal restriction in patients with tricuspid atresia involving the right-sided atrioventricular valve

BACKGROUND

Clinical practice is discrepant regarding routine enlargement of the interatrial communication (IAC) in patients with right-sided atrioventricular valve atresia. We determined the percentage and risk factors of those who develop a restrictive IAC.

METHODS

Medical records were reviewed for patients treated from 1985 to 2006, including those admitted in the first 6 weeks of life (group A), and those referred at a later age (group B), some of whom had routine atrial septal procedures. In group A, we analyzed the initial postnatal echocardiogram.

RESULTS

Group A consisted of 79 patients, 16 of whom had an atrial septectomy as part of the initial surgical procedure. Of the remaining 63 patients, 9 (14%) developed atrial septal restriction. In group A, an atrial septal aneurysm (ASA) (OR 16, P = .006) and IAC diameter < 5 mm (OR 13, P = .009) were associated with atrial septal restriction. Atrial septal restriction occurred in 80% of patients with both features, 20% with IAC > or = 5 mm and ASA, 18% with IAC < 5 mm and no ASA, and 2% with neither feature. Group B consisted of 95 patients, 27 of whom had an atrial septal procedure. Of the remaining 68 patients, 11 (16%) developed atrial septal restriction.

CONCLUSION

Routine enlargement of the IAC is not necessary in patients with right-sided atrioventricular valve atresia. Patients with ASA or IAC < 5 mm are at increased risk for development of atrial septal restriction.

The prospective follow-up of the natural course of interatrial communications diagnosed in 847 newborns

AIMS

The aim of this study was to evaluate the prevalance of interatrial communications (IACs) and IAC types in a large series of newborns, to establish the incidence of spontaneous closure of IACs, to determine the relationship between spontaneous closure and the size and type of IACs, and to investigate the incidence of mitral valve prolapse (MVP) and atrial arrhythmia in newborn infants with atrial septal aneurysm (ASA).

METHODS AND RESULTS

Between 2000 and 2001, a total of 1100 asymptomatic and term newborns were evaluated. Those who had congenital heart diseases and failed to attend the follow-up visits were excluded from the study. The remaining 847 newborns were followed until the closure time or in those where closure did not occur, for a maximum time of 45 months (mean 25 +/- 3 months, range 1-45 months). The mean age at diagnosis was 1.7 +/- 1.4 days (range 1-7 days). According to echocardiographic evaluation, cases were classified into four groups based on the initial size of IAC and into three groups based on the type of IAC. At the end of the 45th month IACs were closed spontaneously in 98.6% of the cases. There was significant relationship between the diameter of IAC and the timing of the closure (P < 0.01). The closure time in the cases with ASA was significantly longer than the cases with valve-like opening and multiple fenestration (P < 0.01). In female newborns, the defects remained open for a significantly longer period than male newborns (P = 0.0397). There was no significant relationship between ASA and atrial arrhythmias (P = 0.294). None of the newborns had MVP.

CONCLUSION

The cases with IACs < 3 mm do not need follow-up. However, the cases with IACs > 3 mm do need to be followed until the defect closes completely. Those with ASA should be followed-up regularly, because these defects can remain open. Spontaneous closure occurs significantly earlier in cases with valve-like opening and multiple fenestration.

Prevalence of interatrial septal aneurysm in newborns and their natural course

The objective of this study was to evaluate the prevalence of atrial septal aneurysm (ASA) in newborns, to define the natural course of ASA, and to investigate its role on closure of associated interatrial septal opening (IASO). A total of 1072 consecutive neonates were examined with echocardiography in the early postnatal period. The length of the interatrial septum, the diameter of IASO, the excursion and base of aneurysm, and the width of the related atrium were measured and the excursion ratio and the basal ratio were calculated for each neonate. Aneurysms with an excursion ratio > or = 25% were diagnosed as ASA. There were 81 neonates (7.6%) with ASA. The prevalence of ASA was 11.1% in preterm (14 of 126) and 7.1% in full-term newborns (67 of 946). All of the ASAs disappeared at the end of the first year of life, and there were no complications related to the lesion during the follow-up period. Although overall IASO prevalence was 78.6% (843 of 1072), it was 72.8% (59 of 81) among the cases with ASA. Although the disappearance time of interatrial septal shunt was not significantly different between the cases with and without ASA, spontaneous closure was less frequent in the cases with ASA than in those without ASA 77.7 and 96.1%), respectively (p < 0.001). The prevalence of ASA is high among newborns, with a high resolution rate. Therefore, it can be considered that it is benign and transient observation. Less frequent spontaneous closure of IASO in cases with ASA indicates that ASA may have a deleterious effect on spontaneous closure.

Familial origin of atrial septal aneurysm

The familial origin of atrial septal defects has been previously reported. This is the first study describing 2 families with atrial septal aneurysm of familial origin. The present study represents both clinically manifested and silent atrial septal aneurysms. Moreover, female gender predominance is also reported. Based on the presented data it could be suggested that all first-degree relatives of affected patients should be screened by cross-sectional echocardiography, particularly if they are women. In these patients, the use of aspirin might be the first line of treatment.

Comparative roles of the atrial septal aneurysm versus patent foramen ovale in systemic embolization with inferences from neonatal studies

Patent foramen ovale (PFO) and atrial septal aneurysm (ASA) have a significant statistical relation to ischemic strokes in adults. We reviewed their prevalence in 106 echocardiograms of neonates. Although all normal neonates have PFO, only 4% had ASA. From fetal and neonatal echocardiograms, we conclude that ASAs are more likely to be caused by inadequate size of the PFO, but the ASA can act as a funnel, enhancing the chances of paradoxic embolization in the presence of a PFO. There is no convincing evidence that an ASA alone causes strokes in adults; the confounder is probably atrial fibrillation.

Inoue balloon mitral valvotomy in patients with atrial septal aneurysm

Atrial septal aneurysms (ASA) are not uncommonly detected in patients with rheumatic mitral stenosis and pose problems during transeptal puncture in patients undergoing balloon mitral valvotomy. From a period of August 1995 to May 1998, we performed a total of 680 Inoue Balloon Mitral Valvotomy (IBMV) procedures with ASA noted in 30 patients, 13 of diffuse and 17 localized type. Transesophageal echocardiography (TOE) was used in all patients with suspected aneurysm on transthoracic echo (TTE) for exact three-dimensional delineation of the location and extent of the aneurysm. The localized type of aneurysms were further subcategorized into five types viz. antero-superior and leftwards (6), postero-superior and rightwards (2), antero-inferior and leftwards (2), postero-inferior and rightwards (5), and central (2), depending on their location in the atrial septum. The site for transeptal puncture was decided after this localization and the remainder of the IBMV procedure was as usual. In the set of thirteen patients with diffuse type of atrial septal aneurysms all but one case had a successful transeptal puncture using standard technique except for a somewhat inferior puncture site so as to be perpendicular to the plane of atrial septum and a successful mitral valve dilatation was possible at first attempt. In the set of 17 patients with localized type of aneurysms, all had a successful transeptal puncture except one. In patients with aneurysms localized antero-superiorly and leftwards the septal puncture was done in a slightly inferior location with transeptal needle pointing some what more posterior, i.e. 5 or 6 o'clock position and in patients with aneurysms localized postero-inferiorly the puncture was done more cephalic with needle directed somewhat anterior, i.e. 3-2 o'clock position. In the two patients with Atrial septal aneurysms located postero-superiorly and to the right the puncture was done slightly inferior but with transeptal needle pointing to about 3 or 2 o'clock position and in the single patient with antero-inferior location the puncture was done in slightly higher but with a more posterior directed needle, i.e. 5-6 o'clock position. The two patients with centrally located localized type of aneurysms had successful transeptal puncture with standard needle direction (4 o'clock) but at a slightly inferior location. We conclude that a good localization of atrial septal aneurysms using transesophageal echocardiography and our technique of transeptal puncture leads to a successful outcome in majority of cases undergoing Inoue balloon mitral valvotomy with associated atrial septal aneurysms.

Incidence and clinical significance of interatrial shunting in patients with atrial septal aneurysm detected by contrast transesophageal echocardiography

The prevalence of atrial septal aneurysm (ASA) in a general referral population of patients was investigated by use of transthoracic (TTE) and transesophageal echocardiographies (TEE). Contrast TEE was performed to detect interatrial shunting in patients with ASA. In this population, the prevalence of ASA as determined by TTE was 0.47% (24/5,079), and 0.78% (40/5,079) by TEE. Of these 40 patients 16 (40%) were judged to be normal by TTE. Of the forty patients who were positive for ASA, 50% demonstrated interatrial shunting (atrial septal defects, 10; patent foramen ovale, 10). The authors concluded that TEE is of significant value in detecting the presence of ASA and associated cardiac abnormalities. Contrast TEE further enhances the detection of interatrial shunting in patients with ASA.

Reduced penetrance, variable expressivity, and genetic heterogeneity of familial atrial septal defects

BACKGROUND

Secundum atrial septal defect (ASD) is a common congenital heart malformation that occurs as an isolated anomaly in 10% of individuals with congenital heart disease. Although some embryological pathways have been elucidated, the molecular etiologies of ASD are not fully understood. Most cases of ASD are isolated, but some individuals with ASD have a family history of this defect or other congenital heart malformations.

METHODS AND RESULTS

Clinical evaluation of three families identified individuals with ASD in multiple generations. ASD was transmitted as an autosomal dominant trait in each family. ASD was the most common anomaly, but other heart defects occurred alone or in association with ASD in individuals from each kindred. Genome-wide linkage studies in one kindred localized a familial ASD disease gene to chromosome 5p (multipoint LOD score=3.6, theta=0.0). Assessment of 20 family members with the disease haplotype revealed that 9 had ASD, 8 were clinically unaffected, and 3 had other cardiac defects (aortic stenosis, atrial septal aneurysm, and persistent left superior vena cava). Familial ASD did not map to chromosome 5p in two other families.

CONCLUSIONS

Familial ASD is a genetically heterogeneous disorder; one disease gene maps to chromosome 5p. Recognition of the heritable basis of familial ASD is complicated by low disease penetrance and variable expressivity. Identification of ASD or other congenital heart defects in more than one family member should prompt clinical evaluation of all relatives.

Atrial septal aneurysm: a new classification in two hundred five adults

Atrial septal aneurysm is a localized "saccular" deformity, generally at the level of the fossa ovalis, which protrudes to the right or the left atrium or both. For 39 months we prospectively analyzed 205 consecutive patients in whom atrial septal aneurysm was diagnosed echocardiographically. The direction and movement of atrial septal aneurysms were carefully studied in multiple views, and, according to our findings, we now propose a new classification: type 1R if the bulging is in the right atrium only, type 2L if the bulging is in the left atrium only, type 3RL if the major excursion bulges to the right atrium and the lesser excursion bulges toward the left, type 4LR if the maximal excursion of the atrial septal aneurysm is toward the left atrium with a lesser excursion toward the right atrium, type 5 if the atrial septal aneurysm movement is bidirectional and equidistant to both atria during the cardiorespiratory cycle. We found an incidence of 1.9%, a mean age of 63 years (25 to 97 years), a female/male ratio of 2:1, valvular regurgitation 74%, hypertension 64%, left ventricular hypertrophy 38%, coronary heart disease 32%, patent foramen ovale 32%, pulmonary hypertension 31%, stroke 20%, dysrhythmias 16%, valvular prolapse 15%, and atrial septal defect 3%. No differences were found between mobile and motionless types of atrial septal aneurysm. However, differences were found between predominantly left bulging or right bulging atrial septal aneurysm (134 versus 57 patients), as well as other variables. All types of atrial septal aneurysm have particular clinical or echocardiographic characteristics. The new classification is a complete, simple, and practical form. Atrial septal aneurysm is associated with congenital and acquired heart diseases but also can present as an isolated abnormality.

Atrial septal aneurysm in adult patients. A multicenter study using transthoracic and transesophageal echocardiography

BACKGROUND

An atrial septal aneurysm (ASA) is a well-recognized abnormality of uncertain clinical relevance. We reevaluated the clinical significance of ASA in a large series of patients. The aims of the study were to define morphological characteristics of ASA by transesophageal echocardiography (TEE), to define the incidence of ASA-associated abnormalities, and to investigate whether certain morphological characteristics of ASA are different in patients with and without previous events compatible with cardiogenic embolism.

METHODS AND RESULTS

Patients with ASA were enrolled from 11 centers between May 1989 and October 1993. All patients had to undergo transthoracic and transesophageal echocardiography within 24 hours of each other; ASA was defined as a protrusion of the aneurysm > 10 mm beyond the plane of the atrial septum as measured by TEE. Patients with mitral stenosis or prosthesis or after cardiothoracic surgery involving the atrial septum were excluded. Based on these criteria, 195 patients 54.6 +/- 16.0 years old (mean +/- SD) were included in this study. Whereas TEE could visualize the region of the atrial septum and therefore diagnose ASA in all patients, ASA defined by TEE was missed by transthoracic echocardiography in 92 patients (47%). As judged from TEE, ASA involved the entire septum in 100 patients (51%) and was limited to the fossa ovalis in 95 (49%). ASA was an isolated structural defect in 62 patients (32%). In 106 patients (54%), ASA was associated with interatrial shunting (atrial septal defect, n = 38; patent foramen ovale, n = 65; sinus venosus defect, n = 3). In only 2 patients (1%), thrombi attached to the region of the ASA were noted. Prior clinical events compatible with cardiogenic embolism were associated with 87 patients (44%) with ASA; in 21 patients (24%) with prior presumed cardiogenic embolism, no other potential cardiac sources of embolism were present. Length of ASA, extent of bulging, and incidence of spontaneous oscillations were similar in patients with and without previous cardiogenic embolism; however, associated abnormalities such as atrial shunts were significantly more frequent in patients with possible embolism.

CONCLUSIONS

As shown previously, TEE is superior to the transthoracic approach in the diagnosis of ASA. The most common abnormalities associated with ASA are interatrial shunts, in particular patent foramen ovale. In this retrospective study, patients with ASA (especially with shunts) showed a high frequency of previous clinical events compatible with cardiogenic embolism; in a significant subgroup of patients, ASA appears to be the only source of embolism, as judged by TEE. Our data are consistent with the view that ASA is a risk factor for cardiogenic embolism, but thrombi attached to ASA as detected by TEE are apparently rare.

Acoustic appearance of atrial septal aneurysm

Atrial septal aneurysm in the otherwise normal heart is a very rare and usually asymptomatic condition. A midsystolic click was described as the only clinical manifestation so far. A low-pitched early-to-midsystolic acoustic phenomenon in a 39-year-old woman corresponding with maximal leftward motion of the aneurysmatic interatrial septum during early systole is the subject of this case report. Our experience, plus review of the literature, supports the suggestion that atrial septal aneurysm should be considered in the interpretation of added systolic sounds.

Prolapsing large aneurysm of the atrial septum simulating a right atrial mass

An unusual case of a large, prolapsing atrial septal aneurysm in a patient with an otherwise normal heart is described. The aneurysm caused right atrial obstruction and resulted in a "tumor effect." The patient experienced debilitating symptoms for years before receiving an appropriate diagnosis and curative surgical treatment.

The neonatal transitional circulation: a combined noninvasive assessment

Dramatic changes occur in the circulation of the newborn during the transition from fetal to neonatal life. Closure of the foramen ovale and ductus arteriosus, decrease in pulmonary vascular resistance, and improvement in right ventricular compliance are among these changes. These physiological-anatomical events were characterized by means of two-dimensional, Doppler and color flow echocardiography. Forty-five full-term infants (22 male, 23 female) were studied at a mean age of 4.2 hours (T1), 25.5 hours (T2), 49.8 hours (T3), and 73.8 hours (T4) by two-dimensional, Doppler and color flow echocardiography. At T1, T2, T3, and T4, the ductus arteriosus was patent by color flow echocardiography in 100%, 34%, 22%, and 11%, respectively. Conversely, patency of the ductus by Doppler alone was detected in 100% (T1), 13% (T2, T3), and 11% (T4). Reversal of flow in the descending aorta, reflective of diastolic ductal filling, was not sensitive in detecting ductal patency (T1 50%, T2 3%, T3 and T4 0%). The patency of the foramen ovale was noted to decrease over the course of the study. Right ventricular compliance was quantitatively assessed by pulsed-Doppler diastolic properties (E-to-A ratio). This changed significantly from T1 to T4 (0.90 to 0.97) reflecting improving compliance of the right ventricle. The ratio of acceleration to ejection time, a Doppler estimation measure of pulmonary vascular resistance, increased from 0.28 to 0.33 (T1 to T4) reflecting a decrease in pulmonary vascular resistance.(ABSTRACT TRUNCATED AT 250 WORDS)