A "teapot" atrial septal aneurysm with spontaneous thrombus in an asymptomatic patient

Atrial Septal Aneurysm: An Incidental Finding or a Clinically Significant Anomaly?

Atrial septal aneurysm (ASA) is a condition involving the bulging of the interatrial septum into one or both of the atrial chambers. We present the case of an ASA found on transesophageal echocardiogram in a patient who presented with exertional dyspnea. This case report aims to highlight the growing clinical association of ASA with arterial embolism through various mechanisms and emphasize the unknown aspects of clinical management for such patients. While there are currently no clear recommendations on whether to start anticoagulation after an ASA is diagnosed, many suggest a careful patient-centered approach for such decisions due to the reported increased risk of thromboembolic events. Further studies regarding the significance of ASA and cardioembolic events are needed.

Wide-ranging clinical spectrum of paradoxical embolism

The purpose of this review is to raise the index of suspicion for paradoxical embolism among generalists. The review is based solely on anecdotal reports compiled from EMBASE, MEDLINE, Googlescholar and Pubmed. Search terms were 'paradoxical embolism', 'pulmonary embolism' and 'pulmonary arteriovenous malformations'. What emerged was that right-to-left paradoxical embolism could occur with or without concurrent pulmonary embolism, and also with and without proof of the presence of an 'embolus-in-transit'. Potential sites of single or multiple systemic involvement included the central nervous system, the coronary circulation, renal arterial circulation, splenic circulation, the mesenteric circulation and the limbs. In many cases, the deep veins of the lower limbs were the source of thromboembolism. In other cases, thrombi originated from an atrial septal aneurysm, from a central venous line, from a haemodialysis-related arterio-venous shunt, from a popliteal vein aneurysm, internal jugular vein, superior vena cava, from a pulmonary arteriovenous malformation, from tricuspid valve endocarditis (with and without pulmonary embolism) and from the right atrium, respectively. Stroke was by far the commonest systemic manifestation of paradoxical embolism. Some strokes were attributable to pulmonary arteriovenous malformations with or without coexistence of intracardiac shunts. Clinicians should have a high index of suspicion for paradoxical embolism because of its time-sensitive dimension when it occurs in the context of involvement of the intracranial circulation, coronary circulation, mesenteric circulation, and peripheral limb circulation.

Association between the maximal distance of atrial septal protrusion and cryptogenic stroke

Background and purpose Previous studies have suggested that atrial septal aneurysm is a potential risk factor for cerebral embolism. However, the association between the level of atrial septal protrusion and cerebral embolism is still unclear. The purpose of the present study was to assess the association between the maximal distance of atrial septal protrusion and cryptogenic stroke. Methods A total of 588 consecutive acute ischemic stroke patients (70 ± 11 (mean ± SD) years, 401 men) who underwent transesophageal echocardiography were enrolled. The maximal distance of atrial septal protrusion into the right or left atrium was measured. Atrial septal aneurysm was diagnosed when the maximal distance of atrial septal protrusion was >10 mm. Cryptogenic stroke was defined as non-lacunar ischemic stroke without >50% proximal artery stenosis or occlusion, cardioembolic sources, ≥4 mm atherosclerotic plaques in the aortic arch, or carotid or vertebral artery dissection. Results The rate of cryptogenic stroke increased with the increasing maximal distance of atrial septal protrusion. The maximal distance of atrial septal protrusion (multivariate-adjusted odds ratio (OR) per 1 mm, 1.14; 95% confidence interval (CI), 1.04-1.24; P = 0.003) and atrial septal aneurysm (multivariate-adjusted OR, 4.32; 95% CI, 1.22-20.39; P = 0.022) was independently associated with cryptogenic stroke. Conclusions The maximal distance of atrial septal protrusion was independently associated with cryptogenic stroke.

From the heart: interatrial septal aneurysm identified on bedside ultrasound

A 61 year-old man presented to the Emergency Department for one day of nonspecific chest pain. Bedside echocardiogram performed by the emergency physician revealed normal systolic cardiac function but also showed a large ( > 10mm) bicornuate interatrial septal aneurysm (IASA) projecting into the right atrium (Figure 1, Video 1). There was no evidence of intraatrial thrombus. A formal echocardiogram performed later that day confirmed the diagnosis and also detected a patent foramen ovale (PFO) with a left-to-right shunt that reversed with Valsalva maneuver.

Systematic review of percutaneous closure versus medical therapy in patients with cryptogenic stroke and patent foramen ovale

OBJECTIVES

To provide a comprehensive comparison of patent foramen ovale (PFO) closure versus medical therapy in patients with cryptogenic stroke or transient ischaemic attack (TIA) and demonstrated PFO.

DESIGN

Systematic review with complete case meta-analysis and sensitivity analyses. Data sources included MEDLINE and EMBASE from 1980 up to May 2013. All randomised controlled trials (RCTs) comparing treatment with percutaneous catheter-based closure of PFO to anticoagulant or antiplatelet therapy in patients with cryptogenic stroke or TIA and echocardiographically confirmed PFO or atrial septal defect (ASD) were eligible.

PARTICIPANTS

1967 participants with prior stroke or TIA and echocardiographically confirmed PFO or ASD.

PRIMARY OUTCOME MEASURES

The primary outcome of interest was recurrence of ischaemic stroke. We utilised data from complete cases only for the primary endpoint and combined data from trials to estimate the pooled risk ratio (RR) and associated 95% CIs calculated using random effects models.

RESULTS

We identified 284 potentially eligible articles of which three RCTs including 2303 patients proved eligible and 1967 patients had complete data. Of the 1026 patients randomised to PFO closure and followed to study conclusion 22 experienced non-fatal ischaemic strokes, as did 34 of 941 patients randomised to medical therapy (risk ratio (RR) 0.61, 95% CI 0.34 to 1.07; heterogeneity: p=0.34, I(2)=8%, confidence in estimates low due to risk of bias and imprecision). Analyses for ischaemic stroke restricted to 'per-protocol' patients or patients with concomitant atrial septal aneurysm did not substantially change the observed RRs. Complication rates associated with either PFO closure or medical therapy were low.

CONCLUSIONS

Pooled data from three RCTs provides insufficient support that PFO closure is preferable to medical therapy for secondary prevention of cryptogenic stroke in patients with PFO.