Clin. Cardiol. 15,541-544 (1992)
Case Reports
Acoustic Appearance of Atrial Septa1 Aneurysm JOSEFKAUTZNER, M.D., MAREK BELOHLAVEK,M.D., FRANTISEK V. HOLM,M.D., MROSLAV J. MUNCLINGER, M.D., PH.D. Department of Medicine 11, Medical Faculty I, Charles University, Prague, Czechoslovakia
Summary: 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.
Key words: atrial septal aneurysm, added systolic sound, midsystolic click, two-dimensional echocardiography
Introduction Atrial septal aneurysm is a rare anomaly which seldom occurs without other cardiac abnormalities.' Usually, it is linked with various congenital heart diseases causing atrial pressure elevation, or with mitral valve prolapse.*Clinical signs and symptoms are commonly absent in an isolated atrial septal aneurysm and the diagnosis is made accidentally by two-dimensional echocardiography.However, Alexander et aL3 reported a midsystolic click as the
Address for reprints: Josef Kautzner, M.D. Department of Medicine I1 Medical Faculty I, Charles University U nemocnice 2 128 08 Prague 2, Czechoslovakia Received: January 20, 1992 Accepted with revision: March 26, 1992
only manifestation of atrial septal aneurysm. This original observation has not been fully accepted so far. We examined a woman with isolated atrial septal aneurysm that induced a systolic acoustic phenomenon corresponding with maximal leftward motion of aneurysmatic atrial septum during early systole.
Case Report A 39-year-old female was evaluated for anxiety, insomnia, weakness, debility with paresthesia, and blurred vision. She had suffered from prolonged psychic stress in the past. No organic cause of her complaints was found after detailed examination and clinical symptoms fulfilled the criteria for the diagnosis of hyperventilation syndrome. Anxiolytic therapy brought a substantial relief. Physical examination was normal except for a lowpitched early-to-midsystolicphenomenon in the third and fourth left intercostal space which became louder during inspiration (Fig. 1). Postural changes did not influence its characteristics. Abnormalities were observed neither in ECG recordings nor on chest x-ray. 2-D echo revealed a redundant interatrial septum involving the fossa ovalis region and undulating in the right atrium. Moreover, an intermittent crossover motion with bulging of the septum into the left atrium was detected in the apical four-chamber view (Fig. 2A, B). A detailed M-mode echocardiographic analysis from subcostal view disclosed the leftward motion of aneurysmatic interatrial septum during the early systole periodically on inspiration (Fig. 2 C). During expiration, the aneurysmatic portion of the atrial septum remained in the right atrium and undulated. No other abnormalities were disclosed by echocardiography including transesophagealapproach (Fig. 3) and color-flow mapping. Right heart catheterization revealed normal blood pressures in the right heart and in pulmonary circulation. Pulmonary artery wedge pressure exceeded the pressure in the right atrium during the whole breathing cycle except early inspiration. At this moment the pulmonary artery wedge
542
Clin. Cardiol. Vol. 15, July 1992
FIG.1 Electrocardiogram, carotic pulse tracing, and two phonocardiographic recordings from the fourth intercostal space (from top to bottom). The low-pitched early-to-midsystolic acoustic phenomenon is displayed on lower phonocardiographic tracing (arrows).
pressure dropped below the right atrial pressure (Fig. 4 ) corresponding to maximal bulging of the atrial septal aneurysm into the left atrium. A left-to-right shunt was excluded by oximetry.
Discussion Atrial septal aneurysm in an otherwise normal heart is a very rare condition.' Clinical signs and symptoms usually are absent.
A midsystolic click in isolated atrial septal aneurysm was described by Alexander et aL3 They hypothesized that the click was induced by tensing of interatrial septum while bulging into the right atrium. Their suggestion was questioned by Vandenbossche et aL4 who met with no abnormal sound or click in a similar patient and attributed the midsystolic click reported by Alexander et aL3 to a probably overlooked mitral valve prolapse. On the other hand, a midsystolic click was observed in 4 of 35 children with atrial septal aneurysm by Brand et aL5 Similarly, a . late systolic click corresponding with maximal bulging of
FIG.2 Apical four-chamber two-dimensional echocardiogram with prominent bulging (arrow) of the fossa ovalis region of interatrial septum into the right atrium (A) and crossover motion into the left atrium (B). M-mode and two-dimensional echocardiogram from subcostal view (C). Leftward motion of aneurysmatic interatrial septum (arrow) during early systole on inspiration (INS) and its undulation in the right atrium during expiration (EX) are shown on the left panel with phonocardiogram, respiration wave, and ECG (from above to bottom). IAS = interatrial septum; RA = right atrium; LA = left atrium; RV = right ventricle; LV = left ventricle.
J. Kautzner et al.: Atrial septal aneurysm
543
FIG.3 Transesophageal echocardiogram showing redundant interatrial septum protruding into the right atrium (arrow). No other abnormalities are visible. Abbreviations as in Fig. 2.
rnrnHg 10
P1
5 E
’
10
FIG.4 Electrocardiogram and blood pressure recordings from the right atrium and wedged pulmonary artery (PAW) during breathing cycle. See text for explanation. Abbreviations as in Fig. 2.
a secondary atrial septal aneurysm in a patient with abnormal attachment of a Bjork-Shiley prosthesis to the interatrial septum was reported.6 However, the low frequency of association between systolic clicks and atrial septal aneurysm observed in the series of 80 consecutive patients by Hanley ef aL7 and the occurrence of clicks with both relatively immobile and mobile aneurysms made explanation of the mechanism of systolic click origin difficult. The low-pitched early-to-midsystolic acoustic phenomenon in our patient corresponds with maximal leftward excursion of aneurysmatic interatrial septum during early systole. The inspiration amplified its intensity by extending the crossover motion of atrial septal aneurysm to the left atrium. This crossover motion coincided with the respiratory-related drop of left atrial blood pressure below the pressure in the right atrium.
Thus, this observation suggests that besides formerly described midsystolic clicks another acoustic phenomenon of earlier systolic location and low-pitched character can be induced by isolated atrial septal aneuysm. It is reasonable to assume that this phenomenon is determined by fast leftward excursion of aneurysmatic interatrial septum and should be considered in the differential diagnosis of added systolic sounds. Moreover, the suggestion that atrial septal motion characteristics are passive reflectors of dynamic pressure gradient changes across the atrial septum was confiied.
Acknowledgments The authors wish to thank Dr. Boris Serf, Associated Professor of Internal Medicine, for his valuable help in reviewing this manuscript.
544
Clin. Cardiol. Vol. 15, July 1992
References 1. Kanemoto N, Kondo H, Hirose S, Ide M, Goto Y A case of atrial septal aneurysm in normal heart. Jpn Circ J 51, 10351038 (1987) 2. Roberts WC: Aneurysm (redundancy) of the atrial septum (fossa ovale membrane) and prolapse (redundancy) of the mitral valve. Am J Cardiol54,1153-1154 (1984) 3. Alexander MD, Bloom KR, Hart P, D’Silva F, Murgo J P Atrial septal aneurysm: A cause for midsystolicclick. Report of a case and review of the literature. Circulation 63, 1186-1188 (1981) 4. Vandenbossche JL, Cong BH, Englert M: Atrial septal aneurysm and midsystolic click (letter to the editor). Circulation 66,680 (1982)
5. Brand A, Keren A, Branski D, Abrahamov A, Stem S:Natural
course of atrial septal aneurysm in children and the potential for spontaneous closure of associated septal defect. Am J Cardiol64,996-1001 (1989) 6. Alfonso F, Rodrigo JL, Banuelos C, Iniguez A, Macaya C, Zarco P: Echocardiographic detection of abnormal attachment of a Bjork-Shiley prosthesis to the interatrial septum causing an atrial septal aneurysm. Am Heart J 117,695-697 (1989) 7. Hanley PC, Tajik AJ, Hynes JK, Edwards WD, Reeder GS, Hagler DJ, Seward JB: Diagnosis and classification of atrial septal aneurysm by two-dimensionalechocardiography: Report of 80 consecutive cases. J Am Coll Cardiol 6, 1370-1382 (1985)
Case Reports
Acoustic Appearance of Atrial Septa1 Aneurysm JOSEFKAUTZNER, M.D., MAREK BELOHLAVEK,M.D., FRANTISEK V. HOLM,M.D., MROSLAV J. MUNCLINGER, M.D., PH.D. Department of Medicine 11, Medical Faculty I, Charles University, Prague, Czechoslovakia
Summary: 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.
Key words: atrial septal aneurysm, added systolic sound, midsystolic click, two-dimensional echocardiography
Introduction Atrial septal aneurysm is a rare anomaly which seldom occurs without other cardiac abnormalities.' Usually, it is linked with various congenital heart diseases causing atrial pressure elevation, or with mitral valve prolapse.*Clinical signs and symptoms are commonly absent in an isolated atrial septal aneurysm and the diagnosis is made accidentally by two-dimensional echocardiography.However, Alexander et aL3 reported a midsystolic click as the
Address for reprints: Josef Kautzner, M.D. Department of Medicine I1 Medical Faculty I, Charles University U nemocnice 2 128 08 Prague 2, Czechoslovakia Received: January 20, 1992 Accepted with revision: March 26, 1992
only manifestation of atrial septal aneurysm. This original observation has not been fully accepted so far. We examined a woman with isolated atrial septal aneurysm that induced a systolic acoustic phenomenon corresponding with maximal leftward motion of aneurysmatic atrial septum during early systole.
Case Report A 39-year-old female was evaluated for anxiety, insomnia, weakness, debility with paresthesia, and blurred vision. She had suffered from prolonged psychic stress in the past. No organic cause of her complaints was found after detailed examination and clinical symptoms fulfilled the criteria for the diagnosis of hyperventilation syndrome. Anxiolytic therapy brought a substantial relief. Physical examination was normal except for a lowpitched early-to-midsystolicphenomenon in the third and fourth left intercostal space which became louder during inspiration (Fig. 1). Postural changes did not influence its characteristics. Abnormalities were observed neither in ECG recordings nor on chest x-ray. 2-D echo revealed a redundant interatrial septum involving the fossa ovalis region and undulating in the right atrium. Moreover, an intermittent crossover motion with bulging of the septum into the left atrium was detected in the apical four-chamber view (Fig. 2A, B). A detailed M-mode echocardiographic analysis from subcostal view disclosed the leftward motion of aneurysmatic interatrial septum during the early systole periodically on inspiration (Fig. 2 C). During expiration, the aneurysmatic portion of the atrial septum remained in the right atrium and undulated. No other abnormalities were disclosed by echocardiography including transesophagealapproach (Fig. 3) and color-flow mapping. Right heart catheterization revealed normal blood pressures in the right heart and in pulmonary circulation. Pulmonary artery wedge pressure exceeded the pressure in the right atrium during the whole breathing cycle except early inspiration. At this moment the pulmonary artery wedge
542
Clin. Cardiol. Vol. 15, July 1992
FIG.1 Electrocardiogram, carotic pulse tracing, and two phonocardiographic recordings from the fourth intercostal space (from top to bottom). The low-pitched early-to-midsystolic acoustic phenomenon is displayed on lower phonocardiographic tracing (arrows).
pressure dropped below the right atrial pressure (Fig. 4 ) corresponding to maximal bulging of the atrial septal aneurysm into the left atrium. A left-to-right shunt was excluded by oximetry.
Discussion Atrial septal aneurysm in an otherwise normal heart is a very rare condition.' Clinical signs and symptoms usually are absent.
A midsystolic click in isolated atrial septal aneurysm was described by Alexander et aL3 They hypothesized that the click was induced by tensing of interatrial septum while bulging into the right atrium. Their suggestion was questioned by Vandenbossche et aL4 who met with no abnormal sound or click in a similar patient and attributed the midsystolic click reported by Alexander et aL3 to a probably overlooked mitral valve prolapse. On the other hand, a midsystolic click was observed in 4 of 35 children with atrial septal aneurysm by Brand et aL5 Similarly, a . late systolic click corresponding with maximal bulging of
FIG.2 Apical four-chamber two-dimensional echocardiogram with prominent bulging (arrow) of the fossa ovalis region of interatrial septum into the right atrium (A) and crossover motion into the left atrium (B). M-mode and two-dimensional echocardiogram from subcostal view (C). Leftward motion of aneurysmatic interatrial septum (arrow) during early systole on inspiration (INS) and its undulation in the right atrium during expiration (EX) are shown on the left panel with phonocardiogram, respiration wave, and ECG (from above to bottom). IAS = interatrial septum; RA = right atrium; LA = left atrium; RV = right ventricle; LV = left ventricle.
J. Kautzner et al.: Atrial septal aneurysm
543
FIG.3 Transesophageal echocardiogram showing redundant interatrial septum protruding into the right atrium (arrow). No other abnormalities are visible. Abbreviations as in Fig. 2.
rnrnHg 10
P1
5 E
’
10
FIG.4 Electrocardiogram and blood pressure recordings from the right atrium and wedged pulmonary artery (PAW) during breathing cycle. See text for explanation. Abbreviations as in Fig. 2.
a secondary atrial septal aneurysm in a patient with abnormal attachment of a Bjork-Shiley prosthesis to the interatrial septum was reported.6 However, the low frequency of association between systolic clicks and atrial septal aneurysm observed in the series of 80 consecutive patients by Hanley ef aL7 and the occurrence of clicks with both relatively immobile and mobile aneurysms made explanation of the mechanism of systolic click origin difficult. The low-pitched early-to-midsystolic acoustic phenomenon in our patient corresponds with maximal leftward excursion of aneurysmatic interatrial septum during early systole. The inspiration amplified its intensity by extending the crossover motion of atrial septal aneurysm to the left atrium. This crossover motion coincided with the respiratory-related drop of left atrial blood pressure below the pressure in the right atrium.
Thus, this observation suggests that besides formerly described midsystolic clicks another acoustic phenomenon of earlier systolic location and low-pitched character can be induced by isolated atrial septal aneuysm. It is reasonable to assume that this phenomenon is determined by fast leftward excursion of aneurysmatic interatrial septum and should be considered in the differential diagnosis of added systolic sounds. Moreover, the suggestion that atrial septal motion characteristics are passive reflectors of dynamic pressure gradient changes across the atrial septum was confiied.
Acknowledgments The authors wish to thank Dr. Boris Serf, Associated Professor of Internal Medicine, for his valuable help in reviewing this manuscript.
544
Clin. Cardiol. Vol. 15, July 1992
References 1. Kanemoto N, Kondo H, Hirose S, Ide M, Goto Y A case of atrial septal aneurysm in normal heart. Jpn Circ J 51, 10351038 (1987) 2. Roberts WC: Aneurysm (redundancy) of the atrial septum (fossa ovale membrane) and prolapse (redundancy) of the mitral valve. Am J Cardiol54,1153-1154 (1984) 3. Alexander MD, Bloom KR, Hart P, D’Silva F, Murgo J P Atrial septal aneurysm: A cause for midsystolicclick. Report of a case and review of the literature. Circulation 63, 1186-1188 (1981) 4. Vandenbossche JL, Cong BH, Englert M: Atrial septal aneurysm and midsystolic click (letter to the editor). Circulation 66,680 (1982)
5. Brand A, Keren A, Branski D, Abrahamov A, Stem S:Natural
course of atrial septal aneurysm in children and the potential for spontaneous closure of associated septal defect. Am J Cardiol64,996-1001 (1989) 6. Alfonso F, Rodrigo JL, Banuelos C, Iniguez A, Macaya C, Zarco P: Echocardiographic detection of abnormal attachment of a Bjork-Shiley prosthesis to the interatrial septum causing an atrial septal aneurysm. Am Heart J 117,695-697 (1989) 7. Hanley PC, Tajik AJ, Hynes JK, Edwards WD, Reeder GS, Hagler DJ, Seward JB: Diagnosis and classification of atrial septal aneurysm by two-dimensionalechocardiography: Report of 80 consecutive cases. J Am Coll Cardiol 6, 1370-1382 (1985)
