Copyright © 2006, The European Society of Cardiology
Comments on "Atrial septal aneurysm and spontaneous echo contrast: An association with higher embolic risk?"
Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum 695 011, India
Received 11 July 2006; accepted after revision 19 August 2006.
* Corresponding author. Tel.: +91 471 2555532; fax: +91 471 2446433. kmkm{at}sctimst.ac.in
We read with interest the scenario of a 53-year-old man with acute ischemic stroke.1 Transesophageal echocardiogram (TEE) showed a large atrial septal aneurysm (ASA) with spontaneous echo contrast (SEC) inside but without thrombi. The ASA bulged into right atrium and was associated with patent foramen ovale. No SEC was observed outside ASA. The authors suggested a novel association of ASA and SEC to contribute to a higher embolic risk.
We would like to share with readers a similar ASA and SEC in a different clinical situation.2 The patient was a 38-year-old lady with rheumatic mitral stenosis and atrial fibrillation. She had no embolism. A higher left atrial pressure caused ASA to bulge into right atrium. Inside ASA, a clot was visualised by TEE (Fig. 1). Although we did not emphasize it at that time, SEC was seen in the cavity of ASA.
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ASA has not been reported in patients with MS. Imaging of clot within the cavity of ASA has also not been reported. Our case directly implicated ASA as responsible for embolism in susceptible patients. Now Cianciulli et al. have attributed SEC to be an additional risk factor in the presence of ASA.1 Only 4% of patients referred for non-embolic reasons have ASA; like our patient, it is 15% in patients with embolism, like that of Cianciulli et al.3
We agree with Cianciulli et al. that SEC adds incremental embolic risk in patients with atrial fibrillation and mitral stenosis. The association of SEC with ASA provides anatomic and rheological substrate for thrombus formation. ASA could be responsible for blood stasis in this low-velocity chamber. Cianciulli et al. postulate a direct positive relation between the larger size and/or reduced motion of ASA and the magnitude of SEC detected. But our patient had only a small ASA with SEC. It may be noted that our patient had all the four elements: ASA, MS, SEC and atrial fibrillation.
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- Cianciulli T.F., Chejtman D., Lipshitz S.B., Saccheri M.C., Dethinne S.L., Prezioso H.A. Atrial septal aneurysm and spontaneous echo contrast: an association with higher embolic risk? Eur J Echocardiogr (2006) 7:243–246.
[Abstract/Free Full Text] - Krishnamoorthy K.M. Atrial septal aneurysm – is it a benign finding? Int J Cardiol (1999) 71:287–288.[CrossRef][Web of Science][Medline]
- Pearson A.C., Nagelhout D., Castello R., Gomez C.R., Labovitz A.J. Atrial septal aneurysm and stroke: a transesophageal echocardiographic study. J Am Coll Cardiol (1991) 18:1223–1229.[Abstract]
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