Atrial septal aneurysms are rare, but the range of their prevalence is
due to variations in ASA diagnostic criteria, materials, methods,
diagnostic equipment, study populations and recognition by
echographers.1 These aneurysms are often associated
with other cardiac anomalies such as an intraarterial shunt, atrial
septal defect type II, PFO, valvular prolapse, etc.2Complications of ASA include cerebrovascular events, arrhythmia and
pulmonary hypertension. Even among these, candidates for surgical repair
of ASA and reports about the surgery of ASA are very rare.
Stroke is one of the worst complications of ASA. Mattioli et al.
reported that ASA is the only potential cardiac source of embolism
detected by transesophageal echocardiography in patients aged
< 45 years.3 Cabanes et al. reported that
PFO and ASA are significantly associated with stroke in adults aged
< 55 years.4 On the other hand, Shinohara et
al. described a thrombus attached to the left side of an atrial septal
aneurysm that disappeared under anticoagulation therapy, but the
aneurysm was eventually excised and repaired with an atrial patch
because of risk of recurrent thrombus and a need for lifelong
anticoagulation therapy.5 The thrombus that was
attached to the left side of the ASA pouch in our patient disappeared
with anticoagulation therapy. However, we identified a PFO next to the
ASA during surgery. Because our patient was at risk for cardiogenic
embolism with intraatrial thrombi and PFO, we decided on surgical
management of the ASA.
Interatrial shunts are similar complications of ASA, and their
prevalence is 54.4% – 77%. One risk of cardiogenic embolism with ASA
is the intraatrial shunt.2,6 Although holes were not
found in the atrial septal wall of our patient, pathological and
macroscopic findings showed that parts of wall were so thin that rupture
seemed imminent. The cause of the interatrial shunt in our patient
remains obscure, but it might have been due rupture of the weakened
atrial septal wall due to long-term bulging and stretching.
Atrial tachyarrhythmias are also complications of ASA, with a prevalence
of 18% – 25%.1,2,7 The cause of arrhythmias in
patients with ASA is not clear, but cardiac abnormalities might be
responsible, such as hypertension, atrial enlargement, systolic
dysfunction, or valvular prolapse.1 Although atrial
tachyarrhythmias in patients with ASA are not a risk for cardiac
embolism per se, ASA does confer thromboembolic potential, and long-term
anticoagulant therapy is indicated for patients with ASA and a history
of embolic events.2,6The incidence of mitral valve prolapse associated with ASA is 12% –
20.5%,1,2,7,8 and the cause is also unclear. Mitral
valve prolapse and ASA might have a similar pathological basis, namely,
a connective disorder involving fibrous cardiac
tissue1. The connective tissue of an ostium primum
atrial septal defect can become defective, especially when patients have
myxomatous degeneration of the mitral valve. As a result, a weakened
atria1 septum might lead to outpouching of the atrial septal
wall4. Taking into consideration these factors,
echocardiography did not reveal mitral valve prolapse or regurgitation
in our patient, but our patient has a potential risk of a mitral valve
prolapse.