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Table of Contents
CASE REPORT
Year : 2013  |  Volume : 14  |  Issue : 2  |  Page : 88-89  

Giant interatrial septal aneurysm mimicking a left atrial mass


Department of Medicine, University of Toledo Medical Center, Toledo, Ohio, USA

Date of Web Publication23-Jul-2013

Correspondence Address:
Samer J Khouri
Department of Medicine, Division of Cardiovascular Medicine, University of Toledo Medical Center, 3000 Arlington Avenue, Toledo, Ohio - 43614
USA
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DOI: 10.4103/1995-705X.115503

PMID: 23983915

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   Abstract 

Interatrial septal aneurysm (IASA) consists of redundant atrial septal tissue, which bulges into either the left or the right atrium. The clinical implications of this entity are not entirely clear; however, if it is associated with other cardiac abnormalities such as patent foramen ovale and atrial septal defects. It may assume significance by increasing the risk of cardioembolic events such as stroke. We present a case of an individual with giant IASA detected by transesophageal echocardiography, which was mimicking a left atrial mass on transthoracic echocardiography. This case emphasizes the superiority of transesophageal imaging over transthoracic echocardiography for this clinical entity.

Keywords: Atrial mass, interatrial septal aneurysm, transesophageal echocardiography


How to cite this article:
Taleb M, Moza A, Khouri SJ. Giant interatrial septal aneurysm mimicking a left atrial mass. Heart Views 2013;14:88-9

How to cite this URL:
Taleb M, Moza A, Khouri SJ. Giant interatrial septal aneurysm mimicking a left atrial mass. Heart Views [serial online] 2013 [cited 2014 Sep 1];14:88-9. Available from: http://www.heartviews.org/text.asp?2013/14/2/88/115503


   Introduction Top


Interatrial septal aneurysm (IASA) along with atrial septal defect and patent foramen ovale are congenital anomalies which are encountered often in the adult patient. With improvement in two dimensional echocardiography and the increasing usage of transesophageal echocardiography, IASA is no longer considered a rare clinical entity. Early detection may prevent hemodynamic and thromboembolic sequelae.


   Case Report Top


A 41-year old male patient was referred to our institution by his primary care physician for transthoracic echocardiography to evaluate his hypertensive heart disease. The transthoracic echocardiography (TTE) showed a large mass measuring 1.4 × 1.4 cm in the left atrium that could represent a thrombus or myxoma [Figure 1]. The patient was asymptomatic and his past medical history was unremarkable except for hypertension. Clinical and laboratory examinations demonstrated no abnormality. Computed tomographic (CT) scan of the chest and heart with intravenous contrast did not show any cardiac tumor. TEE was then done and it showed a giant IASA bulging into the left atrium and mimicking a left atrial mass [Figure 2]. The patient had not had stroke or other cardio embolic phenomenon; therefore no further interventions were undertaken other than starting aspirin.
Figure 1: Transthoracic echocardiography showed a large mass (white arrow) measuring 1.4 × 1.4 cm in the left atrium that could represent a thrombus or myxoma

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Figure 2: Transesophageal echo showing interatrial septal aneurysm (white arrow)

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   Discussion Top


IASA is a congenital malformation of the atrial septum that may occur as an isolated abnormality or in association with various cardiac defects, such as patent foramen ovale (PFO), atrial septal defect (ASD), and mitral valve prolapse or connective tissue diseases. [1],[2] Its prevalence varies depending on the diagnostic method used but with the widespread use of echocardiography, IASA has become an increasingly recognized entity. Rusznak, et al., [3] concluded that IASA is detected in 8% of the patients who undergo TEE; it is associated with PFO in 25% of cases and with ASD in 22.5% of cases. The diagnosis of IASA is very important to prevent various complications and in differentiating it from an intracardiac mass-like myxoma which will have implications on choice of therapy. Nongated chest CT may be unable to distinguish ASA from intracardiac mass like in our case and in such cases, TEE should provide clarification.

However, when echocardiographic evaluation is suboptimal, ECG-gated cardiac MRI and ECG-gated cardiac 64-multidetector CT scan are useful alternative modalities of diagnosis. [4] TEE has to be regarded the imaging modality of choice for initial evaluation of this lesion as various studies have shown that a significant number of patients with IASA detected on TEE were not diagnosed on TTE. [5],[6] Also as in our case TEE can help distinguishing IASA from an atrial mass, which may not be feasible on TTE images.

Although IASA are usually found incidentally as in our case, they can have clinical consequences, such as cardiac thrombo-embolic events, [7] right to left shunt across a PFO or ASD, or can mimic a left or right atrial tumor. An annual stroke rate of 3.8% among patients with IASA and PFO compared with 1.05% among those without these anomalies was found in a systematic review of patients with cryptogenic stroke. [8] This study implied a possible increased risk of recurrent stroke in patients with ASA and PFO.

Observations have also been made regarding prevalence of atrial arrhythmias in patients with IASA but no definite associations have been established in this regard. A study by Hanley, et al., [9] noted atrial arrhythmias in 25% of patients with IASA. [9] In another multicenter study of 195 patients atrial tachycardia was found in 24% of patients with IASA and 14% of patients had atrial fibrillation. [6]

Management options for atrial septal aneurysm vary according to the clinical scenario with interventions ranging from just observation in asymptomatic individuals to ablation by surgical or catheter interventions in patients at high risk of stroke. [10],[11]

 
   References Top

1.Akdemir R, Duran S, Bulur S, Kaya A, Sozen SB, Bilir C, et al. A closed interatrial septal aneurysm mimicking a tumor in the left atrium. Tex Heart Inst J 2006;33:410-1.  Back to cited text no. 1
    
2.Malaterre H, Cohen F, Kallee K, Deharo JC, Djiane P. Giant interatrial septal aneurysm mimicking a right atrial tumor. Int J Card Imaging 1998;14:163-6.  Back to cited text no. 2
    
3.Rusznak M, Hadhazy C, Szucs M, Fazekas L, Balogh G, Szilági A, et al. Incidence of septal aneurysm and its clinical significance. Orv Hetil 1998;139:681-4.  Back to cited text no. 3
    
4.Dodd JD, Aquino SL, Holmvang G, Cury RC, Hoffmann U, Brady TJ, et al. Cardiac septal aneurysm mimicking pseudomass: Appearance on ECG-gated cardiac MRI and MDCT. AJR Am J Roentgenol 2007;188:W550-3.  Back to cited text no. 4
    
5.Schneider B, Hofmann T, Meinertz T, Hanrath P. Diagnostic value of transesophageal echocardiography in atrial septal aneurysm. Int J Card Imaging 1992;8:143-52.  Back to cited text no. 5
    
6.Mügge A, Daniel WG, Angermann C, Spes C, Khandheria BK, Kronzon I, et al. Atrial septal aneurysm in adult patients. A multicenter study using transthoracic and transesophageal echocardiography. Circulation 1996;91:2785-92.  Back to cited text no. 6
    
7.Moorthy SS, Diedorf SF. Significance of atrial septal aneurysm: Report of a case. J Clin Anesth 1996;8:595-7.  Back to cited text no. 7
    
8.Messé SR, Silverman IE, Kizer JR, Homma S, Zahn C, Gronseth G, et al. Practice parameter: Recurrent stroke with patent foramen ovale and atrial septal aneurysm: Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2004;62:1042-50.  Back to cited text no. 8
    
9.Hanley PC, Tajik AJ, Hynes JK, Edwards WD, Reeder GS, Hagler DJ, et al. Diagnosis and classification of atrial septal aneurysm by two-dimensional echocardiography: Report of 80 consecutive cases. J Am Coll Cardiol 1985;6:1370-82.  Back to cited text no. 9
    
10.Hosoba S, Suzuki T, Asai T, Takashima N. Surgical repair of a giant atrial septal aneurysm with patent foramen ovale. Heart Surg Forum 2011;14:E267-8.  Back to cited text no. 10
    
11.Pan M, Suárez de Lezo J, Medina A, Romero M, Segura J, Mesa D. Percutaneous treatment of atrial septal aneurysm. Rev Esp Cardiol 2005;58:222-6.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]



 

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