Recurrent cerebrovascular events associated with patent
foramen ovale, atrial septal aneurysm, or both.
Mas JL, Arquizan C, Lamy C, Zuber M, Cabanes L, Derumeaux G,
Coste J; Patent Foramen Ovale and Atrial Septal Aneurysm Study Group.
N Engl J Med 2001 Dec 13;345(24):1740-6
Department of Neurology, Sainte-Anne Hospital, Paris V University,
Paris, France. mas@chsa.broca.inserm.fr
Abstract
BACKGROUND: Patent foramen ovale and atrial septal aneurysm have been
identified as potential risk factors for stroke, but information about
their effect on the risk of recurrent stroke is limited. We studied
the risks of recurrent cerebrovascular events associated with these
cardiac abnormalities. METHODS: A total of 581 patients (age, 18 to
55 years) who had had an ischemic stroke of unknown origin within
the preceding three months were consecutively enrolled at 30 neurology
departments. All patients received aspirin (300 mg per day) for secondary
prevention. RESULTS: After four years, the risk of recurrent stroke
was 2.3 percent (95 percent confidence interval, 0.3 to 4.3 percent)
among the patients with patent foramen ovale alone, 15.2 percent
(95 percent confidence interval, 1.8 to 28.6 percent) among the patients
with both patent foramen ovale and atrial septal aneurysm, and 4.2
percent (95 percent confidence interval, 1.8 to 6.6 percent) among
the patients with neither of these cardiac abnormalities. There were
no recurrences among the patients with an atrial septal aneurysm alone.
The presence of both cardiac abnormalities was a significant predictor
of an increased risk of recurrent stroke (hazard ratio for the comparison
with the absence of these abnormalities, 4.17; 95 percent confidence
interval, 1.47 to 11.84), whereas isolated patent foramen ovale, whether
small or large, was not. CONCLUSIONS: Patients with both patent foramen
ovale and atrial septal aneurysm who have had a stroke constitute a
subgroup at substantial risk for recurrent stroke, and preventive
strategies other than aspirin should be considered.
Low incidence of embolic strokes with atrial septal aneurysms: A prospective, long-term
study
Burger AJ; Sherman HB; Charlamb MJ
Am Heart J 2000 Jan;139(1 Pt 1):149-52
Abstract
BACKGROUND: Previous retrospective studies have suggested that atrial septal
aneurysms (ASA) are associated with embolic strokes. The purpose of this study was to
evaluate prospectively the embolic potential of ASA. METHODS: Of 846 consecutive
patients undergoing cardiac surgery from December 1990 to March 1993, we identified 42
patients who had ASA as an incidental finding on intraoperative transesophageal
echocardiography. Patency was determined by color and/or contrast echocardiography. The
majority of patients were given aspirin postoperatively. Patients were monitored by
personal and/or telephone interviews, and their clinical conditions were confirmed by their
personal physicians. Any patient with any question of a neurologic event had a detailed
neurologic history, examination, and computed tomographic or magnetic resonance imaging
scan. RESULTS: The incidence of ASA in our population was 4.9%; there were 22 men and
20 women with a mean age of 72 years. Oscillating ASA were present in 28 patients and
fixed aneurysm in 10. The mean diameter of the ASA was 21 +/- 4 mm. Eighteen (56%) of
32 patients had a patent ASA. Patients were monitored for a mean period of 69.5 months
(56 to 85 months). No patient had a cerebrovascular event or systemic embolization.
CONCLUSION: The risk of cerebrovascular events or embolic strokes in our patient
population with incidental ASA was low. If treatment is needed for this condition, aspirin
appears to be effective therapy.
Mugge A. Daniel WG. Angermann C. Spes C. Khandheria BK.
Kronzon I. Freedberg RS. Keren A. Denning K. Engberding R. et
al.
Atrial septal aneurysm in adult patients. A multicenter study
using transthoracic and transesophageal echocardiography
Circulation. 91(11):2785-92, 1995 Jun 1.
Abstract
BACKGROUND: An atrial septal aneurysm (ASA) is a
well-recognized abnormality of uncertain clinical relevance. We reevaluated the
clinical significance of ASA in a large series of patients. The aims of
the study were to define morphological characteristics of ASA by
transesophageal echocardiography (TEE), to define the incidence of
ASA-associated abnormalities, and to investigate whether certain morphological
characteristics of ASA are different in patients with and
without previous events compatible with cardiogenic embolism. METHODS AND
RESULTS: Patients with ASA were enrolled from 11 centers between May 1989 and
October 1993.
All patients had to undergo transthoracic and transesophageal
echocardiography within 24 hours of each other; ASA was defined
as a
protrusion of the aneurysm > 10 mm beyond the plane of the
atrial septum
as measured by TEE. Patients with mitral stenosis or prosthesis
or after
cardiothoracic surgery involving the atrial septum were
excluded. Based on
these criteria, 195 patients 54.6 +/- 16.0 years old (mean +/-
SD) were
included in this study. Whereas TEE could visualize the region
of the
atrial septum and therefore diagnose ASA in all patients, ASA
defined by
TEE was missed by transthoracic echocardiography in 92 patients
(47%). As
judged from TEE, ASA involved the entire septum in 100 patients
(51%) and
was limited to the fossa ovalis in 95 (49%). ASA was an
isolated
structural defect in 62 patients (32%). In 106 patients (54%),
ASA was
associated with interatrial shunting (atrial septal defect, n =
38; patent
foramen ovale, n = 65; sinus venosus defect, n = 3). In only 2
patients
(1%), thrombi attached to the region of the ASA were noted.
Prior clinical
events compatible with cardiogenic embolism were associated
with 87
patients (44%) with ASA; in 21 patients (24%) with prior
presumed
cardiogenic embolism, no other potential cardiac sources of
embolism were
present. Length of ASA, extent of bulging, and incidence of
spontaneous
oscillations were similar in patients with and without previous
cardiogenic embolism; however, associated abnormalities such as
atrial
shunts were significantly more frequent in patients with
possible
embolism. CONCLUSIONS: As shown previously, TEE is superior to
the
transthoracic approach in the diagnosis of ASA. The most common
abnormalities associated with ASA are interatrial shunts, in
particular
patent foramen ovale. In this retrospective study, patients
with ASA
(especially with shunts) showed a high frequency of previous
clinical
events compatible with cardiogenic embolism; in a significant
subgroup of
patients, ASA appears to be the only source of embolism, as
judged by TEE.
Our data are consistent with the view that ASA is a risk factor
for
cardiogenic embolism, but thrombi attached to ASA as detected
by TEE are
apparently rare.
Cabanes L. Mas JL. Cohen A. Amarenco P. Cabanes PA. Oubary
P. Chedru
F. Guerin F. Bousser MG. de Recondo J.
Atrial septal aneurysm and patent foramen ovale as risk factors
for
cryptogenic stroke in patients less than 55 years of age. A
study using
transesophageal echocardiography.
Stroke. 24(12):1865-73, 1993 Dec.
Abstract
BACKGROUND AND PURPOSE: An association between atrial septal
aneurysm and
embolic events has been suggested. Atrial septal aneurysm has
been shown
to be associated with patent foramen ovale and, in some
reports, with
mitral valve prolapse. These two latter cardiac disorders have
been
identified as potential risk factors for ischemic stroke. The
aim of this
prospective study was to assess the role of atrial septal
aneurysm as an
independent risk factor for stroke, especially for cryptogenic
stroke.
METHODS: We studied the prevalence of atrial septal aneurysm,
patent
foramen ovale, and mitral valve prolapse in 100 consecutive
patients < 55
years of age with ischemic stroke who underwent extensive
etiological
investigations. We compared these results with those in a
control group of
50 consecutive patients. The diagnosis of atrial septal
aneurysm and
patent foramen ovale relied on transesophageal echocardiography
with a
contrast study and that of mitral valve prolapse, on
two-dimensional
transthoracic echocardiography. RESULTS: Stepwise logistic
regression
analysis showed that atrial septal aneurysm (odds ratio, 4.3;
95%
confidence interval, 1.3 to 14.6; P = .01) and patent foramen
ovale (odds
ratio, 3.9; 95% confidence interval, 1.5 to 10; P = .003) but
not mitral
valve prolapse were significantly associated with the diagnosis
of
cryptogenic stroke. The stroke odds of a patient with both
atrial septal
aneurysm and patent foramen ovale were 33.3 times (95%
confidence
interval, 4.1 to 270) the stroke odds of a patient with neither
of these
cardiac disorders. For a patient with atrial septal aneurysm of
> 10-mm
excursion, the stroke odds were approximately 8 times the
stroke odds of a
patient with atrial septal aneurysm of < 10 mm. CONCLUSIONS:
This study
shows that atrial septal aneurysm and patent foramen ovale are
both
significantly associated with cryptogenic stroke and that their
association has a marked synergistic effect. Atrial septal
aneurysms of >
10-mm excursion are associated with a higher risk of stroke.
Pearson AC. Nagelhout D. Castello R. Gomez CR. Labovitz AJ.
Atrial septal aneurysm and stroke: a transesophageal
echocardiographic
study.
Journal of the American College of Cardiology. 18(5):1223-9,
1991 Nov 1.
Abstract
The prevalence and morphologic characteristics of atrial septal
aneurysms
identified by transesophageal echocardiography in 410
consecutive patients
are described. Two groups of patients were compared: Group I
consisted of
133 patients referred for evaluation of the potential source of
an embolus
and Group II consisted of 277 patients referred for other
reasons. An
atrial septal aneurysm was diagnosed by transesophageal
echocardiography
in 32 (8%) of the 410 patients. Surface echocardiography
identified only
12 of these aneurysms. Atrial septal aneurysm was significantly
more
common in patients with stroke (20 [15%] of 133 vs. 12 [4%] of
277) (p
less than 0.05); right to left shunting at the atrial level was
demonstrated in 70% of patients in Group I and 75% of patients
in Group II
by saline contrast echocardiography. Four patients in Group I
had an
atrial septal defect with additional left to right flow. There
was no
difference between the two groups in aneurysm base width, total
excursion
or left atrial or right atrial excursion. However, Group I
patients had a
thinner atrial septal aneurysm than did Group II patients. It
is concluded
that an atrial septal aneurysm occurs commonly in patients with
unexplained stroke, is more frequently detected by
transesophageal
echocardiography than by surface echocardiography and is
usually
associated with right to left atrial shunting. Treatment
(anticoagulant
therapy vs. surgery) of atrial septal aneurysm identified in
stroke
patients can be determined only by long-term follow-up studies.
Belkin RN. Hurwitz BJ. Kisslo J.
Atrial septal aneurysm: association with cerebrovascular and
peripheral
embolic events.
Stroke. 18(5):856-62, 1987 Sep-Oct.
Abstract
Patient records in 36 consecutively identified patients with
typical
echocardiographic findings of atrial septal aneurysm were
reviewed. Ten of
the 36 (28%) had cerebrovascular events. Of these 10, 5 had
completed
strokes of definite embolic origin on the basis of clinical,
angiographic,
and computed tomographic findings; 2 had transient ischemic
attacks of
probable embolic origin. One of the 36 patients had a definite
peripheral
vascular embolus. Thus, 6 of 36 consecutively identified
patients with
atrial septal aneurysm (17%) had definite embolic events and 8
of 36 (22%)
had definite or possible embolic events. The cause of the
association
between atrial septal aneurysm and emboli is unknown. While
aneurysm-associated thrombus has been suggested, the high
proportion (90%)
of patients with interatrial shunting demonstrated by contrast
echocardiography in this study suggests paradoxical
embolization as a
potential cause. Whatever its mechanism, the high prevalence of
embolic
events in this series strongly supports the premise that atrial
septal
aneurysm is a cardiac abnormality with embolic potential.
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