Giant Atrial Septal Aneurysm in a 25-Year-Old Woman
A 25-year-old physical fitness trainee was referred to receive an echocardiogram after being told that her ECG was mildly abnormal. She had experienced no symptoms apart from occasional deep, sighing breathing and rare vasovagal spells during adolescence. On physical examination, her second heart sound was somewhat more widely split with inspiration, and a grade 1/6 systolic ejection murmur was heard at the pulmonic region. The echocardiogram showed a huge fenestrated atrial septal aneurysm with marked mobility into the right atrium prolapsing into the tricuspid orifice (Figure 1 and Movie I). There was mild to moderate enlargement of the right ventricle and right atrium with a borderline decrease of right ventricular systolic function. Right ventricular systolic pressure was calculated to be 41 mm Hg. After saline contrast injections from an antecubital vein in the standing position and with Valsalva release, a significant but transient right-to-left shunt at the atrial level was consistently observed (Figure 1, middle panel, and Movie II). In view of an enlarged right ventricle and a redundant aneurysm that transiently obstructed the tricuspid valve, surgical repair was recommended and performed a week later. The aneurysm was excised and the resulting atrial septal defect was closed with a bovine pericardial patch (Figure 2). The removed tissue measured 4.5×3.4 cm and contained multiple small fenestrations 2 mm in size. After surgery, there was no residual shunt seen by echocardiography. Of note, the patient’s mother had also been diagnosed with a small atrial septal aneurysm.
The online-only Data Supplement, which contains movies, can be found at http://circ.ahajournals.org/cgi/content/full/114/22/e607/DC1.