Multiperforated atrial septal “aneurysm in aneurysm”:
Percutaneous closure guided by real-time three-dimensional
Feifei Sun MD, PhD
Miao Fan MM
Ying Li MD, PhD
Weidong Ren MD, PhD
Yanli Chen MD, PhD
Department of Ultrasonography, Shengjing
Hospital, China Medical University,
Department of Cardiology, Shengjing
Hospital, China Medical University,
Weidong Ren, MD, PhD, Department of
Ultrasound, Shengjing Hospital of China
Medical University, No. 36 Sanhao Street,
Heping District, Shenyang 110004, China.
Atrial septal aneurysm (ASA) is a localized deformity of the interatrial septum, which protrudes into
the right and/or left atrium. ASA with defects is a source of cardiac embolism. Although transcath-
eter closure is now a common procedure, it is still challenging in patients with complicated ASA.
We describe a case of giant atypical multiperforated ASA with irregular mobility, which showed a
rare “aneurysm in aneurysm” structure. Real-time three-dimensional transesophageal echocardiog-
raphy showed vivid images, which clearly demonstrated these irregular shaped defects mimicking
the atriotomy view, and played a crucial role in guiding the transcatheter closure.
atrial septal aneurysm, congenital heart disease, percutaneous closure, three-dimensional, trans-
Atrial septal aneurysm (ASA) is a localized deformity, generally at the lev-
els of the fossa ovalis, of the interatrial septum which protrudes into the
right or left atrium or both.
Its association with cardiac pathology,
especially cardiogenic embolic events, contributes to its clinical
It may be isolated, but is often found in association with
other structural cardiac malformations.
Therefore, thorough investiga-
tion is important in patients with ASA. Small, asymptomatic isolated
ASAs do not require treatment. However, large ASAs may herniate into
the mitral or tricuspid valve and cause mechanical obstruction, or even
severe hemodynamic changes or complications (such as aneurysm throm-
bosis with the risk of cerebral infarction, or rupture leading to atrial-
septal defect), and need cardiac surgery. Patients with ASA combined
with atrial-septal defect are eligible to interventional therapy, especially if
they have a history of stroke/transient ischemic attack. Nevertheless,
patients with complex heart abnormalities need surgical resection of ASA
and correction of the other heart abnormalities. ASA is detected inciden-
tally in 2%–10% of the general population.
Percutaneous closure has
been proposed as an effective option for prevention of paradoxical
embolism but remains challenging in patients with giant complicated ASA
and atrial-septal defect of mesh aperture type.
In this case, real-time
three-dimensional transesophageal echocardiography (RT3D TEE) clearly
showed a rare “aneurysm in aneurysm” structure with multiple perfora-
tions of the interatrial septum. Percutaneous transcatheter closure was
performed and two occlusion devices were embedded into the ASA suc-
cessfully guided by RT3D TEE without sedation.
A 48-year-old male presented with a 6-month history of exertional dysp-
nea and palpitations. He had history of stroke. Cardiovascular examina-
tion was notable for a grade 3/6 systolic murmur at left sternal border.
The rest of the systemic examination was normal. His electrocardiogra-
phy showed sinus rhythm and intermittent right bundle branch block
with right leaning axis. Two-dimensional transthoracic echocardiography
(2D TTE) showed a mild right-sided heart enlargement (anteroposterior
diameter of right chamber was 24mm) and pulmonary hypertension (pul-
monary systolic artery pressure was 40 mm Hg). It also raised the suspi-
cion of an ASA with defects but no additional associated cardiovascular
abnormality. The LV systolic function was normal. Two-dimensional
transesophageal echocardiography (2D TEE) revealed that the dysplastic
long-winded interatrial septum, the main component of septum primum,
J Clin Ultrasound. 2018;46:421–423. wileyonlinelibrary.com/journal/jcu
2017 Wiley Periodicals, Inc.
Received: 16 July 2017
Revised: 24 August 2017
Accepted: 11 September 2017