Loading ...
Sorry, an error occurred while loading the content.
 

[echocardiography] Atrial Septal Aneurysm

Expand Messages
  • Daniel Shindler
    Question to the group? young patient, no history of cerebroembolic event, incidental finding of atrial septal aneurysm, no right to left contrast shunt.
    Message 1 of 7 , Aug 4 8:52 AM
      Question to the group?

      "young" patient, no history of cerebroembolic event, incidental finding
      of atrial
      septal aneurysm, no right to left contrast shunt.

      Aspirin, coumadin or nothing? You pick the class from below.

      Dan Shindler

      ------------------------------------------------------------------------------------

      Echocardiographic Classifications of Atrial Septal
      Aneurysm Motion

      J Am Soc Echocardiogr 1997;10:644-56.

      Type 1R: The ASA protrudes from the midline of the atria to the
      right atrium throughout the
      cardiorespiratory cycle.
      Type 2L: The ASA protrudes from the midline of the atrial septum to
      the left atrium
      throughout the cardiorespiratory cycle.
      Type 3RL: The maximal excursion of the ASA is toward the right
      atrium with a lesser
      excursion toward the left atrium.
      Type 4LR: The maximal excursion of the ASA is toward the left
      atrium with a lesser excursion
      toward the right atrium.
      Type 5: The ASA movement is bidirectional and equidistant to the
      right as well as to the left
      atrium during the cardiorespiratory cycle.



      Am J Cardiol 1985;56:653-67.

      Type 1: The ASA projects into the right atrium during diastole,
      with early systolic bulging into
      the left atrium, followed by a rightward crossing-over motion in
      mid-systole and during
      inspiration or expiration.
      Type 2: Sustained rightward deviation during expiration and a
      leftward motion only during
      inspiration in early ventricular systole.
      Type 3: The ASA remains in the right atrium, with an undulating
      motion during all phases of
      the cardiorespiratory cycle.



      J Am Coll Cardiol 1985;6:1370-82.

      Type 1A: The bulging in the right atrium is motionless.
      Type 1B: The bulging is confined to the right atrium but with rapid
      phasic oscillation during
      inspiration.
      Type 2: The ASA protrudes maximally into the left atrium and is
      accompanied by excursion
      into the right atrium.
      -------------------------------------------------------------------------------------

      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.


      ----
      Read this list on the Web at http://www.FindMail.com/list/echocardiography/
      To unsubscribe, email to echocardiography-unsubscribe@...
      To subscribe, email to echocardiography-subscribe@...
      --
      Start a FREE E-Mail List at http://makelist.com !
    • Kwan Chan, MD
      My response is no treatment. A more difficult scenario is : same patient but a recent stroke. The studies cited showed an association not casuality. There are
      Message 2 of 7 , Aug 4 9:58 AM
        My response is no treatment. A more difficult scenario is : same patient but
        a recent stroke. The studies cited showed an association not casuality. There
        are also other studies that showed no association of this finding with stroke,
        with the most recent study being the SPAF-TEE study inthe April issue of
        Annals Int Med.At 11:52 AM 8/4/98 -0400, you wrote:
        >Question to the group?
        >
        >"young" patient, no history of cerebroembolic event, incidental finding
        >of atrial
        >septal aneurysm, no right to left contrast shunt.
        >
        >Aspirin, coumadin or nothing? You pick the class from below.
        >
        >Dan Shindler
        >
        >---------------------------------------------------------------------------
        ---------
        >
        >Echocardiographic Classifications of Atrial Septal
        >Aneurysm Motion
        >
        >J Am Soc Echocardiogr 1997;10:644-56.
        >
        > Type 1R: The ASA protrudes from the midline of the atria to the
        >right atrium throughout the
        > cardiorespiratory cycle.
        > Type 2L: The ASA protrudes from the midline of the atrial septum to
        >the left atrium
        > throughout the cardiorespiratory cycle.
        > Type 3RL: The maximal excursion of the ASA is toward the right
        >atrium with a lesser
        > excursion toward the left atrium.
        > Type 4LR: The maximal excursion of the ASA is toward the left
        >atrium with a lesser excursion
        > toward the right atrium.
        > Type 5: The ASA movement is bidirectional and equidistant to the
        >right as well as to the left
        > atrium during the cardiorespiratory cycle.
        >
        >
        >
        >Am J Cardiol 1985;56:653-67.
        >
        > Type 1: The ASA projects into the right atrium during diastole,
        >with early systolic bulging into
        > the left atrium, followed by a rightward crossing-over motion in
        >mid-systole and during
        > inspiration or expiration.
        > Type 2: Sustained rightward deviation during expiration and a
        >leftward motion only during
        > inspiration in early ventricular systole.
        > Type 3: The ASA remains in the right atrium, with an undulating
        >motion during all phases of
        > the cardiorespiratory cycle.
        >
        >
        >
        >J Am Coll Cardiol 1985;6:1370-82.
        >
        > Type 1A: The bulging in the right atrium is motionless.
        > Type 1B: The bulging is confined to the right atrium but with rapid
        >phasic oscillation during
        > inspiration.
        > Type 2: The ASA protrudes maximally into the left atrium and is
        >accompanied by excursion
        > into the right atrium.
        >---------------------------------------------------------------------------
        ----------
        >
        >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.
        >
        >
        >----
        >Read this list on the Web at http://www.FindMail.com/list/echocardiography/
        >To unsubscribe, email to echocardiography-unsubscribe@...
        >To subscribe, email to echocardiography-subscribe@...
        >--
        >Start a FREE E-Mail List at http://makelist.com !
        >
        >



        ----
        Read this list on the Web at http://www.FindMail.com/list/echocardiography/
        To unsubscribe, email to echocardiography-unsubscribe@...
        To subscribe, email to echocardiography-subscribe@...
        --
        Start a FREE E-Mail List at http://makelist.com !
      • jamestam
        I consider the atrial septum aneurysm a finding of curiosity only and until prospective studies indicate the treatment of choice, I would continue to
        Message 3 of 7 , Aug 4 11:00 AM
          I consider the atrial septum aneurysm a finding of curiosity only and until
          prospective studies indicate the treatment of choice, I would continue to
          prescribe NOTHING. Many echo findings initially felt to be causative for
          stroke are only now being realized to be associations only (take for example
          the valvular strands issue). Unfortunately, I think the technology has
          gotten ahead of the science and the evidence and we must resist the
          temptation to act before we know what we are doing.

          JT


          -----Original Message-----
          From: Daniel Shindler <shindler@...>
          To: echocardiography@... <echocardiography@...>
          Date: Tuesday, August 04, 1998 10:59 AM
          Subject: [echocardiography] Atrial Septal Aneurysm


          >Question to the group?
          >
          >"young" patient, no history of cerebroembolic event, incidental finding
          >of atrial
          >septal aneurysm, no right to left contrast shunt.
          >
          >Aspirin, coumadin or nothing? You pick the class from below.
          >
          >Dan Shindler
          >
          >---------------------------------------------------------------------------
          ---------
          >
          >Echocardiographic Classifications of Atrial Septal
          >Aneurysm Motion
          >
          >J Am Soc Echocardiogr 1997;10:644-56.
          >
          > Type 1R: The ASA protrudes from the midline of the atria to the
          >right atrium throughout the
          > cardiorespiratory cycle.
          > Type 2L: The ASA protrudes from the midline of the atrial septum to
          >the left atrium
          > throughout the cardiorespiratory cycle.
          > Type 3RL: The maximal excursion of the ASA is toward the right
          >atrium with a lesser
          > excursion toward the left atrium.
          > Type 4LR: The maximal excursion of the ASA is toward the left
          >atrium with a lesser excursion
          > toward the right atrium.
          > Type 5: The ASA movement is bidirectional and equidistant to the
          >right as well as to the left
          > atrium during the cardiorespiratory cycle.
          >
          >
          >
          >Am J Cardiol 1985;56:653-67.
          >
          > Type 1: The ASA projects into the right atrium during diastole,
          >with early systolic bulging into
          > the left atrium, followed by a rightward crossing-over motion in
          >mid-systole and during
          > inspiration or expiration.
          > Type 2: Sustained rightward deviation during expiration and a
          >leftward motion only during
          > inspiration in early ventricular systole.
          > Type 3: The ASA remains in the right atrium, with an undulating
          >motion during all phases of
          > the cardiorespiratory cycle.
          >
          >
          >
          >J Am Coll Cardiol 1985;6:1370-82.
          >
          > Type 1A: The bulging in the right atrium is motionless.
          > Type 1B: The bulging is confined to the right atrium but with rapid
          >phasic oscillation during
          > inspiration.
          > Type 2: The ASA protrudes maximally into the left atrium and is
          >accompanied by excursion
          > into the right atrium.
          >---------------------------------------------------------------------------
          ----------
          >
          >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.
          >
          >
          >----
          >Read this list on the Web at http://www.FindMail.com/list/echocardiography/
          >To unsubscribe, email to echocardiography-unsubscribe@...
          >To subscribe, email to echocardiography-subscribe@...
          >--
          >Start a FREE E-Mail List at http://makelist.com !
          >





          ----
          Read this list on the Web at http://www.FindMail.com/list/echocardiography/
          To unsubscribe, email to echocardiography-unsubscribe@...
          To subscribe, email to echocardiography-subscribe@...
          --
          Start a FREE E-Mail List at http://makelist.com !
        • Howard Dittrich
          ... No therapy warranted under this circumstance. Agree with above comments. There maybe another reason for this patient to take aspirin (headache) but this
          Message 4 of 7 , Aug 4 12:27 PM
            Daniel Shindler wrote:
            >
            > Question to the group?
            >
            > "young" patient, no history of cerebroembolic event, incidental finding
            > of atrial
            > septal aneurysm, no right to left contrast shunt.
            >
            > Aspirin, coumadin or nothing? You pick the class from below.
            >
            > Dan Shindler
            >
            > ------------------------------------------------------------------------------------
            >
            > Echocardiographic Classifications of Atrial Septal
            > Aneurysm Motion
            >
            > J Am Soc Echocardiogr 1997;10:644-56.
            >
            > Type 1R: The ASA protrudes from the midline of the atria to the
            > right atrium throughout the
            > cardiorespiratory cycle.
            > Type 2L: The ASA protrudes from the midline of the atrial septum to
            > the left atrium
            > throughout the cardiorespiratory cycle.
            > Type 3RL: The maximal excursion of the ASA is toward the right
            > atrium with a lesser
            > excursion toward the left atrium.
            > Type 4LR: The maximal excursion of the ASA is toward the left
            > atrium with a lesser excursion
            > toward the right atrium.
            > Type 5: The ASA movement is bidirectional and equidistant to the
            > right as well as to the left
            > atrium during the cardiorespiratory cycle.
            >
            > Am J Cardiol 1985;56:653-67.
            >
            > Type 1: The ASA projects into the right atrium during diastole,
            > with early systolic bulging into
            > the left atrium, followed by a rightward crossing-over motion in
            > mid-systole and during
            > inspiration or expiration.
            > Type 2: Sustained rightward deviation during expiration and a
            > leftward motion only during
            > inspiration in early ventricular systole.
            > Type 3: The ASA remains in the right atrium, with an undulating
            > motion during all phases of
            > the cardiorespiratory cycle.
            >
            > J Am Coll Cardiol 1985;6:1370-82.
            >
            > Type 1A: The bulging in the right atrium is motionless.
            > Type 1B: The bulging is confined to the right atrium but with rapid
            > phasic oscillation during
            > inspiration.
            > Type 2: The ASA protrudes maximally into the left atrium and is
            > accompanied by excursion
            > into the right atrium.
            > -------------------------------------------------------------------------------------
            >
            > 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.
            >
            > ----
            > Read this list on the Web at http://www.FindMail.com/list/echocardiography/
            > To unsubscribe, email to echocardiography-unsubscribe@...
            > To subscribe, email to echocardiography-subscribe@...
            > --
            > Start a FREE E-Mail List at http://makelist.com !


            No therapy warranted under this circumstance. Agree with above
            comments. There maybe another reason for this patient to take aspirin
            (headache) but this isn't it.

            Howard Dittrich


            ----
            Read this list on the Web at http://www.FindMail.com/list/echocardiography/
            To unsubscribe, email to echocardiography-unsubscribe@...
            To subscribe, email to echocardiography-subscribe@...
            --
            Start a FREE E-Mail List at http://makelist.com !
          • Dr. Alejandro F. Luque Coqui
            I think the answer is nothing, but I have another question what about if the patient would have atrial fibrillation?, the patient should take full coumadin for
            Message 5 of 7 , Aug 6 7:44 AM
              I think the answer is nothing, but I have another question what about if the
              patient would have atrial fibrillation?, the patient should take full
              coumadin for the atrial septal aneurysm? or atrial fibrilation? both? only
              aspirin?

              Alejandro F. Luque-Coqui

              -----Original Message-----
              From: Daniel Shindler <shindler@...>
              To: echocardiography@... <echocardiography@...>
              Date: martes 4 de agosto de 1998 11:00
              Subject: [echocardiography] Atrial Septal Aneurysm


              >Question to the group?
              >
              >"young" patient, no history of cerebroembolic event, incidental finding
              >of atrial
              >septal aneurysm, no right to left contrast shunt.
              >
              >Aspirin, coumadin or nothing? You pick the class from below.
              >
              >Dan Shindler
              >
              >---------------------------------------------------------------------------
              ---------
              >
              >



              ----
              Read this list on the Web at http://www.FindMail.com/list/echocardiography/
              To unsubscribe, email to echocardiography-unsubscribe@...
              To subscribe, email to echocardiography-subscribe@...
              --
              Start a FREE E-Mail List at http://makelist.com !
            • Howard Dittrich
              The SPAF data would say that if this young patient has normal LV function, no hypertension, and no prior thromboembolic event that no treatment is warranted
              Message 6 of 7 , Aug 6 8:46 AM
                The SPAF data would say that if this young patient has normal LV function,
                no hypertension, and no prior thromboembolic event that no treatment is
                warranted since the per year risk rate is so low. Having said that, I
                don't imagine there are too many patients or doctors who would be very
                opposed to daily use of aspirin, but it would be based on emotion more than
                science. As for warfarin, in this case, I believe, and SPAF data would say
                that it would certainly work and reduce risk further (by 1%/year) but would
                the risk of bleeding (low in young) be worth it? I wouldn't take it and I
                would have a harder time telling the young patient he "had" to take it.
                I'm sure you'll find BAATAF trialists who say that warfarin should be taken
                by all a fib patients, but I believe that view is extreme.

                H Dittrich


                >I think the answer is nothing, but I have another question what about if the
                >patient would have atrial fibrillation?, the patient should take full
                >coumadin for the atrial septal aneurysm? or atrial fibrilation? both? only
                >aspirin?
                >
                >Alejandro F. Luque-Coqui
                >
                >-----Original Message-----
                >From: Daniel Shindler <shindler@...>
                >To: echocardiography@... <echocardiography@...>
                >Date: martes 4 de agosto de 1998 11:00
                >Subject: [echocardiography] Atrial Septal Aneurysm
                >
                >
                >>Question to the group?
                >>
                >>"young" patient, no history of cerebroembolic event, incidental finding
                >>of atrial
                >>septal aneurysm, no right to left contrast shunt.
                >>
                >>Aspirin, coumadin or nothing? You pick the class from below.
                >>
                >>Dan Shindler
                >>
                >>---------------------------------------------------------------------------
                >---------
                >>
                >>
                >
                >
                >
                >----
                >Read this list on the Web at http://www.FindMail.com/list/echocardiography/
                >To unsubscribe, email to echocardiography-unsubscribe@...
                >To subscribe, email to echocardiography-subscribe@...
                >--
                >Start a FREE E-Mail List at http://makelist.com !





                ----
                Read this list on the Web at http://www.FindMail.com/list/echocardiography/
                To unsubscribe, email to echocardiography-unsubscribe@...
                To subscribe, email to echocardiography-subscribe@...
                --
                Start a FREE E-Mail List at http://makelist.com !
              • tvakani@netcom.ca
                I would say nothing. Dr. vakani ... Read this list on the Web at http://www.FindMail.com/list/echocardiography/ To unsubscribe, email to
                Message 7 of 7 , Aug 6 2:04 PM
                  I would say nothing.

                  Dr. vakani


                  ----
                  Read this list on the Web at http://www.FindMail.com/list/echocardiography/
                  To unsubscribe, email to echocardiography-unsubscribe@...
                  To subscribe, email to echocardiography-subscribe@...
                  --
                  Start a FREE E-Mail List at http://makelist.com !
                Your message has been successfully submitted and would be delivered to recipients shortly.