Fig. 10. Apical four-chamber view (A4C) showing interatrial septal aneurysm. (Please see companion DVD for corresponding video.)

Fig. 10. Apical four-chamber view (A4C) showing interatrial septal aneurysm. (Please see companion DVD for corresponding video.)

please see companion DVD for corresponding video for Fig. 10). It is very frequently associated with PFO, and typically involves the area of the fossa ovalis, but can extend to include the surrounding limbic areas or even the entire interatrial septum. The criteria for the diagnosis of ASA vary, but it is generally accepted that maximal excursion of the interatrial septum more than 10 mm from centerline defines an ASA. Localized

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Fig. 11. Transesophageal echocardiography images showing atrial septal aneurysm (A-D). Color flow Doppler interrogation of interatrial septum (B) and agitated saline contrast "bubble" study (C,D) revealed no shunt. The aneurysmal wall inverted intermittently during the cardiac cycle (D, arrow).

thrombi have been found on an anecdotal basis nestled within ASAs, and ASAs are associated three- to sixfold higher in patients with ischemic stroke, again with the highest incidence in the younger population.

The incidence of both a PFO and an ASA is markedly increased in patients with embolic stroke, more than 15-fold in one meta-analysis. The data is compelling for a causal connection between these two entities, and theories to explain the causality include paradoxical embo-lus from venous sources, direct embolus from thrombus formed within the aneurysm, and formation of atrial thrombus as an indirect result of atrial arrhythmia.

Currently the treatment of young patients with inter-atrial septal abnormalities and an ischemic event is still controversial. Patients younger than 55 yr of age with a PFO alone appear not to be at higher risk of stroke than the general population. However, the presence of both PFO and ASA appears to confer a higher risk of a recurrent ischemic event, despite treatment with aspirin. A large amount of right-to-left shunting may also confer increased risk of paradoxical emboli. Options for therapy and secondary risk prevention at this point include aspirin, plus additional anticoagulation and/or closure of the PFO by surgery or transcatheter devices (Fig. 12; please see companion DVD for corresponding video).

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