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45
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_16, © Springer International Publishing Switzerland 2015
A 43-year-old man was referred for the evaluation of the
cause of a transient ischemic attack.
Patent Foramen Ovale with
Aneurysmal Interatrial Septum
Case 16
RA
RV
a
LV
LA
b
Fig. 16.1 Transthoracic echocardiography shows the aneurysmal for-
mation of the interatrial septum (IAS). The aneurysm is 10 mm [ 37 ] in
diameter and 29 mm in length ( a ). After contrast injection with the
Valsalva maneuver, a large number of bubbles ( arrow ) passed through
the IAS, suggestive of a large patent foramen ovale (PFO) ( b ). LA left
atrium, LV left ventricle, RA right atrium, RV right ventricle
Diagnosis
The patient was diagnosed with transient ischemic attack and
a large PFO from a physiological point of view.
Comment
The patient was recommended to undergo transesophageal
echocardiography [ 38 ].
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_16 ) contains supplementary
material, which is available to authorized users.
47
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_17, © Springer International Publishing Switzerland 2015
A 55-year-old man was referred to our clinic due to one
episode of transient ischemic attack. He was a known case of
diabetes mellitus and had left ventricular systolic dysfunction
(ejection fraction of about 30 %). However, angiography
revealed normal coronary arteries.
Patent Foramen Ovale with
Partially Aneurysmal
Interatrial Septum
Case 17
RA
a
LA
LV
RA
b
LA
RA
c
LA
Fig. 17.1 The patent foramen ovale (PFO) fl ow at rest from left to
right is evident on transesophageal echocardiography (TEE) 0° ( a ) and
long- axis view ( b ) ( arrows ). The interatrial septum (IAS) is partially
aneurysmal without defects ( curved arrow ) ( c ). LA left atrium, LV left
ventricle, RA right atrium
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_17 ) contains supplementary
material, which is available to authorized users.
48
LA
RA
RA
LA
AO
c
a
RA
LA
b
Fig. 17.2 TEE (short-axis view) shows that the IAS is bilayered ( arrow ) ( a ). The distance between the two layers is 4 mm ( b ). The left-to-right
shunt is evident in this view ( c ) ( arrow ). LA left atrium, RA right atrium, AO aorta
LA
RA
Fig. 17.3 The tunnel length is 15 mm on TEE (long-axis view). LA left
atrium, RA right atrium
LA
RA
AO
Fig. 17.4 The IAS is partially aneurysmal, the diameter is 7 mm, and
the length is 22 mm by TEE (short-axis view). LA left atrium, RA right
atrium, AO aorta
Case 17 Patent Foramen Ovale with Partially Aneurysmal Interatrial Septum
49
Diagnosis
Transient ischemic attack with a low ejection fraction, normal
coronary arteries, and a moderate size PFO with a left-toright shunt (probably due to an elevated left atrial pressure).
Comment
Medical treatment and anticoagulation with warfarin was
recommended.
Lesson
1. PFOs present in up to 25 % of adults [ 2 ]. If a PFO gives
rise to recurrent cryptogenic stroke or a cryptogenic
stroke is associated by PFO and IAS aneurysm, PFO clo-
sure should be considered [ 2 , 40 ]. As the result of
RESPECT trial showed, there is no signifi cant benefi t of
PFO closure in the patients with cryptogenic ischemic
stroke [ 37 ].
2. The PFO fl ow is bidirectional. However, if there is a high
left atrial pressure (e.g., due to a reduced left ventricular
ejection fraction), it can produce a left-to-right shunt.
3. There are different classifi cations for the size of a PFO
depending on the following anatomic or physiological
viewpoints:
3.1. The anatomic classifi cation is based on the distance
between the two layers of the PFO: it is small if it is
smaller than 2 mm [ 41 , 42 ], moderate if it is between
2 and 4 mm, and large if it is greater than 4 mm [ 38 ].
3.2. The physiological classifi cation is according to the
number of bubbles passing through the foramen
ovale during the Valsalva maneuver: a PFO is small
if there are fewer than 6–9 bubbles, moderate if there
are between 6–9 and 20–25 bubbles, and large if
there are more than 20–25 bubbles [ 37 , 38 ].
4. There is an association between the aneurysm of the IAS
and PFO (48 %) [ 43 ] and ASD.
5. In this case, there is PFO fl ow at rest, and there is a defect
4 mm in size in the interatrial septum just in the fossa
ovalis site, and some authors believe that up to 10-mm
defect in the site of foramen ovale can be considered as
PFO [ 44 ].
6. The tunnel length is 15 mm in this case, and when the
tunnel length is more than 8 mm, a PFO device closure
may be performed using a special device [ 45 , 46 ].
LA
AO
RA
a
b
Fig. 17.5 The rim of the center of the PFO from the aorta is 6 mm, and the atrial depth is 42 mm on TEE (short-axis view) ( a ). The rim of the
PFO from the superior vena cava is 23 mm ( b ). LA left atrium, RA right atrium, AO aorta [ 13 , 39 ]
LA
Fig. 17.6 No clot in the left atrial appendage is seen on TEE (long-
axis view) ( arrow ). LA left atrium
Case 17 Patent Foramen Ovale with Partially Aneurysmal Interatrial Septum
51
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_18, © Springer International Publishing Switzerland 2015
A 34-year-old woman presented with migraine unresponsive
to medical treatment.
Interatrial Septal Aneurysm with
a Large Patent Foramen Ovale
Case 18
RV
a
LV
RA
LA
b
Fig. 18.1 The apical four-chamber view shows the aneurysmal formation of the interatrial septum (IAS) ( arrow ) ( a ). The aneurysm measures
13 mm ( b ). LA left atrium, LV left ventricle, RA right atrium, RV right ventricle
LV
RA LA
RV
ab
RA
LV
RV
Fig. 18.2 There is no fl ow across the IAS by color Doppler study ( arrow ) ( a ). A large number of bubbles passed through the IAS after the injec-
tion of agitated saline and the Valsalva maneuver ( b ). LA left atrium, LV left ventricle, RA right atrium, RV right ventricle
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_18 ) contains supplementary
material, which is available to authorized users.
52
LA
RA
ab
RA
LA
Fig. 18.5 The rim of the PFO is about 27 mm to the superior vena cava and 11 mm to the aorta by TEE [long- ( a ) and short-axis ( b ) views].
LA left atrium, RA right atrium
RA
ab
LA
RA
LA
Fig. 18.3 The aneurysm is 35 mm in length ( a ) and 14 mm in diameter by transesophageal echocardiography (TEE) (four-chamber view) ( b ). LA
left atrium, RA right atrium
RA
LA
Fig. 18.4 There is a patent foramen ovale (PFO) fl ow ( arrow ) at rest
without any defect. The fl ow measures 4 mm in size. LA left atrium, RA
right atrium
Case 18 Interatrial Septal Aneurysm with a Large Patent Foramen Ovale
53
Diagnosis
The patient was diagnosed with aneurysm of the IAS and a
large size PFO from physiologic point of view and moderate
size PFO from anatomic point of view [ 38 , 47 ].
Recommendation
The patient was recommended for PFO closure.
Lesson
1. When a PFO produces migraine resistant to medical therapy, one of the possible interventions is PFO closure,
although it is controversial [ 48 – 51 ].
2. For ASD Amplatzers, the left atrial arm is greater than the
right one, and for PFO devices, usually the right arm is
larger than the left one, and two arms of PFO Amplatzer
size 18 are equal [ 13 ].
3. The size of the PFO Amplatzer depends on the rim of the
PFO to the superior vena cava and aorta [ 13 ].
Case 18 Interatrial Septal Aneurysm with a Large Patent Foramen Ovale
55
H. Sadeghian, Z. Savand-Roomi, Echocardiographic Atlas of Adult Congenital Heart Disease,
DOI 10.1007/978-3-319-12934-1_19, © Springer International Publishing Switzerland 2015
A 17-year-old girl presented with dyspnea on exertion
( functional class II) since childhood. Physical examination
revealed a harsh holosystolic murmur at the left sternal
border and apex. Electrocardiography showed normal sinus
rhythm and left axis deviation.
Atrioventricular Septal Defect
(Intermediate Form)
Case 19
a b
Fig. 19.1 This is an atrioventricular septal defect (AVSD) ( arrow ) in the apical four-chamber view ( a ). A schematic illustration of the AVSD is pre-
sented in the apical four-chamber view ( b ). LA left atrium, LV left ventricle. RA right atrium, RV right ventricle, AVSD atrioventricular septal defect
Electronic supplementary material The online version of this
chapter (doi:
10.1007/978-3-319-12934-1_19 ) contains supplementary
material, which is available to authorized users.
56
a
c
b
Fig. 19.3 The parasternal long-axis view demonstrates the cleft of the
anterior mitral leafl et ( arrow ) ( a ) and moderately severe mitral regurgi-
tation, originating from this cleft ( arrow ) ( b ). A schematic illustration
of the cleft is presented in this view ( c ). LA left atrium, LV left ventricle,
RV right ventricle, AO aorta, AML anterior mitral leafl e t
Fig. 19.2 The apical four-chamber view shows that there is a common
AV valve and that the tricuspid valve and mitral valve are at one level
( arrow ). The atrioventricular valve has one annulus and two orifi ces;
accordingly, this is an intermediate form of an AVSD. LA left atrium,
LV left ventricle, RA right atrium, RV right ventricle
Case 19 Atrioventricular Septal Defect (Intermediate Form)
57
Fig. 19.4 This is a four-dimensional reconstruction of the cleft ( arrow )
in the parasternal long-axis view. LA left atrium, LV left ventricle, RV
right ventricle, AO aorta
ab
Fig. 19.5 The ventricular septal
defect component of the AVSD
( arrow ) is demonstrated in the
apical four-chamber view by
two-dimensional
echocardiography ( a ) and
color-fl ow Doppler study ( b ). An
atrial septal defect (ASD)
(ostium primum type) and the
fl ow across it are also evident in
this view ( curved arrow ) ( b ). LA
left atrium, LV left ventricle, RA
right atrium, RV right ventricle
Case 19 Atrioventricular Septal Defect (Intermediate Form)
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