SUMMARY Aneurysms of the interatrial septum are rare. They have been associated with complications such as embolic phenomena and atrioventricular orifice obstruction. We describe two patients, one adult and one child, with atrial septal aneurysms that were diagnosed by real-time, two-dimensional echocardiography. Atrial septal aneurysms appeared as thin, localized outpouchings of the atrial septum that protruded into the right atrium and showed marked variations in their contour and size during the cardiac cycle. They could be differentiated from other intra-atrial structures such as tumor mass, large eustachian valve and intra-atrial baffle by their relatively low reflectance, relationship to the atrial septum, considerable alterations in their outline during the cardiac cycle and characteristic patterns during peripheral venous contrast echocardiography.ANEURYSMS of the interatrial septum are uncommon lesions' that have been mistaken for intra-atrial tumors angiocardiographically.2 Hence, a method is needed for making a definitive diagnosis of this condition. In this study we report two patients with atrial septal aneurysms diagnosed by real-time, twodimensional echocardiography. Case Reports Case IPatient WL was a 68-year-old man in good health until 18 months before admission, when he noted the onset of shortness of breath while mowing his lawn. His exertional dyspnea progressively worsened and at the time of admission he could walk only 100 feet. Several weeks before admission he developed syncope while voiding. He had no other symptoms.Physical findings included a blood pressure of 120/70 mm Hg and a regular pulse of 70 beats/min. No jugular venous distention was detected and the carotid upstroke was described as normal. The first heart sound was normal, S2 was widely split and an S, was heard. A grade 3/6 systolic ejection murmur was audible at the base and radiated to the neck. A grade 2/6 diastolic decrescendo murmur was heard at the left sternal border. The lungs were clear. The clinical findings were consistent with the diagnosis of aortic stenosis and aortic regurgitation. A 12-lead ECG showed normal sinus rhythm, complete right bundle branch block and left ventricular hypertrophy with strain. Chest x-ray demonstrated marked cardiac enlargement and markedly increased pulmonary vascularity. Echocardiographic Findings M-mode echocardiography revealed a calcified aortic valve and a symmetrically hypertrophied left ventricle. The right ventricle was markedly enlarged (50 mm in end-diastole) and the interventricular septum demonstrated paradoxical anterior motion during systole. The mitral valve was normal. A band of abnormal linear echoes was also detected in the right atrium behind the prominent but structurally normal tricuspid valve and showed an undulating pattern in the cardiac cycle. Phasic differences in motion were present between the anterior and posterior limits of the echoes, and during atrial systole the anteriorly situated echoes moved toward the tricuspid orifice but did not prolapse into t...
SUMMARY Five patients (four adults and one child) with clinically suspected myocardial perforation by temporary transvenous pacemakers were studied by real-time, two-dimensional echocardiography. In three patients, the catheters were visualized passing through the right ventricular apical wall with the tip located outside the cardiac border. In one patient the catheter perforated the atrioventricular septum and entered the left ventricle with the tip lodged against the posterior wall. In another patient, the catheter had partially penetrated the ventricular septum near the apex. Pericardial effusion was observed in two patients, in one of whom it was localized to the site of perforation. No patient had evidence of cardiac tamponade. In four patients, the catheters were withdrawn under echocardiographic visualization and the catheter tips could be seen moving from the abnormal locations back into the right-heart chambers. Perforation was verified at autopsy in two patients, including one in whom the catheter was not withdrawn.Real-time, two-dimensional echocardiography appears to be valuable in the diagnosis of pacemaker perforation.INTRACARDIAC PACING is invaluable in the management of patients with bradyarrhythmias and tachyarrhythmias, but may cause complications, including myocardial wall perforation, especially with temporary pacing catheters.'1-" Real-time, two-dimensional echocardiography is useful in the detection of myocardial wall perforation by temporary transvenous pacemakers. Materials and MethodsWe studied five patients in the Intensive Care Unit of Strong Memorial Hospital who developed problems with their temporary transvenous (arm vein) pacing catheters, such as loss of pacing, increased threshold or electrocardiographic evidence of catheter misplacement. These patients were part of an ongoing study in which 50 patients with right ventricular pacing catheters were evaluated by real-time, twodimensional echocardiography.Two-dimensional echocardiograms were performed using a commercially available, real-time, wide-angle (90°) mechanical sector scanner and a 3.0-MHz transducer (Advanced Technology Laboratories, Inc.). Images were recorded on videotapes for later analysis in real-time or slow motion. Polaroid photographs were made of stop-action frame images.Standard echocardiographic examinations were performed with the patient in the supine and left lateral decubitus positions.17' 18 Particular attention was given to the long-axis, apical and subcostal fourchamber planes. An the right atrium and right ventricle in long axis by rotating the transducer from the apical position. In all five patients the temporary pacing catheters were imaged as thick, dense, linear echoes in the rightsided chambers.'9 Catheter identification was supported by the presence of prominent posterior reverberatory echoes in four patients and a shadowing effect in the one patient.20 In all patients the catheter was followed distally to locate the tip. In three patients identification of the catheter tip was aided by the pre...
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