Atrial Septal Pouch Research Articles

Left-Sided Atrial Septal Pouch is a Risk Factor for Cryptogenic Stroke

The atrial septal pouch is an anatomic variant of the interatrial septum. The morphology of the left-sided septal pouch (LSSP) may favor blood stasis and predispose to thromboembolic events. The aim of this study was to determine the association between LSSP presence and cryptogenic stroke. A total of 126 consecutive patients with cryptogenic stroke and 137 age-matched control patients without stroke were analyzed retrospectively. The presence and dimensions of LSSPs were assessed using transesophageal echocardiography. LSSP was present in 55.6% of patients with cryptogenic stroke and in 40.9% of those without stroke (P=.02). In univariate analysis, patients with LSSP were more likely to have cryptogenic stroke (odds ratio, 1.81; 95% CI, 1.11-2.95; P=.02). After adjusting for other risk factors using multiple logistic regression, the presence of an LSSP was found to be associated with an increased risk for cryptogenic stroke (odds ratio, 2.02; 95% CI, 1.19-3.41; P=.01). There were no statistically significant differences in size of the LSSP between patients with and those without stroke (P>.05). There is an association between the presence of an LSSP and an increased risk for cryptogenic stroke. More attention should be paid to clinical evaluations of LSSPs.

Porcine heart interatrial septum anatomy

BackgroundThe left-sided atrial septal pouch (SP), a recently re-discovered anatomical structure within the human interatrial septum, has emerged as a possible source of thrombi formation and a trigger for atrial fibrillation, thereby potentially increasing the risk for ischemic stroke. In many studies, the swine interatrial septum has been used as model of the human heart. Also, possible new strategies and devices for management of the SPs may first be tested in this pig model. Therefore, in this study, we aimed to evaluate swine interatrial septum morphology and to compare it with the human analog, especially in the light of SP occurrence. MethodsA total of 75 swine (Sus scrofa f. domestica) hearts were examined. The interatrial septum morphology was assessed, and SPs were measured. ResultsThe most common variant of the interatrial septum was smooth septum (26.6%) followed by the patent foramen ovale channel and right SP (both 22.7%). No left or double SPs were observed. In 28.0% of all cases the fold of tissue (left septal ridge) was observed on the left side of the interatrial septum in the location where the left-sided SP should be expected. The mean length of the patent foramen ovale channel was 7.1±1.5mm. The mean right SP depth was 6.3±2.2mm, and its ostium width and height were 5.8±1.2 and 5.3±1.6mm, respectively. ConclusionsThere are significant differences between human and porcine interatrial septum morphology that should be taken into account during experimental studies. The absence of the left SP in swine results in the inability to use porcine heart as an experimental model for left-sided SP management.

The left atrial septal pouch as a possible location for thrombus formation

The left atrial septal pouch as a possible location for thrombus formation

Double Interatrial Septum appearing as an Atrial Myxoma: A Case Report and Review of the Literature

ABSTRACT A double interatrial septum (DIS) is a rare finding during echocardiographic evaluation and can often be mistaken for other more common atrial anomalies. The interatrial cavity created by the septum creates a low-flow state that increases risk of thrombus formation and thromboembolic events. Transesophageal echocardiography (TEE) plays a vital role in accurate diagnosis as a DIS is often not seen during transthoracic echocardiography (TTE). In this case, we report a patient who presented for surgery with a preoperative diagnosis of an atrial myxoma, was instead discovered to have a DIS, and then subsequently underwent DIS resection without complication. We discuss the differential of a DIS, including an atrial septal pouch, cor triatriatum, atrial myxoma, and aneurysmal interatrial septum and the classic features of each anomaly for appropriate diagnosis and management. How to cite this article Wyrobek J, Brown CH IV, Kostibas MP, Mayer SA, Cameron DE, Hayanga HK. Double Interatrial Septum appearing as an Atrial Myxoma: A Case Report and Review of the Literature. J Perioper Echocardiogr 2017;5(1):16-20.

Atrial septal pouch — Morphological features and clinical considerations

BackgroundThe atrial septal pouch (SP) is a new anatomical entity within the interatrial septum. The left-sided SP may be the source of thrombus and contribute to ischemic stroke. The aim of this study was to provide a detailed morphometric description of the SP. MethodsTwo hundred autopsied hearts (23% deriving from females) with a mean age of 46.7±19.1years were investigated. We assessed the morphology of the interatrial septum. We obtained measurements and casts of the SPs, and we conducted histological staining of the left-sided SPs. ResultsPatent foramen ovale was observed in 25% of hearts. We found a left SP in 41.5%, right in 5.5% and a double SP in 5.5% of hearts. We found the patent foramen ovale (PFO) more often in younger hearts, and the SP and smooth septum were more prevalently found in older hearts (p=.0023). The mean volume of the left-sided SP was 0.31±0.11ml, which represented 13.6±9.4% (range: 3.1–44.9%) of the left atrial appendage volume. The SP shape resembled a cone or a cylinder with some smaller diverticula originating from the main body. The SP free wall was composed of two layers of endocardium, transverse muscle fibers and connective tissue. ConclusionsA left-sided SP was present in 47% of individuals. The SP arises as a result of PFO channel closure. The anatomy of left-sided SP may promote blood stasis and thrombus formation. The universal formula for SP volume was calculated.

The Left Atrial Septal Pouch as a Possible Risk Factor for Stroke.

The left atrial septal pouch (LASP) is formed by the caudal fusion of the area of overlap of the septum primum and the septum secundum, leaving an opening toward the left atrium. The association between LASP and stroke has not been validated by the previous studies. The prevalence of the LASP was determined in 223 ischemic stroke patients and 223 control subjects with other cardiac pathologies, in a monocentric retrospective case-control study design. Stroke subtypes were defined according to the modified TOAST criteria. The mean age was 66 ± 15, 54% males, with a high prevalence of cardiovascular risk factors. The prevalence of the LASP was 81 (18%), irrespective of age or pathology. The number of LASP was similar in the stroke and control groups (18% vs. 19%, P = 0.7), as well as in the cryptogenic stroke subgroup (16%, P = 0.6). LASP was not associated with ischemic stroke on univariate (OR = 1.095; 95% CI = 0.676-1.772; P = 0.7) and multivariate logistic regression analysis (OR = 1.004; 95%CI = 0.574-1.758, P = 0.98). There was no statistical association between LASP and cryptogenic stroke on univariate (OR = 1.26; 95%CI = 0.526-3.016; P = 0.6) or multivariate analysis (OR = 0.705; 95%CI = 0.193-2.577, P = 0.6). The association of LASP to AF, left ventricular dysfunction, and thrombophilia did not lead to a higher incidence of stroke (OR = 0.99; 95%CI = 0.37-2.66; P = 0.99). Our study did not show any association between LASP and ischemic stroke. A septal pouch was present in 18% of the population. Other associated risk factors need to be considered to incriminate the septal pouch as the etiology of a stroke.

Prevalence of atrial septal pouch and risk of ischemic stroke.

It has been postulated that atrial septal pouch (ASP) may favor the stasis of blood and predispose to thromboembolic complications. We sought to evaluate the prevalence of ASP, and its association with ischemic stroke. We retrospectively studied 500 patients, who underwent transesophageal echocardiography (TEE) due to clinical indications. Seventy two patients due to image quality, and 104 patients with atrial septal defect or PFO were excluded. The remaining 324 patients were included in the analysis. The depth of ASP was measured. ASP was detected in 98 patients [left side ASP (LASP) in 58 (59.2%), and right side ASP (RASP) in 40 (40.8%) patients]. LASPs were significant deeper than RASPs (10.1±5.2 vs 4.4±1.4mm, p<0.0001). Patient characteristics were categorized by the presence or absence of LASP. The age (61±12 vs 61±12), gender and stroke risk factors were no significant difference between patients with or without LAPS. Ischemic stroke occurred in 21 patients without LASP, 10 patients with LASP. The presence of a LASP was found to be associated with an increased risk of ischemic stroke, in either univariable analysis (17.2 vs. 7.9%, p=0.03; OR=2.43, 95% CI=1.1-5.5, p=0.033) or after adjustment for other stroke risk factors using multiple logistic regression analysis (OR=2.45, 95% CI 1.1-5.8, p=0.036). This study demonstrated evidence of association between LASP and ischemic stroke. Among 324 patients, the risk of ischemic stroke was twice more among patients with LASP than cases without LASP.

Left atrial septal pouch thrombus: A common pathology in an uncommon location

Left atrial septal pouch thrombus: A common pathology in an uncommon location

Incremental Value of Live/Real Time Three‐Dimensional over Two‐Dimensional Transesophageal Echocardiography in the Assessment of Atrial Septal Pouch

An atrial septal pouch (ASP) results from partial fusion of the septum primum and the septum secundum, and depending on the site of fusion, the pouch can be left-sided (LASP) or right-sided (RASP). LASPs have been described in association with thrombi found in patients admitted with acute strokes, raising awareness of its potential cardioembolic role, especially in those with no other clearly identifiable embolic source. We retrospectively studied 39 patients in whom the presence of an ASP had been identified by three-dimensional transesophageal echocardiography (3DTEE) and who had a two-dimensional transesophageal echocardiogram (2DTEE) performed during the same clinical encounter. The incremental value provided by 3DTEE over 2DTEE included the detection of six ASPs not found by 2DTEE; the detection of two ASPs in the same subject (in four patients) not identified by 2DTEE; larger ASP measurements of length and height in over 80% of the cases; and measurement of the ASP width (elevational axis) for the calculation of the area of the ASP opening, because of its unique capability to view the pouch en face. In addition, the volume of ASP and of the echogenic masses contained in the ASP (four of 39 patients) could be calculated by 3DTEE, which is a superior parameter of size characterization when compared to individual dimensions. One of these patients who presented with ischemic stroke diagnosed by magnetic resonance imaging had a large (>2 cm) mass in a LASP, with echolucencies similar to those seen in thrombi and associated with clot lysis and resolution. This mass completely disappeared on anticoagulant therapy lending credence that it was most likely a thrombus. There was no history of stroke or any other type of embolic event in the other three patients with masses in ASP. In conclusion, this retrospective study highlights the incremental value of 3DTEE over 2DTEE in the comprehensive assessment and characterization of ASPs, which can aid in the clarification of their role in cryptogenic stroke patients.

Left atrial septal pouch in cryptogenic stroke.

Background: The left atrial septal pouch (LASP), an anatomic variant of the interatrial septum, has uncertain clinical significance. We examined the association between LASP and ischemic stroke subtypes in patients undergoing transesophageal echocardiography (TEE).Methods: We determined the prevalence of LASP among consecutive patients who underwent TEE at our institution. Patients identified with ischemic strokes were further evaluated for stroke subtype using standard and modified criteria from the Trial of Org 10172 in Acute Stroke Treatment (TOAST). We compared the prevalence of LASP in ischemic stroke, cryptogenic stroke, and non-stroke patients using prevalence ratios (PR).Results: The mean age of all 212 patients (including stroke and non-stroke patients) was 57 years. The overall prevalence of LASP was 17% (n = 35). Of the 75 patients who were worked-up for stroke at our institution during study period, we classified 31 as cryptogenic using standard TOAST criteria. The prevalence of LASP among cryptogenic stroke patients (using standard and modified TOAST criteria) was increased compared to the prevalence among other ischemic stroke patients (26 vs. 9%, p = 0.06; PR = 1.8, 95% CI = 1.1–3.1, and 30 vs. 10%, p = 0.04; PR = 2.2, 95% CI = 1.2–4.1, respectively).Conclusion: In this population of relatively young patients, prevalence of LASP was increased in cryptogenic stroke compared to stroke patients of other subtypes. These findings suggest LASP is associated with cryptogenic stroke, which should be verified by future large-scale studies.

Correlation of Left Atrial Septal Pouch with the Prevalence of Patent Foramen Ovale: A Retrospective Review

Purpose: To determine the prevalence of Left Atrial Septal Pouch (LASP) and assess the association with Patent Foramen Ovale (PFO). Materials and Methods: We retrospectively reviewed 275 cardiac-gated CT examinations at Indiana University from January 2010 to June 2012, 160 cardiac CTs performed prior to pulmonary vein ablation, 115 for evaluation of coronary artery evaluation. Consensus readings were performed by two readers on a PACS workstation using the Multiplanar Reformat software to identify the presence or absence of LASP and PFO. PFO was diagnosed by the presence of a contrast jet extending from the left atrium to the right atrium. Results: Overall prevalence of LASP was 24.7% (68 LASPs out of 275 patients). There was no Original Research Article Terpenning et al.; CA, 3(2): 122-129, 2015; Article no.CA.2015.010 123 significant difference regarding the gender and age between patients with and without LASP, pvalues 0.054 and 0.63 respectively. The overall prevalence of PFO in both groups is low 2.2% (6 PFOs out of 275 patients). The prevalence of PFO in patients with LASP was 5.9% (4 out of 68 patients) and was 1.0% (2 PFOs out of 207 patients) in patients without LASP. There was a significant difference in prevalence of PFO between patients with and without LASP, p-value 0.035. Conclusions: LASP is a common finding on cardiac CT, its prevalence not affected by age or gender. Patients with LASP have statistically greater prevalence of PFO than patients without LASP, but the prevalence remains low.

Abstract W MP56: Left Atrial Septal Pouch as a Stroke Risk Factor: Association With Cryptogenic Stroke

Background: The left atrial septal pouch (LASP) is an anatomic variant of the interatrial septum, and its pathophysiological significance is uncertain (J Am Coll Cardiol Intv 2010;3:98-104). We examined the potential association between LASP and ischemic stroke subtypes in patients undergoing transesophageal echocardiography (TEE). Methods: In this cross-sectional study, we determined the prevalence of LASP ( Figure ) using a database of patients who underwent TEE at our institution between July 2008 and June 2011. Patients with ischemic strokes were evaluated by a vascular neurologist (blinded to the presence of LASP) for stroke subtyping using standard and modified TOAST (excluding ischemic stroke patients with multiple competing etiologies from the cryptogenic category) criteria. We compared the prevalence of LASP in ischemic stroke, cryptogenic stroke, and non-stroke patients. Results: The mean age of all 212 patients studied (including stroke and non-stroke patients) was 57 years. The overall prevalence of LASP was 17% (n=35). We studied 75 ischemic stroke patients. There were no significant differences in demographics or stroke risk factors comparing patients with or without LASP, except for hypertension (LASP 49% vs. no LASP 66% among all patients, p = 0.05). The prevalence of LASP among cryptogenic stroke (using standard and modified TOAST criteria) was increased compared to the prevalence among other ischemic stroke patients (26% vs. 9%, RR=1.8, 95% CI 1.1-3.1; and 30% vs. 9%, RR=2.3, 95% CI 1.2-4.1, respectively). There was no significant difference between LASP prevalence among all ischemic stroke patients (16%) and patients with no history of stroke or TIA (14%). Conclusion: In this population of relatively young patients, prevalence of LASP was increased in cryptogenic stroke compared to stroke patients of other subtypes. These findings suggest LASP may be a risk factor for stroke, which should be verified by further large-scale studies.

Thrombus in the left atrial septal pouch mimicking myxoma

A 15 × 13 mm mobile ovoid mass attached via a 15 × 5 mm stalk to the interatrial septum in the left atrium was detected on transesophageal echocardiography and was diagnosed as a myxoma in a 70-year-old woman with chronic atrial fibrillation. She was prescribed anticoagulant therapy with warfarin before elective cardiac surgery and demonstrated no thromboembolic event during a 2.5-month period. Preoperative transesophageal echocardiography showed the disappearance of the intracardiac mass and the presence of a left atrial septal pouch, suggesting that the initial image was a thrombus originating from the left atrial septal pouch.

Cryptogenic Stroke and the Left Atrial Septal Pouch: A Case Report

The left atrial septal pouch (LASP) is an anatomic variant of the interatrial septum and may be a nidus for thromboembolism. We present the case of a 49 year-old man without known vascular risk factors who experienced bi-hemispheric strokes over the course of 10 days, suggestive of multiple emboli. Transesophageal echocardiography revealed a prominent LASP. We suggest that presence of LASP was a likely cause of stroke in this patient and that further study of a possible association between LASP and ischemic stroke in younger individuals may be warranted.

Atrial septal pouch: not always a thrombus. A case report and literature review

A 69-year-old patient with dilated cardiomyopathy and atrial fibrillation experienced a transient ischemic attack. A septal pouch was diagnosed by transesophageal echocardiography and a mass into the pouch was detected, which was initially defined as thrombotic material. Since the mass did not disappear after a period of effective anticoagulation, a different etiology was suspected and cardiac magnetic resonance showed a lipomatous nature. As far as we know this is the first case of septal pouch lipoma.

Left atrial septal pouch thrombus assessed on three-dimensional transoesophageal echocardiography

The left atrial septal pouch (LASP) is an anatomical entity that came to the attention of the medical community in 2010 when Krishnan and Salazar described it as a possible source of embolism. It is formed by the caudal fusion of the area of overlap of the septum primum and the septum secundum. The …

Thromboembolic stroke with concurrent left atrial appendage and left atrial septal pouch thrombus

A 71-year old man with permanent atrial fibrillation and recurrent thromboembolic strokes presented after sudden collapse followed by transient aphasia and quadriparesis, with evidence of recent cerebellar as well as right thalamic infarction on cranial computed tomography. He had been anticoagulated with warfarin for over 10 years, however at the time of presentation the INR was sub-therapeutic at 1.8. Transoesophageal echocardiography showed a dilated left atrium with severe spontaneous echocardiographic contrast, severely impaired left atrial appendage (LAA) contractile function (peak emptying velocity b10 cm/s), and a thrombus measuring 20×13mm at the tip of the LAA (Fig. 1). In addition, a 23×7 mm thrombus (Fig. 2; Supplemental video) was observed between the septumprimum and secundum, likely within a left atrial septal pouch. No extension of the thrombus into the right atriumwas observed. The remainder of the echocardiographic examination was normal. The patient made a full neurological recovery and was continued on anticoagulationwith a plan for strict INR control. The foramen ovale is a slit-like opening located in the inter-atrial wall of the fetal heart which enables right-to-left shunting during fetal development. This opening remains patent in 27% of the overall population [1]. Paradoxical thromboembolism from the venous to the arterial circulation through aprobe-patent foramenovale (PFO) is believed to contribute to the incidence of cryptogenic stroke, especially in young patients [2].

Left atrial septal pouch causing an ischaemic stroke in association with aortic coarctation

A 61-year-old lady presented with recurrent right middle cerebral artery (MCA) territory stroke. She had a previous stroke 3 years earlier which was investigated with transthoracic echocardiogram, Holter monitor, and carotid Doppler, but no thrombo-embolic source was identified. She has been on Asasantin® SR 200/25 for secondary stroke prevention since then. She also had a history of hypertension secondary to coarctation of the descending thoracic aorta which was …

Right Atrial Septal Pouch—A Potential Nidus for Thrombosis

During embryological development, an incomplete fusion of septum primum (SP) and septum secundum (SS) occurring cranially results in an inverted pouch-like structure with its base opening into the right atrium. This has been recently termed as right atrial septal pouch (RASP). Whether this pouch predisposes to intracardiac thrombosis by creating a milieu of localized stasis is unknown. Although some case reports have alluded to thromboembolic potential of left atrial septal pouch with similar origin, there has been no description regarding RASP acting as a thrombogenic nidus. We present a case of thrombus in the RASP with sequential imaging.

Thrombus Attached to the Left Atrial Septal Pouch Assessed on 3-Dimensional Transesophageal Echocardiography

ecently, left atrial septal pouch (LASP), a kangaroo pouch-like structure on the left atrial side of the interatrial septum, has gained significant interest as a new anatomical entity with a potential for cardioembolic stroke.1 A 52-year-old man with a longstanding history of cardiac murmur was admitted to the municipal hospital with a 1-week history of progressive dyspnea. Electrocardiogram showed normal sinus rhythm and possible left ventricular hypertrophy. Chest X-ray showed cardiomegaly, pulmonary congestion and bilateral pleural effusion. Transthoracic echocardiography indicated severe aortic stenosis (AS) probably due to bicuspid aortic valve and severely depressed left ventricular function (left ventricular ejection fraction: 25%). He was transferred to University Hospital of Occupational and Environmental Health as a definite surgical candidate for aortic valve replacement after the stabilization of heart failure symptoms. He had not taken anticoagulants. Transesophageal echocardiography (TEE) showed that he had severe AS with the anteroposterior type of bicuspid aortic valve. Although the left atrium was severely dilated with a mild degree of spontaneous echo contrast, there was no thrombus in the left atrial appendage. A small mobile mass was incidentally found to be attached on the inter-atrial septum, where fusion between the septum primum and septum secundum is limited to the