Prevalence of Interatrial Septal Aneurysm in Newborns and Their Natural Course N Ozcelik,1 S Atalay,2 E Tutar, F Ekici2 17710 Van Zandt Dr , Corpus Christin, Texas 78413, USA 2Department of Pediatric.
Pediatr Cardiol 27:343–346, 2006 DOI: 10.1007/s00246-005-1224-9 Prevalence of Interatrial Septal Aneurysm in Newborns and Their Natural Course N Ozcelik,1 S Atalay,2 E Tutar, F Ekici2 7710 Van Zandt Dr., Corpus Christin, Texas 78413, USA Department of Pediatric Cardiology, Ankara University School of Medicine, Ankara, Turkey Abstract The objective of this study was to evaluate the prevalence of atrial septal aneurysm (ASA) in newborns, to define the natural course of ASA, and to investigate its role on closure of associated interatrial septal opening (IASO) A total of 1072 consecutive neonates were examined with echocardiography in the early postnatal period The length of the interatrial septum, the diameter of IASO, the excursion and base of aneurysm, and the width of the related atrium were measured and the excursion ratio and the basal ratio were calculated for each neonate Aneurysms with an excursion ratio ‡25% were diagnosed as ASA There were 81 neonates (7.6%) with ASA The prevalence of ASA was 11.1% in preterm (14 of 126) and 7.1% in full-term newborns (67 of 946) All of the ASAs disappeared at the end of the first year of life, and there were no complications related to the lesion during the follow-up period Although overall IASO prevalence was 78.6% (843 of 1072), it was 72.8% (59 of 81) among the cases with ASA Although the disappearence time of interatrial septal shunt was not significantly different between the cases with and without ASA, spontaneous closure was less frequent in the cases with ASA than in those without ASA 77.7 and 96.1%), respectively (p < 0.001) The prevalence of ASA is high among newborns, with a high resolution rate Therefore, it can be considered that it is benign and transient observation Less frequent spontaneous closure of IASO in cases with ASA indicates that ASA may have a deleterious effect on spontaneous closure Key words: Atrial septal aneurysm — Newborn Atrial septal aneurysm (ASA) is a localized bulging of the interatrial septum into the right, left, or both atriums The pathogenesis of the lesion is not wellknown There are various complications related to Correspondence to: N Ozcelik, email: nozcelik@sbcglobal.net ASA, and it is still debated whether the lesion is benign or not [11, 13, 18, 20] Since a limited number of studies have been conducted on ASA in children, the incidence of ASA in childhood is not well-known The objectives of this study are to evaluate the prevalence of ASA in newborns, to define the natural course of the lesion, and to investigate the role of ASA in closure of associated interatrial septal openings (IASOs) Materials and Methods Neonates who were born in the obstetric department of a university hospital between May 2002 and May 2003 and for whom informed consent was obtained from the parents were examined with twodimensional and color Doppler echocardiography (Model Sonos 5500, Hewlett Packard; 3.5- 8- to MHz multifrequency transducer) 24–72 hours postnatally Newborns with major congenital heart disease were not included in the study All neonates were studied in standard echocardiographic positions Interatrial septum was examined mainly in subcostal positions The presence of aneurysmatic excursion of the interatrial septum and associated IASOs with shunt confirmed by color Doppler echocardiography was noted The presence of other associated cardiac lesions was also evaluated With the use of two-dimensional echocardiography, the length of the interatrial septum (IASL) and the diameter of IASO if present were measured at the end of diastole in the subcostal bicaval view The maximum aneurysmatic excursion length from the interatrial septum and the base length of the aneurysm were measured at the subcostal four-chamber view (Fig 1) The ratio of excursion length of ASA to the width of the related atrium, which is the maximum excursion seen through it (excursion ratio) was calculated The ratio of the base length of ASA to the IASL (basal ratio) was also calculated When the excursion ratio was ‡25%, the lesion was diagnosed as an ASA [21] The shape and the direction of motion of the aneurysm were noted After ASA was diagnosed, the first reassessment was done at month of age Then all cases were followed up in the first year of life in month intervals to evaluate the natural course of ASA Statistical analysis was done by using SPSS 11.0 for Windows Mann–Whitney U, Kruskal–Wallis and chi-square tests were used for comparisons In addition, to show correlations between the results, Pearson correlation analysis was used All values are given as mean (standard deviation) and p < 0.05 is accepted as significant 344 Fig Echocardiographic measurements of atrial septal aneurysm (ASA) IASL, length of interatrial septum; LA, left atrium; RA, right atrium; LV, left ventricle; RV, right ventricle Results A total of 1075 consecutive neonates were evaluated with echocardiography Three neonates had major congenital heart disease (tetralogy of Fallot, abnormal left coronary artery originating from the pulmonary artery, and transposition of the great arteries) These patients were excluded The study population consisted of 1072 newborns Septal aneurysmatic excursion into the atria was seen in 101 newborns; 81 (7.6%) of them qualified to have ASA The mean gestational age was 38.1 (2.0) weeks (range, 30–41) and the mean birth weight was 3085 (627) g (range, 1050–4500) Forty-one patients (50.6%) were male and 40 (49.4%) were female One hundred and twenty-six neonates were preterm, with a gestational age of 0.05) and was higher in preterm compared to full-term neonates (11.1 and 7.1%, respectively; p = 0.028) All ASAs were moving (56.8% into the left, 3.7% into the right, and 39.5% into both atriums) and all were hemispherical in shape Echocardiographic measurements and calculations related to the size of ASA are shown in Table Eight hundred and fourty-three of 1072 neonates (78.6%) had IASOs IASO was detected in 59 of 81 newborns with ASA (72.8%) The mean diameter of IASO was not different between the patients with and without ASA (3.51 ± 1.40 and 3.35 ± 1.12 mm, respectively; p = 0.699) There were also no differences in excursion length, excursion ratio, base length, and basal ratio of ASA between the patients with ASA associated with and those without IASO (Table 1) Echocardiographic evaluation showed other congenital heart defects that were also identified in Pediatric Cardiology Vol 27, No 3, 2006 our study population, including isolated ventricular septal defect (VSD) in 51, patent ductus arteriosus in 2, and bicuspid aortic valve in patients We found that of the 51 VSDs were associated with ASA Follow-up examinations were completed in 65 neonates with ASA Septal aneurysm disappeared in all cases Aneurysm no longer existed in 69.2% (45 of 65) after month and in 93.8% (61 of 65) after months of age (Fig 2) We found that there was no correlation between disappearance time of ASA and gestational age, birth weight (p > 0.05), and previously mentioned echocardiographic measurements and calculations (Table 2) Follow-up was completed in 509 patients with IASO, consisting of 45 with ASA and 464 without ASA IASO closed spontaneously in 35 patients with ASA (77.7%) and 446 patients without ASA (96.1%) (p < 0.001) There was no difference in the closure time of IASO between the two groups (p = 0.853) Mean closure time of IASO was 3.7 (2.6) months in patients with ASA and 3.6 (2.5) months in patients without ASA There were no complications related to ASA during follow-up examinations Discussion ASA is not usually clinically recognized but can be easily diagnosed by cross-sectional echocardiography Diagnostic criteria used for the diagnosis of ASA in children are different from those for adults [8, 10] As did Wolf et al [21], we designated the lesion as an ASA if the excursion ratio was ‡25% Different prevalences of ASA have been reported for different age groups in various studies This may be due to both the criteria used for the diagnosis and the age at which the patients were studied The accurate prevalence of ASA in the population is not well defined The prevalence has been reported to be 0.2–0.5%, 1.7–4.9%, and 26–64% for adults, children, and fetuses, respectively [10, 14–17, 21] The overall high prevalence of ASA (7.6%) in this study and the increased prevalence in preterm compared to fullterm infants (11 vs 7.1%) indicate that the prevalence of ASA is clearly affected by gestational age [4, 16] ASAs are usually associated with additional cardiac anomalies [1, 3, 4, 12, 14, 18] The association of ASA and interatrial septal-communication was found to be 72.8% in our study, and this result is comparable to previous reports [3–7, 18] Guntheroth et al [9] reported that ASA is associated with small patent foramen ovales, but we did not find any difference in the prevalence and diameter of IASOs between the patients with and without ASA in our study Brand et al [6] described that ASA may have a Ozcelik et al.: Atrial Septal Aneurysm in Newborns 345 Table Echocardiographic measurements and calculations in cases with ASA Echocardiographic measurement Mean (SD) Upper–lower limits Cases with IASO (n = 59) Cases without IASO (n = 22) p IASL (mm) Excursion length of ASA (mm) Base length of ASA (mm) Excursion ratio of ASA (%) Basal ratio of ASA (%) 18.9 5.3 8.4 37.3 44.7 13.7–24.9 3.0–7.9 3.7–13.3 25.7–68.3 23.8–67.8 18.9 5.3 8.5 38.0 45.2 18.9 5.2 8.1 35.5 43.1 0.903 0.659 0.308 0.358 0.418 (2.0) (1.1) (2.1) (9.2) (10.4) (2.2) (1.1) (2.1) (9.6) (10.5) (1.7) (1.0) (1.8) (8.0) (9.9) ASA, atrial septal aneurysm; IASL, length of interatrial septum; IASO, interatrial septal opening Fig Disappearence time of atrial septal aneurysm (ASA) with Kaplan–Meier curve Table Correlations between disappearance time of ASA and echocardiographic measurements Echocardiographic measurement Pearson correlation coefficient (r) p IASL (mm) Excursion length of ASA (mm) Base length of ASA (mm) Excursion ratio of ASA (%) Basal ratio of AS A (%) 0.102 0.104 )0.048 )0.056 )0.069 0.426 0.410 0.708 0.656 0.588 was conducted on an unselected newborn population, we believe that it gives a better estimate of the prevalence of ASA than those previously reported Regarding the high resolution rate, we believe that ASA is a benign and transient lesion Less frequent spontaneous closure of IASO in the patients with ASA indicates that aneurysms may have a negative influence on spontaneous closure of IASOs, but more studies are needed ASA, atrial septal aneurysm; IASL, length of interatrial septum role in spontaneous closure of associated IASO in children, as have some other authors [2, 9, 15, 19] On the contrary, we found that although spontaneous closure time of IASO was not different between two groups, it was less frequent in patients with ASA Thus, our findings suggest that ASA may have a deleterious effect on spontaneous closure of IASO Spontaneous recovery of ASA occurred in all of our patients who completed year of follow-up This finding is also supported by the fact that ASA is regressed and recovered in the course of time [4, 16, 21] Conclusion We found a high ASA prevalence (7.6%) among newborns in this prospective study Since our study References Arvan S (1986) Incidental interatrial septal aneurysm associated with mitral valve prolapse Am Heart J 111:603–605 Awan IH, Rice R, Moodie DS (1982) Spontaneous closure of atrial septal defect with interatrial aneurysm formation Documentation by noninvasive studies, including digital substraction angiography Pediatr Cardiol 3:143–145 Barbosa MM, Pena Motta MM, Fortes PR (1990) Aneurysms of the atrial septum diagnosed by echocardiography and their associated cardiac abnormalities Int J Cardiol 29:71–78 Baysal K, Belet N, Kolbakır F, Yalın T (2001) Atrial septal aneurysm in children Turk J Pediatr 43:293–297 Belkin RN, Waugh RA, Kisslo J (1986) Interatrial shunting in atrial septal aneurysm Am J Cardiol 57:310–312 Brand A, Keren A, Branski D, Abrahamov A, Stern S (1989) Natural course of atrial septal aneurysm in children and the potential for spontaneous closure of associated septal defects Am J Cardiol 64:996–1001 346 Fox ER, Picard MH, Chow CM, et al (2003) Interatrial septal mobility predicts larger shunts across patent foramen ovales: an analysis with transmitral Doppler scanning Am Heart J 145:730–736 Gallet B, Malergue MC, Adams C, et al (1985) Atrial septal aneurysm—a potential cause of systemic embolism: an echocardiographic study Br Heart J 53:292–297 Guntheroth WG, Schwaegler R, Trent E (2004) Comparative roles of the atrial septal aneurysm versus patent foramen ovale in systemic embolization with inferences from neonatal studies Am J Cardiol 94:1341–1343 10 Hanley PC, Tajik AJ, Hynes JK, et al (1985) Diagnosis and classification of atrial septal aneurysm by two-dimensional echocardiography: report of 80 consecutive cases J Am Coll Cardiol 6:1370–1382 11 Kirk R (1996) Atrial septal aneurysm in children Circulation 93:398 12 Magherini A, Margiotta C, Bandini F, Simonetti L, Bartolozzi G (1986) Atrial septal aneurysm, ectasia of Valsalva and mitral valve prolapse in Marfan’s syndrome Am J Cardiol 58:172–173 13 Miga D, Case CL, Gillette PC (1996) Interatrial septal aneurysms and atrial arrhythmias in infants Am Heart J 132:776–778 Pediatric Cardiology Vol 27, No 3, 2006 14 Rice MJ, McDonald RW, Reller MD (1988) Fetal atrial septal aneurysm; 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Int J Cardiol 69:101–103 21 Wolf WJ, Casta AC, Sapire DW (1987) Atrial septal aneurysms in infants and children Am Heart J 113:1149–1153 ... 21] The overall high prevalence of ASA (7.6%) in this study and the increased prevalence in preterm compared to fullterm infants (11 vs 7.1%) indicate that the prevalence of ASA is clearly affected... examinations were completed in 65 neonates with ASA Septal aneurysm disappeared in all cases Aneurysm no longer existed in 69.2% (45 of 65) after month and in 93.8% (61 of 65) after months of. .. consisting of 45 with ASA and 464 without ASA IASO closed spontaneously in 35 patients with ASA (77.7%) and 446 patients without ASA (96.1%) (p < 0.001) There was no difference in the closure time of