Ann Thorac Surg 2003;76:286-287
© 2003 The Society of Thoracic Surgeons
Case report
Cerebral embolism and thrombus in a membranous interventricular septal aneurysm
Jose Salazar, MDa*,
Andres Gutierrez, MDa,
Eduardo Cay, MDa,
Carlos Ballester, MDa,
Jose J. Salazar, MDa,
Luis Placer, MDa
a Hospital Universitario Miguel Servet, Cardiologia, Zaragoza, Spain
Accepted for publication December 23, 2002.
* Address reprint requests to Dr Salazar, Hospital Universitario Miguel Servet, Cardiologia, 50009 Zaragoza, Spain
e-mail: jjsalazar{at}comz.org
 |
Abstract
|
|---|
This report describes the occurrence of a thrombus in an aneurysm of the membranous interventricular septum with cerebral embolism in a young patient. We would recommend periodic echocardiography checkups in patients with aneurysm of the membranous interventricular septum with or without a small ventricular septal defect. The findings of a mass in the aneurysm, suggestive of thrombus, may justify anticoagulation treatment or even surgical intervention.
|
Introduction
|
|---|
Aneurysm of the interventricular membranous septum (AMS) can spontaneously close a ventricular septal defect (VSD). Complications such as rupture, endocarditis, pulmonary infundibular stenosis, tricuspid incompetence, or thrombosis are unusual. This report describes the occurrence of a thrombus in an AMS with cerebral embolism in a young patient.
A 14-year-old girl was previously asymptomatic. She was controled once a year in cardiology for a small perimembranous VSD, 3-mm diameter, partially closed with the formation of an AMS. She was seen in the emergency department because she noticed an abrupt diminution of visual acuity in her left eye. Clinical examination revealed a BP of 120/75 mm Hg, a heart rate of 85/min and a respiratory rate of 15. Breathing sound was clear. A systolic murmur was heard with normal heart sounds. The hematocrit and coagulation profile were normal. The diagnosis was cilioretinal artery obstruction. Anticoagulant therapy was instituted.
Transthoracic and transesophageal echocardiography revealed an AMS protruding into the right ventricular outflow tract, containing a mass with homogenous echodensity suggestive of thrombus (Fig 1).
Surgical intervention was performed. A spherical aneurysmal pouch, 1-cm diameter, was visualized containing a fresh thrombus (Fig 2).
A small VSD was detected along the margin of the aneurysm adjacent to the tricuspid valve. The aneurysm was resected and the VSD closed. After surgery anticoagulant therapy was instituted for 6 months and then stopped. Two years later her visual field exhibits a pericentral scotoma.
View larger version (84K):
[in this window]
[in a new window]
|
Fig 1. Transesophageal echocardiography. A four-chamber view revealing an aneurysm of the membranous interventricular septum protruding to the right atrium, containing a mass with homogenous echodensity suggestive of thrombus (arrow). (AD = right atrium; VD = right ventricle; VI = left ventricle.)
|
|
View larger version (148K):
[in this window]
[in a new window]
|
Fig 2. Surgical view. Right atrium opened revealing a spherical aneurysmal pouch 1 cm in diameter (arrow).
|
|
|
Comment
|
|---|
In the presence of a VSD, aquired aneurysm in this region may form by adhesion of the septal leaflet of the tricuspid valve to the margin of the VSD. The first postmortem observation of AMS was reported by Laennec in 1826. This anomaly is frequently associated with small perimembranous VSD [1]. Diagnosis is made by two-dimensional echocardiography. The clinical course of most patients is silent. Because the AMS is a pouch, in patients with small or no VSD, conditions are favorable for blood stasis and thrombus formation. Subsequent distal embolization of the thrombus may result in cerebral embolism. Other trasesophageal echocardiographic findings that may cause cerebral embolism include patent foramen ovale, interatrial septal aneurysm, thrombus in the left atrial appendage, and protruding atherosclerotic plaque in the aortic arch. In previously reported AMS patients with thromboembolism (Table 1),
there was no VSD in some patients [2–4], and a small VSD in other patients [5, 6]. In our patient there was a small VSD 2 to 3 mm in diameter.
Although the clinical course of most patients with AMS is silent, periodic echocardiography checkups are recomended. The findings of a mass in the aneurysm, suggestive of thrombus, might justify anticoagulation treatment or even surgical intervention.
|
References
|
|---|
- Kaplan M., Demirtas M.M., Sayrakt H., et al. An anatomopathologic study of membranous septum aneurysms and significance of their surgical treatment. Cardiovasc Surg 2000;8:561-566.[Medline]
- Soyer R., Bouchart F., David N., et al. Anéurysme du septum membraneux: a propos de 4 cas opérés. Arch Mal Coeur 1990;83:85-90.
- Thomas D., Salloum J., Rancurel G. Aneurysm of the interventricular membranous septum with thrombo-embolism—an indication for surgical repair?. Eur Heart J 1993;14:1717-1718.[Abstract/Free Full Text]
- Lin J.M., Hwang J.J., Chiu I.S. Cerebral embolism from the thrombus in the atrioventricular septal aneurysm. Cardiology 1995;86:441-443.[Medline]
- Pernot C., Hoeffel J.C., Henry M., et al. L’anéurysme du septum membraneux: a propos de 20 observations. Coeur et Med Int 1976;15:199-213.
- Bush H.S., Perin E., Massumi A., et al. Detection of thrombus in an aneurysm of the ventricular septum. Am J Cardiol 1989;63:1533-1535.[Medline]
This article has been cited by other articles:
|
|
|
|
 
J. D. Dodd, S. L. Aquino, G. Holmvang, R. C. Cury, U. Hoffmann, T. J. Brady, and S. Abbara
Cardiac Septal Aneurysm Mimicking Pseudomass: Appearance on ECG-Gated Cardiac MRI and MDCT
Am. J. Roentgenol.,
June 1, 2007;
188(6):
W550 - W553.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
