Thorac Cardiovasc Surg 2007; 55(6): 365-370
DOI: 10.1055/s-2007-965304
Original Cardiovascular

© Georg Thieme Verlag KG Stuttgart · New York

Echocardiographic Evaluation of the Left Atrium and Left Atrial Appendage Function in Patients with Atrial Septum Aneurysm - Implications for Thromboembolic Complications

A. Goch1 , M. Banach1 , G. Piotrowski2 , I. Szadkowska3 , J. H. Goch1
  • 1Department of Cardiology, 1st Chair of Cardiology and Cardiac Surgery, University Hospital No. 3, Medical University of Lodz, Lodz, Poland
  • 2Department of Internal Diseases and Cardiology, District Specialist M. Copernicus Hospital, Lodz, Poland
  • 3Invasive Cardiology Unit, 1st Chair of Cardiology and Cardiac Surgery, University Hospital No. 3, Lodz, Poland
Further Information

Publication History

received Nov 19, 2006

Publication Date:
24 August 2007 (online)


Background: Our study aimed to assess left atrium (LA) and left atrial appendage (LAA) function in patients with atrial septum aneurysm (ASA) and to relate it to thromboembolic complications. Methods: The study group comprised 25 patients with isolated ASA (group I) and 17 clinically healthy subjects (control group = group II). Transthoracic and transesophageal echocardiography were performed in all investigated patients. Results: In group I, the following parameters were significantly higher than in the controls: LA minimal dimension (LAmin) was 2.13 vs. 1.7 cm; LA presystolic dimension (LAa) was 2.66 vs. 2.29 cm and LA pre-ejection period/LA ejection time index (PEP/ETLA) was 1.26 vs. 0.41 (p < 0.05). There were no statistically significant differences between groups as to P wave and PR-interval duration, which were 69 vs. 72 ms and 167 vs. 173 ms, respectively. All LAA parameters were investigated, but LAA minimal areas (LAAarea min) were higher in the study group than in controls: LAA transversal dimension (LAAtrans) was 1.89 vs. 1.32 cm; LAA longitudinal dimension (LAAlong) was 4.24 vs. 3.11 cm; LAA maximal area (LAAarea max) was 4.35 vs. 3.1 cm2; LAA ejection fraction (EFLAA) was 56 vs. 33 %; LAA peak emptying (LAAE) was 0.64 vs. 0.41 m/s, and filling velocities (LAAF) was 0.55 vs. 0.42 m/s (p < 0.05). The results indicate a depression of LA systolic and an enhancement of LAA function in patients with ASA compared with clinically healthy subjects. Conclusion: (1) Atrial septum aneurysm impairs left atrium systolic function. (2) In patients with atrial septum aneurysm, left atrium appendage function changes; its systolic as well as a reservoir function improve. (3) The enhancement of LAA function in ASA may be a compensatory mechanism for LA systolic function deterioration. (4) As LAA systolic function is enhanced, it is rather unlikely that LAA is the place of origin of thrombi, which occur relatively frequently (according to the literature) in patients with ASA. The thrombi seem to be formed in the bulging sack of ASA, i.e., in the part of the LA whose systolic function is depressed.


  • 1 Silver M D, Dorsey J S. Aneurysms of the septum primum in adults.  Arch Pathol Lab Med. 1978;  102 62-65
  • 2 Schneider B, Hofmann T, Meinertz T, Hanrath P. Diagnostic value of transesophageal echocardiography in atrial septal aneurysm.  Int J Card Imaging. 1992;  8 143-152
  • 3 Agmon Y, Khandheria B K, Meisneener I. et al . Frequency of atrial septal aneurysms in patients with cerebral ischemic events.  Circulation. 1999;  99 1942-1944
  • 4 Person A C, Nagelhout D, Castello R. et al . Atrial septal aneurysm and stroke: a transesophageal echocardiographic study.  J Am Coll Cardiol. 1991;  18 1223-1229
  • 5 Hanley P C, Tajik A J, Hynes J K, Edwards W D, Reeder G S, Hagler D J, Seward J B. Diagnosis and classification of atrial septal aneurysm by two-dimensional echocardiography: report of 80 consecutive cases.  J Am Coll Cardiol. 1985;  6 1370-1382
  • 6 Gallet B, Malergue M C, Adam C, Saudemont J P, Collot A MC, Druon M C, Hiltgen M. Atrial septal aneurysm: a potential cause of systemic embolism.  Br Heart J. 1985;  53 292-297
  • 7 Belkin R N, Hurwitz B J, Kisslo J. Atrial septal aneurysm: association with cerebrovascular and peripheral embolic events.  Stroke. 1987;  18 856-862
  • 8 Zabalgoitia-Reyes M, Herrera C, Ghandi D K, Mehlman D J, McPherson D D, Talano J V. A possible mechanism for neurologic ischemic events in patients with atrial septal aneurysm.  Am J Cardiol. 1990;  66 761-764
  • 9 Lucas C, Goullard L, Marchau M J. et al . Higher prevalence of atrial septal aneurysms in patients with ischemic stroke of unknown cause.  Acta Neurol Scand. 1994;  89 210-213
  • 10 Kosmider A, Banach M, Zaslonka J. et al . The role of intraoperative transesophageal echocardiography in tricuspid valve annuloplasty - 15 years follow-up (1988 - 2003).  Arch Med Sci. 2005;  1 48-54
  • 11 Otto C M. The Practice of Clinical Echocardiography. Philadelphia; W.B. Saunders 2002
  • 12 Schneider B, Hanrath P, Vogel P, Meinertz T. Improved morphologic characterization of atrial septal aneurysm by transesophageal echocardiography. Relation to cerebrovascular events.  J Am Coll Cardiol. 1990;  16 1000-1009
  • 13 Jones C J, Song G J, Gibson D G. An echocardiographic assessment of atrial mechanical behaviour.  Br Heart J. 1991;  65 31-36
  • 14 Piotrowski G, Goch A, Wlazlowski R, Gawor Z, Goch J H. Non-invasive methods of atrial function evaluation in heart diseases.  Med Sci Monit. 2000;  6 827-839
  • 15 Yamaguchi M, Arakawa M, Tanaka T, Takaya T, Nagano T, Hirakawa S. Study on left atrial contractile performance - participation of Frank-Starling mechanism.  Jpn Circ J. 1986;  254 84-89
  • 16 Wang Y P, Takenaka K, Sakamoto T. et al . Effects of volume loading, propranolol and heart rate changes on pump function and systolic time intervals of the left atrium in open-chest dogs.  Acta Cardiol. 1993;  3 245-262
  • 17 Okamoto M, Tsubokura T, Tsuchioka Y. et al . Determinants of left atrial systolic time intervals - assessment by pulsed Doppler echocardiography.  Jpn Circ J. 1991;  55 232-237
  • 18 Chan S K, Kannam J P, Douglas P S, Manning W J. Multiplane transesophageal echocardiographic assessment of left atrial appendage anatomy and function.  Am J Cardiol. 1995;  76 528-530
  • 19 Agmon Y, Khandheria B K, Gentile F, Seward J B. Echocardiographic assessment of the left atrial appendage.  J Am Coll Cardiol. 1999;  34 1867-1877
  • 20 Piechowiak M, Banach M, Ruta J. et al . Risk factors of atrial fibrillation in adult patients in long-term observation following surgical closure of atrial septal defect type II.  Thorac Cardiovasc Surg. 2006;  54 259-263
  • 21 Pollick C, Taylor D. Assessment of left atrial appendage function by transesophageal echocardiography. Implications for the development of thrombus.  Circulation. 1991;  84 223-231
  • 22 Slavin L, Tobis J M, Rangarajan K, Dao C, Krivokapich J, Liebeskind D S. Five-year experience with percutaneous closure of patent foramen ovale.  Am J Cardiol. 2007;  99 1316-1320
  • 23 Hausmann D, Daniel W G, Mügge A, Ziemer G, Pearlman A S. Value of transesophageal color Doppler echocardiography for detection of different types of atrial septal defects in adults.  J Am Soc Echocardiogr. 1992;  5 481-488
  • 24 Hausmann D, Mügge A, Becht I, Daniel W G. Diagnosis of patent foramen ovale by transesophageal echocardiography and association with cerebral and peripheral embolic events.  Am J Cardiol. 1992;  70 668-672
  • 25 Rysz J, Goch A, Wilk R, Grycewicz T, Luciak M, Goch J H. Left atrial function in patients with renal transplantation.  Med Sci Monit. 2002;  8 CR508-CR511
  • 26 Sigwart W, Grbic M, Goy J J, Kappenberger L. Left atrial function in acute transient left ventricular ischemia produced during percutaneous transluminal coronary angioplasty of left anterior descending coronary artery.  Am J Cardiol. 1990;  65 282-286
  • 27 Rahko P S, Xu Q B. Increased prevalence of atrial septal aneurysm in mitral valve prolapse.  Am J Cardiol. 1990;  66 235-237
  • 28 Abe H, Yokouchi M, Deguchi F. et al . Measurement of left atrial systolic intervals in hypertensive patients using Doppler echocardiography: relation to fourth heart sound and left ventricle wall thickness.  J Am Coll Cardiol. 1988;  11 800-805
  • 29 Zeppelini R, Erbel R, Schon F, Gheno G, Cucchini F. Recent morphofunctional findings on the left atrium: their relations to thromboembolic risk.  G Ital Cardiol. 1995;  25 1055-1065
  • 30 Ito T, Suwa M, Kobashi A, Yagi A, Hirota Y, Kawamura K. Influence of alerted loading conditions on left atrial appendage function in vivo.  Am J Cardiol. 1998;  81 1056-1059
  • 31 Cornelius A, Davis I, Judith C R, Joseph C G. Compliance of left atrium with and without left atrium appendage.  Am J Physiol. 1990;  259 H1006-H1008
  • 32 Kamp O, Verhorst P MJ, Welling R C, Visser C A. Importance of left atrial appendage flow as a predictor of thromboembolic events in patients with atrial fibrillation.  Eur Heart J. 1999;  20 979-985
  • 33 Manning W J, Silverman D I, Katz S E. et al . Impaired left atrial mechanical function after cardioversion: relation to the duration of atrial fibrillation.  J Am Coll Cardiol. 1994;  23 1535-1540
  • 34 Belloti P, Spirito P, Lupi G, Vechio C. Left atrial appendage function assessed by transesophageal echocardiography before and on the day after elective cardioversion for nonvalvular atrial fibrillation.  Am J Cardiol. 1998;  81 1199-1202
  • 35 Harjai K, Mobarek S, Abi-Samra F. et al . Mechanical dysfunction of the left atrium and the left atrial appendage following cardioversion of atrial fibrillation and its relation to total electrical energy used for cardioversion.  Am J Cardiol. 1998;  81 1125-1129
  • 36 Das S, Paul S. Additional openings of the coronary sinus and associated anomalies.  Arch Med Sci. 2006;  2 128-130
  • 37 Tabata T, Oki T, Fukuda N. et al . Influence of aging on left atrial appendage flow velocity patterns in normal subjects.  J Am Soc Echocardiogr. 1996;  9 274-280
  • 38 Di Pascuale G, Andreoli A, Grazi P. et al . Cardioembolic stroke from atrial septum aneurysm.  Annu Rev Med. 1985;  36 579-605
  • 39 Mattioli A V, Aquilina M, Oldani A. Atrial septal aneurysm as a cardioembolic source in adult patients with stroke and normal carotid arteries. A multicentre study.  Eur Heart J. 2001;  22 261-268
  • 40 Burger A J, Sherman H B, Charlamb M J. Low incidence of embolic strokes with atrial septal aneurysm: a prospective, long term study.  Am Heart J. 2000;  139 149-152
  • 41 Mas J L. Patent foramen ovale, atrial septal aneurysm and ischemic stroke in young adults.  Eur Heart J. 1994;  15 446-449
  • 42 Grosgogeat Y, Lhermitte F, Carpentier A, Facquet J, Alhomme P, Tran T X. Aneurysme de la cloison interauriculaire révélé par une embolie cérébrale.  Arch Mal Coeur. 1973;  66 169-177
  • 43 Pozzoli M, Febo O, Torbicki A. et al . Left atrial appendage dysfunction a cause of thrombosis? Evidence by transesophageal echocardiography Doppler studies.  J Am Soc Echocardiogr. 1991;  4 435-441
  • 44 Fatkin D, Kuchar D L, Thorburn C W, Feneley M P. Transesophageal echocardiography before and during direct current cardioversion of atrial fibrillation: evidence for “atrial stunning” as a mechanism of thromboembolic complications.  J Am Coll Cardiol. 1994;  23 307-316
  • 45 Agmon Y, Khandheria B K, Meissner I. et al . Are left atrial appendage flow velocities adequate surrogates of global left atrial function? A population-based transthoracic and transesophageal echocardiographic study.  J Am Soc Echocard. 2002;  15 433-440

Dr. MD, PhD Maciej Banach

Department of Cardiology
University Hospital No. 3
Medical University of Lodz

Sterlinga St. 1/3

91-425 Lodz


Phone: + 48 4 26 36 44 71

Fax: + 48 4 26 36 44 71