Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 48-year-old man with newly diagnosed hypertension is referred for an echocardiogram to assess findings of left ventricular hypertrophy noted on the electrocardiogram. He is asymptomatic, and his medical history is unremarkable other than hypertension. His only medication is chlorthalidone.

On physical examination, blood pressure is 128/70 mm Hg, pulse rate is 60/min and regular, and respiration rate is 18/min. BMI is 24. The cardiac examination is normal other than the presence of an S₄.

The transthoracic echocardiogram demonstrates normal left ventricular size, function, and mass index. An atrial septal aneurysm with a small left-to-right shunt indicative of a patent foramen ovale is noted by color-flow Doppler imaging. The right ventricular chamber size, systolic function, and estimated pressures are normal.

Which of the following is the most appropriate management based on this patient’s echocardiographic findings?

A: Anticoagulation therapy
B: Closure of the defect
C: Transesophageal echocardiography
D: No further evaluation or treatment

MKSAP Answer and Critique

The correct answer is D: No further evaluation or treatment.

No further evaluation or treatment is the appropriate management approach for this patient with an incidentally discovered atrial septal aneurysm. Atrial septal aneurysm is redundant atrial septal tissue that is often associated with a patent foramen ovale. When atrial septal aneurysm is identified incidentally, no medical treatment or intervention is needed. Antiplatelet therapy is recommended for patients with cryptogenic stroke and an isolated atrial septal aneurysm.

In patients with an atrial septal aneurysm and recurrent stroke while taking antiplatelet therapy, anticoagulant therapy is recommended if no other cause of stroke is identified.

Rarely, surgical excision of an atrial septal aneurysm and defect closure is considered in patients in whom antiplatelet or warfarin therapy fails to prevent stroke recurrence or in patients with a large left-to-right shunt causing right heart enlargement. Percutaneous device closure is rarely performed in patients with atrial septal aneurysms, because a large device is required to plicate the atrial septal aneurysm and close multiple fenestrations.

Atrial septal aneurysms are most commonly detected by transesophageal echocardiogram. However, when an incidental atrial septal aneurysm is well visualized by transthoracic echocardiogram, additional imaging with a transesophageal echocardiogram is not needed.

Key Point

• When an atrial septal aneurysm is identified incidentally, no further evaluation, medical treatment, or intervention is needed.

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