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The persistent left superior vena cava (LSVC) is a common anomaly of congenital heart disease. The presence of LSVC is commonly associated with other congenital cardiac anomalies such as atrial septal defect, tetralogy of fallot, aortic coarctation, ventricular septal defect and very rarely it occurs as an isolated finding. During a routine dissection for undergraduate students, a persistent LSVC along with variation in anterior cardiac vein and right septal pouch (RSP) was observed in heart of an approximately 48-year-old male cadaver. The persistent LSVC was draining into the right atrium via coronary sinus. The persistent LSVC is usually insignificant haemodynamically as commonly it drains into right atrium via coronary sinus, but incidental finding of LSVC is important to surgeons, interventional nephrologists and radiologists before placement of central venous access device. The insertion of central venous catheter via left internal jugular vein is difficult in presence of persistent LSVC. The right superior vena cava was normal. An anterior cardiac vein joined with the right marginal vein to form a common vein. The common vein opened into the right atrium. We also observed a RSP attached to the limbus fossa ovalis inferiorly which is a kangaroo pouch–like structure. A septal pouch is potential site predispose to thrombus formation and is more common on left side. In this case report we discuss embryology, clinical significance and review of literature related to persistent LSVC, anterior cardiac vein and SP.

Background Macroreentrant biatrial tachycardia (BiAT) associated with interatrial septal incisions after mitral valve (MV) surgery has been rarely reported. Objective The purpose of this study was to assess the mapping and ablation strategy of this special category of atrial tachycardia (AT). Methods We identified 10 BiATs from a total of 84 ATs after MV surgery performed at 3 institutions. Activation maps for both the right atrium (RA) and left atrium (LA) were obtained using an ultrahigh-density mapping system. We also performed entrainment pacing from multiple LA and RA site within the speculative circuit. Results By analyzing activation and propagation maps of both atria, we classified the circuit into 3 distinct types. In all types, posteroinferior interatrial connections act as a critical limb that, combined with other interatrial connections (Bachmann bundle, fossa ovalis, and coronary sinus ostium in 3 types, respectively), complete the circuit of BiATs. Most ATs (8/10) were terminated targeting the RA and LA end of posteroinferior interatrial connection sites. Conclusion Ultrahigh-density mapping provides a detailed description of the macroreentrant circuit of BiAT associated with interatrial septal incisions. Posteroinferior interatrial connections were essential for the circuit and should be the preferred target for ablation.

This study sought to assess patent fossa ovalis (PFO) anatomy by transesophageal echocardiography (TEE) in patients undergoing percutaneous suture-mediated PFO closure to identify predictors of post-procedural residual atrial right-to-left shunt (RLS).Percutaneous suture-mediated PFO closure has been proven to be a safe and effective technique in most PFO patients.From June 2016 to October 2019, 247 consecutive patients underwent percutaneous suture-mediated PFO closure at our institution. Of them, 230 (46 ± 13 years of age, 146 women) had complete and technically evaluable pre-procedural TEE. The following parameters in short-axis view were assessed: presence and grade of spontaneous RLS, PFO length and width, presence of atrial septal aneurysm and its maximal bulge, and presence of an embryonic or fetal remnant (Chiari network or Eustachian valve).At the first follow-up transthoracic echocardiography performed between 3 and 6 months from the closure procedure, a residual RLS ≥2 grade was found in 37 (16%) patients. Grade of pre-procedural spontaneous RLS (hazard ratio: 1.99; 95% confidence interval: 1.14 to 3.48; p = 0.016) shunt and PFO width (hazard ratio: 2.52; 95% confidence interval: 1.85 to 3.43; p 0.001) were both found to be significantly associated with significant residual RLS at multivariable analysis. The presence of atrial septal aneurysm and its maximal bulge and of congenital remnants was not associated with significant residual RLS.Percutaneous suture-mediated PFO closure is feasible in the majority of septal anatomies; however, PFO5 mm in width and spontaneous large RLS are less likely to be closed with 1 stitch only.

Objectives This study sought to define electrographic characteristics of the fossa ovalis (FO) and use these findings in developing a 3-dimensional (3D) transseptal puncture (TSP) technique that does not rely on fluoroscopy or echocardiography. Background Traditional TSP method based on fluoroscopy or echocardiography is basically a 2-dimensional (2D) technique. A valid 3D method of TSP has not been sufficiently clarified. Methods The shape of the FO and its center were “electrographically” defined by comparing their potential characteristics to those of the surrounding limbus. After validation by intracardiac echocardiography, this FO mapping was incorporated into 3D electroanatomical reconstruction of the right atrium. Using a new catheter connection, the transseptal needle could be visualized nonfluoroscopically and directed to the precise localization of the FO on the electroanatomic map. Results A total of 276 patients who underwent atrial fibrillation ablation were included. The central FO was identified in all cases with atrial electrogram voltage at 0.33 ± 0.21 mV. The amplitude of atrial potential at the FO annulus was 1.70 ± 0.72 mV (p Conclusions Electrographic characteristics of the FO center are distinct from those of the surrounding regions. This information can be leveraged to define the FO on 3D electroanatomic mappings, thereby facilitating safe TSP without the need of ancillary imaging with fluoroscopy or echocardiography.

Graphical abstract, Highlights • Left atrial ridge may affect planning of trans-septal approach for interventions. • Left atrial septal pouch may become a nidus for thrombus and source of embolus. • Complete interrogation of the atrial septum can identify these anatomic variants.

Interest in the anatomy of the interatrial septum (IAS) and its adjoining atrioventricular (AV) junction has risen enormously in the past two decades with the simultaneous evolution of left-sided percutaneous structural heart disease and complex electrophysiologic procedures. These procedures require, in fact, a direct route to the left atrium through the IAS. Thus, a thorough understanding of the complex anatomy of the IAS and AV junction is essential for performing a safe and effective transseptal puncture. There is a large amount of literature carefully describing the anatomy of the IAS and AV junction. These studies are based almost exclusively on anatomic specimens. Conversely, in this review the authors emphasize the role of noninvasive imaging techniques, in particular cardiac magnetic resonance, two- and three-dimensional transesophageal echocardiography, and computed tomography in visualizing specific aspects of the normal IAS and AV junction. Where appropriate, the authors present images side by side, with corresponding anatomic specimens.

Introduction The management of incidental cardiac shunts at the time of orthotopic heart transplantation (OHT) is rarely described in literature. We present a case involving surgical correction of a partial anomalous pulmonary venous connection (PAPVC) at the time of OHT. Case Report The patient is a 65-year-old woman with a history of idiopathic dilated cardiomyopathy (diagnosed in 2010), and a PAPVC. She was diagnosed with the PAPVC incidentally after a right heart catheterization. CT angiogram confirmed an anomalous connection of her right superior and middle pulmonary veins to her superior vena cava (SVC). Serial echocardiograms showed a left ventricular ejection fraction of 20 to 25% and mild pulmonary hypertension. Her right atrium and ventricle were mildly dilated in size and her right ventricular function remained normal. In the year preceding her OHT she developed NYHA class III-IV symptoms and frequent episodes of decompensated heart failure, necessitating advanced cardiac therapies. Ultimately she underwent OHT with concomitant PAPVC repair. At the time of transplantation, the recipient's SVC was divided above the anomalous vein and a pericardial patch was applied to the orifice created on the right atrium. The recipient right atrium and interatrial septum were constructed into an atrial baffle with bovine pericardium, which was then anastomosed to the donor left atrium with a surgically created atrial septal defect in the fossa ovalis. Afterwards, the transplantation proceeded using the standard bicaval technique with the donor left atrium connected to recipient left atrium and the atrial baffle. There were no intra-operative complications, and the patient did well post-operatively. Summary PAPVCs typically cause shunting of oxygenated blood to the right atrium. For patients with clinically significant PAPVCs, surgical correction may be necessary and usually involves a Warden procedure, which can require reconstruction of the right atrial appendage. In patients undergoing PAPVC repair at the time of bicaval OHT, the recipient SVC is anastomosed to donor SVC which is simpler technically than atrial reconstruction and offers better outcomes regarding arrhythmias and tricuspid regurgitation. Furthermore, this maintains adequate pulmonary and systemic venous outflow into the atria. To our knowledge, this is the first reported case of PAPVC repair at the time of OHT in the US.

Objectives Using high-resolution 3-dimensional (3D) mapping, the aim of this study was to further characterize right atrial macro–re-entrant tachycardias and answer unresolved questions in the understanding of this arrhythmia. Background Despite advances in understanding of the mechanisms of right atrial macro–re-entrant tachycardias, many questions lack definitive answers. The advent of high-resolution 3D mapping provides an opportunity to gain further insights into the nature of these common circuits. Methods A total of 25 patients with right atrial macro–re-entrant tachycardia were studied. High-resolution 3D mapping (Rhythmia mapping system, Boston Scientific, Natick, Massachusetts) was performed. Regional voltage and conduction velocity were determined. Maps were analyzed to characterize wave front propagation patterns in all atrial regions. The relationship between substrate and conduction was evaluated. Results A total of 42 right atrial macro–re-entrant circuits were observed. The most common location of the posterior line of block was the posteromedial right atrium (73%). This line of block continued superiorly into the superior vena cava, taking an oblique course to finish on the anterior superior vena cava aspect in 73%. Conduction delay at the crista terminalis was less common (23%). Conduction slowing or block was seen at the limbus of the fossa ovalis (73%) and Eustachian ridge (77%). Highly variable and localized areas of slow conduction were also observed in the inferior septum (45%), superior septum (27%), anterosuperior right atrium (23%), and lateral right atrium (23%). Localized conduction slowing was seen in the cavotricuspid isthmus in 50% of patients, but there was no generalized conduction slowing in this isthmus. The voltage in regions of slow conduction was significantly lower compared with areas of normal conduction velocity (p Conclusions High-resolution 3D mapping has provided new insights into the nature of right atrial macro–re-entrant tachycardias. Variable regions of abnormal atrial substrate were associated with conduction slowing and block. Individual variation in propagation patterns was observed in association with this variable substrate. (Mapping of Atrial Arrhythmias Using High Spatial Resolution Mapping Catheters and the Rhythmia Mapping System; ACTRN12615000544572)

Background Transseptal puncture for left heart interventions became a routine procedure guided by fluoroscopy and echocardiography. The use of intracardiac potentials derived from the sheath-transseptal-needle/guidewire-combination may provide helpful information to increase safety of this procedure. Methods and results We recorded the intracardiac potentials from the sheath-transseptal-needle/guidewire-combination during the transseptal puncture procedure in 31 consecutive patients (mean age 67.2 ± 8.2 years; 21 in sinus rhythm, 10 in atrial fibrillation) designated for ablation of atrial fibrillation by the Cryo-balloon ® technique (Medtronic, Minnesota, USA). The EP-Navigator ® 3-D-image integration tool (Philips Healthcare, Hamburg, Germany) was used for visualization of the device position in relation to the cardiac structures. Typical and reproducible potentials could be derived in all patients for the different device localizations at transseptal puncture procedure. Especially the transition from the muscular interatrial septum into the fossa ovalis could be easily depicted by the changes of both morphology and magnitude of the atrial signal (6.1 ± 2.3 mV in sinus rhythm [SR]/3.5 ± 0.9 mV in atrial fibrillation [AF] at the muscular interatrial septum and 0.5 ± 0.2 mV in SR/0.5 ± 0.1 mV in AF in the fossa ovalis). Conclusions The crucial steps of a transseptal procedure can be verified by typical changes (morphology and amplitude) of the intracardiac signals derived from the sheath-transseptal-needle/guidewire-combination in patients with sinus rhythm as well as in atrial fibrillation.

In recent years, the transseptal puncture approach has enabled passage of increasingly large and complex devices into the left atrium. Traditional tools remain effective in creating and dilating the initial puncture, with an acceptable safety profile. Even for skilled operators, the procedure is technically demanding and requires sound understanding of atrial anatomy. Intracardiac echocardiography is useful in cases of previous septal repair, poorly defined fossa ovalis anatomy or when considering patent foramen ovale portal crossing. Iatrogenic atrial septal defect (iASD) is the most commonly encountered long-term complication and there is increasing evidence that larger devices are leading to symptomatic defects. The size of the sheath crossing the septum is the strongest predictor of iASD formation but other factors such as longer procedure times, significant catheter manipulation and high pulmonary pressures also contribute. Transcatheter mitral valve repair involves the use of large 22 Fr catheters which carry alarmingly high rates of defect persistence with precipitation of symptoms and possible influence on mortality. Long-term follow up data, particularly beyond the 12-month period are lacking and resultantly, evidence to guide management is sparse. Refinements of conventional instruments, as well as innovations to puncture the septum without mechanical pressure, herald a progressively safer future for the transseptal technique.

Sinus venosus defects (SVD) of the inferior vena cava (IVC) type, or inferior SVDs, are an uncommon form of atrial communication located outside the confines of the fossa ovalis and involve override of the IVC. Despite numerous studies describing the anatomical and echocardiographic features of the inferior SVD, distinguishing this defect from a large secundum atrial septal defect (ASD) by echocardiography is often challenging. Accurate diagnosis of an inferior SVD and correct differentiation from a secundum ASD is essential for appropriate presurgical planning. Absence of the posterior rim in the parasternal short-axis views may serve as a useful clue in diagnosing inferior SVDs. We sought to determine the utility of using the presence or absence of a posterior atrial rim in the parasternal short-axis view to help distinguish an inferior SVD from a secundum ASD. This sign may help clinch the diagnosis when subcostal imaging is suboptimal.We retrospectively reviewed transthoracic echocardiograms from 15 patients with a known surgical diagnosis of an inferior SVD between 2004 and 2015. The presence or absence of a posterior rim in the parasternal short-axis view was determined by two primary investigators. The posterior rim was also evaluated in 14 patients with a secundum ASD repair as controls. Echocardiograms were then reviewed blindly by attending-level echocardiographers and cardiology fellows in training. Diagnostic accuracy was assessed both with and without the use of the posterior rim criterion. Statistical analysis was used to determine the effect of using the rim criterion on inferior SVD diagnosis. We also reviewed all surgically diagnosed secundum ASDs that were incorrectly diagnosed as inferior SVD by preoperative imaging and determined whether use of the posterior rim criterion would have resulted in the correct diagnosis.The posterior rim was absent in all 15 patients with a surgical diagnosis of inferior SVD and present in all 14 patients with a secundum ASD. For all observers, there was a statistically significant increase in diagnostic accuracy of inferior SVDs with the use of the rim criterion (P .0001). We noted that secundum ASDs with inferior extension also have persistent posterior rims. The rim criterion correctly classified all large secundum ASDs with inferior extension that were previously misdiagnosed by echocardiogram preoperatively.Absence of the posterior rim ("bald" posterior wall) is a consistent finding in patients with an inferior SVD and distinguishes an inferior SVD from a large secundum ASD with inferior extension. Parasternal short-axis evaluation of the posterior atrial rim is a helpful tool for all levels of physician training in improving diagnostic accuracy for detecting inferior SVDs and in distinguishing them from secundum ASDs.

We thank Dr. Jiang and colleagues for their interest in our paper and for their remarks. We agree that transseptal puncture (TSP) in patients with atrial septal aneurysm (ASA) could be challenging. As indicated in our paper, in the presence of ASA, the fossa ovalis (FO) center usually deviates

Yu et al. ([1][1]) reported the electrographic characteristics of the fossa ovalis (FO) and successful transseptal puncture (TSP) by 3-dimensional (3D) electroanatomic mappings (EAM) of the right atrium (RA) and the FO with a fluoroscopy-free and echocardiography-free method in 276 patients

The development of new transseptal transcatheter interventions for patients with structural heart disease is fueling increasing interest in transseptal puncture techniques. The authors review contemporary transseptal puncture indications and techniques and provide a step-by-step approach to challenging transseptal access and procedural complications.

Lipomatous atrial septal hypertrophy (LASH) is a histologically benign cardiac lesion characterized by excessive fat deposition in the region of the interatrial septum that spares the fossa ovalis. The etiology of LASH remains unclear, though it may be associated with advanced age and obesity. Because of the sparing of the fossa ovalis, LASH has a pathognomonic dumbbell shape. LASH may be mistaken for various tumors of the interatrial septum. Histologically, LASH is composed of both mature and brown (fetal) adipose tissue, but the role of brown adipose tissue remains unclear. In interventional procedures requiring access to the left atrium, LASH may interfere with transseptal puncture, as traversing the thickened area can reduce the maneuverability of catheters and devices. This may cause the needle to enter the epicardial space, causing dangerous pericardial effusions. LASH was once considered a contraindication to percutaneous device closure of atrial septal defects because of an associated increased risk for incorrect device deployment. However, careful attention to preprocedural imaging and procedural intracardiac echocardiography enable interventional cardiologists to perform procedures in patients with LASH without serious complications. In this review article, the authors describe anatomic and functional aspects of LASH, with emphasis on their roles in percutaneous interventions.

Device closure is now an accepted modality of treatment for cardiac septal defects such as fossa ovalis Atrial Septal Defect (ASD), Ventricular Septal Defect (VSD) and Patent Ductus Arteriosus (PDA) and have well-accepted indication and long term results. Devices used for these defects have been specifically designed for use in closing these defects. In this manuscript, we are reporting the efficacy of closure of nonseptal defects with devices conventionally used for septal cardiac defects although they have not been prototyped for use in such conditions. Aim To study use of occluder devices in nonseptal defects/malformation. Material & methods 39 patients, in the age group 2–67 yrs, were treated percutaneously with occluder devices for various conditions. These included: coronary arteriovenous (CAV) fistula ( n = 6), pulmonary AV fistula ( n = 4), systemic AV fistula (vascular plug; n = 1), closure of AP window (duct occluder; n = 3), closure of ascending aorta perforation (septal occluder; n = 2), ruptured sinus of Valsalva (RSOV) (duct occluder; n = 13), Fontan fenestration closure (ASD septal occluder, patent foramen ovale device, vascular plug n = 3,1 each), splenic artery (duct occluder; n = 1), Balock Taussig shunt (duct occlude; n = 1)and closure of mitral paravalvular leak ( n = 3; duct occlude devices = 2, VSD device: n = 1) and aortic paravalvular leak n = 2 (duct occluder; n = 2 additional vascular plug = 2). Results Procedural success: Successful closure as signified by no residual shunt was achieved in all coronary AV fistula (immediately n = 2, at 3 months in all), ruptured sinus of Valsalva (immediate in all), fenestrated Fontan (immediately in all), and ascending aorta perforations (immediate), mitral paravalvular leak (immediate in none, and late in 2/3). The aortic paravalvular leak closed at 3 months follow-up in one and small residual persisted after 1 month in another. Complications: Local site Hematoma was observed in 4 patients. 2 of them required post procedure transfusion for the same. Hematuria was observed in 2 of the 4 patients of mitral paravalvular leak and 2 patients of RSOV device closure. Hematuria subsided with conservative management before discharge from hospital in all the 4 cases. One patient with residual mitral regurgitation required surgical management for continuing hematuria, anemia and hyperbilirubenemia. There was one mortality observed on table during the attempted closure of a very large RSOV who presented to us in severe congestive heart failure and shock. On follow up ranging from 2 months to 6 years, all the patients are asymptomatic. There was no late complication related to device in any patient. Conclusion It is feasible in selected nonseptal defects, which traditionally have been subjected to surgical interventions, to treat successfully, non surgically with the use of non prototype occluder devices without significant complications. Conventionally these devices have not been recommended for closure of nonseptal defects but show good early outcome. Adequate sample size with good follow up data is necessary before concluding that it can be safe alternative to surgery on long term.

It is known that expanded epicardial fat is associated with atrial fibrillation (AF). However, infiltrated intraatrial fat has not been previously quantified in individuals at risk as determined by the ARIC AF risk score.Patients in sinus rhythm (N=90, age 57 ± 10 years; 55 men [63.2%]), in 3 groups at risk of AF as determined by the ARIC AF risk score [low (≤ 11 points; n=15), moderate (12-18 points; n=40), high (≥ 19 points; n=23) risk of AF], and paroxysmal AF (n=12) underwent cardiac magnetic resonance study. Intraatrial and epicardial fat was analyzed with a Dark-blood DIR-prepared Fat-Water-separated sequence in the horizontal longitudinal axis. OsiriX DICOM viewer (Geneva, Switzerland) was used to quantify the intraatrial fat area. Width of the cephalad portion of the interatrial septum was measured at the level of the fossa ovalis.Intraatrial fat monotonically increased with growing AF risk in study groups (low AF risk 16 ± 4 vs. moderate AF risk 32 ± 18 vs. high AF risk 81 ± 83 mm(2); ANOVA P=0.012). Log-transformed intraatrial fat predicted ARIC AF risk score in multivariate ordered probit regression after adjustment for sex, race, left and right atrial area indices, and body mass index (β-coefficient 0.50 [95% CI 0.03-0.97]; P=0.037), whereas epicardial fat did not. Interatrial septum width showed similar association (3.0 ± 1.4 vs. 5.0 ± 1.8 vs. 7.1 ± 2.7 mm; ANOVA P0.001; adjusted β-coefficient 2.80 [95% CI 1.19-4.41]; P=0.001).Infiltrated intraatrial fat characterizes evolving substrate in individuals at risk of AF.

Left atrial tear is an infrequent sequela of severe mitral regurgitation due to myxomatous mitral valve degeneration. Interatrial septal tear due to mitral regurgitation causing a left-to-right shunt is uncommon. Right to left shunting secondary to acute interatrial septal tear is very rarely reported in the human literature, and has not been reported in the veterinary literature in a dog. This case describes the clinical, radiographic, echocardiographic, gross pathologic, and histopathologic features of a dog presented in acute respiratory distress secondary to acute onset right to left shunting through the interatrial septum. This was later documented to be due to a tear in the septum secondary to tricuspid regurgitation and pulmonary hypertension. The presence of an acquired right to left shunting atrial septal defect is of clinical and prognostic significance, and should be considered in cases of acute respiratory distress.

Introduction During ablation procedures in the left atrium (LA), safe puncture of the septum requires precise localization of the fossa ovalis (FO). An intracavitary echocardiography (ICE) catheter positioned in the right atrium provides clear visualization of the interatrial septum and FO. The aim of this multicenter observational study was to assess the feasibility of trans-septal puncture under ICE guidance and its impact on procedure length. Methods This is an observational study conducted during one year in 8 centers specialized in ablation techniques requiring a trans-septal approach. The following data were collected amongst other things: time required for trans-septal catheterization, length of the FO to the LA wall before advancement of the trans-septal dilator, distance when maximum tenting of the FO by the trans-septal dilator, complications occurring during or at distance from the procedure. Results The study population included 123 patients (M 72%; mean age 60±10 years). Median times were as following: to prepare ICE catheter, 70 sec (38; 115); to insert ICE into the sheath, 40 sec (21; 88); to reach the LA, 153 sec (69; 310); time of fluoroscopy duration was 142 sec (80;256). Length of the FO was 16 ± 5 mm, distance from the FO to the LA wall before advancement of the trans-septal dilator was 29 ± 9 mm, distance when maximum tenting of the FO by the trans-septal dilator 15.9 ± 9 mm. Pericardial effusions occurred in 10 patients: 1 severe tamponade necessitating pericardial puncture (FO was not visible with ICE), 6 moderate per procedure and 3 light delayed pericardial effusions (not related to trans septal puncture). Conclusion This observational study shows that ICE does not add a long additional time to ablation procedure. It gives a direct indication of the position of the FO and the length of the LA. Although a tamponade occurred in one patient (0.8%), this technique is helpful in procedures requiring a transseptal approach. The author hereby declares no conflict of interest

Easy access to echocardiography and its extensive and repeated use (as is the case in Portugal) now facilitates the early diagnosis of cardiac myxoma (CM). Objective: To re-evaluate the clinical and pathological profile of CM under current diagnostic conditions. Methods: We performed a retrospective study of 40 patients consecutively referred for surgery (between January 2003 and January 2010) with a histologically confirmed diagnosis of CM – 26 female (F) and 14 male (M), with a mean age of 64 ± 12 years (range 12–81; 53% over 65, 43% over 70); 39 patients were operated (one was not operable due to major neurological deficit). Clinical characteristics, surgical protocols, follow-up records of survivors (range 1–76 months, with serial echocardiograms), and histological data were reviewed. Results: The apparent incidence was 2.6 cases/million/year; the overall F/M ratio was 1.9:1 (1.3:1 in those aged over 65, similar to the general population). The CM was located in the left atrium (LA) in 92.5%, with insertion in the fossa ovalis of the interatrial septum (IAS) in 53% (only 57% of LA myxomas), and outside the IAS in 30%. The mean size was 4.6 cm × 3.7 cm. Asymptomatic tumors occurred in 48% of the total population (sessile and/or atypically inserted in 74%; 63% of large size, over 3 cm × 3 cm), 61% were in patients referred in the last 25 months of the study; 23% of patients showed constitutional symptoms (all with very large CMs – mean 6.7 cm × 5.1 cm), 35% had hemodynamic/obstructive symptoms, and 15% presented with embolic events. There was evidence of CM-related mitral valve (MV) disease in 20% of patients, resulting in moderate to severe mitral regurgitation requiring associated MV surgery in 13%. Significant comorbidities were present in 69%. Surgical procedures included simple excision in 74%; septoplasty/atrioplasty associated with extensive resection of the insertion site in 26%; and combined surgery (CM excision plus other procedures) in 28%. There were significant postoperative complications in 38%. In-hospital mortality was 10%; postoperative mortality was 7.7%. Mean follow-up was 30 months (100% of survivors, 44% for >2 years); late mortality was 5.6% and no CM recurrences were observed. Conclusions: (1) CM has a higher incidence than described in the literature and mainly affects patients aged over 65; the reported predominance of female patients disappears after the age of 65. (2) Most CM cases are now asymptomatic at presentation as a result of earlier diagnosis. (3) CM is the cause of MV disease requiring surgical correction in more than 10% of cases, and is associated with significant postoperative mortality, mainly due to the presence of comorbidities. Resumo: O acesso fácil à ecocardiografia (ECOCG) e o seu uso extensivo e repetido (como acontece em Portugal) facilitará atualmente o diagnóstico precoce dos mixomas cardíacos (MC). Objetivo: Reavaliar os perfis clínico e anatomopatológico dos MC à luz das actuais condições diagnósticas. Material e métodos: Estudo retrospetivo de 40 doentes (dts) consecutivamente propostos para cirurgia (entre janeiro 2003 e janeiro 2010), com o diagnóstico confirmado histologicamente de MC – 26 dts do sexo feminino (F) e 14 do sexo masculino (M), com idade média de 64+-12 anos (12-81; 53% com > 65 anos, 43% com > 70 anos); 39 dts foram operados (um dt inoperável, por sequelas neurológicas major). Efetuou-se a revisão das características clínicas dos dts, dos protocolos operatórios e do seguimento (1-76 meses, com ECOCG seriada) dos sobreviventes, e ainda dos dados histológicos. Resultados: 1) Incidência aparente de 2,6 casos/milhão/ano; relação F/M (global)= 1,9:1; relaçãoF/M (dts com > 65 anos)= 1,3:1 (sobreponível à da população geral). 2) Localização: aurícula esquerda (AE) em 92,5% dts; inserção na fossa ovalis do SIA (AE) em 53% dts (apenas 57% dos MC da AE) e fora do SIA em 30% dts. Tamanho médio=4,6x3,7 cm 3). Dts assintomáticos – 48% (MC séssil e/ou com inserção atípica em 74% dos casos; 63% com dimensão > 3x3 cm), sendo 61% nos últimos 25 meses; 23% com sintomas constitucionais (MC sempre muito volumoso – média de 6,7x5,1 cm), 35% com sintomas hemodinâmicos/obstrutivos e 15% com fenómenos embólicos (83% dts com MC viloso; todos com localização atípica; 83% com MC volumoso). 4) Presença de patologia da válvula mitral (VM) relacionada diretamente com o MC em 20% dts, resultando em insuficiência mitral moderada/grave, com indicação para cirurgia VM associada, em 13% dts. 5) Comorbilidades significativas em 69% dts. 6) Protocolo operatório: excisão simples - 74% dts; septoplastia/atrioplastia associada à excisão alargada da base do MC – 26% dts; cirurgia combinada (ressecção do MC + outros procedimentos) – 28% dts. Complicações pós-operatórias significativas: 38% dts. Mortalidade hospitalar global: 10% (4 dts); mortalidade pós-operatória global=7,7% (3 dts; 2,6% aos 30 dias). 7) Seguimento pós-operatório (100% dts; média de 30 meses, 44% com mais de 2 anos): mortalidade tardia – 5,6% (2 dts); ausência de recorrência de MC. Conclusões: 1) O MC tem uma incidência superior à estimada na bibliografia clássica e afeta maioritariamente dts com mais de 65 anos. O proclamado predomínio no sexo feminino desaparece acima dos 65 anos. 2) Atualmente, a maioria dos MC apresenta-se na forma assintomática, como consequência de um diagnóstico muito mais precoce. 3) O MC associa-se diretamente a patologia valvular mitral merecedora de correção cirúrgica em mais de 10% dos casos e tem uma mortalidade pós-operatória relevante, marcada pela influência das comorbilidades. Keywords: Myxoma, Early diagnosis, Mitral regurgitation, Chordal rupture, Papillary fibroelastoma, Prognosis, Palavras-chave: Mixoma, Diagnóstico precoce, Insuficiência mitral, Ruptura de cordas, Fibroelastoma papilar, Prognóstico

Extraordinary advances in technology have made possible percutaneous catheter-based treatment of a wide spectrum of specific pediatric and adult "structural" heart diseases. Many of these percutaneous interventional procedures require access to the left heart via transseptal catheterization. Being able to see the anatomy can be a considerable advantage. However, septal anatomy is more complex than perceived at first sight. The true interatrial septum comprises a valvelike flap forming the floor of the fossa ovalis. On the right atrial aspect, the muscular rim surrounding the fossa is an infolding of the atrial wall. Hence, the target area for safe crossing, without exiting the heart, is the fossa floor and its immediate margin of the rim. Real-time (RT) three-dimensional (3D) transesophageal echocardiography is a recently developed technique that provides 3D images of the heart. Because of lack of interference from bone and lung and the closer proximity of the transducer to the posterior structures of the heart, this technique provides 3D RT images of atrial structures of unprecedented quality. In this review, the authors describe two key areas: a step-by-step approach for acquiring and processing RT 3D transesophageal echocardiographic images of the interatrial septum and, second, septal anatomy as it is visualized by RT 3D transesophageal echocardiography. To demonstrate their consistency with actual anatomy, several RT 3D transesophageal echocardiographic images are matched to equivalent anatomic specimens.

Background Percutaneous transvenous mitral commissurotomy (PTMC) is an effective treatment for mitral stenosis, but transseptal puncture carries a certain risk of complications. Our previous report has shown the effectiveness of phase-array intracardiac echocardiography (ICE)-guided transseptal puncture in patients with dilated left atrium undergoing PTMC. However, there are few reports comparing the new-generation mechanical versus phase-array ICE-guided transseptal puncture in PTMC. Methods Between March 2007 and March 2008, 6 consecutive patients with symptomatic mitral stenosis with dilated left atrium (range, 4.1–6.1 cm) underwent transseptal puncture by mechanical ICE guidance in PTMC by the same experienced operator. The procedural, echocardiographic and clinical results were retrospectively retrieved and analyzed. In addition, phase-array ICE-guided transseptal cases ( n = 7), which included consecutive cases from May to December 2008, were compared. Results All 6 patients could have fossa ovalis visualized by ICE, and none of them had false transseptal puncture. Mechanical ICE provided a panoramic wider view of the interatrium septum, and offered better knowledge of the needle's geographic contact to the fossa ovalis than did the phase-array system. The fluoroscopic time of PTMC in the mechanical ICE-guided group (37 ± 9 minutes, n = 6) was similar ( p = 0.465) to that of phase-array guidance (31 ± 15 minutes, n = 7). Conclusion Mechanical ICE is effective in guiding transseptal puncture in PTMC.

Inferior sinus venosus defect (SVD) is a rare congenital heart disease involving an interatrial communication outside the confines of the fossa ovalis. It overrides the inferior vena cava and extends into the inferoposterior border of the left atrium, leaving no residual atrial septal tissue at the

Purpose The authors performed this study to report their initial preclinical experience with real-time magnetic resonance (MR) imaging–guided atrial septal puncture by using a MR imaging–conspicuous blunt laser catheter that perforates only when energized. Materials and Methods The authors customized a 0.9-mm clinical excimer laser catheter with a receiver coil to impart MR imaging visibility at 1.5 T. Seven swine underwent laser transseptal puncture under real-time MR imaging. MR imaging signal-to-noise ratio profiles of the device were obtained in vitro. Tissue traversal force was tested with a calibrated meter. Position was corroborated with pressure measurements, oximetry, angiography, and necropsy. Intentional non-target perforation simulated serious complication. Results Embedded MR imaging antennae accurately reflected the position of the laser catheter tip and profile in vitro and in vivo. Despite having an increased profile from the microcoil, the 0.9-mm laser catheter traversed in vitro targets with similar force (0.22 N ± 0.03) compared with the unmodified laser. Laser puncture of the atrial septum was successful and accurate in all animals. The laser was activated an average of 3.8 seconds ± 0.4 before traversal. There were no sequelae after 6 hours of observation. Necropsy revealed 0.9-mm holes in the fossa ovalis in all animals. Intentional perforation of the aorta and atrial free wall was evident immediately. Conclusions MR imaging–guided laser puncture of the interatrial septum is feasible in swine and offers controlled delivery of perforation energy by using an otherwise blunt catheter. Instantaneous soft tissue imaging provides immediate feedback on safety.

Background A fatal pulmonary tumor microembolism is rarely caused by an occult gastric cancer. Methods and results We report the case of a 40-year-old woman who died after 3 days of progressive dyspnea, cough, and pulmonary hypertension. Postmortem examination demonstrated the presence of an occult diffuse-type gastric carcinoma, which had caused emboli in about 80% of small pulmonary arteries and arterioles. Despite an interatrial defect in the fossa ovalis, no parenchymal metastases were documented. Conclusion Pulmonary tumor microembolism may be suspected in patients complaining of unexplained progressive dyspnea and who develop acute or subacute cor pulmonale.

OBJECTIVES We report the data from the Italian Survey on trans-septal catheterization (TSP-C) for catheter ablation of arrhythmias in the left heart that covered 2003 and previous years. BACKGROUND Over the last decade the use of TSP-C in the electrophysiology laboratory has greatly increased. Recent data on number of procedures, accomplishment rate, and complications related to this procedure are lacking in a large cohort of patients. METHODS Thirty-three centers participated in the survey. The data collected retrospectively for 2003 included the number of procedures, indications, methods, and the number and reason for unaccomplished cases along with complications. Retrospective data collected for previous years included the annual number of procedures and cumulative data concerning indications, accomplishments, and complications. RESULTS Since 1992, 5,520 TSP-C procedures were used in arrhythmia ablation, with the peak increase in the use occurring in 2001. Trans-septal catheterization was performed for atrial fibrillation (AF) ablation in 78.3% of the procedures in 2003. The electrophysiologist independently performed the procedure in 29 of 33 centers. Trans-septal catheterization was successfully performed in 99.1% of the cases; the main reason for TSP-C not being performed was related to fossa ovalis/atrial septum anatomy. Complications were low both in 2003 and in the previous years (0.79% and 0.74%, respectively). CONCLUSIONS Trans-septal catheterization in the electrophysiology laboratory is associated with a high success and low complication rate. The use of TSP-C has progressively increased over the last decade and is currently used primarily for AF ablation. Although possible, severe complications were rare.

Partial anomalous pulmonary venous connection to superior vena cava occurs in about 10 to 15% of all patients with an atrial septal defect. Most commonly one or more pulmonary veins from the right lung connect to the superior vena cava or the right atrium, or both. The usual sinus venosus atrial septal defect occurs above the fossa ovalis immediately beneath the orifice of the superior vena cava, which typically overrides the atrial defect to some extent. Rarely there is no atrial septal defect. 1 Because the clinical manifestationsofbothlesionsaresimilar,itisnotunusualtoencounter anomalous pulmonary veins at the time of operation for presumed uncomplicated secundum atrial septal defect. Idealsurgicalrepairdemandscompleteclosureoftheatrial septal defect and redirection of the anomalous pulmonary veins into the left atrium without pulmonary venous or superior vena cava obstruction and without injury to the sinus node or its blood supply. Normally this is simple when the anomalous pulmonary veins are close to the right atrium. However when they enter further up the superior vena cava, the surgical treatment can be more complex. Various techniques have been described using prosthetic grafts, pericardial patches, or atrial wall flaps to baffle the anomalous pulmonary veins into the left atrium. An alternative atrio-caval anastomosis technique has been utilized at our institution for 42 years to lessen the risk of undesirable complications, particularly sinus node dysfunction.

Background Surgical closure of patent foramen ovale (PFO) has been considered definitive and the gold standard for preventing recurrent paradoxical embolism. However, in contrast to transcatheter PFO closure, patients undergoing operation have not systematically been re-evaluated for residual shunting. This study aimed to assess the efficacy of surgical PFO closure during follow-up by transesophageal echocardiography (TEE). Methods Eleven adult patients with diagnosis of a PFO by contrast and/or color Doppler TEE underwent PFO closure by thoracotomy and direct suturing because of paradoxical embolism (n = 4), because of impending paradoxical embolism (n = 1), or during valve operation (n = 6). Results TEE performed 5 days to 7 months after PFO closure revealed residual shunting in 8 of 11 patients (73%). The shunt size was unchanged in two patients. According to the color Doppler jet width across the atrial septum, the postoperative PFO diameter was smaller in 5 of the remaining 6 patients. Right-to-left shunting by contrast TEE, however, had newly developed (n = 1) or increased (n = 2) for patients with concomitant valve operation. Despite therapeutic anticoagulation a cerebrovascular event occurred in one patient 4 weeks after attempted PFO closure. The mechanism for persistent shunting was incomplete sealing of septum primum and septum secundum by the suture line (n = 6) or a new iatrogenic defect of the fossa ovalis caused by surgical manipulation (n = 2). In two patients a second TEE after 12 and 41 months revealed enlargement of the PFO diameter. Conclusions Surgical PFO closure can not be regarded as the gold standard for definitive treatment of interatrial shunts. Residual shunting present in a high proportion of patients may partly explain the recurrence of embolic events.

EFECTS OF THE interatrial septum are among the most common congenital cardiac lesions found in adults. The foramen ovale, a fetal remnant, remains probe patent in more than one third of the general population, making it the most common congenital cardiac abnormality. Functional closure of the foramen ovale usually occurs soon after birth when the left atrial pressure rises and presses the valve of the fossa ovalis against the septum secundum. A patent foramen ovale (PFO) occurs when the foramen ovale does not anatomically seal. This relatively common entity is detectable in up to 34% of the population at postmortem examination. 1,2 The incidence has been shown to be even higher in patients with stroke. 3 Complications associated with a PFO include right-to-left shunting with refractory hypoxemia, paradoxic embolism, migraine headache, 4 transient global amnesia, 5 decompression illness with paradoxic gas embolism in divers and astronauts, 6 and orthostatic desaturation with platypnea-orthodeoxia syndrome.7 Atrial septal aneurysm (ASA) is frequently seen in association with a PFO,8 and its presence has been related to focal cerebral events including stroke and transient ischemic attacks. Because of this association, paradoxic embolism is believed to be a likely mechanism of embolism in many patients with ASA. Transesophageal echocardiography (TEE) is the modality of choice for the detection of PFO and ASA. Because of the increasingly routine use of TEE in the operating room during cardiac surgery, it can be expected that more cases of previously undiagnosed PFO and ASA will be detected. The question then becomes whether these findings should prompt further surgical intervention, particularly if the patient is asymptomatic. Unfortunately, at this time, there are no data to support the optimal approach to this clinical dilemma. The authors present a patient with a history of transient ischemic attacks (TIA) of unknown origin who was scheduled for elective off-pump coronary artery bypass (OPCAB) surgery. Preoperative diagnostic tests did not disclose the source of TIAs; however, intraoperative TEE revealed an ASA with PFO leading to alteration of the planned surgical procedure.

Recent studies have suggested that a higher mobility of the fossa ovalis membrane (FOM) may be associated with an increased risk for stroke in patients with patent foramen ovale (PFO). The current study analyzed whether Doppler tissue echocardiography is useful for quantitation of FOM motion velocities.FOM dynamics were prospectively studied in 107 consecutive patients (average age 50.7 +/- 15.3 years, 48 men) with in sinus rhythm who underwent transesophageal echocardiography for various indications. With pulsed wave Doppler tissue echocardiography interrogation, a characteristic quadrophasic signal was recorded in all patients, consisting of a positive wave toward the left atrium (A-wave) at late diastole, followed by a negative wave (B-wave) toward the right atrium, a pronounced, again positive wave during midsystole (C-wave), and a final negative wave (D-wave).Peak velocities of A-wave, B-wave, C-wave, and D-wave were 0.08 +/- 0.02 m/s, 0.11 +/- 0.05 m/s, 0.17 +/- 0.07 m/s, and 0.14 +/- 0.06 m/s, respectively. In 21 of 107 (19.6%) patients, PFO was detected. Patients with PFO had significantly higher C-wave and D-wave peak velocities compared with the 86 patients without PFO (0.23 +/- 0.10 m/s vs 0.15 +/- 0.05 m/s, P.001 and 0.16 +/- 0.07 m/s vs 0.12 +/- 0.06 m/s, P = .04, respectively).Assessment of FOM dynamics using Doppler tissue echocardiography is feasible. It allows definition of a characteristic quadrophasic FOM motion pattern, thereby providing new insights into the physiology of FOM mobility. Patients with PFO were found to have increased FOM mobility compared with patients without PFO.

We prospectively analyzed the learning process for transseptal catheterization guided by intracardiac echocardiography, in 50 patients who underwent radiofrequency ablation for left atrial arrhythmias. In 20 patients the intracardiac echocardiography catheter was positioned in the right atrium to visualize the fossa ovalis and the tenting of the fossa caused by the Brockenbrough needle. In the other 30 patients, the intracardiac echocardiography catheter was positioned so that it impinged upon the fossa ovalis, and the needle was advanced alongside the intracardiac echocardiography catheter under fluoroscopic guidance in two orthogonal projections. In all but one patient, transseptal catheterization was performed successfully on the first attempt. The learning process for transseptal puncture guided by intracardiac echocardiography was uncomplicated, resulting in a procedure that is safe and effective. The intervention is simplified by positioning the echocardiography catheter at the fossa ovalis and using this as a reference point for fluoroscopic monitoring of the progress of the Brockenbrough needle.

Using transesophageal echocardiography, we sought to determine the anatomic characteristics of the secundum atrial septal defects (ASDs) that extend into the inferior sinus venosus and have no posteroinferior (PI) rim, to determine the factors related to potential closure with an Amplatzer occluder. We also sought to understand why large secundum ASDs with a PI but without an anterosuperior (AS) rim may require special techniques to reorient the left atrial disk before deployment of the waist and right atrial disk. We measured the lengths of 5 separate rims of the circumferences of 76 secundum ASDs, including anteroinferior, AS, superior, posterosuperior, and PI rims. We also measured anteroposterior and superoinferior defect diameters, total septal lengths, and the ratios of defect diameter to total septal length. The atrial depth was measured at the axial angle of the delivery sheath in 5 defects with no AS rim for which special techniques were required to achieve successful closure. Of 76 secundum ASDs, 13 (17%) had no PI rim. Each defect extended from the fossa ovalis into the inferior sinus venosus. Compared with defects with a PI rim, the factors related to potential closure included 100% larger defect diameters, shorter posterosuperior rim lengths, larger defect to total septal length ratios, and completely flat posterior atrial walls. When the AS rim was absent the factors related to the need for special techniques included diameters >/= 22 mm, atrial depth < the calculated Amplatzer occluder left atrial disk diameter, rigid wire/disk interface, and obligatory left atrial disk orientation more or less perpendicular to the atrial septal plane.

Background Lipomatous hypertrophy of the interatrial septum (LHIS) is a benign disorder characterized by fat accumulation in the interatrial septum. It typically occurs in elderly, obese patients and may cause arrhythmia. Objectives The purpose of this study was to determine the imaging features of this cardiac pathology using multislice CT (MSCT), and its relationship with clinical findings. Materials and methods A total of 1,292 consecutive patients who underwent MSCT of the thorax from September 2001 to August 2002 were prospectively studied. Beside the analysis of patient records, the amount of fat in the interatrial septum, and its size and shape were determined. Results Among the 1,292 patients investigated, we found 28 (2.2%) with LHIS. The mean age of affected patients was 72.2 years. MSCT studies revealed a mass of fat attenuation with sharp margins and sparing of the fossa ovalis, resulting in a dumbbell shape in all patients. The median thickness of the interatrial septum was 32 mm (range, 20 to 62 mm), and the median craniocaudal extend was 62 mm (range, 51 to 89 mm). Twenty-one patients (75.0%) showed increased epicardial fat, 18 patients (64.3%) had significant pulmonary emphysema, and 13 of 21 patients (61.9%) showed ECG abnormalities. Three patients underwent functional cardiac MRI studies. In one patient, hemodynamic obstruction by LHIS was shown. Conclusions MSCT scanning is a useful method to diagnose LHIS, a cardiac condition that in our series reached a 2.2% incidence. The lesion shows characteristic features, thus differentiating it from other cardiac tumors. Advanced age, obesity, pulmonary emphysema, and atrial arrhythmias are common additional findings in patients with LHIS.

Objectives We assessed the use of intracardiac echocardiography (ICE) as the primary means for both selection of the Amplatzer Septal Occluder (ASO) and the guidance of transcatheter closure of secundum atrial septal defects (ASDs). Background The standard method for transcatheter closure of ASDs requires balloon-sizing maneuver and transesophageal echocardiographic (TEE) monitoring. The role of ICE during transcatheter closure of ASDs has not yet been established. Methods In 91 patients with ASDs, two standardized orthogonal sections were used to obtain ICE-derived measurements of the fossa ovalis and to assess optimal device deployment: the transverse section on the aortic valve plane, and the longitudinal section on the four-chamber plane. Results In all patients, ICE planes were identified with excellent resolution, providing proper measurements of the fossa ovalis, from which to derive geometric assumptions for the selection of an appropriately sized device. The ASO waist diameter was chosen on the basis of the r value ( r = c 2 + p 2 , where r is the radius of an ideal circle that intersects the elliptical fossa ovalis in its semi-latus rectum, c is the foci half-distance of the fossa ovalis, and p is its semi-latus rectum). During the procedure, the four-chamber plane allowed us to obtain easily interpretable images of all stages of device deployment. Midterm complete occlusion rate was 97.8%. No ICE-related complications occurred. Conclusions The ICE evaluation of ASDs allows quantitative and qualitative information for both proper ASO selection and optimal device placement, thus eliminating the cumbersome balloon-sizing maneuver and the need for general anesthesia during TEE monitoring.

Background: Aneurysm of the fossa ovalis is an out pouching, space-occupying, interatrial septal structure. The anatomic morphology and characteristics of this aneurysm are of interest for pathologists and cardiologists alike. Methods: We identified 33 specimens of adult hearts with a large size aneurysm of the fossa ovalis (length equal to or more than 10 mm from the plane of the atrial septum) in a registry of cardiovascular disease. Anatomic–morphologic features of these aneurysms were examined by macroscopic and histopathologic studies. Results: Nineteen aneurysms were from females (57%) and 14 were from males (43%). Most aneurysms had a dome shape with maximal length of the aneurysmal excursion into an atrium varying from 10 to 35 mm (mean 16±5 mm) and width varying from 16 to 40 mm (mean 24±6 mm). Twenty-four aneurysms (73%) protruded into the right atrium while only nine (27%) penetrated into the left atrium. In 24 patients the interatrial ostium II was patent, and in 22 (91%) of them, abnormal increased intracardiac pressure was deemed responsible for the formation of the aneurysm. Among nine patients in whom the foramen ovale was closed, eight (89%) had an aneurysm protruding into the right atrium, and only one aneurysm penetrated into the left atrium. In six patients, the aneurysm further stretched an already patent foramen ovale resulting in creation of an atrial septal defect so that bidirectional shunting could occur, and in three cases, the aneurysm narrowed the inferior vena caval orifice. In three hearts, the aneurysm wall had endocardial fibrosis, and in three other specimens, a focal mural thrombus was present on the aneurysmal surface. Most common associated cardiac conditions in this series included atherosclerotic coronary artery disease (51%), aortic valvular disease (21%) and mitral valve disease (24%). Conclusions: Aneurysm of the fossa ovalis is a space-occupying, redundant structure, most commonly with a dome shape. In a majority of cases, the formation of this aneurysm relates to the effect of extrinsic mechanisms, which create abnormally elevated intracardiac pressures. The aneurysm protruded into the right atrium in 73% of cases. Endocardial fibrosis and a focal mural thrombus were present in several cases on the aneurysmal wall. Bidirectional shunt via stretched patent foramen ovale and distal embolization can contribute to complications related to the aneurysm.

We describe a novel technique of left atrial volume reduction in a patient presenting with severe dyspnea from severe mitral insufficiency, giant left atrium, and compressive symptoms of dysphagia and dysphonia. Resection involved circumferential excision of the left atrium anterior to the pulmonary venous vestibule and posterior to the mitral valve and fossa ovalis, including the left atrial appendage. A chordal-sparing bioprosthetic mitral valve replacement, tricuspid valve annuloplasty, and coronary bypass were also performed. Significant reduction of left atrial volume by 50% was achieved and clinical resolution of compressive symptoms was seen at 6-month follow-up.

The electrophysiological phenomena related to AF are still incompletely understood, and despite the advances in pharmacological and non-pharmacological management of AF, we are far from being satisfied with the available treatment modalities and predictors of their success. Impaired interatrial conduction has been demonstrated in patients with AF [1], and it has been indicated that this condition can be associated with a reduced left atrial function [2]. In the intact human heart, conduction from the right atrium to the left atrium (LA) is known to occur through Bachmann bundle (BB), the posterior rim of fossa ovalis (FO), and the coronary sinus ostial region (CS) [3]. Impairment of interatrial conduction has been evaluated by ECG as prolongation of P wave duration or its morphology changes. Changes of P wave duration (>120 ms) andmorphology (+/−) in leads D3 and aVF have been utilized to indicate the existence of a conduction delay through Backmann bundle [4]. A +/−P-wave morphology in V1 has been advocated as expression of an interatrial conduction defect through the posterior rim of FO [3]. The latter interatrial delay can be further evidenced measuring P-wave terminal force (PTF), defined as product of the duration (D) by the amplitude (A) of the terminal phase of the P-wave in V1 [5]. The aim of our study was to furnish a contribution for verifying the diagnostic accuracy of these electrocardiographic criteria by comparison of ECG and electroanatomic mapping. Patients were studied just before catheter ablation of atrial fibrillation. At the time of electroanatomic mapping all patients were in sinus rhythm. A quadripolar diagnostic catheter was placed in the coronary sinus for time reference. Electroanatomic mapping was performed using the Carto system (Biosense Webster, Diamond Bar CA USA) with either a 7F Navistar or Thermocool catheter (Biosense Webster). ⁎ Corresponding author at: University of Florence, Department of Medical and Surgical Critical Care, Viale Morgagni 85, 50134 Florence, Italy. Tel.: +39 055 7947514. E-mail address: gemma@gmx.it (G. Filice). Fig. 3. Coronary angiography of the right internal thoracic artery “free” graft to the left anterior descending artery (A, B) after angioplasty of its proximal third (white arrow). Angiogram of the saphenous vein graft to a diagonal branch (C) shows the disappearance of the collateral circulation between the grafts (black arrow).

Background: AcuNav ultrasound catheter (UC) (10F, 5.5-10 MHz) has unique advantages for left heart imaging with its 4-way tip flexible maneuverability, maximal 16-cm intracardiac imaging depth, and Doppler and color flow imaging capability. Methods: We assessed the initial use of this UC in 40 consecutive patients (34 men; age 53 ± 11 years old). All patients were also undergoing transseptal catheterization for percutaneous catheter mapping and ablation of either left atrium (focal initiated atrial arrhythmia/fibrillation, n=32) or left ventricle (ventricular tachycardia, n=4), or transcatheter atrial septal defect closure (n = 4) procedures. During each procedure, the UC was placed in the right atrium, superior vena cava, or right ventricular inflow/outflow tract. Results: In all patients, UC successfully guided transseptal catheterization and provided imaging of normal or aberrant anatomy of the right/left atrial (interatrial septum, fossa ovalis, appendages, 4 pulmonary vein ostia) and right/left ventricular (valves and papillary muscles) structures. UC was important in early identification procedure complications, including pericardial effusion (n = 2, detected before systematic hemodynamic deterioration) and thrombus formation on sheaths deployed in the right atrium (n = 9) and left atrium (n = 2, early elimination with management of the sheath). With Doppler and color flow imaging, UC provided effective monitoring of increased flow velocity of all ablated pulmonary vein ostia and detection of patent foramen ovale (n = 6) or residual trivial/small atrial septal defect posttransseptal catheterization (n = 2). UC was also used to successfully image and guide transcatheter closure of atrial septal defect with positioning of the cardioseal septal occluder (Nitinol Medical Technologies Inc, Boston, Mass) and color Doppler imaging of no significant residual shunt. Conclusion: AcuNav UC with Doppler and color flow imaging has significant use, especially during left heart ablation. Uses include guidance of transseptal and mapping/ablation catheters and closure devices, and prompt diagnosis of cardiac complications. (J Am Soc Echocardiogr 2002;15:1301-8.)

trioventricular (AV) canal defects represent a syecA trum of cardiac. defects involving varying degrees of incomplete cleveloyment of the septa1 tissue surrounding the AV valves as well as varying degrees of almormalities of the AV valves themselves. This article focuses on partial AV canal defects (PAVSDs), in which the dominant part of the septal deformity is a crescentshaped atrial septal c1efec.t (RSD) in the inferior portion of the atrial septum just ahove the AV valves known as an ostium primum defect. Anatomy Ostium primum defects generally acwiunt for hetween S% and 10% of all ASDs. They are bounded below hy the inferiorly clisplac*cvl AV valve leaflets and above by t-shaped ridge of atrial septum that fuses with the AV valve ring only at its extremities. The fossa ovalis is normally formed, and there is often an associated patent foramen ovale- or fossa ovalis-type ASD. There may also he an associated small vrntricwlar septal defect (VSD) just below the AV valves, an anatomic. variant commonly called a transitional or intermediate AV canal defect. In contrast to the Rastelli classification uscd to tlescrihe the anatomic variants of the AV valves in cwmplete RV septal defwts, the AV valve apparatus in PAVSDs is generally understood to have two distinct right and left AV valve orifices. Nonetheless, PAVSDs are usually associated with varying clegrees of left-sided AV valve malformation. Specifically, unlike a typical mitral valve, the left-sided AV valve in PAVSDs has three leaflets: left hupwior, left lateral (or left mural), antl left inferior. Thc. left superior and left inferior leaflets fuse with the septum, and the zone of coaptation of these two leaflets is generally referred to as the left'^ in the left AV valve. The final important anatomic consideration is that as in the case of complete AV septal defects, in PAVSDs the AV node is not in the triangle of Koch, but rather is displaced posteroinferiorly. As originally clewrilwd by Lev and reviewed by Anderson, the conduction axis lies in a new nodal triangle hounded by the annulus of the right AV valve, the coronary sinus, and thr lower edge of the interatrial st*ptum.I This altered anatomy must he kept in mind when repairing these defects. Finally, morphologic ahnornialities of the left AV suhvalvar apparatus are more common in patients with PAVSDs than in patients with complete AV canal defects. Such abnormalities, which may be present in up to 2.59" of patients with partial

Objectives This study was designed to test the feasibility of high-resolution phased-array intracardiac imaging. Background Intracardiac echocardiographic imaging of the heart during interventional electrophysiologic (EP) procedures has been limited by inadequate ultrasound penetration and absence of Doppler hemodynamic and flow information produced by rotating mechanical ultrasound elements. Methods A 10F (3.2 mm) phased-array, variable 5.5 to 10 MHz frequency imaging catheter with a four-way deflectable tip was applied in 24 patients undergoing EP studies. Sixteen prespecified cardiac targets were imaged from a right heart venue. Results Fifteen patients had no underlying organic heart disease; nine had ischemic, cardiomyopathic, valvular or congenital heart disorders. Longitudinal and short-axis imaging readily disclosed each cardiac valve, support structures and chamber, as well as the pericardium, right and left atrial appendages, the junction of the right atrium and superior vena cava, crista terminalis, tricuspid valve isthmus, coronary sinus orifice, membranous fossa ovalis and pulmonary veins. The average target depth was 8.8 ± 1.5 cm (range 0.5 to 15 cm), with adequate penetration at a 7.5 MHz imaging frequency. Color flow and Doppler utilities clearly characterized transaortic and pulmonic valve and pulmonary vein blood flow, including during low output states. Conclusions These first human studies with this technology demonstrate the methods, feasibility and utility of intracardiac phased-array vector and Doppler imaging for long-axis, apex-to-base global cardiac imaging. High resolution of endocardial structures and catheters suggests additional utility for visualizing interventional procedures from the right heart.

OBJECTIVES We sought to characterize a method of attenuating interatrial conduction using radiofrequency ablated lesions applied to the right atrial septum. BACKGROUND Interatrial conduction occurs in specific zones. Recent data suggest that interatrial conduction can be important in triggering and sustaining atrial fibrillation. Therefore, a method for attenuating interatrial conduction may have therapeutic value. METHODS In 13 healthy pigs, interatrial conduction was evaluated before and after sequential ablation of the right atrial septum, targeting interatrial conduction zones. In six animals, zone 1 (crista terminalis and limbus) was ablated first, followed by ablation of zone 2 (fossa ovalis and coronary sinus ostium). In the other seven animals, the order of ablation was reversed. Electrophysiologic and pathologic findings were correlated. RESULTS After ablation of zone 1, interatrial conduction was slowed, but there was no block. After ablation of zone 2, conduction was unchanged. After ablation of both zones, complete block was observed in four animals, and there was left atrial quiescence. In the remaining nine animals, incomplete block was observed, with marked conduction slowing or block during sinus rhythm and pacing. Ablation did not adversely affect atrioventricular node conduction, nor did it facilitate sustenance of an atrial arrhythmia. Pathologic analysis revealed that complete interatrial conduction block was associated with confluent ablation of both targeted zones. CONCLUSIONS Catheter ablation of the right atrial septum attenuated interatrial conduction without disturbing atrioventricular conduction.

A new low-frequency (9 MHz, 9 Fr) catheter-based ultrasound (US) transducer has been designed that allows greater depth of cardiac imaging. To demonstrate the imaging capability and clinical utility, intracardiac echocardiography (ICE) using this lower frequency catheter was performed in 56 patients undergoing invasive electrophysiological procedures. Cardiac imaging and monitoring were performed with the catheter transducer placed in the superior vena cava (SVC), right atrium (RA) and/or right ventricle (RV). In all patients, ICE identified distinct endocardial structures with excellent resolution and detail, including the crista terminalis, RA appendage, caval and coronary sinus orifices, fossa ovalis, pulmonary vein orifices, ascending aorta and its root, pulmonary artery, RV and all cardiac valves. The left atrium and ventricle were imaged with the transducer at the limbus fossa ovalis of the interatrial septum and in the RV, respectively. ICE was important in identifying known or unanticipated aberrant anatomy in 11 patients (variant Eustachian valve, atrial septal aneurysm and defect, lipomatous hypertrophy, Ebstein's anomaly, ventricular septal defect, tetralogy of Fallot, transposition of the great arteries, disrupted chordae tendinae and pericardial effusion) or in detecting procedure-related abnormalities (narrowing of SVC-RA junction orifice or pulmonary venous lumen, atrial thrombus, interatrial communication). In patients with inappropriate sinus tachycardia, ICE was the primary ablation catheter-guidance technique for sinus node modification. With ICE monitoring, the evolution of lesion morphology with the three imaging features including swelling, dimpling and crater formation was observed. In all patients, ICE was contributory to the mapping and ablation process by guiding catheters to anatomically distinct sites and/or assessing stability of the electrode-endocardial contact. ICE was also used to successfully guide atrial septal puncture (n = 9) or RA basket catheter placement (n = 4). Thus, ICE with a new 9-MHz catheter-based transducer has better imaging capability with a greater depth. Normal and abnormal cardiac anatomy can be readily identified. ICE proved useful during electrophysiological mapping and ablation procedures for guiding interatrial septal puncture, assessing placement and contact of mapping and ablation catheters, monitoring ablation lesion morphological changes, and instantly diagnosing cardiac complications.

EFT ATRIAL MYXOMA is infrequently associated with mitral valve pathology. A case of left atrial myxoma resection requiring mitral valve repair is described, showing the importance of intraoperative transesophageal echocardiogram (TEE) in the management of these patients. CASE REPORT A 61-year-old man presented to his family physician with a 2-month history of shortness of breath. On examination, the patient was found to be in atrial fibrillation and have a holosystolic murmur audible on the precordium. The patient denied any fevers, chest pains, syncopal episodes, or symptoms suggesting embolic phenomena. Past medical history was significant for a 150 pack/year history of smoking. The patient was started on warfarin for his atrial fibrillation and referred to the cardiology department. A transthoracic echocardiogram showed a large mass within the left atrium measuring 5.5 cm 3.2 cm. The mass was attached to the inferior part of the interatrial septum and was prolapsing across the mitral valve. The left ventricle was described as mildly dilated with preserved systolic function. Posterolaterally directed mitral regurgitation was present and was believed to be secondary to the prolapsing mass interfering with leaflet coaptation because prolapse through the valve was observed to occur during systole (Fig 1). By pulmonary vein Doppler profile, the regurgitation was severe. The left-heart catheterization showed normal coronary vessels, with the left ventricle not being entered for fear of tumor embolization. Given the size of the mass and the possibility of serious sequelae, such as obstruction or embolism, the patient consented to and underwent urgent cardiac surgery to resect the mass. An intraoperative TEE confirmed the presence of a large mass within the left atrium. The mass was attached to the interatrial septum slightly inferior to the fossa ovalis and approximately 1 cm from the mitral annulus. The echocardiographic appearance of the large mass was typical for atrial myxoma (Fig 1). The mitral valve leaflets appeared at most mildly thickened. Severe mitral regurgitation was present with an eccentric, posterolaterally directed jet. Again, it was believed that the regurgitation was caused by prolapse of the myxoma across the mitral valve and would resolve with resection of the tumor. The mediastinum was approached through a standard median sternotomy. Both the left and right atrial chambers were enlarged. Bicaval cannulation was used with both cavae encircled and snared. The patient underwent cardiopulmonary bypass (CPB). Cold antegrade cardioplegia was used to arrest the heart. A large, smooth tumor mass with a very broad base was found to occupy much of the left atrial chamber (Fig 2). The base started medial to the fossa ovalis and extended almost to the anterior annulus of the mitral valve. The tumor could not be removed through the left atrium; therefore, an oblique incision was made in the right atrium. The fossa ovalis was identified and opened; the tumor base was medial to this. Via sharp dissection, the tumor was excised by circumferentially dividing the intra-atrial septum around the tumor base. This resulted in a large defect in the septum measuring 4 cm in length and 2 cm in diameter. The medial extent of this was skirting the anterior annulus of the

Background The echocardiographic criteria that have been used to evaluate severity of Ebstein's anomaly in utero are the same as those applied after birth. Objective The objective of this study was to establish prognostic criteria that take into account the peculiarities of the fetal hemodynamics. Method The video recordings of eight fetuses with Ebstein's anomaly were retrospectively reviewed. Results The following indexes had no prognostic significance either on fetal or neonatal outcome: the ratio of functional tricuspid opening over the diameter of the annulus, the degree of displacement of the tricuspid valve opening, and the degree of tricuspid regurgitation. The index of severity (based on the surfaces of right atrium + atrialized right ventricle) and the cardiothoracic ratio had a significant impact only on neonatal survival. The smallest fossa ovalis were found in two fetuses who had hydrops. Fetuses who reached term without problems had higher left ventricular outputs. A positive linear correlation was found between the z score of the left ventricular output and the size of the fossa ovalis ( r = 0.81, p Conclusion The prognosis of Ebstein's anomaly during fetal life is not influenced by criteria described for postnatal life and may be related to factors that control the volume load of the left ventricle. (Am Heart J 1998;135:1081-5.)

• Objective To evaluate the potential utility of transthoracic two-dimensional echocardiography as an aid in the technique of transseptal catheterization. • Design We performed a prospective study of 58 patients (29 men and 29 women; mean age, 64.2 years) referred for cardiac catheterization, in whom a systematic approach was used with selective application of two-dimensional echocardiography. • Material and Methods The study group of 58 patients had the following diagnoses: mitral stenosis in 17, hypertrophic cardiomyopathy in 13, dilated cardiomyopathy in 13, aortic stenosis in 13, and prosthetic valve dysfunction and pulmonary hypertension in 1 each. With use of only fluoroscopic guidance, initial gentle pressure on the dilator alone was attempted for left atrial access. If the catheter resisted entry into the left atrium, two-dimensional echocardiography was performed to assess the catheter's position relative to the atrial septum, and adjustments were made accordingly. Transseptal puncture with a Brockenbrough needle was performed only after confirmation of the catheter position at the region of the fossa ovalis with two-dimensional echocardiography. • Results The catheterization procedure was performed without complication in all 58 patients; the mean time to catheter placement was 5.6 ± 3.5 minutes (range, 3 to 20). Two-dimensional echocardiography was used in 33 patients (57%) when left atrial access was not obtained. On the basis of echocardiographic images, the transseptal catheter had to be repositioned in 16 of these 33 patients (48%). • Conclusion Two-dimensional echocardiography offers value in demonstrating catheter position during transseptal catheterization and may be used in some patients to ensure transseptal puncture at the region of the fossa ovalis.

The normal heart is the size of the patient's closed fist. The venae cavae drain into the right atrium, which bears the fossa ovalis and receives the coronary sinus and the anterior cardiac vein. The atrium empties into the right ventricle through the tricuspid valve. Both ventricles have trabeculated walls (trabeculae carneae), and from some project the papillary muscles, bearing the chordae tendinae attached to the free borders of the tricuspid valve. The same arrangement is seen on the left side. The right ventricle leads to the pulmonary trunk, guarded by its three valve cusps. Oxygenated blood returns to the left atrium via the four pulmonary veins and passes to the left ventricle via the mitral valve. Exit is through the tricuspid aortic valve. The right and left coronary arteries arise above the valves, their orifices lying in the sinuses of Valsava. The right coronary artery lies in the right part of the atrioventricular groove and gives off the posterior interventricular artery. The left coronary arteries divide into the anterior (descending) interventricular branch and the circumflex branch. Major veins accompany the arteries, except for the anterior cardiac vein, which drains directly into the right atrium.