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Forum Name: Valvular Heart Diseases

Question: Atrial Septal Aneurysm....Aortic Insuffiency


 Guinevere - Sat Feb 01, 2003 12:17 am

Last May I was admiited to the hospital presenting syncope 2x, near passing out episodes for over a year, and seeing stars, upon rising from sitting and laying position.

I am a 30 year old female who has been diagnosed with orthostatic hypotension, and Postural Orthostatic Tachycardia syndrome after 2 postive tilt table tests last May 2002.

They also did an Echo at that time which showed an intra atrial septal aneurysm, a trace of aortic insuffiency and tricuspid regurg. I am aware that everyone has some tricuspid regurg, and that is not very concerning, as long as it stays mild.

However, I am concerned about aortic insuffiency at my age, even if it is only a trace. I should not have any at my age. I am also concerned about the atrial septal aneurysm.

I am a Physician's Asst, and I have heard alot of opinion's from the doctors I work with at the hospital. I have been told that I should not worry about the aneurysm....no big deal. And then another Cardio says, I should be taking a baby aspirin daily, and
that my doctor should find out why I have even a trace of aortic insuffiency at my age.

I had a follow up echo last month, and everything was noted once again, but this time,mitral regurgation was noted as well.

I have had shortness of breath for 2 months, occasional chest tightness, and rapid pulse. Should I be concerned about an atrial septal aneurysm? And aortic insuffiency?

They have not put me on any meds, their advice was too icrease fluid and salt intake to help with my low blood pressure...usually 90/52,
it has gone as low as 60/32
I appreciate any advice you can give me.

My echo from May states...pulmonary artery systolic pressure of 26mmHg
Mild tricuspid regurg was noted at the level of the valve with peak flow velocities reaching 1.8 meters per second.

Flow velocities in the left ventricular outflow tract and across the aortic valve appeared to be within normal limits with peak flow velocities recorded of 1.4 meters per second.

Now my echo from Dec 02 says Ejection fraction is estimated to be about 55%
Interatrial aneurysm appears to be bowing into the right side consistent with interatrial septal aneurysm change.
My pulmonary systolic pressure this time was between 20-25mmHg

Is my ejection fraction normal?
Because of the change from May's echo to Dec regarding that they are saying the aneurysm is bowing into the right side, and there is change, is that serious?
 Dr. Yasser Mokhtar - Wed Feb 05, 2003 10:06 pm

User avatar Dear Guinevere,

Thank you very much for using our website.

The reason an echocardiogram was checked in your case was to find out whether you have any structural heart disease that is causing you to faint. It looks from what you described to me that you had an unremarkable echocardiogram.

More and more people are getting more and more echocardiograms done for reasons like shortness of breath, palpitations, etc... without clinical evidence (e.g murmurs) of structural heart disease. Many of these people have normal hearts. There is an increased incidence of discovering trivial valvular insufficiencies like the ones that you described. If there were no structural abnormalities in your valves described on the echocardiogram, i would totally disregard these findings.

As regards aortic insufficiency, since you are very worried about that, although i believe that what you have is to be ignored (followed up by yearly echo at best for your own reassurance if you are still worried), i will mention some points about aortic insufficiency to you.

The commonest causes of aortic insufficiency are:
1. Rheumatic fever.
You did not mention a history of rheumatic fever and the echo does not show any evidence of that.
2. Bicsuspid aortic valve (although with bicuspid valves stenosis is more common).
Should have appeared on the echo.
3. Infective endocarditis.
No history.
4. Trauma.
Do you have a history of severe trauma to the chest?
5. Other less common causes include
a. Marfan's syndrome. Are you tall and thin?
b. Syphyllis. Ever had syphyllis?
c. Ankylosing spondylitis. Any back stifness?
d. Rheumatoid arthritis. Any symptoms and signs of rheumatoid?
e. Hypertension. You are hypotensive.
f. Other vasculitis syndromes. You can rule them out by just doing a crp or a sed rate.

To be clinically significant, the regurgitant blood should be of a certain quantified volume on the echocardiogram. The most common finding on the echocardiogram for patients with signficant aortic insufficiency is dilated left ventricle.

Your ejection fraction is normal and your pulmonary artery pressure is normal so even if you had clinically siginificant aortic insufficiency, it has not affected your heart yet.

Having shortness of breath with this normal ejection fraction implies that most probably the cause of your shortness of breath is not related to the heart.

Bulging of the atrial septum towards one of the atrium is not an atrial septal aneurysm by definition. The atrial septum should have a certain minimal excursion or bulging to be considered as aneurysmatic. Atrial septal aneurysms have been incriminated in cases of embolic events without an identifiable obvious cause. They are usually associated with other abnormalities that are also incriminated in cases of embolic events without a cause such as a patent foramen ovale. No strong causal relationship was identified between atrial septal aneurysms and patent foramen ovale and stroke but they were found in people who have cryptogenic stroke (or stroke without a cause) and were suggested to be "potential causes". The argument is that they are present in the general population without associated problem. Atrial sepral aneurysm are usually asymptomatic. If you want to investigate this more then the best way to do this is through a tranesophageal echocardiography and an iv agitated saline contrast injection to know what of atrial septal aneurysm you have and whether it is associated with a shunt or not and also to take a better look at your aortic valve.

Having shortness of breath, occasional chest tightness and rapid pulse can be because of the hypotension that you have. i am not sure what was done in addition to the tilt table test to find out the cause of your orthostatic blood pressure such as look for adrenal insufficiency. Are you taking any herbal supplements or any medications that could lower the blood pressure?

This is a very long answer. i hope that i have not lost track of what i was supposed to tell you. Bottom line, not to worry. This is a more or less unremarkable echocardiogram. If you are still really worried, then check some blood work to make sure that you do not have any of the very rare causes of aortic insufficiency (if you have symptoms to suggest that you have any of the causes), otherwise, if you want to be cautious, follow-up this echocardiogram in a year's time. This is my advice to you putting in mind that i have not examined you.

Once more, thank you very much for using our website http://doctorslounge.com and i hope that this information helped and if you still have questions that have not been answered, do not hesitate to post them immediately.

Yasser Mokhtar, M.D.
 Anonymous - Thu Feb 06, 2003 12:51 am

[quote="Yasser Mokhtar, M.D."]Dear

I followed up with my Cardiologist today, and he said I do have an atrial septal aneurysm, and it is bowing toward right atrium, he wants me to take a baby aspirin a day.

He said that there is a higher incidence of stroke with ASA and when combined with PFO's-patent foramen ovale. However, I was seen at The Cleveland Clinic and they did a bubble study, and they said there was no evidence of PFO.

He also said my tricuspid valve has mild regurg, but many people have minimal leakage of this valve.
He also said, that my mitral valve has mild regurg, and he is not sure whether it is associated with MVP. He said there was no significant appearance of mitral valve prolapse. At age 16 I was diagnosed with MVP, but my family doctor in later years had said I outgrew it.
So my cardiologist said he would keep his eye on it.


He also said I had mild
aortic insuffiency (regurg) and he was concerned and that I should not have any at my age. He did say it could possibly give way to Aortic stenosis in my 70's or 80's.


I told him that over the last month, I have had extreme exhaustion, weakness and short of breath at rest and at bedtime, combined with chest pain. All other tests have been done to rule out noncardiac issues. Recently I had crushing pain down my left arm, which has never happened before.


Also, when I awake, when my eyes open in the morning, my vision goes black, like I am going to pass out.
This is when I am still laying down, and have not even gotten up yet. When this happens, my pulse is at a crawl, Bradycardia, I am assuming. He was quite concerned about this, because I do have moderate sinus arrythmia. He ordered a stress test and a 48hour holter monitor.


He wants me to take my BP with a manual cuff when this happens. My BP has gone as low as 60/32 in the past. The only tests that were done to define my hypotension were adrenal bloodwork, and Tilt.


Cleveland Clinic wants me to come back up for Hemodynamic tests. Cleveland Clinic suggested I may have hypokinetic heart syndrome....do not know what that is? They also wondered if I had a early mild form of peripheral autonomic insuffiency...do not understand that either. If you can shed any light on those, it would be appreciated.


He said my echo was pretty clear, because I am 139lb and he does not foresee a TEE procedure anytime soon, unless a neg. stress test.
I have never had any of the things you stated in your post that would cause aortic insuffiency.

However, I have had repeated strep throat infections, with 3 documented last year alone. So, as far as rheumatic fever, I am sure I would have known, I had that. also had a root canal on a first molar done 2 years ago, I did not follow up and get a crown. The tooth broke a year and a half ago, and it became infected.

I did not have it pulled, and neglected it. I recently went to the oral surgeon, and he has just gotten clearance to pull it with prior antibotic therapy. My one concern is I had Bronchiectisis for 6 years, with repeated medrol use and antibiotics. My body is practically immune to pencicillin, amoxyl, and the like. The last time I had strep, after a week of anitbiotic therapy, it had not helped. How do I know, it will protect my heart with this oral procedure?


You stated:'' If there were no structural abnormalities in your valves described on the echocardiogram, i would totally disregard these findings."
What kind of structural damage are you referring to?

You also stated " No strong causal relationship was identified between atrial septal aneurysms and patent foramen ovale" I did some research over the last year reg. this topic, and the journal studies I looked at stated otherwise, they said that when ASA and PFO are combined that there is a higher incident of TIA.
I hope to hear from you again, thank you for your time. I appreciate it.
guinevere
 Dr. Yasser Mokhtar - Thu Feb 06, 2003 1:57 am

User avatar Dear Guinevere,

Thank you very much for the update.

About atrial septal aneurysm and patent foramen ovale and the risk of stroke. There were no patients who were followed because they had asa and/or pfo and then they devellopped a stroke, patients had strokes and there was no explanation for their stroke and during the search for a cause asa and/or pfo were found. i am not saying they are not related, they could very well be, but a sure causal relationship has not been proven yet. About my quote, you did not complete the quote till the end which is "No strong causal relationship was identified between atrial septal aneurysms and patent foramen ovale and stroke but they were found in people who have cryptogenic stroke (or stroke without a cause) and were suggested to be "potential causes". ". Taking an aspirin a day i hope is not something harmful for you and you can continue taking that if it does not cause you any problems.

Regarding hypokinetic heart syndrome. i have not heard about it unless it is a fancy name for a common condition.

About you taking steroids for bronchiectasis, if you have taken those for a while and then stopped them suddenly you might have adrenal insufficiency and this could be the reason behind your orthostatic hypotension. What is the cause of your bronchiectasis?

About the autonomic neuropathy, there are two types of nerves in our body, the ones that we can control like the nerves going to our muscles and the nerve that carry sensations and there the nerves that control the involuntary functions of the body like heart beating and movements of the stomach, etc... When these nerves are destroyed, then the control of these functions fail. One of the functions of these nerves is holding blood pressure by vasoconstricting the arteries when the person stands up and the blood is shifted downwards by gravity. If the nerves are desroyed then the patient develops hypotension when he stands up (orthostatic hypotension).

About aortic stenosis in the old age, this is a not uncommon occurrence in the elderly and many of them require valve replacement and it is related to degenerative changes of the valve because of age.

The structural abnormalities that i was referring to are fibrosis or valves with 2 cusps (not 3) or destruction by previous rheumatic fever, that type of thing.

The chest pain that you are describing could be worrisome, so i guess having a stress test is not unreasonable. Although, if you do not have any major risk factors, the results of the stress test most probably will be negative especially that you are a 30 years old female, naturally protected from heart disease by your hormones unless you have strong risk factors such as a first degree relative with heart disease, smoking, diabetes or high cholesterol. If the stress test came back negative i would encourage you to do an x-ray of the neck as sometimes neck stiffness and arthritis of the neck can give symptoms to chest pain radiating to the arm or neck and even back.

If you have structural heart abnormalities like the ones i have mentionned, then you have to protect your heart against bacteria that gets access to the blood and the commonest way the bacteria gets to the blood is throguh the mouth and teeth, gastrointestinal tract and genitourinary instrumentation. You have to be given antibiotic prophylaxis in that case and this can be always through your cardiologist if he thinks that you need it.

Once more thank you very much for using our website http://doctorslounge.com and i hope that this information helped and i really enjoyed this conversation and please, feel free to update me and if you have any questions please post them immediately.

Yasser Mokhtar, M.D.
 Anonymous - Fri Feb 07, 2003 5:10 pm

I had blood work done to rule out adrenal insuffiency. My doctor said the tests came back negative-no adrenal insuffiency.

I had Bronchiectisis for many years, one infection of bronchitis and or pneumonia after another. I have gone through over at least 50 to 60 courses of antibiotics in the last 6 years.

The only thing that works is Levaquin. Amoxil and any form of pennicillin-I do not respond. I am allergic to the enitre Eurythromycin class of drugs, so I can not take those.

They are not sure what caused the bronchiectisis, but my dad was a heavy smoker, and I moved out when I was 25 years old. So his smoking may have been a major contributing factor. My grandfather died of lung cancer, he also was a heavy smoker.

I find it odd though, that as a child, I only got occasional colds, with sore throat. I never had bronchitis or any lung issues until my middle 20's. Until that time, my health was impecable!

I worked in the Pathology dept at a hospital for a year, and that is the time I started to have all the problems with my lungs. A good friend of mine who is a doctor, suspects I may have been exposed to something in the Pathology dept, that may have contributed. However, I find that rare. I would like your thoughts on that.

My father has had 2 heart attacks, and he is only 56 years of age. He has heart damage from the first one, and has 2 or 3 stents as well.
He also has high BP. He is not overweight.

My mom has had 2 episodes of atrial phib with successful cardioversion.
She is on high doses of coumadin.
She also is 56 years old, and she is overweight-210lb's
Is atrial phib hereditary?

I think my dad's heart attack and high BP happened because of his lifestyle.He smokes Lucky Strike nonfilter ciggarettes since he was 9 years old, and he is an alcoholic, he has been drinking since he was 11 years old.

I do not believe I am in any way a candidate for heart disease. I excercise regularly, and eat well, I do not smoke or drink. I would not say that heart disease runs in our family. I truly believe that if my dad did not smoke and drink, he would not have the issues he has today.

In regards to your statements about peripheral autonommic insuffiency, does this refer to Lupus, Multiple Sclerosis, etc? Is that why Cleveland Clinic want to do Hemodynamic tests to rule any autonomic disorder out?

My main concern is when I awake in the morning, and my eyes open, my vision goes black, and my pulse is in a state of bradycardia.
I am concerned I am not getting enough oxygen when I sleep. I am not sure why that happens.
This has been going on for 2 years, and has gotten worse.

I also started having episodes during the day where my right eye would go completely blurry. I went to the opthamologist and he said my eyes were fine, and he believed I was not getting enough blood and oxygen to the brain and eyes.
He told me to get my blood gases checked, they still need to check that. However, I am scared about getting blood taken from my artery, to check that.

Perhaps you could share your thought on that as well.

Thanks again!
 Dr. Yasser Mokhtar - Sun Feb 09, 2003 1:22 pm

User avatar Dear Guinevere,

Thank you very much for using our website.

By now, i guess that you already know what is bronchiectasis. It is permanent dilatation and destruction of the bronchi leading to infections leading to more dilatation and destruction of the bronchi and lung.

Bronchiectasis has many causes including:
1. Infections with viruses (influenza virus for instance) and many bacteria. Your first attack of pneumonia could be the one that initiated the whole thing.
2. Congential (you are born with it). Many mechanisms could cause that.
3. Aspiration of stomach acid (ever lost consciosness??).
4. Exposure to certain toxic gases (you worked in lab for a while).

Sometimes, doctors start patient on antibiotics like the first ten days of each month as preventive measures against recurrent infections. Some doctors agree to it and some not. The reason that the antibiotics that you mentionned are not doing the trick is because the bugs that cause the infection in your lungs most probably developed resistance to them, so they became ineffective.

About heart disease, if your dad had his first heart attack before the age of 50 years then you have a family history of coronary disease meaning that you as a person has a higher chance than any person (whose father did not have a heart attack before 50). The lifestyle that you mentionned (eating healthy, exercsing) is a very good one. You have to continue to live it. i do not think that atrial fibrillation is hereditary.

About autonomic neuropathy, it can be caused by lots of things, if you were diagnosed with it, then the doctors will have to find out what caused it.

Let me ask you if you take any medications or herbal remidies that you have not mentionned before.

Now to your questions about blackening of vision when you wake up, if you have when you wake up and try to stand up then you feel that your vision is going black, this is related to the orthostatic hypotension that you have. If not, i do not have any explanation that comes to my mind for the time being.

About bradyacardia, it is normal that you have slow heart rate while you are asleep and the lowest is usually immediately before you wake up because this is the time of the night where the parasympathetic nervous system (the one that causes your heart to be slow is at the top of its activity).

About your concern that you might not be getting enough oxygen during sleep, this could be a possibility especially that you have a chronic lung disease. About this causing the blackening of vision in the morning, i can not really say that i ever heard of it as the results of night time hypoxia are well known and their effect is on:
1. Heart (in the form of pulmonary hypertension. Your echo showed normal pulmonary pressures)
2. Energy level (feeling tired and sleeping during the day a lot).
3. Developing hypertension (you have hypotension).
4. Others.

About the right blurring during the day, the opthalmologist who examined could have given you the right explanation.

Abou the blood gases, it is considered a very safe procedure and it is done daily to lots and lots of patients.

Once more thank you very much for using our website http://doctorslounge.com and waiting for your reply.

Yasser Mokhtar, M.D.
 Guinevere - Mon Sep 20, 2004 2:21 am

My mother is 57 years old, 5ft 3' 210lb with no prior health issues till 3 years ago.
Three years ago, she was diagnosed with her first episode of atrial She was prescribed coumadin, and she had her first successful cardioversion. She has never had high blood pressure until her first episode of atrial fib. She had her second episode of atrial fib last year, followed by another successful cardioversion- but they had to shock her twice to get her heart back in rythym.

She had a recent echo showing moderate regurg in her mitral valve, and they prescribed her lisinipril. She took it for one month and had many side effects. ( Coughing to gagging and throwing up, extreme fatigue)
They stopped the Lisinipril, and 3 days later she was told she is in atrial fib. again. Her blood pressure was very high 173/80 at the time she was checked. We tend to think that the Lisinipril may have caused her to go back into atrial fib, because her heart and BP have been very good since last cardioversion. Wondering what you think.
After they told her that she was in a-fib again, they put her on 2 Metoprol a day, well, she had extreme fatigue, and her legs were so heavy she could hardly walk. They immediately cut the dosage to 1 pill a day.
They have now prescribed her Cardiazem, and she takes Metoprol, lasix, and Coumadin and Potassium as well.
Today she had a warm tingiling behind her ears and pain in her head, and she complained of alot of jitters. We checked her BP and it was again 173/84, pulse 104. She called Cardiologist and he said to take 1/2 Metoprol and that should bring it down, and it did.
I am very concerned about her, I do not want to see her get lost in the system.
You are very thorough and I appreciate any wisdom you can shed on this.
Thank you for your help in the past.
She is scheduled this friday for her Cardioversion
 Dr. Yasser Mokhtar - Fri Sep 24, 2004 11:06 pm

User avatar Dear Guinevere,

Was the cause behind atrial fibrillation ever sought? Were thyroid function tests done? Does she have lung disease? Any reason for the lasix (i assume it is used for treating high blood pressure)? Has a magnesium level checked? Does potassium level get checked every time she develops atrial fibrillation? Did the echo suggest that she might have coronary disease? What was the left atrial size on the echo?

Atrial fibrillation can be caused by several things including
1. Increased activity of the sympathetic nervous system which can be caused by stress, a hyperactive thyroid gland or a tumour of the adrenal gland called pheochromocytoma.
2. Heart disease including hypertension and coronary disease.
3. Lung disease.
4. Electrolyte imbalance.
5. No known etiology, called Lone atrial fibrillation.

If the atrial fibrillation has a treatable cause, then it is going to be of extreme difficulty to keep her in sinus rhythm without treating the cause. The cause has to be treated first.

Since there is a correlation between her blood pressure being high and developing atrial fibrillation, i think there are two possibilities.
1. Your mother has high blood pressure and is not adequately controlled and since your mother's heart is not accustomed to such high blood pressure, her heart goes into atrial fibrillation.
2. There is one thing that causes both of them every time and this can be explained by a tumour of the adrenal gland called pheochrmocytoma. High blood pressure in this case comes in attacks and otherwise, the patient does not have any problems. The attacks are usually associated with sweating, tremors, headaches and pallor. This is a long shot because metoprolol should have caused worsening of the blood pressure if this was the case, but i think it is worth it to check for its presence or absence.

If the left atrial size on the echo is increased upto 5 cm (50 mm), the chances of your mother remaining in sinus rhythm are not high and every time cardioversion is performed, your mother will go back into atrial fibrillation.

If the left atrial size is normal and your mother does not have a cause for atrial fibrillation and every time she is cardioverted, she flips back to atrial fibrillation once more, i think it will be beneficial if she is started on an antiarrhythmic medication to help her stay in sinus rhythm.

i am not sure what kind of work-up besides the echo was done, but let me recommend some tests i think should be done if they were not done.
1. Thyroid function tests.
2. Electrolytes including magnesium, calcium and phosphorus levels at the time of atrial fibrillation.
3. Work-up for pheopchromocytoma if her doctor thinks that this is a reasonable thing to do as checking for this tumour is not easy and i think is not cheap as well.

Thank you very much for using our website http://doctorslounge.com and i hope that this information helped.

Yasser Mokhtar, M.D.
 Guinevere - Sat Oct 16, 2004 2:02 am

They do not no why she has atrial fib
She does not have lung disease
She has had her thyroid checked and it is normal
We will ask her doctor to check magnesium and potassium, and her adrenal glands.

However, I am very concerned about my mom....I just got the results from her last echo, and the doctor had told her it was normal. Today she went into the hospital to have her cardiversion, and this is her third one in 3 years.

This cardioversion did not work, she is still out of rythym, they even went as high as 200 joules, they tried 3 times, but it did not work.

While we were there, I had a chance to look at her chart, and I saw her echo report.

It states they noted
Mild Left ventricle hypertrophy
Moderate Tricuspid and Mitral regurgatation
Small area of Anterior and Posterior Pericardial Effusion
And her ejection fraction was greater than 50%

Because this time she did not have a succeful cardioversion they are sending her back to the Doctor next week.
She has been on Toprol, Lasix, Potassium, 10mg of Coumadin a day,
and Cardiazem.
She previously took Lisinipril and had adverse effects to it.

Now they are saying they may try another arrythmic drug instead of the Toprol.

With her results reg. her Echo, should she be concerned?
She is 5"3 and 205lbs and 58 years old

Are her results a sign of congestive heart failure?

Thanks for your time!!!!
jenn

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