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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 32  |  Issue : 2  |  Page : 134-136

Incidental echocardiographic finding of a membranous ventricular septal aneurysm in an 18-year-old asymptomatic athlete


1 Cardiology Hospital, University Hospital Policlinico of Bari “Aldo Moro”, Bari, Italy
2 Department of Biomedical Sciences and Human Oncology, Clinica Medica “A. Murri”, University Hospital Policlinico of Bari “Aldo Moro”, Bari, Italy

Date of Submission14-Feb-2022
Date of Acceptance14-Mar-2022
Date of Web Publication17-Aug-2022

Correspondence Address:
Paolo Colonna
Cardiology Hospital, University Hospital Policlinico of Bari “Aldo Moro”, Bari 70124
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcecho.jcecho_10_22

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  Abstract 


Membranous ventricular septal aneurysm (VSA) is an uncommon cardiac abnormality, potentially leading to several cardiac complications such as aortic valve prolapse, arrhythmias, and aneurysm rupture. A young competitive soccer player presented for a post-COVID sports cardiology assessment, denying any previous cardiological evaluations. On transthoracic echocardiography, a membranous VSA was incidentally found with no other cardiac abnormality nor hemodynamic impairment associated. A well-oriented anamnesis guided by echocardiographic findings revealed that a ventricular septal defect was diagnosed at birth with spontaneous closure at 4 years old. From that moment, no further follow-up was performed. Before granting cardiological approval to competitive sport, transesophageal echocardiography and Holter electrocardiogram were performed to confirm the absence of interventricular shunt and any other cardiac abnormality or arrhythmias associated with VSA. This case highlights the value of an accurate and comprehensive clinical and echocardiographic evaluation when performing a cardiological sports assessment, even in a young asymptomatic athlete.

Keywords: Asymptomatic competitive sports athlete, congenital heart defect, sports medicine and cardiology, ventricular septal aneurysm, ventricular septal defects


How to cite this article:
Giovannetti G, Tota A, Palmieri VO, Colonna P. Incidental echocardiographic finding of a membranous ventricular septal aneurysm in an 18-year-old asymptomatic athlete. J Cardiovasc Echography 2022;32:134-6

How to cite this URL:
Giovannetti G, Tota A, Palmieri VO, Colonna P. Incidental echocardiographic finding of a membranous ventricular septal aneurysm in an 18-year-old asymptomatic athlete. J Cardiovasc Echography [serial online] 2022 [cited 2022 Oct 3];32:134-6. Available from: https://www.jcecho.org/text.asp?2022/32/2/134/353850




  Introduction Top


Membranous ventricular septal aneurysm (VSA) is an uncommon cardiac abnormality with no accurate incidence rate.[1] It has been reported in association with congenital heart diseases (0.3%), especially with ventricular septal defects (VSDs, 19%).[2] Etiology is often related to the delayed spontaneous closure of VSDs, causing the membranous tissue of the interventricular septum (IVS) to expand under a higher left ventricular (LV) systolic pressure.[3] Generally, this condition is asymptomatic, and clinical examination and electrocardiogram (ECG) fail to expose its presence. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) are the mainstays of diagnosis, showing a thin hyperechogenic membrane bulging into the right ventricular (RV) cavity.[4] Follow-up is crucial since patients may incur cardiac complications, such as aortic valve (AV) prolapse, RV outflow tract (RVOT) obstruction, tricuspid valve (TV) insufficiency, arrhythmias, conduction defects, aneurysm rupture, and bacterial endocarditis.[5] These complications could lead to hemodynamic impairment, requiring surgical intervention.[3]

Herein, we report a case of an incidental finding in a young competitive athlete of a membranous VSA on TTE performed as a post-COVID protocol, according to the Italian Federation of Sports Medicine (FMSI).[6]


  Case Report Top


An 18-year-old male soccer player presented for a post-COVID sports cardiology evaluation. Family history was negative for sudden cardiac death and cardiomyopathies and the patient denied any previous cardiological evaluation. He practiced soccer 6 days per week (about 12 h per week). He was asymptomatic both at rest and during exercise. Heart rate was 65 bpm, blood pressure 105/65 mmHg. On auscultation, grade 1/6 systolic ejection murmur was heard along the left sternal border, which disappeared in orthostasis and after effort. ECG was within normal limits. Maximal stress test (HR max 189 bpm, 93% of predicted) was negative for inducible ischemia and arrhythmias, showing normal chronotropic rate and excellent exercise capacity (METS 12.2 ml O2/kg/min, 96% of predicted).

According to FMSI guidelines,[6] he underwent a TTE which revealed a VSA located at the membranous area, immediately caudal to the right coronary sinus measuring 11 mm × 11.5 mm (neck width and depth, respectively) in parasternal long-axis [Figure 1] and [Video 1] and short-axis view [Video 2]. There was no evidence of an associated shunting with color Doppler technique [Video 3]. There were no signs of RV hypertrophy (right free wall 3 mm), pulmonary hypertension (PAPs: 20 mmHg; pulmonary artery diameter: 23 mm; acceleration time: 125 msec, RV influx: 37 mm; normal RV/LV ratio), aortic insufficiency [Video 4] or other valves regurgitation. Pulmonary-to-systemic flow ratio was normal (Qp/Qs ratio: 1). LV was within normal limits (EDD: 50 mm; IVS: 9 mm; and mass indexed: 88.4 g/m2).
Figure 1: Transthoracic parasternal long-axis view echocardiography showing the membranous ventricular septal aneurysm (arrow) measuring 11 mm × 11.5 mm (neck width and depth, respectively) bulging into the right ventricle. LA, left atrium; LV, left ventricle; RV, right ventricle

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Through a well-oriented anamnesis based on these echocardiographic findings, the patient finally reported that he knew he had a certain type of cardiac abnormality at birth, for which he performed follow-up until the age of 4. At the end of this period, he was told that the problem was solved and his parents decided that no further follow-up was needed. Once acquired the clinical documentation, we verified that a congenital VSD was diagnosed at birth, with spontaneous closure at 4 years old.

Before granting eligibility for competitive sport, further examinations were required. To verify the absence of interventricular shunting and any other cardiac abnormalities, a TEE was required, as it was never previously performed. The presence of membranous VSA measuring 10 mm × 13 mm (neck width and depth, respectively) was confirmed [Figure 2] without signs of intraventricular shunting [Video 5] or AV involvement [Figure 3] and [Video 6]. To exclude arrhythmias, Holter ECG was requested, with no premature ventricular complex found in 24 h.
Figure 2: Transesophageal two-dimensional echocardiography mid-esophageal at 132° showing the membranous ventricular septal aneurysm (arrow) measuring 10 mm × 13 mm (neck width and depth, respectively) and bulging into the right ventricle. AV, aortic valve; LA, left atrium; LV, left ventricle; RV, right ventricle

Click here to view
Figure 3: Transesophageal three-dimensional echocardiography short-axis at 45° at aortic valve level showing the membranous ventricular septal aneurysm (arrow) without aortic valve cusps involvement. LC, left aortic cusp; NC, non-coronary; RC, right aortic cusp; RV, right ventricle; RVOT, right ventricular outflow tract

Click here to view




Finally, according to the Italian Cardiological Guidelines for Competitive Sports Eligibility,[7] eligibility for competitive sports was granted, recommending an annual echocardiographic follow-up except for any clinical change.


  Discussion Top


Membranous VSA is an uncommon cardiac abnormality[1] with few cases reported in the literature among young asymptomatic athletes. It is often associated with VSD and it is mainly a consequence of its natural delayed closure.[2] Careful attention should be paid to distinguish a membranous VSA from a sinus of Valsalva aneurysm, which could follow a more aggressive course, often requiring surgical intervention.[2] Although patients are typically asymptomatic, in a review article[5] among 51 patients with membranous VSA associated with VSD, several potential complications were reported such as AV prolapse (47%), aortic regurgitation (29%), TV insufficiency (17%), arrhythmias (16%), bacterial endocarditis (14%), RVOT obstruction (4%), and aneurysm rupture (2%). High systolic pressure developed during intense sports activity could be a trigger to develop some of these VSA-related complications. Thus, an annual echocardiographic follow-up is needed, especially among athletes.

This is a case of a VSA incidentally detected by TTE on a young asymptomatic competitive athlete. The patient initially denied any previous cardiac problems. Only additional accurate and well-oriented anamnesis, guided by echocardiographic findings, revealed a previous history of spontaneous closure of VSD. This condition requires a careful investigation to establish eligibility for competitive sports. To verify the absence of interventricular shunts, hemodynamic compromise, and AV involvement, TEE should be performed. Holter ECG is also necessary to exclude arrhythmias.

This case highlights the value of collecting an accurate clinical history when performing a sports cardiology evaluation, even in a young asymptomatic athlete. Furthermore, it remarks on the importance of a comprehensive TTE, performed according to the guidelines.[8] Athletes with VSA, regardless of the level of the competition, should pursue an annual follow-up to avoid potential complications, also related to physical activity. Finally, patients and their parents should be warned about potential complications and educated on recognizing their suggestive symptoms.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Acknowledgments

The authors would like to thank Dr. C. D'Agostino (director of Cardiothoracic Department of the Policlinico University Hospital of Bari) and all physicians and nurses of the Cardiothoracic and Sports Medicine Department (Dr. P. Amico, Dr. L. De Michele, Dr. V. Ostuni, Dr. M. Andreani, Dr. M. Ciannarella, Dr. D. Mazzili, M. Rubino).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Naidu A, Ricketts M, Goela A, Shoemaker G, Li S. Incidental discovery of a membranous ventricular septal aneurysm in two dissimilar patients. Case Rep Cardiol 2012;2012:324326.  Back to cited text no. 1
    
2.
Choi M, Jung JI, Lee BY, Kim HR. Ventricular septal aneurysms in adults: Findings of cardiac CT images and correlation with clinical features. Acta Radiol 2011;52:619-23.  Back to cited text no. 2
    
3.
Yavuz S, Eris C, Goncu T, Sezen M, Ata Y, Turk T. An incidental aneurysm of the interventricular membranous septum. Arch Iran Med 2010;13:363-4.  Back to cited text no. 3
    
4.
Mehta NA, Sabzwari SR, Godil S, Akbar G, Dusaj R, Shah N. Ventricular septal aneurysm mimicking right ventricular outflow tract mass in a patient with ventricular septal defect. JACC Case Rep 2020;2:2111-4.  Back to cited text no. 4
    
5.
Yilmaz AT, Ozal E, Arslan M, Tatar H, Oztürk OY. Aneurysm of the membranous septum in adult patients with perimembranous ventricular septal defect. Eur J Cardiothorac Surg 1997;11:307-11.  Back to cited text no. 5
    
6.
Federazione Medico Sportiva Italiana (FMSI) – Post-COVID19 Return to Play Protocols. Available from: https://www.fmsi.it/covid-19/. [Last accessed on 2021 Dec 22].  Back to cited text no. 6
    
7.
Delise P, Mos L, Sciarra L, Basso C, Biffi A, Cecchi F, et al. Italian Cardiological Guidelines (COCIS) for Competitive Sport Eligibility in athletes with heart disease: Update 2020. J Cardiovasc Med (Hagerstown) 2021;22:874-91.  Back to cited text no. 7
    
8.
Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015;28:1-39.e14.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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