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A 75 year old man was admitted to the hospital for elective coronary artery bypass grafting (CABG). He had a history of stable coronary artery disease for five years but he complained of angina at rest during the last two months. Coronary angiography revealed severe stenosis of the proximal left anterior descending artery, which was not suitable for angioplasty. He also had chronic atrial fibrillation, but was not receiving any anticoagulation. His medications were aspirin, β blockers, and nitrates. Transthoracic echocardiography showed good left ventricular function with mild dilation of both atria. Before the CABG a transoesophageal probe was inserted for routine cardiac function evaluation. A large echogenic mass in the right atrium (panel A) and a secundum atrial septal defect with biphasic flow were detected (panel B). The mass was at first thought to be a large thrombus or myxoma attached to the atrial septum. After bolus injection of normal saline in the right jugular vein, intra-atrial shunt was excluded (panel C) and a giant atrial septal aneurysm with automated contrast and low flow through the patent foramen ovale was revealed. The diagnosis was subsequently confirmed when the patient’s blood pressure fell, the automated contrast disappeared, and the aneurysm wall was clearly seen (panel D). The aneurysm was resected and CABG was performed.
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