There is a significantly higher incidence of
cerebral ischemia among patients with an atrial septal
aneurysm and/or a
patent foramen ovale. According to the information provided by modern diagnostic procedures--and in particular by transesophageal echocardiography--two pathogenic mechanisms should be considered as possible causes of the
cerebral ischemia. Thrombi may develop locally in the left atrium or atrial septal
aneurysm and lead to embolization or, alternatively, thrombi from the inflow region of the inferior vena cava may become trapped in the atrial septal
aneurysm and pass through the
patent foramen ovale to bring about embolization in the arterial bloodstream. Current treatment consists of life-long anticoagulation with
coumarin derivatives in order to prevent further neurological complications. With this treatment, however, the risk of producing
hemorrhages cannot be regarded as trivial, especially in old people. Surgical intervention with the insertion of a button device has so far only been attempted in a few isolated cases, and it is in any case no use if there is only an atrial septal
aneurysm without a
patent foramen ovale. As an alternative to administering
anticoagulants for the rest of the patient's life, we operated on five cases of atrial septal
aneurysm with
patent foramen ovale followed by the appearance of
cerebral ischemia. As with the surgical treatment of
atrial septal defects in general, the risk of the operation (or of subsequent complications) is very slight indeed. No such problems arose in any of our patients, no
blood transfusions were necessary, and after short postoperative treatment they could all be discharged. For younger patients with little risk from the treatment itself, we regard surgical intervention in cases of atrial septal
aneurysm with a
patent foramen ovale and
cerebral ischemia as an important therapeutic alternative.