Can abnormal septal motion on echocardiogram (echo) be an incidental finding in an asymptomatic patient?

Abnormal Septal Motion on Echocardiography in Asymptomatic Patients

Abnormal septal motion on echocardiography in an asymptomatic patient without other findings can indeed be an incidental finding and does not necessarily indicate pathology requiring intervention.

Understanding Abnormal Septal Motion

Abnormal septal motion (including paradoxical septal motion) can occur due to various causes, both pathological and non-pathological:

Common Non-Pathological Causes:

• Post-cardiac surgery: One of the most common causes of abnormal septal motion is previous cardiac surgery. A large study of 3,292 cases showed that paradoxical septal motion is frequently observed after cardiac surgery, particularly valve surgery 1.
• Conduction abnormalities: Conditions like left bundle branch block or Wolff-Parkinson-White syndrome can cause abnormal septal motion due to altered electrical activation patterns 2.
• Post-pericardiotomy: Evidence suggests that excessive anterior cardiac mobility due to pericardiotomy rather than myocardial ischemia can cause paradoxical septal motion 3.

Pathological Causes (requiring further evaluation):

• Right ventricular volume overload: Conditions like atrial septal defect
• Cardiomyopathies: Particularly those affecting the septum
• Previous myocardial infarction: Especially anteroseptal infarctions 4
• Pulmonary hypertension

Clinical Approach to Abnormal Septal Motion in Asymptomatic Patients

Initial Assessment:

1. Review patient history: Look for:

   • Previous cardiac surgery
   • Known conduction abnormalities
   • Previous myocardial infarction
   • Congenital heart disease

2. Evaluate other echocardiographic parameters:

   • Left and right ventricular size and function
   • Valve function
   • Septal thickening (preserved septal thickening with abnormal motion suggests non-pathological cause)
   • Presence of other structural abnormalities

Management Algorithm:

1. If isolated finding with normal septal thickening and no other abnormalities:

   • Likely an incidental finding, especially if there's history of cardiac surgery
   • No specific follow-up required beyond routine care

2. If accompanied by other abnormal findings:

   • Further evaluation based on specific findings
   • Consider stress testing if concerned about coronary artery disease

3. If uncertain:

   • Compare with previous echocardiograms if available
   • Consider ECG to evaluate for conduction abnormalities
   • Follow-up echocardiogram in 6-12 months to assess for changes

Evidence-Based Considerations

The American College of Cardiology/American Heart Association guidelines do not recommend routine echocardiography for risk assessment in asymptomatic adults without clinical evidence of heart disease 5. This supports the concept that isolated abnormal findings on echocardiography in asymptomatic patients may not warrant extensive evaluation.

According to the ACC/AHA guidelines for clinical application of echocardiography, echocardiography is not indicated for asymptomatic patients with a low probability of heart disease 5. This suggests that in the absence of symptoms or other clinical findings, isolated abnormal septal motion may not require further investigation.

Important Caveats

• Septal thickening: Assess whether septal thickening is normal despite abnormal motion. Normal thickening with abnormal motion suggests a mechanical or electrical cause rather than ischemia 1.

• Context matters: In patients with anteroseptal myocardial infarction, abnormal septal motion and thickening are associated with higher complication rates and mortality 4, highlighting the importance of clinical context.

• Conduction abnormalities: If abnormal septal motion is accompanied by conduction abnormalities like left bundle branch block, the pattern of septal motion may correlate with left ventricular function 6.

In conclusion, while abnormal septal motion can indicate significant cardiac pathology, in an asymptomatic patient with no other abnormal findings, it is often an incidental finding that does not require specific intervention, particularly if there is a history of cardiac surgery or known conduction abnormality.