case_images: PMC4386897_01
case_images: (A) Transesophageal echocardiogram in the dorsal decubitus position (0o) showing
  an exuberant atrial septal aneurysm with right-to-left shunt (arrow) evidenced on
  color Doppler and contrast medium flow; (B) Transesophageal echocardiogram on the
  tilt table (60 ) with increased right-to-left flow evidenced on color Doppler and
  contrast medium flow.
case_images: abc-104-01-00e4-g01.jpg
case_images: PMC4386897_01_abc-104-01-00e4-g01.jpg
case_images: f01
case_images: At 60o, the prolapse of the AS aneurysm to the left atrium was maintained, and the contrast flow to the left chambers was immediate and greater than that observed in the decubitus position (Figure 1B).
case_images: Transesophageal echocardiogram after closure of the atrial septal defect, showing
  the occlusion device (arrow), adjacent to the atrial septal aneurysm and
  persistence of the contrast medium flow.
case_images: abc-104-01-00e4-g02.jpg
case_images: PMC4386897_01_abc-104-01-00e4-g02.jpg
case_images: f02
case_images: TEE with agitated saline was repeated and showed a well-positioned device adjacent to the AS aneurysm, with persistence of the right-to-left contrast medium flow at a lower degree than in the previous exam, and almost exclusively associated with the Valsalva maneuver. That flow did not increase at the 60o position on the tilt table; however, a PaO2 reduction from 102 mm Hg to 75 mm Hg was observed (Figure 2).