International Journal of Cardiology 180 (2015) 262–263
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
A three-dimensional echocardiographic approach to cor triatriatum Alexandros Briasoulis ⁎, Shikha Sharma, Luis Afonso Division of Cardiology, Detroit Medical Center, Wayne State University, USA
a r t i c l e
i n f o
Article history: Received 14 November 2014 Accepted 23 November 2014 Available online 27 November 2014 Keywords: Cor triatriatum Left atrium Three-dimensional echocardiography
A 58-year-old African American male with past medical history of hypertension presented with acute ischemic stroke of left middle cerebral artery supplying the left corona radiata. A transthoracic echocardiogram (TTE) demonstrated left atrial dilatation with a transverse septation across the mid-left atrium with no turbulence appreciated between superior and inferior left atrial chambers on color flow Doppler or spectral Doppler mapping. 3D echocardiography was applied to further describe the left atrial structure. An asymmetric crescent shaped membrane with an ovoid orifice and a transverse diameter of 3.0 cm was seen dividing the left atrial (Fig. 1). The communication between anterior–inferior and posterior–superior chambers of the left atrium was through this single ovoid orifice. Pulmonary veins were noted to be draining into the posterior superior chamber. No evidence of an interatrial communication was found. No obstruction was noted at that level on color flow or spectral Doppler mapping. These findings were consistent with fenestrated cor triatriatum (CT) sinister without a transmembranous gradient. A 23-year-old Caucasian female presented with increasing fatigue and exertional shortness of breath for a year. She was referred for a cardiac MRI which showed a septation in the left atrium. To further define the structure a transesophageal echocardiogram (TEE) showed an incomplete septation which was seen coursing diagonally across right superior atrium and appeared to enclose the confluence of the right pulmonary veins but not the left pulmonary veins which were identified draining unimpeded into the left atrium. Findings were consistent with a nonobstructive atypical cor triatriatum across the left atrium (Fig. 1).
⁎ Corresponding author at: Division of Cardiology, Detroit Medical Center, Wayne State University, Detroit, MI 48201, USA. E-mail address: [email protected] (A. Briasoulis).
http://dx.doi.org/10.1016/j.ijcard.2014.11.172 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
Cor triatriatum is among the rarest of all congenital cardiac anomalies (0.1–0.4% of all congenital cardiac malformations) and is often a hemodynamically mild incidental finding [1,2]. The membrane of cor triatriatum appears as a linear echo bisecting the left atrium, into an upper chamber (embryonic common pulmonary vein) containing the pulmonary veins and a lower chamber (embryonic left atrium) leading to the mitral inflow tract. Color flow mapping usually demonstrates mild increases in velocity, suggesting minimal obstruction [3]. Cor triatriatum can be classified on the basis of the number and size of the openings in the anomalous membrane, and the location of membrane into cor triatriatum sinister in the left atrium and triatriatum dexter in the right atrium. Adults with cor triatriatum most frequently present with dyspnea, hemoptysis, and orthopnea which may be related to development of supra mitral inflow obstruction, mitral regurgitation, pulmonary hypertension or atrial fibrillation. In our cases, we demonstrated that cor triatriatum and its relation with the atrial structures, as well as the location and size of the orifice can be accurately assessed with transthoracic and transesophageal 3D echocardiography. Assessment of cor triatriatum with transthoracic or transesophageal echocardiography offers additional anatomical and physiologic information compared to CT of MRI. Management of cor triatriatum depends on the grade of obstruction between the chambers. Surgery is generally reserved for those patients with significant obstruction. No acknowledgments declared. No funding for the current work. No ethical approval needed. Conflict of interest No conflicts of interest declared. References [1] G. Niwayama, Cor triatriatum, Am. Heart J. 59 (1960) 291–317. [2] J. Marin-Garcia, R. Tandon, R.V. Lucan Jr., J.E. Edwards, Cor triatriatum: study of 20 cases, Am. J. Cardiol. 35 (1975) 59–66. [3] C. Melzer, T. Bartel, S. Müller, F.X. Kleber, G. Baumann, Dynamic three-dimensional echocardiography in the assessment of cor triatriatum, Clin. Cardiol. 20 (1997) 82–83.
A. Briasoulis et al. / International Journal of Cardiology 180 (2015) 262–263
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Fig. 1. (1a & 1b) Transthoracic echocardiogram showed a transverse septation across the mid-body of the LA with no turbulence seen between superior and inferior LA chambers on color flow Doppler. (1c & 1d) Real time 3-dimensional transthoracic echocardiogram and cropped full volume acquisitions confirmed the presence of an asymmetric crescent shaped membrane across left atrium with an ovoid orifice demarcating site of communication between atrial chambers. (1e) 3-dimensional transesophageal echocardiogram full volume crop showing the left atrial septation with the ostium of the right pulmonary vein on the background. Abbreviations: CT; cor triatriatum, LPV; left pulmonary vein, and RPV; right pulmonary vein.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
A three-dimensional echocardiographic approach to cor triatriatum Alexandros Briasoulis ⁎, Shikha Sharma, Luis Afonso Division of Cardiology, Detroit Medical Center, Wayne State University, USA
a r t i c l e
i n f o
Article history: Received 14 November 2014 Accepted 23 November 2014 Available online 27 November 2014 Keywords: Cor triatriatum Left atrium Three-dimensional echocardiography
A 58-year-old African American male with past medical history of hypertension presented with acute ischemic stroke of left middle cerebral artery supplying the left corona radiata. A transthoracic echocardiogram (TTE) demonstrated left atrial dilatation with a transverse septation across the mid-left atrium with no turbulence appreciated between superior and inferior left atrial chambers on color flow Doppler or spectral Doppler mapping. 3D echocardiography was applied to further describe the left atrial structure. An asymmetric crescent shaped membrane with an ovoid orifice and a transverse diameter of 3.0 cm was seen dividing the left atrial (Fig. 1). The communication between anterior–inferior and posterior–superior chambers of the left atrium was through this single ovoid orifice. Pulmonary veins were noted to be draining into the posterior superior chamber. No evidence of an interatrial communication was found. No obstruction was noted at that level on color flow or spectral Doppler mapping. These findings were consistent with fenestrated cor triatriatum (CT) sinister without a transmembranous gradient. A 23-year-old Caucasian female presented with increasing fatigue and exertional shortness of breath for a year. She was referred for a cardiac MRI which showed a septation in the left atrium. To further define the structure a transesophageal echocardiogram (TEE) showed an incomplete septation which was seen coursing diagonally across right superior atrium and appeared to enclose the confluence of the right pulmonary veins but not the left pulmonary veins which were identified draining unimpeded into the left atrium. Findings were consistent with a nonobstructive atypical cor triatriatum across the left atrium (Fig. 1).
⁎ Corresponding author at: Division of Cardiology, Detroit Medical Center, Wayne State University, Detroit, MI 48201, USA. E-mail address: [email protected] (A. Briasoulis).
http://dx.doi.org/10.1016/j.ijcard.2014.11.172 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
Cor triatriatum is among the rarest of all congenital cardiac anomalies (0.1–0.4% of all congenital cardiac malformations) and is often a hemodynamically mild incidental finding [1,2]. The membrane of cor triatriatum appears as a linear echo bisecting the left atrium, into an upper chamber (embryonic common pulmonary vein) containing the pulmonary veins and a lower chamber (embryonic left atrium) leading to the mitral inflow tract. Color flow mapping usually demonstrates mild increases in velocity, suggesting minimal obstruction [3]. Cor triatriatum can be classified on the basis of the number and size of the openings in the anomalous membrane, and the location of membrane into cor triatriatum sinister in the left atrium and triatriatum dexter in the right atrium. Adults with cor triatriatum most frequently present with dyspnea, hemoptysis, and orthopnea which may be related to development of supra mitral inflow obstruction, mitral regurgitation, pulmonary hypertension or atrial fibrillation. In our cases, we demonstrated that cor triatriatum and its relation with the atrial structures, as well as the location and size of the orifice can be accurately assessed with transthoracic and transesophageal 3D echocardiography. Assessment of cor triatriatum with transthoracic or transesophageal echocardiography offers additional anatomical and physiologic information compared to CT of MRI. Management of cor triatriatum depends on the grade of obstruction between the chambers. Surgery is generally reserved for those patients with significant obstruction. No acknowledgments declared. No funding for the current work. No ethical approval needed. Conflict of interest No conflicts of interest declared. References [1] G. Niwayama, Cor triatriatum, Am. Heart J. 59 (1960) 291–317. [2] J. Marin-Garcia, R. Tandon, R.V. Lucan Jr., J.E. Edwards, Cor triatriatum: study of 20 cases, Am. J. Cardiol. 35 (1975) 59–66. [3] C. Melzer, T. Bartel, S. Müller, F.X. Kleber, G. Baumann, Dynamic three-dimensional echocardiography in the assessment of cor triatriatum, Clin. Cardiol. 20 (1997) 82–83.
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Fig. 1. (1a & 1b) Transthoracic echocardiogram showed a transverse septation across the mid-body of the LA with no turbulence seen between superior and inferior LA chambers on color flow Doppler. (1c & 1d) Real time 3-dimensional transthoracic echocardiogram and cropped full volume acquisitions confirmed the presence of an asymmetric crescent shaped membrane across left atrium with an ovoid orifice demarcating site of communication between atrial chambers. (1e) 3-dimensional transesophageal echocardiogram full volume crop showing the left atrial septation with the ostium of the right pulmonary vein on the background. Abbreviations: CT; cor triatriatum, LPV; left pulmonary vein, and RPV; right pulmonary vein.
