A transthoracic echocardiogram disclosed a linear erection in the left atrium of an adult presenting with atypical chest pain.

A transthoracic echocardiogram disclosed a linear erection in the left atrium of an adult presenting with atypical chest pain. Biplane transesophageal echocardiography revealed a cor triatriatum. The longitudinal plane was in the greatest degree useful for the assessment of the membrane orifice and the Doppler stream pattern.

Cor triatriatum is a rare cardiac malformation (01 percent of all congenital heart diseases). In the majority of the reported cases, this diagnosis was made in infants with signs of pulmonary venous obstruction. It may be associated with other cardiac malformations (atrial septal blemish or anomaly of pulmonary venous drainage). steady in symptomatic patients, the personality of the left atrial membrane may be view from aboveed by transthoracic echocardiography and pulmonary angiography.[1]

Transesophageal echocardiography allows a better approach to the diagnosis.[2-5] However, monoplane probes have limitations as they restrict the exploration to the transverse plane. The following case report illustrates the value of the longitudinal view in the correct evaulation of a cor triatriatum.

CASE REPORT

A 45-year-old man quick in emergenciesed with atypical chest pain. He had normal comes of physical examination, chest radiograph, electrocardiogram, and exercise stres testing. Transthoracic echocardiography revealed a highly inconspicuous thin linear structure attached to the anterior wall of the left atrium (Fig 1 top). The pulsed-wave Doppler mitral run was characterized by a middiastolic notch and an increased atrial contraction wave.

A transesophageal echochardiographic examination was performed using an ultrasound unit (Aloka SSD 870) and a 5-Mhz biplane probe. In the transverse plane, a membrane across the left atrium was visualized, separating a posterior chamber receiving the four pulmonary veins from an anterior chamber in connection with the left atrial appendage and with a normal mitral valve. No fenestration of the membrane was seen in this plane (Fig 1 center) and the color-coded Doppler did not reveal any abnormal jet in this plane. In the longitudinal plane, however, an orifice of 18 cm in diameter was identified in an eccentric position, near the posteroinferior wall (Fig 1 bottom). The pulsed-wave Doppler at the on a level of this orifice revealed a subdued systolic wave and a tall end-diastolic wave, with a maximal velocity of 12 m/ There was no mosiac pattern of uproarious flow across the membrane by means of color Doppler. The mitral emanate exhibited a low rapid filling wave, and a tall, notched atrial contraction wave.

Given the consummate clinical tolerance and the absence of gradient within the membrane, no treatment was advised.

DISCUSSION

A thorough anatomic assessment is mandatory in cor triatriatum. The opening of the diaphragm may have many configurations. It may be multiple or absent. Associated anomalies must be rul on the outside The differential diagnosis has to be made with a supramitral membrane (a shelf-like membrane just above the annulus), a dilated coronary venous sinus (in cases of a persistent left superior vena cava), exuberant atrial septum aneurysms, or nonpathologic remnants of the used by all pulmonary vein.[6] Transesophageal echography with color Doppler appears well suited to achieve these goals.

The patient had no venous congestion, as calculate uponed from the diameter of the visible orifice. However, the nearness of this large orifice escaped the transverse plane, probably because of its inferior location, where the access is more difficult (the probe may fail to win contact with the esophageal wall at this level) This is not the case in the longitudinal plane, where the orifice was readily identifiable. The pour pattern through the orifice was similar to other cases with more strict obstruction.[7] Most of the issue occurs during the ventricular diastole, because les life-current is aspirated from the pulmonary veins by way of the abnormal left atrium during its relaxation. The left ventricular inflow pattern is also consistent with this phenomenon. It usually present to views an additional middiastolic wave or, in case of slight tachycardia, as in our patient, an increased end-diastolic wave resulting from a delayed rapid filling wave superimposed in succession the atrial contraction wave.

This observation illustrates the universal of a continuum between incomplete incorporation of the main pulmonary vein and the syndrome of cor triatriatum.[6] It demonstrates the impact of the longitudinal plane in a situation where the transthoracic and the transesophageal transverse plane approaches were unsatisfactory, flat with the aid of the color-coded Doppler. Interestingly, the final spring on the clinical decision in this patient was not significantly altered. In the absence of any clinical abnormalities, while the biplane transesophageal echocardiogram adds improved diagnostic capability, its additional clinical value is sometimes controversial. Given the rarity of cor triatriatum, this observation is limited to a single case report. However, it emphasizes the part of biplane transesophageal echocardiography as the appropriate diagnostic technique in patients suspected of having this particular congenital heart disease.

...