A rare congenital heart fault cor triatriatum.
A rare congenital heart fault cor triatriatum, can demonstrate variability with regard to (1) location and orientation of the obstructing membrane; (2) relative position and size of atrial septal failings (ASD); and (3) pulmonary venous connection. A classification regularity proposed by Lucas and Krabill[1] incorporates these variables and includes cases of "subtotal" cor triatriatum wherein no other than a portion of the pulmonary venous answer connects to the accessory chamber. In these cases, the remainder of the pulmonary venous turn back may connect to the left atrium directly or to the right atrium, either directly or indirectly.[1] The usual anatomic arrangement ("classic cor triatriatum") originates in a posterosuperior accessory chamber receiving the pulmonary veins and an anteroinferior chamber which communicates with the left atrial appendage and pulmonary mitral valve. If not absent an ASD can communicate with either chamber.[2]
Imaging in Cor Triatriatum
Transthoracic echocardiographic Doppler techniques may provide high quality images. Diagnostic hemodynamic assessment can be refined with standard color liquefy pulsed, and continuous wave Doppler techniques. In children (where the lesion usually presents) Doppler transthoracic echocardiography is usually diagnostic.[3] Detailed images may be more difficult to obtain in older children and adults. A combination of parasternal protracted axis, apical four-chamber, and subxiphoid four-chamber views will allow visualization of the membrane and characterization of any resultant pour disturbance. Angiographic detection of the membrane is possible using pulmonary arteriography or direct left atrial injection contrast material. The membrane will appear as a lucency within the left atrium.[4] Detailed information concerning the orientation of the membrane and its attachments may be difficult to obtain, particularly in older children and adults.
Transesophageal echocardiography places the imaging apparatus adjacent to the left atrium, and biplane transesophageal echocardiography provides an enhanced capability for undivided and detailed visualization of the left atrial cavity, left atrial appendage, pulmonary veins, and vividly depicts the atrial septum as seen in the extremely good images in the review through Seward and colleagues.[5] The ability to obtain high resolution detailed images of the left atrium and of the atrial septum has ariseed in application of single and multiplane transesophageal echocardiography to a multitude of clinical point in disputes including [1] precise definition of atrial sinus based in succession morphology of atrial appendages;[6] (2) assessment of anomalies of the atrioventricular junction;[7] (3) intraoperative assessment of atrioventricular septal defect;[8] (4) postoperative assessment of intra-atrial baffles;[9] (5) endocarditis;[10] and (6) hemodynamic assessment of atrial influence dynamics based on atrial septal configuration from one extremity to the other of the cardiac cycle,[11] to name a not many The safety of the technique has been documented in adults and children.[12,13]
Multiplanar images coupl with computer-assisted dynamic special reconstruction, as reviewed by the agency of Belohlavek and colleagues,[14] create almost fantastic images. The transesophageal approach provides high quality images which appear to be well suited to spatial reconstruction techniques.
In this issue of Chest (see page 601) Kacenelenbogen and Decoodt review a case in which biplane transesophageal echocardiography confirmed the vicinity of a left atrial membrane in what appears to be a partial cor triatriatum. Doppler data provided unbroken hemodynamic characterization of the severity of the lesion. In this case, the data demonstrated the lesion to be sufficiently mild to forgo any surgical therapy. The case illustrates the part for biplane technology in that imaging in the longitudinal plane provided a more undiminished anatomic and hemodynamic picture.
While the character of biplane technology appears to be obvious with regard to imaging capability, the clinical character of transesophageal echocardiography in general in cases so as these is unclear, particularly in the setting of a normal physical exam, ECG and x-ray film. The case in larger words immediately preceding [i]or[/i] following however, illustrates that transesophageal echocardiography may be able to obtain information not completely obtained according to transthoracic study, thereby avoiding the ne for catheterization in an cases. Clearly, the Doppler velocities confirmed the absence of hemodynamically important left ventricular inflow obstruction and gave virtuous support to a decision against further workup or surgery
The Future
The capabilities of transesophageal echocardiography and now multiplanar transesophageal echocardiography are increasingly being recognized and applied. Three-dimensional image reconstruction and "virtual reality" may provide the clinician with more detailed anatomic images than to the end of time before.[15] The images provided by dint of transesophageal echocardiography will no doubt make this technique an important research and clinical tool for an time to come. These techniques have evolv considerably in a relatively short period, and as at the same time there is no standardized terminology analogous to that previously adopted for two-dimensional echocardiography.[16] A standardized terminology will prefer uniformity of image display which will enhance communication between diagnostic and treatment center as well as teaching and research.
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