Cor Triatriatum Dexter With a Sinus Venosus Atrial Septal Defect in a 50-Year-Old Woman: A Case Report

The diagnosis of atrial septal defect (ASD) may be delayed until adulthood or even later in life as it is a well-tolerated congenital heart disease. If patients are not examined and investigated well in childhood, the diagnosis may be delayed until later in adulthood when patients present with palpitations and sometimes dyspnea due to the right chambers dilatation from right ventricular volume overload. In this report, we present a case of a 50-year-old female patient with symptoms of heart failure and atrial fibrillation who was found to have dilated right cardiac chambers, dilated pulmonary artery, severe tricuspid regurgitation, pulmonary hypertension, and a pulmonary-to-systemic flow ratio (Qp/Qs) of more than 1.5 by transthoracic echocardiography and Doppler, indicating left to right shunt at the atrial level. However, transthoracic echocardiography could not visualize the defect, and two-dimensional (2D) transesophageal echocardiography was done in this patient and documented the presence of a sinus venosus ASD with an incomplete cor triatriatum dexter membrane; all four pulmonary veins were identified going to the left atrium. Since the presence of an incomplete cor triatriatum dexter membrane (despite causing no symptoms) makes the percutaneous closure of the sinus venosus ASD and the percutaneous repair of tricuspid regurgitation very difficult, we decided to advise surgical ASD closure and tricuspid valve repair for the patient.

Partial Venous Inflow Occlusion under Mild Hypothermia for Membranectomy in a Dog with Cor Triatriatum Dexter

Cor triatriatum dexter (CTD) is an uncommon congenital cardiac anomaly in dogs. This case report describes successful membranectomy for CTD via partial venous inflow occlusion under mild hypothermia in a dog. A 7-month-old intact male mixed-breed dog weighing 20.5 kg presented with a history of abdominal distention, lethargy, and anorexia. Clinical examination, radiography, echocardiography, microbubble testing, and computed tomography revealed a remnant right atrium membrane obscuring the venous blood inflow from the vena cava. Considering the potential risk of re-stenosis following interventional treatment, curative resection involving surgical membranectomy via venous inflow occlusion was performed. By performing partial venous inflow occlusion under mild hypothermia (34.5 °C), sufficient time was obtained to explore the defect and resect the remnant membrane. The dog recovered without any complications, and the clinical signs were relieved. This case illustrates that partial venous inflow occlusion under mild hypothermia is feasible for achieving curative resection of cor triatriatum dexter in dogs.

Cor Triatriatum Dexter Associated with an Ostium Primum Atrial Defect and Left-Sided Opening of the Coronary Sinus in a Stillborn Fetus

Cor triatriatum is a very rare cardiac malformation characterized by the presence of an abnormal interatrial membrane separating either the left or right atrial chamber into two compartments. It can be associated with other cardiac defects and is often symptomatic in childhood. The signs depend on the size and position of the interatrial membrane and other associated malformations. Here we report a case of right-sided cor triatriatum associated with an ostium primum-type interatrial septum defect and left-sided opening of the coronary sinus in a fetus. The cause of intrauterine death was asphyxia due to total placental abruption.

Percutaneous Edge-to-Edge Tricuspid Valve Repair in a Patient with Cor Triatriatum Dexter: A Case Report

Background: Tricuspid regurgitation is gaining importance due to its high morbidity and mortality. Especially in the elderly, novel technologies in percutaneous therapies have become valuable options due to the commonly present high surgical risk. Case presentation: We report a case of a 78-year-old female suffering from massive tricuspid regurgitation with repetitive right-sided heart failure hospitalizations. As the patient was very frail and deemed as high surgical risk, we used the TriClip^® system to improve her symptomatic status. During diagnostic work-up, an additional membrane separating the right atrium, consistent with the definition of a cor triatriatum dexter, was found. Although increasing the complexity of the procedure, implantation of 3 clips with reduction of tricuspid regurgitation to a mild-to-moderate degree was achieved without any notable complications. The patient was discharged with ameliorated symptoms on the fourth postoperative day. Conclusions: Our case highlights the feasibility of percutaneous edge-to-edge tricuspid valve repair in an elderly woman with cor triatriatum dexter. Accurate echocardiographic visualization is an absolute requirement to gain access to the tricuspid valve without interacting with prevailing additional membranes.

Surgical management of divided atrial chambers

BACKGROUND AND AIM

The morphological variations when one, or both, of the atrial chambers is subdivided, are many and varied. We sought to address clinical presentations, potentially misdiagnosed cases, diagnostic modalities, surgical approaches, and outcomes of this "family" of uncommon lesions.

METHODS

A total of 193 published investigations were synthesized. Diagnostic information was provided by clinical presentation, and multimodality imaging studies.

RESULTS

Almost three-quarters of patients with divided atrial chambers present during infancy with severe pulmonary hypertension and cardiac failure. Associated cardiac and extra-cardiac defects are present in between half and nine-tenths of cases. Acquired division of the left atrium has been reported after the Fontan operation, orthotopic cardiac transplantation, and complicated aortic valvar infective endocarditis. Surgery under cardiopulmonary bypass remains the definitive treatment. Balloon dilation may be considered in anatomically compatible variants in the setting of cardiac failure and pregnancy as a bridge todefinitive treatment. Overall, mortality has been cited between nil to 29%. Presentation during infancy, associated congenital anomalies, pulmonary hypertension, and surgery in the previous era, have been the reported causes of death. The operative survivors have long-term favourable outcomes, with near normal cardiac dimensions and low risk of recurrence. While asymptomatic patients with division of the right atrium do not need treatment, surgical resection of the dividing partition under cardiopulmonary bypass is recommended in symptomatic patients with complex anatomy, the spinnaker malformation, or associated cardiac anomalies. Balloon dilation may be considered in uncomplicated patients with less obstructive lesions. Hybrid intervention and endoscopic robotic correction also have been performed.

CONCLUSIONS

Resection of the dividing shelf allows the survivors to regain near normal dimensions with a low risk of recurrence. We submit that an increased appreciation of the anatomic background to division of the atrial chambers will contribute to improved surgical management.

A Systematic Review of a Long-forgotten Cause of Atrial Fibrillation and Stroke: Cor Triatriatum

Cor triatriatum is a rare congenital cardiac condition characterized by the division of one atrium into two chambers by a fibromuscular membrane, resulting in three atrial chambers. The goal of this study was to determine the associations of cor triatriatum with cyanosis, atrial fibrillation (AF), and stroke.

MEDLINE (PubMed, Ovid), Embase, and Cochrane databases were searched on April 25, 2019, for relevant articles on cor triatriatum. After initial screening and removal of duplicates, 235 articles were selected. Data were extracted from these articles, including types, presentations, diagnostic findings, management, and outcomes of patients with cor triatriatum.

Approximately 83% of patients with cor triatriatum had cor triatriatum sinistrum (CTS) and 17% had cor triatriatum dextrum (CTD). The mean age of all patients was 29±23 years. Mean ages at diagnosis differed significantly in patients with CTS and CTD (31±23 years vs. 21±20 years, p=0.02). CTS showed a significantly greater association with AF (14.65% vs. 12.5%, p=0.036) and had a substantially higher risk of stroke (7.9% vs. 5.0%, p=0.04) than CTD. CTS also had a numerically higher association with atrial septal defects (15.13% vs. 15.6%), but this difference was not statistically significant (p=0.89). In contrast, cyanosis at presentation was significantly more frequent in patients with CTD than CTS (5.5% vs. 5.3%, p=0.05). Management did not differ significantly between these groups (p=0.29). The overall mortality rate was 16%, with no significant difference between patients with CTS and CTD (p=0.33).

The higher likelihood of AF and stroke in CTS than in CTD patients warrants treatment of the former with anticoagulation agents, irrespective of their CHA₂DS₂-VASc scores (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, age, sex category). Patients with CTS usually present at an older age due to their lower risk of cyanosis and asymptomatic AF.

Cor Triatriatum Dexter as an Incidental Finding: Role of Two-Dimensional Transthoracic Echocardiography

Cor triatriatum dexter (CTD) is a rare congenital cardiac anomaly in which a membranous structure divides the right atrium (RA) into two chambers. Persistence of the right valve of the sinus venosus, which usually regresses as a part of normal embryological development, is responsible for membranous partition. There is a high incidence of right-sided congenital abnormalities of the heart associated with this condition. Clinical manifestations vary depending on the degree of partitioning or septation of the RA. We present a case of CTD discovered as an incidental finding during transthoracic echocardiography and further discuss the role of two-dimensional echocardiography as a noninvasive diagnostic tool.

Cor triatriatum dexter, atrial septal defects, and pulmonary stenosis-a rare association

Cor triatriatum dexter (CTD) is an extremely rare congenital anomaly in which the right atrium is divided into 2 chambers by a membrane. The estimated incidence of cor triatriatum has been reported as 0.1% of congenital cardiac malformations. The septation of the right atrium in the setting of CTD is the result of failed resorption of the right valve of the sinus venosus. This results in anterolateral and posteromedial portions of the divided right atrium. CTD can be diagnosed at any age, especially if it is incidentally discovered.

Cor triatriatum dexter: A rare cause of childhood cyanosis

Cor triatriatum dexter is a rare congenital heart anomaly where the right atrium is divided into two chambers by a membrane. We report a boy who had persistent mild cyanosis and diagnosed to have cor triatriatum dexter with secundum atrial septal defect by transoesophageal echocardiography. Interestingly, he had persistent mild cyanosis despite insignificant obstruction to the right ventricular inflow and normal pulmonary artery pressure. The pathophysiology, approach to the diagnosis, and mode of treatment are also discussed.

An isolated fetal cor triatriatum dexter during a targeted anatomic survey at 22 weeks' gestation

OBJECTIVE

Cor triatriatum dexter is a rare cardiac malformation characterized by division of the right atrium into two compartments by a usually fenestrated membrane, whose degree of partitioning or septation is responsible for different clinical manifestations.

METHODS

We report the first case of an isolated fetal cor triatriatum dexter that was diagnosed during ultrasound screening at 22 weeks of gestation.

RESULTS

The sonographic examination of the fetal cardiac morphology revealed the presence of a membrane stretched between the medial and lateral walls of right atrium in the apical four-chamber view. Fetal morphology and biometric features were normal and appropriate for gestational age.

CONCLUSION

This is the first report of an isolated fetal cor triatriatum dexter that was diagnosed during ultrasound screening at 22 weeks of gestation.