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Accessory right atrial chamber: the diagnostic role of transthoracic contrast echocardiography

Accessory right atrial chamber: the diagnostic role of transthoracic contrast echocardiography Accessory chamber, Atrial septal defect, Contrast agent, Cardiac CT An 81-year-old woman was admitted in our department due to stress cardiomyopathy with apical ballooning related to bronchospasm crises during acute chronic obstructive pulmonary disease (COPD) exacerbation. Complete left bundle branch block was present. Coronary angiography showed non-obstructive coronary artery disease. Seventy-two hour later, transthoracic echocardiography (TTE) revealed full regional wall motion and global systolic function recovery. Of note, a wide (about 2.5 cm diameter) hypoechogenic right-sided atrial lesion, without colour Doppler signal, was detected at TTE. An additional diagnostic evaluation was performed using transthoracic contrast echocardiography. First, bubble test (Figure 1, Video 1) with agitated saline solution enhanced right chambers but not the lesion that appeared functionally isolated from the right atrium; this finding excluded therefore right atrial embryonic remnants such as Chiari’s network, prominent Eustachian or Tebesian valves. Second, SonoVue venous injection transpulmonary opacified the left chambers and the accessory right atrial lesion simultaneously (Figure 1, Video 2), thus suggesting its communication with the left atrium and definitively ruling out the possibility of a cystic lesion. Figure 1 Open in new tabDownload slide Hypoechogenic right-sided atrial lesion (arrows) at TTE in four-chamber apical view (panel A) and subcostal view (panel B). Bubble test enhances right chambers sparing the lesion (panel C), while SonoVue injection fills the accessory chamber together with the left chambers (panel D). Cardiac CT (panels E and F) describes 3D anatomy of an accessory chamber inside the right atrium with normal right venous return. Video 1 Bubble test. Bubble test enhances right chambers sparing the accessory chamber. Transesophageal echocardiography revealed an ostium secundum atrial septal defect between the left atrium and the accessory chamber without abnormal pulmonary venous return. Finally, cardiac computed tomography (CT) confirmed echocardiographic findings and 3D and 4D VR reconstructions demonstrated the accessory chamber localized in the right atrium (right to the interatrial septum and interventricular septum) (Figure 1, Video 3). This accessory ‘smooth’ right-sided atrium was bounded by the interatrial septum and a thick fibromuscular band; the venous returns (cava veins and coronary sinus) drained in the ‘trabeculated’ right atrium where the tricuspid valve communicated with the right ventricle. Video 2 SonoVue. SonoVue injection fills the accessory chamber together with the left chambers. Video 3 Cardiac CT. Cardiac CT describes 3D anatomy of an accessory chamber inside the right atrium with normal right venous return. Multimodality imaging is of paramount importance in the diagnosis of congenital heart abnormalities and the combination of functional and anatomical information allows for a differential diagnosis. Consent: The authors confirm that written consent for submission and publication of this case report including images and associated text has been obtained from the patient in line with COPE guidance. Conflict of interest: None declared. Funding: None declared. © The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal - Case Reports Oxford University Press

Accessory right atrial chamber: the diagnostic role of transthoracic contrast echocardiography

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Publisher
Oxford University Press
Copyright
© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.
eISSN
2514-2119
DOI
10.1093/ehjcr/ytac248
Publisher site
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Abstract

Accessory chamber, Atrial septal defect, Contrast agent, Cardiac CT An 81-year-old woman was admitted in our department due to stress cardiomyopathy with apical ballooning related to bronchospasm crises during acute chronic obstructive pulmonary disease (COPD) exacerbation. Complete left bundle branch block was present. Coronary angiography showed non-obstructive coronary artery disease. Seventy-two hour later, transthoracic echocardiography (TTE) revealed full regional wall motion and global systolic function recovery. Of note, a wide (about 2.5 cm diameter) hypoechogenic right-sided atrial lesion, without colour Doppler signal, was detected at TTE. An additional diagnostic evaluation was performed using transthoracic contrast echocardiography. First, bubble test (Figure 1, Video 1) with agitated saline solution enhanced right chambers but not the lesion that appeared functionally isolated from the right atrium; this finding excluded therefore right atrial embryonic remnants such as Chiari’s network, prominent Eustachian or Tebesian valves. Second, SonoVue venous injection transpulmonary opacified the left chambers and the accessory right atrial lesion simultaneously (Figure 1, Video 2), thus suggesting its communication with the left atrium and definitively ruling out the possibility of a cystic lesion. Figure 1 Open in new tabDownload slide Hypoechogenic right-sided atrial lesion (arrows) at TTE in four-chamber apical view (panel A) and subcostal view (panel B). Bubble test enhances right chambers sparing the lesion (panel C), while SonoVue injection fills the accessory chamber together with the left chambers (panel D). Cardiac CT (panels E and F) describes 3D anatomy of an accessory chamber inside the right atrium with normal right venous return. Video 1 Bubble test. Bubble test enhances right chambers sparing the accessory chamber. Transesophageal echocardiography revealed an ostium secundum atrial septal defect between the left atrium and the accessory chamber without abnormal pulmonary venous return. Finally, cardiac computed tomography (CT) confirmed echocardiographic findings and 3D and 4D VR reconstructions demonstrated the accessory chamber localized in the right atrium (right to the interatrial septum and interventricular septum) (Figure 1, Video 3). This accessory ‘smooth’ right-sided atrium was bounded by the interatrial septum and a thick fibromuscular band; the venous returns (cava veins and coronary sinus) drained in the ‘trabeculated’ right atrium where the tricuspid valve communicated with the right ventricle. Video 2 SonoVue. SonoVue injection fills the accessory chamber together with the left chambers. Video 3 Cardiac CT. Cardiac CT describes 3D anatomy of an accessory chamber inside the right atrium with normal right venous return. Multimodality imaging is of paramount importance in the diagnosis of congenital heart abnormalities and the combination of functional and anatomical information allows for a differential diagnosis. Consent: The authors confirm that written consent for submission and publication of this case report including images and associated text has been obtained from the patient in line with COPE guidance. Conflict of interest: None declared. Funding: None declared. © The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

Journal

European Heart Journal - Case Reports – Oxford University Press

Published: Jun 17, 2022

Keywords: Accessory chamber; Atrial septal defect; Contrast agent; Cardiac CT

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