Ann Thorac Surg 2002;73:1985
© 2002 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
A prominent Chiari network
Hiroyuki Tanaka, MD*a,
Kazuo Ueda, MDa,
Mikiko Murakami, MDa,
Satoru Hasegawaa,
Makoto Sunamori, MDa
a Department of Thoracic and Cardiovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
* Address reprint requests to Dr Tanaka, Department of Thoracic and Cardiovascular Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-0034, Japan
e-mail: hiroyuki-tanaka.tsrg{at}tmd.ac.jp
We treated a 68-year-old woman in 1998 with an aortic valve replacement for severe aortic stenosis. During weaning from cardiopulmonary bypass, transesophageal echocardiography showed a long, thin, highly mobile echo in the right atrium moving in rapid whiplike motion toward and away from the tricuspid valve ring. The abnormal echo was indicative of tricuspid valve disruption, right heart vegetation, flail tricuspid leaflet, a small right heart thrombus, or a pendiculated right heart tumor. Thus the right atrium was incised on the beating heart after conversion to total bypass by bicaval venous cannulation from the already established partial bypass through single two-stage venous cannulation. We found a large, saccular, honeycombed structure—a prominent Chiari network (Fig 1)—
with one side attached to the crista terminalis on the free wall of the right atrium and the other side attached to the coronary sinus (Thebesian valve). No thrombus was observed. It was resected through a right atriotomy. Preoperative parasternal echocardiography did not detect this abnormal structure. The Chiari network is an embryologic remnant that is said to be present in only 1.5% to 3% of adults [1]. It is rarely of clinical importance but can be the site of thrombosis [2]. Among the most recent 200 open-heart surgery patients needing either a right atriotomy for closure of an atrial septal defect or mitral valve surgery, we have found no other cases of a prominent Chiari network like that shown here.
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Fig 1. A prominent Chiari network. The two upper panels show the excised structure. The upper right panel is a photograph of the Chiari network floated in water. (*) indicates attachment to the coronary sinus and (**) indicates attachment to the crista terminalis. The two lower left photographs show the operative view through the right atriotomy. The lower right panel is a transesophageal echocardiographic image of the Chiari network. (Ao = aorta; CS = coronary sinus; LA = left atrium; RA = right atrium; RV = right ventricle.)
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References
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Werner J.A., Cheitlin M.D., Gross B.W., Speck S.M., Ivey T.D. Echocardiographic appearance of the Chiari network: differentiation from right-heart pathology. Circulation 1981;63:1104-1109.[Abstract/Free Full Text]
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Goedde T.A., Conetta D., Rumisek J.D. Chiari network entrapment of thromboemboli: congenital inferior vena cava filter. Ann Thorac Surg 1990;49:317-318.[Abstract/Free Full Text]
