Ann Thorac Surg 2006;81:1893-1895
© 2006 The Society of Thoracic Surgeons
Case report
Creation of Coronary Sinus Using Left Atrial Diaphragm in the Patient With Cor Triatriatum and Unroofed Coronary Sinus
Kiyoharu Nakano, MD
*
,
Keiich Ayusawa, MD,
Akihiko Gome, MD,
Hayao Nakatani, MD,
Yositsugu Nakamura, MD,
Koich Sughimoto, MD,
Atsuhiko Sato, MD
Department of Cardiovascular Surgery, Kanto Medical Center, Tokyo, Japan
Accepted for publication April 25, 2005.
* Address correspondence to Dr Nakano, Department of Cardiovascular Surgery, Kanto Medical Center, NTT EC, 5-9-22 Higashi-gotanda Shinagawa-ku, Tokyo, 141-8625 Japan (Email: knakano{at}kmc.mhc.east.ntt.co.jp).
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Abstract
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Surgical correction of cor triatriatum with unroofed coronary sinus consisted of creation of the coronary sinus using the left atrial diaphragm and closure of the atrial septal defect in an adult patient. No materials other than intracardiac components were used to repair all anomalies.
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Introduction
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Cor triatriatum is a rare cardiac anomaly and is sometimes associated with an unroofed coronary sinus. Operative correction of cor triatriatum is usually performed by the excision of the diaphragm separating the common pulmonary venous chamber and the remainder of the left atrium, using the autologous pericardium or other patches to repair the associated anomalies [1–4]. Recently, we performed the surgical repair of cor triatriatum associated with the unroofed coronary sinus in an adult patient. The coronary sinus was created using the in situ diaphragm separating the left atrial chambers so that coronary veins could return to the right atrium. The shunt at the atrial level was corrected without using any pericardial patches or other baffles.
A 36-year-old man was referred to our hospital for treatment with the diagnosis of an atrial septal defect (ASD). Transesophageal echocardiography revealed a linear echo-dense structure traversing the left atrium and extending to the lateral left atrial wall. Cardiac catheterization demonstrated a left-right shunt between the left atrium and coronary sinus. The left-right shunt ratio was 55% and the right-left shunt ratio was 3%. The pressure in the right atrium and the pulmonary artery were 7 mm Hg and 39/16 mm Hg, respectively. The innominate vein was identified. We diagnosed cor triatriatum and a coronary sinus ASD without persistent left superior vena cava (SVC); operation was indicated.
The operation was performed under the standard cardiopulmonary bypass with moderate hypothermia (Figs 1–4).
Through the right atriotomy, the atrial septum was incised from the superior margin of a coronary sinus ASD to the fossa ovalis and then to the superior atrial septum. There was a large Thebesian valve. The coronary sinus was completely unroofed and three independent ostiums of the coronary vein were observed. The diaphragm separating the pulmonary venous chamber from the true left atrium and the orifices of the pulmonary veins were identified. The muscle bridge between the diaphragm and the left atrial inferior wall was cut and the muscle flap was trimmed, turned over, and sutured to create a coronary sinus covering the ostia of the coronary veins. Then, the atrial septum was closed so that the coronary veins could return to the right atrium. To augment the left atrial cavity, the in situ large Thebesian valve was trimmed and was used for closing the atrial septum. The postoperative course was uneventful. The echocardiography just before hospital discharge demonstrated no cardiac shunt with normal pulmonary pressure. In the two-year follow-up after the operation, the echocardiography has not revealed any hemodynamic disturbance including supramitral obstruction.
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Fig 1. (A) The muscle bridge between the diaphragm and the left atrial inferior wall was cut and the muscle flap was trimmed (dotted line). The three holes are the ostia of the coronary vein. (B) The trimmed muscle flap was turned over and sutured to create a coronary sinus covering the ostia of the coronary vein. A part of the Thebesian valve was cut (dotted line). (C) The atrial septum was closed so that the coronary veins could return to the right atrium. To augment the left atrial cavity, an in situ large Thebesian valve was used for closing the atrial septum. (APP = left atrial appendage; CS = coronary sinus; MV = mitral valve; Th = Thebesian valve; TV = tricuspid valve.)
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Fig 2. The diaphragm (Di) separating the pulmonary venous chamber and the remainder of the left atrium. The diaphragm was cut and trimmed as shown by the dotted line.
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Fig 4. Trimmed large Thebesian valve (Th) that was utilized for closing the atrial septum is observed.
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Comment
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This is a case of cor triatriatum with unroofed coronary sinus without the left SVC in an adult patient. The coronary sinus was created using the left atrial diaphragm flap. The ASD was closed with his own atrial septum and the large Thebesian valve so that the coronary veins could return to the right atrium. The advantages of the present methods are (1) no materials other than autologous intracardiac components are used to repair all anomalies, (2) all major coronary veins returned to the right atrium, (3) the coronary sinus was created with thick and flexible in situ muscle flap so that the new roof of the coronary sinus could not be deformed.
The excision of the diaphragm separating the common pulmonary venous chamber and the remainder of the left atrium, and the repair of other anomalies using autologous pericardium or other patches are simple and common procedures for the correction of a cor triatriatum [1–4]. In the patient with the unroofed coronary sinus and the persistent left SVC, intracardiac rerooting with pericardial or other artificial patches is required [4]. A pericardial patch, however, could be calcified or shrink and artificial baffles are thrombogenetic. The in situ muscle flap, therefore, is the ideal material for the intracardiac rerooting.
Another major concern of this technique of the ASD closure relates to the creation of a small and low-compliance left atrial compartment with its adverse effect on the left ventricular filling. In this case, fortunately, the enlarged Thebesian valve was available for closing of the ASD and also for keeping the left atrial cavity larger.
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References
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- Kouchoukos NT, Blackstone EH, Doty DB, Hanley FL, Karp RB. Cor triatriatumIn: Kirklin JW, Barratt-Boyes BG, editors. Cardiac Surgery. 3rd ed.. Philadelphia, PA: Churchill Livingstone; 2003. pp. 781-789.
- Oglietti J, Cooley DA, Izquierdo JP, et al. Cor triatriatumoperative results in 25 patients. Ann Thorac Surg 1983;35:415-420.[Abstract/Free Full Text]
- Salomone G, Tiraboschi R, Bianchi T, Ferri F, Crippa M, Parenzan L. Cor triatriatum. Clinical presentation and surgical results J Thorac Cardiovasc Surg 1991;101:1088-1092.[Abstract]
- van Son JAM, Autschbach R, Mohr FW. Repair of cor triatriatum associated with partially unroofed coronary sinus Ann Thorac Surg 1999;68:1414-1416.[Abstract/Free Full Text]
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Abstract
Introduction
