Naoki Norioka

Cor triatriatum dexter with atrial septal defect evaluated by real-time three-dimensional transesophageal echocardiography.

An 82-year-old woman presented with palpitation chest oppression and exertional dyspnea. Medical history included systemic hypertension treated by a nearby clinic. On admission, chest X-ray revealed increased cardiothoracic ratio of 64 % and vascular congestion. ECG showed atrial fibrillation with about 92 bpm. On examination, she had blood pressure of 164/66 mmHg and oxygen saturation of 96 % on room air. At physical examination, a soft systolic murmur was present on 4LSB (Levine 3/6) and pitting edema at lower extremities. Laboratory investigation showed elevated BNP (791 pg/ml). Transthoracic echocardiography (TTE) demonstrated the dilated right heart with volume overload and left ventricular function was normal. The morphology of the tricuspid valve (TV) looked normal but systolic pressure gradient over the TV was 46 mmHg. The size of the inferior vena cava (IVC) was 22 mm. TTE revealed a large band in the right atrium (RA) dividing into two chambers (Fig. 1a, b). However, Doppler analysis revealed no gradient between the two chambers and, accordingly, absence of obstruction in the RA. TTE showed a secundum atrial septal defect (ASD) with left-to-right shunt by color-flow imaging and pulmonary to systemic flow ratio was estimated to be about 1.8 (Fig. 1a). An anomalous membrane in the RA is shown with cardiac CT. These findings were compatible with persistence of valve of sinus venosus [1, 2]. To confirm the diagnosis and to image the front view of the membrane, real-time 3D-TEE was performed with iE33 (Philips Ltd., Netherlands) and analyzed online and offline. The 3D image was displayed as a volumetric data set and with the ability to manipulate the direction of the view and two-dimensional (2D) images of any section. 3D-TEE showed a large hole in the center of the membrane (32 9 27 mm) allowing communication between the two chambers of the RA (Fig. 1c, d) [3]. During the procedure, a contrast study using agitated saline injected from the left brachial vein (Fig. 2a) revealed partitioning of the RA into two chambers by the membrane. IVC flow was not obstructed, but restricted. The patient was diagnosed as having cor triatriatum dexter and successfully treated with diuretics, vasodilator, and antiplatelet medicine. She was discharged without surgical treatment.

Greater nighttime blood pressure variability is associated with left atrial enlargement in atrial fibrillation patients with preserved ejection fraction

Left atrial enlargement is an independent risk factor for ischemic stroke in patients with atrial fibrillation. Little is known regarding the association between nighttime blood pressure variability and left atrial enlargement in patients with atrial fibrillation and preserved ejection fraction. The study population consisted of 140 consecutive patients with atrial fibrillation (mean age 64 ± 10 years) with preserved ejection fraction (≥50%). Nighttime blood pressure was measured at hourly intervals, using a home blood pressure monitoring device. Nighttime blood pressure variability was expressed as the standard deviation of all readings. Left atrial volume index was measured using the modified Simpson’s biplane method with transthoracic echocardiography. Multiple regression analysis indicated that nighttime mean systolic/diastolic blood pressure and its variability remained independently associated with left atrial enlargement after adjustment for age, sex, anti-hypertensive medication class, and left ventricular mass index (P < 0.01). When patients were divided into four groups according to nighttime blood pressure and its variability, the group with higher nighttime blood pressure and its variability had significantly larger left atrial volume than the group with lower nighttime blood pressure and its variability (46.6 ml/m2 vs. 35.0 ml/m2, P < 0.0001). Higher nighttime blood pressure and its variability are associated with left atrial enlargement. The combination of nighttime blood pressure and its variability has additional predictive value for left atrial enlargement. Intensive intervention for these high-risk patients may avoid or delay progression of left atrial enlargement and reduce the risk of stroke.