© 2003 by European Society of Cardiology
Copyright © 2003, The European Society of Cardiology
Enlargement of the right atrium—diverticulum or aneurysm?
Cardiovascular Centre, Cardiology, University Hospital Zurich, Zurich, Switzerland
Received 22 July 2002; accepted after revision 1 October 2002.
* Address correspondence to: Rolf Jenni, Cardiology, University Hospital, Raemistrasse 100, CH-8091 Zurich, Switzerland. Tel: +41-1-255-34-47; Fax: +41-1-255-44-01 karjer{at}usz.unizh.ch
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Abstract |
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Diverticula and aneurysms are rare congenital anomalies of the right atrium. Here, we report a case of a giant congenital diverticulum of the right atrium in a 27-year-old female and discuss the morphological characteristics distinguishing diverticula and aneurysms.
Keywords: diverticulum; aneurysm; atrial; echocardiographic; congenital; enlargement
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Case report |
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A 27-year-old physically active woman was seen, because of atrial flutter, with 2:1 conduction. Previously, she had had three uneventful pregnancies. A chest X-ray showed enlargement of the right atrial silhouette (cardiothoracic ratio = 0.55). The patient was put on anticoagulants and electrical cardioversion was performed successfully 3 weeks later.
Upon echocardiographic evaluation a large, perfused diverticulum (Fig. 1) arising from the right atrial lateral wall was seen, extending over the right ventricle up to the level of the moderator band. Entry into the diverticulum occurred via a defect in the lateral free atrial wall. Right ventricular inflow was not impaired. Strands were stretched across the diverticulum. The right atrial appendage was normally developed. A patent foramen ovale was present.
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During surgery, which was performed with normothermic cardiopulmonary bypass, venous return was achieved with bi-caval cannulation. Ventricular fibrillation was induced for a short period to allow direct closure of a foramen ovale. The operation was thereafter performed on the beating heart. The diverticulum was opened from its apex (Fig. 2) to its base and resected with special care taken not to injure the right coronary artery. The right atrium was fully opened. The inferior border of the atriotomy was sewn around the anterior part of the tricuspid annulus, and the superior border was brought over the lateral wall of the right atrium as a flap, and sewn near the interatrial groove. This provided adequate reduction of the atrial size and reinforcement of the atrial wall. Postoperative echocardiography showed normal contractility of both atria and ventricles. The size of the right atrium and venous return flow were normal. The patient remained in sinus rhythm.
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Discussion |
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Diverticula and aneurysms are rare congenital anomalies of the right atrium[1,2]. Bailey was the first to excise a diverticulum of the right atrium in 1953[3]. There are clear characteristics distinguishing these two entities. An aneurysm is defined as the dilatation of the atrium involving all layers of the atrial wall. In the patient reported here, an entry across the atrial wall into the diverticulum was present and fibromuscular strands were stretched between its walls. This morphological pattern corresponds to the definition of a diverticulum, where communication through an entry has to be present. Atrial diverticula have been observed at any time from birth to adult life. Patients are frequently asymptomatic[4], although progressive atrial dilatation supraventricular arrhythmias may develop[1,5,6]. Congestive heart failure rarely occurs and is usually related to impaired systolic left ventricular function caused by incessant tachycardia. Further complications include thrombus formation in the right atrium or the diverticulum. Surgical excision is the therapy of choice and has been shown to reduce the risk of atrial arrhythmia[1].
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References |
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- Binder T.M., Rosenhek R., Frank H., Gwechenberger M., Maurer G., Baumgartner H. Congenital malformations of the right atrium and the coronary sinus. Chest (2000) 117:1740–1748.[CrossRef][Web of Science][Medline]
- Nager G., Jenni R., Goebel N., Krayenbuhl H.P. Follow-up of familial idiopathic dilatation of the right atrium. Z Kardiol (1985) 74(7):384–388.[Web of Science][Medline]
- Bailey C.P. Surgery of the Heart. (1955) Lea & Febiger. 413 pp.
- Kim Y.J., Kim H., Choi J.Y. Right atrial aneurysm. Cardiol Young (1995) 5:354–356.
- Shah K., Walsh K. Giant right atrial diverticulum: an unusual cause of Wolff–Parkinson–White syndrome. Br Heart J (1992) 17:874–882.
- Scalia G.M., Stafford W.J., Burstow D.J., Curruthers T., Tesar P.J. Successful treatment of incessant atrial flutter with excision of congenital giant right atrial aneurysm diagnosed by transesophageal echocardiography. Am Heart J (1995) 129:834–835.[CrossRef][Web of Science][Medline]
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