European Journal of Echocardiography 2008 9(2):298-300; doi:10.1016/j.euje.2006.10.002
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org
‘Coumadin ridge’ in the left atrium demonstrated on three dimensional transthoracic echocardiography
Tanya McKay1 and
Liza Thomas1,2,*
1 Westmead Hospital, Sydney, Australia
2 University of Sydney, Sydney, Australia
Received 26 July 2006; accepted after revision 6 October 2006; online publish-ahead-of-print 28 November 2007.
* Corresponding author: Department of Cardiology, Westmead Hospital, Darcy Road, Sydney 2145, NSW, Australia. Tel: +61 2 98456795; fax: + 61 2 98458323. E-mail address: lizat{at}westgate.wh.usyd.edu.au (L. Thomas).
 |
Abstract
|
|---|
An echogenic band like structure was seen in the left atrium
on two dimensional transthoracic echocardiography (2D TTE).
Full volume three dimensional (3D) TTE and colour Doppler established
the surrounding anatomical landmarks, and demonstrated the absence
of obstruction related to this band. 3D TTE confirmed that this
band like structure was consistent with the ridge between the
left atrial appendage and left superior pulmonary vein (‘warfarin/coumadin
ridge’).
Keywords: Warfarin ridge; Coumadin ridge; 3D transthoracic echocardiography
|
Case presentation
|
|---|
A routine TTE was performed on a 39-year-old patient for the
investigation of a new murmur. The TTE was normal except for
the finding of a linear band like structure within the left
atrium (LA), in the parasternal long axis view (
Figure 1). This
structure could be reproduced in multiple views (the parasternal
short axis and apical four chamber views). A full volume 3D
TTE loop and 3D images with colour Doppler wedge were acquired
and analysed using a TomTech/Philips QLab offline analysis system.
In the parasternal long axis 3D view (
Figures 1 and 2),
the structure appeared as a band possibly dividing the left
atrium such as in cor triatriatum sinister.
1 However using the
short axis 3D view (
Figure 3) it was demonstrated that
the structure was a ridge continuous with the roof of the left
atrial appendage (LAA) that extended into the body of the left
atrium with a rounded end.
View larger version (61K):
[in this window]
[in a new window]
[Download PowerPoint slide]
|
Figure 3 Left: 2D parasternal short axis view. Right: 3D reconstruction; the structure is seen to be continuous with the wall of the left atrial appendage and left superior pulmonary vein. LA – left atrium, LAA – left atrial appendage, LSP – left superior pulmonary vein.
|
|
2D colour Doppler demonstrated that colour flow was present
on either side of the structure (
Figure 4). With 3D colour
Doppler the structure could be viewed both from the original
parasternal long axis cut (
Figure 5, left) and from a 180°
rotation in the parasternal long axis view along a craniocaudal
axis. This cut permits one to view the LA from the posterior
wall towards the anterior atrial wall by cropping through the
data set (
Figure 5, right). From this 180° rotated
view, which could not be obtained from a 2D TTE image, colour
flow could be seen to move through the atrium without any aliasing
to suggest flow obstruction. Thus the structure was seen as
consistent with the ridge between the LAA and the left superior
pulmonary vein (LSPV) often described as the ‘warfarin
or coumadin ridge’.
2 Figure 6 is a diagrammatic representation
of the anatomy of the lateral left atrium.
3
View larger version (58K):
[in this window]
[in a new window]
[Download PowerPoint slide]
|
Figure 5 Left: 3D full volume reconstruction with colour Doppler. Colour Doppler can be seen to move either side of the structure. Right: The same wedge rotated 180°. Colour Doppler is now seen to move freely within the left atrial chamber behind the structure. No aliasing is seen. LA – left atrium, MVA – mitral valve annulus.
|
|
View larger version (12K):
[in this window]
[in a new window]
[Download PowerPoint slide]
|
Figure 6 Drawing of the anterolateral wall of the left atrium adapted from Sra et al.3 Red dashed line – warfarin ridge, MV – mitral valve, LAA – left atrial appendage, LIPV – left inferior pulmonary vein, LSPV – left superior pulmonary vein.
|
|
|
Discussion
|
|---|
3D TTE is being increasingly utilised in the clinical setting
to identify cardiac pathology more accurately. However, its
role is in contributing additional information but not replacing
2D TTE. Improved technologies in 2D imaging have resulted in
physiological structures becoming more readily visualised and
3D TTE has enabled these ‘normal variants’ to be
identified. We have previously observed a prominent crista terminalis,
identified on 2D TTE as a ‘band’ in the right atrium,
utilising a 3D full volume data set.
4
Pathological findings of a fibromuscular membrane dividing the left atrium into two chambers is called cor triatriatum sinister and can mimic the findings of mitral stenosis.1 Spectral Doppler information excluded a gradient within the left atrium and across the mitral valve. Full volume 3D TTE and colour Doppler mapping demonstrated the ‘coumadin ridge’ between the LAA and LSPV. In previous studies the ‘coumadin ridge’ has been utilised as a site for catheter ablation of AF.2 The 3D echocardiographic views obtained were a sagittal section (traditionally named the long axis), from the parasternal window (Figures 1 and 2) and a transverse section (Figure 3) at the level of the aortic valve (the parasternal short axis on 2D TTE).
In conclusion,we have demonstrated that a linear band noted in the LA on 2D TTE, was a normal variant of the ridge between the LAA and LSPV often referred to as the ‘warfarin/coumadin ridge’.
|
References
|
|---|
- Slight RD, Nzewi OC, Sivaprakasam R, Mankad PS. Cor triatriatum sinister presenting in the adult as mitral stenosis. Heart (2003) 89:e26.[Abstract/Free Full Text]
- Kistler PM, Earley MJ, Harris S, Abrams D, Ellis S, Sporton SC, et al. Validation of three-dimensional cardiac image integration: use of integrated CT image into electroanatomic mapping system to perform catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol (2006) 17:341–8.[CrossRef][Web of Science][Medline]
- Sra J, Krum D, Okerlund D, Thompson H. Endocardial imaging of the left atrium in patients with atrial fibrillation. J Cardiovasc Electrophysiol (2004) 15:247.[CrossRef][Web of Science][Medline]
- McKay T, Thomas L. Prominent crista terminalis and Eustachian ridge in the right atrium: two dimensional (2D) and three dimensional (3D) imaging. Eur J Echocardiogr (2007) 8:288–91.[Abstract/Free Full Text]
CiteULike 
Connotea 
Del.icio.us What's this?
Top
Abstract
Case presentation
