21672201 Visualization

A 33 Age - year Age old Age woman Sex presented Clinical_event to our cardiology service with signs and symptoms of congestive Sign_symptom heart Sign_symptom failure Sign_symptom .
Her medical History history History was unremarkable Detailed_description , however a History year History ago History and soon after her third child Other_event delivery Other_event , she had been admitted Clinical_event in another hospital Nonbiological_location for acute Disease_disorder pulmonary Disease_disorder oedema Disease_disorder after labor.
Cor Disease_disorder triatriatum Disease_disorder with obstructive behavior causing pulmonary Sign_symptom hypertension Sign_symptom had bee diagnosed Clinical_event , while the left Biological_structure ventricle Biological_structure was structurally Detailed_description and Detailed_description functionally Detailed_description intact Detailed_description .
The patient at that time denied surgey Clinical_event and had been discharged Clinical_event on medical Detailed_description therapy Therapeutic_procedure .
At present admission the patient presented Clinical_event with NYHA Disease_disorder functional Disease_disorder class Disease_disorder III Disease_disorder , symptoms of heart Sign_symptom failure Sign_symptom and Sign_symptom palpittions Sign_symptom as a result of persistent Sign_symptom atrial Sign_symptom flutter Sign_symptom .
On physical Diagnostic_procedure examination Diagnostic_procedure a loud pulmonary component of the 2nd heart sound and a diastolic murmur was heard in the mitral Biological_structure area Biological_structure .
Signs of right Detailed_description - sided Detailed_description heart Disease_disorder failure Disease_disorder were absent.
A transthoracic Diagnostic_procedure echocardiography Diagnostic_procedure revealed a moderately Detailed_description dilated Detailed_description left Biological_structure ventricle Biological_structure ( LV Biological_structure ), globally Detailed_description hypokinetic Disease_disorder , with severely Detailed_description impaired Detailed_description systolic Disease_disorder function Disease_disorder (EF estimated ≥30%).
Left Biological_structure atrium Biological_structure ( LA Biological_structure ) was dilated Shape , with a mobile, Detailed_description membrane Detailed_description - like Detailed_description echogenic Biological_structure structure Biological_structure into it.
Transesophageal Diagnostic_procedure echocardiogram Diagnostic_procedure ( TEE Diagnostic_procedure ) documented a fibromuscular Biological_structure membrane Biological_structure across the LA Biological_structure , dividing it into two compartments, a proximal one receiving the pulmonary venous flow and a distal one containing the left Biological_structure atrial Biological_structure appendage Biological_structure ( LAA Biological_structure ).
The two chambers Biological_structure communicated via a non Detailed_description - restrictive Detailed_description orifice Biological_structure , but the membrane Biological_structure prolapsed towards the mitral Biological_structure valve Biological_structure inflow causing severe obstruction.
Mitral Biological_structure valve Biological_structure appeared normal, with mild regurgitation.
Patent Disease_disorder foramen Disease_disorder ovale Disease_disorder ( PFO Disease_disorder ), atrial Disease_disorder septal Disease_disorder defect Disease_disorder ( ASD Disease_disorder ) and anomalous venous connections were ruled out and the diagnosis of cor Disease_disorder triatriatum Disease_disorder was reconfirmed Clinical_event .
Magnetic Diagnostic_procedure resonance Diagnostic_procedure imaging Diagnostic_procedure ( MRI Diagnostic_procedure ) of the heart also revealed the fibromuscular Biological_structure septum Biological_structure into the left Biological_structure atrium Biological_structure and the low left ventricular Lab_value ejection Lab_value fraction Lab_value [( LVEF Lab_value ) 30% Lab_value , cardiac Lab_value index Lab_value 1,6 Lab_value L/min/m2 Lab_value , cardiac Lab_value output Lab_value 2,7 Lab_value L/min Lab_value ] (figure ​1).
Coronary Diagnostic_procedure angiography Diagnostic_procedure showed normal coronary Biological_structure arteries Biological_structure .
With these findings the patient was scheduled Clinical_event for surgery.
Anesthetic induction was achieved Outcome with standard technique including administration Clinical_event of sodium Medication pentothal Medication , sevofluorane Medication , fentanyl Medication and muscle Medication relaxant Medication .
Invasive monitoring included the use of right Other_entity radial Other_entity arterial Other_entity lines Other_entity , a pulmonary Other_entity artery Other_entity catheter Other_entity and a foley Other_entity catheter Other_entity with temperature Other_entity probe Other_entity to measure bladder temperature as an indicator of core body temperature.
Transesophageal Diagnostic_procedure echocardiography Diagnostic_procedure ( TEE Diagnostic_procedure ) was also instituted Clinical_event .
Surgery was performed through a median Therapeutic_procedure sternotomy Therapeutic_procedure .
Connection to cardiopulmonary bypass (CPB) was achieved by standard ascending aorta and bicaval cannulation.
Mildly hypothermic Sign_symptom ( 32°C Lab_value ) CPB was established.
Cold blood cardioplegia was administered in an antegrade fashion through the aortic root after clamping the aorta.
The interatrial groove was developed and the common pulmonary venous chamber of the left atrium was opened through a vertical incision anterior to the right pulmonary veins, exactly as for mitral Therapeutic_procedure valve Therapeutic_procedure surgery Therapeutic_procedure .
After insertion of a self-retaining retractor to facilitate exposure, the diaphragm Biological_structure was exposed and the central hole in it was identified.
A preliminary incision out from the hole improved exposure for the definitive excision.
Orifices of the pulmonary Biological_structure veins Biological_structure on both sides were located.
Position of the atrial Disease_disorder septum Disease_disorder was also identified by a small opening in the right Biological_structure atrium Biological_structure and by inserting a curved Other_entity clamp Other_entity to displace the septum into the common pulmonary venous chamber of the left Biological_structure atrium Biological_structure .
There was no atrial Disease_disorder septal Disease_disorder defect Disease_disorder or patent Disease_disorder foramen Disease_disorder ovale Disease_disorder .
The diaphragm Biological_structure was then easily completely excised exposing the mitral Biological_structure valve Biological_structure (figure ​2).
The left atrial appendage was closed from inside the left atrium using a running 3-0 polypropylene suture to prevent future thrombus Sign_symptom formation Sign_symptom .
The atriotomy Therapeutic_procedure incisions Therapeutic_procedure were closed, the heart having been filled with blood before the last few sutures were placed.
The patient was rewarmed, the aortic Other_entity cross Other_entity - clamp Other_entity was removed and additional de-airing was carried out in the usual manner.
CPB was terminated with minimal inotropic support, involving milrinone and levophed with good hemodynamics.
The postoperative course was uneventful and the patient was extubated after 12 hours and discharged Clinical_event from the hospital on the fifth postoperative day.
At 3 months follow-up, the patient was asymptomatic Outcome (NYHA class I), in sinus rhythm.
TTE Diagnostic_procedure and MRI Diagnostic_procedure revealed a mildly dilated LV with great improvement in systolic function and an estimated LVEF Lab_value of 50% Lab_value .