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Pulmonary Hypoplasia

Total Anomalous Pulmonary Venous Connection




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AUTHOR AND EDITOR INFORMATION

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Author: Manuel Caceres, MD, Staff Physician, Department of Surgery, Division of Cardiothoracic Surgery, University of Tennessee Health Sciences Center

Manuel Caceres is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, Society of Thoracic Surgeons, and Southern Medical Association

Coauthor(s): James Jaggers, MD, Chief of Pediatric Cardiac Surgery, Professor, Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center; Jeff L Myers, MD, PhD Chief, Pediatric and Congenital Cardiac Surgery, Department of Surgery, Massachusetts General Hospital; Associate Professor of Surgery, Harvard Medical School

Editors: Juan Carlos Alejos, MD, Associate Clinical Professor, Department of Pediatrics, Division of Cardiology, University of California at Los Angeles; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Ameeta Martin, MD, Associate Professor, Department of Pediatrics, Section of Pediatric Cardiology, University of Nebraska College of Medicine; Gilbert Herzberg, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College; Steven R Neish, MD, SM, Director of Pediatric Cardiology Fellowship Program, Department of Pediatrics, Baylor College of Medicine

Author and Editor Disclosure

Synonyms and related keywords: cor triatriatum, cardiac anomaly, subdivided left atrium, accessory atrium, congenital heart disease, congenital cardiac anomaly

INTRODUCTION

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Background

Cor triatriatum is a rare congenital cardiac anomaly, representing 0.1% of all congenital cardiac malformations, without any known associated genetic abnormalities. It has no gender predilection and is associated with other cardiac defects in up to 50% of cases. The term cor triatriatum was first used by Borst in 1905, and the first surgical repair was performed by Vineberg in 1956.

In its most common form, cor triatriatum sinister, the left atrium is divided into a proximal and distal chamber. Both chambers are separated by a diaphragm with 1 or more restrictive ostia, with the pulmonary veins draining into the proximal chamber. Variable types of subtotal cor triatriatum also exist, with only the right or left pulmonary veins draining into the proximal chamber.

The location of the atrial appendage is a key landmark in this congenital malformation. It differentiates cor triatriatum from a similar condition, supravalvular mitral stenosis. In cor triatriatum, the left atrial appendage is invariably found in the same chamber with the mitral valve ring, distal to the dividing atrial diaphragm. An embryologically unrelated membrane may rarely divide the right atrium; this finding, so-called cor triatriatum dexter, is usually asymptomatic and is mostly reported as an incidental finding.

The natural history of this defect is dependent on the size of the ostia. If small, the infants are critically ill and succumb at a young age. If the connection is larger, patients present in childhood or young adulthood with a clinical picture similar to mitral stenosis. The latest reported presentation in life corresponds to a 70-year-old woman with an unrecognized nonobstructive cor triatriatum due to multiple fenestrations in the left atrial membrane.

Pathophysiology

Initially, the fetal lungs and pulmonary veins are connected to the systemic venous circulation. Subsequently, a dorsal outgrowth from the common atria, also referred as common pulmonary vein, evaginates and joins the pulmonary veins, while the connection to the systemic circulation disappears. As the fetal heart grows, the common pulmonary vein is completely absorbed. Failure of this dorsal outgrowth to join the pulmonary veins results in total anomalous pulmonary venous drainage (TAPVD). An abnormal connection between the common pulmonary vein and the atria results in any of the variants of cor triatriatum.

The critical anatomic feature of cor triatriatum is a diaphragm that divides the left atrium into 2 chambers (see Image 1). It consists of fibromuscular tissue, and the proximal chamber that is created represents a vestigial common pulmonary vein. The pulmonary veins thus drain into the proximal chamber.

Outcome depends on the size of the communication to the distal chamber, which communicates with the mitral valve. If present, a patent fossa ovalis or secundum atrial septal defect permits decompression of the proximal chamber into the right atrium.

The presentation of cor triatriatum is one of decreased cardiac output and pulmonary venous hypertension. If a connection between the common pulmonary venous chamber and the right atrium is present, pulmonary overcirculation may result in significant right ventricular enlargement.

Frequency

United States

This is a very rare malformation. Incidence is probably 0.1-0.4% of all infants with congenital cardiac disease. In a combined series from the Mayo Clinic (1955-1967) and University of Alabama at Birmingham (1967-1991), only 10 patients underwent surgical repair. The Texas Heart Institute repaired defects in 25 patients over a 21-year period. Doty conducted a series at 2 institutions over a 23-year period that involved 21 patients.

Mortality/Morbidity

  • Approximately 75% of patients die in infancy (generally from pulmonary hypertension) if the defect is unrepaired. If the communication between the proximal and distal chambers is not very restrictive or if an atrial septal defect exists that allows decompression of the hypertensive left atrium, the prognosis is significantly improved.
  • The only treatment is surgical correction. The majority of postoperative deaths occur in the first 30 days. The early mortality rate in each large series was consistently 15-20%. Early deaths had a higher rate of associated severe cardiac anomalies.
  • Long-term results are excellent, with survival of 80-90% in patients surviving surgery. Survivors have excellent functional results without residual sequelae and a life expectancy that approaches the general population. This is particularly true when repair is performed in infancy.

Sex

There appears to be a slight male predilection with a male-to-female ratio of 1.4:1.

Age

  • Diagnosis is primarily made in infancy.
  • Later presentation does occur but is usually in childhood or early adulthood. Eighty-five percent of patients presenting are younger than 40 years.
  • Rare reports of patients presenting in their eighth or ninth decade of life do exist.


CLINICAL

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History

  • Most patients present early in life.
  • Cor triatriatum is essentially a form of supravalvular mitral stenosis and presents similarly, with signs and predominating symptoms of pulmonary venous obstruction.
  • Infants usually present with evidence of low cardiac output, including pallor, diminished peripheral pulses, and tachypnea.
  • Feeding difficulties, poor weight gain, and recurrent bouts of pulmonary edema are common.
  • Presentation later in life is less classic, but evidence of pulmonary venous obstruction predominates. It may be noted incidentally on echocardiography (ECHO).

Physical

  • Despite the intracardiac defect, no characteristic murmur or pathognomonic physical characteristics are present. This often leads to incorrect diagnosis of primary pulmonary vascular or parenchymal disease.
  • Signs of pulmonary venous obstruction and pulmonary hypertension are present. A right ventricular lift and accentuation of the pulmonary second sound are frequent and may be accompanied by an early diastolic murmur of pulmonary insufficiency. Rales may be present in the lung bases.
  • A slight, continuous murmur may be present and is suggestive of flow across diaphragmatic aperture. A murmur at the left sternal border is heard in patients with an atrial septal defect and a left-to-right shunt. A diastolic rumble of mitral stenosis at the apex is generally not heard with cor triatriatum.
  • Low cardiac output manifests as pallor, tachypnea, and diminished peripheral pulses.
  • Children are typically small, suffering from poor weight gain.
  • Patients presenting later in life are dyspneic and often have a history of frequent pulmonary infections. They often have signs of right-sided heart failure, including distended peripheral veins and hepatomegaly. Signs and symptoms of pulmonary hypertension are often severe.

Causes

  • There are no known risk factors or associated genetic abnormalities.
  • Embryologically, the common pulmonary vein is normally absorbed and incorporated into the left atrium. Incomplete absorption results in a fibromuscular membrane that subdivides the left atrium into 2 chambers resulting in cor triatriatum.
  • Observation that a left superior vena cava (SVC) is frequently associated with this lesion has led some to propose impingement of the left SVC to the developing left atrium as a potential pathogenesis.


DIFFERENTIALS

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Mitral Stenosis, Supravalvular Ring
Partial Anomalous Pulmonary Venous Connection
Pulmonary Hypertension, Idiopathic
Pulmonary Hypertension, Persistent-Newborn
Pulmonary Hypoplasia
Total Anomalous Pulmonary Venous Connection

Other Problems to be Considered

Mitral stenosis, valvar
Pulmonary vein stenosis


WORKUP

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Lab Studies

  • No specific laboratory studies are indicated.

Imaging Studies

  • Chest radiography
    • Findings are usually nonspecific but may include pulmonary congestion with diffuse haziness or Kerley B lines and the ground glass pattern of acute pulmonary edema in hilar areas.
    • Patients may have mild cardiac enlargement and prominence of the pulmonary arterial segment.
    • The dilated proximal chamber may produce the appearance of left atrial enlargement.
    • Presence of an atrial septal defect or of an associated partial anomalous pulmonary venous connection adds pulmonary overcirculation to the pulmonary venous obstruction. The radiograph may then show significant right ventricular enlargement.
  • Echocardiography
    • Echocardiography is often sufficient for diagnosis and is the diagnostic modality of choice.
    • The diaphragm dividing the left atrial chambers can be visualized by means of 2-dimensional echocardiography and by the presence of an associated atrial septal defect. The origin of each of the pulmonary veins should be identified because anomalous pulmonary venous return may coexist.
    • The distinction between cor triatriatum and a supramitral ring should be made by the location of the left-atrial appendage. Differentiating between cor triatriatum and total anomalous pulmonary venous drainage to the coronary sinus may be difficult.
    • Common cardiac anomalies also can be demonstrated.
  • Angiography
    • This test is generally indicated to assess pulmonary venous return and pulmonary arterial pressures. Because approximately 10% of patients have partial anomalous venous return, angiography is helpful in defining the precise venous anatomy.
    • When performed, catheterization generally reveals pulmonary hypertension in a degree that varies directly with the severity of obstruction to pulmonary venous drainage. Demonstration of a pressure gradient between the left atrium and capillary wedge pressure is classic.
    • The proximal chamber is visualized during the venous phase, and a delay then occurs before the true left atrium and left ventricle are visualized. The proximal chamber then remains opacified and does not contract with the distal chamber.

Other Tests

  • ECG: Findings are nonspecific, but ECG findings may reveal right-axis deviation with right-atrial and right-ventricular hypertrophy.

Histologic Findings

Histology plays no part in the diagnosis; however, pulmonary hypertension results in well-defined structural changes. Increased pulmonary arterial muscularity is present very early, with increased thickness of the arterial wall and extension of muscle into the arterioles.


TREATMENT

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Medical Care

  • Medical care is primarily supportive to manage pulmonary venous congestion until surgical resection can be performed.
  • Patients presenting in extremis should be operated on immediately after resuscitation, without time spent for prolonged medical therapy.
  • On occasion, extracorporeal membrane oxygenation is initiated to stabilize a patient.

Surgical Care

  • Surgery is the treatment of choice. Recently, interventional catheterization techniques have evolved and been used successfully in some patients.
  • Surgical correction
    • Open correction is currently preferred over closed (percutaneous) procedures.
    • The procedure is performed on cardiopulmonary bypass through an atrial incision with complete resection of the diaphragm.
  • Interventional cardiology: The role of percutaneous balloon dilation in managing this condition remains to be determined.

Consultations

  • Pediatric cardiac surgery
  • Pediatric cardiology

Diet

No specific dietary restrictions exist.

Activity

  • Physical activity should not be limited in patients with early and complete correction.
  • Patients with persistent pulmonary or cardiac dysfunction secondary to long-standing disease may have moderate restriction of exercise tolerance.


MEDICATION

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Medical management is targeted toward associated elevation in pulmonary vascular resistance and heart failure. It is continued in the postoperative period until the pulmonary resistance falls and right ventricular performance improves. Mainstays of treatment are inotropic agents and diuretics.

Drug Category: Inotropic agents

Cardiac glycosides (eg, digoxin) increases myocardial contractility in patients with heart failure. Adrenergic and dopaminergic agents (eg, dopamine) provide myocardial support in the perioperative period for patients with heart failure. The more restrictive the connection between proximal and distal chambers, the more likely inotropic support will be required. A number of agents are available in this category.

Drug NameDigoxin (Lanoxin)
DescriptionExerts its inotropic action by increasing the amount of intracellular calcium available during excitation-contraction coupling. It is one of numerous inotropic agents that can be used in infants with congenital cardiac defects. Other agents, such as dopamine (described below), are more appropriate for acute management of heart failure in ICU setting.
Adult DoseTotal digitalizing dose (TDD): 0.75-1.5 mg PO; 0.5-1 mg IV/IM
Administer 50% of TDD initially; remaining 2 doses at 25% TDD q6-12h
Maintenance dose: 0.125-0.5 mg/d PO; 0.1-0.4 mg/d IV/IM
Pediatric DoseTDD PO:
Preterm infant: 20-30 mcg/kg
Term infant: 25-35 mcg/kg
1 month to 2 years: 35-60 mcg/kg
2-5 years: 30-40 mcg/kg
5-10 years: 20-35 mcg/kg
>10 years: 10-15 mcg/kg
TDD IV/IM:
Preterm infant: 15-25 mcg/kg
Term infant: 20-30 mcg/kg
1 month to 2 years: 30-50 mcg/kg
2-5 years: 25-35 mcg/kg
5-10 years: 15-30 mcg/kg
>10 years: 8-12 mcg/kg
Administer 50% of TDD initially; remaining 2 doses at 25% TDD q6-12h
Maintenance dose PO:
Preterm infant: 5-7.5 mcg/kg/d divided bid
Term infant: 6-10 mcg/kg/d divided bid
1 month to 2 years: 10-15 mcg/kg/d divided bid
2-5 years: 7.5-10 mcg/kg/d divided bid
5-10 years: 5-10 mcg/kg/d divided bid
>10 years: 2.5-5 mcg/kg qd
Maintenance dose IV/IM:
Preterm infant: 4-6 mcg/kg/d divided bid
Term infant: 5-8 mcg/kg/d divided bid
1 month to 2 years: 7.5-12 mcg/kg/d divided bid
2-5 years: 6-9 mcg/kg/d divided bid
5-10 years: 4-8 mcg/kg/d divided bid
>10 years: 2-3 mcg/kg qd
ContraindicationsDocumented hypersensitivity; digitalis-induced toxicity; AV block (without pacemaker); idiopathic hypertrophic subaortic stenosis; constrictive pericarditis
InteractionsLevels can be markedly altered by a number of medications; cholestyramine, metoclopramide, sulfasalazine, and chemotherapy all significantly lower digoxin levels; erythromycin, tetracycline, amiodarone, verapamil, quinidine, and quinine increase serum levels
PregnancyC - Safety for use during pregnancy has not been established.
PrecautionsDosage adjustment is required in patients with renal impairment; can cause cardiac arrhythmias; patients are predisposed to digoxin toxicity with hypokalemia, hypomagnesemia, hypercalcemia, and hypermagnesemia; CNS effects, such as drowsiness, and GI effects, such as nausea and vomiting, are some of the more common adverse drug reactions

Drug NameDopamine (Intropin)
DescriptionAdrenergic agonists are often used in the critical care setting for their rapid onset of action and rapid peak effect. They are, therefore, much easier to titrate to effect in acute settings. Their half-life is also much shorter than digoxin's, and their effects are rapidly lost when drug is discontinued.
Adult Dose1-20 mcg/kg/min continuous IV infusion; not to exceed 50 mcg/kg/min
Pediatric DoseAdminister as in adults
ContraindicationsDocumented hypersensitivity; ventricular fibrillation
InteractionsEffects are prolonged and intensified by MAOIs, alpha- and beta-blockers, general anesthetics, and phenytoin
PregnancyC - Safety for use during pregnancy has not been established.
PrecautionsHypovolemia should be treated before infusion of this drug; administration through a central vein is recommended; do not use umbilical artery for infusion; if dosages >20 mcg/kg/min are required, a different agent should be considered (eg, epinephrine, dobutamine)

Drug Category: Loop diuretics

These agents are used for management of right heart failure and pulmonary edema.

Drug NameFurosemide (Lasix)
DescriptionFirst-line drug for diuresis in newborns and infants and can be expected to be highly effective. It is a sulfonamide derivative that exerts its effects on the loop of Henle and distal renal tubule, thus inhibiting reabsorption of sodium and chloride.
Adult Dose10-200 mg PO/IV average dose; titrate to effect; doses as high as 600 mg/d may be used; continuous IV infusions may be more successful; usual maximum dosage approximately 0.4 mg/kg/h
Pediatric Dose1-2 mg/kg/dose PO/IV bid/tid/qid; titrate to effect; not to exceed 6 mg/kg/dose
ContraindicationsDocumented hypersensitivity; hypokalemia; renal failure
InteractionsDecreases effectiveness of oral hypoglycemic agents; may enhance effects of antihypertensives; may potentiate effects of succinylcholine; potentiates ototoxicity of aminoglycosides
PregnancyC - Safety for use during pregnancy has not been established.
PrecautionsInform patients of potential for photosensitivity; most popular strengths of digoxin and furosemide are white tabs of approximately equal size and may be confused in patients taking these medications on an outpatient basis; monitor serum potassium levels closely; may produce intravascular dehydration, severe hypokalemia, and significant hypochloremic metabolic alkalosis; may cause hyperuricemia; may produce deafness due to ototoxicity; administer oral dose with food or milk to decrease stomach upset


FOLLOW-UP

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Further Inpatient Care

  • Admit postoperative patients to a pediatric ICU experienced in dealing with congenital cardiac defects.
  • Provide postoperative treatment of heart failure and pulmonary hypertension until pulmonary vascular resistance normalizes.

Further Outpatient Care

  • Serial ECHO is a reliable and effective method for following patients on an outpatient basis. Late complications are rare.
  • Recurrent membrane stenosis from incomplete surgical resection can occur and is well demonstrated by ECHO. ECHO also may demonstrate residual pulmonary vein stenosis.
  • Postoperative function and exercise tolerance should approach normal. Long-term activity restrictions are unlikely.

In/Out Patient Meds

  • Medications include inotropes in patients with low cardiac output secondary to heart failure. Agents such as dopamine predominate in the ICU, while agents such as digoxin are sometimes used in the outpatient setting.
  • Diuretics are employed in patients with pulmonary edema.
  • Patients with pulmonary edema are unlikely to respond to inhaled nitric oxide preoperatively since the pulmonary hypertension is secondary to mechanical obstruction.

Transfer

  • Transfer to a major medical center experienced in operative and perioperative care of patients with congenital cardiac defects is mandatory.
  • If diagnosis is made in utero, delivery should be in an institution with a neonatal ICU and an ability to perform congenital cardiac surgery.

Complications

  • If the condition is unrecognized and untreated, problems include right heart failure and death.
  • Late complications include pulmonary vein stenosis with recurrence of symptoms. Similar symptoms occur late if the diaphragm is incompletely excised.

Prognosis

  • Prognosis without surgical repair is poor with a mortality rate of 75% in infancy.
  • Presence of associated cardiac anomalies adversely affects prognosis.
  • If the connection between the proximal and distal chambers is not very restrictive or if an atrial septal defect is present, prognosis is improved. In fact, in the latter patients, the defect may escape detection in infancy and present later in life.
  • Mortality associated with surgery is primarily in the immediate postoperative period and patients that survive can expect a late mortality rate of less than 10% and a near normal life expectancy. Late survivors have essentially normal lifestyles without sequelae from the anomaly or surgical correction. The short-term, 30-day mortality rate is 15-20%. Survivors have a 10% long-term mortality rate.

Patient Education

  • Successful surgical correction will allow return to a normal lifestyle without restriction of activity or need for medications.


MISCELLANEOUS

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Medical/Legal Pitfalls

  • Failure to diagnose this and other structural abnormalities in children with pulmonary hypertensive disease

Special Concerns

  • Patients should have an experienced congenital cardiac surgeon to treat this rare lesion. One of the few late complications is recurrence secondary to incomplete resection of the intra-atrial diaphragm.


MULTIMEDIA

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Media file 1:  Echocardiogram showing the proximal chamber (PC) and distal chamber (DC) of the left atrium. The right atrium (RA), left ventricle (LV), and right ventricle (RV) are also shown.Echocardiogram provided with permission from Guido Giordano, MD, Cardiovascular Department - Azienda Ospedaliera Cannizzaro, Catania, Italy, as shown at http://space.tin.it/scienza/guidogio/.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  ECG

Media file 2:  Echocardiogram provided with permission from Guido Giordano, MD, Cardiovascular Department - Azienda Ospedaliera Cannizzaro, Catania, Italy, as shown at http://space.tin.it/scienza/guidogio/.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  ECG

Media file 3:  Echocardiogram provided with permission from Guido Giordano, MD, Cardiovascular Department - Azienda Ospedaliera Cannizzaro, Catania, Italy, as shown at http://space.tin.it/scienza/guidogio/.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Image

Media file 4:  Echocardiogram provided with permission from Guido Giordano, MD, Cardiovascular Department - Azienda Ospedaliera Cannizzaro, Catania, Italy, as shown at http://space.tin.it/scienza/guidogio/.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Image

Media file 5:  Echocardiogram provided with permission from Guido Giordano, MD, Cardiovascular Department - Azienda Ospedaliera Cannizzaro, Catania, Italy, as shown at http://space.tin.it/scienza/guidogio/.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Image

Media file 6:  This film shows the classic pattern of pulmonary edema associated with pulmonary overcirculation and pulmonary venous obstruction. The patient has an anomalous pulmonary venous connection that was only obvious after a pulmonary artery shunt. The particular radiograph is not of a patient with cor triatriatum, but the appearance of prominent pulmonary vascularity is the same. Echocardiogram provided with permission from Guido Giordano, MD, Cardiovascular Department - Azienda Ospedaliera Cannizzaro, Catania, Italy, as shown at http://space.tin.it/scienza/guidogio/.
Click to see larger pictureClick to see detailView Full Size Image
 
Media type:  Video

Media file 7:  Echocardiogram provided with permission from Guido Giordano, MD, Cardiovascular Department - Azienda Ospedaliera Cannizzaro, Catania, Italy, as shown at http://space.tin.it/scienza/guidogio/.
Click to see larger pictureClick to see detailView Full Size Image
 
Media type:  Video

Media file 8:  Echocardiogram provided with permission from Guido Giordano, MD, Cardiovascular Department - Azienda Ospedaliera Cannizzaro, Catania, Italy, as shown at http://space.tin.it/scienza/guidogio/.
Click to see larger pictureClick to see detailView Full Size Image
 
Media type:  Video

Media file 9:  Echocardiogram provided with permission from Guido Giordano, MD, Cardiovascular Department - Azienda Ospedaliera Cannizzaro, Catania, Italy, as shown at http://space.tin.it/scienza/guidogio/.
Click to see larger pictureClick to see detailView Full Size Image
 
Media type:  Video

Media file 10:  Echocardiogram provided with permission from Guido Giordano, MD, Cardiovascular Department - Azienda Ospedaliera Cannizzaro, Catania, Italy, as shown at http://space.tin.it/scienza/guidogio/.
Click to see larger pictureClick to see detailView Full Size Image
 
Media type:  Video

Media file 11:  Echocardiogram provided with permission from Guido Giordano, MD, Cardiovascular Department - Azienda Ospedaliera Cannizzaro, Catania, Italy, as shown at http://space.tin.it/scienza/guidogio/.
Click to see larger pictureClick to see detailView Full Size Image
 
Media type:  Video


REFERENCES

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  • Tantibhedhyangkul W, Godoy I, Karp R, Lang RM. Cor triatriatum in a 70-year-old woman: role of transesophageal echocardiography and dynamic three-dimensional echocardiography in diagnostic assessment. J Am Soc Echocardiogr. Aug 1998;11(8):837-40. [Medline].

Cor Triatriatum excerpt

Article Last Updated: Jul 6, 2006