Unmasking of a Sinus Venosus Atrial Septal Defect During Right Coronary Artery Myocardial Infarction

Figures

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  Visual Summary. Anatomical Changes post Right Myocardial Infarct vs Sinus Venous Defect with Right Myocardial Infarct (A) Dilated RV after RV infarct. (B) Dilated RV and RA as seen in sinus venosus defect with right myocardial infarction. RA = right atrium; RV = right ventricle.

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  Figure 1. Admission and Discharge Electrocardiograms (A) Inferior ST-segment elevation myocardial infarction with junctional rhythm. (B) Atrial ectopic rhythm with resolution of ST-segment changes.

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  Figure 2. Coronary Angiogram Primary PCI (A) Ostially occluded RCA. (B) TIMI flow grade 3 after drug-eluting stent to ostial/proximal RCA. PCI = percutaneous coronary intervention; RCA = right coronary artery.

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  Figure 3. TTE + Bubble Study (A) Severely dilated RV/RA. (B) No color flow across atrial septum. (C) Early positive bubble study (bubbles in left-sided and right-sided chambers almost simultaneously). RA = right atrium; RV = right ventricle; TTE = transthoracic echocardiography.

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  Figure 4. CT Pulmonary Angiography Right upper (RU) and right middle (RM) pulmonary veins (PVs) draining into SVC. CT = computed tomography; SVC = superior vena cava.

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  Figure 5. Transesophageal Echocardiography Findings (A) Severely dilated RV/RA. (B and C) Bicaval view of sinus venosus ASD with bidirectional shunt. (D) Basal view with RU PV (right upper pulmonary vein) draining into the SVC. ASD = atrial septal defect; RA = right atrium; RV = right ventricle; SVC = superior vena cava.

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  Figure 6. Transesophageal Echocardiography Findings (A) No secundum ASD. (B) Moderate to severe tricuspid regurgitation. (C) Normal estimated pulmonary artery systolic pressure (18 mm Hg + RAP). TEE Qp:Qs ratio was 2.2. (D) Two- and 3-chamber views of LV with normal systolic function. ASD = atrial septal defect; LV = left ventricle; Qp:Qs = pulmonary-to-systemic flow; RAP = right atrial pressure; TEE = transesophageal echocardiography.

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  Figure 7. Results of Right Heart Catheterization With Oxygen Saturation Levels Step up in oxygen saturations from the SVC/IVC to the RA. Mild mixed pre- and postcapillary pulmonary hypertension with a Qp:Qs ratio of 2.0. CI = cardiac index; CO = cardiac output; HR = heart rate; IVC = inferior vena cava; PA = pulmonary artery; PVR = pulmonary vascular resistance; Qp:Qs = pulmonary-to-systemic flow; RA = right atrium; RV = right ventricle; SV = stroke volume; SVC = superior vena cava.

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  Figure 8. Cardiac MRI (A) Four-chamber severely dilated RA and RV with mild-moderate systolic impairment. (B) No inferior wall LGE. (C) Axial sequence showing right upper and right middle lobe PV draining into the SVC. (D) No RV LGE. MRI = magnetic resonance imaging; RA = right atrium; RV = right ventricle; PV = pulmonary vein; SVC = superior vena cava.

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  Figure 9. TTE 2 Months Postsurgery (A) Mildly dilated RV with mild systolic impairment. (B) TV annuloplasty ring with no transvalvular or paravalvular regurgitation. (C) Postoperative RV measurements (RV base: 40 mm). (D) Preoperative RV measurements for comparison (RV base: 53 mm). RV = right ventricle; TTE = transthoracic echocardiography; TV = tricuspid valve.