PMC270092_01
ECG and transthoracic echocardiogram. ECG shows qR pattern in V1, QRS right axis deviation and diffuse repolarization abnormalities; transthoracic echocardiogram, apical 4-chamber view shows dilatation of the right atrium and of the right ventricle(max. diameter = 57 mm).
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F1
There was no clear evidence for any of the commonly diagnosed adult congenital abnormalities causing left to right shunt (ASDs, ventricular septal defect, patent ductus arteriosus) (Fig 1).
Contrast-enhanced chest CT scan. Four-chamber view of the heart. Right cavities enlargement with consequential abnormal anatomical orientation of the heart; leftward shift of the atrial septum is clearly shown.
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F2
CT scan of the chest, performed with the intent to rule out the presence of pulmonary thromboembolism was negative but confirmed right cavities enlargement with a consequential abnormal anatomical orientation of the heart; leftward shift of the atrial septum was evident too (Fig 2).
TEE-Midesophageal longitudinal view of both the atria and venae cavae. TEE shows the presence of a big ASD(maximum diameter = 29 mm), SVD-superiorvena cava type. RA=right atrium, LA=left atrium, IVC=inferior vena cava, SVC=superior vena cava.
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F3
Transesophageal echocardiogram (TEE) showed the presence of a big ASD(maximum diameter = 29 mm), (Fig 3).
Same 4-chamber image as in Figure 2; the direction of the ultrasound beam, from the esophagus through the right atrium, is represented in yellow.
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F4
TEE-Bicaval longitudinal view. Same image as in Fig. 3 correctly reinterpreted. Image is reinterpreted in light of the atypical anatomy obtained by the cut-plane used, indicated by the yellow line in Fig. 4. Caption is consequently changed in the image. RA=right atrium, IVC=inferior vena cava, SVC=superior vena cava.
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F5
In this setting the presence of a linear echogenic structure, mistakenly interpreted as the atrial septum, apparently showed the absence of the superior limbus of the atrial septum, typical for SVD (Fig. 5).
a) Same image as in Fig. 5, reoriented to be compared with Fig. 6b; the right part is added to show "virtual" anatomy(yellow line-drawing in the grey sector), should the probe be placed higher in the esophagus; b) Modified from"The echo manual 2nd edition" by Oh JK, Seward JB, Tajik AJ. SVD image obtained using the correct scan plane(higher transducer positioning compared with Fig. 6a) for imaging of the higher atrial septum and eventual SVD; the presence of the right pulmonary artery(RPA), here showed in its short axis, posteriorly to the fatty limbus of the atrial septum, confirms correct positioning for eventual SVD imaging(SVD is definitely present in this case).
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F6