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   Case report
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Table of Contents
CASE REPORT  
Year : 2014  |  Volume : 17  |  Issue : 4  |  Page : 309-310
Large Eustachian valve: An incidental finding yet perplexing


1 Department of Cardiac Anaesthesia, Pushpanjali Crosslay Hospital, Vaishali, Ghaziabad, Uttar Pradesh, India
2 Department of CTVS, Pushpanjali Crosslay Hospital, Vaishali, Ghaziabad, Uttar Pradesh, India

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Date of Submission24-Mar-2014
Date of Acceptance18-Aug-2014
Date of Web Publication1-Oct-2014
 

   Abstract 

Eustachian valve (EV), a remnant of the right valve of sinus venosus in the right atrium can be puzzling. Often it is confused with Chiari network or atrial adhesions and is reported with unusual complications. We report a case of large EV impeding cannulation of inferior vena cava (IVC) during aortic valve replacement. Transesophageal echocardiography diagnosed the presence of large EV and warned of the difficulty with IVC cannulation and helped preparedness for an alternative plan during surgery.

Keywords: Eustachian valve; Inferior vena cava cannulation; Transesophageal echocardiography

How to cite this article:
Sarupria A, Bhuvana V, Mani M, Kumar A S. Large Eustachian valve: An incidental finding yet perplexing. Ann Card Anaesth 2014;17:309-10

How to cite this URL:
Sarupria A, Bhuvana V, Mani M, Kumar A S. Large Eustachian valve: An incidental finding yet perplexing. Ann Card Anaesth [serial online] 2014 [cited 2019 Nov 19];17:309-10. Available from: http://www.annals.in/text.asp?2014/17/4/309/142073



   Introduction Top


Remnants in the right atrium (RA), due to incomplete resorption of the right valve of sinus venosus, can be perplexing. One of these structures, the  Eustachian valve More Details (EV), is often reported with unusual complications. [1] We report a case where a large EV impeded cannulation of inferior vena cava (IVC) during aortic valve replacement (AVR).


   Case report Top


A 58-year-old woman was admitted with complaints of worsening dyspnea and chest pain since 3 months. Examination of the cardiovascular system revealed an ejection systolic murmur in 2 nd intercostal space radiating to carotids. Chest roentgenogram revealed cardiomegaly with calcified aortic knuckle. Further two-dimensional transthoracic echocardiography (TTE) showed calcified aortic valve with severe aortic stenosis, mild aortic regurgitation and trivial mitral regurgitation. Coronary angiogram showed normal coronaries. Transesophageal echocardiography (TEE) during pre-bypass period confirmed the TTE finding and also showed a large linear structure originating from anterior rim of IVC coiling into RA with an extension to the interatrial septum; the finding was informed to the operating surgeon. The cardiopulmonary bypass (CPB) was planned with aortic and dual stage single venous RA cannulation. However, after aortic cannulation, repeated attempts to advance cannula in IVC failed even under TEE guidance. IVC cannulation with dual-stage venous cannula was abandoned, and bicaval cannulation was performed for the establishment of CPB. Thereafter, AVR was performed, and the remaining course of the patient remained uneventful.


   Discussion Top


In general a dual-stage singe venous catheter (right atriocaval cannulation) is preferred in patients undergoing AVR and/or coronary artery bypass grafting and provides adequate venous return for CPB. In some cases, insertion of the cannula tip into the IVC becomes difficult requiring bicaval cannulation. The difficulty in IVC cannulation can be due to various factors like atrial adhesions; tumors, vegetation's, thrombus, Chiari network or a large EV. [2] Peculiar relationship of this long linear nonfilamentous structure with IVC and its extension to the interatrial septum favors the diagnosis of large EV. This finding on TEE was later on confirmed by operating surgeon. There are reports of long EV interfering access to the coronary sinus during pacemaker implantation [3] but none describing difficulty in venous cannulation. Forcing of the cannula can be harmful and may lead to damage and hazardous bleeding complications. In our patient difficulty in IVC, cannulation was due to a large EV [Figure 1]. Though diagnosis of long EV was an incidental finding, it became important.
Figure 1: Thick rim of eustachian valve at the inferior vena cava opening into the right atrium

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A persistent EV is present in about 67% of children, but it is visualized in only 0.20% adults undergoing routine echocardiographic examinations. [4],[5] There is a large variability in size, shape, thickness, and texture of the persistent EV. The average length of the EV is 3.6 mm with a range of 1.5-23 mm. [1] In our patient, it was a long EV and measured approximately 50-60 mm [Figure 2]. A persisting EV without other structural heart disease is believed to have no clinical importance. However, a long EV can be mistaken for "cor triatriatum dexter" [6] or an atrial septal defect. [7] Tumors, cysts or vegetation's can originate from the EV. [8],[9] Venous thrombi migrating from the upper or lower extremities can be entrapped by the EV, which further can result in pulmonary or paradoxical embolism. [10] In the present patient, the EV was excised to prevent these complications.
Figure 2: Large serpiginous eustachian valve fl oating into the right atrium anteriorly from inferior vena cava

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To summarize, a long EV can interfere access to IVC cannulation. Thus, a structured and detailed right atrial anatomy described with TEE ensured preparedness during surgery.

 
   References Top

1.Limacher MC, Gutgesell HP, Vick GW, Cohen MH, Huhta JH. Echocardiographic anatomy of the eustachian valve. Am J Cardiol 1986;57:363-5.  Back to cited text no. 1
[PUBMED]    
2.Ionac A, Dragulescu A, Mornos C, Gaspar M, Slovenski M, Stefan losif Dragulescu. Large eustachian valve - A puzzling echocardiographic diagnosis and a difficult therapeutic management. Timisoara Med J 2004;54:4.  Back to cited text no. 2
    
3.Uçar O, Canbay A, Diker E, Aydogdu S. Long Eustachian valve interfering with the access to coronary sinus during biventricular pacemaker implantation. Anadolu Kardiyol Derg 2010;10:185-6.  Back to cited text no. 3
    
4.Schuchlenz HW, Saurer G, Weihs W, Rehak P. Persisting eustachian valve in adults: Relation to patent foramen ovale and cerebrovascular events. J Am Soc Echocardiogr 2004;17:231-3.  Back to cited text no. 4
    
5.Schrem SS, Freedberg RS, Gindea AJ, Kronzon I. The association between unusually large eustachian valves and atrioventricular valvular prolapse. Am Heart J 1990;120:204-6.  Back to cited text no. 5
    
6.Yavuz T, Nazli C, Kinay O, Kutsal A. Giant eustachian valve with echocardiographic appearance of divided right atrium. Tex Heart Inst J 2002;29:336-8.  Back to cited text no. 6
    
7.Becker A, Buss M, Sebening W, Meisner H, Döhlemann C. Acute inferior cardiac inflow obstruction resulting from inadvertent surgical closure of a prominent Eustachian valve mistaken for an atrial septal defect. Pediatr Cardiol 1999;20:155-7.  Back to cited text no. 7
    
8.Bonde P, Sachithanandan A, Graham AN, Richardson SG, Gladstone DJ. Right atrial myxoma arising from the Eustachian valve in a patient with colonic polyposis. J Heart Valve Dis 2002;11:601-2.  Back to cited text no. 8
    
9.Sawhney N, Palakodeti V, Raisinghani A, Rickman LS, DeMaria AN, Blanchard DG. Eustachian valve endocarditis: A case series and analysis of the literature. J Am Soc Echocardiogr 2001;14:1139-42.  Back to cited text no. 9
    
10.Munir A, Minderman D, D'Cruz I. Unusual superior vena cava thrombus (partly obstructive) extending through right atrium to eustachian valve. Echocardiography 2007;24:77-8.  Back to cited text no. 10
    

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Correspondence Address:
Anju Sarupria
3rd Floor, Department of Cardiac Anaesthesia, Puspanjali Crosslay Hospital, Vaishali,
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.142073

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    Figures

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