Anatomy of a wrong diagnosis: false Sinus Venosus Atrial Septal Defect
© Gaibazzi et al; licensee BioMed Central Ltd. 2003
Received: 18 October 2003
Accepted: 07 November 2003
Published: 07 November 2003
In contrast with transthoracic echocardiography, transesophageal echocardiography provides a sure way to make the diagnosis of sinus venosus atrial septal defect; on the other hand this abnormality is more complex than that seen with the secundum atrial septal defect, and inexperienced operators may fail to recognize properly the defect. In front of a high reported sensitivity using transesophageal echocardiography, specificity is difficult to assess, due to possible underreporting of diagnostic errors. We describe a false positive diagnosis of sinus venosus atrial septal defect, in the setting of enlarged right chambers of the heart because of pressure overload. Modified anatomy of the heart, together with the presence of a prominent linear structure(probably Eustachian Valve) and an incomplete examination in this case made image interpretation very prone to misinterpretation. In this anatomical setting transesophageal longitudinal "bicaval" view may be sub-optimal for examining the atrial septum, potentially showing false images that need to be known for correct image interpretation. Nonetheless, a scan plane taken more accurately at the superior level would have demonstrated/excluded the pathognomonic feature of sinus venosus atrial septal defect in the high atrial septum, between the fatty limbus and the inferior aspect of the right pulmonary artery; moreover TEE allows morphological information about the posterior structures of the heart that need to be investigated in detail for a complete diagnosis.
Transthoracic echocardiography has high sensitivity to detect secundum-type atrial septal defects(ASDs) and up to 100% for defects of the interatrial foramen primum, while its diagnostic usefulness for more uncommon causes of shunting at the atrial level is considerably less [1, 2]. In particular, diagnostic images of the sinus venosus atrial septal defect (SVD) usually are not obtainable in most adults .
In contrast to clinical examination or transthoracic echocardiography, transesophageal echocardiography (TEE) provides a sure way to make the diagnosis of SVD; on the other hand this abnormality is more complex than that seen with the secundum ASDs, and inexperienced operators may fail to recognize the defect. TEE is a highly accurate means to diagnose SVD, especially when performed by experienced operators .
In front of a high reported sensitivity for SVD diagnosis, specificity is difficult to assess, due to possible underreporting of diagnostic errors.
The following case report is to date the first in medical literature to describe a false positive diagnosis of SVD, even if probably it is not such a rare mistake, particularly in the setting of modified heart anatomy.
A 30-year-old woman presented for evaluation of multiple syncopal spells. She had been in her usual state of health until four months earlier when first syncopal episode presented; since then she has had five similar episodes. She was not using any type of medication; five years earlier she gave birth to a healthy baby, following an uncomplicated pregnancy. She described her syncopal episodes as typical for true syncope: episodes were 1) transient, 2) self-limited 3) leading to falling, 4) the onset was relatively rapid with spontaneous recovery.
Echocardiogram showed: massive dilatation of both the right atrium and the right ventricle, with a high estimated systolic pulmonary artery pressure = 75 mmHg. 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).
On the contrary cardiac cath ultimately demonstrated the absence of whatsoever ASD, confirming the presence of pulmonary hypertension, consequently diagnosed as primary.
We analyzed all the TEE images once again, trying to figure out where the diagnostic error originated; longitudinal "bicaval view" is usually utilized in TEE to investigate the atrial septum in its supero-posterior limbus, on a vertical plane starting from the inferior vena cava through the superior vena cava. In this case it is possible that this very view, usually ideal for most common secundum-ASDs detection, was misleading and inappropriately obtained, so that high atrial septum was not shown.
We can only speculate about the nature of this "false atrial septum" structure: it probably represents a prominent Eustachian Valve or it could be part of the Chiari network or it could simply be generated by right atrial extreme distortion and enlargement.
Nonetheless TEE examination was at best incomplete in this case, since we obtained only mid-atrial longitudinal images (fig. 3, fig. 5, Video 1-see additional file 1) not only inappropriate for SVD-Superior Vena Cava type diagnosing, but misleading in this particular anatomical setting.
This type of ASD can be correctly diagnosed only by a higher longitudinal scan with respect to the one we performed during the above-mentioned TEE exam.
Moreover TEE has the potential to show morphological information about the posterior structures of the heart, that always need to be investigated in detail for a complete diagnosis since, in one third of the cases, SVD-Superior Vena Cava type is associated with anomalous entry of the right pulmonary veins to the heart.
a) An incomplete TEE exam, with no images of the most superior part of the atrial septum(between the fatty limbus and the inferior aspect of the right pulmonary artery) and b)the unlucky contextual presence of a prominent Eustachian Valve and a very dilated right heart, together were responsible for wrong image interpretation in this case; nonetheless careful evaluation of different views with different probe/beam orientation by a more experienced operator could have established the correct diagnosis.
Echocardiographers performing TEE should be aware of this pitfall when examining patients with enlarged right chambers and abnormal heart orientation; this may be more relevant for "real-world" adult echocardiographers, generally poorly trained in recognition of the rarest congenital abnormalities.
Mid-atrial longitudinal "bicaval" view, normally utilized to diagnose most common ASDs, is sub-optimal for SVD-Superior Vena Cava type; it is not only insufficient for a complete examination of the higher atrial septum, but, particularly when confronted with modified heart anatomy, it may potentially show false images that need to be taken into consideration for correct image interpretation.
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