A Rare Case of the Right Atrial Diverticulum Encroaching the Left Ventricle

Usha Mandikal Kodandarama; Arnab Ghosh Chaudhury; Prabhavathi Bhat; Manjunath Cholenahally Nanjappa

doi:10.4103/jiae.jiae_3_21

INTERESTING CASE REPORT

Year : 2022 | Volume : 6 | Issue : 2 | Page : 129-131

A Rare Case of the Right Atrial Diverticulum Encroaching the Left Ventricle

Usha Mandikal Kodandarama¹, Arnab Ghosh Chaudhury², Prabhavathi Bhat¹, Manjunath Cholenahally Nanjappa¹
¹ Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
² Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka; Department of Cardiology, Vivekananda Hospital, Durgapur, West Bengal, India

Date of Submission	28-Jan-2021
Date of Decision	03-May-2022
Date of Acceptance	04-May-2022
Date of Web Publication	20-Jun-2022

Correspondence Address:
Dr. Arnab Ghosh Chaudhury
Flat No. A 801, Aquapolis Residential Complex, Tarashankar Sarani, Paschim Bardhaman, Durgapur - 713 216, West Bengal
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiae.jiae_3_21

Abstract

Single diverticulum of the right atrium is a rare congenital malformation. We describe echocardiographic and computed tomography scan findings of a congenital right atrial diverticulum and its successful surgical resection in a 5-year-old boy. A review of available literature is also done discussing the possible etiology and management of this disease entity.

Keywords: Diverticulum, echocardiography, right atrium

How to cite this article:
Kodandarama UM, Chaudhury AG, Bhat P, Nanjappa MC. A Rare Case of the Right Atrial Diverticulum Encroaching the Left Ventricle. J Indian Acad Echocardiogr Cardiovasc Imaging 2022;6:129-31

How to cite this URL:
Kodandarama UM, Chaudhury AG, Bhat P, Nanjappa MC. A Rare Case of the Right Atrial Diverticulum Encroaching the Left Ventricle. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2022 [cited 2023 Mar 20];6:129-31. Available from: https://jiaecho.org/text.asp?2022/6/2/129/347860

Introduction

Right atrial diverticulum is a rare cardiac condition, and only 21 cases are reported till date.^[1] The etiology and management of this condition is not well defined. Treatment options are conservative approach (in asymptomatic cases) and surgical excision. One school of thought favoring surgical treatment believes that surgery is justified to avoid fatal complications which have been reported with this disease entity.

Case Report

A 5-year-old boy came to our institute for cardiac evaluation. The patient had a history of occasional palpitations. General survey and cardiovascular system examinations were normal. Electrocardiogram was normal except occasional atrial premature complexes. Echocardiographic examination revealed a large diverticulum (6 cm × 4 cm) arising from the right atrial free wall encroaching toward the left ventricle [Figure 1] and [Video 1]. Color Doppler flow revealed small turbulent flow of blood moving in and coming out of the diverticulum [Figure 2] and [Video 2]. In tricuspid inflow view, it was clearly visible that the diverticulum was arising from the right atrial free wall [Figure 3] and [Video 3]. Subcostal short-axis view demonstrated that the right atrial diverticulum was encroaching the left ventricle [Figure 4]. Cardiac computed tomography (CT) scan clearly demonstrated a large (6 cm × 4 cm) right atrial diverticulum encroaching the left ventricle from the posterior aspect [Figure 5]. In view of the possible potential complications including sudden cardiac death, the patient was referred to the cardiothoracic and vascular surgery department. The right atrial diverticulum was surgically excised followed by repair of the right atrium. The surgical specimen of the excised diverticulum had a very thin parchment-like wall. The patient was discharged in a stable condition. He is doing well at present.

Figure 1: Modified parasternal long-axis view with anterior tilt showing diverticulum (yellow arrow) arising from the right atrium. D: Diverticulum, RA: Right atrium, RV: Right ventricle

Click here to view

Figure 2: Modified parasternal long-axis view showing blood flow (yellow arrow) into and from the right atrial diverticulum. D: Diverticulum

Click here to view

Figure 3: Tricuspid inflow view showing the diverticulum (yellow arrow) as a posterior structure. D: Diverticulum, RA: Right atrium, RV: Right ventricle

Click here to view

Figure 4: Subcostal short-axis view showing the right atrial diverticulum encroaching the left ventricle (yellow arrow). D: Diverticulum, LV: Left ventricle

Click here to view

Figure 5: Cardiac computed tomography scan showing the right atrial diverticulum (yellow arrow) encroaching the left ventricle. LV: Left ventricle, RA: Right atrium

Click here to view

Video 1: Modified parasternal long-axis view with anterior tilt showing the diverticulum arising from the right atrium.[Additional file 1]

Video 2: Modified parasternal long-axis view showing blood flow into and from the right atrial diverticulum.[Additional file 2]

Video 3: Tricuspid inflow view showing the diverticulum as a posterior structure.[Additional file 3]

Discussion

Right atrial diverticulum is a rare entity. It has been described as a saccular structure originating from the atrial free wall or the right atrial appendage.^[2] Differential diagnosis includes idiopathic dilatation of the right atrium and pericardial cyst. Color flow Doppler demonstrated turbulent flow in and out of the diverticulum in our case, indicating its communication to the right atrial cavity. Thus, it ruled out the possibility of a pericardial cyst. Right atrial diverticulum is a localized asymmetric outpouching with a narrow neck unlike idiopathic right atrial dilatation where the right atrium is dilated symmetrically. Proposed pathogenesis includes atrial variety of Uhl's anomaly or persistence of the left Cuvier vein. The wall of the diverticulum often demonstrates lipomatous degeneration and reduction of muscular elements.^[3] A literature review found that almost all reports had noted an absence of myocardial elements in the wall of the diverticulum, favoring the theory of localized Uhl's anomaly. Usually, these patients remain asymptomatic for a long time.^[4] Diagnosis is usually incidental during routine cardiac evaluation. Known complications are mechanical compression of the adjacent chambers, thromboembolism, atrial arrhythmias, and even sudden cardiac death.^[5],[6] Treatment is surgical excision in symptomatic cases^[5] or asymptomatic cases with a huge right atrial diverticulum.^[6] In our case, surgical excision was done in view of the relatively large size of the diverticulum.

Conclusion

Congenital right atrial diverticulum is a rare entity. Although, in majority of the cases, it is an incidental finding in asymptomatic individuals, it is known to cause arrhythmias, thromboembolism, and even sudden cardiac death. Timely surgical excision can prevent possible complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Tomar M, Radhakrishnan S, Iyer KS, Shrivastava S. Giant congenital diverticulum of the right atrium. Indian Heart J 2008;60:359-62.
2.	Morrow AG, Behrendt DM. Congenital aneurysm (diverticulum) of the right atrium. Clinical manifestations and results of operative treatment. Circulation 1968;38:124-8.
3.	Tenckhoff L, Stamm SJ, Beckwith JB. Sudden death in idiopathic (congenital) right atrial enlargement. Postmortem findings and review of cases. Circulation 1969;40:227-35.
4.	Asayama J, Matsuura T, Endo N, Matsukubo H, Furukawa K. Idiopathic enlargement of the right atrium. Am J Cardiol 1977;40:620-3.
5.	Binder TM, Rosenhek R, Frank H, Gwechenberger M, Maurer G, Baumgartner H. Congenital malformations of the right atrium and the coronary sinus: An analysis based on 103 cases reported in the literature and two additional cases. Chest 2000;117:1740-8.
6.	Agematsu K, Okamura T, Ishihara K, Kurosawa H. Remarkable giant right atrial diverticulum in asymptomatic patient. Interact Cardiovasc Thorac Surg 2009;8:705-7.