A prominent crista terminalis associated with atrial septal aneurysm that mimics right atrial mass leading to atrial arrhythmias: a case report
© Bolognesi and Bolognesi; licensee BioMed Central Ltd. 2012
Received: 2 August 2012
Accepted: 24 October 2012
Published: 26 November 2012
The crista terminalis is a variant of normal anatomical structures within the right atrium that mimics an atrial mass on a transthoracic echocardiogram. Atrial septal aneurysm is a rare but well-recognized cardiac abnormality of uncertain clinical significance. The association between crista terminalis and atrial septal aneurysm is unusual but not completely casual. Both anatomical heart structures can lead to atrial arrhythmias.
This case report describes the accidental discovery during an echocardiographic examination of a 64-year-old Caucasian woman who had a left bundle branch block and palpitations.
The clinical relevance of this anatomical evidence in unknown. This was an occasional finding of transthoracic echocardiography, but in this case it is possible to assume its relationship with the occurrence of atrial arrhythmias, and also that computed tomography scan and cardiovascular magnetic resonance is mandatory to define the structure and function of these incidental findings.
KeywordsAtrial arrhythmias Atrial septal aneurysm Cardiovascular magnetic resonance Computed tomography scan Echocardiography Prominent crista terminalis
The crista terminalis is a fibromuscular vertical ridge of smooth myocardium within the right atrium of the heart. It is located on the posterolateral wall of the chamber. It extends between the right side of the orifice of the superior vena cava inferiorly to the right side of the valve of the inferior vena cava. The echocardiographic finding of a prominent crista terminalis can mimic a right atrial mass, such as a tumor or thrombus[2, 3]. Atrial septal aneurysm (ASA) is a rare cardiac abnormality of uncertain clinical significance; it has a variable incidence but transthoracic echocardiographic (TTE) studies estimate the rate to be between 0.08% and 1.2%. It is recognized as a bulging of the thin, billowing septal tissue typically involving the region of the fossa ovalis. ASA is generally considered benign, but it has been associated with atrial septal defects, atrioventricular valvular prolapse[5, 6], and atrial arrhythmias. Manifestations attributed to ASA are atrial arrhythmias and arterial embolism. Interatrial septal aneurysm can act as an arrhythmic focus, generating focal atrial tachycardias.
Approximately two thirds of focal right atrial tachycardias occurring in the absence of structural heart disease will arise from along the crista terminalis. Descriptions of the association between prominent crista terminalis and ASA are rare, and both are important anatomic structures responsible for atrial tachyarrhythmias. In this case report we describe the original association between a prominent terminal ridge, which appeared as a ‘mass’ in the right atrium that needed to be differentiated from a pathological cardiac mass, and a small ASA, in a clinical context of dyspnea and palpitations in a woman with probable atrial tachyarrhythmias. The identification of physiological structures in the right atrium on TTE using subsequent cardiovascular magnetic resonance (CRM) imaging can avoid additional unnecessary, more invasive and expensive tests such as transesophageal echocardiography.
In a recent report, normal right atrial structures were identified using MRI in 59% of 149 healthy patients. These structures included the Eustachian valve, Thebesian valve, persistent sinus venosus, crista terminalis and the Chiari network. Most of these normal anatomic structures in the right atrium are not visualized on TTE routine standard views. The crista terminalis and ASA are important anatomical structures that can not only mimic pathological atrial mass, but can also be the site of origin of right atrial tachyarrhythmias, referred to as ‘cristal tachycardias’ or paroxysmal atrial fibrillation and atrial flutter, by initiating ectopic atrial beats[7–9]. For these reasons, their association is highly suspected to be the cause of not well-identified arrhythmias, and particularly for the patient described in this report who had a history of recurrent palpitations.
We consider this report interesting for the following reasons: (1) it concerns a rare anatomical finding (namely the combination between crista terminalis and ASA); (2) the discovery of such an abnormality is incidental; (3) an unusual anatomy can produce atrial arrhythmias; and (4) TTE with subsequently CT scan or CMR are mandatory to define the structure and function of these anatomical findings.
Informed consent was collected from the patient for the procedures performed. Consent for data publication was also collected from the patient.
Written informed consent was obtained from the patient for publication of this manuscript and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
We would like to thank Filippo Cademartiri and Erica Maffei for their assistance in the preparation of the manuscript.
- Ho SY, Anderson RH, Sanchez-Quintana D: Gross structure of the atriums: more than an anatomic curiosity?. Pacing Clin Electrophysiol. 2002, 25: 342-350. 10.1046/j.1460-9592.2002.00342.x.View ArticlePubMed
- D’Amato N, Pierfelice C, D’Agostino C: Crista terminalis bridge: a variant mimicking right atrial mass. Eur J Echocardiogr. 2009, 10: 444-445. 10.1093/ejechocard/jen316.View ArticlePubMed
- Gaudio C, Di Michele S, Cera M, Nguyen BL, Pannarale G, Alessandri N: Prominent crista terminalis mimicking a right atrial mixoma: cardiac magnetic resonance aspects. Eur Rev Med Pharmacol Sci. 2004, 8: 165-168.PubMed
- Hanley PC, Tajik AJ, Hynes JK, Edwards WD, Reeder GS, Hagler DJ, Seward JB: Diagnosis and classification of atrial septal aneurysm by two-dimensional echocardiography: report of 80 consecutive cases. J Am Coll Cardiol. 1985, 6: 1370-1382. 10.1016/S0735-1097(85)80228-X.View ArticlePubMed
- Rahko PS, Xu QB: Increased prevalence of atrial septal aneurysm in mitral valve prolapse. Am J Cardiol. 1990, 66: 253-257.View Article
- Schneider B, Hofmann T, Meinertz T: Atrial septal aneurysm: is there an association between arrhythmias and stroke?. Circulation. 1993, 88 (suppl I): I-222-
- Sanchez-Quintana D, Anderson RH, Cabrera JA, Climent V, Martin R, Farre J: The terminal crest: morphological features relevant to electrophysiology. Heart. 2002, 88: 406e11-View Article
- Gibelli G, Biasi S: Another right atrial pitfall: prominent crista terminalis and atrial septal aneurysm. J Cardiov Echography. 2011, 21: 179-182. 10.1016/j.jcecho.2011.09.005.View Article
- Kalman JM, Olgin JE, Karch MR, Hamdan M, Lee RJ, Lesh MD: “Cristal tachycardias”: origin of right atrial tachycardias from the crista terminalis identified by intracardiac echocardiography. J Am Coll Cardiol. 1998, 31: 451e9-View Article
- Ducharme A, Tardif JC, Mercier LA, Burelle D, Rodrigues A, Petitclerc R: Remnants of the right valve of the sinus venosus presenting as a right atrial mass on transthoracic echocardiography. Can J Cardiol. 1997, 13: 573e6-
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.