Resection of Cor Triatriatum Dexter via Vertical Right Axillary Thoracotomy in an Infant

This patient is an eight-week-old, 4.6 kg infant who was diagnosed postnatally with cor triatriatum dexter and a patent foramen ovale. A follow-up was recommended at that time, as she was asymptomatic. She presented at eight weeks of age with intermittent cyanosis. She had no prior surgical or significant medical history. A preoperative chest X-ray showed situs solitus with levocardia and no obvious pathology. A preoperative electrocardiogram showed sinus rhythm and prolonged QT. A transesophageal echocardiogram showed the cor triatriatum dexter membrane extending from the mouth of the inferior vena cava (IVC) to just below the superior vena caval (SVC) junction. There were small fenestrations in the membrane near the IVC with laminar flow across the opening. The membrane was prolapsing into the tricuspid valve (TV) annulus in diastole with mild TV inflow gradient.

The decision was made to proceed with surgical resection via a vertical right axillary thoracotomy (VRAT). In these cases, the patient is positioned in the modified left lateral decubitus position with the right side up, and a routine erector spinae block catheter is placed.

The Surgery

First, a 5 cm vertical skin incision was made in the right midaxillary line from the third to fifth intercostal spaces. Bilateral skin and subcutaneous flaps were created with electrocautery. The right chest was entered through the right fourth intercostal space. The right lung was retracted, and the pericardium was exposed. Next, the right lobe of the large thymus was resected, and the pericardial sac was entered anterior to the right phrenic nerve. Heparin was administered and the ascending aorta was cannulated with an 8 French arterial cannula, followed by the superior and inferior venae cavae. Caval snares were placed, and cardiopulmonary bypass was initiated without difficulty. 

After this, an ascending aorta cardioplegia needle was placed. The ascending aorta was cross-clamped and cardioplegic arrest was achieved with antegrade cardioplegia. Both cavae were snared, and an oblique right atriotomy was performed. Then stay sutures were placed. A large membrane was clearly visualized inside the right atrium with multiple fenestrations, and the membrane was resected in its entirety. The patent foramen ovale was subsequently closed using running 5-0 Prolene sutures.

Next, the right atriotomy was closed using running 5-0 Prolene sutures. The heart was then deaired and the cross-clamp was removed. The patient was then weaned off cardiopulmonary bypass, and once transesophageal echocardiogram was satisfactory, all cannulas were removed and protamine was administered. The pericardium was partially closed with interrupted Prolene sutures, and the chest was closed in a routine fashion.

The aortic cross-clamp time was twenty-five minutes, and the bypass time was thirty-six minutes. The patient’s postoperative course was uneventful. She was extubated in the operating room, and she was discharged on post operative day two. She continued to do well during her follow-up appointment.

References

1. Said SM. Commentary: Cor triatriatum dexter: A tale of 2 horns. JTCVS Tech 2020 Sep 14; 4: 259-260
2. Aliyu I, Ibrahim ZF. Cor-Triatriatum Dexter with Associated Cyanosis in a 3-Month-Old Girl. J Cardiovasc Echogr. 2018 Apr-Jun;28(2):143-145
3. Alghamdi MH. Cor triatriatum dexter: A rare cause of cyanosis during neonatal period. Ann Pediatr Cardiol. 2016 Jan-Apr;9(1):46-8
4. Kalangos A., Shatelen N., Demyanchuk V., Ruban N., Sfyridis P., Todurov B. Cor triatriatum dexter in children: literature review and case report. J Thorac Cardiovasc Surg Tech. 2020;4:254–258

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The author S.M.S is a consultant for Artivion, Abbott, and Stryker.

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