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Year : 2020  |  Volume : 14  |  Issue : 2  |  Page : 50-52

A large eustachian valve, rare to spot

CVTA Department, Seth G S Medical College and KEM Hospital, Mumbai, Maharashtra, India

Date of Submission01-Mar-2020
Date of Decision01-Jul-2020
Date of Acceptance29-Jul-2020
Date of Web Publication20-Nov-2020

Correspondence Address:
MBBS, DNB Renu Upadhyay
DM Resident, Department of Cardiovascular and Thoracic Anesthesia (CVTA), Seth G S Medical College and K.E.M. Hospital, Mumbai, Maharashtra, 400012
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejca.ejca_4_20

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Intraoperative use of transesophageal echocardiography (TEE) can detect a structure that is in reality a rare variant. We are reporting a case where we incidentally found large eustachian valve (EV) on transesophageal echocardiography which was missed on transthoracic echocardiography. It was giving right atrium two chamber appearance. We will recommend the importance of obtaining multiple echocardiographic views routinely during TEE to diagnose and differentiate such structures and its implications.

Keywords: eustachian valve, IVC, right atrium, transesophageal echocardiography

How to cite this article:
Upadhyay R, Ramteke JH, Nebu R, Umbarkar S. A large eustachian valve, rare to spot. Egypt J Cardiothorac Anesth 2020;14:50-2

How to cite this URL:
Upadhyay R, Ramteke JH, Nebu R, Umbarkar S. A large eustachian valve, rare to spot. Egypt J Cardiothorac Anesth [serial online] 2020 [cited 2020 Nov 24];14:50-2. Available from:

  Introduction Top

Intraoperative use of transesophageal echocardiography (TEE) can detect a structure that is in reality a rare, yet normal, variant. It may lead to unnecessary surgical intervention [1]. We report a case where we incidentally found a large  Eustachian valve More Details (EV) on TEE, which was missed in preoperative transthoracic echocardiography. EV was giving the right atrium (RA) a two-chamber appearance.

  Case report Top

A 41-year-old woman, an operated case of mitral valve replacement 20 years back, admitted with complaints of severe respiratory distress, palpitation, and pedal edema since 1 week. On investigation, the patient had atrial fibrillation. On transthoracic echocardiography, normally functioning mitral prosthetic valve in situ was noted. Inferior vena cava was dilated (IVC of 28 mm) and congested, dilated RA reached a size of 76 mm and left atrium 62 mm, severe tricuspid regurgitation, tricuspid valve annulus was 54 mm, tricuspid annular plane systolic excursion was 14 mm, and right heart dysfunction was also noted. Coronary angiography was normal.

The patient was planned for tricuspid valve replacement after medical stabilization.

On the day of surgery, after confirming NPO status, the patient was shifted to OT. Standard monitors were attached and left radial artery and right internal jugular vein were secured. General anesthesia was given as per the institutional protocol. As it was a redo surgery, femoral artery and vein were kept ready for peripheral bypass as a standby to aortobicaval cannulation.

Intraoperative TEE showed dilated RA of 8.5 cm, Tricuspid valve annulus of 4.61 cm ([Figure 1]), large central TR jet, IVC 2.45 cm, and coronary sinus of 1.25 cm. An unusual structure was noticed in the RA, which appears to be dividing RA into two chambers. It was like a membranous structure, 6.89 cm, extending from IAS and traceable to the IVC–RA junction (Video 1 and [Figure 2]).
Figure 1 TEE mid-esophageal 4-chamber view showing tricuspid annulus (46 mm) and dilated right atrium (85 mm). TEE, transesophageal echocardiography.

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Figure 2 TEE view (mid-esophageal four-chamber, probe turned to right) showing large eustachian valve (6.89 cm) (divided right atrium look). TEE, transesophageal echocardiography.

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After adequate heparinization, median sternotomy with oscillating saw was done followed by aortobicaval cannulation. The surgeon decided to go for cardiopulmonary bypass and beating heart tricuspid valve replacement.

Right atriotomy was done, and a huge EV was noticed. Tricuspid valve was replaced with bioprosthetic valve. Patient came out of cardiopulmonary bypass on Milrinone infusion (0.5 μg/kg/min) and protamine was given. The rest of the course was uneventful.

  Discussion Top

EV is due to the persistence of the right sinus venosus valve. It can present as a thin fibrous or membranous structure or as a fold of the endocardium. It usually arises from the anterior rim of the IVC orifice [2]. A persistent EV is seen in only 0.20% of adults during echocardiographic examination. Their presentations vary in size, shape, thickness, and extension. The approximate length of the EV noted is 3.6 mm with a range of 1.5–23 mm [3]. It may give divided RA look on echocardiography [4]. It can be mistaken with clot/thrombus, tumors, or vegetations or for ‘cor triatriatum dexter’ [5]. Cor triatriatum dexter results from persistence of the entire right sinus venosus valve, which forms a large, obstructive flap across the RA and divides it into two chambers. This cardiac malformation can be differentiated from the giant EV dividing the RA, by echocardiographic demonstration of the atrial septal defect and by the presence of cyanosis in cor triatriatum [6].

Occasionally, a large EV can obstruct the flow, causing a dilated IVC. Sometimes a prominent EV was mistaken for the atrial septum and surgically closed for instead of ASD. It can cause lower inflow obstruction [7]. A persisting EV can prevent spontaneous closure of PFO after birth and directs the blood from the inferior cava to the interatrial septum, which may predispose to paradoxical embolism and stroke [8],[9]. Its other reported complications are hindrance in cannulation especially dual-stage single-venous RA cannulation, endocarditis (specially in intravenous drug abusers), and very rarely myoma or fibroelastoma can arise from EV [10].

In our case, it was an accidental finding during intraoperative TEE. EV was huge in size, making the RA to look like two chambered. IVC and hepatic artery were dilated but mostly due to tricuspid regurgitation and not due to obstruction to IVC. In various TEE views, its course was traced to be arising from the anterior rim of the IVC orifice and end at the orifice of the coronary sinus. Although peripheral bypass was not done in our case, in case it had been needed, EV would have proved difficult for cannulation.

We will recommend the importance of obtaining multiple echocardiographic views routinely during TEE to diagnose and differentiate such structures and its implications.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Chaney MA. Transesophageal echocardiography and normal variants. Anesth Analg 1995; 81:1112–1113.  Back to cited text no. 1
Martínez‐Quintana E, Rodríguez‐González F, Marrero‐Santiago H, Santana‐Montesdeoca J, López‐Gude MJ. Cor triatriatum dexter versus prominent eustachian valve in an adult congenital heart disease patient. Congenit Heart Dis 2013; 8:589–591.  Back to cited text no. 2
Sarupria A, Bhuvana V, Mani M, Kumar AS. Large eustachian valve: an incidental finding yet perplexing. Ann Card Anaesth 2014; 17:309–310.  Back to cited text no. 3
[PUBMED]  [Full text]  
Corno AF, Bron C, von Segesser LK. Divided right atrium. Diagnosis by echocardiography, and considerations on the functional role of the eustachian valve. Cardiol Young 1999; 9:427–429.  Back to cited text no. 4
Malaterre HR, Kallee K, Périer Y. Eustachian valve mimicking a right atrial cystic tumor. Int J Cardiovasc Imaging 2000; 16:305–307.  Back to cited text no. 5
Yavuz T, Nazli C, Kinay O, Kutsal A. Giant eustachian valve with echocardiographic appearance of divided right atrium. Tex Heart Inst J 2002; 29:336–338.  Back to cited text no. 6
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; 20:155–157.  Back to cited text no. 7
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; 17:231–233.  Back to cited text no. 8
Strotmann JM, Voelker W, Schanzenbaecher P. Persistence of the eustachian valve in secundum atrial septal defects: possible implications for cerebral embolism and transcatheter closure procedures. Heart 2001; 86:e5.  Back to cited text no. 9
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. 10


  [Figure 1], [Figure 2]


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