Figure 1 shows a case of Incomplete Cor triatriatum dexter. Considering that there are two compartments in the right atrium which are more prominent, there will be a restricted flow of oxygenated blood. The right ventricle will receive limited blood and oxygen because of the involution in the right atrium. That causes a significant amount of abnormalities. The image shows the complications that occur due to percutaneous closure of atrial septal defect (ASD), and disk insertion help offer greater rigidity and traction maneuvers [3].

22Surgical correction can help in reducing the risks of the abnormality. CT is a hereditary abnormality in which an impeding membrane divides the right (dexter) or left (sinister) atrium into two compartments. Cor triatriatum dexter, the rarer of the two disorders, is identified nearly entirely during embryonic stage using echocardiography and may be related with pulmonary artery stenosis, tricuspid abnormalities, or hypoplastic right ventricle [4]. Echocardiography is fundamental in diagnosing the condition. The right atrium's degree of separation can help enhance clinical manifestation. Cor triatriatum dexter is associated or isolated from other heart conditions.

Figure 2 shows the echocardiography images of a neonate with Cor triatriatum dexter. The blue color in the picture signifies the systemic venous blood that is taken back to the right atrium [5].

On the other hand, the red color represents the blood flow on the right atrium's outer part. The diagnosis process is critical to help establish the treatment options that a child or adult suffering from Cor triatriatum dexter will receive.

CASE REPORT

The patient was an immigrant in his 40s, repeatedly admitted to the hospital over the last ten years with a past medical history of congenital heart disease cor triatriaum dexter, abnormal echocardiography of the heart, permanent atrial fibrillation, and chronic heart failure. Transesophageal echocardiogram found small patent foramen ovale (PFO), possibly unroofed coronary sinus with connection to left superior vena cava (SVC). The patient reported that he often had bilateral upper and bilateral lower extremity edema. He denied syncope, dizziness, palpitations, orthopnea, and shortness of breath. The patient got cardiology consults at every admission, but no surgical procedure has been intervened. His BNP was 650, and troponin I was < 0.006. His symptoms, rate, rhythm control, anticoagulation, and thrombotic prophylaxis were treated and get discharged every time. He was compliant with his home medications at home. However, he was non-compliant with his cardiac diet. In addition, he drank 1-2 beers daily. The patient reported he had been sick since childhood but has not had any history of surgical procedure intervention for his heart condition since the patient doesn’t have health insurance. The individual was transferred to other healthcare facilities for further consults and surgery evaluation, but the family could not afford pre-op testing due to financial hardship. Therefore, the patient has been repeatedly admitted here to manage his chronic heart failure symptoms with aspirin (ECOTRIN), 81 MG EC tablet, digoxin (LANOXIN) 125 mcg tablet, furosemide (LASIX) 40 MG tablet, enoxaparin, acetaminophen tablet 650 mg, furosemide injection 40 mg.

DISCUSSION

Cor triatriatum (CT) is a sporadic defect in which the right atrium is separated into binary compartments by a thin, fibromuscular membrane causing division of either the left or right atrium, contributing to the presence of three atrial compartments [6]. In the 4th week of embryonic growth, the atrium is separated from the venous sinus by a valve with two flaps (the venous sinus valve). During the embryo's maturation, the left leaflet of the venous sinus valve is merged into the interatrial septum and is made up of a component of the septum secundum. As the growth occurs, the right leaflet is reabsorbed around the twelfth week of gestation, leaving two structures. The Eustachian valve appears at the junction of the inferior vena cava. On the other hand, the coronary valve appears at the mouth of the coronary sinus. To a high or low level, the tenacity of the right leaflet of the venous sinus valve leads to a wide range of abnormalities, which comprise of a prominent the Chiari network, Eustachian valve, and Cor triatriatum dexter CTD [3]. CTD is another rarer form of cor triatriatum. CTD can be diagnosed by echocardiography and magnetic resonance imaging [1]. In CTD, the right valve of the sinus venous endured, splitting up the right atrium into binary compartments. It is challenging to identify the distinctive features as the symptoms of CTD are similar to those of Ebstein's anomaly [6].

CTD is usually associated with right-side faults caused by abnormal fetal circulation. Among these, the most frequent is stenosis or atresia of the pulmonary valve, tricuspid valve abnormalities, and atrial septal defect [7]. Clinical signs are contingent upon the degree of obstruction in the heart, and there may be an absence of symptoms. It can contribute to trapped catheters, embolisms, or supraventricular arrhythmias [3]. The presentation of Cor triatriatum dexter differs from other heart conditions, and the development of the cardiac lesions can make the condition life-threatening [8]. In infants, the disease is characterized by heart failure and poor feeding. In adults, heart failure and stroke are presentations of CTD. According to the case report, the 40-year-old patient has been repeatedly admitted to hospitals due to his heart condition. Failure to afford healthcare impeded them from managing CTD, making the ailment grow and become chronic. Early interventions through surgery would have helped to enhance the survival rate. Patients with Cor triatriatum aged below 19 years who underwent surgery had an 83% survival rate as they received management options from cardiovascular surgeons [9]. The practitioners would help decipher the complex anatomy of the patient’s heart. The insight from the analysis will help establish the cause of the congestion, such as an inflow obstruction. Cardiac catheterization diagnosis can show if there is any pulmonary artery hypertension or pulmonary venous blocking.

The individuals had a clear case of CTD in childhood, and lack of treatment led to the isolated abnormality in adulthood. Patients like the 40-year-old suffer from reduced blood flow in the pulmonary. Any form of obstruction in the right ventricle will lead to an undesirable case of cyanosis. Transesophageal echocardiography-guided can be administered through surgery, which will help improve pulmonary blood flow and prevent stroke risks in the CTD patient. In children, the clinical manifestation of CTD depends on factors such as sinoatrial orifice size, an atrial septal defect, TV hypoplasia, and obstruction of right ventricular outflow [10]. The patient may be at risk of death since a low supply of oxygen in the body. Medication such as digoxin would not help the 40-year-old since there is limited blood flow, and it will be challenging to enhance the ventricular rate without surgery. Echocardiography and magnetic resonance imaging need to be conducted to inform the treatment plan. Alcohol is harmful to the individual and may have contributed to making the condition chronic. It is reported the 40-year-old consumes one or two beers a day. Alcohol contributes to further heart abnormalities as the heart chambers deflate, limiting normal systolic function [11]. The right atrium and ventricle will deflate unevenly, contributing to issues of life arrhythmia. The irregular heartbeats will affect the four chambers and limit the flow of oxygen, carbon dioxide, and blood in the body. In other instances, there can be inflammations. It would make the medical practitioners misdiagnose a patient and not provide a long-term solution to a patient. In addition, excessive alcohol will cause impaired contraction, making the heart less efficient. When consuming alcohol, the body produces Acetaldehyde, which is responsible for breaking down the alcohol. The toxic material can accumulate in the heart, considering low blood movement. The contraction will occur as it takes more time for the toxic chemical to break down the alcohol.

The patient is also affected by fluid buildup. When the heart is not pumping blood correctly, there will be a buildup of fluids, which is a common cause of post-discharge mortality [12]. The symptom is common in patients with long-term heart conditions such as CTD. The poor fluid retention, there are higher indications of deteriorating heart failure. The cause for the patient can be non-compliance with diet. A pericardium surrounds the heart, and any disease will lead to a buildup of fluids. The fluids in the delicate layers will strain the heart and its ability to regulate blood flow. The 40-year-old had troponin I levels at < 0.006, and the protein is responsible for muscle contraction. The high level of troponin complex is an indication of heart failure. Anatomic images show that atrial remnants reduce the ability of atrial septal defect [13]. It means that percutaneous catheterization may not be effective if a patient suffering from CTD or any heart condition does not watch their diet and prevent consumption of alcohol. High alcohol consumption leads to a buildup of calcium in the heart cells. Some of the calcium will attach to the troponin and cause a change in shape. That will expose the active sites and contribute to extreme contraction of the heart. The contraction will occur since the calcium will trigger a macular force. The troponin levels show that the patient has high levels of calcium. Regulating the complex proteins will allow an individual to watch their diet to prevent more abnormalities. Ischemic changes start to occur due to the closure of ASD, and a diagnostic dilemma can arise as percutaneous catheterization may not handle the technical changes [13]. Device selection would be fundamental to guarantee the 40-year-old patient will benefit from the surgery.

Results of the physical examination will be necessary to diagnose the patient with CTD. For instance, the rate a rhythm appears to be irregular, and there has been an increase in chest tightness. These are vital signs, and practitioners can miss some of the episodes since the symptoms occur intermittently in CTD patients. Comprehensive echocardiography is needed, and that will be helpful to exclude other complex heart diseases and have a correct diagnosis. Other conditions can present systemic venous abnormalities similar to CTD and make the patient continue to suffer. A satisfactory surgical repair, including excision of the membrane, can help reduce the obstruction caused by Cor triatriatum. Besides, a postoperative program is needed to ensure the 40-year-old will be at lost risk of encountering more complications. It should include a change in diet and a reduction in alcohol consumption. The patient would recover from the rear heart condition and enhance their survival rate.

CONCLUSION