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Minimally Invasive Periareolar Approach to Cor Triatriatum Repair

Gottschalk, Byron H., MD*; Fujii, Satoru, MD; Grant, Aaron, MD; Iglesias, Ivan, MD; Chu, Michael W. A., MD*

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: November/December 2018 - Volume 13 - Issue 6 - p 445–447
doi: 10.1097/IMI.0000000000000565
Case Reports

Cor triatriatum sinister is an uncommon cardiac abnormality characterized by a membrane that divides the left atrium into two chambers. Definitive management requires surgical resection, traditionally through sternotomy. Minimally invasive reparative techniques are associated with reduced blood loss, shorter hospitalization, faster recovery time, and improved cosmesis with excellent patient satisfaction. We present a 29-year-old woman with cor triatriatum sinister and associated atrial septal defect who underwent successful minimally invasive repair through a right periareolar approach.

From the *Division of Cardiac Surgery,

Department of Anesthesia and Perioperative Medicine, and

Department of Plastic and Reconstructive Surgery, Western University, London, ON Canada.

Accepted for publication October 28, 2018.

A video clip is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

Disclosures: Michael W. A. Chu, MD, receives speaker's honoraria for Medtronic, Inc, Vancouver, BC Canada, LivaNova, London, United Kingdom, Boston Scientific, Marlborough, MA USA, and Abbott Vascular, Santa Clara, CA USA. Byron H. Gottschalk, MD, Satoru Fujii, MD, Aaron Grant, MD, and Ivan Iglesias, MD, declare no conflicts of interest.

Address correspondence and reprint requests to Michael W. A. Chu, MD, B6-106 University Hospital, London Health Sciences Centre, 339 Windermere Rd, London, ON Canada N6A-5A5. E-mail:

Cor triatriatum is an uncommon cardiac abnormality characterized by an anomalous fibromuscular membrane that divides one of the atria into two chambers. In the most common form, cor triatriatum sinister (CTS), the left atrium is divided into proximal and distal chambers with a communication. Surgical resection provides definitive management, traditionally performed through a median sternotomy. Minimally invasive endoscopic surgical techniques offer patients reduced hospitalization, quicker recovery times, and a more cosmetically appealing result.1 Periareolar approaches have been demonstrated to provide excellent surgical access with improved esthetic results without compromising nipple and areolar function.2 We discuss a 29-year-old woman with CTS and associated atrial septal defect (ASD) who underwent successful minimally invasive repair through a right periareolar approach.

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A 29-year-old woman with a lifelong history of shortness of breath on exertion presented with recurrent palpitations and profound exacerbation of symptoms consistent with New York Heart Association class III–IV. A medical history was significant for fibromyalgia and bronchitis. She had never been diagnosed with acquired or congenital heart disease. Physical examination demonstrated fixed splitting of the second heart sound. Respiratory examination was unremarkable. She had no ankle edema and her jugular venous pressure was normal.

Holter monitoring revealed sinus tachycardia. Echocardiogram demonstrated a 1.4 × 1.1-cm secundum ASD with a left to right shunt (shunt fraction 1.5:1) as well as cor triatriatum with mild to moderate right ventricular dilation (Fig. 1A). A computed tomography confirmed the membrane consistent with CTS with normal pulmonary venous connections (Fig. 2B).





At the time of operation, she was placed in a 20-degree left lateral decubitus position. A 3.5-cm inferior periareolar incision was made under the right nipple. The chest was entered through the third intercostal space, and cardiopulmonary bypass was initiated through the femoral artery with venous drainage through bicaval cannulation through the internal jugular vein and femoral vein. Intraoperative transesophageal echocardiogram confirmed the anatomy (Video 1, Supplemental Digital Content 1, A transthoracic aortic cross clamp and 5-mm endoscope were placed through lateral stab wounds near the anterior axillary line and mid clavicular lines, respectively. A vertical right atriotomy was used to expose the secundum ASD (Fig. 1C), which had to be somewhat extended to gain full access to the fibromuscular membrane of the CTS. The membrane was carefully excised to eliminate any residual obstruction without wandering extra-atrially (Fig. 1D, Video 1, Supplemental Digital Content 1, After complete resection of the 7-cm membrane, the left atrial chamber was unobstructed with a normal view of the pulmonary veins and mitral valve apparatus (Fig. 2A). The ASD was repaired by parachuting a 2 × 2-cm autologous pericardial patch through the periareolar incision and completed with a running suture(Fig. 2B, Video 1, Supplemental Digital Content 1, The operative field and entire right chest had been flooded with CO2 and careful deairing performed. Transesophageal echocardiography confirmed successful resection of the CTS and complete closure of the ASD (Fig. 2C, Video 2, Supplemental Digital Content 2, The aortic cross-clamp and cardiopulmonary bypass times were 52 and 88 minutes, respectively.

The patient did well and was discharged from hospital symptom free on the fourth postoperative day. At 1-year follow-up, she was well with no symptoms. Her incision had healed well with a good cosmetic result (Fig. 2D). Transthoracic echocardiogram reported a decrease in right heart size with no evidence of any residual shunt.

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Cor triatriatum occurs in less than 0.1% of patients with congenital heart disease.3 In CTS, the proximal chamber typically contains the pulmonary venous return, whereas the distal chamber contains the atrial appendage and mitral valve. The condition typically presents in infancy with symptoms of pulmonary congestion, although the severity of these symptoms depends on the degree of obstruction to venous return. Milder forms of the disease may present in adulthood with exacerbation of symptoms. A variety of venous drainage patterns facilitate communication of the proximal chamber with the heart. Most commonly, the membrane itself contains one or multiple fenestrations. Alternatively, communication may be facilitated through an ASD or a variety of anomalous venous pathways.3 Although the CTS was classified as nonobstructive in our patient, we felt that her symptoms were likely due to a predominance of flow shunting through the ASD rather than the fenestration in the fibromuscular membrane.

The anterolateral minithoracotomy approach near the inframammary crease is well described for mitral valve repair with reduced blood loss, shorter hospitalization, faster recovery time, and more cosmetic incisions when compared with median sternotomy.4 Furthermore, minithoracotomy approaches in the correction of congenital heart disease have reported outcomes similar to conventional techniques.5 Repair of CTS through minithoracotomy or robotic approaches have rarely been reported in the literature1,5,6; however, robotic techniques have been well established for repair of similar defects such as ASDs. In the periareolar approach, the chest is entered more medially than the lateral approach and more superiorly than the inframammary approach in larger breasted women. In our experience, this provided excellent exposure to the interatrial septum to facilitate complete resection of the fibromuscular membrane and ASD patch repair. The use of a 5-mm endoscope further facilitated exposure.

We believe that minimally invasive approaches to repair of CTS should be considered in appropriate patients. The periareolar approach is an important option that provides good exposure with short recovery time and excellent cosmetic results in women.

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1. Poffo R, Montanhesi PK, Toschi AP, et al. Periareolar access for minimally invasive cardiac surgery: the Brazilian technique. Innovations. 2018;13:65–69.
2. Poffo R, Pope RB, Toschi AP, Mokross CA. Video-assisted minimally invasive mitral valve repair: periareolar approach. Rev Bras Cir Cardiovasc. 2009;24:425–427.
3. Yaroglu Kazanci S, Emani S, McElhinney DB. Outcome after repair of cor triatriatum. Am J Cardiol. 2012;109:412–416.
4. Falk V, Cheng DC, Martin J, et al. Minimally invasive versus open mitral valve surgery: a consensus statement of the international society of minimally invasive coronary surgery (ISMICS) 2010. Innovations. 2011;6:66–76.
5. Chu MW, Losenno KL, Fox SA, et al. Clinical outcomes of minimally invasive endoscopic and conventional sternotomy approaches for atrial septal defect repair. Can J Surg. 2014;57:E75–E81.
6. Gao C, Yang M, Xiao C, et al. Totally endoscopic robotic correction of cor triatriatum sinister coexisting with atrial septal defect. Innovations. 2016;11:451–452.

Minimally invasive cardiac surgery; Periareolar approach; Cor triatriatum; Congenital heart disease

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©2018 by the International Society for Minimally Invasive Cardiothoracic Surgery