Misdiagnosis of unroofed coronary sinus syndrome as an ostium primum atrial septal defect by echocardiography: A case report

Unroofed coronary sinus syndrome (UCSS) is a rare congenital heart disease, which has variable morphologic features and is strongly associated with persistent left superior vena cava (PLSVC). However, it is often difficult to visualize the left-to-right shunt pathway through the CS by transthoracic echocardiography (TTE). A 37-year-old female was admitted to the hepatological surgery department of a hospital with complaint of subxiphoid pain that had started 1 wk prior. Physical examination revealed a grade 3/6 systolic murmur at the left margin of the sternum, between the 2 and 3 intercostal cartilage. The patient underwent echocardiography and was diagnosed with ostium primum atrial septal defect (ASD); thus, she was subsequently transferred to the cardiovascular surgery department. A second TTE evaluation before surgery showed type IV UCSS with secundum ASD. Right-heart contrast echocardiography (RHCE) showed that the right atrium and right ventricle were immediately filled with microbubbles, but no microbubble was observed in the CS. Meanwhile, negative filling was observed at the right atrium orifice of the CS and right atrium side of the secundum atrial septal. RHCE identified UCSS combined with secundum ASD but without PLSVC in this patient. This rare case of UCSS highlights the value of TTE combined with RHCE in confirming UCSS with ASD or PLSVC.