Minimally invasive surgical repair for unroofed coronary sinus syndrome directed by three-dimensional transesophageal echocardiography

BACKGROUND: The recent remarkable development of cardiac imaging technology for unroofed coronary sinus syndrome has led to accurate preoperative diagnosis. We report a case of unroofed coronary sinus syndrome repaired via a minimally invasive approach, under the excellent command of three-dimensional transesophageal echocardiography. CASE PRESENTATION: A 77-year-old woman with hypertension was admitted for aggravation of bilateral leg edema and diagnosed with type III unroofed coronary sinus syndrome with Qp/Qs ratio of 1.6:1. The unroofed portion was detected at the atrial side between P2 and P3 of posterior mitral leaflet by preoperative three-dimensional transesophageal echocardiography. Right minithoracotomy was performed at the fourth intercostal space and cardiopulmonary bypass routinely established. Right atriotomy and left atriotomy incisions were made under antegrade cardioplegic arrest. The unroofed portion was revealed at the same location by preoperative transesophageal echocardiography and was clearly recognized only by endoscopy, not by direct vision. It was repaired by direct running suture under endoscopic visualization. We observed no blood cardioplegia leakage or mitral insufficiency, which was also confirmed by postoperative transesophageal echocardiography. The patient’s postoperative course was uneventful and she was discharged home 14 days after surgery without any residual shunt. CONCLUSIONS: Successful repair of unroofed coronary sinus syndrome was safely and effectively achieved by a minimally invasive approach supported by preoperative three-dimensional transesophageal echocardiography.