Acute ischemia of fingers caused by permeable foramen ovale and an elongated eustachian valve: role of cardiac magnetic resonance.

A 30-year-old man was admitted for acute ischemia of the fingers. Physical examination was normal, with normal sinus rhythm on the ECG. Transthoracic echocardiography showed a dilated right atrium (RA) with a suspected cor triatriatum dexter. Cardiac magnetic resonance found a mobile undulating elongated Eustachian valve (EV) (Figure 1 A, B, C), creating a posterior tunnel in the bottom of the RA with accelerated flow from the inferior vena cava (IVC) (Figure 1D). This tunnel was largely open at the top of the RA, causing no significant obstruction to the route of the venous return. However, it induced a kinking of the flow path (red arrow), reflecting against the atrial septum and a patent foramen ovale (PFO), thus explaining the possibility of paradoxical embolic events (i.e. acute finger ischemia). An elongated EV is a persistent part of the embryological valve of the sinus venosus. This condition is rare and should not be confused with cor triatriatum dexter, in which there are attachments on the atrial septum giving the appearance of a divided atrium.1 In this case, the interesting imaging finding relies on the relationship between the IVC return flow path, directed toward the PFO, which explains the paradoxical embolism in this patient.