5/14: Education of the Week, Chiari Network

This week we will discuss something new. 

32 yo M presents with chest pain x 2 days.   EKG is pending. No shortness of breath. Able to do usual work activities. Came in today because pain is not resolving. No underling medical problems. No trauma. No heavy lifting. You get a pocus echo and see the attached video.   (Please watch it. It is important to the entire education for the week.)

You show this still image to your attending.

A4 view and you are concerned about the structure depicted by the white arrow. 

What next?? What do you think this could be? What imaging would you order next? Is there anything else you are looking for in this echo to help support your diagnosis??

Here are more views of the same echo to review. Thoughts?

Screen Recording 2024-05-14 at 8.09.15 AM.mov

If you are worried about a clot in the right atrium, that is a good thought. As EM physicians, we are trained to consider the "CAN'T MISS" diagnoses. You bring the machine to your US faculty who inform you that this looks a little thin to consider it a mass like structure. Looks like a thin fibrous tissue but we are pleased you noticed it and caught this on your exam. 

CHIARI NETWORK!

This can often be an incidental finding.  It is a filamentous, weblike structure in the right atrium that results from incomplete resorption of the embryonic sinus venosus.  Based on embryonic development, this is often see attached to the posterior part of the RA and can be tethered to the orifice of the IVC which can be best visualized when we are in our  IVC view and have it draining into the RA. The Chiari network is a membrane that has a "whip-like"  movement with fenestrations. 

This can be associated with a PFO and put patients at increased risk of arrythmias (due to close proximity to SA node) stroke, infective endocarditis, and tricuspid regurgitation. 

Why should we care?

It is benign but can mimic more ominous diagnoses to the untrained eye. 

Do not be that person.  

This is not uncommon and you WILL see it during your career.

Keep this in mind. 

Thanks for reading!