Prominent Crista Terminalis: As An Anatomic
Structure Leading to Atrial Arrhythmias and
Mimicking Right Atrial Mass
Murat Akcay, MD, Emine Senkaya Bilen, MD, Mehmet Bilge, MD, Tahir Durmaz, MD,
and Mustafa Kurt, MD, Ankara, Turkey
Crista terminalis is a fibromuscular ridge at the
posterolateral region of the right atrium (RA).
Superiorly localized prominent crista terminalis
can mimic pathologic RA mass on transthoracic
echocardiograms. Transesophageal echocardiog-
raphy can be used to differentiate nonpathologic
structures from pathologic ones. Besides mimick-
CASE SUMMARY
A 51-year-old woman was referred to our clinic with
diagnosis of right atrial (RA) thrombus. Her symptoms
were dyspnea and palpitation for 2 years. On physical
examination, blood pressure was 130/80 mm Hg and
pulse was regular at 82/min. Chest examination revealed
prolongation of expiration and bilateral rhonchi. Other
findings of physical examination were normal. Laboratory
findings revealed anemia with hemogram and hematocrit
levels of 11 g/dL and 33%, respectively, and no other
pathologic findings were detected including thyroid func-
tions.
On telecardiogram, there were no pathologic findings.
Electrocardiography showed no significant change. Trans-
thoracic echocardiogram (TTE) revealed a RA mass. It was
round, 15 mm in diameter, immobile, not calcified, and
located at the posterior region of RA (Figure 1). Trans-
esophageal echocardiography (TEE) showed prominent
crista terminalis superiorly located beneath superior vena
cava in the RA at 130 degrees midesophageal position
(Figure 2). There were no other pathologic findings on
TEE. Magnetic resonance imaging showed no abnormality
except prominent crista terminalis. On 24-hour Holter
monitoring, atrial ectopic beats (100/24 h) were detected
(Figures 1 and 2, Videos 1 and 2).
From the Ankara Ataturk Education and Research Hospital, De-
partment of Cardiology.
Reprint requests: Murat Akcay, MD, Umit mah. Kermes Sitesi.
1.Blok No:20, Umitkoy 06800 Ankara, Turkey (E-mail:
drmuratakcay@yahoo.com).
0894-7317/$32.00
Copyright 2007 by the American Society of Echocardiography.
doi:10.1016/j.echo.2006.08.037
ing RA mass, crista terminalis is an important
anatomic structure responsible for paroxysmal
atrial fibrillation and atrial flutter by initiating
ectopic atrial beats. In this case we discuss a
patient with atrial arrhythmias who had promi-
nent crista terminalis misdiagnosed as RA mass.
(J Am Soc Echocardiogr 2007;20:197.e9-e10.)
DISCUSSION
The crista terminalis is a fibromuscular ridge at the
posterolateral region of the RA. It is originated from
regression of the septum spirium as the sinus veno-
sus is incorporated into the RA wall. Thus, the
regression of the crista terminalis shows wide vari-
ations, and so does its prominence.1 Crista termina-
lis may achieve a thickness of 3 to 6 mm in adoles-
cents and adults.2 It separates the smooth posterior
region of the RA from a more muscular anterior
region. There is no study evaluating the prevalence
of the crista terminalis during TTE examination.
However, Meier and Hartnell1 and Mirowitz and
Gutierrez3 searched the prevalence of the promi-
nent crista terminalis during magnetic resonance
imaging. Mirowitz and Gutierrez3 defined crista ter-
minalis as a soft tissue structure along the posterior
lateral wall between the superior and inferior vena
cava in 90% of cases. In the study of Meier and
Hartnell1 the frequency of a prominent crista termi-
nalis was approximately 40%. Pharr et al4,5 reported
two cases of prominent crista terminalis that were
first diagnosed as RA mass on TTE. In the first case,
during TEE, the diagnosis was corrected as promi-
nent crista terminalis. In the other case, prominent
crista terminalis with lipomatous hypertrophy of
atrial septum was reported. In our case, the thick-
ness of crista terminalis was measured as 15 mm.
This thickness was more than 2-fold of the thickness
that was reported in the literature.2 In our case crista
terminalis seems to be more prominent than the
cases that were reported by Pharr et al.4,5 Several
congenital structures and normal variants such as
Chiari’s network, eustachian and thebesian valves,
and atrial septal aneurysms may simulate pathologic
RA masses such as RA thrombus or myxomas.6
197.e9

197.e10 Akcay et al
Figure 1 Transthoracic echocardiogram reveals right atrial
(RA) mass. Arrow, Crista terminalis (CT ). LA, Left atrium;
LV, left ventricle; RV, right ventricle.
Figure 2 Transesophageal echocardiogram shows promi-
nent crista terminalis (CT ). LA, Left atrium; RA, right
atrium; VCS, vena cava superior.
Superiorly localized prominent crista terminalis can
also mimic pathologic RA mass on TTE when imaged
tangentially.5 TEE can be used to differentiate non-
pathologic structures from pathologic ones. Thus,
echocardiographers and cardiologists must pay at-
tention while performing TEE to recognize these
anatomic structures.
Crista terminalis forms one of the tracts for inter-
nodal conduction. It is also important to explain the
reason of atrial fibrillation and atrial flutter by initi-
ating ectopic atrial beat.7,8 In the study of Lin et al,7
Journal of the American Society of Echocardiography
February 2007
crista terminalis was the origin of ectopic beats and
atrial fibrillation in 3.7% of paroxysmal atrial fibrilla-
tion. In the literature a relationship between atrial
arrhythmias and prominent crista terminalis seen on
TTE has not been reported yet. Although our patient
had anemia and mild obstructive lung disease to
explain the reason of the atrial arrhythmias, promi-
nent crista terminalis may also be the other reason to
explain this situation.
Conclusion
In this case we want to emphasize that prominent
crista terminalis can mimic RA mass and may lead to
atrial arrhythmias. TEE can be used to differentiate
normal structures from pathologic ones and further
investigation to explain the relationship between
the prominent crista terminalis seen on TTE and
atrial arrhythmias is warranted.
REFERENCES
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SUPPLEMENTARY DATA
Supplementary data associated with this article can
be found, in the online version, at 10.1016/j.
echo.2006.08.037.