International Journal of Cardiology 172 (2014) e487–e488
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Giant left atrium in a patient with prosthetic mitral valve Miao-Yan Chen a, Zhi-Qiang Ying b,⁎ a b
Department of Internal Medicine, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou 310009, China Department of Cardiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou 310009, China
a r t i c l e
i n f o
Article history: Received 4 January 2014 Accepted 7 January 2014 Available online 23 January 2014 Keywords: Giant left atrium Rheumatic heart disease Prosthetic mitral valve
A 56-year-old woman was admitted to our department with a chief complaint of progressive shortness of breath. She had undergone mitral valve replacement surgery with a mechanical prosthesis for rheumatic mixed mitral valve disease 15 years previously and pacemaker placement 5 years earlier. On physical examination, the patient was found to have a pulse of 73 beats/min while in atrial fibrillation. A prosthetic valve sound and a grade 3/6 holosystolic murmur were present at the sternal border. A chest X-ray revealed asymmetrical cardiomegaly with the right heart border extending to the right lateral chest wall and a prosthetic mitral valve (Fig. 1). The cardiothoracic ratio was 0.86. Transthoracic echocardiography demonstrated a giant left atrium (GLA) measuring 14.2 × 11.4 cm (Fig. 2) and a functioning prosthetic mitral valve with preserved left and right ventricle function. A computer tomography scan of the chest revealed severe enlargement of the left atrium (17.3 × 14.4 cm) (Fig. 3). The right lung was compressed by the left atrium. GLA is a condition in which the left diameter exceeds 65 mm or one that touches the right lateral thoracic wall [1]. Frequently, it is associated with atrial fibrillation and increased risk for stroke and sudden death. Left atrium enlargement is thought to be due not only to severe mitral regurgitation in rheumatic heart disease, but also to intrinsic characteristics of the left atrium wall. Primary rheumatic involvement of the left atrial wall as a component of rheumatic pancarditis causes the damaged left atrium to dilate more easily under the prolonged pressure and volume overload [2]. Atrial fibrillation, which can occur secondary to left atrium enlargement, contributes more to the increase in overload on the left atrium and causes more enlargements. The symptoms in GLA
⁎ Corresponding author. Tel./fax: +86 571 877 847 49. E-mail address: [email protected] (Z.-Q. Ying). 0167-5273/$ – see front matter © 2014 Elsevier Ireland. Ltd All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2014.01.045
originate from the anatomic relation of enlarged posterior wall of the left atrium pressing the esophagus and airways [3]. The elevated left atrial pressures causing enlargement can also lead to elevated pulmonary pressure, pulmonary edema, and can contribute to right heart failure [4]. When the right border of the cardiac shadow touches the right thoracic wall, it may be misdiagnosed to a mass lesion or pleural or pericardial effusion. Biopsy, pleurocentesis, or pericardiocentesis is dangerous in this setting and other diagnostic modalities are needed. The cardiac CT or MRI is not only reliable in confirming the diagnosis, but also useful for a precise estimation size of the atrium and its relations with other adjacent organs. There is no consensus regarding the management of GLA [3]. In general, the surgical indication of GLA is the presence of intracardiac or extracardiac compressive symptoms from neighboring organs [3]. We advised the patient to undergo left atrium size reduction, but she refused. The patient was discharged home on medical management with diuresis and anticoagulant therapy. The prevalence of rheumatic heart disease has decreased considerably in industrialized countries during the last 30 years, however, we must be alert to the fact that rheumatic fever is still relatively common in a developing country [5]. This case highlights the importance of considering left atrial enlargement as possible diagnosis in a patient presenting with shortness of breath. Acknowledgment The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology. References [1] Kucukdurmaz Z, Gunes H, Kurt R, Karapınar H. Giant left atrium. Echocardiography 2013;30(4):E110. [2] Tanita A, Hosokawa Y, Tomiyama T, et al. Giant left atrium due to mitral stenosis with massive atelectasis: a successful case with perioperative approach. Int J Cardiol 2013;163(2):e23–5. [3] Apostolakis E, Shuhaiber JH. The surgical management of giant left atrium. Eur J Cardiothorac Surg 2008;33(2):182–90. [4] Chick JF, Sheehan SE, Miller JD, Bair RJ, Madan R. Giant left atrium in rheumatic heart disease: the classic signs of left atrial enlargement. J Emerg Med 2013;44(6):e393–4. [5] Fattouch K, Sampognaro R, Coppola G, et al. Giant left atrium: a condition that is rarely seen today. J Cardiovasc Med (Hagerstown) 2008;9(9):967–8.
e488
M.-Y. Chen, Z.-Q. Ying / International Journal of Cardiology 172 (2014) e487–e488
Fig. 1. Posteroanterior (A) and lateral (B) chest X-ray study revealed massive asymmetrical cardiomegaly and a prosthetic mitral valve.
Fig. 2. Transthoracic echocardiography showed the prosthetic mitral valve and a markedly dilated left atrium (LA).
Fig. 3. Computer tomography revealed severe enlargement of the left atrium. LA, left atrium; RA, right atrium; LV, left atrium; RV, right atrium.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Giant left atrium in a patient with prosthetic mitral valve Miao-Yan Chen a, Zhi-Qiang Ying b,⁎ a b
Department of Internal Medicine, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou 310009, China Department of Cardiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou 310009, China
a r t i c l e
i n f o
Article history: Received 4 January 2014 Accepted 7 January 2014 Available online 23 January 2014 Keywords: Giant left atrium Rheumatic heart disease Prosthetic mitral valve
A 56-year-old woman was admitted to our department with a chief complaint of progressive shortness of breath. She had undergone mitral valve replacement surgery with a mechanical prosthesis for rheumatic mixed mitral valve disease 15 years previously and pacemaker placement 5 years earlier. On physical examination, the patient was found to have a pulse of 73 beats/min while in atrial fibrillation. A prosthetic valve sound and a grade 3/6 holosystolic murmur were present at the sternal border. A chest X-ray revealed asymmetrical cardiomegaly with the right heart border extending to the right lateral chest wall and a prosthetic mitral valve (Fig. 1). The cardiothoracic ratio was 0.86. Transthoracic echocardiography demonstrated a giant left atrium (GLA) measuring 14.2 × 11.4 cm (Fig. 2) and a functioning prosthetic mitral valve with preserved left and right ventricle function. A computer tomography scan of the chest revealed severe enlargement of the left atrium (17.3 × 14.4 cm) (Fig. 3). The right lung was compressed by the left atrium. GLA is a condition in which the left diameter exceeds 65 mm or one that touches the right lateral thoracic wall [1]. Frequently, it is associated with atrial fibrillation and increased risk for stroke and sudden death. Left atrium enlargement is thought to be due not only to severe mitral regurgitation in rheumatic heart disease, but also to intrinsic characteristics of the left atrium wall. Primary rheumatic involvement of the left atrial wall as a component of rheumatic pancarditis causes the damaged left atrium to dilate more easily under the prolonged pressure and volume overload [2]. Atrial fibrillation, which can occur secondary to left atrium enlargement, contributes more to the increase in overload on the left atrium and causes more enlargements. The symptoms in GLA
⁎ Corresponding author. Tel./fax: +86 571 877 847 49. E-mail address: [email protected] (Z.-Q. Ying). 0167-5273/$ – see front matter © 2014 Elsevier Ireland. Ltd All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2014.01.045
originate from the anatomic relation of enlarged posterior wall of the left atrium pressing the esophagus and airways [3]. The elevated left atrial pressures causing enlargement can also lead to elevated pulmonary pressure, pulmonary edema, and can contribute to right heart failure [4]. When the right border of the cardiac shadow touches the right thoracic wall, it may be misdiagnosed to a mass lesion or pleural or pericardial effusion. Biopsy, pleurocentesis, or pericardiocentesis is dangerous in this setting and other diagnostic modalities are needed. The cardiac CT or MRI is not only reliable in confirming the diagnosis, but also useful for a precise estimation size of the atrium and its relations with other adjacent organs. There is no consensus regarding the management of GLA [3]. In general, the surgical indication of GLA is the presence of intracardiac or extracardiac compressive symptoms from neighboring organs [3]. We advised the patient to undergo left atrium size reduction, but she refused. The patient was discharged home on medical management with diuresis and anticoagulant therapy. The prevalence of rheumatic heart disease has decreased considerably in industrialized countries during the last 30 years, however, we must be alert to the fact that rheumatic fever is still relatively common in a developing country [5]. This case highlights the importance of considering left atrial enlargement as possible diagnosis in a patient presenting with shortness of breath. Acknowledgment The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology. References [1] Kucukdurmaz Z, Gunes H, Kurt R, Karapınar H. Giant left atrium. Echocardiography 2013;30(4):E110. [2] Tanita A, Hosokawa Y, Tomiyama T, et al. Giant left atrium due to mitral stenosis with massive atelectasis: a successful case with perioperative approach. Int J Cardiol 2013;163(2):e23–5. [3] Apostolakis E, Shuhaiber JH. The surgical management of giant left atrium. Eur J Cardiothorac Surg 2008;33(2):182–90. [4] Chick JF, Sheehan SE, Miller JD, Bair RJ, Madan R. Giant left atrium in rheumatic heart disease: the classic signs of left atrial enlargement. J Emerg Med 2013;44(6):e393–4. [5] Fattouch K, Sampognaro R, Coppola G, et al. Giant left atrium: a condition that is rarely seen today. J Cardiovasc Med (Hagerstown) 2008;9(9):967–8.
e488
M.-Y. Chen, Z.-Q. Ying / International Journal of Cardiology 172 (2014) e487–e488
Fig. 1. Posteroanterior (A) and lateral (B) chest X-ray study revealed massive asymmetrical cardiomegaly and a prosthetic mitral valve.
Fig. 2. Transthoracic echocardiography showed the prosthetic mitral valve and a markedly dilated left atrium (LA).
Fig. 3. Computer tomography revealed severe enlargement of the left atrium. LA, left atrium; RA, right atrium; LV, left atrium; RV, right atrium.
