Case Report
Resection of a Giant Left Atrial Appendage Aneurysm via Limited Thoracotomy
World Journal for Pediatric and Congenital Heart Surgery 2014, Vol. 5(3) 475-477 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150135114524602 pch.sagepub.com
Joseph B. Clark, MD1,2, Jennifer G. Ting, MD3, Ronald J. Polinsky Jr, MD4, and Lewis T. Wolfe, MD2
Abstract A left atrial appendage aneurysm is a rare cause of atrial arrhythmia in a young adult. Resection of the aneurysm is uniformly recommended in order to prevent thromboembolism and stroke. In patients without evidence of clot within the aneurysm, operative resection via a limited thoracotomy provides a safe and effective alternative to median sternotomy with cardiopulmonary bypass. Keywords aneurysm, atrial fibrillation/flutter, atrium, congenital heart disease, adult congenital heart disease, thoracotomy Submitted November 15, 2013; Accepted January 24, 2014.
Case Report
Discussion
A 23-year-old previously healthy woman presented with palpitations, dyspnea, and fatigue. A chest radiograph showed an enlarged cardiac silhouette with a prominent left atrium and an electrocardiogram demonstrated rate-controlled atrial flutter. Transthoracic and transesophageal echocardiography revealed a giant left atrial appendage aneurysm (5.4 8.8 cm2) with a narrow neck (2.2 cm; Figure 1). The aneurysm extended to the apex of the left ventricle and was entirely intrapericardial and did not show signs of thrombus. Resection of the aneurysm was recommended. At presentation for surgery, the patient was found to have converted to sinus rhythm. A double-lumen endotracheal tube and an epidural catheter were placed. Intraoperative transesophageal echocardiography confirmed again the absence of intracardiac thrombus. A limited muscle-sparing left thoracotomy (incision length ¼ 11 cm) was performed through the fifth intercostal space. The pericardium was opened longitudinally posterior to the phrenic nerve. The neck of the aneurysm was palpated and then controlled with a clamp. The aneurysm was opened and resected and the left atrial tissue was closed with two layers of running polypropylene suture (Figure 2). The pericardium was loosely reapproximated, a chest tube placed, and the wound closed. The patient was extubated in the operating room. Her postoperative course was unremarkable and she was discharged home on postoperative day 3 in sinus rhythm. Pathologic evaluation of the aneurysm showed focal myocyte hypertrophy and scarring. At follow-up of 21 months, the patient was asymptomatic and free of dysrhythmias.
Left atrial appendage aneurysm is a rare congenital anomaly with approximately 100 cases reported in the literature to date.1,2 The aneurysmal dilatation is believed to result from congenital dysplasia of the pectinate muscles of the atrial appendage.3 Although a few cases have been described in infants and children, this congenital anomaly usually presents during adulthood in patients with symptoms of palpitations and dyspnea. Atrial arrhythmias such as atrial fibrillation and atrial flutter are commonly found. The aneurysm sac may be predisposed to clot formation and some patients may present with stroke or other sequelae of thromboembolism.1,4 In others, the aneurysm may impinge upon the lateral wall of the left ventricle and impair diastolic filling, thus contributing to symptoms of heart failure.5 A chest film typically shows an enlarged cardiac contour over the left heart border. Echocardiography alone should be able to establish the diagnosis. Additional imaging modalities such as computed tomography and magnetic resonance imaging are often used and may provide further anatomic details.1,2,4,5
1
Department of Surgery, Penn State College of Medicine, Hershey, PA, USA Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA 3 Department of Medicine, Penn State College of Medicine, Hershey, PA, USA 4 St Joseph Medical Center, Heart Institute, Reading, PA, USA 2
Corresponding Author: Joseph B. Clark, Department of Surgery, Penn State College of Medicine, 500 University Drive, H085, Hershey, PA 17033, USA. Email: [email protected]
Downloaded from pch.sagepub.com at Freie Universitaet Berlin on May 8, 2015
476
World Journal for Pediatric and Congenital Heart Surgery 5(3)
Figure 1. A, Chest radiograph showing abnormal left heart border (arrow). B, Transesophageal echocardiogram showing the giant left atrial appendage aneurysm (LAAA) with a narrow neck (asterisk).
Resection of the aneurysm is recommended to treat associated atrial arrhythmias or heart failure and to prevent further thromboembolic complications.4,5 Removal of the dilated portion of atrium usually results in resolution of atrial arrhythmias.4,6 Nevertheless, some have advocated concomitant antiarrhythmia surgery at the time of resection.1 A variety of surgical techniques for resection of left atrial appendage aneurysm have been described.6 The most commonly reported operative approach has been median sternotomy with cardiopulmonary bypass support. This technique has been recommended in the setting of documented intracardiac thrombus as it allows for aortic clamping to prevent systemic embolization during manipulation of the aneurysm.4 Off-pump resection via sternotomy has also been reported, with surgical control of the neck of the aneurysm accomplished with either a stapler4 or a purse string suture and a tourniquet.2 Although resection via thoracotomy has been described less frequently,5,6 the reported outcomes have been good. As the patient in this case did not have intracardiac thrombus, and the aneurysm appeared to have a narrow neck, she was offered resection via a limited, muscle-sparing left thoracotomy. This
Figure 2. A, Left atrial appendage aneurysm exposed through a limited left thoracotomy. B, Base of aneurysm clamped and oversewn. C, Resected aneurysm sac.
approach afforded excellent exposure of the aneurysm and safe control of its base. Direct palpation of the neck of the aneurysm facilitated accurate clamp placement and avoidance of the left circumflex coronary artery traveling in the nearby atrioventricular groove. Following resection, a secure, double-layered suture closure was performed. This technique averted the small but finite risks of cardiopulmonary bypass and satisfied the
Downloaded from pch.sagepub.com at Freie Universitaet Berlin on May 8, 2015
Clark et al
477
patient’s desire to avoid a sternotomy. Although the morbidity associated with a limited thoracotomy is arguably not less than that of a sternotomy, this patient’s postoperative pain management was well controlled with the addition of epidural analgesia. In select patients, resection of a congenital left atrial appendage aneurysm via a thoracotomy approach can provide a safe, effective, and reproducible alternative to median sternotomy and cardiopulmonary bypass. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Kuiten WMM, de Heer LM, van Aarnhem EEHL, Onsea K, van Herwerden LA. Giant left atrial appendage: a rare anomaly. Ann Thorac Surg. 2013;96(4): 1478-1480. 2. DiBardino DJ, Aggarwal A, Knudson JD. Off-pump snare technique for congenital left atrial appendage aneurysm. Cardiol Young. 2013: 1-4. 3. Victor S, Nayak VM. Aneurysm of the left atrial appendage. Texas Heart Inst J. 2001;28(2): 111-118. 4. Burke RP, Mark JB, Collins JJ, Cohn LH. Improved surgical approach to left atrial appendage aneurysm. J Card Surg. 1992; 7(2): 104-107. 5. Zhao J, Ge Y, Yan H, Pan Y, Liao Y. Treatment of congenital aneurysms of the left atrium and left atrial appendage. Tex Heart Inst J. 1999;26(2): 136-139. 6. Vagefi PA, Choudhry M, Hilgenberg AD. Excision of an aneurysm of the left atrial appendage. J Thorac Cardiovasc Surg. 2007; 133(3): 822-823.
Downloaded from pch.sagepub.com at Freie Universitaet Berlin on May 8, 2015
Resection of a Giant Left Atrial Appendage Aneurysm via Limited Thoracotomy
World Journal for Pediatric and Congenital Heart Surgery 2014, Vol. 5(3) 475-477 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150135114524602 pch.sagepub.com
Joseph B. Clark, MD1,2, Jennifer G. Ting, MD3, Ronald J. Polinsky Jr, MD4, and Lewis T. Wolfe, MD2
Abstract A left atrial appendage aneurysm is a rare cause of atrial arrhythmia in a young adult. Resection of the aneurysm is uniformly recommended in order to prevent thromboembolism and stroke. In patients without evidence of clot within the aneurysm, operative resection via a limited thoracotomy provides a safe and effective alternative to median sternotomy with cardiopulmonary bypass. Keywords aneurysm, atrial fibrillation/flutter, atrium, congenital heart disease, adult congenital heart disease, thoracotomy Submitted November 15, 2013; Accepted January 24, 2014.
Case Report
Discussion
A 23-year-old previously healthy woman presented with palpitations, dyspnea, and fatigue. A chest radiograph showed an enlarged cardiac silhouette with a prominent left atrium and an electrocardiogram demonstrated rate-controlled atrial flutter. Transthoracic and transesophageal echocardiography revealed a giant left atrial appendage aneurysm (5.4 8.8 cm2) with a narrow neck (2.2 cm; Figure 1). The aneurysm extended to the apex of the left ventricle and was entirely intrapericardial and did not show signs of thrombus. Resection of the aneurysm was recommended. At presentation for surgery, the patient was found to have converted to sinus rhythm. A double-lumen endotracheal tube and an epidural catheter were placed. Intraoperative transesophageal echocardiography confirmed again the absence of intracardiac thrombus. A limited muscle-sparing left thoracotomy (incision length ¼ 11 cm) was performed through the fifth intercostal space. The pericardium was opened longitudinally posterior to the phrenic nerve. The neck of the aneurysm was palpated and then controlled with a clamp. The aneurysm was opened and resected and the left atrial tissue was closed with two layers of running polypropylene suture (Figure 2). The pericardium was loosely reapproximated, a chest tube placed, and the wound closed. The patient was extubated in the operating room. Her postoperative course was unremarkable and she was discharged home on postoperative day 3 in sinus rhythm. Pathologic evaluation of the aneurysm showed focal myocyte hypertrophy and scarring. At follow-up of 21 months, the patient was asymptomatic and free of dysrhythmias.
Left atrial appendage aneurysm is a rare congenital anomaly with approximately 100 cases reported in the literature to date.1,2 The aneurysmal dilatation is believed to result from congenital dysplasia of the pectinate muscles of the atrial appendage.3 Although a few cases have been described in infants and children, this congenital anomaly usually presents during adulthood in patients with symptoms of palpitations and dyspnea. Atrial arrhythmias such as atrial fibrillation and atrial flutter are commonly found. The aneurysm sac may be predisposed to clot formation and some patients may present with stroke or other sequelae of thromboembolism.1,4 In others, the aneurysm may impinge upon the lateral wall of the left ventricle and impair diastolic filling, thus contributing to symptoms of heart failure.5 A chest film typically shows an enlarged cardiac contour over the left heart border. Echocardiography alone should be able to establish the diagnosis. Additional imaging modalities such as computed tomography and magnetic resonance imaging are often used and may provide further anatomic details.1,2,4,5
1
Department of Surgery, Penn State College of Medicine, Hershey, PA, USA Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA 3 Department of Medicine, Penn State College of Medicine, Hershey, PA, USA 4 St Joseph Medical Center, Heart Institute, Reading, PA, USA 2
Corresponding Author: Joseph B. Clark, Department of Surgery, Penn State College of Medicine, 500 University Drive, H085, Hershey, PA 17033, USA. Email: [email protected]
Downloaded from pch.sagepub.com at Freie Universitaet Berlin on May 8, 2015
476
World Journal for Pediatric and Congenital Heart Surgery 5(3)
Figure 1. A, Chest radiograph showing abnormal left heart border (arrow). B, Transesophageal echocardiogram showing the giant left atrial appendage aneurysm (LAAA) with a narrow neck (asterisk).
Resection of the aneurysm is recommended to treat associated atrial arrhythmias or heart failure and to prevent further thromboembolic complications.4,5 Removal of the dilated portion of atrium usually results in resolution of atrial arrhythmias.4,6 Nevertheless, some have advocated concomitant antiarrhythmia surgery at the time of resection.1 A variety of surgical techniques for resection of left atrial appendage aneurysm have been described.6 The most commonly reported operative approach has been median sternotomy with cardiopulmonary bypass support. This technique has been recommended in the setting of documented intracardiac thrombus as it allows for aortic clamping to prevent systemic embolization during manipulation of the aneurysm.4 Off-pump resection via sternotomy has also been reported, with surgical control of the neck of the aneurysm accomplished with either a stapler4 or a purse string suture and a tourniquet.2 Although resection via thoracotomy has been described less frequently,5,6 the reported outcomes have been good. As the patient in this case did not have intracardiac thrombus, and the aneurysm appeared to have a narrow neck, she was offered resection via a limited, muscle-sparing left thoracotomy. This
Figure 2. A, Left atrial appendage aneurysm exposed through a limited left thoracotomy. B, Base of aneurysm clamped and oversewn. C, Resected aneurysm sac.
approach afforded excellent exposure of the aneurysm and safe control of its base. Direct palpation of the neck of the aneurysm facilitated accurate clamp placement and avoidance of the left circumflex coronary artery traveling in the nearby atrioventricular groove. Following resection, a secure, double-layered suture closure was performed. This technique averted the small but finite risks of cardiopulmonary bypass and satisfied the
Downloaded from pch.sagepub.com at Freie Universitaet Berlin on May 8, 2015
Clark et al
477
patient’s desire to avoid a sternotomy. Although the morbidity associated with a limited thoracotomy is arguably not less than that of a sternotomy, this patient’s postoperative pain management was well controlled with the addition of epidural analgesia. In select patients, resection of a congenital left atrial appendage aneurysm via a thoracotomy approach can provide a safe, effective, and reproducible alternative to median sternotomy and cardiopulmonary bypass. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Kuiten WMM, de Heer LM, van Aarnhem EEHL, Onsea K, van Herwerden LA. Giant left atrial appendage: a rare anomaly. Ann Thorac Surg. 2013;96(4): 1478-1480. 2. DiBardino DJ, Aggarwal A, Knudson JD. Off-pump snare technique for congenital left atrial appendage aneurysm. Cardiol Young. 2013: 1-4. 3. Victor S, Nayak VM. Aneurysm of the left atrial appendage. Texas Heart Inst J. 2001;28(2): 111-118. 4. Burke RP, Mark JB, Collins JJ, Cohn LH. Improved surgical approach to left atrial appendage aneurysm. J Card Surg. 1992; 7(2): 104-107. 5. Zhao J, Ge Y, Yan H, Pan Y, Liao Y. Treatment of congenital aneurysms of the left atrium and left atrial appendage. Tex Heart Inst J. 1999;26(2): 136-139. 6. Vagefi PA, Choudhry M, Hilgenberg AD. Excision of an aneurysm of the left atrial appendage. J Thorac Cardiovasc Surg. 2007; 133(3): 822-823.
Downloaded from pch.sagepub.com at Freie Universitaet Berlin on May 8, 2015
