1820
CASE REPORT LEI ET AL OPERATION FOR GIANT LEFT ATRIAL DIVERTICULUM
Surgical Treatment of Giant Left Atrial Diverticulum in an Adult Qian Lei, MD, Hui-Ming Guo, MD, and Zhi-Chao Luo, MD Department of Cardiac Surgery and Anesthesiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, and Guangdong Academy of Medical Sciences, Guangzhou, China
Giant left atrial diverticulum is a rare congenital abnormality that is most commonly diagnosed in childhood. Here, we report the case of an 18-year-old woman who presented with chest tightness. Contrast-enhanced computed tomography imaging revealed a 12-cm 3 7-cm left atrial diverticulum. After transesophageal echocardiography was used to exclude left atrial thrombus and mitral regurgitation, an isolated left atrial diverticulum resection was performed. The patient had an uneventful recovery. (Ann Thorac Surg 2014;98:1820–1) Ó 2014 by The Society of Thoracic Surgeons
L FEATURE ARTICLES
eft atrial diverticulum is a rare congenital abnormality. Diverticula commonly manifest with mitral regurgitation, atrial fibrillation, thromboembolism, or compression of the surrounding structures [1–3]. Giant left atrial diverticula are mostly diagnosed in childhood [1, 2]. Here, we present a case of giant left atrial diverticulum in an adult who presented with chest tightness and ultimately underwent diverticulum resection. An 18-year-old woman (weight, 40 kg; height, 157 cm) was hospitalized with a 5-month history of recurrent chest tightness. Her symptoms were relieved in the right lateral decubitus position. She had no medical, family, or surgical history of cardiac or pulmonary diseases. Inspection and palpation of the apex beat was normal.
Accepted for publication Oct 29, 2013. Address correspondence to Dr Guo, Department of Cardiac Surgery and Anesthesiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, and Guangdong Academy of Medical Sciences, 106 Zhongshan Er Rd, Guangzhou 510080, China; e-mail: guohuiming_ggh@ 163.com.
Ann Thorac Surg 2014;98:1820–1
Percussion of the left heart border indicated cardiac enlargement. No abnormal heart murmur was heard. Transthoracic echocardiography revealed a giant left atrial diverticulum that compressed the left ventricle toward the right side, without any other cardiac structural malfunction. The diagnosis was confirmed using contrastenhanced computed tomography (CT) imaging (Fig 1A). The diverticulum was approximately 12 cm 7 cm and communicated with the left atrium. After anesthesia was induced, intraoperative transesophageal echocardiography indicated a normal mitral valve and no thrombus in the diverticulum (Fig 1B). Cardiopulmonary bypass was set up, and the heart was arrested with cold cardioplegia after a conventional median sternotomy. The diverticulum originated in the left atrial appendage as a giant, thin cavity that extended over the left ventricle (Fig 2A). It was resected at the base of the left atrial appendage and directly closed with continuous suturing, but without residual diverticulum tissue. On pathology, the diverticulum was identified as endocardium and epicardium with thin myocardium and infiltrated lymphocytes (Fig 2B). The patient had an uneventful recovery.
Comment Atrial and ventricular diverticula are extremely uncommon. With the application of dual-source CT, small left atrial diverticula are detected as common anatomic structures with a prevalence of more than 30% [3]. There have been isolated reports of very large left atrial diverticula that extend to the apex of the heart over the ventricular surface [1, 2, 4, 5]. To our knowledge, this is one of the largest left atrial diverticula to be reported. Giant left atrial diverticula are usually diagnosed in childhood because of the appearance of symptoms [1, 2] and have even been detected using prenatal fetal echocardiography [4]. Diagnosis can be delayed until adulthood when a patient has only the nonspecific symptom of chest tightness without the other characteristic symptoms of concomitant atrial fibrillation, left atrial thrombus, mitral regurgitation, or other cardiac malformations. Surgical resection was considered appropriate because of the patient’s symptom of compression and the risk of thrombosis and rupture. The operation was performed
Fig 1. Imaging data leading to the diagnosis. (A) Computed tomography shows the diverticulum filled with contrast and communicating with the left atrium. (B) Intraoperative transesophageal echocardiography indicates no thrombus in the left diverticulum. (D ¼ diverticulum; L ¼ left; LA ¼ left atrium; LV ¼ left ventricle; P ¼ posterior; RV ¼ right ventricle.)
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.10.110
Ann Thorac Surg 2014;98:1821–3
CASE REPORT KRANTZ AND LAWTON ENDOCARDITIS OF ATRIAL SEPTAL CLOSURE DEVICE
1821
under cardiopulmonary bypass through a median sternotomy because the left atrial diverticulum was giant and thin.
subacute endocarditis of the completely endothelialized device 2 years after placement. (Ann Thorac Surg 2014;98:1821–3) Ó 2014 by The Society of Thoracic Surgeons
References
T
1. McGuinness J, Kindawi A, Tajri S, Walsh K, Nolke L, Wood AE. Surgical management of giant left atrial diverticulum. J Thorac Cardiovasc Surg 2007;133:820–2. 2. Nomura K, Matsumura Y, Shinohara G, Nakamura Y. A 4-year-old girl with giant left atrial diverticulum resulting in severe mitral regurgitation. Cardiovasc Pathol 2008;17: 254–5. 3. Peng LQ, Yu JQ, Yang ZG, et al. Left atrial diverticula in patients referred for radiofrequency ablation of atrial fibrillation: assessment of prevalence and morphologic characteristics by dual-source computed tomography. Circ Arrhythm Electrophysiol 2012;5:345–50. 4. Stanczyk J, Moll J, Wilczynski J. Prenatal diagnosis of a fetal left atrial diverticulum. Prenat Diagn 1999;19:1055–7. 5. Gao C, Wang R, Wang G, Wang Y. Giant left atrial diverticulum. J Card Surg 2011;26:70.
Subacute Endocarditis of an Atrial Septal Closure Device in a Patient With a Patent Foramen Ovale
he treatment of patent foramen ovale (PFO) in patient with cryptogenic stroke remains controversial. There have been three multicenter prospective, randomized, controlled trials comparing transcatheter closure with medical therapy, and none has shown a benefit for transcatheter closure. As many as half of PFOs are incidental findings. Determining which patients show the most benefit for closure remains a challenge. Balancing the risks against this uncertain benefit remains a major challenge for clinicians and patients alike. Further studies are needed to clarify which patients will derive the greatest benefit. A 37-year-old obese man with a history of poorly controlled type I diabetes mellitus, transient ischemic attacks, and transcatheter closure of a PFO in 2011 with an Amplatzer Septal Occluder (St. Jude Medical, St. Paul, MN), presented to the emergency department with diffuse chest pain, diaphoresis, and generalized malaise. After an emergent evaluation for an acute myocardial infarction, including coronary angiogram, was found to
Seth B. Krantz, MD, and Jennifer S. Lawton, MD Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
The role of transcatheter closure of a patent foramen ovale for cryptogenic stroke remains controversial. The most common complications include atrial arrhythmia and bleeding. Infectious complications are exceedingly rare. We describe a 37-year-old man with a history of transient ischemic attacks and a patent foramen ovale who underwent transcatheter closure, complicated by Accepted for publication Dec 30, 2013. Address correspondence to Dr Lawton, Washington University School of Medicine, Division of Cardiothoracic Surgery, Department of Surgery, 660 S Euclid Ave, Campus Box 8234, St. Louis, MO 63110; e-mail: lawtonj@ wustl.edu.
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
Fig 1. Transesophageal echocardiogram demonstrating vegetations on the Amplatzer Septal Occluder device. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.12.079
FEATURE ARTICLES
Fig 2. The macrostructure and pathologic morphology: (A) The diverticulum is seen as a giant, thin cavity that extends over the left ventricle. (B) Hematoxylin and eosin staining of the diverticulum tissue demonstrates endocardium and thin myocardium (original magnification 100).
CASE REPORT LEI ET AL OPERATION FOR GIANT LEFT ATRIAL DIVERTICULUM
Surgical Treatment of Giant Left Atrial Diverticulum in an Adult Qian Lei, MD, Hui-Ming Guo, MD, and Zhi-Chao Luo, MD Department of Cardiac Surgery and Anesthesiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, and Guangdong Academy of Medical Sciences, Guangzhou, China
Giant left atrial diverticulum is a rare congenital abnormality that is most commonly diagnosed in childhood. Here, we report the case of an 18-year-old woman who presented with chest tightness. Contrast-enhanced computed tomography imaging revealed a 12-cm 3 7-cm left atrial diverticulum. After transesophageal echocardiography was used to exclude left atrial thrombus and mitral regurgitation, an isolated left atrial diverticulum resection was performed. The patient had an uneventful recovery. (Ann Thorac Surg 2014;98:1820–1) Ó 2014 by The Society of Thoracic Surgeons
L FEATURE ARTICLES
eft atrial diverticulum is a rare congenital abnormality. Diverticula commonly manifest with mitral regurgitation, atrial fibrillation, thromboembolism, or compression of the surrounding structures [1–3]. Giant left atrial diverticula are mostly diagnosed in childhood [1, 2]. Here, we present a case of giant left atrial diverticulum in an adult who presented with chest tightness and ultimately underwent diverticulum resection. An 18-year-old woman (weight, 40 kg; height, 157 cm) was hospitalized with a 5-month history of recurrent chest tightness. Her symptoms were relieved in the right lateral decubitus position. She had no medical, family, or surgical history of cardiac or pulmonary diseases. Inspection and palpation of the apex beat was normal.
Accepted for publication Oct 29, 2013. Address correspondence to Dr Guo, Department of Cardiac Surgery and Anesthesiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, and Guangdong Academy of Medical Sciences, 106 Zhongshan Er Rd, Guangzhou 510080, China; e-mail: guohuiming_ggh@ 163.com.
Ann Thorac Surg 2014;98:1820–1
Percussion of the left heart border indicated cardiac enlargement. No abnormal heart murmur was heard. Transthoracic echocardiography revealed a giant left atrial diverticulum that compressed the left ventricle toward the right side, without any other cardiac structural malfunction. The diagnosis was confirmed using contrastenhanced computed tomography (CT) imaging (Fig 1A). The diverticulum was approximately 12 cm 7 cm and communicated with the left atrium. After anesthesia was induced, intraoperative transesophageal echocardiography indicated a normal mitral valve and no thrombus in the diverticulum (Fig 1B). Cardiopulmonary bypass was set up, and the heart was arrested with cold cardioplegia after a conventional median sternotomy. The diverticulum originated in the left atrial appendage as a giant, thin cavity that extended over the left ventricle (Fig 2A). It was resected at the base of the left atrial appendage and directly closed with continuous suturing, but without residual diverticulum tissue. On pathology, the diverticulum was identified as endocardium and epicardium with thin myocardium and infiltrated lymphocytes (Fig 2B). The patient had an uneventful recovery.
Comment Atrial and ventricular diverticula are extremely uncommon. With the application of dual-source CT, small left atrial diverticula are detected as common anatomic structures with a prevalence of more than 30% [3]. There have been isolated reports of very large left atrial diverticula that extend to the apex of the heart over the ventricular surface [1, 2, 4, 5]. To our knowledge, this is one of the largest left atrial diverticula to be reported. Giant left atrial diverticula are usually diagnosed in childhood because of the appearance of symptoms [1, 2] and have even been detected using prenatal fetal echocardiography [4]. Diagnosis can be delayed until adulthood when a patient has only the nonspecific symptom of chest tightness without the other characteristic symptoms of concomitant atrial fibrillation, left atrial thrombus, mitral regurgitation, or other cardiac malformations. Surgical resection was considered appropriate because of the patient’s symptom of compression and the risk of thrombosis and rupture. The operation was performed
Fig 1. Imaging data leading to the diagnosis. (A) Computed tomography shows the diverticulum filled with contrast and communicating with the left atrium. (B) Intraoperative transesophageal echocardiography indicates no thrombus in the left diverticulum. (D ¼ diverticulum; L ¼ left; LA ¼ left atrium; LV ¼ left ventricle; P ¼ posterior; RV ¼ right ventricle.)
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.10.110
Ann Thorac Surg 2014;98:1821–3
CASE REPORT KRANTZ AND LAWTON ENDOCARDITIS OF ATRIAL SEPTAL CLOSURE DEVICE
1821
under cardiopulmonary bypass through a median sternotomy because the left atrial diverticulum was giant and thin.
subacute endocarditis of the completely endothelialized device 2 years after placement. (Ann Thorac Surg 2014;98:1821–3) Ó 2014 by The Society of Thoracic Surgeons
References
T
1. McGuinness J, Kindawi A, Tajri S, Walsh K, Nolke L, Wood AE. Surgical management of giant left atrial diverticulum. J Thorac Cardiovasc Surg 2007;133:820–2. 2. Nomura K, Matsumura Y, Shinohara G, Nakamura Y. A 4-year-old girl with giant left atrial diverticulum resulting in severe mitral regurgitation. Cardiovasc Pathol 2008;17: 254–5. 3. Peng LQ, Yu JQ, Yang ZG, et al. Left atrial diverticula in patients referred for radiofrequency ablation of atrial fibrillation: assessment of prevalence and morphologic characteristics by dual-source computed tomography. Circ Arrhythm Electrophysiol 2012;5:345–50. 4. Stanczyk J, Moll J, Wilczynski J. Prenatal diagnosis of a fetal left atrial diverticulum. Prenat Diagn 1999;19:1055–7. 5. Gao C, Wang R, Wang G, Wang Y. Giant left atrial diverticulum. J Card Surg 2011;26:70.
Subacute Endocarditis of an Atrial Septal Closure Device in a Patient With a Patent Foramen Ovale
he treatment of patent foramen ovale (PFO) in patient with cryptogenic stroke remains controversial. There have been three multicenter prospective, randomized, controlled trials comparing transcatheter closure with medical therapy, and none has shown a benefit for transcatheter closure. As many as half of PFOs are incidental findings. Determining which patients show the most benefit for closure remains a challenge. Balancing the risks against this uncertain benefit remains a major challenge for clinicians and patients alike. Further studies are needed to clarify which patients will derive the greatest benefit. A 37-year-old obese man with a history of poorly controlled type I diabetes mellitus, transient ischemic attacks, and transcatheter closure of a PFO in 2011 with an Amplatzer Septal Occluder (St. Jude Medical, St. Paul, MN), presented to the emergency department with diffuse chest pain, diaphoresis, and generalized malaise. After an emergent evaluation for an acute myocardial infarction, including coronary angiogram, was found to
Seth B. Krantz, MD, and Jennifer S. Lawton, MD Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
The role of transcatheter closure of a patent foramen ovale for cryptogenic stroke remains controversial. The most common complications include atrial arrhythmia and bleeding. Infectious complications are exceedingly rare. We describe a 37-year-old man with a history of transient ischemic attacks and a patent foramen ovale who underwent transcatheter closure, complicated by Accepted for publication Dec 30, 2013. Address correspondence to Dr Lawton, Washington University School of Medicine, Division of Cardiothoracic Surgery, Department of Surgery, 660 S Euclid Ave, Campus Box 8234, St. Louis, MO 63110; e-mail: lawtonj@ wustl.edu.
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
Fig 1. Transesophageal echocardiogram demonstrating vegetations on the Amplatzer Septal Occluder device. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.12.079
FEATURE ARTICLES
Fig 2. The macrostructure and pathologic morphology: (A) The diverticulum is seen as a giant, thin cavity that extends over the left ventricle. (B) Hematoxylin and eosin staining of the diverticulum tissue demonstrates endocardium and thin myocardium (original magnification 100).
