Massive calcification of the left atrium: surgical implications

Long-Term Outcomes of the Maze Procedure Combined with Endoatriectomy for Patients with Calcified Left Atria

PURPOSE

Left atrial calcification (LAC) is found in long-lasting rheumatic valvular disease and is almost always accompanied by atrial fibrillation (AF). In the presence of LAC, endoatriectomy is required when performing the maze procedure. However, the technical feasibility of endoatriectomy and the long-term outcomes of the maze procedure in patients with LAC are uncertain.

METHODS

The medical records of 18 consecutive patients who underwent combined endoatriectomy and maze procedure were analyzed retrospectively.

RESULTS

Accompanying operations were mitral valve replacement (n = 16) and commissurotomy (n = 2). There was 1 operative death from sepsis following mediastinitis. When patients were divided into "broad" (n = 11) and "limited" (n = 7) groups, with the extent of LAC either greater or less than half of the left atrium, respectively, there was no intergroup difference in postoperative complications. During follow-up (median, 11.4 years), AF recurred in 11 patients. At the last follow-up visits, electrocardiography revealed significantly fewer patients in the broad group maintaining sinus rhythm (1/11 vs 4/6, P = 0.03). The 10-year AF recurrence-free survival rates were 13.9% and 66.7% in the broad and limited groups, respectively (P = 0.01).

CONCLUSIONS

The maze procedure combined with endoatriectomy seems technically feasible with acceptable long-term rhythm outcomes if the LAC extent is limited.

Biatrial and interatrial septal calcification in the setting of rheumatic heart disease and mitral and tricuspid valves replacement

Background

Although cardiac calcifications are described in the literature, calcification of atria is less frequently reported. There have been few case studies about atrial wall calcification in the literature, most of which were in middle-age females and were attributable to chronic heart diseases including rheumatic heart disease and valve replacement. In majority of the reported cases, interatrial septum has been spared. Only one case of bilateral atrial wall calcification has been reported prior to the current report, which has been in a patient with renal failure, calciphylaxis and long-term haemodialysis and calcium supplement intake.

Case presentation

The patient was a 57-year-old female with history of rheumatic valvular heart disease and two prior valve replacement surgeries. She didn’t have any history of renal function impairment and haemodialysis or calcium supplements intake. Her laboratory data showed anaemia, increased cardiac biomarkers and active urinalysis. Performed echocardiography showed moderate right ventricular dilation with relatively poor contraction, normal left ventricular size and contraction, dilated right and left atria and good prosthetic valve function. On computed tomography (CT) scan, calcification of left atrial posterior and free walls, interatrial septum and right atrial free wall were noted. Evidence of hepatic congestion and cirrhosis was seen in abdominal CT scan and ultrasonography.

Conclusion

Atrial wall calcification is a rare finding but is important to report since it can complicate cardiac surgeries. It's also probable that this kind of dystrophic calcification could not be detected during routine echocardiography and CT scan should be performed in suspected cases.

Characterization of the interatrial septum by high-field cardiac MRI: a comparison with multi-slice computed tomography

Background

Assessment of the interatrial septum (IAS) has become an attractive area of interest for a variety of important interventional procedures. Newer imaging modalities like multi-slice computed tomography (MSCT) and cardiac MRI (CMR) can provide higher resolution and wider field of view than echocardiography. Moreover, high-field (3-Tesla) CMR can even enhance spatial and temporal resolution.

The characteristics of the interatrial septum were retrospectively studied in 371 consecutive subjects (201 men, 31–73 years old) in whom MSCT was performed primarily for non-invasive evaluation of the coronary arteries. All subjects underwent both MSCT and MRI scans within 0–30 day’s interval. A 3D volume covering the whole heart was acquired across the heart with and without contrast enhancement. Also, patients underwent cardiac MSCT examinations using 64-row MSCT scanners.

Results

The mean scan time of MSCT was 10.4 ± 2.8 s and 9.7 ± 2.9 min for CMR. The mean length of IAS by CMR and CT was 39.65 ± 4.6 mm and 39.28 ± 4.7 mm, respectively. The mean maximal thickness of IAS by CMR and CT was 3.1 ± 0.97 mm and 3.15 ± 0.95 mm, respectively. The mean thickness of fossa ovalis by CMR and CT was 1.04 ± 0.36 mm and 1.04 ± 0.44 mm, respectively. The mean length of fossa ovalis by CMR and CT was 12.8 ± 3.7 mm and 12.8 ± 3.5 mm, respectively. Finally, the mean angle of IAS by CMR and CT was identical (155 ± 9.2°). Measurements of various morphological features of IAS showed no statistically significant difference between CMR and CT, with an excellent correlation and close relationship regarding IAS length, maximal IAS thickness, fossa ovalis thickness, fossa ovalis length, and IAS angle (r = 0.98, 0.98, 0.95, 0.96, and 0.92, respectively).

Conclusion

Whole-heart 3D acquisition at 3-T MRI using a free-breathing technique provides a valuable non-invasive imaging tool for excellent assessment of the interatrial septum—as compared to MSCT—that may have significant clinical implication for diagnostic purposes and therapeutic interventional procedures, as it may facilitate planning, improve outcome, and shorten its duration.

Characteristics and Implications of Left Atrial Calcium on Cardiac Computed Tomography in Patients With Earlier Mitral Valve Operation

Left atrial calcium (LAC) is often observed in patients who have undergone mitral valve (MV) surgery, but little is known about its characteristics and clinical implications. Therefore, we sought to investigate the structural and hemodynamic significance of LAC and its association with clinical outcomes. We investigated 327 patients with repaired or prosthetic MV who underwent cardiac CT from 2010 to 2017. The degree of LAC was analyzed and classified into three groups: group 1 (no LAC), group 2 (mild-to-moderate LAC), and group 3 (severe LAC). Clinical and echocardiographic characteristics and clinical outcomes were compared in three groups. LAC was seen in 79 (24.2%) patients. Groups 2 and 3 showed more prevalent atrial fibrillation, a rheumatic etiology, a higher number of previous surgeries, a larger LA volume index, and higher pulmonary artery systolic pressure than group 1. Paravalvular leakage of the MV increased progressively according to severity of LAC (15.4% in group 1, 39.3% in group 2, and 66.7% in group 3, p <0.001). Event-free survival rate for major adverse cardiovascular adverse events (log rank p = 0.033) and all-cause mortality (log rank p <0.001) were significantly different according to LAC group. In Cox regression analyses, presence of severe LAC was an independent predictor of all-cause mortality (hazard ratio: 4.44, 95% confidence interval: 1.71 to 11.58, p = 0.002). LAC on cardiac CT is not uncommon and reflects more advanced LA remodeling and a stiff LA. The presence and severity of LAC are associated with a worse clinical outcome after MV surgery.

A rare case of stiff left atrial syndrome caused by both coconut left atrium and vertebral compression: a case report

Background 

Calcification of the left atrium (LA) is a rare condition and can be the result of long-standing rheumatic mitral stenosis or an unusual complication after mitral valve replacement. Cases of massive LA calcification have sometimes been referred to as those with 'coconut LA' or 'porcelain LA'.

Case summary 

A 75-year-old woman was referred to our hospital because of chest discomfort and exertional dyspnoea. Doppler echocardiography revealed the presence of elevated filling pressure with significant LA dysfunction. A cardiac catheter examination revealed a quite impressive pulmonary capillary wedge pressure waveform with a steep up-slope and prominent v wave of 43 mmHg (mean: 15 mmHg). Multidetector row computed tomography revealed that LA was sandwiched by dense calcifications along the roof and bottom of the LA, and the posterior wall was compressed by a vertebral body. Integration of these functional and anatomical findings ultimately led to the diagnosis of 'stiff LA syndrome'.

Discussion 

She had a history of tuberculosis but no history of rheumatic fever or cardiac surgery. Thus, it appeared that the tuberculous pericarditis might have led to the calcified LA by long lasting inflammation. In this case, the LA was encased by a dense calcification and compressed by vertebral body from the posterior direction. Therefore, we speculated that the LA pressure could easily elevate even with a slight haemodynamic load in this special case, and thus eventually resulting in decompensated heart failure.

Measurement of interatrial septal thickness by echocardiography in patients with moderate to severe rheumatic mitral stenosis undergoing percutaneous balloon mitral valvuloplasty

Background

Longstanding severe rheumatic mitral stenosis (MS) is associated with changes in the atrial chamber dimensions. It is not known whether there is an increased thickness of the inter-atrial septum (IAS) in patients with severe rheumatic mitral stenosis. The objective of this study was to evaluate pre-procedural IAS thickness by echocardiography in patients with moderate to severe rheumatic mitral stenosis undergoing percutaneous balloon mitral valvuloplasty (PBMV).

Methods

The thickness of the IAS was measured by transesophageal echocardiography (TEE) in 86 patients between 14 and 65 years of age. Patients with moderate to severe rheumatic mitral stenosis undergoing percutaneous mitral balloon valvuloplasty (PMBV) at the National Institute of Cardiovascular Diseases (NICVD), Karachi were recruited for this study. IAS thickness was measured by TEE using standard views and 3 different phases of cardiac cycles were evaluated.

Results

Out of 86 patients, almost three fourths (73.3%) were between 14 and 29 years of age and two thirds (62.8%) were females. Mean IAS thickness was 2.56 (SD 0.92) mm at anterior region (AR), 1.89 (SD 0.75) mm at fossa ovalis (FO), and 2.95 (SD 0.97) mm at posterior region (PR). None of the demographic and clinical groups showed any statistically significant difference in IAS thickness.

Conclusions

Inter-atrial septum (IAS) thickness measurement does not change in the presence of moderate to severe rheumatic mitral stenosis as compared to the reported normal values of IAS thickness in cadaveric hearts.

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Understanding of the anatomy of atrial septum is important for the interventionist for safe and effective performance of trans-septal puncture.

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Echocardiography is the preferred imaging modality for evaluating the IAS.

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IAS thickness measurement by echocardiography provides a reasonable roadmap to guide transseptal puncture.

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IAS thickness measurement does not change in the presence of moderate to severe rheumatic mitral stenosis.

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A pre-procedural TEE may be sufficient for assessment of IAS thickness and anatomy relevant to the performance of transseptal procedures.

Transaortic Repair as Bailout Procedure for Left Atrial Tear in Redo Mitral Valve Surgery via Superior Transseptal Approach

We encountered a tear of the left atrium with severe calcification during redo mitral surgery, and report a technique for its repair. An 82-year-old woman underwent redo mitral valve replacement. The mitral valve was performed via a superior transseptal approach. The atriotomy was closed directly. The roof of the left atrium was found to be torn after aortic de-clamping. There was no remaining intact left atrial tissue on the aortic side. Patch closure was performed using transaortic stitches passing through the subaortic curtain to fix the patch. The left atrial roof and atrial septum were closed with the same patch.

Pathological evaluation of massive left atrial calcification 35 years after mitral-aortic valve replacement

Massive calcification of the left atrium is an uncommon complication of long-standing rheumatic valve disease, and is frequently revealed in patients with a previous operation on the mitral valve. An 84-year-old woman, who had a history of rheumatic valvulopathy and mitral-aortic valve replacement surgery 35 years previously, was admitted to our hospital due to congestive heart failure. Chest X-ray showed severe cardiomegaly with rim of calcification outlining the enlarged left atrium. Computed tomographic scan of the thorax clearly illustrated dense and partially thick plate-like calcification of left atrial free wall and interatrial septum. She died due to congestive heart failure 14 days after hospitalization and an autopsy was performed. Enlargement of left atrium with massive calcification was evident by gross pathology. Thick plate-like calcification with both erosion and mural hemorrhage was clearly shown by a cross-section of atrial wall. Organized and fresh fibrin thrombi were identified at the surface of left atrium. Calcified tissue penetrated into the wall of the left atrium and lack of myocardium underneath the massive calcified lesion was evident. Although rheumatic calcification of left atrium revealed by medical images was previously described, this is the first case report that demonstrates histopathological evaluation of massive atrial calcification. <Learning objective: Rheumatic calcification of entire left atrium after valve replacement surgery is known. Erosive calcification of the atrial wall with mural thrombi was identified by histology in this case. Old renal infarction was revealed by autopsy; therefore calcified atrium could be a source of distal embolism. Transmural calcification penetrated into the left atrial wall. We speculate on the difficulty in finding a cleavage plane for the endoatriectomy of massive calcified atrium in such a situation.>.

Echocardiographic detection of left atrial mobile calcium debris of trido valve surgery: a case report

Calcification of the cardiac chambers is among the challenges associated with reoperative cardiac surgeries by increasing the risk of systemic embolization. We experienced a case of an unexpected detected mass by intraoperative transesophageal echocardiography during weaning from cardiopulmonary bypass in a patient undergoing trido mitral and tricuspid valve replacement surgery. The surgically removed mass was identified as calcified tissue. This case shows the importance of careful echocardiographic evaluation of the left heart in patients undergoing repeat valve surgery given their greater potential for embolic sources.

Porcelain atrium: a case report with literature review

Massive left atrial wall calcification, or porcelain atrium, is very rare. We describe a case of an unusual pattern of cardiac calcification demonstrated on routine preoperative chest X-ray for cataract surgery in a 71-year-old Nigerian woman. Past medical history was significant for mitral stenosis and atrial fibrillation. Radiographic imaging revealed curvilinear high density areas of calcification outlining the left atrium on the chest X-ray. Noncontrast CT scan of the thorax confirmed the left atrial distribution of calcification and, thus, the diagnosis of porcelain left atrium.

Massive left atrial calcification associated with mitral valve replacement

Calcification of the left atrium can be observed in patients with a long-lasting rheumatic heart disease. However, massive calcification of the atrial wall, so called porcelain or coconut atrium is very rare and has been generally reported only as incidental radiographic findings. We report a case of massive and firm calcifications at the left atrium in patient who underwent mitral valve replacement.

Multidetector CT of left atrium

MDCT angiography has enabled visualization of left atrium in addition to coronary arteries. CT images can be utilized to demonstrate normal anatomy and pathologies. Left atrium variations and pathologies include atrial septal pouch, patent foramen ovale, atrial septal defect, atrial band, lipomatous hypertrophy, cor triatriatum, diverticulum, accessory appendages, atrial thrombus and masses. Left atrium should be carefully evaluated in patients undergoing coronary CT angiography. MDCT is becoming an alternative modality for the evaluation of left atrium.

Left atrial calcifications: computed tomographic imaging findings of an unusual sign of rheumatic heart disease

Left atrial wall calcifications are an extremely rare finding of unknown cause usually associated with rheumatic disease. Only a few case reports of this entity are found in the literature, mostly describing the findings on conventional chest radiography, echocardiography, and angiography. To the best of our knowledge, this is the first case documented with multislice computed tomography.

Massive left atrial calcification and devastating systemic emboli in a patient with chronic renal failure

Valvular calcification is a common consequence of systemic calcium deposition resulting from chronic renal failure. Thrombi can form on such vascular calcifications and embolize to the cerebral, myocardial, and mesenteric vasculature with devastating consequences. We report the unique case of a patient with myocardial and cerebrovascular ischemia resulting from emboli arising from a massive mitral annular calcification.

Left atrial calcification in a hemodialysis patient with cor triatriatum

Myocardial calcification is a rare manifestation of abnormal calcium metabolism seen in some patients with chronic renal failure. This report describes the transesophageal echocardiographic and spiral computed tomography (CT) findings in a young hemodialysis female with severe secondary hyperparathyroidism. These findings included calcification of the multiperforated membrane of a cor triatriatum and the wall of the left atrium.

Implantation of a mechanical valve within the orifice of a mitral bioprosthesis in a case with severely calcified left atrium--a case report

The case of a 61-year-old woman with deterioration of mitral bioprosthesis and severe left atrial calcification is presented. Although the implantation of a mechanical valve within the orifice of a mitral bioprosthesis was tried, we found a major pitfall in this method was exact orifice matching.

Mitral valve replacement associated with massive left atrial calcification

Massive calcification of the atrial walls is a rare condition that entails important implications for mitral valve operations. Endoatriectomy is the procedure of choice in this situation. A technique of total replacement of the left atrium and mitral valve by means of a valved, T-shaped graft is presented as a possible alternative when a more conventional approach is not feasible.