Left Atrial Dissection after Left Ventricular Aneurysm Repair

Redo mitral valve replacement with annular reconstruction of left atrial dissection following mitral valve replacement for infective endocarditis: a case report

BACKGROUND

Left atrial dissection is a rare and occasionally fatal complication of cardiac surgery and is defined as the creation of a false chamber through a tear in the mitral valve annulus extending into the left atrial wall. Some patients are asymptomatic, while others present with various symptoms, such as chest pain, dyspnea, and even cardiac arrest. Although there is no established management for left atrial dissection, surgery should be considered in patients with hemodynamic disruption. Herein, we report a case of left atrial dissection managed using redo mitral valve replacement (MVR) with annular reconstruction.

CASE PRESENTATION

A 60-year-old man presented to our hospital with bilateral lower-extremity purpura and cognitive decline. Blood tests showed an elevated inflammatory response, and blood culture revealed Streptococcus mitis. Transesophageal echocardiography (TEE) revealed severe mitral regurgitation with vegetation on both the anterior and posterior leaflets, and infective endocarditis was diagnosed. We performed minimally invasive cardiac surgery-MVR through a right mini thoracotomy using Epic mitral valve 29 mm (Abbott Laboratories, Green Oaks, IL, USA). On postoperative day (POD) 2, the patient was discharged from the intensive care unit (ICU). On POD 3, sudden cardiac arrest occurred; we started cardiopulmonary resuscitation and urgently inserted a peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) cannula. Contrast-enhanced computed tomography revealed extravasation from the posterior wall of the left atrium. Therefore, we performed an emergency median sternotomy, controlled the bleeding from the posterior wall of the left atrium, and returned the patient to the ICU with gauze packing under VA-ECMO. Two days later, when the gauze was removed, TEE revealed a false lumen on the left atrial wall, and left atrial dissection was diagnosed. Accordingly, we performed annular reconstruction with bovine pericardium to close the entry point and, in succession, redo MVR with a bioprosthetic Epic mitral valve 27 mm. The postoperative course was uneventful. The patient was transferred to a rehabilitation hospital on POD 74.

CONCLUSION

We report a case of left atrial dissection following MVR. The complex lesion was successfully repaired using redo MVR with annular reconstruction.

Case report and systematic review of iatrogenic left atrial dissection in different cardiovascular specialties: A common treatment for an uncommon complication?

OBJECTIVES

Left atrial dissection (LatD) is a rare and heterogeneous condition affecting many cardiovascular areas. The present article, by the means of personal case report illustration and systemic review of different clinical management, is aimed to give to clinicians further knowledge on this controversial topic.

BACKGROUND

LatD is an exceedingly rare but potentially fatal complication of cardiac surgery or catheter-based interventional procedures. Most of the cases are iatrogenic and its incidence is expected to grow due to an increase in the number of percutaneous coronary intervention and structural heart disease procedures. The management of this complication is controversial, and it may depend on related etiologies.

METHODS

We have reported our single-case experience and review of the scientific literature, focusing on the decision-making process and the strategical approach by multimodality imaging techniques.

RESULTS

Our case of LatD with initial hemodynamic instability was surgically treated. Conservative approach is often employed in literature despite the fact that conservative versus surgical approach is debatable, depending on clinical presentation, hemodynamic stability, multimodal imaging findings, and personal experience of the center.

CONCLUSIONS

According to systematic literature review, a watchful-waiting strategy supported by multimodality imaging could be a safe and effective management in stable LatD.

Role of transesophageal echocardiography: a rare case of acute left atrial free wall dissection

Transesophageal echocardiography (TEE) has been used routinely in the diagnosis and follow-up of cardiac cases. Left atrial dissection (LAd), an exceedingly rare complication of cardiac surgery, is most commonly associated with mitral valve surgery. A case of LAd is presented, and the pathology was accurately defined and immediately diagnosed using intraoperative TEE. This case highlights the importance of prompt diagnosis of LAd using intraoperative TEE, and a second cardiac surgery was avoided.

Spontaneous dissecting aneurysm of the left atrium complicated by cerebral embolism: A report of two cases with review of literature

Left atrial dissection is a very uncommon complication of cardiac surgery and usually causes significant hemodynamic compromise. Little is known about spontaneous dissection of the left atrium. Two patients, one middle-aged man and another elderly woman were evaluated following stroke. Routine trans-thoracic echocardiogram showed vertical division of the left atrium with both chambers communicating with each other through an orifice. Detailed trans-oesophageal echocardiographic study revealed dissection of the left atrium producing an additional false chamber (pseudo-aneurysm) placed posterior to the left atrial appendage and above the postero-lateral aspect of mitral annulus. Spontaneous dissection of the left atrium is extremely rare, and there is no report of cerebral embolism associated with it. Review of literature reveals interesting facets of this rare entity.

Left atrial wall dissection: a rare sequela of native-valve endocarditis

Left atrial wall dissection is a rare condition; most cases are iatrogenic after mitral valve surgery. A few have been reported as sequelae of blunt chest trauma, acute myocardial infarction, and invasive cardiac procedures. On occasion, infective endocarditis causes left atrial wall dissection. We report a highly unusual case in which a 41-year-old man presented with native mitral valve infective endocarditis that had caused left atrial free-wall dissection. Although our patient died within an hour of presentation, we obtained what we consider to be a definitive diagnosis of a rare sequela, documented by transthoracic and transesophageal echocardiography.

Left atrial dissection: etiology and treatment

BACKGROUND

Left atrial dissection (LatD) is a rare entity most commonly associated with mitral valve surgery. We have reviewed our experience with 4 patients to better define the etiology and the treatment of LatD.

METHODS

From 1991 to 2012, 4 patients experienced LatD after surgery (1 of 6,302, or 0.02%, of isolated coronary artery bypass grafting patients and 3 of 1,895, or 0.16%, of mitral valve patients). Patient and perioperative data and management were reviewed.

RESULTS

Two patients were women, and ages ranged from 49 to 80 years. Three patients underwent mitral procedures (two replacements with coronary artery bypass grafting and one repair) for mitral regurgitation. One patient underwent emergent isolated coronary artery bypass grafting after cardiopulmonary resuscitation for a left main dissection during percutaneous coronary intervention. Three LatDs were found during surgery, and one LatD was found 12 days after mitral repair and was successfully treated nonoperatively. The LatD was located along the posterior atrial wall originating from the atrioventricular junction in all cases and obstructed mitral valve inflow. Operative repair focused on the evacuation of hematoma, obliteration of the false lumen, and repair of the entry injury. No mortality occurred.

CONCLUSIONS

Left atrial dissection is a rare complication of cardiac surgery, probably related to a contained atrioventricular separation allowing pressurized blood to separate the layers of the posterior left atrium. Prompt intraoperative diagnosis, obliterating the false cavity, and addressing the entry point are essential. In contrast, a nonoperative approach in a stable patient with a delayed LatD suggests healing of the dissection, and atrial remodeling occurs.