Giant left atrium associated with massive thrombus formation

Left Atrial Enlargement in Primary Cryptogenic Strokes Without Atrial Fibrillation

The relationship between left atrial enlargement (LAE) and primary cryptogenic stroke (PCS) remains a mystery. LAE has been proposed to be an independent risk factor of PCS, recurrent ischemic strokes, paroxysmal atrial fibrillation, and thromboembolism. Our study evaluates the prevalence of LAE among patients with PCS in the absence of atrial fibrillation, unlike previous studies that included atrial fibrillation, in order to isolate LAE as a risk factor. We hypothesize there is a direct correlation between the prevalence of LAE and the incidence of PCS. Our multi-center, retrospective, cross-sectional study constructed a database of 646 patients identified with a diagnosis of cerebral infarction over a three-year period. Detailed chart review excluded all patients with known etiologies for stroke, including atrial fibrillation, atrial flutter, prior stroke, systolic heart failure, carotid artery stenosis, patent foramen ovale, thromboembolic disease, previous anticoagulation, or an active cancer diagnosis. Diagnosis of LAE utilized a composite of criteria for transthoracic echocardiogram measurements, including left atrial diameter (LAD) and left atrial volume index (LAVI). All study criteria were met by 154 patients (24%) for analysis, where baseline characteristics included: 79 (51%) male, 104 (67.5%) Caucasian ethnicity, 108 (70%) diagnosed of hypertension (HTN), 80 (52%) previous or current tobacco users, and 47 (31%) diagnosed of diabetes (DM). We utilized logistic regression modeling to examine correlations in our population. Our preliminary analysis found that 74 (48%) patients met at least one criterion for LAE. The mean LAD for patients with and without LAE was 4.1 cm and 3.4 cm, respectively (SD 0.87 vs 0.55, p<0.0001). The mean LAVI for patients with and without LAE was 29.68 mL/m2 and 18.44 mL/m2, respectively (SD 7.37 vs 5.13, p<0.0001). Our findings support the significance of LAE as a risk factor for cases of PCS. Multiple risk factors were identified in our study population that reflect the importance of preventative counseling for patients with HTN, hyperlipidemia, history of tobacco use, and DM. Routine screening for LAE in patients who suffer a PCS will encourage additional research that may elucidate the clinical relevance of identifying LAE in PCS. For example, whether LAE alone or in the setting of specific comorbidities warrants universal screening practices such as closer monitoring of arrhythmias such as paroxysmal atrial fibrillation to initiate anticoagulation earlier. Additionally, randomized control trials are necessary to determine whether prophylactic anticoagulation reduces future stroke risk among patients identified with LAE.

Giant left atrium and management modalities (surgical vs. conservative): a case report from Mauritania

Introduction and importance

Giant left atrium (GLA) is a rare condition often associated with rheumatic heart disease and can lead to cardiac and extracardiac complications. In this case report, the authors present a rare case of GLA with extracardiac complications, highlighting the importance of prompt diagnosis and management.

Case presentation

A 54-year-old woman with a 25-year history of mitral stenosis caused by rheumatic heart disease presented with symptoms of dyspnea, orthopnea, and palpitations. Diagnostic tests revealed an enlarged left atrium, pleural effusion, severe pulmonary hypertension, and tricuspid regurgitation. The patient was treated with diuretics and ACE (angiotensin-converting enzyme) inhibitors and is currently on a medication regimen with regular follow-up appointments.

Clinical discussion

GLA can cause cardiac and extracardiac complications, and conservative treatment and surgery are both involved in the management plan. The reduction of left atrial size by surgery may eliminate symptoms, reduce postoperative complications, and increase the probability of regaining sinus rhythm.

Conclusion

Observational data on managing GLA is limited, and mortality can be high. Cardiovascular surgeons should carefully consider surgical options, and screening and follow-up are essential for early detection and management in patients with long-standing rheumatic heart disease.

Giant right atrium: a long-term complication of rheumatic heart disease

Giant right atrium (RA) is a rare entity often seen during childhood due to congenital anomalies. Limited literature has reported such finding in patients with rheumatic valvular heart disease. Here we present a case of a 68-year-old female with a history of rheumatic valve disease treated with a Starr Edwards mechanical ball-in-cage mitral valve replacement and tricuspid valve annuloplasty ring procedures. The patient developed heart failure and had multiple hospital admissions over three decades for heart failure exacerbations mostly triggered by medication and dietary non-compliance. She eventually developed a giant RA that filled most of her thorax. This case demonstrates an extreme form of cardiac remodeling caused by long-term rheumatic valvular heart disease.

Paroxysmal supraventricular tachycardia and risk of ischemic stroke: A systematic review and meta-analysis

BACKGROUND

Paroxysmal supraventricular tachycardia (PSVT) has been traditionally considered as a benign rhythm disorder. However, recent studies have suggested that patients with PSVT may have a higher risk of ischemic stroke although the data are limited and inconclusive. The current systematic review and meta-analysis was conducted with the aims to identify all available studies and summarize their results together to better characterize the risk of ischemic stroke among patients with PSVT.

METHODS

A comprehensive literature review was conducted by searching for published articles indexed in MEDLINE and EMBASE databases from inception through November 11, 2018 to identify all observational studies that compared the risk of ischemic stroke between patients with PSVT and individuals without PSVT. Pooled risk ratio (RR) and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method of DerSimonian and Laird.

RESULTS

A total 5 studies (4 cohort studies and 1 case-control study) with 4 886 977 participants met the eligibility criteria and were included into the meta-analysis. The risk of ischemic stroke among patients with PSVT was significantly higher than individuals without PSVT with the pooled RR of 2.03 (95% CI, 1.22-3.38, I 2 = 89%).

CONCLUSION

This study found that PSVT is associated with a higher risk of ischemic stroke. Whether this association is causal and how it should be addressed in clinical practice require further investigations.

Cardiac autotransplantation and ex vivo surgical repair of giant left atrium: a case presentation

BACKGROUND

Chronic Mitral Valve disease is strongly associated with Left atrial enlargement; the condition has a high mortality risk. Clinical manifestations include atrial fibrillation, pulmonary hypertension, thromboembolic events, and in cases of Giant Left Atrium (GLA) and a distorted cardiac silhouette. Full sternotomy, conventional open-heart surgery, reductive atrioplasty and atrioventricular valve repair are required to resolve symptoms. However, these procedures can be complicated due to the posterior location of the GLA and concomitant right lateral protrusion. Cardiac autotransplantation is superior under these conditions; it provides improved visual access to the posterior atrial wall and mitral valve, hence, facilitates corrective surgical procedures. We aimed to assess the clinical outcome of patients undergoing cardiac autotransplantation as the primary treatment modality to resolve GLA. Moreover, we evaluated the procedural safety profile and technical feasibility.

CASE PRESENTATION

Four patients, mean EuroSCORE II of 23.7% ± 7.7%, presented with heart failure, atrial fibrillation, left atrial diameter > 6.5 cm and a severe distorted cardiac silhouette; X-ray showed prominent right lateral protrusion. We performed cardiac autotransplantation using continuous retrograde perfusion with warm blood supplemented with glucose followed by atrioplasty, atrial plication, valve annuloplasty and valve repair on the explanted beating heart. The surgical approach reduced the left atrial area, mean reduction was - 90.71 cm² [CI95% -153.3 cm² to - 28.8 cm², p = 0.02], and normalized pulmonary arterial pressure, mean decrease - 11.25 mmHg [CI95% -15.23 mmHg to - 7.272 mmHg, p = 0.003]. 3 out of 4 patients experienced an uneventful postoperative course; 2 out of 4 patients experienced a transient return to sinus rhythm following surgery. One was operated on in 2017 and is still in good condition; two other patients survived for more than 10 years; Kaplan-Meier determined median survival is 10.5 years.

CONCLUSIONS

Cardiac autotransplantation is an elegant surgical procedure that facilitates the surgical remodelling of Giant Left Atrium. Surgical repair on the ex vivo beating heart, under continuous warm blood perfusion, is a safe procedure applicable also to high-risk patients.

Giant left atrium with left lung damage: a case report

Giant left atrium is most commonly associated with rheumatic mitral valve disease, causing a series of cardiac and extracardiac complications. Cardiac complications are often reported, such as atrial fibrillation, decreased cardiac output, and atrial thrombus formation. Extracardiac complications are rarely described in the literature. We report an unusual case of a 55-year-old woman who was diagnosed with rheumatic heart disease 20 years earlier. Her chief complaints were episodes of chest tightness and difficulty breathing, which she had for more than 30 years. Echocardiography showed severe mitral stenosis with severe mitral insufficiency. Contrast-enhanced chest CT showed that the left thoracic cavity was occupied by a giant left atrium. The left main bronchus was compressed, and the left lung showed complete consolidation without pulmonary function.