Giant left atrium: a review

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.

A new surgical technique for left atrial reduction in giant left atrium

Objective

The study objective was to evaluate the safety and clinical and echocardiographic outcomes of a new surgical technique in adult patients diagnosed with a giant left atrium.

Methods

We analyzed a cohort of patients who underwent left atrium reduction surgery between January 2016 and June 2020 performed by a specialized surgical team in 2 national reference centers in Lima, Peru. We assessed the major adverse valvular-related events and the New York Heart Association functional class as primary clinical outcomes. Also, our primary echocardiographic endings were the diameter, area, and volume of the left atrium. We assessed these variables at 3 time periods: baseline (t0), perioperative period (t1), and extended follow-up (t2: 12 ± 3.4 months). We carried out descriptive and bivariate exploratory statistical analysis for dependent measures.

Results

We included 17 patients, 70.6% of whom were women. Rheumatic mitral valve disease (76.5%) was the main etiology. We performed 14 (82.4%) mitral valve replacements and 3 repairs. Major adverse valvular-related events occurred in 1 patient (5.9%) (hemorrhagic stroke) at t1. A significant reduction in the size of the left atrium was observed: diameter (77 mm vs 48 mm, P < .001), area (75 cm² vs 31 cm², P < .001), and volume (332 cm³ vs 90 cm³, P < .001). Compared with t0 and t1, these echocardiographic findings remained without significant changes during t2.

Conclusions

Our surgical left atrium reduction technique was associated with improved clinical functionality and reduced left atrium measures in patients with a giant left atrium undergoing mitral valve surgery.

Silent giant left atrium: A case report

A 30-year-old woman presented with low-grade dyspnea on exertion. Chest X-ray demonstrated enlarged cardiac silhouette but was insufficient to delineate the cause. Echocardiogram revealed the cause to be the giant left atrium from mitral stenosis.

A case report: cardiac dysphagia—a ghost of the past?

Background

Rheumatic heart disease has become rare in developed countries and physicians have grown unfamiliar with the disease and its clinical course. The mitral valve is most commonly affected leading to mitral regurgitation and/or stenosis. The chronic volume and/or pressure overload leads to atrial remodelling and enlargement, driving the development of atrial fibrillation and thrombo-embolic events.

Case summary

A 87-year-old patient with a history of rheumatic mitral stenosis and mitral valve replacement was admitted to the neurology department for vertigo. A stroke was suspected, and she underwent a transoesophageal echocardiogram (TOE) which was complicated by dysphagia. Oesophageal manometry and computed tomography revealed oesophagogastric junction outflow obstruction due to extrinsic compression by a giant left atrium (GLA).

Discussion

Dysphagia due to a GLA is rare. Various diagnostic criteria exist and the prevalence thus depends on which criterium is used. It is mostly encountered in rheumatic mitral disease, although there are reports of non-rheumatic aetiology. When the left atrium assumes giant proportions it can compress adjacent intrathoracic structures. Compression of the oesophagus can lead to dysphagia, as in our case. A TOE in these cases is relatively contraindicated and should only be performed if there is considerable reason to believe that it may change patient management.

Dextroversion due to giant left atrium in a child

Giant left atrium is extremely rare in pediatric population. We hereby report a case of 4-year-old child with giant left atrium (LA) due to "non-rheumatic" mitral regurgitation (MR). The giant LA caused dextro-rotation of the heart, which immediately reverted to normal cardiac position after surgical repair. The case is reported for the unusual manifestation of giant LA as dextroversion.

Non-rheumatic giant left atrium: An illustrative case successfully treated by surgical intervention

A 45-year-old male presented to us with decompensated heart failure. He had been diagnosed as having atrial fibrillation when he was 31 years old. Transthoracic and transesophageal echocardiography revealed an excessive left atrial (LA) enlargement with left ventricular dysfunction and severe functional mitral regurgitation. There were no specific findings of rheumatic valve disease. He underwent surgical mitral valve replacement and LA volume reduction surgery after optimal medical therapy. Surgically-removed specimens of the LA and the anterior mitral leaflet were examined and there were no specific histopathological findings suggesting the specific etiology of the giant LA in this patient. The patient's condition significantly improved after the surgery without any cardiac events ever since. <Learning objective: Non-rheumatic giant left atrium (LA) is rare but can cause decompensated heart failure with various types of complications and hemodynamic problems. Mitral annular dilation and changes in the valve morphology often cause functional mitral regurgitation in giant LA, which adversely affect the hemodynamic condition. Valve surgery and surgical reduction of LA was effective in the present case.>.

Prognostic value of left atrial volume index in patients with rheumatic mitral stenosis

Background

The significance of left atrial volume index (LAVI) for predicting outcomes in patients with mitral stenosis (MS) has been unclear, even though rheumatic MS is known to be associated with left atrium enlargement and functional deterioration.

Hypothesis

The current study aimed to investigate the prognostic value of LAVI, based on the severity in patients with rheumatic MS.

Methods

We retrospectively reviewed 611 patients with pure rheumatic MS. The prognostic value of LAVI and the effect of MS severity on the prognostic value of LAVI for events were evaluated. The events were defined as a composite end‐point that included all‐cause death, heart failure admission, mitral valve replacement, percutaneous mitral valvuloplasty, and stroke.

Results

There were 236 (38.6%) overall events during a median follow‐up of 8 months. The optimal LAVI cutoff for the prognostic threshold was 57 ml/m². The MS severity had a significant effect on the prognostic value of LAVI. A LAVI >57 ml/m² was a prognostic value for events in progressive MS (hazard ratio [HR]: 2.40, 95% confidence interval [CI]: 1.41–5.40, p = .004) and in patients with severe MS (HR: 1.70, 95% CI: 1.06–2.74, p = .029), but it was not prognostic in patients with very severe MS (HR: 1.02, 95% CI: 0.56–1.84, p = .955).

Conclusions

The prognostic value of LAVI varies and is dependent on the MS severity. A LAVI >57 mL/m² was independently associated with poor outcomes in patients with progressive MS, while this association was minimized in patients with severe MS.

Reduction plasty for giant left atrium causing dysphagia: a case report

The giant left atrium is described as an atrium with a diameter of 6.5 cm or larger and which can rarely cause dysphagia by compressing on the esophagus. Left atrial enlargement is usually seen due to mitral valve disease. The most common indication of left atrial volume reduction plasty during mitral valve surgery is the compression symptoms. We performed mitral valve replacement in our case and transformed the giant left atrium into an anatomical chamber with the technique we applied. In this way, we successfully eliminated cardiac and compression symptoms. Cardiac causes of dysphagia are rarely seen, usually, cardiac complaints are more prominent than dysphagia. However, it should be kept in mind in the differential diagnosis. We think that cardiac mortality and morbidity may be prevented with early diagnosis and treatment.

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 Disguised as Right-Sided Pleural Effusion

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RHD is common in developing countries.

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GLA should be considered in patients presenting with rheumatic mitral disease history.

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The left atrium often appears as a pleural or pericardial effusion or mass lesion.

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Echocardiography provides the evidence for diagnosis of GLA.

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.

Associates and Prognosis of Giant Left Atrium; Single Center Experience

Background

Left atrial (LA) remodeling develops as a result of longstanding pressure overload. However, determinants and clinical outcome of excessive remodeling, so called giant left atrium (GLA), are not clear.

Methods

Clinical characteristics of patients with GLA (antero-posterior diameter higher than 65 mm), including echo-Doppler parameters, and follow-up clinical outcomes from a tertiary referral hospital were investigated.

Results

Among 68519 consecutive primary patients who underwent echocardiography over a period of 10 years, data from 163 GLA cases (0.24%) were analyzed. Main causes were significant rheumatic mitral stenosis (n = 58, 36%); other causes comprised significant rheumatic mitral regurgitation (MR; n = 10, 6%), mitral valve (MV) prolapse or congenital mitral valvular disease (MVD) (n = 20, 12%), and functional MR (n = 25, 15%). However, mild rheumatic MV disease (n = 4, 3%) or left ventricular (LV) systolic or diastolic dysfunction without significant MR (n = 46, 28%) were also causes of GLA. During median follow-up of 22 months, 42 cases (26%) underwent composite events. MV surgery was related to lower rate of composite events. In multivariate analysis, MV surgery, elevated pulmonary arterial systolic pressure, and increased LA volume index were independent predictors of future events (p < 0.05) regardless of underlying diseases or history of MV surgery.

Conclusion

Although rheumatic MVD with atrial fibrillation is the main contributor to GLA, longstanding atrial fibrillation with LV dysfunction but without MVD also could be related to GLA. Even in GLA state, accurate measurement of LA volume is crucial for risk stratification for future events, regardless of underlying disease.

Asymptomatic post-rheumatic giant left atrium

A 78-year-old asymptomatic woman was referred to our clinic for a second opinion regarding indication for mitral valve surgery. An echocardiogram showed a moderate mitral stenosis with a concomitant severe regurgitation. The most striking feature, however, was a giant left atrium with a parasternal anteroposterior diameter of 79 mm and a left atrial volume index of 364 mL/m². There are various echocardiographic definitions of a giant left atrium, which are mainly based on measurements of the anteroposterior diameter of the left atrium using M-mode in the parasternal long axis view. Since the commonly accepted method for echocardiographic evaluation of left atrial size is left atrial volume index, we propose a cut-off value of 140 mL/m² for the definition of a “giant left atrium”.

Rheumatic mitral stenosis in children: more accelerated course in sub-Saharan patients

Background

Mitral stenosis, one of the grave consequences of rheumatic heart disease, was generally considered to take decades to evolve. However, several studies from the developing countries have shown that mitral stenosis follows a different course from that seen in the developed countries. This study reports the prevalence, severity and common complications of mitral stenosis in the first and early second decades of life among children referred to a tertiary center for intervention.

Methods

Medical records of 365 patients aged less than 16 and diagnosed with rheumatic heart disease were reviewed. Mitral stenosis was graded as severe (mitral valve area < 1.0 cm²), moderate (mitral valve area 1.0-1.5 cm²) and mild (mitral valve area > 1.5 cm²).

Results

Mean age at diagnosis was 10.1 ± 2.5 (range 3–15) years. Of the 365 patients, 126 (34.5%) were found to have mitral stenosis by echocardiographic criteria. Among children between 6–10 years, the prevalence of mitral stenosis was 26.5%. Mean mitral valve area (n = 126) was 1.1 ± 0.5 cm² (range 0.4-2.0 cm²). Pure mitral stenosis was present in 35 children. Overall, multi-valvular involvement was present in 330 (90.4%). NYHA functional class was II in 76% and class III or IV in 22%. Only 25% of patients remember having symptoms of acute rheumatic fever. Complications at the time of referral include 16 cases of atrial fibrillation, 8 cases of spontaneous echo contrast in the left atrium, 2 cases of left atrial thrombus, 4 cases of thrombo-embolic events, 2 cases of septic emboli and 3 cases of airway compression by a giant left atrium.

Conclusion

Rheumatic mitral stenosis is common in the first and early second decades of life in Ethiopia. The course appeared to be accelerated resulting in complications and disability early in life. Echocardiography-based screening programs are needed to estimate the prevalence and to provide support for strengthening primary and secondary prevention programs.