Giant right and left atrium: spectrum of rheumatic triple valve disease (double hit with double impact): a case report and review of the literature.

BACKGROUND: Rheumatic heart disease (RHD) continues to pose a significant burden on global health, particularly in socioeconomically disadvantaged populations. We present the case of a 38-year-old woman with severe multivalvular RHD and giant atria, highlighting the challenges and complexities of managing this condition. CASE PRESENTATION: The patient presented with progressively worsening dyspnoea, signs of right heart failure, and severe valvular abnormalities. Diagnostic evaluations revealed severe mixed mitral valve disease in the form of mitral stenosis and regurgitation, along with involvement of the aortic and tricuspid valves, leading to significant enlargement of both atria. Despite facing socioeconomic constraints and poor adherence to treatment, the patient underwent successful surgical intervention, resulting in remarkable symptomatic improvement. CONCLUSIONS: Through this case, we emphasise the importance of early detection, comprehensive management strategies, and multidisciplinary care in addressing the complexities of RHD. Despite the challenges posed by socioeconomic disparities, positive outcomes can be achieved with timely diagnosis and appropriate intervention. This case underscores the need for targeted efforts to improve access to healthcare resources and reduce the global burden of RHD.

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.

Clinical Effects of Surgical Left Atrial Reduction and Concomitant Mitral Valve Replacement in Patients with Giant Left Atrium.

INTRODUCTION: A giant left atrium may cause respiratory dysfunction and hemodynamic disturbance postoperatively. This retrospective study aimed to evaluate clinical effects of surgical left atrial reduction in concomitant cardiac valves operations. METHODS: One hundred and thirty-five patients with heart valve diseases and giant left atriums from January 2004 to July 2021 were enrolled into this research. They were divided into the folded group (n=63) and the unfolded group (n=72). Patients in the folded group had undergone cardiac valve operations concomitantly with left atrial reductions. The perioperative characteristics were compared between both groups, and subgroup analysis was performed. RESULTS: There were five deaths in the folded group and 25 deaths in the unfolded group (P<0.001). Complications including pneumonia, sepsis, multiple organs dysfunction syndrome, low cardiac output syndrome, and the use of continuous renal replacement therapy were significantly fewer in the folded group. The receiver operating characteristic curve of left atrial max. diameter predicting mortality was significant (area under the curve=0.878, P=0.005), and the cutoff point was 96.5 mm. The stratified analysis for sex showed that more female patients died in the unfolded group. Logistic regression for mortality showed that the left atrium unfolded, left atrial max. diameter, cardiopulmonary bypass time, and mechanical ventilation time increased the risk of death. CONCLUSION: Surgical left atrial reduction concomitantly with valves replacement could decrease mortality and was safe and effective in giant left atrium patients.

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.

Clinical Effects of Surgical Left Atrial Reduction and Concomitant Mitral Valve Replacement in Patients with Giant Left Atrium

ABSTRACT Introduction: A giant left atrium may cause respiratory dysfunction and hemodynamic disturbance postoperatively. This retrospective study aimed to evaluate clinical effects of surgical left atrial reduction in concomitant cardiac valves operations. Methods: One hundred and thirty-five patients with heart valve diseases and giant left atriums from January 2004 to July 2021 were enrolled into this research. They were divided into the folded group (n=63) and the unfolded group (n=72). Patients in the folded group had undergone cardiac valve operations concomitantly with left atrial reductions. The perioperative characteristics were compared between both groups, and subgroup analysis was performed. Results: There were five deaths in the folded group and 25 deaths in the unfolded group (P<0.001). Complications including pneumonia, sepsis, multiple organs dysfunction syndrome, low cardiac output syndrome, and the use of continuous renal replacement therapy were significantly fewer in the folded group. The receiver operating characteristic curve of left atrial max. diameter predicting mortality was significant (area under the curve=0.878, P=0.005), and the cutoff point was 96.5 mm. The stratified analysis for sex showed that more female patients died in the unfolded group. Logistic regression for mortality showed that the left atrium unfolded, left atrial max. diameter, cardiopulmonary bypass time, and mechanical ventilation time increased the risk of death. Conclusion: Surgical left atrial reduction concomitantly with valves replacement could decrease mortality and was safe and effective in giant left atrium patients.

Radiofrequency Ablation in Patients Undergoing Mitral Valve Surgery with or without Giant Left Atria.

PURPOSE: We aimed to compare the efficacy of radiofrequency ablation (RFA) in patients undergoing mitral valve (MV) surgery with or without giant left atria. METHODS: This retrospective, single-center, cohort study investigated patients who underwent MV surgery and concomitant RFA from 2009 to 2019. Patients were divided into non-giant left atria (diameter ≤65 mm, n = 1543) and giant left atria (diameter >65 mm, n = 241) groups. Five-year freedom from atrial tachyarrhythmia recurrence and thromboembolic event (TE) rates were assessed with death as the competing risk factor with and without propensity-score matching. RESULTS: Patients with giant left atria had higher mortality (10.8% versus 6.2%, P = 0.008) and readmission rates for heart failure than those without (12.0% versus 6.8%, P = 0.004). Atrial tachyarrhythmia recurrence rates were higher in patients with giant left atria than in those without (49% versus 24% at 5 years, P <0.001), but the cumulative incidence of TEs before (P = 0.944) and after (P = 0.695) propensity-score matching was comparable. CONCLUSIONS: RFA effectively prevented TEs in patients with giant left atria, despite significant atrial tachyarrhythmia recurrence. Atrial tachyarrhythmia recurrence did not increase the risk of TEs. A lower success rate should be considered when deciding whether to perform surgical ablation in patients with giant left atria.

Surgical ablation for atrial fibrillation is efficacious in patients with giant left atria.

OBJECTIVE: The Cox-Maze IV procedure (CMP-IV) is the most effective treatment for atrial fibrillation. Increased left atrial (LA) size has been identified as a risk factor for failure to restore sinus rhythm. This has biased many surgeons against ablation in patients with giant left atrium (GLA), defined as LA diameter >6.5 cm. In this study we aimed to define the efficacy of the CMP-IV in patients with GLA. METHODS: From April 2004 through March 2020, 786 patients with a documented LA diameter underwent elective CMP-IV, 72 of whom had GLA. Median follow-up duration was 4 years (interquartile range, 1-7 years). Recurrence was defined as any documented atrial tachyarrhythmia (ATA) lasting 30 seconds. ATA recurrence and survival were analyzed across GLA versus non-GLA groups. RESULTS: Median age at surgery was 65 (interquartile range, 56-73) years. Median LA diameter within the GLA group was 7.0 (range, 6.6-10.0) cm. There were no differences in rates of postoperative complications for the 2 groups, including rate of postoperative stroke and pacemaker placement (GLA 14%; non-GLA 12%; P = .682). A trend toward increased 30-day mortality in the GLA group did not reach statistical significance (GLA 6%; non-GLA 2%; P = .051). Freedom from ATAs at 5 years postoperatively was comparable for the 2 groups (GLA 82%; non-GLA 84%). CONCLUSIONS: The CMP-IV had good efficacy in patients with GLA. Our results suggest that LA diameter >6.5 cm should not preclude a patient from undergoing surgical ablation for atrial fibrillation.

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.

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. .

Largest giant left atrium in rheumatic heart disease.

In the current era of echocardiography, early diagnosis and treatment of rheumatic heart disease make giant left atrium a rare condition, with a reported incidence of 0.3%, and following mainly with rheumatic mitral valve disease. We report a 50-year-old female, a known case of rheumatic heart disease who presented with breathlessness and dysphagia, and the cardiothoracic ratio on chest roentgenogram was 0.95. Echocardiography was suggestive of giant left atrium with a size of 19.4 x 18.3 cm, while magnetic resonance imaging revealed a size of 22.3 x 19.2 x 20.1 cm making it the largest left atrium to be reported in the literature. .

Rare Case of a Giant Left Atrium With Cerebrovascular Accident.

Left atrium enlargement is very common in patients with valvular heart disease and atrial fibrillation but an extremely dilated left atrium is a very rare condition and rarely reported in the literature. It is a risk factor for ischemic cerebrovascular accidents due to blood stasis as the cavity diameter increases. We are reporting a case of rarely seen severely dilated left atrium with a normal functioning prosthetic mechanical mitral valve with a cerebrovascular accident on anti-vitamin K and aspirin. The patient had a left atrium diameter of 12.7 cm, an area of 200 cm square, and a volume of 2000 cc. We elected to keep the international normalized ratio (INR) slightly above the therapeutic range in order to decrease the risk of ischemic events. It might be necessary to do the same for patients with a similar condition to decrease the stroke rates.

Efficacy of left atrial plication for atrial functional mitral regurgitation.

OBJECTIVE: Atrial functional mitral regurgitation (AFMR) is caused by atrial fibrillation and left atrial enlargement. Our study aimed to evaluate the efficacy of left atrial plication (LAP) for AFMR. METHODS: Of 1164 mitral valve surgery patients at our hospital from January 2000 to May 2019, 22 patients underwent surgery for AFMR. Our retrospective analysis divided the patients with AFMR into two groups according to whether LAP was performed (LAP + group, n = 9; LAP - group, n = 13). Mitral valve angle (MV angle) (horizontal inclination of mitral valve) was measured by pre- and post-operative computed tomography scan. Individuals with type II mitral regurgitation, left ventricular ejection fraction of < 55%, males with left ventricular endo-diastolic dimension of > 60 mm and females with > 55 mm, aortic valve disease, mitral valve calcification, hypertrophic obstructive cardiomyopathy, and both "redo" and emergency cases were excluded. RESULT: Mitral valve replacement was performed in 6 patients and mitral ring annuloplasty in 16 cases. No recurrence of mitral regurgitation or structural valve deterioration occurred during the follow-up period. There were no hospital deaths; 3 deaths occurred during the follow-up period. Compared to the LAP - group, the LAP + group demonstrated a significantly greater decrease of MV angle (16.6 ± 8.1° vs. 1.2 ± 6.9°, p < 0.01) and left atrial dimension (18.4 ± 7.0 mm vs. 6.9 ± 14.6 mm, p = 0.02). CONCLUSIONS: Surgical results of AFMR were satisfactory. LAP may be appropriate for correcting the angle of a mitral valve tilted horizontally. More cases need to be considered in the future.

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.

[Three-valve reconstruction with prosthetic repair of the ascending portion of the aorta in elderly patients]. / Trekhklapannaia rekonstruktsiia s protezirovaniem voskhodiashchego otdela aorty u bol'nogo pozhilogo vozrasta.

Elderly and aged patients appear to have a significantly increased risk from a cardiosurgical intervention combining three-valve reconstruction and prosthetic repair of the ascending portion of the aorta. Triple-valve pathology in pronounced mitral insufficiency is often accompanied by concomitant dilatation of the left atrium, i. e., atriomegaly. With the aim to eliminate the syndrome of compression of surrounding tissues and normalize intracardiac haemodynamics, reduction of the left atrium should become an inherent procedure for atriomegaly in patients with multiple-valve pathology.

Massive calcification of giant left atrium in a rheumatic mitral stenosis patient: A case report.

Giant left atrium is a condition characterized by an extreme enlargement of the left atrium with a diameter more than 80 mm and it is usually associated with long standing rheumatic mitral valve disease. We present a case of giant left atrium with massive calcification in a female patient who had a history of rheumatic heart disease, severe mitral stenosis, permanent atrial fibrillation, and cerebral infarctions.

Efficacy of Cut-and-Sew Surgical Ablation for Atrial Fibrillation in Patients With Giant Left Atria Undergoing Mitral Valve Surgery: A Propensity-Matched Analysis.

Surgical management for patients with long-standing persistent (LSP) AF and giant left atria (GLA) associated with mitral valve diseases remains a challenge. We aimed to assess the efficacy of the cut-and-sew maze procedure (CSM) in this subgroup of patients, in terms of maintenance of sinus rhythm (SR), atrial function, and to identify the operative risks of this procedure. A total of 229 patients with LSP-AF underwent CSM at our institution from December 2013 to October 2017. Patients were divided into 2 groups based on LA diameter: NGLA group (<65 mm, n = 171), GLA group (≥65 mm, n = 58). Patients with GLA were propensity score matched to patients without GLA resulting in 45 pairs of patients. Early death occurred in 1 (2.2%) in GLA group and no deaths in NGLA group (P = 0.315). Early complications did not differ significantly between the 2 groups. The GLA group showed similar rates of SR on and off antiarrhythmic drugs compared with NGLA group at 2 years (86.36% vs 93.9%, P = 0.338; 81.82% vs 90.91%, P = 0.322). At 2 years, LA contraction was comparable between patients with and without GLA (81.81% vs 90.9%, P = 0.322). Right atrial contraction recovery rate was 96% in NGLA group, and 86.36% in GLA group (P = 0.138). Concomitant CSM is effective and feasible for restoration of SR and atrial contraction, for patients with LSP-AF and GLA associated with mitral valve diseases with acceptable operative risks.

A case of esophageal perforation after intraoperative transesophageal echocardiography in a patient with a giant left atrium: unexpectedly large distortion of the esophagus revealed on retrospectively constructed three-dimensional imaging.

BACKGROUND: Esophageal perforation is a rare but serious complication of transesophageal echocardiography (TEE). An enlarged left atrium (LA), which is commonly associated with mitral stenosis (MS), is an under-recognized risk factor for esophageal perforation after intraoperative TEE. CASE PRESENTATION: We describe a case of TEE-induced esophageal perforation after cardiac surgery in a 79-year-old woman with a giant LA due to MS. Esophageal perforation was detected on postoperative day 6. After surgical repair, the patient gradually recovered with prolonged conservative treatment. Retrospectively constructed three-dimensional chest computed tomography images revealed an unusually distorted esophagus that was possibly vulnerable to injury. CONCLUSION: A giant LA can markedly distort the esophagus. It should be recognized as a risk factor for TEE-induced esophageal perforation.

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.