European Journal of Echocardiography 2008 9(1):190-191; doi:10.1016/j.euje.2007.08.002
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org
Acquired accessory left atrium
Mohammad Bagher Sharifkazemi,
Reza Mollazadeh*,
Mahmood Zamirian and
Ali Reza Moaref
Cardiology Department, Nemazee Hospital, Shiraz University of Medical Science, Zand Avence, P.O. Box: 71435-1414, Shiraz, Iran
Received 21 June 2007; accepted after revision 5 August 2007; online publish-ahead-of-print 8 October 2007.
* Corresponding author. Tel: +98 917 313 3749; fax: +98 711 6261089. E-mail address: mollazar{at}yahoo.com
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Abstract
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The patient was a 61-year-old woman brought to our hospital
due to dyspnea and lower extremity swelling in shock state three
weeks after mitral valve replacement due to rheumatic mitral
regurgitation. Cardiothoracic examination revealed bilateral
diffuse rales, metallic first heart sound and a loud holo systolic
murmur in apex with radiation to axilla. Transesophageal echocardiography
revealed a large echo lucent area representing a separate chamber
in the lateral part of left atrium which communicates with left
ventricle through a relatively large orifice far from normal
functioning prosthesis. In operation left atrial dissection
was confirmed but the patient did not wean from cardiopulmonary
bypass and died on the operating table.
Keywords: Dissection; Left atrium; Mitral valve surgery complication; Transesophageal echocardiography
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Case presentation
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The patient was a 61-year-old woman brought to our hospital
due to dyspnea and lower extremity swelling since two days earlier.
Her mitral valve was replaced with a 29 mm St. Jude prosthesis
due to rheumatic mitral regurgitation three weeks earlier. The
postoperative course was uneventful and she was discharged five
days later. At home she consumed warfarin, furosemide and spironolactone
regularly. On admission, blood pressure, respiratory and pulse
rate were 90/60, 34 and 116, respectively. She had elevated
jugular veins and cold extremities. Chest examination revealed
bilateral diffuse rales. In companion to metallic first heart
sound a loud (grade IV) holo systolic murmur in apex with radiation
to axilla could be heard.
Transthoracic echocardiography showed normal left ventricular and mitral valve function. An ill-defined echo density was noted in the left atrium. There were new findings of severe tricuspid regurgitation and reduced right ventricular function. The tricuspid valve appeared morphologically normal. Transesophageal echocardiography (TEE) revealed a large echo lucent area representing a separate chamber in the lateral part of left atrium (Movie 1, Figure 1). There was increased echogenicity and thickness of flap in the most upper part suggesting hematoma (Movie 2). More attentive examination revealed a systolic flow from the left ventricle to this chamber (Movie 3) through a relatively large (9 mm) (Figure 2) orifice (Movie 4) far from normal functioning prosthesis. Neither any communication was noted between this chamber and the true left atrium nor there any paravalvular leakage (Movie 5). Normal flow patterns were seen in the pulmonary veins. Immediate reoperation was planned. At surgery right ventricle was dilated with severe hypokinesia. Pulmonary artery pressure was 70 mmHg. An intimal tear with irregular margins was found approximately 1 cm away from the prosthetic annulus. The St. Jude prosthesis was intact, and there were no paravalvular leaks. The left atrial dissection (LAD) was closed using pledget-reinforced sutures anchored to the ring of the mitral prosthesis, thus obliterating the false left atrial lumen. Unfortunately severe right ventricular dysfunction persisted and patient could not be weaned from cardiopulmonary bypass. Finally she died on the operating table.
Most cardiac ruptures after mitral valve surgery occur in the
posterior wall of the left ventricle or at the atrioventricular
groove.
1 They are rare, and often lethal. LAD is a much rarer
complication defined by Gallego
et al. as a gap from the mitral
or tricuspid annular area to interatrial septum or left atrial
wall, creating a new chamber with or without communications
into the true left or right atrium.
2 The most common etiology
of LAD is mitral valve surgery. Debridement of much calcified
valves annulus, improper suturing of the annulus to the prosthetic
cuff, excessive traction on sutures in the posterior annulus,
inadvertent incision of the posterior annulus and the hemodynamic
influence of the paraprosthetic leak extended the dissection
into the left atrial wall, developing a false cavity. Also left
atrial thrombectomy can be associated with injury to the left
atrial endocardium as a mechanism of primary tear.
3 Coronary
sinus rupture or inner-wall perforation of the right atrium
secondary to retrograde cardioplegia has been previously reported.
2 Other less common etiologies include infective endocarditis,
4 aortic valve surgery, external cardiac massage, acute myocardial
infarction, and blunt chest trauma.
1
Hemodynamic compromise with LAD in the literature has been illustrated to be due to prosthetic valve dysfunction, left to right atrial shunts (in the case of interatrial septum dissection), and pulmonary venous obstruction but the etiology of heart failure symptoms in our patient was felt to be due to reduced left atrial compliance and decreased chamber size caused by large area of LAD. Pulmonary hypertension and subsequent right ventricular dilatation with tricuspid regurgitation were presumed to be due to the increase in left atrial pressure.
Clinical presentation can be the appearance of a new systolic murmur, associated with or without symptoms of heart failure and low-output syndrome, hours to days after the operation but there were patients in whom clinical onset occurs years after surgery.1,5 TEE is the diagnostic modality of choice for LAD.6 In a series of 11 patients 2 findings on TEE included: mycotic left atrial aneurysm, fistulous communication between aortic root and right atrium, pseudo aneurysm and left to right shunt. In two patients, a communication between the false and true chamber was not seen (such as our case) and in six cases systolic inflow from the left ventricle into the false chamber was noted (such as our case). Rarely, LAD can be an incidental finding on TEE in an asymptomatic patient.2 No definitive criteria exist to help guide management of LAD. Prompt surgical repair is usually required because of coexistent significant mitral regurgitation, intracardiac shunt, mycotic aneurysm, pseudo aneurysm or fistulous communication or severe pulmonary hypertension (such as our case). However, in the absence of these findings, surgery may not always be necessary2 and occasionally successful repair has been performed years after diagnosis.7
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Supplementary material
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Supplementary material associated with this article can be found in the online version.
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References
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- Karlson KJ, Ashraf MM, Berger RL. Rupture of left ventricle following mitral valve replacement. Ann Thorac Surg (1988) 46:590–7.[Abstract]
- Gallego P, Oliver JM, Gonzalez A, Dominguez FJ, Sanchez-Recalde A, Mesa JM. Left atrial dissection: pathogenesis, clinical course, and transesophageal echocardiographic recognition. J Am Soc Echocardiogr (2001) 14:813–20.[CrossRef][Web of Science][Medline]
- Sekino Y, Sadahiro M, Tabayashi K. Successful surgical repair of left atrial dissection after mitral valve replacement. Ann Thorac Surg (1996) 61:1528–30.[Abstract/Free Full Text]
- Cordero Lorenzana ML, Lopez Perez JM, Merayo Macias E, Gulias Lopez JM, Paz Rodriguez J. Left atrial dissection and infective endocarditis. Rev Esp Cardiol (1998) 51:402–3.[Web of Science][Medline]
- Jani S, Hecht S, Leibowitz K, Berger M. Left atrial dissection: an unusual complication of mitral valve surgery. Echocardiography (2007) 24:443–4.[CrossRef][Web of Science][Medline]
- Martinez-Selles M, Garcia-Fernandez MA, Moreno M, Bermejo J, Delcan JL. Echocardiographic features of left atrial dissection. Eur J Echocardiogr (2000) 1:147–50.[Abstract/Free Full Text]
- Maeda K, Yamashita C, Shida T, Okada M, Nakamura K. Successful surgical treatment of dissecting left atrial aneurysm after mitral valve replacement. Ann Thorac Surg (1985) 39:382–4.[Abstract]
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Abstract
Case presentation
