Annals of Pediatric Cardiology
About us | Current Issue | Archives | Ahead of Print | Instructions | Submission | Subscribe | Advertise | Contact | Login 
     
     
 


 

 
     
    Advanced search
 

 
 
     
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  


    References
    Article Figures

 Article Access Statistics
    Viewed2563    
    Printed56    
    Emailed0    
    PDF Downloaded120    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents   
LETTER TO EDITOR  
Year : 2015  |  Volume : 8  |  Issue : 1  |  Page : 95-97
A "non-rheumatic" giant left atrium


Department of Cardiology, Pediatric Cardiology Unit, Institute of Post-Graduate Medical Education and Research, Seth Sukhlal Karnani Memorial Hospital, Kolkata, West Bengal, India

Click here for correspondence address and email

Date of Web Publication19-Jan-2015
 

How to cite this article:
Ahmed I, Sarkar A, Pande A, Kundu C. A "non-rheumatic" giant left atrium. Ann Pediatr Card 2015;8:95-7

How to cite this URL:
Ahmed I, Sarkar A, Pande A, Kundu C. A "non-rheumatic" giant left atrium. Ann Pediatr Card [serial online] 2015 [cited 2019 Aug 23];8:95-7. Available from: http://www.annalspc.com/text.asp?2015/8/1/95/149542


Sir,

Giant left atrium (GLA) is a rare condition with a reported incidence of 0.3%. Definition of GLA is varied. Piccoli et al. defined the giant left atrium as a cardio-thoracic ratio on chest X-ray (CXR) of >0.7 combined with a left atrial anterior-posterior diameter of >8 cm on transthoracic echocardiography. [1] According to the definition by Isomura and coworkers, left atria larger than 6 cm in diameter are giant left atria. [2] Giant left atrium is commonly associated with longstanding rheumatic mitral valve regurgitation or mixed mitral disease with predominant regurgitation. The largest ever GLA reported to our knowledge measured 19.3 × 14.7 cm and was due to untreated rheumatic heart disease. [3] However, not many reports of "non-rheumatic"causes of GLA are available. The largest ever "non-rheumatic" GLA reported, measured 12 × 13 cm in a case of mitral valve prolapse. [4]

A 22-year-old male was admitted with signs of acute decompensated heart failure. The physical examination revealed anterior precordial bulging with scoliosis, his blood pressure was 100/60 mmHg, his heart rate was 110/min with atrial fibrillation, neck veins were distended, and crepitations were present at the basal regions of his lungs. [Figure 1] A grade 3/6 pansystolic murmur and a diastolic flow murmur were present at the anterior axillary line, and there was peripheral edema. Chest radiography revealed cardiomegaly (cardiothoracic ratio, 0.74) leading to splaying of the carina, an elevated left main bronchus and severe thoracic scoliosis [Figure 2]. Echocardiogram showed massive left atrial enlargement, cleft anterior mitral leaflet, double mitral regurgitation jets, a small ostium primum atrial septal defect, and an (7 mm) inlet ventricular septal defect [Figure 3] and [Figure 4] - both with left to right shunts. A diagnosis of "Giant Left Atrium" (GLA) with partial atrioventricular septal defect was confirmed by cardiac computed tomography (CT) scan [Figure 5] and [Figure 6]. Maximum diameter of left atrium (LA) recorded by CT was 14.4 × 12.4 cm. [Figure 7] and LA volume was 840 ml. The patient was judged to be in New York Heart Association (NYHA) functional class IV. After initial attempt to stabilize him with infusion of furosemide (6 mg/hour) and isosorbide dinitrate (5 μg/min), he was referred to cardiac surgery department for LA size reduction and corrective surgery for the atrio-ventricular septal defect, as clinical and echo parameters predicted only a moderate pulmonary hypertension. Intra-operative findings confirmed the structural defects. [5] The patient's post-operative recovery was briefly punctuated by surgical wound infection; otherwise, patient has improved, with NYHA status at present class II/IV.
Figure 1: Photo of the patient showing precordial bulging and scoliosis

Click here to view
Figure 2: Chest radiography shows cardiomegaly, splaying of the carina, an elevated left main bronchus and scoliosis

Click here to view
Figure 3: Echocardiogram showing massive left atrial enlargement

Click here to view
Figure 4: Echocardiogram showing cleft anterior mitral leaflet with double mitral regurgitation jets; a small osteum primum atrial septal defect and an inlet VSD

Click here to view
Figure 5: Cardiac computed tomography (CT) Scan showing dilated LA

Click here to view
Figure 6: Cardiac CT Scan with 3D reconstruction showing dilated LA

Click here to view
Figure 7: Maximum diameter of LA recorded by CT scan is 14.4 × 12.4 cm

Click here to view


This case probably represents the largest ever "non-rheumatic" GLA reported, demonstrating the extent to which a LA can expand even in a congenital heart disease condition. Although not many reports of "non-rheumatic" GLA are available but its identification is essential because of the complications associated. GLA can be associated with atrial fibrillation, thromboembolic complications, hemodynamic, and respiratory complications. GLA may lead to skeletal changes in the thorax related to direction of enlargement of LA; as in non-structural (postural) scoliosis seen in our case. [6] Surgical options for GLA are divided for either performing mitral valve surgery with left atrial volume reduction or performing mitral valve surgery alone. [7] A giant LA is an indication for the initiation of anti-coagulant therapy.

 
   References Top

1.
Piccoli GP, Massini C, Di Eusanio G, Ballerini L, Tacobone G, Soro A, et al. Giant leftatrium and mitral valve disease: Early and late results of surgical treatment in 40 cases. J Cardiovasc Surg (Torino) 1984;25:328-36.  Back to cited text no. 1
    
2.
Isomura T, Hisatomi K, Hirano A, Maruyama H, Kosuga K, Ohishi K. Left atrial placation and mitral valve replacement for giant left atrium accompanying mitral lesion. J Card Surg 1993;8:365-70.  Back to cited text no. 2
    
3.
Ozkan A, Tuncer A, Ozkan M. Giant left atrium. J Am Coll Cardiol 2012;60:e13.  Back to cited text no. 3
    
4.
Pande A, Sarkar A, Ahmed I, Chandra NG, Patil SK, Kundu CK, et al. Non-invasive estimation of pulmonary vascular resistance in patients of pulmonary hypertension in congenital heart disease with unobstructed pulmonary flow. Ann Pediatr Cardiol 2014;7:92-7.  Back to cited text no. 4
    
5.
Phua GC, Eng PC, Lim SL, Chua YL. Beyond Ortner′s syndrome - Unusual pulmonarycomplications of the giant left atrium. Ann Acad Med 2005;34:642-5.  Back to cited text no. 5
    
6.
Scoliosis. Suken A. Shah, MD - Nemours. Available from: http://www.nemours.org/content/dam/nemours/wwwv2/filebox/service/medical/spinescoliosis/scoliosisguide.pdf [Last accessed on 2014 Jul 25].  Back to cited text no. 6
    
7.
Apostolakis E, Shuhaiber JH. The surgical management of giant left atrium. Eur J Cardiothorac Surg 2008;33:182-90.  Back to cited text no. 7
    

Top
Correspondence Address:
Imran Ahmed
Department of Cardiology, Pediatric Cardiology Unit, Institute of Post-Graduate Medical Education and Research, Seth Sukhlal Karnani Memorial Hospital, Kolkata, West Bengal
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2069.149542

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

Top