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Left Atrial Appendage Aneurysm: A Rare Cause of Paroxysmal Supraventricular Tachycardia
246
Case Reports
Heart, Lung and Circulation 2008;17:243–263
CASE REPORT
Left Atrial Appendage Aneurysm: A Rare Cause of Paroxysmal Supraventricular Tachycardia Aliakbar Soleimani, MD ∗ , Roya Sattarzadeh, MD, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
Left atrial appendage aneurysm is a rare abnormality and a diagnostic dilemma in patients with cardiomegaly. Patients most commonly present with atrial tachyarrhythmias and thromboembolic events. Resection of the aneurysm is usually curative. We report herein the case of a 27-year-old man with massive left atrial appendage aneurysm diagnosed incidentally in the course of pre-operative evaluation for a non-cardiac surgery. The marked cardiomegaly detected in a routinely ordered pre-operative chest X-ray and the history of previous episodes of palpitation accompanied by chest discomfort guided us to the diagnosis. The diagnosis was made by transthoracic echocardiography and confirmed by angiography and then surgery. (Heart, Lung and Circulation 2008;17:243–263) © 2007 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Heart aneurysm; Left atrial appendage; Supraventricular tachycardia
Introduction
L
eft atrial appendage aneurysm is a rare condition which can lead to dangerous complications if left untreated. Here, we present a case report of a 27-year-old male with an eight-month history of palpitation and chest discomfort found to have a large left atrial appendage aneurysm. The patient was successfully treated with resection of the aneurysm.
Case A 27-year-old man was admitted to our hospital for a non-cardiac surgery. In pre-operative evaluation, his medical history revealed frequent episodes of palpitation and chest discomfort for a period of eight months. Physical examination was unremarkable. The CXR showed marked prominence of the left cardiac border (Fig. 1). Owing to these findings, the patient was referred to the cardiology clinic for further investigations. Transthoracic echocardiography unveiled a large echo-free space (9.5 cm × 9.4 cm) adjacent to the posterolateral wall of the left ventricle, communicated with the left atrium through a wide neck (Fig. 2). An echocardiogram showed the ejection fraction of 35–40% and mild to moderate mitral regurgitation. Cardiac catheterisation revealed a huge cavity connected to Received 24 December 2006; received in revised form 28 February 2007; accepted 18 April 2007; available online 4 June 2007 ∗
Corresponding author at: Cardiac Surgery Operating Room, Imam Khomeini Hospital, Keshavarz Blvd., Tehran 1419731351, Iran. Tel.: +98 912 1480625; fax: +98 21 66438634. E-mail address: [email protected] (A. Soleimani).
the left atrium, normal coronary arteries and mitral regurgitation. The initial ECG showed normal sinus rhythm without evidence of left atrial enlargement. The patient was then referred to cardiac surgery ward for resection of left atrial aneurysm. Before the operation, he experienced an attack of palpitation. The ECG during palpitation, showed a supraventricular tachycardia at a rate of 180 beats/min. The patient underwent operation through median sternotomy using cardiopulmonary bypass. The pericardium was intact and the wall of the aneurysm was thin. The course of the coronary arteries, the confluence of the pulmonary veins and the interatrial septum were normal. After cross clamping of the aorta and injection of ante grade cardioplegia, the aneurysm was opened. There was an obvious communication between the aneurysm and the left atrium through a wide neck about 3 cm in diameter. There was no thrombus inside the cavity of aneurysm and atrium. Having resected the aneurysm, the remnant of the left atrial appendage was closed with running suture and the mitral valve was repaired. Histopathology report confirmed benign cardiac and fibrous tissue. The patient had an uneventful postoperative course and was discharged home in sinus rhythm on the sixth postoperative day. He has remained in sinus rhythm off medications for six months postoperatively.
Discussion Left atrial appendage aneurysm is a rare condition first described by Semans and Taussig in 1938.1 They reported a saccular dilatation of the left atrium in a 5-year-old girl with dextrorotation of the heart. The appendage was not involved. Left atrial appendage aneurysm may be primary with an intact pericardium or secondary to left ventricular dysfunction, mitral valve pathology or herniation of the left
© 2007 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2007.04.004
Figure 1. Pre-operative chest X-ray.
Case Reports
247
ond to fourth decades of life. Asymptomatic adults usually present with palpitation, dyspnoea on exertion, chest pain and systemic embolisation (due to stasis in the aneurismal cavity). Physical examination is often unrevealing but ECG may reveal tachyarrhythmia,5 as in our case. Echocardiography, radionuclide angiography, CT scan, MRI and cardiac catheterisation have been used to establish the diagnosis. Transoesophageal echocardiography is a useful diagnostic tool, particularly for detection of thrombi inside the left atrium or the aneurysm but it is more invasive than transthoracic echocardiography and carries a small risk of aneurismal rupture and embolisation. It can be performed after induction of anaesthesia. In our case, transthoracic echocardiography adequately demonstrated the aneurysm. Therefore, we saw no point in performing transoesophageal echocardiography. Since devastating complications such as thromboembolism or cardiac arrhythmia may occur, surgical resection is strongly recommended to both abolish the arrhythmogenic focus as well as eliminate a potential source of systemic emboli even in asymptomatic patients. To summarise, a chest X-ray showing prominent left cardiac border should always raise the suspicion of left atrial aneurysm. Other conditions that can produce similar shadows include: cardiac tumours, pericardial fluid collection, pericardial cysts and mediastinal masses. We also suggest that, even though rare, if a young patient presents with paroxysmal supraventricular arrhythmia with no other associated pathologies, a left atrial aneurysm should be ruled out.
References
Figure 2. Pre-operative two-chamber transthoracic echocardiogram showing aneurysmal left atrial appendage (LA: left atrium; LV: left ventricle).
atrial appendage through a pericardial defect.2,3 Intrapericardial left atrial appendage aneurysm is believed to be due to congenital weakness involving left atrial appendage or left atrial free wall. Most cases are asymptomatic in childhood.4 The condition is usually diagnosed in the sec-
1. Victor S, Nayak V. Aneurysm of the left atrial appendage. Tex Heart Inst J 2001;28:111–8. 2. Tanabe T, Ishizaka M, Ohta S, Sugie S. Intrapericardial aneurysm of the left atrial appendage. Thorax 1980;35:151–3. 3. Godwin TS, Avager P, Key JA. Intrapericardial aneurysm dilatation of the left atrial appendage. Circulation 1988;37:397–400. 4. Behrendt DM, Aberdeen E. Congenital aneurysm of the left atrium. Ann Thorac Surg 1972;13:54–9. 5. Krueger SK, Ferlic RM, Mooring PK. Left atrial appendage aneurysm: correlation of noninvasive with clinical and surgical findings: report of a case. Circulation 1975;52:732–8.
CASE REPORT
Heart, Lung and Circulation 2008;17:243–263
Case Reports
Heart, Lung and Circulation 2008;17:243–263
CASE REPORT
Left Atrial Appendage Aneurysm: A Rare Cause of Paroxysmal Supraventricular Tachycardia Aliakbar Soleimani, MD ∗ , Roya Sattarzadeh, MD, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
Left atrial appendage aneurysm is a rare abnormality and a diagnostic dilemma in patients with cardiomegaly. Patients most commonly present with atrial tachyarrhythmias and thromboembolic events. Resection of the aneurysm is usually curative. We report herein the case of a 27-year-old man with massive left atrial appendage aneurysm diagnosed incidentally in the course of pre-operative evaluation for a non-cardiac surgery. The marked cardiomegaly detected in a routinely ordered pre-operative chest X-ray and the history of previous episodes of palpitation accompanied by chest discomfort guided us to the diagnosis. The diagnosis was made by transthoracic echocardiography and confirmed by angiography and then surgery. (Heart, Lung and Circulation 2008;17:243–263) © 2007 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Heart aneurysm; Left atrial appendage; Supraventricular tachycardia
Introduction
L
eft atrial appendage aneurysm is a rare condition which can lead to dangerous complications if left untreated. Here, we present a case report of a 27-year-old male with an eight-month history of palpitation and chest discomfort found to have a large left atrial appendage aneurysm. The patient was successfully treated with resection of the aneurysm.
Case A 27-year-old man was admitted to our hospital for a non-cardiac surgery. In pre-operative evaluation, his medical history revealed frequent episodes of palpitation and chest discomfort for a period of eight months. Physical examination was unremarkable. The CXR showed marked prominence of the left cardiac border (Fig. 1). Owing to these findings, the patient was referred to the cardiology clinic for further investigations. Transthoracic echocardiography unveiled a large echo-free space (9.5 cm × 9.4 cm) adjacent to the posterolateral wall of the left ventricle, communicated with the left atrium through a wide neck (Fig. 2). An echocardiogram showed the ejection fraction of 35–40% and mild to moderate mitral regurgitation. Cardiac catheterisation revealed a huge cavity connected to Received 24 December 2006; received in revised form 28 February 2007; accepted 18 April 2007; available online 4 June 2007 ∗
Corresponding author at: Cardiac Surgery Operating Room, Imam Khomeini Hospital, Keshavarz Blvd., Tehran 1419731351, Iran. Tel.: +98 912 1480625; fax: +98 21 66438634. E-mail address: [email protected] (A. Soleimani).
the left atrium, normal coronary arteries and mitral regurgitation. The initial ECG showed normal sinus rhythm without evidence of left atrial enlargement. The patient was then referred to cardiac surgery ward for resection of left atrial aneurysm. Before the operation, he experienced an attack of palpitation. The ECG during palpitation, showed a supraventricular tachycardia at a rate of 180 beats/min. The patient underwent operation through median sternotomy using cardiopulmonary bypass. The pericardium was intact and the wall of the aneurysm was thin. The course of the coronary arteries, the confluence of the pulmonary veins and the interatrial septum were normal. After cross clamping of the aorta and injection of ante grade cardioplegia, the aneurysm was opened. There was an obvious communication between the aneurysm and the left atrium through a wide neck about 3 cm in diameter. There was no thrombus inside the cavity of aneurysm and atrium. Having resected the aneurysm, the remnant of the left atrial appendage was closed with running suture and the mitral valve was repaired. Histopathology report confirmed benign cardiac and fibrous tissue. The patient had an uneventful postoperative course and was discharged home in sinus rhythm on the sixth postoperative day. He has remained in sinus rhythm off medications for six months postoperatively.
Discussion Left atrial appendage aneurysm is a rare condition first described by Semans and Taussig in 1938.1 They reported a saccular dilatation of the left atrium in a 5-year-old girl with dextrorotation of the heart. The appendage was not involved. Left atrial appendage aneurysm may be primary with an intact pericardium or secondary to left ventricular dysfunction, mitral valve pathology or herniation of the left
© 2007 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
1443-9506/04/$30.00 doi:10.1016/j.hlc.2007.04.004
Figure 1. Pre-operative chest X-ray.
Case Reports
247
ond to fourth decades of life. Asymptomatic adults usually present with palpitation, dyspnoea on exertion, chest pain and systemic embolisation (due to stasis in the aneurismal cavity). Physical examination is often unrevealing but ECG may reveal tachyarrhythmia,5 as in our case. Echocardiography, radionuclide angiography, CT scan, MRI and cardiac catheterisation have been used to establish the diagnosis. Transoesophageal echocardiography is a useful diagnostic tool, particularly for detection of thrombi inside the left atrium or the aneurysm but it is more invasive than transthoracic echocardiography and carries a small risk of aneurismal rupture and embolisation. It can be performed after induction of anaesthesia. In our case, transthoracic echocardiography adequately demonstrated the aneurysm. Therefore, we saw no point in performing transoesophageal echocardiography. Since devastating complications such as thromboembolism or cardiac arrhythmia may occur, surgical resection is strongly recommended to both abolish the arrhythmogenic focus as well as eliminate a potential source of systemic emboli even in asymptomatic patients. To summarise, a chest X-ray showing prominent left cardiac border should always raise the suspicion of left atrial aneurysm. Other conditions that can produce similar shadows include: cardiac tumours, pericardial fluid collection, pericardial cysts and mediastinal masses. We also suggest that, even though rare, if a young patient presents with paroxysmal supraventricular arrhythmia with no other associated pathologies, a left atrial aneurysm should be ruled out.
References
Figure 2. Pre-operative two-chamber transthoracic echocardiogram showing aneurysmal left atrial appendage (LA: left atrium; LV: left ventricle).
atrial appendage through a pericardial defect.2,3 Intrapericardial left atrial appendage aneurysm is believed to be due to congenital weakness involving left atrial appendage or left atrial free wall. Most cases are asymptomatic in childhood.4 The condition is usually diagnosed in the sec-
1. Victor S, Nayak V. Aneurysm of the left atrial appendage. Tex Heart Inst J 2001;28:111–8. 2. Tanabe T, Ishizaka M, Ohta S, Sugie S. Intrapericardial aneurysm of the left atrial appendage. Thorax 1980;35:151–3. 3. Godwin TS, Avager P, Key JA. Intrapericardial aneurysm dilatation of the left atrial appendage. Circulation 1988;37:397–400. 4. Behrendt DM, Aberdeen E. Congenital aneurysm of the left atrium. Ann Thorac Surg 1972;13:54–9. 5. Krueger SK, Ferlic RM, Mooring PK. Left atrial appendage aneurysm: correlation of noninvasive with clinical and surgical findings: report of a case. Circulation 1975;52:732–8.
CASE REPORT
Heart, Lung and Circulation 2008;17:243–263