Pulmonary Manifestations of Giant Left Atrium — A “Pressing” Issue

October 2012, Vol 142, No. 4_MeetingAbstracts Signs and Symptoms of Chest Diseases | October 2012

Pulmonary Manifestations of Giant Left Atrium — A "Pressing" Issue Anupama Tiwari*, MD; Vijay Balasubramanian, MD UCSF Fresno, Fresno, CA Chest. 2012;142(4_MeetingAbstracts):972A. doi:10.1378/chest.1387114

Abstract SESSION TYPE: Miscellaneous Case Report Posters I PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM INTRODUCTION: Giant Left Atrium (GLA) is a well-known complication of mitral valve disease. Compression of adjacent structures can result in interesting manifestations such as Cardiovocal syndrome (otherwise known as Ortner’s Syndrome) due to recurrent laryngeal nerve compression/palsy and “wheezing” due to bronchomalacia. These manifestations are well described but rare. We illustrate a case of mitral valve disease with GLA which had both of the above manifestations. CASE PRESENTATION: An 81-year old man presented with cough productive of yellow sputum for 3 days. He reported chronic hoarseness of voice for 4 years. Past medical history included chronic atrial fibrillation, hypertension and mitral valve replacement with pacemaker placement. On exam, significant “dysphonia” was confirmed without stridor. Auscultation revealed diffuse wheezing bilaterally. Chest radiograph revealed severe cardiomegaly with marked left atrial dilatation and pulmonary artery enlargement. Lateral view revealed complete obliteration of the retrosternal space. CT Chest confirmed remarkable main pulmonary arterial dilatation, biatrial enlargement (Left >> Right) along with atelectasis of the right middle lobe, right lower lobe and left lower lobe. Significant compression of the left main bronchus and esophagus was observed (Fig 1). Echocardiogram revealed severe left atrium dilatation (measured at 9 cm) along with right atrial enlargement. The patient was managed conservatively with antibiotics, continuous positive airway pressure, bronchodilators, and oxygen. DISCUSSION: Nobert Ortner ascribed hoarseness of voice to left recurrent laryngeal nerve palsy in 3 patients with severe mitral stenosis (MS) (1). Other causes of Ortner’s or “cardio-vocal” syndrome may include - congenital heart disease, thoracic aortic aneurysm surgery and adult disorders such as pulmonary hypertension. Extrinsic compression of posterior mediastinal structures secondary to posterior enlargement of left atrium may result in dysphonia (recurrent laryngeal nerve), dysphagia (esophagus) and wheezing (Left main bronchus). It is a highly uncommon manifestation. Our patient had 2 of the 3 key manifestations.

CONCLUSIONS: Cardio-vocal syndrome and bronchomalacia are uncommon compressive manifestations of GLA. Recognition of these important clinical manifestations may help management and avoid unnecessary diagnostic evaluations. 1) Mulpuru SK, Vasavada BC, Punukollu GK, Patel AG. Heart Lung Circ. 2008 Feb; 17(1):1-4. Epub 2007 Dec 4. Review. 2) Plastiras SC, Pamboucas C, Zafiriou T, Lazaris N, Toumanidis S, Clin Cardiol. 2010 Jun; 33(6):E99-100. 3) Hartl DM, Travagli JP, Leboulleux S, Baudin E, Brasnu DF, Schlumberger M. J Clin Endocrinol Metab. 2005 May; 90(5):3084-8. Epub 2005 Feb 22. Review. DISCLOSURE: The following authors have nothing to disclose: Anupama Tiwari, Vijay Balasubramanian No Product/Research Disclosure Information UCSF Fresno, Fresno, CA