Huge left atrial appendage aneurysm, the five-chamber heart

Mahmood Momtahen; Seifollah Abdi; Bahram Mohebbi; Saeid Hosseini; Ali Mohammadzadeh

doi:10.4103/rcm.rcm_1_18

CASE REPORT

Year : 2018 | Volume : 7 | Issue : 2 | Page : 103-105

Huge left atrial appendage aneurysm, the five-chamber heart

Mahmood Momtahen¹, Seifollah Abdi¹, Bahram Mohebbi¹, Saeid Hosseini², Ali Mohammadzadeh²
¹ Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
² Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran

Date of Web Publication

22-May-2018

Correspondence Address:
Dr. Bahram Mohebbi
Rajaie Cardiovascular Medical and Research Center, Valiasr Ave., Adjacent to Mellat Park, Niyayesh Blvd., Tehran
Iran

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/rcm.rcm_1_18

Abstract

A 21-year-old girl with congenital aneurysm of the left atrial appendage represented with recent-onset palpitation and exertional dyspnea. The diagnosis was established by transthoracic and transesophageal echocardiography and chest multislice computed tomography scan. Surgical excision of the aneurysm and repair of the neck were done under extracorporal circulation and left ventricular function (ejection fraction = 50%) improved with mild mitral regurgitation.

Keywords: Congenital aneurysm, heart, left atrial aneurysm

How to cite this article:
Momtahen M, Abdi S, Mohebbi B, Hosseini S, Mohammadzadeh A. Huge left atrial appendage aneurysm, the five-chamber heart. Res Cardiovasc Med 2018;7:103-5

How to cite this URL:
Momtahen M, Abdi S, Mohebbi B, Hosseini S, Mohammadzadeh A. Huge left atrial appendage aneurysm, the five-chamber heart. Res Cardiovasc Med [serial online] 2018 [cited 2022 Aug 9];7:103-5. Available from: https://www.rcvmonline.com/text.asp?2018/7/2/103/232970

Introduction

Left atrial appendage (LAA) aneurysm as an extremely congenital or acquired anomaly ^[1],[2],[3] are asymptomatic cases which usually diagnosed using observation of unexplained prominence at the upper left heart border on the chest radiograph or abnormal initial echocardiography.^[3],[4] Furthermore, symptomatic patients complain of palpitation, dyspnea or history of systemic embolization, and atrial fibrillation.^[5] Conclusive diagnosis is generally made by imaging modalities including chest X-ray, echocardiography, computed tomography (CT), CT angiography and magnetic resonance imaging (MRI), or a combination of them.^[3],[6] LAA clot as a serious concern must be considered when the blood flow velocity is low using anticoagulant therapy.^[7] Treatment options include surgical resection of aneurysmal tissue and repairing the aneurysm neck.^[5] Here, clinical diagnosis and therapeutic measures to manage a symptomatic patient with huge LAA aneurysm are presented.

Case Report

A 21-year-old female referred to our center due to recent-onset palpitation at rest and exertional dyspnea functional class II – according to the New York Heart Association functional classification with possible diagnosis of pericardial cyst. Physical examination revealed regular heart rhythm with normal heart sounds. There was II/IV apical systolic murmur. Electrocardiogram showed normal sinus rhythm with nonspecific ST-T changes. Transthoracic and transesophageal echocardiography including three-dimensional examination demonstrated normal left ventricular (LV) size with severe systolic dysfunction. LV Ejection Fraction (EF) was about 30% with global hypokinesia. Normal biatrials size with mild smoke in LA. Normal mitral valve leaflets had up to moderate functional mitral regurgitation. There was a large echo-free space (6 cm × 7.7 cm) which seems to be connected to LA and suggestive for huge LAA aneurysm [Figure 1]a, [Figure 1]b, [Figure 1]c. The aneurysm neck was about 3.4 cm. No thrombus was identified within the aneurysms.

Figure 1: (a-c) Transesophageal echocardiography (including three-dimensional examination) revealing huge left atrial appendage from different views

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Multislice CT scan (MSCT 256 dual source definition flash – Siemens) of the thorax revealed aneurysmal dilatation of the LAA (7.5 cm × 8.5 cm × 7.7 cm) with about 300 cm³ volume, with mass effect on LV and significant compression on left anterior descending (LAD) coronary artery. The aneurysm neck dimension was 3.5 cm.

The patient was referred for surgical resection and repair of LAA aneurysm. Left thoracotomy was performed while the patient was on extracorporeal circulation. The pericardium was intact and a huge LAA aneurysm was observed. The aneurysm was excised and its orifice was repaired. The patient postoperative course was uneventful. One-month postoperative transesophageal echocardiography revealed the improvement of LV function (EF = 50%) with mild MR. In fact, LAA aneurysm had compressive effect on LAD [Figure 2] with LV ischemia which resulted in reduced EF. After surgical resection of aneurysm, compressive effect and ischemia were improved, and LV function improved (EF = 50%).

Figure 2: Huge left atrial appendage aneurysm with compressive effect on the left anterior descending coronary artery

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Discussion

Atrial appendage aneurysm may affect the left or right atrium. Aneurysm of LAA is a rare anomaly which reported less than one hundred cases in literature. The majority of cases is congenital and became evident during the second or third decade of life. Some patients may develop acquired aneurysm usually related to and associated with mitral valve disease,^[8] which can lead to weakened muscle wall and raised LAA pressure.

However, reports exist on the occurrence of mitral regurgitation as a sequel of LAA aneurysm.^[9] Congenital cases with symptoms early in life are frequently associated with other anomalies, while asymptomatic patients with congenital aneurysm usually have this single anomaly.^[3]

The symptoms include palpitations usually due to atrial fibrillation, dyspnea, chest discomfort, and manifestation of systemic embolization. The reduced blood flow velocity in the LAA aneurysm may facilitate thrombus formation and lead to systemic embolization and myocardial infarction. Diagnosis is confirmed by transesophageal echocardiography, chest CT, or MRI. Impaired LV function could be due to compression of epicardial coronary arteries, especially LAD coronary artery due to a mass effect from the aneurysm [Figure 2] which will be improved postsurgical resection of aneurysm.^[10] Despite a rare disease, initial intervention to prevent thrombotic events, severe arrhythmia, and cardiac function deterioration is effective to achieve appropriate EF even in asymptomatic cases,^[11] operation recommended because of the low risks to patients in order to gain better outcomes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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