Eur J Cardiothorac Surg 2001;20:412-414
© 2001 Elsevier Science NL
A novel technique for giant left atrium reduction
Riccardo Sinatra,
Ivana Pulitani,
Andrea Antonazzo,
Giovanni Melina
Department of Cardiac Surgery, University of Rome "La Sapienza", Rome, Italy
Received 12 February 2001;
received in revised form 27 April 2001;
accepted 15 May 2001.
Corresponding author. Istituto di Cardiochirurgia, Policlinico Umberto I, Università "La Sapienza", Viale del Policlinico 155, 00161 Rome, Italy. Tel.: +39-06-4997-2659; fax: +39-06-445-3891
e-mail: riccardosinatra{at}uniroma1.it
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Abstract
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We herein describe a safe and reproducible technique for left atrial volume reduction in patients with a giant left atrium. In a 56-year-old patient undergoing redo mitral valve replacement, the left atrium measured 18x20x17 cm occupying the middle-lower segment of the right hemithorax with compression of the adjacent organs. The left atrial volume was reduced by triangular resections of the atrial wall and the mitral valve was replaced using a mechanical prosthesis. The postoperative course was uneventful and the left atrial diameter was 11.2 cm at the latest control.
Key Words: Atriomegaly • Left atrial reduction • Mitral valve replacement
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1. Clinical and operative data
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A 56-year-old man was operated on for mitral valve replacement and left atrial volume reduction. He previously underwent mitral valve repair with implantation of a Carpentier ring and replacement of chordae tendineae. At hospital admission the patient was asymptomatic and the echocardiographic study showed good left ventricular function with a left ventricular end diastolic diameter of 73 mm, massive mitral regurgitation and a left atrial diameter of 17 cm. Magnetic resonance revealed a left atrial size of 18x20x17 cm without endocavitary thrombosis and nearly total occupation of the middle-lower portion of the right hemithorax with compression of the right cardiac chambers, caval veins, pulmonary artery, right main bronchus, esophagus, descending aorta and right hemidiaphragm (Fig. 1A)
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Fig. 1. (A) Preoperative TSE-T2 weighted magnetic resonance image shows left atrial dilatation and total occupation of the medial-inferior portion of the right emithorax. (B) Postoperative TSE-T1 weighted magnetic resonance image shows the reduction of the left atrial dimensions and the expansion of the right lung. LA, left atrium; RA, right atrium; RV, right ventricle; LV, left ventricle; LL, left lung.
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After median sternotomy, the heart and the caval veins in particular were cleared from all their adhesions and the cardiopulmonary bypass was started. The Sondergaard plane was then isolated and another portion of the left atrium roof was delivered from its reflection into the interatrial septum. The left atriotomy was performed parallel to the atrial septum and extended posteriorly to the inferior vena cava and superiorly to the atrial roof and to the left trigone of the mitral valve. A large triangular segment of left atrium with the base on the posterior portion of the atriotomy and the apex towards the outlet of the left pulmonary veins was removed (Fig. 2c)
. Another two triangular segments of atrium, both with the base on the atriotomy, were removed (Fig. 2a,b). The incisions on the left atrium walls were repaired with a continuous suture of Prolene 3/0. The Carpentier ring was removed together with the anterior leaflet of the mitral valve and its chordae, the posterior leaflet was preserved, and a 31 mm Sulzer Carbomedics mechanical prosthesis was implanted. The left appendage was tied from outside and the left atriotomy was repaired as usual, removing simultaneously a large stripe of the reflection of the left atrium into the interatrial septum.
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Fig. 2. Schematic representation of triangular atriectomies (a–c) performed to reduce giant left atrium. AO, aorta; PA, pulmonary artery; MV, mitral valve; LAA, left atrial appendage; ICV, inferior caval vein; LSPV, left superior pulmonary vein; LIPV, left inferior pulmonary vein; RSPV, right superior pulmonary vein; RIPV, right inferior pulmonary vein.
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The patient made an uncomplicated recovery without respiratory failure secondary to the compression of the right lung or bronchus or signs of low cardiac output syndrome. The left atrial diameter was 11 cm and the left ventricular end diastolic diameter was reduced to 64 mm at the echocardiogram performed before discharge. The patient was well enough to go home 9 days after the operation. At the control after 60 days from operation, the magnetic resonance showed a clear reduction of the left atrial dimensions (10.6x11.2 cm) with a good expansion of the right pulmonary base (Fig. 1B).
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2. Comment
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We reported a new, simple and effective surgical technique to reduce the left atrial volume in patients with a giant left atrium.
Isomura et al. [1] defined ‘giant’ as an atrium with a maximum diameter of >6 cm on echocardiography. The dilatation of the left atrium is not secondary only to mitral regurgitation, even if massive, but it could also be related to a primary pathology of the left atrial wall itself [2].
The increased left atrial compliance with consequent left atrial dilatation in patients with mitral valve pathology may avoid pulmonary hypertension as in the present case. The surgical indication was based on the left ventricular dilatation and on the entity of the mitral regurgitation, but especially on the enormous dimensions of the left atrium. In fact, the presence of a giant left atrium increases the thromboembolic risk in spite of anticoagulant therapy, and the compression of the adjacent organs can cause recurrent bronchopneumonia, dysphagia, etc. [3].
The surgical techniques to reduce the left atrium are different, from the plication of the posterior wall of the atrium along the outlet area of the pulmonary veins [1–3], to the autotransplantation [4]. In this patient we performed triangular resections of the atrial walls with a simple and direct continuous suture drawn near them, obtaining a reduction of 40% of the left atrial volume. We believe it was important to isolate the heart from its adhesions, especially the left atrium from the caval veins, its roof from the reflection in the interatrial septum and the outlet of the pulmonary veins too. This allowed us to perform triangular resections with the base on the atriotomy and the apex variously directed. The efficacy of the technique described was demonstrated not only by routine investigations but also from the immediate postoperative course without any sign of low cardiac output syndrome secondary to compression of the left atrium and left ventricle and without respiratory failure during weaning from the ventilatory support.
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Acknowledgments
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The authors thank Dr Marcello De Santis who provided us with the images of magnetic resonance and their interpretation.
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References
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Isomura T., Hisatomi K., Hirano A., Maruyama H., Kosuga K., Ohishi K. Left atrial plication and mitral valve replacement for giant left atrium accompanying mitral lesion. J Card Surg 1993;8:365-370.[Medline]
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Johnson J., Danielson G.K., MacVaugh H., 3rd, Joyner C.R. Plication of the giant left atrium at operation for severe mitral regurgitation. Surgery 1967;61:118-121.[Medline]
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Kawazoe K., Beppu S., Takahara Y., Nakajima N., Tanaka K., Ichihashi K., Fujita T., Manabe H. Surgical treatment of giant left atrium combined with mitral valvular disease. Plication procedure for reduction of compression to the left ventricle, bronchus, and pulmonary parenchyma. J Thorac Cardiovasc Surg 1983;85:885-892.[Abstract]
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Lessana A., Scorsin M., Scheublè C., Raffoul R., Rescigno G. Effective reduction of a giant left atrium by partial autotransplantation. Ann Thorac Surg 1999;67:1164-1165.[Abstract/Free Full Text]
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Abstract
1. Clinical and operative...
