Mitral stenosis with free-floating left atrial thrombus and recurrent systemic embolisation. A case report

A 64-year-old white woman with moderately severe rheumatic mitral stenosis complicated by atrial fibrillation and recurrent systemic embolisation to the brain was found at operation to have a large 'free-floating' left atrial thrombus, as well as multiple left atrial appendage thrombi. These had not been detected by echocardiography. She also had significantly reduced left ventricular contractility on cine angiography, and right coronary artery atherosclerosis. She underwent successful mitral valve replacement and excision of the left atrial appendage.     

Avoiding potential complications in left atrial reduction: partial heart autotransplantation

Left atrial reduction is a surgical procedure designed in order to eliminate the chronic atrial fibrillation caused by mitral valve disease. However, this surgical technique is not high-risk free. Since a mount of tissue is excised from the left atrium, misalignment of the left atrium can be present. Bleeding of the posterior suture line in this chamber, as well as injury of the circumflex coronary artery may be fatal complications of this technique. Partial heart autotransplantation offers a good solution allowing an excellent visual operative field. The circumflex coronary artery is under direct vision while performing the anastomosis of the left atrium, and the suture line becomes safer and easier.     

Ischemic cardiomyopathy with mitral valve regurgitation and atrial fibrillation; report of a case

A 45-year-old man suffering from severe heart failure due to mitral regurgitation and atrial fibrillation was admitted to our hospital. He underwent intracoronary thrombolysis for left anterior descending artery 10 years ago and stent insertion for right coronary artery 3 years ago. We performed mitral annuloplasty using a Carpentier-Edwards Physio ring 28mm and modified maze procedure. The modified maze procedure consists of right sided left atriotomy extended to the left margin of the left pulmonary vein orifices and cryoablation applied to the remnant of the left atrial wall between the left upper and lower pulmonary vein orifice and cryoablation applied to the right atrial isthmus. These procedures could be effective for endstage heart failure.     

Complete left atrial ablation with bipolar radiofrequency.

OBJECTIVE: Despite its efficacy and swiftness, bipolar radiofrequency is generally not used on the left isthmus for concern of injuring a coronary branch. Incomplete lesion sets or use of an additional unipolar device are often considered. We report a technique to perform a full left lesion set involving the mitral line using a standard bipolar radiofrequency device. METHODS: An innovative complete left atrial lesion set was performed using only bipolar radiofrequency in 70 consecutive patients (study group). In 67/70 patients (96%) mitral valve disease was the main indication to surgery. Atrial fibrillation was permanent in 42 patients (60%), persistent in 25 (36%) and paroxysmal in three patients (4%). After beating-heart pulmonary vein isolation on-pump, the coronary-free area of the AV groove was marked epicardially by sticking a needle into the left atrial wall, behind the coronary sinus. The projection of the needle marker on the mitral annulus was then identified through the atriotomy and an endo-epicardial ablation was performed with the bipolar device involving the atrial wall, the coronary sinus, up to the annulus. The lesion set was then completed by connecting the encirclings and the left appendage, which was then sutured. Follow-up was 100% complete. Results were compared with those of a control group of 33 patients receiving bipolar radiofrequency left atrial ablations and a mitral connecting line with a second unipolar device. RESULTS: All patients survived. No major complication occurred. Haematoma of the AV groove was observed during retrograde cardioplegia in one case. No myocardial ischaemia or re-exploration for bleeding (median 325 cc, interquartile range 250-442) occurred. Two out of 70 patients required a permanent pacemaker for AV block. Freedom from atrial fibrillation was 84% (95% CI: 75%, 93%) at 6 months and 81% (95% CI: 70%, 93%) at 1 year. One patient had left flutter. Comparison with the control group did not show any difference in clinical outcomes, but revealed bipolar ablation to the mitral annulus to abate the per patient cost of the ablation devices (1245+/-50 euro vs 2403+/-17 euro; p<0.0001). CONCLUSIONS: Performing the mitral line with bipolar radiofrequency is safe and cost-effective. A complete left atrial ablation with a single bipolar radiofrequency device yields excellent clinical mid-term results.     

Left atrial myxoma with neovascularization presenting as a sick sinus syndrome

Myxoma is benign tumor of the heart. It is mostly located in the left atrium and revascularized by the left and right coronary artery in 30% to 40% of cases. Symptoms of these neovascularized cardiac myxomas are typically quite variable, from obstruction of mitral valve to coronary embolism resulting in acute myocardial infarction. In this case, left atrial myxoma that is revascularized by nodal branches of the right coronary artery presented as a sick sinus syndrome, which is rare in literature.     

Combined operation for left atrial myxoma, mitral regurgitation, coronary artery stenosis and abdominal aortic aneurysm

A 68-year-old male patient with a left atrial myxoma, mitral regurgitation, ischemic heart disease and abdominal aortic aneurysm underwent resection of the myxoma, mitral valve replacement, 4 coronary artery bypass grafting and replacement of the aneurysm simultaneously. The aneurysm was replaced under partial cardiopulmonary bypass. Combined cardiac and abdominal aortic operation is useful in selected patients who require IABP support postoperatively or whose cardiac function is poor.     

Mitral valve replacement through a giant left atrial appendage

We report a rare case of a 45-year-old male with a giant left atrial appendage (13x10 cm in size) and chronic massive regurgitation at the mitral valve. Massive dilatation was compressing most of the left lower lobe and the large size of the appendage was pushing the mediastinum to the right. Therefore under median sternotomy, the mitral valve was clearly accessible and chordal sparing mitral valve replacement with left atrial plication was successfully performed through the giant left atrial appendage.     

A case of infected left atrial myxoma

A rare case with infected left atrial myxoma is described. A 52 year-old male was admitted to our hospital because of pain and redness in the left forearm. He has had a history of fever and treatment with antibiotic after pulling out his tooth for two months. At admission, the temperature was 37.4 degrees C. A systolic ejection murmur was heard at the apex on auscultation. Initial investigation of blood showed infective signs. Ultrasonics and angiography revealed a embolus in the left brachial artery at the bifurcation of the radial artery and the ulnar artery. Echocardiography showed the typical feature of a large left atrial myxoma with vegetation. Embolectomy was performed. At the next day, the left atrial myxoma was removed and mitral valve with vegetation was replaced with a prosthetic valve. On microscopic examination, colonies of gram-positive cocci were seen in the thrombus on the typical myxoma. After treatment with antibiotics for six weeks, the patient was discharged from the hospital. He remains asymptomatic for ten months after the operation. Only 12 cases of infected left atrial myxomas have been reported previously in the world.     

Left atrial reduction plasty: a novel technique

We describe a novel technique of left atrial volume reduction in a patient presenting with severe dyspnea from severe mitral insufficiency, giant left atrium, and compressive symptoms of dysphagia and dysphonia. Resection involved circumferential excision of the left atrium anterior to the pulmonary venous vestibule and posterior to the mitral valve and fossa ovalis, including the left atrial appendage. A chordal-sparing bioprosthetic mitral valve replacement, tricuspid valve annuloplasty, and coronary bypass were also performed. Significant reduction of left atrial volume by 50% was achieved and clinical resolution of compressive symptoms was seen at 6-month follow-up.     

Translocation of the atrial septum

Translocation of the atrial septum to the left of the mitral valve is a congenital anomaly: the author has not found a similar case previously reported in the English literature. The curious anomaly described here was associated with deformed mitral and tricuspid valves, a postero-inferior atrial septal defect, a persistent left superior vena cava, a hypoplastic aorta, and a short innominate artery. The patient lived to a remarkable age.     

Cryosurgery for left atrial myxoma with coronary artery bypass grafting]

This is the first report of cryoblasion of atrial myxoma which was performed in conjunction with coronary artery bypass grafting. A 63-year-old man was admitted for left atrial tumor and ischemic heart disease. Following coronary artery bypass grafting and resection of left atrial myxoma, cryosurgery was carried out for the residual tumor on atrial septum and left atrial posterior wall. Ultrasonic cardiogram after 1 year revealed no signs of recurrence. Cryoablasion was effective in preventing the recurrence of atrial myxoma.     

Successful repair of atrial fibrillation by surgical ablation in a patient with persistent left superior vena cava and mitral stenosis

We recently cared for a woman who had mitral stenosis, atrial fibrillation, absent right superior vena cava, and persistent left superior vena cava. She underwent mitral valve replacement and surgical ablation of the pulmonary vein, and conjunction of the coronary sinus and left superior vena cava. Her atrial fibrillation was cured and successfully restored to sinus rhythm postoperatively.     

Intrathoracic pulmonary artery catheter allocation in the background of left atrial dilatation

AIM: The aim of the study was to find out whether dilatation of the left atrium (LA) influences the intra-thoracic distribution of thermodilution pulmonary artery (TPA) catheter in either branch of pulmonary artery and compare the measured cardiac output. METHODS: In this prospective study of 132 consecutive patients in a university hospital setting, LA size and ejection fraction was assessed by echocardiography, in the preoperative period. In 66 patients posted for coronary artery bypass grafting (Group 1), a standard anaesthesia regimen was used and TPA catheter was floated through the right internal jugular. In another 66 patients of long-standing mitral stenosis for mitral valve repair/replacement (Group 2), TPA catheters were similarly floated. Intrathoracic placement of the tip of the TPA catheter into the right or left pulmonary artery (PA) was confirmed on chest X-ray. TPA catheter length to its wedging, intra-arterial pressure, heart rate, PA pressure, pulmonary artery wedge pressure (PAWP) and cardiac output by thermodilution technique were noted. RESULTS: Leftwards TPA catheter placement was significantly (p<0.001) more frequent (71%) in mitral stenosis patients (group 2) than the CABG (group 1), (18%). On regrouping the observations of rightwards placed TPA (Group R) and leftwards placed TPA (Group L), we observed that large LA (> or = 25 mm3/m2) body surface area (BSA) and high PAWP (> or = 20 mmHg) was associated with significantly (p<0.001) higher incidence of leftwards TPA catheters. Positive predictive value of both the factors in combination was significantly higher (96%) than individual factors large LA (81%) and high PAWP (88%). CONCLUSION: In long standing mitral stenosis, left atrium enlargement, with high PAWP and the hypokinesia of left atrium (atrial fibrillation) likely to influence the angulation of left PA with main PA and so the predominant entry of TPA catheter tip in left PA.     

Very-low-dose continuous drip infusion of landiolol hydrochloride for postoperative atrial tachyarrhythmia in patients with poor left ventricular function

Three patients with poor left ventricular function (left ventricular ejection fraction <30 %) developed postoperative atrial tachyarrhythmia in intensive care. Case 1 was a 64-year-old man who underwent a modified Bentall procedure and mitral valve annuloplasty. Case 2 was a 63-year-old woman who underwent quintuple coronary artery bypass grafting. Case 3 was a 65-year-old man who underwent mitral valve replacement. Preoperative intra-aortic balloon pumping was required in Cases 2 and 3. Excellent heart rate control with no hemodynamic deterioration was achieved in all three cases by very-low-dose continuous drip infusion of landiolol hydrochloride (2–5 μg/kg/min). Very-low-dose continuous drip infusion of landiolol hydrochloride is a safe and useful alternative for the control of perioperative atrial tachyarrhythmias in patients with poor left ventricular function.     

Intramural left atrial hematoma after aortocoronary artery surgery

We report the occurrence of an intraoperative left atrial hematoma during coronary artery bypass grafting surgery. Echocardiography proved to be of great help in diagnosis and monitoring of this patient. After severe hemodynamic impairment the patient recovered and could be transferred on postoperative day eight. Follow-up examination showed no signs of atrial pathologies. Differential diagnosis and echocardiographic findings are discussed. IMPLICATIONS: The authors report the utility of transesophageal echocardiography for diagnosis and management of an intramural left atrial hematoma during coronary artery surgery.     

Congenital left atrial appendage aneurysm with unexpected course of left anterior descending coronary artery

The left atrial appendage (LAA) aneurysm is a rare condition that can produce local compressive effects and complications including supraventricular tachyarrhythmias, thromboembolic events and myocardial ischaemia. We present a rare case of a neonate with a congenital LAA aneurysm which resulted in local compressive effects on the left ventricle, severe mitral regurgitation and malposition of the left anterior descending (LAD) coronary artery. Intraoperatively, the LAD was found to be within the aneurysmal wall exterior to the left ventricular epicardium and was inadvertently injured during LAA aneurysm resection. Retrospective review of the preoperative computed tomography and echocardiography scans demonstrated the LAD lying within the wall of the LAA aneurysm, although this had not been well appreciated at that time. This highlights the importance of thorough multimodal preoperative imaging and intraoperative assessment for recognition of this rare association between the LAA aneurysm and LAD malposition, and prevention of inadvertent LAD injury during aneurysm resection.     

Coronary artery to the left atrial fistula after resection of atrial appendages

We report the case of a fistula formation between the left circumflex coronary artery draining into the left atrium as a complication of radiofrequency cardio-ablation and resection of the atrial appendages. This complication was diagnosed with the use of transesophageal echocardiography and was subsequently confirmed on coronary angiography.     

Microwave ablation of atrial fibrillation in conjunction with treatment of early postoperative massive left atrial thrombosis

Left atrial thrombosis is a rare complication of both atrial fibrillation and mitral valve surgery. A patient with a massive atrial thrombosis associated with symptoms of severe heart failure is presented. Restoration of rhythmical ventricular contraction and, ultimately, atrial contractility is of great benefit for providing relief from symptoms and for preventing thrombus recurrence. We present an approach to surgically treat atrial fibrillation using a new microwave energy source in a patient with left atrial thrombosis who requires a mitral valve prosthesis replacement.     

Encircling isolation of pulmonary vein orifice for elimination of persistent atrial fibrillation associated with mitral valve disease

The authors treated a 70-year-old woman with persistent atrial fibrillation associated with mitral valve stenosis. Restoration of sinus rhythm was achieved with encircling isolation of pulmonary vein orifices concomitant with mitral valve replacement. A vertical incision in the right side of left atrium was extended to the margin of the upper and lower left pulmonary vein orifices. Supplemental cryo-coagulation was applied to the remnant of the circular incision, avoiding the entire encircling incision. Consequently, all pulmonary veins were electrically isolated. Encircling pulmonary vein orifice isolation is less invasive than the MAZE procedure because of reductions in surgical time and cardiopulmonary bypass time, minimization of atrial incisions, and prevention of injury to the coronary artery. It is thus an effective option for selected patients with atrial fibrillation.     

An alternative procedure for correction of anomalous origin of left coronary artery from the pulmonary artery

Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital cardiac malformation that is commonly associated with mitral insufficiency. Direct implantation of the anomalous origin of the left coronary artery from the pulmonary artery into the aorta is ideal, but it may not be fit for some patients whose anomalous left coronary arteries arise remotely from the ascending aorta. To solve the same technical problem in a boy with anomalous origin of the left coronary artery from the pulmonary artery in combination with moderate mitral insufficiency, we successfully elongated the anomalous coronary artery by creating a tube-shape graft using part of the pulmonary arterial wall. Simultaneous mitral annuloplasty was performed after a dual-coronary repair.