Gargantuan Left Atrium: A Sequela of Mitral Regurgitation and Mitral Stenosis

Cardiac magnetic resonance imaging and echocardiography revealed a gargantuan left atrium measuring 18.9 cm × 15.7 cm × 11.3 cm in a 56‐year‐old patient diagnosed with severe rheumatic mitral stenosis, severe pulmonary hypertension, and permanent atrial fibrillation. A chest x‐ray also revealed a cardiothoracic ratio approaching 1.0 and a transthoracic echocardiogram measured diameters as large as 19.2 cm. The patient then underwent mitral valve replacement and left atrial reduction surgery and has had no further admissions or complications.     

Giant Right Atrium Due to Congenital Dysplastic Tricuspid Valve in an Elderly Female Patient

Isolated tricuspid valve disease is rare. We report the case of a 65‐year‐old female patient who presented with right heart failure. Initial echocardiographic evaluation revealed a giant right atrium (RA) with severe tricuspid inflow obstruction with regurgitation. A comprehensive two‐ and three‐dimensional echocardiographic evaluation revealed a dysplastic tricuspid valve resulting in the inflow obstruction and regurgitation. Rheumatic and carcinoid etiologies were ruled out by relevant tests. It is very rare for dysplastic tricuspid valve to present in late adulthood. The classic echocardiographic findings are discussed followed by a brief review of the literature.     

Isolated Rheumatic Tricuspid Stenosis with Reverse Lutembacher's Physiology

Tricuspid valve dysfunction occurs frequently in patients with rheumatic heart disease and is usually manifested as functional or organic tricuspid regurgitation. Rheumatic tricuspid stenosis is less common and occurs characteristically in the presence of concomitant mitral valve disease. In this report, we describe the clinical and echocardiographic findings in a patient with isolated rheumatic tricuspid stenosis and a right-to-left shunt across the interatrial septum, likely as a result of a patent foramen ovale, resulting in central cyanosis. This case illustrates an interesting association of tricuspid stenosis and an interatrial right-to-left shunt suggestive of a reverse Lutembacher's physiology.     

Free-Floating Ball Thrombus in Left Atrium

Left atrial (LA) ball thrombus is a rare disorder. These ball thrombi are generally associated with mitral stenosis, and the restricted mitral orifice encloses the free-floating thrombus in the LA. There is a potential for fatal systemic emboli or mitral value orifice occlusion that may result in sudden death. We report the case of a patient with tight rheumatic mitral stenosis in whom a ball thrombus was observed to bounce and rebound off the walls of LA on echocardiography. After the patient received anticoagulant therapy for 1 month, the thrombus was not found at surgery.     

巨大左心房患者的经皮二尖瓣球囊成形术

本文介绍了13例巨大左心房患者的经皮二尖瓣球囊成形术(PBMV).认为手术成功的关键是房间隔穿刺,但已不能采用常规的方法.作者探索了正中法、右侧法和左侧法,并认为右侧法最好.巨大左心房者常为风湿性心脏病二尖瓣严重狭窄的晚期表现,病情重,合并症多,全身情况差,无法耐受开胸手术,而一般内科治疗效果不好.虽然PBMV也有一定风险,但可能是目前唯一较好的治疗方法.本组病例效果令人满意.     

Impact of Pulmonary Artery Stiffness on Right Ventricular Function and Tricuspid Regurgitation after Successful Percutaneous Balloon Mitral Valvuloplasty: The Importance of Early Intervention

Aims: We assessed impact of pulmonary artery stiffness (PAS) on the long‐term right ventricular (RV) function and tricuspid regurgitation (TR) changes after percutaneous balloon mitral valvuloplasty (PBMV). Methods and Results: Using Doppler echocardiography, PAS was calculated by dividing maximal frequency shift of pulmonary flow by the acceleration time, and mitral area, RV function, and degree of TR severity were evaluated before, immediately after, 6 months, and 12 months after successful PBMV in 81 consecutive patients. Compared with control subjects patients with mitral stenosis (MS) had significant higher PAS (P < 0.001). The PAS was significantly lower in patients with progressive RV function improvement and regression of TR (P < 0.001). PAS was significantly correlated with the degree of pulmonary artery systolic pressure (PASP), tricuspid annular plane systolic excursion (TAPSE), and E/E'm ratio (P < 0.0001, <0.0001, and < 0.001, respectively). Multivariate regression analysis showed that the PAS is an independent predictor of TR regression and sustained RV functional improvement after successful PBMV (P < 0.0001). Conclusions: The changes in RV function and TR after successful PBMV were significantly correlated with the degree of PAS. Despite a sustained increase in mitral valve area, some patients showed no regression of TR, and progressive RV dysfunction suggests a significant role of PAS on RV function and the degree of TR regression in patients with MS suggests that PBMV must be performed early, utilizing PAS as a noninvasive parameter for proper timing for PBMV.     

The Impact of Mitral Stenosis on Left Atrial Function Assessed by Two‐Dimensional Speckle Tracking Echocardiography

Aims: The aim of this study is to investigate the effect of mitral stenosis (MS) on left atrial (LA) function using two‐dimensional speckle tracking echocardiography (2DSTE). Methods and Results: The study subjects consisted of 52 patients with asymptomatic MS and 52 control subjects. LA function was assessed using prototype speckle tracking software and manual tracking method. Maximal LA volume (LAVmax) and minimal LA volume (LAVmin) and LA volume before atrial contraction (LAVpre‐a) were measured. Using these volumes, LA reservoir, conduit and booster pump fuction parameters were calculated. Indexed LAVmax, LAVmin, and LAVpre‐a measurements via speckle tracking were highly correlated with manual tracing methods in both groups. Expansion index (67.8 ± 36.4 vs. 148.3 ± 44.2), diastolic emptying index (37.7 ± 12.9 vs. 58.0 ± 8.5), passive emptying (37.3 ± 14.1 vs. 70.4 ± 10.4) and passive emptying index (13.3 ± 6.3 vs. 41.3 ± 10.6) were decreased significantly in MS patients (P < 0.001). In contrast active emptying index (62.6 ± 4.1 vs. 29.5 ± 10.1) increased in MS group (P < 0.001) while active emptying (28.1 ± 13.0 vs. 28.3 ± 6.9) remained same among both groups. Conclusions: This is the first study relating LA volumes and function assessed by 2DSTE to MS. 2D speckle tracking analysis of LA volume is relatively easy and provides more detailed information regarding the changes in LA volumes during the cardiac cycle.     

Preoperative Right Ventricular Function in Patients with Organic Mitral Regurgitation

Aims: To assess the right ventricular (RV) function in patients with severe mitral regurgitation (MR); to find a relation between preoperative and postoperative parameters. Methods: RV function was echocardiographically assessed by determining the tricuspid annular plane systolic excursion (TAPSE) and the peak systolic velocity of the lateral tricuspid annulus (Sa) in 45 patients with severe organic MR (53.3% men, age 58 ± 10 years). Mean NYHA class was 2.6 ± 0.4, LVEF was 55.3 ± 12%, RV end‐diastolic diameter was 28.7 ± 4.7, left ventricular end‐systolic diameter (LVESD) was 44.6 ± 12.6 mm, and LV end‐diastolic volume (Simpson) was 160.6 ± 50.3 ml. All patients underwent mitral valve replacement with posterior chordal sparing. Results: Mean preoperative TAPSE and Sa were 19.4 ± 4.3 mm and 10.3 ± 3 cm/sec, respectively. RV dysfunction, defined as TAPSE < 22 mm, had 66.6% of the patients, and Sa < 11 cm/sec was found in 62.2% of the patients preoperatively. Preoperative TAPSE and Sa were significantly correlated (P < 0.00001, r = 0.61). Both TAPSE and Sa were correlated with the RV end‐diastolic diameter (P < 0.01), LVESD (P < 0.05) left ventricular dp/dt (P < 0.05), and LVEF (P < 0.0001). Postoperative LVEF was 50% (P < 0.001), Sa 5.3 ± 2 cm/sec (P < 0.001), and TAPSE 8.7 ± 3.2mm (P < 0.001). Twenty‐one patients (46.6%) reached the study end point of decrease of LVEF by more than 10%. Univariate predictors were age (P = 0.04), male gender (P = 0.01), TAPSE (P = 0.007), and Sa (P = 0.009), while a trend was found for regurgitation fraction (P = 0.058) and LV end‐diastolic volume index (P = 0.09). By multivariate analysis, TAPSE (P = 0.01) and Sa (P = 0.01) were predictive for the study end point. Conclusion: The assessment of the RV function by echocardiography is a simple tool that provides prognostic information in patients with MR. (Echocardiography 2010;27:282‐285)     

左心瓣膜病合并三尖瓣关闭不全的诊断及外科治疗

左心瓣膜术后出现三尖瓣关闭不全及其加重严重影响瓣膜患者术后的生活质量,目前如何正确的诊断和治疗左心瓣膜疾病合并的三尖瓣关闭不全已成为心脏外科的热点,现就其诊断及治疗做一综述。     

Mitral Regurgitation Associated with Mitral Annular Dilation in Patients with Lone Atrial Fibrillation: An Echocardiographic Study

Background: Whether and how lone atrial fibrillation (AF) is associated with functional mitral regurgitation (MR) remain unclear. Method: We studied 12 lone AF patients without left ventricular (LV) dysfunction and/or dilatation, who underwent mitral valve annuloplasty for functional mitral regurgitation (MR). Ten lone AF patients without MR served as controls. Results: Lone AF Patients with MR had a greater mitral valve annular area and left atrial area than those without MR. There were no differences in LV volumes or LV ejection fraction. Conclusions: Therefore, we concluded that left atrial dilation and corresponding mitral annular dilation may cause MR in lone AF patients without LV dysfunction and/or dilatation.     

Differential Left Atrial Remodeling in LV Diastolic Dysfunction and Mitral Regurgitation

Objective: Chronic pressure and volume overload may cause different type of left atrial (LA) remodeling in left atrial enlargement (LAE) leading to different cardiovascular outcomes. These two different patterns of LA remodeling can be discriminated by LA eccentricity index (LAEi). The goal of our study was to evaluate an association between LAEi, LV diastolic dysfunction (LVDD), and mitral regurgitation (MR). Method: LAEi was calculated from 3D of left atrium (LA): anteroposterior (D1), superoinferior (D2), mediolateral (D3), and LAEi = D2×2/ (D1+D3). LAE was described as elongated left atrium (EA) if LAEi ≥ 1.27, and spherical left atrium (SA) if LAEi < 1.27. Results: A group of 501 patients (10.4%) with LAE were categorized into two subgroups; 232 (46.3%) with EA and 269 (53.7%) with SA based on LAEi. Among 108 patients (21.6%) with LVDD without MR, 102 had EA and only 6 had SA (P < 0.0001). The cohort of 155(30.1%) patients with MR without LVDD, only 8 had EA and143 had SA (P < 0.0001). Of the total group of 501 patients, 59 had persistent AF and in this subgroup only 10 patients had EA and 49 patients had SA (P < 0.0001). There was a statistically significant difference for AF rate between EA-patients with LVDD without MR and SA-patients with MR without LVDD (P < 0.001). Conclusions: LVDD may contribute to pressure overload LA remodeling in a way quite different from volume overload LA remodeling by MR. LAEi can discriminate two different LA morphologies with significantly different potential outcomes. It may identify patients associated with a higher rate of AF with a higher cardiovascular risk.