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\begin{document}

\title{Reduction plasty for giant left atrium causing dysphagia: Case report}



\author[1]{Abdul Kerim Buğra}%
\author[2]{Ersin Kadirogullari}%
\author[3]{Burak Onan}%
\affil[1]{Bagcilar Training and Research Hospital}%
\affil[2]{Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital}%
\affil[3]{University of Health Sciences Turkey, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Hospital}%


\vspace{-1em}



  
  \date{May 15, 2024}


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\selectlanguage{english}
\begin{abstract}
The giant left atrium is described as atrium with a diameter of 6.5 cm
or larger, and can rarely cause dysphagia by compressing on esophagus.
We wanted to present this case since we successfully reduced left atrial
volume and eliminated gastrointestinal and cardiac complaints with a
successful surgery. Cardiac causes of dysphagia are rare, but should be
kept in mind in differential diagnosis. With early diagnosis and
treatment, cardiac mortality and morbidity can be prevented.%
\end{abstract}%



\sloppy


\textbf{INTRODUCTION}

The most common cause of left atrial dilatation is rheumatoid mitral
valve disease. Giant left atrium (GLA) is used for atrium with a
diameter of 6.5 cm and larger \textsuperscript{{[}1{]}}. Massive
expansion of cardiac structures can cause compression symptoms such as
dysphagia, dysphonia, or Ortner syndrome. The most common indication of
left atrial volume reduction plasty during mitral valve surgery is
compression symptoms \textsuperscript{{[}2{]}}. The choice of left
atrial reduction technique should consider factors such as the patient's
comorbidities, major bleeding risk, or prolongation of cardiopulmonary
bypass time.

\textbf{CASE REPORT}

A 60-year-old woman who has been treated with rheumatic valve disease
presented with New York Heart Association class 3 dyspnea to the
emergency clinic. At the same time, dysphagia was present in solid foods
for previous three years. Echocardiographic evaluation showed left
ejection fraction of 45\%, severe mitral and tricuspid regurgitation,
and left atrial dimensions of 5.7 x 9.5 x 12.5 cm. Coronary angiography
was normal. There was chronic atrial fibrillation that did not affect
hemodynamics. Computerized tomography revealed compression of the middle
segment of the esophagus by the left atrium (Figure 1A). Surgery was
planned to relieve compression symptoms, to decrease blood stagnation
and thrombus formation and to avoid associated thromboembolization.

During operation, right atriotomy was performed and transseptal approach
was used. First, posterior atrial wall was plicated parallel to the p2-3
segments of the mitral annulus. Plication line continued to the anterior
wall of the atrium. Starting from the para-annular plication line, the
posterior atrial wall between the right and left pulmonary veins was
plicated. The superior wall was partially plicated, and suture line was
extended to the roof of the atrium. The para-annular plication line
continued to the left pulmonary vein laterally. The atrial appendage was
ligated. In this way, we had reduction in surface area of the five walls
of the left atrium, which became an anatomical chamber, rather than a
giant cavity (Figure 1B). Subsequently, the rheumatic mitral valve was
replaced with a 29 no mechanical valve (St Jude Medical Inc., USA) with
posterior chordal sparing. All plication lines were supported by
double-layered continuous prolene sutures for hemostasis (Figure 1C).
The interatrial septum was also plicated during septal closure.
Tricuspid valve annuloplasty was done with 29 no flexible ring
(Medtronic Inc, USA). After cardiopulmonary bypass, transesophageal
echocardiography showed left hat atrial volume was significantly
decreased, mitral valve functions were normal and mild tricuspid
regurgitation was seen. Under stable conditions, the patient was
transferred to the intensive care unit and extubated.

The patient was stable in the hospital follow-up and no complications
were observed. Postoperative control echocardiographic evaluation showed
that the ejection fraction was 45\%, there is no valvular pathology. The
left atrial diameter was measured as 4.9 centimeters at its widest point
(Figure 1D). The patient was discharged on postoperative 6th day.

No surgical pathology was found during follow-up 14 months and the
dysphagia complaint were significantly improved. Computerized tomography
showed a reduction in left atrial volume by more than 60\% (Figure 2).

\textbf{DISCUSSION}

Compression of the esophagus by neighboring structures cause dysphagia.
However, a massive dilated left atrium is a rarely considered cause of
dysphagia, like our case \textsuperscript{{[}2{]}}.

The most common cause of left atrial enlargement is rheumatologic mitral
valve disease. The GLA is used for the 6.5 cm and larger
atrium\textsuperscript{{[}1{]}}. In their series, El
Maghraby\textsuperscript{{[}3{]}} et al found the incidence of GLA in
rheumatologic valve disease about by 0,6\%, which is 11-12 times more
common than non-rheumatological valve diseases.

The presence of compression symptoms, thrombus history and
thromboembolic events are the indications for atrial
reduction\textsuperscript{{[}1{]}}. Traditional left atrial reduction
surgery performed as; inferior atrial wall partial plication or excision
of inferior atrial wall, partial plication or excision of both superior
and inferior atrial walls, partial auto-transplantation of the heart.
Weakening of the atrial wall due to rheumatologic factors and/or
dilatation and increased atrial wall fragility and patients'
comorbidities are likely to increase the risk of the complications in
resection surgery \textsuperscript{{[}1,3,4{]}}. In the present case, we
have preserved anatomic structure and symmetric reduction by providing a
decrease in surface areas of the five walls of left atrium.

Possible rheumatologic process leading to pancarditis leads to
attenuation of the atrial wall. Also increased atrial pressure causes an
increase in atrial wall thickness with a fibrous tissue accumulation
mechanism. Fibrosis plays an important role in the development of atrial
fibrillation. The atrial reduction surgery decreases the recurrence of
atrial fibrillation and improves the success of the ablation
procedure\textsuperscript{{[}1,3,5,6{]}}. In our case, we observed that
the atrium wall became thicker and non-contractile. Chronic atrial
fibrillation was not affecting hemodynamics; therefore, we did not
perform ablation procedure.

We did not cause a significant increase in the operation time, and we
did not encounter any complications in the perioperative postoperative
period. We also succeeded in reducing left atrium volume by over 60\%
and eliminating gastrointestinal and cardiac complaints.

\textbf{CONCLUSION}

Cardiac causes of dysphagia are rare but should be kept in mind in the
differential diagnosis. Thus, a gastrointestinal symptom may indicate
heart disease. With early diagnosis, cardiac mortality and morbidity can
be prevented.

\textbf{Declaration of conflicting interests}

The authors declared no conflicts of interest with respect to the
authorship and/or publication of this article.

\textbf{Author contributions}

Abdul Kerim Bugra : Concept/design, Drafting article, Approval of
article

Ersin Kadiro\selectlanguage{polish}ğ\selectlanguage{english}ullar\selectlanguage{polish}ı : \selectlanguage{english}Concept/design, Critical revision of article,
Approval of article

Burak Onan : Concept/design, Critical revision of article, Approval of
article

\textbf{REFERENCES}

{[}1{]} Apostolakis E, Shuhaiber JH. The surgical management of giant
left atrium. Eur J Cardiothorac Surg. 2008;33:182--90.

{[}2{]} Gajanana D, Morris DL, Janzer SF, George JC, Figueredo VM. Giant
Left Atrium Causing Dysphagia. 2016;43(5):469--71.

{[}3{]} El Maghraby A, Hajar R. Giant left atrium: a review.~\emph{Heart
Views} . 2012;13(2):46-52.

{[}4{]} Patel DA, Lavie CJ, Milani RV, Shah S, Gilliland Y. Clinical
implications of left atrial enlargement: a review.~\emph{Ochsner J} .
2009;9(4):191-196.

{[}5{]} Aydin U, Sen O, Kadirogullari E, Kahraman Z, Onan B. Robotic
Mitral Valve Surgey Combined with Left Atrial Reduction and Ablation
Procedures.~\emph{Braz J Cardiovasc Surg} . 2019;34(3):285-289.

{[}6{]} Bakir I, Onan B, Onan IS, Gul M, Uslu N. Is rheumatic mitral
valve repair still a feasible alternative?: indications, technique, and
results.~\emph{Tex Heart Inst J} . 2013;40(2):163-169.

\textbf{FIGURE LEGENDS}

\textbf{Figure 1} . A: Thorax CT computerized tomography view shows
esophageal compression site (Black arrow), LA: Left atrium, *:
Esophagus, B: Illustration of atrial plication lines, C: Intraoperative
picture of atrial plication lines after mitral valve replacement, D:
Postoperative 5th day transthoracic echocardiography, first and second
dotted lines are diameters of the left atrium, LA: Left atrium, RA:
Right atrium, LV: Left Ventricule, RV: Right Ventricule, CS: Coronary
sinus.

\textbf{Figure 2} : Three-dimensional computerized tomography
angiography images, Ao: Aorta, LA: Left atrium, PA: Pulmonary vein. A:
Preoperative, B: Postoperative\selectlanguage{english}
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