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).