Download Giant left atrial appendage aneurysm compressing the left anterior

DOI: 10.1111/echo.13296
Giant left atrial appendage aneurysm compressing the left
anterior descending coronary artery
Kerolos Wagdy M.B.B.Ch., M.Sc.1 | Amir Samaan M.Sc.1,2 | Soha Romeih M.D.,
Ph.D.1,3 | Walid Simry M.Sc.4 | Ahmed Afifi M.D., F.R.C.S. (CTh)4 | Mohamed Hassan M.D.1,2
1
Adult Cardiology, Aswan Heart
Centre, Magdi Yacoub Foundation, Aswan,
Egypt
2
Cardiovascular Department, Cairo
University, Cairo, Egypt
3
Radiology Department, Aswan Heart
Centre, Magdi Yacoub Foundation, Aswan,
Egypt
4
Cardiothoracic Department, Aswan Heart
Centre, Magdi Yacoub Foundation, Aswan,
Egypt
Correspondence
Kerolos Wagdy, M.B.B.Ch., M.Sc., Adult
Cardiology Department, Aswan Heart
Centre, Magdi Yacoub Foundation, Aswan,
Egypt.
Email: [email protected]
Left atrial appendage aneurysm (LAAA) is a rare congenital structural heart disease.
It is often diagnosed by echocardiography; however, other imaging modalities can
add to its diagnosis and its potential effects on the surrounding structures. A
16-­year-­old boy presented with dyspnea and palpitation. Transthoracic echocardiography showed a large LAAA communicating with the LA through a narrow neck
with impaired left ventricular (LV) systolic function. Multidetector cardiac tomography showed that the LAAA is compressing the left anterior descending artery.
The LAAA was surgically resected followed by improvement of the LV systolic
function.
KEYWORDS
aneurysm, computed tomography, coronary artery, left atrial appendage function, transthoracic
echocardiography
Left atrial appendage aneurysm (LAAA) is a rare structural heart dis1
atrial muscle bands. On pathological background, LAAA is classified to
ease. LAAA often has a congenital origin and grows in size over several
intra-­pericardial and extrapericardial types. The extrapericardial type
years; however, it can rarely be acquired.2 The acquired forms usually
has a pericardial defect through which the appendage can herniate
occur due to left atrial enlargement as in cases of mitral valve disease.
and grow as aneurysm over the time, while the intra-­pericardial type is
Congenital forms arise from dysplasia of musculi pectinati and related
thought to be due to developmental weakness of the wall of left atrium
F I G U R E 1 A. Chest x-­ray film showing marked left atrial enlargement. B. Transthoracic echocardiography apical four-­chamber view showing
a large (8.0 × 7.0 cm) saccular aneurysm, communicating with the left atrium (LA) through a narrow “valve-­like” neck (red arrow). LV = left
ventricle; RV = right ventricle; RA = right atrium
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F I G U R E 2 Multidetector computed tomography (A) Coronal view, (B) 3D volume rendering reconstruction; revealing a huge aneurysm that
was connected to the left atrium (LA) just below and leftward of the left upper pulmonary vein. (LUPV)
F I G U R E 3 Multidetector computed tomography showing that
the left atrial appendage aneurysm (LAAA) is compressing the left
anterior descending artery (LAD). LV = left ventricle; Ao = aorta
F I G U R E 4 Cardiac MRI showing no thrombus in the aneurysm with
hyperenhancement of its wall denoting presence of fibrous tissue (blue
arrows). LAAA = left atrial appendage aneurysm; LV = left ventricle
(LA) and or the appendage.3 LAAA is usually associated with atrial
arrhythmias and thromboembolism. The most common symptoms are
palpitation and/or dyspnea.4 Here, we are presenting a 16-­year-­old boy
with a 3 months history of dyspnea and palpitation. On presentation, he
had an atrial tachycardia with rapid ventricular rate (220 beat per minute) requiring electrical cardioversion. Chest x-­ray showed marked left
atrial enlargement (Fig. 1A). Transthoracic echocardiography showed a
large saccular aneurysm measured 8.0 × 7.0 cm, communicating with
the LA through a narrow “valve-­like” neck (Fig. 1B) (movie clips S1–S3)
with spontaneous echo contrast filling the aneurysm (movie clip S4).
The aneurysm was compressing the left ventricle (LV) with mildly
impaired systolic function (EF was 40%) (movie clips S1 and S3). Multidetector computed tomography revealed that the aneurysm was connected to the LA just below and leftward of the left upper pulmonary
F I G U R E 5 Intra-­operative image showing left atrial appendage
aneurysm compressing the LV and left anterior descending (LAD)
artery. * = aneurysm; green arrow = left atrial appendage
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vein (LUPV) (Fig. 2) and compressing the left anterior descending
Movie clip S1. Two-­dimensional trans-­thoracic echocardiography
(LAD) coronary artery (Fig. 3). Late gadolinium hyperenhancement MRI
apical four chamber view, showing a huge left atrial appendage aneu-
images revealed no thrombus in the aneurysm with hyperenhancement
rysm (LAAA) with a valve-­like neck (yellow arrow head).
of its wall denoting the presence of fibrous tissue (Fig. 4, movie clip S5).
Diagnosis of a large LAAA compressing the LV and LAD was confirmed
intra-­operatively (Fig. 5). The aneurysm was successfully resected. Follow-­up showed improvement of the LV systolic function. To the best of
our knowledge, this is the first case to be reported showing a congen-
Movie clip S2. Two-­dimensional trans-­thoracic echocardiography apical four chamber view with color flow mapping, showing a communicating left atrial appendage aneurysm (LAAA) with the left atrium (LA)
by a valve-­like neck (yellow arrow head).
itally huge LAAA compressing the LAD coronary artery with improve-
Movie clip S3. Two-­dimensional trans-­thoracic echocardiography
ment of the LV systolic function after aneurysmal resection.
subcostal four chamber view, showing the huge left atrial appendage
aneurysm (LAAA) compressing the left ventricle (LV).
REFERENCES
1. Chowdhury UK, Seth S, Govindappa R, Jagia P, Malhotra P. Congenital
left atrial appendage aneurysm: a case report and brief review of literature. Heart Lung Circ. 2009;18:412–416.
2. Culver DL, Bezante GP, Schwarz KQ, Meltzer RS. Transesophageal
echocardiography in the diagnosis of acquired aneurysms of the left
atrial appendage. Clin Cardiol. 1993;16:149–151.
3. Victor S, Nayak VM. Aneurysm of the Left Atrial Appendage. Tex Heart
Inst J. 2001;28:111–118.
4. Aryal MR, Hakim FA, Ghimire S, et al. Left atrial appendage aneurysm: a
systematic review of 82 cases. Echocardiography. 2014;31:1312–1318.
SUPPORTI NG I NFO RM ATI O N
Additional Supporting Information may be found online in the supporting information tab for this article.
Movie clip S4. Two-­dimensional trans-­thoracic echocardiography
apical two chamber view, showing the huge left atrial appendage
aneurysm (LAAA) with valve-­like neck (yellow arrow head) LA; Left
atrium.
Movie clip S5. SSFP cine images of coronal view cardiac MRI showing
the left atrial appendage aneurysm (LAAA) connecting with left
atrium (LA) by a valve like neck (yellow arrow head) and compressed
the left ventricle (LV).
How to cite this article: Wagdy, K., Samaan, A., Romeh, S., Simry, W.,
Afifi, A., Hassan, M. (2016), Giant left atrial appendage aneurysm
compressing the left anterior descending coronary artery.
Echocardiography, 33: 1790–1792. doi: 10.1111/echo.13296