Giant left atrium

A 58-year-old woman with a history of mitral valve replacement (MVR) 17 years ago was admitted to our outpatient clinic with shortness of breath and a nonproductive cough. On physical examination, her blood pressure was 90/ 60 mmHg, and heart rate was 122 beats/min. Distended neck veins were noted, basal crepitations were heard in lungs, and there was grade I peripheral edema. A prosthetic valve sound and a grade III pansystolic murmur were present along the left mid-clavicular line. ECG (Cardioline Delta 60 Plus CP/1 version, Remco Italy Cardioline, Milan, Italy) showed atrial fibrillation with a ventricular rate of 110 beats/min. Laboratory evaluation revealed a creatinine level of 1.36 mg/dL (0.4–1.0), an albumin level of 3.8 mg/dL (3.2– 4.8), and pro-brain natriuteric peptide level of 3050 ng/L (12–133). Chest x-ray revealed marked cardiomegaly (Fig. 1). Echocardiographic examination (Vivid 7 pro, GE, Horten, Norway) showed normal functioning MVR with massive biatrial enlargement (left larger than right), moderate mitral regurgitation, severe tricuspid regurgitation, and mildly depressed left ventricular systolic function. The left atrium, measuring 209 9 96 mm, was so large that it was not possible to fit it to the screen in its entirety (Fig. 2). Giant left atrium is a condition in which the left atrial diameter exceeds 65 mm or one that touches the right lateral thoracic wall. This condition is commonly caused by rheumatic mitral disease and malfunctioning replaced mitral valve. Dilatation is the left atrial compensation mechanism due to the chronic pressure overload in mitral stenosis, to balance pulmonary capillary wedge pressure. It may be misdiagnosed as pleural effusion or a mass, so the clinician must be alert to avoid from further invasive examinations like pleurocentesis or biopsy, which may be associated with dangerous complications. References 1. Hurst JW: Memories of patients with giant left atrium. Circulation 2001;104:2630–2631. 2. Akdemir I, Davutoglu V, Aksoy M: Giant left atrium, giant thrombus, and left atrial prolapse in a patient with mitral valve replacement. Echocardiography 2002;19(8):691– 692. Figure 1. Increased cardiothoracic index and left atrial size in x-ray.