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).