PMC6195934_01
Frontal radiograph of the chest reveals cardiomegaly with a prominent convexity (arrows) of the upper left heart border. The lung fields are unremarkable.
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A chest radiograph revealed normal lung fields and an abnormal cardiac silhouette, with a prominent bulge along the left cardiac border (Figure 1).
Transthoracic echocardiography (four-chamber view). Echocardiography shows a large left paracardiac lesion (star) widely communicating with the LA. LA, left atrium; LV, left ventricle.
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fig2
This led to further evaluation by a transthoracic echocardiogram (TTE), which revealed a large left paracardiac blood-filled sac with sluggish flow (Figure 2).
(a) Still images taken from four-chamber cine fast-field echo sequence and (b) reconstructed image from three-dimensional whole-heart sequence. LAAA is seen as a "dog ear" like protrusion. It is adherent to the lateral wall of the basal LV. The left superior pulmonary vein (star) is being compressed by the aneurysm. Ao, aorta; LA, left atrium; LAAA, left atrial appendage aneurysm; LV, left ventricle; MVL, mitral valve; RA, right atrium.
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fig3
The CMR depicted a 7-cm large, predominantly intrapericardial dog ear-like protrusion arising from the LA (Figure 3a) with slow swirling flow within (Supplementary Video 1). It was diagnosed as a congenital LAAA compressing the left superior pulmonary vein (Figure 3a). It was seen adhering to the adjoining left ventricle (LV) and causing a mild mass effect on the LV in the form of a flattening of its basal lateral wall (Figure 3b).
Reconstructed image from three-dimensional whole-heart sequence shows an extrapericardial component of the lesion protruding across the pericardial defect. A septum at the level of the MPA bifurcation probably represents the margin of the pericardial defect. Ao, aorta; LAAA, left atrial appendage aneurysm; MPA, main pulmonary artery; RPA, right pulmonary artery; SVC, superior vena cava.
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fig4
The superior aspect of the aneurysmal sac showed a small septum, which was suspected to be the site of a pericardial defect owing to a small extrapericardial herniation of the aneurysm (Figure 4).