PMC5943883_01
The posteroanterior chest x-ray demonstrating abnormal left heart border.
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The electrocardiogram, however, showed sinus rhythm with a notched P wave, and the chest x-ray revealed that the left border of the heart was greatly enlarged (Fig. 1).
Transthoracic echocardiograms. Apical 3-chamber (A, B) and 4-chamber (C, D) views showing a 8.4 x 6.8 x 4.3-cm size mass communicating to LA and the presence of mild mitral regurgitation. AAO = ascending aorta, LA = left atrium, LAA = left atrial appendage, LV = left ventricle, RA = right atrium, RV = right ventricle.
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The apical 3-chamber and 4-chamber views demonstrated this cavity, measuring 8.4 x 6.8 cm, related to and communicated with the left atrium via a broad neck whose diameter was 4.3 cm (Fig. 2A and C) (supplementary video 1 and supplementary video 3). Left ventricular size and systolic function were normal, with mild mitral regurgitation (Fig. 2B and D) (supplementary video 2 and supplementary video 4).
Contrast echocardiograms. Apical 3-chamber (A) and 4-chamber (B) views confirming this mass (arrow) communicating to the LA. LA = left atrium, LV = left ventricle, RA = right atrium, RV = right ventricle.
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Contrast-enhanced ultrasound findings demonstrated the echo-contrast agent filled of the LAAA (Fig. 3) (supplementary video 5 and supplementary video 6).
Transesophageal echocardiograms. The mid-esophageal 2-chamber and LAA view (A) revealing a giant LAA. Color Doppler flow imaging (B) showing communication of flow between LAA and the LA. Pulsed wave Doppler (C) echocardiographic examination of blood flow at the orifice. Three-dimensional view (D) confirming the presence of giant LAA. LA = left atrium, LAA = left atrial appendage, LV = left ventricle, LUPV = left upper pulmonary vein.
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LAA with intense spontaneous echo contrast, but without thrombi (Fig. 4A and D) (supplementary video 7 and supplementary video 9). Low velocity blood flow between LA and aneurysm are detected by color Doppler and pulsed Doppler echocardiography (Fig. 4B and C) (supplementary video 8).
CT views characterizing the giant LAA measuring 9.6 x 4.5 x 3.8 cm. AAO = ascending aorta, LA = left atrium, LAA = left atrial appendage, LV = left ventricle, RA = right atrium, RV = right ventricle, RAA = right atrial appendage.
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CT and MRI demonstrated that a 9.6 x 4.5 x 3.8-cm size LAA compressing the left ventricular wall (Figs. 5 and 6).
MRI. Axial spin-echo T1-weighted (E) and Coronal spin-echo T1-weighted image (F) showing the LAA aneurysm with no evidence of thrombus. LA = left atrium, LV = left ventricle, MRI = magnetic resonance imaging, RA = right atrium, RV = right ventricle.
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CT and MRI demonstrated that a 9.6 x 4.5 x 3.8-cm size LAA compressing the left ventricular wall (Figs. 5 and 6).
Intraoperative views (A-D) and histopathological pictures (E, F). The resected aneurysm measured 8.7 x 7.0 cm (C, D) through a limited left thoracotomy (A, B). Histopathological section of the aneurysm showing the myocardial thinning with fatty infiltration.
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After intraoperative TEE confirmed the absence of thrombus within LAAA, the surgical resection was approached via left lateral sternotomy with cardiopulmonary bypass (Fig. 7A and B). Aneurysm neck was clamped and the aneurysm was excised (Fig. 7C and D). The muscle fibers did not have morphological anomalies, although there was thinning of the myocardium due to fatty infiltration (Fig. 7E and F).