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Abstract Background Rheumatic heart disease (RHD) continues to pose a significant burden on global health, particularly in socioeconomically disadvantaged populations. We present the case of a 38-year-old woman with severe multivalvular RHD and giant atria, highlighting the challenges and complexities of managing this condition. Case presentation The patient presented with progressively worsening dyspnoea, signs of right heart failure, and severe valvular abnormalities. Diagnostic evaluations revealed severe mixed mitral valve disease in the form of mitral stenosis and regurgitation, along with involvement of the aortic and tricuspid valves, leading to significant enlargement of both atria. Despite facing socioeconomic constraints and poor adherence to treatment, the patient underwent successful surgical intervention, resulting in remarkable symptomatic improvement. Conclusions Through this case, we emphasise the importance of early detection, comprehensive management strategies, and multidisciplinary care in addressing the complexities of RHD. Despite the challenges posed by socioeconomic disparities, positive outcomes can be achieved with timely diagnosis and appropriate intervention. This case underscores the need for targeted efforts to improve access to healthcare resources and reduce the global burden of RHD.

Background: Rheumatic heart disease (RHD) continues to pose a significant burden on global health, particularly in socioeconomically disadvantaged populations. We present the case of a 38-year-old woman with severe multivalvular RHD and giant atria, highlighting the challenges and complexities of managing this condition. Case presentation: The patient presented with progressively worsening dyspnoea, signs of right heart failure, and severe valvular abnormalities. Diagnostic evaluations revealed severe mixed mitral valve disease in the form of mitral stenosis and regurgitation, along with involvement of the aortic and tricuspid valves, leading to significant enlargement of both atria. Despite facing socioeconomic constraints and poor adherence to treatment, the patient underwent successful surgical intervention, resulting in remarkable symptomatic improvement. Conclusions: Through this case, we emphasise the importance of early detection, comprehensive management strategies, and multidisciplinary care in addressing the complexities of RHD. Despite the challenges posed by socioeconomic disparities, positive outcomes can be achieved with timely diagnosis and appropriate intervention. This case underscores the need for targeted efforts to improve access to healthcare resources and reduce the global burden of RHD. [ABSTRACT FROM AUTHOR]

This article, published in Acta Cardiologica, discusses the case of a man in his 50s who presented with symptoms of worsening dyspnea and irregular heartbeat. The patient had a previous diagnosis of rheumatic heart disease but was lost to follow-up. The chest radiograph revealed massive cardiomegaly, and further tests showed moderate mitral stenosis, severe mitral regurgitation, mild aortic stenosis, and moderate aortic regurgitation. The patient also had a giant left atrium, which was causing compression on other structures in the chest. The article highlights the management of giant left atrium, which involves left atrial reduction during mitral valve surgery. [Extracted from the article]

Objective: To evaluate the outcome of Left Artrial Reduction by Auto Transplant technique in Giant LA with Mitral valve disease. Methods: This prospective study conducted in the Department of Cardio Thoracic and Vascular Surgery MGM Super Specialty Hospital Indore from 1"September 2022 to 30" August 2023.The aortic and bicaval cannulation was done and CPB instituted followed by cardioplegic arrest of heart. First the root, then the coronary ostia, provided cardioplegia. Transection of the Aorta, PA, SVC, and IVC followed by giant LA mobilization. An excised strip of LA wall and LAA (3-4cm width) was re-sutured with 5-0 prolene. Sutures repaired the SVC, IVC, PA, and aorta. Bleeding from Coseal-secured sutures. Interrupted stiches mobilized and sutured the mediastinal pleura and pericardium to reduce pulmonary vein suture line tension. Patient elective ventilation lasted 48 hours. Results: 10 patients underwent LA reduction. In 6 patients, concomitant Mitral valve replacement was done while in 4 patients concomitant Double valve replacement was done., 60% were in the age group between 33-35 years, and this was followed by the patients in the age group between 25-30 years of age (40%).Out of 5 patients who were included in the study, 8 patients had Atrial Fibrillation and 8 patients had Dysphagia. This was followed by previous history of thromboembolism seen in 4patients. LAA clot was seen in 4 patients. The mean LA size on Pre-Operative ECHO was 74 mm +/- 10 mm ranging from 64mm to 84mm. There was reduction in LA size (from 74+/- 10mm to 48 +/- 6mm) ranging from 42mm to 54mm. Conclusion: Giant LA associated with extra cardiac compressive symptoms should be reduced in size by Auto transplant technique which is safe in expert hands. Giant LA is typically found in patients with rheumatic mitral valve disease with severe regurgitation, Diagnosis is at times possible by routine chest x ray, Echocardiography is an excellent modality to establish its diagnosis, assess and direct correct management. [ABSTRACT FROM AUTHOR]

Introduction: A giant left atrium may cause respiratory dysfunction and hemodynamic disturbance postoperatively. This retrospective study aimed to evaluate clinical effects of surgical left atrial reduction in concomitant cardiac valves operations. Methods: One hundred and thirty-five patients with heart valve diseases and giant left atriums from January 2004 to July 2021 were enrolled into this research. They were divided into the folded group (n=63) and the unfolded group (n=72). Patients in the folded group had undergone cardiac valve operations concomitantly with left atrial reductions. The perioperative characteristics were compared between both groups, and subgroup analysis was performed. Results: There were five deaths in the folded group and 25 deaths in the unfolded group (P<0.001). Complications including pneumonia, sepsis, multiple organs dysfunction syndrome, low cardiac output syndrome, and the use of continuous renal replacement therapy were significantly fewer in the folded group. The receiver operating characteristic curve of left atrial max. diameter predicting mortality was significant (area under the curve=0.878, P=0.005), and the cutoff point was 96.5 mm. The stratified analysis for sex showed that more female patients died in the unfolded group. Logistic regression for mortality showed that the left atrium unfolded, left atrial max. diameter, cardiopulmonary bypass time, and mechanical ventilation time increased the risk of death. Conclusion: Surgical left atrial reduction concomitantly with valves replacement could decrease mortality and was safe and effective in giant left atrium patients. [ABSTRACT FROM AUTHOR]

Giant left atrium (GLA) is a rare condition typically found in patients with rheumatic mitral valve disease. On chest radiographs, this condition often mimics another cause of cardiomegaly. A 52-year-old man was admitted to the hospital with complaints of shortness of breath and orthopnea. Mid-diastolic and grade IV pansystolic murmurs could be heard at the apex radiating to the axilla on cardiac auscultation. The electrocardiogram showed a junctional tachycardia rhythm, while the chest radiograph displayed extreme cardiomegaly with Erlenmeyer-shaped heart. Massive pericardial effusion was suspected. Transthoracic echocardiography (TTE) was then performed, revealing GLA with a left atrial volume index (LAVi) of 1101 ml/m2. Meanwhile, transoesophageal echocardiography (TEE) confirmed calcification of P2 and P3 extending to the border of the mitral leaflet up to one third of the chordae tendineae, with moderate mitral stenosis and eccentric mitral regurgitation jet due to prolapse of A2. The patient was treated with optimal medical therapy while awaiting cardiac surgery. GLA is a rare complication of mitral valve disease and an almost forgotten cause of cardiomegaly. Diagnostic imaging procedures with echocardiography are a less invasive and readily available modality to establish the diagnosis of cardiomegaly. [ABSTRACT FROM AUTHOR]

We presented a clinical case of surgical treatment of gigantic left atrium in longstanding mitral regurgitation due to mitral valve disease diagnosed 23 years ago (patient refused surgery and was on medical treatment) and complicated by atrial fibrillation. The patient was referred for surgery with complaints on severe dyspnea on minimal exertion, weakness, fatigue, palpitations and massive leg edema. Diagnosis was established using electrocardiography, chest X-Ray, transthoracic and transesophageal echocardiography, and computed tomography. The patient underwent mitral valve replacement, tricuspid valve annuloplasty and left atrial reduction surgery (atrioplasty by Kawazoe). After surgery, left atrial volume decreased from 813 ml to 294 ml and antero-posterior size from 11.2 to 6.2 cm. The patient was discharged on 8th day after surgery. Control examinations after 6 months and 1 year showed reduction of left atrial volume (319 ml and 294 ml); patient feels well and has no complaints. Thus, our case demonstrated reduction of left atrium early in postoperative period and its slow reduction after surgery during 1 year. It is also showed human reserve capacity and possibility of left atrial dilatation to such sizes. Late diagnosis of such changes in heart is possibly related to the fact that patient was afraid to see doctors and undergo surgery. The left atrial cavity size determination can be done intraoperatively using method of surgical glove we suggested.

A 59-year-old male patient presented with a history of dyspnea on exertion for the past 10 years, which was gradually progressive in nature. The patient had orthopnea and paroxysmal nocturnal dyspnea for the past few months. On evaluation, he was found to have cardiomegaly and a giant left atrium. Contrast-enhanced computed tomography of the heart showed the left atrium to be enlarged to a dimension of 20.7 cm which, as of the time of writing, is the largest ever reported.

Background Rheumatic heart disease has become rare in developed countries and physicians have grown unfamiliar with the disease and its clinical course. The mitral valve is most commonly affected leading to mitral regurgitation and/or stenosis. The chronic volume and/or pressure overload leads to atrial remodelling and enlargement, driving the development of atrial fibrillation and thrombo-embolic events. Case summary A 87-year-old patient with a history of rheumatic mitral stenosis and mitral valve replacement was admitted to the neurology department for vertigo. A stroke was suspected, and she underwent a transoesophageal echocardiogram (TOE) which was complicated by dysphagia. Oesophageal manometry and computed tomography revealed oesophagogastric junction outflow obstruction due to extrinsic compression by a giant left atrium (GLA). Discussion Dysphagia due to a GLA is rare. Various diagnostic criteria exist and the prevalence thus depends on which criterium is used. It is mostly encountered in rheumatic mitral disease, although there are reports of non-rheumatic aetiology. When the left atrium assumes giant proportions it can compress adjacent intrathoracic structures. Compression of the oesophagus can lead to dysphagia, as in our case. A TOE in these cases is relatively contraindicated and should only be performed if there is considerable reason to believe that it may change patient management. [ABSTRACT FROM AUTHOR]

Abstract Background Esophageal perforation is a rare but serious complication of transesophageal echocardiography (TEE). An enlarged left atrium (LA), which is commonly associated with mitral stenosis (MS), is an under-recognized risk factor for esophageal perforation after intraoperative TEE. Case presentation We describe a case of TEE-induced esophageal perforation after cardiac surgery in a 79-year-old woman with a giant LA due to MS. Esophageal perforation was detected on postoperative day 6. After surgical repair, the patient gradually recovered with prolonged conservative treatment. Retrospectively constructed three-dimensional chest computed tomography images revealed an unusually distorted esophagus that was possibly vulnerable to injury. Conclusion A giant LA can markedly distort the esophagus. It should be recognized as a risk factor for TEE-induced esophageal perforation.

A 45-year-old male presented to us with decompensated heart failure. He had been diagnosed as having atrial fibrillation when he was 31 years old. Transthoracic and transesophageal echocardiography revealed an excessive left atrial (LA) enlargement with left ventricular dysfunction and severe functional mitral regurgitation. There were no specific findings of rheumatic valve disease. He underwent surgical mitral valve replacement and LA volume reduction surgery after optimal medical therapy. Surgically-removed specimens of the LA and the anterior mitral leaflet were examined and there were no specific histopathological findings suggesting the specific etiology of the giant LA in this patient. The patient's condition significantly improved after the surgery without any cardiac events ever since. < Learning objective: Non-rheumatic giant left atrium (LA) is rare but can cause decompensated heart failure with various types of complications and hemodynamic problems. Mitral annular dilation and changes in the valve morphology often cause functional mitral regurgitation in giant LA, which adversely affect the hemodynamic condition. Valve surgery and surgical reduction of LA was effective in the present case.> [ABSTRACT FROM AUTHOR]

In the current era of echocardiography, early diagnosis and treatment of rheumatic heart disease make giant left atrium a rare condition, with a reported incidence of 0.3%, and following mainly with rheumatic mitral valve disease. We report a 50-year-old female, a known case of rheumatic heart disease who presented with breathlessness and dysphagia, and the cardiothoracic ratio on chest roentgenogram was 0.95. Echocardiography was suggestive of giant left atrium with a size of 19.4 x 18.3 cm, while magnetic resonance imaging revealed a size of 22.3 x 19.2 x 20.1 cm making it the largest left atrium to be reported in the literature. < Learning objective: Giant left atrium is extremely rare in the current era, and if at all present, it is almost always secondary to rheumatic heart disease. These patients will have long duration of rheumatic heart disease, more chance of atrial fibrillation, compressive symptoms, and thromboembolism. Giant atrium is an indication for anticoagulation even if it is in sinus rhythm.> [ABSTRACT FROM AUTHOR]

The giant left atrium is described as an atrium with a diameter of 6.5 cm or larger and which can rarely cause dysphagia by compressing on the esophagus. Left atrial enlargement is usually seen due to mitral valve disease. The most common indication of left atrial volume reduction plasty during mitral valve surgery is the compression symptoms. We performed mitral valve replacement in our case and transformed the giant left atrium into an anatomical chamber with the technique we applied. In this way, we successfully eliminated cardiac and compression symptoms. Cardiac causes of dysphagia are rarely seen, usually, cardiac complaints are more prominent than dysphagia. However, it should be kept in mind in the differential diagnosis. We think that cardiac mortality and morbidity may be prevented with early diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Objective: Atrial functional mitral regurgitation (AFMR) is caused by atrial fibrillation and left atrial enlargement. Our study aimed to evaluate the efficacy of left atrial plication (LAP) for AFMR. Methods: Of 1164 mitral valve surgery patients at our hospital from January 2000 to May 2019, 22 patients underwent surgery for AFMR. Our retrospective analysis divided the patients with AFMR into two groups according to whether LAP was performed (LAP + group, n = 9; LAP − group, n = 13). Mitral valve angle (MV angle) (horizontal inclination of mitral valve) was measured by pre- and post-operative computed tomography scan. Individuals with type II mitral regurgitation, left ventricular ejection fraction of < 55%, males with left ventricular endo-diastolic dimension of > 60 mm and females with > 55 mm, aortic valve disease, mitral valve calcification, hypertrophic obstructive cardiomyopathy, and both "redo" and emergency cases were excluded. Result: Mitral valve replacement was performed in 6 patients and mitral ring annuloplasty in 16 cases. No recurrence of mitral regurgitation or structural valve deterioration occurred during the follow-up period. There were no hospital deaths; 3 deaths occurred during the follow-up period. Compared to the LAP − group, the LAP + group demonstrated a significantly greater decrease of MV angle (16.6 ± 8.1° vs. 1.2 ± 6.9°, p < 0.01) and left atrial dimension (18.4 ± 7.0 mm vs. 6.9 ± 14.6 mm, p = 0.02). Conclusions: Surgical results of AFMR were satisfactory. LAP may be appropriate for correcting the angle of a mitral valve tilted horizontally. More cases need to be considered in the future. [ABSTRACT FROM AUTHOR]

Abstract Background Chronic Mitral Valve disease is strongly associated with Left atrial enlargement; the condition has a high mortality risk. Clinical manifestations include atrial fibrillation, pulmonary hypertension, thromboembolic events, and in cases of Giant Left Atrium (GLA) and a distorted cardiac silhouette. Full sternotomy, conventional open-heart surgery, reductive atrioplasty and atrioventricular valve repair are required to resolve symptoms. However, these procedures can be complicated due to the posterior location of the GLA and concomitant right lateral protrusion. Cardiac autotransplantation is superior under these conditions; it provides improved visual access to the posterior atrial wall and mitral valve, hence, facilitates corrective surgical procedures. We aimed to assess the clinical outcome of patients undergoing cardiac autotransplantation as the primary treatment modality to resolve GLA. Moreover, we evaluated the procedural safety profile and technical feasibility. Case presentation Four patients, mean EuroSCORE II of 23.7% ± 7.7%, presented with heart failure, atrial fibrillation, left atrial diameter > 6.5 cm and a severe distorted cardiac silhouette; X-ray showed prominent right lateral protrusion. We performed cardiac autotransplantation using continuous retrograde perfusion with warm blood supplemented with glucose followed by atrioplasty, atrial plication, valve annuloplasty and valve repair on the explanted beating heart. The surgical approach reduced the left atrial area, mean reduction was − 90.71 cm2 [CI95% -153.3 cm2 to − 28.8 cm2, p = 0.02], and normalized pulmonary arterial pressure, mean decrease − 11.25 mmHg [CI95% -15.23 mmHg to − 7.272 mmHg, p = 0.003]. 3 out of 4 patients experienced an uneventful postoperative course; 2 out of 4 patients experienced a transient return to sinus rhythm following surgery. One was operated on in 2017 and is still in good condition; two other patients survived for more than 10 years; Kaplan-Meier determined median survival is 10.5 years. Conclusions Cardiac autotransplantation is an elegant surgical procedure that facilitates the surgical remodelling of Giant Left Atrium. Surgical repair on the ex vivo beating heart, under continuous warm blood perfusion, is a safe procedure applicable also to high-risk patients.

Remote extracorporeal life support (ECLS) implantation and mobile ECLS are increasingly applied to enable the treatment of patients with refractory heart failure at specialized care centers. Giant left atrium (GLA) is a rare cause but may lead to acute and devastating heart failure.

Surgical management for patients with long-standing persistent (LSP) AF and giant left atria (GLA) associated with mitral valve diseases remains a challenge. We aimed to assess the efficacy of the cut-and-sew maze procedure (CSM) in this subgroup of patients, in terms of maintenance of sinus rhythm (SR), atrial function, and to identify the operative risks of this procedure. A total of 229 patients with LSP-AF underwent CSM at our institution from December 2013 to October 2017. Patients were divided into 2 groups based on LA diameter: NGLA group (<65 mm, n = 171), GLA group (≥65 mm, n = 58). Patients with GLA were propensity score matched to patients without GLA resulting in 45 pairs of patients. Early death occurred in 1 (2.2%) in GLA group and no deaths in NGLA group (P = 0.315). Early complications did not differ significantly between the 2 groups. The GLA group showed similar rates of SR on and off antiarrhythmic drugs compared with NGLA group at 2 years (86.36% vs 93.9%, P = 0.338; 81.82% vs 90.91%, P = 0.322). At 2 years, LA contraction was comparable between patients with and without GLA (81.81% vs 90.9%, P = 0.322). Right atrial contraction recovery rate was 96% in NGLA group, and 86.36% in GLA group (P = 0.138). Concomitant CSM is effective and feasible for restoration of SR and atrial contraction, for patients with LSP-AF and GLA associated with mitral valve diseases with acceptable operative risks. [ABSTRACT FROM AUTHOR]

BACKGROUND: The surgical treatment of atrial fibrillation associated with giant left atrium and rheumatic mitral valve disease is still a challenge, because the recurrence rate is high. Cut-and-sew maze procedure is the gold standard for the treatment of atrial fibrillation, but few studies are reported on cut-and-sew procedure used to treat this disease. OBJECTIVE: To evaluate the safety and efficacy of cut-and-sew maze procedure and mitral valve (mechanical valve and biovalve) replacement in the treatment of atrial fibrillation associated with giant left atrium and rheumatic mitral valve disease. METHODS: Patients with atrial fibrillation associated with rheumatic mitral valve disease who underwent the cut-and-sew maze procedure and mitral valve replacement in our hospital during April 2014 to October 2017 were retrospectively analyzed; 114 patients were enrolled according to the inclusion and exclusion criteria. By defining 60 mm as the boundary of the left atrial dimension, patients were divided into a non-giant left atrium group (left atrial dimension < 60 mm, n=85) and a giant left atrium group (left atrial dimension ≥ 60 mm, n=29). Perioperative safety indexes and postoperative curative effect were compared between the two groups. This study was approved by the Ethics Committee of General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Region), China (approval No. lunshen-k(2015)33). RESULTS AND CONCLUSION: Intraoperative safety indexes: There were no significant differences in the time of aortic occlusion, intraoperative cardiopulmonary bypass, intraoperative blood loss, operation duration and mitral valve replacement type between the two groups (P > 0.05). Postoperative safety indexes: There were no significant differences in the proportion of secondary thoracotomy after surgery, proportion of electrical cardioversion and temporary pacemaker applications, the time of ventilator use, ICU stay, length of hospitalization, early postoperative drainage volume and the incidence of early postoperative compilations between non-giant left atrium and giant left atrium groups (P > 0.05). Postoperative efficacy analysis: there was no significant difference in the recovery rate of sinus rhythm between non-giant left atrium and giant left atrium groups on the day of surgery, at discharge, and 6 months and 1 year after surgery (P > 0.05). There was no significant difference in cardiac function recovery between non-giant left atrium and giant left atrium groups at 6 months and 1 year after surgery (P > 0.05). These results suggest that cut-and-sew maze procedure and mitral valve replacement for the treatment of atrial fibrillation associated with giant left atrium and rheumatic mitral valve disease are highly safe and exhibit encouraging short-term efficacy. [ABSTRACT FROM AUTHOR]

The Cox-Maze IV procedure (CMP-IV) is the most effective treatment for atrial fibrillation. Increased left atrial (LA) size has been identified as a risk factor for failure to restore sinus rhythm. This has biased many surgeons against ablation in patients with giant left atrium (GLA), defined as LA diameter >6.5 cm. In this study we aimed to define the efficacy of the CMP-IV in patients with GLA. From April 2004 through March 2020, 786 patients with a documented LA diameter underwent elective CMP-IV, 72 of whom had GLA. Median follow-up duration was 4 years (interquartile range, 1-7 years). Recurrence was defined as any documented atrial tachyarrhythmia (ATA) lasting 30 seconds. ATA recurrence and survival were analyzed across GLA versus non-GLA groups. Median age at surgery was 65 (interquartile range, 56-73) years. Median LA diameter within the GLA group was 7.0 (range, 6.6-10.0) cm. There were no differences in rates of postoperative complications for the 2 groups, including rate of postoperative stroke and pacemaker placement (GLA 14%; non-GLA 12%; P =.682). A trend toward increased 30-day mortality in the GLA group did not reach statistical significance (GLA 6%; non-GLA 2%; P =.051). Freedom from ATAs at 5 years postoperatively was comparable for the 2 groups (GLA 82%; non-GLA 84%). The CMP-IV had good efficacy in patients with GLA. Our results suggest that LA diameter >6.5 cm should not preclude a patient from undergoing surgical ablation for atrial fibrillation. [Display omitted] [ABSTRACT FROM AUTHOR]

A 65 years old female with rheumatic heart disease presented to us with worsening breathlessness and palpitations. Echocardiogram revealed a giant left atrium. Here we discuss the clinical and imaging clues to the diagnosis of giant left atrium.

Background: Chronic Mitral Valve disease is strongly associated with Left atrial enlargement; the condition has a high mortality risk. Clinical manifestations include atrial fibrillation, pulmonary hypertension, thromboembolic events, and in cases of Giant Left Atrium (GLA) and a distorted cardiac silhouette. Full sternotomy, conventional open-heart surgery, reductive atrioplasty and atrioventricular valve repair are required to resolve symptoms. However, these procedures can be complicated due to the posterior location of the GLA and concomitant right lateral protrusion. Cardiac autotransplantation is superior under these conditions; it provides improved visual access to the posterior atrial wall and mitral valve, hence, facilitates corrective surgical procedures. We aimed to assess the clinical outcome of patients undergoing cardiac autotransplantation as the primary treatment modality to resolve GLA. Moreover, we evaluated the procedural safety profile and technical feasibility.Case Presentation: Four patients, mean EuroSCORE II of 23.7% ± 7.7%, presented with heart failure, atrial fibrillation, left atrial diameter > 6.5 cm and a severe distorted cardiac silhouette; X-ray showed prominent right lateral protrusion. We performed cardiac autotransplantation using continuous retrograde perfusion with warm blood supplemented with glucose followed by atrioplasty, atrial plication, valve annuloplasty and valve repair on the explanted beating heart. The surgical approach reduced the left atrial area, mean reduction was - 90.71 cm2 [CI95% -153.3 cm2 to - 28.8 cm2, p = 0.02], and normalized pulmonary arterial pressure, mean decrease - 11.25 mmHg [CI95% -15.23 mmHg to - 7.272 mmHg, p = 0.003]. 3 out of 4 patients experienced an uneventful postoperative course; 2 out of 4 patients experienced a transient return to sinus rhythm following surgery. One was operated on in 2017 and is still in good condition; two other patients survived for more than 10 years; Kaplan-Meier determined median survival is 10.5 years.Conclusions: Cardiac autotransplantation is an elegant surgical procedure that facilitates the surgical remodelling of Giant Left Atrium. Surgical repair on the ex vivo beating heart, under continuous warm blood perfusion, is a safe procedure applicable also to high-risk patients. [ABSTRACT FROM AUTHOR]

The three EBMs in the title refer to the following concepts: evidence-based medicine, experience-based medicine, and echo-based medicine. Evidence-based medicine: I have carried out the following clinical research using transthoracic Doppler echocardiography: (1) noninvasive pulsed-wave Doppler echocardiographic detection of the direction of shunt flow in patients with atrial septal defect: usefulness of the right parasternal approach (1985), (2) significance of laminar systolic regurgitant flow in patients with tricuspid regurgitation: a combined pulsed-wave, continuous-wave, and two-dimensional echocardiography (1990), (3) obstruction of the inferior vena caval orifice by the giant left atrium in patients with mitral stenosis: a Doppler echocardiographic study from the right parasternal approach (1992), and (4) demonstration of a localized acceleration flow signal in the transmural penetrating coronary artery using transthoracic color and pulsed-wave Doppler echocardiography in patients with hypertrophic cardiomyopathy (1996–2017). Experience-based medicine: Dr. Eugene Braunwald says “The best book of cardiology is the patient itself.” I have conducted my modest research activities gleaning hints through day-to-day routine work and sometimes investigating experimentally using the Doppler echocardiographic method. I have also learned from the Japanese Society of Echocardiography that a physician should stand between evidence-based medicine and experience-based medicine. Echo-based medicine: This term is intended to express my personal determination. I believe that echocardiography is the stethoscope of the 21st century. It is a safe, painless, low-cost, and repeatable tool at the bedside. I expect that echocardiography can reduce unnecessary healthcare costs and appropriately select reasonable examinations for patients. I would like to devote the time left in my career to the study of cardiovascular medicine, believing in the power of echocardiography and the Doppler method to provide a link between evidence-based medicine and experience-based medicine. [ABSTRACT FROM AUTHOR]

Giant left atrium is a rare condition, with a reported incidence of 0.3%, and mainly associated with rheumatic mitral valve disease with predominant regurgitation. Giant left atrium has significant hemodynamic effects and requires specific management in the most of the cases. We present an unusual case of a 65-year-old woman with massive left atrial enlargement accompanied by frequent right ventricular pacing, who was documented with severe pacing-induced left ventricular dyssynchrony.

Enlargement of left atrium occurs in patients with longstanding mitral valve disease due to chronic pressure and volume overload and occasionally left atrium reaches a massive enlargement, condition known as giant left atrium. It is most commonly associated with rheumatic mitral valve disease, both stenosis and regurgitation. This unique case deals with a 70-year-old woman who developed a giant left atrium due to a severe mitral regurgitation from complete prolapse of both mitral leaflets, as a consequence of previous undersized mitral ring annuloplasty.

A 44-year-old male patient presented with breathlessness on exertion but no compressive symptoms. Transthoracic two-dimensional echocardiography revealed a giant left atrium (LA) with severe mitral stenosis (MS) and mild mitral regurgitation (LA size 8.9 cm; LA volume 1133 ml). Giant LA has been variably described in literature, but there is no definition based on LA volume. A giant LA is rarely seen with MS.

Giant left atrium is a rare condition, with a reported incidence of 0.3%, and following mainly rheumatic mitral valve disease. Although rheumatic heart disease represents the main cause of giant left atrium, other etiologies have been reported. Giant left atrium has significant hemodynamic effects and requires specific management. In this review, we present two cases, discuss the different definitions, etiologies, clinical presentation and management modalities.

Introduction and Importance: Giant left atrium (GLA) is a rare condition often associated with rheumatic heart disease and can lead to cardiac and extracardiac complications. In this case report, the authors present a rare case of GLA with extracardiac complications, highlighting the importance of prompt diagnosis and management., Case Presentation: A 54-year-old woman with a 25-year history of mitral stenosis caused by rheumatic heart disease presented with symptoms of dyspnea, orthopnea, and palpitations. Diagnostic tests revealed an enlarged left atrium, pleural effusion, severe pulmonary hypertension, and tricuspid regurgitation. The patient was treated with diuretics and ACE (angiotensin-converting enzyme) inhibitors and is currently on a medication regimen with regular follow-up appointments., Clinical Discussion: GLA can cause cardiac and extracardiac complications, and conservative treatment and surgery are both involved in the management plan. The reduction of left atrial size by surgery may eliminate symptoms, reduce postoperative complications, and increase the probability of regaining sinus rhythm., Conclusion: Observational data on managing GLA is limited, and mortality can be high. Cardiovascular surgeons should carefully consider surgical options, and screening and follow-up are essential for early detection and management in patients with long-standing rheumatic heart disease., Competing Interests: The authors declare that they have no conflicts of interest.Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Enlargement of left atrium occurs in patients with longstanding mitral valve disease due to chronic pressure and volume overload and occasionally left atrium reaches a massive enlargement, condition known as giant left atrium. It is most commonly associated with rheumatic mitral valve disease, both stenosis and regurgitation. This unique case deals with a 70-year-old woman who developed a giant left atrium due to a severe mitral regurgitation from complete prolapse of both mitral leaflets, as a consequence of previous undersized mitral ring annuloplasty. [ABSTRACT FROM AUTHOR]

Giant left atrium (GLA) is defined as those measuring larger than 8 cm and are typically found in patients who have rheumatic mitral valve disease with severe regurgitation. GLA is a rare condition, with a reported incidence of 0,3%.The patient usually presents with complaints of shortness of breath and/or dysphagia. The correct diagnosis of GLA is at times not possible through the routine chest roentgenogram and may require echocardiography, computerized tomography or cardiac MRI to reach a diagnosis. GLA is associated with complications such as heart failure, valvular heart disease, dislocations of electrode. Patients with GLA are candidates for surgical/catheter interventional treatment at any age.

Objective: The study objective was to evaluate the safety and clinical and echocardiographic outcomes of a new surgical technique in adult patients diagnosed with a giant left atrium., Methods: We analyzed a cohort of patients who underwent left atrium reduction surgery between January 2016 and June 2020 performed by a specialized surgical team in 2 national reference centers in Lima, Peru. We assessed the major adverse valvular-related events and the New York Heart Association functional class as primary clinical outcomes. Also, our primary echocardiographic endings were the diameter, area, and volume of the left atrium. We assessed these variables at 3 time periods: baseline (t0), perioperative period (t1), and extended follow-up (t2: 12 ± 3.4 months). We carried out descriptive and bivariate exploratory statistical analysis for dependent measures., Results: We included 17 patients, 70.6% of whom were women. Rheumatic mitral valve disease (76.5%) was the main etiology. We performed 14 (82.4%) mitral valve replacements and 3 repairs. Major adverse valvular-related events occurred in 1 patient (5.9%) (hemorrhagic stroke) at t1. A significant reduction in the size of the left atrium was observed: diameter (77 mm vs 48 mm, P  < .001), area (75 cm 2 vs 31 cm 2 , P  < .001), and volume (332 cm 3 vs 90 cm 3 , P  < .001). Compared with t0 and t1, these echocardiographic findings remained without significant changes during t2., Conclusions: Our surgical left atrium reduction technique was associated with improved clinical functionality and reduced left atrium measures in patients with a giant left atrium undergoing mitral valve surgery., (© 2022 The Author(s).)

Purpose: We aimed to compare the efficacy of radiofrequency ablation (RFA) in patients undergoing mitral valve (MV) surgery with or without giant left atria., Methods: This retrospective, single-center, cohort study investigated patients who underwent MV surgery and concomitant RFA from 2009 to 2019. Patients were divided into non-giant left atria (diameter ≤65 mm, n = 1543) and giant left atria (diameter >65 mm, n = 241) groups. Five-year freedom from atrial tachyarrhythmia recurrence and thromboembolic event (TE) rates were assessed with death as the competing risk factor with and without propensity-score matching., Results: Patients with giant left atria had higher mortality (10.8% versus 6.2%, P = 0.008) and readmission rates for heart failure than those without (12.0% versus 6.8%, P = 0.004). Atrial tachyarrhythmia recurrence rates were higher in patients with giant left atria than in those without (49% versus 24% at 5 years, P <0.001), but the cumulative incidence of TEs before (P = 0.944) and after (P = 0.695) propensity-score matching was comparable., Conclusions: RFA effectively prevented TEs in patients with giant left atria, despite significant atrial tachyarrhythmia recurrence. Atrial tachyarrhythmia recurrence did not increase the risk of TEs. A lower success rate should be considered when deciding whether to perform surgical ablation in patients with giant left atria.

Giant left atrium is a condition characterized by huge enlargement of the left atrium with a diameter exceeding 65mm. It is most commonly associated with long standing rheumatic mitral valve disease. We present a 45-year-old female patient with rheumatic mitral stenosis associated with giant left atrium occupied by an 11 × 10 × 5 cm thrombus weighing 500 gms. The patient underwent successful mitral valve replacement and thrombectomy through an inverted T-shaped biatrial incision. [ABSTRACT FROM AUTHOR]

Giant left atrium is a rare condition, with a reported incidence of 0.3%, and following mainly rheumatic mitral valve disease. Although rheumatic heart disease represents the main cause of giant left atrium, other etiologies have been reported. Giant left atrium has significant hemodynamic effects and requires specific management. In this review, we present two cases, discuss the different definitions, etiologies, clinical presentation and management modalities. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this article is to review anatomic, physiologic, and clinical features of fetuses and neonates with severe mitral regurgitation (MR) in conjunction with aortic stenosis (AS) and left ventricular (LV) and left atrial (LA) dilation and to present preliminary results of pre-natal intervention for this condition. Background: Severe fetal valvar AS with an abnormal mitral valve (MV) and MR can lead to left heart dilation, with consequent compression of the right ventricle (RV); hydrops and low cardiac output are often associated. Methods: This is a retrospective review of fetuses diagnosed with AS, severe MR, and LA dilation (2002 to 2009) and neonates with the same combination of abnormalities (1988 to 2009). Results: Fourteen fetuses and 7 neonates were investigated. Eleven fetuses had severe hydrops; all had polyhydramnios and a structurally abnormal MV, abnormal MV inflow pattern, restrictive/intact atrial septum, retrograde flow in the transverse aortic arch, and compression of the right heart. The mean indexed RV output was 326 ± 160 ml/kg/min, lower than the normal average fetal combined ventricular output of 550 ± 150 ml/kg/min. Ten fetuses underwent pre-natal cardiac intervention: aortic valvuloplasty (n = 8) and/or atrial septal dilation/stenting (n = 5). Seven of these, and 11 overall, were live born. Nine patients died (median age 6 days), and 2 patients are currently alive. All 7 patients diagnosed in the neonatal period died (median age 1 day). Conclusions: Aortic stenosis associated with significant MR in the fetus can cause severe LA and LV enlargement, leading to low cardiac output and hydrops. Despite the potential advantages of early pre-natal diagnosis and both fetal and neonatal interventions, this rare complex of anomalies carries a poor prognosis. [ABSTRACT FROM AUTHOR]