A 68-year-old woman presented to our hospital complaining of dyspnea at rest for approximately 2 months and was classified as New York Heart Association functional class III. She had previously been treated for breast and colon cancers and had not suffered from cardiovascular disease. Her height, weight, and body mass index were 150.0 cm, 91.0 kg, and 40.4 kg/m2, respectively. A grade IV/VI pan-systolic murmur was heard at the apex on cardiac auscultation. Her pulse rate was 105 beats/min and she was diagnosed with an irregularly rapid heartbeat (tachycardia). Her blood pressure was 124/76 mmHg. A chest radiograph revealed severe cardiomegaly with a cardiothoracic ratio of 80%, while an electrocardiogram showed persistent atrial fibrillation with a low-voltage F-wave. Computed tomography demonstrated the retention of pleural fluid or abdominal dropsy and hepatosplenomegaly. No significant coronary stenosis was observed by coronary angiography. Transthoracic echocardiography revealed severe mitral regurgitation with annular enlargement and severe tricuspid regurgitation. The cause of mitral regurgitation was severe tethering due to extreme annular enlargement, and the prolapse of the anterior leaflet. The left ventricular ejection fraction was 49%, the left ventricular diastolic diameter was 63 mm, and the left atrial diameter was 71 mm. Laboratory evaluations did not show any abnormalities, apart from an N-terminal-proB-type natriuretic peptide level of 7439 pg/ml. Because of the medication-refractory heart failure, we decided to perform surgery after a written informed consent was obtained.\nA median sternotomy was performed and standard cardio-pulmonary bypass was initiated with ascending aortic and bicaval cannulation. A left atrial vent was introduced from the right upper pulmonary vein. Myocardial protection was achieved in an antegrade and retrograde fashion. The retrograde cardioplegia cannula was inserted smoothly under direct vision. After aortic cross-clamping, the left atrium was opened through a longitudinal left atriotomy, revealing the tethering mechanism secondary to the prolapse of the anterior leaflet of the mitral valve. The clear zone of the anterior leaflet was excised and the rough zone with its attached chord were divided equally. Each divided structure was transferred to the anterolateral and the posteromedial commissures separately. The posterior leaflet, including the subvalvular apparatus, was wholly preserved. The mitral valve was replaced with a 29-mm St. Jude mechanical valve (St. Jude Medical Inc., St. Paul, MN) in an intra-annular position using everting mattress sutures. Subsequently, tricuspid annuloplasty was performed with a 32-mm Carpentier-Edwards PhysioTricuspid ring (Edwards LifeSciences, Irvine, CA) for annular enlargement. Weaning from the cardio-pulmonary bypass was successful. After closing the thorax, to our surprise, an atrial mass of 3 cm × 2 cm was detected by TEE, which showed an oval hypoechoic appearance extending from the posterior annulus of the mitral valve to the posterior wall of the left atrium (Fig. a). Although it occupied one-third of the left atrium, there was no significant obstruction of the pulmonary venous return and left ventricular filling. The prosthetic valve movement was unobstructed and there were no paravalvular leaks or pericardial effusion. No communication between the mass and the atrial true lumen was detected using color Doppler echocardiogram. We diagnosed the mass as LAD. Because hemodynamic conditions were stable after a consulting with the anesthesiologist, the patient was deemed unsuitable for surgery. She was transferred to the intensive care unit and remained under close observation. On postoperative day 2, TEE showed that the atrial mass had vanished and the broken piece of the endocardium merely remained fluttering in the atrium (Fig. b). On postoperative day 6, the appearance of the left atrium had normalized completely, leaving no traces of LAD (Fig. c). The patient had an uneventful postoperative course, except for prolonged respiratory failure. She was discharged from the hospital on postoperative day 47 and is currently being followed up once a month.
A 54-year-old female, a known case of rheumatic heart disease with severe mitral stenosis, MV area was 0.9 cm2, and moderate mitral regurgitation, was admitted to our hospital. The MV and subvalvular apparatus were calcified and there was moderate pulmonary arterial hypertension. Bilateral ventricular functions were within normal limits. She was posted for MV replacement (MVR) and informed consent was obtained. Her preoperative hematological investigations were within normal limits. General anesthesia was induced with standard medications and cardiopulmonary bypass (CPB) was established.\nShe underwent MVR with bioprosthetic valve 25 mm (EPIC, St. Jude Medical). Immediate post-CPB TEE showed normal functioning prosthetic valve and Doppler also revealed normal pressure gradients across the valve []. Her intraoperative period was uneventful and shifted to postoperative Intensive Care Unit (ICU) with minimal doses of inotropes. Postoperative day (POD) 0 was uneventful; however, on POD 1, she developed hypotension (arterial pressure 84/50 mmHg) that required increasing doses of inotropic support. Her central venous pressure was 20 mmHg and pulmonary artery pressure was 60/38 mmHg. Arterial blood gases also revealed metabolic acidosis. Due to her hemodynamic status, she could not be weaned off the mechanical ventilation.\nTEE was done to rule out cardiac tamponade and to evaluate the prosthetic MV function. It revealed a large cavitatory mass occupying the whole of left atrium (LA) which was obliterating the movement of MV leaflets [ and ]. Continuous wave Doppler (CWD) showed pressure gradient (peak/mean) of 19/10 mmHg across MV []. However, bilateral ventricular functions were within normal limits.\nOwing to her deteriorating hemodynamic condition, she was immediately shifted to the operating room. Chest was reopened and CPB was established. Opening of LA revealed dissection of the LA wall extending from the posterior annulus of the MV to the roof of LA. Clots were removed from the LA; however, the cavity again filled up. Therefore, it was decided to do the “marsupialization” for clearing of the cavity [ and ]. The bioprosthetic valve was also examined and was found to be normal. CWD also revealed normal gradient across prosthetic MV []. The patient was weaned off the CPB with low dose of inotropes. She was mechanically ventilated for 24 h and inotropes were gradually weaned off. She had longer stay in the ICU; otherwise her postoperative period was uneventful.