Ann Thorac Surg 1995;60:1226-1229
© 1995 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Massive Calcification of the Left Atrium: Surgical Implications
José L. Vallejo, MD, PhD,
Carlos Merino, MD,
José M. González-Santos, MD,
Emilia Bastida, MD,
José Albertos, MD,
Mariano J. Riesgo, MD,
Fermin González de Diego, MD
Departments of Cardiovascular Surgery and Anesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
Accepted for publication May 30, 1995.
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Abstract
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Background. Massive calcification of the atrial walls (``porcelain atrium'') is a rare condition that usually has been reported as an incidental radiologic finding.
Methods. Between January 1988 and June 1993, 971 patients underwent valvular operation at our institution; 21 patients showed extensive calcification of the left atrium. In 8 patients the calcification was massive, involving almost all the atrial surface. The diagnoses were established by radiology and were confirmed at operation. The mean age of these patients (4 men, 4 women) was 55 ± 9.6 years. All had rheumatic valve disease, were on atrial fibrillation, and had undergone at least one operation previously. Pulmonary artery pressure was severely increased, even up to systemic levels, in all patients except 1. Total endoatriectomy of the left atrium and mitral valve replacement were performed. No patient was lost during the follow-up.
Results. Hospital mortality rate was 12.5% (1 patient) and 2 patients died in the late postoperative period. None of these deaths are attributable to the surgical procedure.
Conclusions. In toto endoatriectomy of a massively calcified atrium is an easy to perform technique that helps to replace the mitral valve and close the atrial wall.
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Introduction
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The presence of calcifications in the left atrium is a relatively common finding in the setting of long-standing rheumatic valve disease [1–7]. These calcifications may appear in other unusual places [8, 9]. Nevertheless, massive calcification of atrial walls (``porcelain atrium'') is rare and generally has been reported previously only as an incidental radiologic finding [10], the interatrial septum usually remaining unaffected. The first description of this condition was made by Oppenheimer in 1912 [11]. From a surgical point of view, the patients had undergone closed mitral commissurotomy or cardiopulmonary bypass [1, 12] and 1 additional patient could not be on cardiopulmonary bypass because of the massive calcification of the atrium [13]. This calcification is supposed to be promoted by chronic strain forces acting on the atrial walls for a long time, but the evolution is not always the same. Atrial calcification does not necessarily imply the presence of associated mural thrombosis. In many of these patients, nonnegligible obstacles increase the difficulty of surgical procedures such as the suture of heavily calcified atrial walls or the mobilization of the mitral valve plane.
We usually treat massive thrombosis of the left atrium searching for the best cleavage plane that allows a total excise, sometimes ``en bloc.'' We decided to apply this technique in those cases of massive calcification, achieving a good plastic result and an easier closure of the atriotomy. We describe our experience in 8 patients.
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Patients and Methods
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From January 1988 to December 1993, 971 patients underwent valvular operation at our institution; 21 patients were found to have extensive calcification of the left atrial wall. In 10 patients the calcification was massive, involving the entire atrial endocardium. The last 2 patients were operated on using the superior transseptal approach as the resection of calcified endocardium was not considered essential. The interatrial septum was free from calcifications in all patients, except for 1 patient. The diagnoses were established by radiology (in 1 patient echocardiography could establish the diagnosis) and were confirmed at operation. The mean age of the 8 patients (4 men, 4 women) was 55.4 ± 9.6 years. All had rheumatic valve disease, were on atrial fibrillation, and had undergone operation at least once before. Pulmonary artery pressure was severely increased, even up to systemic levels, in 7 of the 8 patients. Clinical data are summarized in Table 1
. No patient was lost to follow-up.
Operative Procedure
Cardiopulmonary bypass was performed using a bubble oxygenator (Shiley 100-A; Shiley Inc, Irvine, CA) in 2 patients and a membrane oxygenator (Cobe Cardiovascular, Arvada, Co) in the remainder. In all patients the ascending aorta and both cava veins were cannulated with angled cannulas. Moderate hypothermia (28°C) and clamping of the ascending aorta were carried out to achieve a myocardial temperature of approximately 16°C; both infusion of cold cardioplegic solution and external cooling of the heart were applied. The approach to the left atrium was done through the interatrial groove, following the axis of the caval veins and enlarging the incision behind these veins. With this technique we reached the roof of the left atrium from the top and its posterior wall (in the vicinity of the coronary sinus) from the bottom, achieving good access to the mitral valve.
Once in the left atrium, we looked for the best cleavage plane to excise the calcified endocardium, without removing thrombus, if any. The endocardium was carefully excised from the valvular annulus (or from the sewing ring in the patients that had prosthesis). The calcified endocardium was then dissected and removed, in many cases en bloc (Figs 1 and 2). Afterward, the mitral valve was excised as usual; in the case of prosthetic valves, the suture stitches were cut and the prosthesis removed. The new prosthesis was fixed with noncontinuous sutures rested on Teflon pledgets (Ticron 2/0; Cynamid of Great Britain, Ltd, Gosport, Great Britain). The atrial wall was closed with a running suture (Prolene 2/0; Ethicon, Somerville, NJ). Once the patient was warmed again, electrical cardioversion was performed and circulating heparin was neutralized with intravenous protamine. Hemostasis was tested for the right level and sternotomy was closed as usual. Table 2 summarizes the different procedures that were performed.
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Fig 1. . (A) Calcified endocardium. (MVO = mitral valve orifice.) (B) Calcification of the left atrial appendage (LAA) can be seen.
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Fig 2. . (A) Lateral chest roentgenogram showing atrial calcification (arrows). This patient was operated on for mitral commissurotomy and aortic valve replacement. (B) The same patient after reoperation. Disappearance of atrial calcification.
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All the patients were anticoagulated with low-dose subcutaneous calcic heparin (2,500 units three times a day), starting 24 hours after the operation. When the drainage tubes were removed, oral anticoagulants (acenocumarol, 3 mg/day) were administered. The infusion of heparin was withheld once the target international normalized ratio (3.5 to 4) was achieved.
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Results
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Definitions
The definitions proposed by The Society of Thoracic Surgeons [14] and The American Association for Thoracic Surgery are followed.
HOSPITAL MORTALITY.
No patient died intraoperatively. One patient (12.5%) died on the 58th day after the operation of multisystem failure. The clinical course was complicated by the impossibility of weaning the patient from mechanical ventilation and by the development of an acute cholecystitis that had to be treated surgically. Afterward, diffuse sepsis caused the multisystem failure and the patient died in a few days.
LATE MORTALITY.
Hepatic cirrhosis and hypersplenism resulting from hepatitis C developed in 1 patient. Five years after the last operation the patient was reoperated on to relieve significant tricuspid regurgitation caused by severe pulmonary hypertension (systolic pressure, 75 mm Hg). A tricuspid annuloplasty with a Carpentier ring was performed; the left atrium was free of calcifications. The patient died of uncontrollable bleeding.
Another patient died 8 years after the operation of terminal cardiac failure.
MORBIDITY.
In our series, no cases of thromboembolism or bleeding caused by anticoagulation were recorded.
There were no cases of endocarditis in this group of patients.
Only the patient with hepatic cirrhosis had hemolysis unrelated to the prosthetic valve (it was caused by hypersplenism).
All patients were on chronic atrial fibrillation and only one had an atrial flutter that resulted in acute cardiac failure and required electrical cardioversion.
Left arm monoparesis developed in 1 patient and showed progressive improvement during the follow-up period.
One patient presented in anaphylactic shock as a reaction to protamine; such hypersensitivity had not been known beforehand. The patient achieved total recovery.
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Comment
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A few cases of the left atrial calcification, even in uncommon places such as the atrial appendage, have been reported in the literature [8, 9]. Most of these cases are reported as unusual conditions and incidental radiographic findings [4–7].
Calcification of the left atrium is an uncommon complication of the longstanding valvular rheumatic disease. Calcification of the atrial endocardium is even more uncommon. It has been suggested that the calcification of the left atrium is a response to the chronic strain forces present in the setting of mitral disease. Another theory supports a previous ulceration of the atrial wall as the origin of the calcification [1]; one of the leading factors may be the turbulence resulting from the valvular alteration. Most of these patients had undergone previous operation for their mitral valvular disease. A further review [3] has remarked that the interatrial septum is often free from calcifications. In our experience only 1 patient was found to have septum calcification. For this reason and taking in account our two decades of surgical experience we think that the approach to the left atrium through the right atrium and interatrial septum (Dubost's incision) was advisable in these patients. Nevertheless, at present we do not use this approach because of the frequent postoperative arrhythmias. With the superior septal approach, we have never found problems and we think it is the elective approach to the mitral valve in those patients where we expect a difficult access. The massive calcification of the left atrium entails three major problems from a surgical point of view: (1) a complex approach to the left atrium, also remarked in a recent report [15]; (2) the handling of a rigid wall that makes the access to the mitral valve difficult; and (3) once the surgical treatment of the valve is done, the closure of the atriotomy is quite difficult and sometimes impossible.
In operations on rheumatic valves, when we find massive thrombosis of the left atrium, we look for the best cleavage plane to remove the thrombus en bloc, if possible. In this way we avoid the fragmentation of the thrombus and the subsequent risk of systemic embolization of thrombotic particles. We decided to apply this technique to the patients with massive calcification of the left atrium, obtaining good results. Once the calcified ``cortex'' is removed, the atrial wall is still thick enough to be sutured without problems: in our experience there have been no cases of rupture of the atrial wall, or need of pericardial or prosthetic patches to close the atriotomy.
In our opinion, the mortality rate of this series is acceptable, taking into account the period of time within which the patients were operated, the antecedent of at least one previous surgical procedure, and the presence of pulmonary hypertension, severe in many cases. We believe that this mortality rate is related to the patients' advanced diseases rather than to the operative technique.
In conclusion, total endoatriectomy of a calcificated left atrium is an easy surgical technique, without associated morbidity, that facilitates both the approach to the mitral valve and the suture of the atrial wall. However, no postoperative research has been done to test the improvement of the atrial compliance after the operations.
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Footnotes
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Address reprint requests to Dr Vallejo, Department of Cardiovascular Surgery, Hospital G.U. Gregorio Marañón, Dr Esquerdo 46, 28007 Madrid, Spain.
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References
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Abstract
Introduction
