Ann Thorac Surg 1996;62:1507-1509
© 1996 The Society of Thoracic Surgeons
Case Report
Posttraumatic Aneurysm of the Right Atrium
Juergen von der Emde, MD, PhD,
Robert A. Cesnjevar, MD,
Stephan Kretschmer, MD,
Gerhard H. Janssen, MD,
Christian Wittekind, MD, PhD
Departments of Cardiac Surgery, Cardiology, and Surgical Pathology, University Hospital Erlangen, Erlangen, Germany
Accepted for publication May 13, 1996.
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Abstract
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We report on an acquired right atrial false aneurysm, which was removed under extracorporeal circulation. The patient remembered three occasions of blunt chest trauma with rib fractures. Clinical syptoms were ongoing dyspnea, chest pain, and atrial fibrillation.
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Introduction
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Aneurysms of the atria are very rare lesions of congenital or acquired origin. They seem to be more common on the left atrial side [1, 2]. Few congenital right atrial aneurysms have been published in the reviewed literature. Here we report an acquired right atrial false aneurysm.
A 60-year-old man was admitted to the hospital for ongoing dyspnea, chest pain, and atrial fibrillation. He remembered three occasions of blunt chest trauma with rib fractures on the left side. He had already retired. His chest roentgenogram showed a huge pleural effusion, and diuretic therapy was initiated. On transthoracic echocardiography a right atrial "tumor" was diagnosed. On transesophageal echocardiography it showed a central echogenic structure, surrounded by echo-free signals and free-floating parts. Cardiac nuclear magnetic resonance imaging visualized a 6 x 7 x 2-cm intrapericardial "tumor" with communicating blood flow to the right atrium.
Cardiac catheterization confirmed an aneurysmatic structure with a free-floating mass on the right atrial side. Left ventricular ejection fraction was 0.31, and cardiomyopathy was suspected by the cardiologists. The patient was referred to our cardiac surgical unit for removal of his "tumor." The heart was exposed via median sternotomy. Contractility of the right and left ventricle were normal. There was a 6 x 6-cm protrusion of the right atrium covering a region of turbulent bloodflow with a thin translucent membrane. Aortic and vena caval cannulas were inserted and the patient was taken on bypass. The inferior vena cava was cannulated on its diaphragmatic edge like in Fontan procedures, due to the small distance between the "tumor" and the foramen of the vena cava. Under extracorporeal circulation, after electrical fibrillation in normothermia without cross-clamping of the aorta, the membrane was incised and the "tumor," which was attached by a small base to the right atrial wall, was removed (Fig 1
). The patient had no atrial septal defect. There was an opening of 2 x 2 cm in the right atrial wall (Fig 2). The atrium was closed with a running suture of 3-0 Prolene (Ethicon, Somerville, NJ) (Fig 3), and biopsy specimens from the left ventricular wall were taken for histologic examination. Atrial fibrillation converted to normal sinus rhythm after defibrillation.
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Fig 2. . Posttraumatic aneurysm of the right atrium; the incorporated thrombus is surrounded by a thin bloodstream (arrows).
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The postoperative course was uneventful. The patient was extubated 4 hours after the operation. Atrial fibrillation occured again on the sixth postoperative day but could be terminated by electroconversion. The patient was discharged on the 13th day, markedly improved compared with the preoperative status.
Histologic examination of the excised material showed an old organized thrombus with fibrous stroma, granulating parts, and lymphocyte infiltration covered by a thin membrane. In the neighborhood macrophages with pigment inclusions, fibroblast proliferation, and foam cells could be seen. Myocardial biopsies showed normal heart muscle with low-grade hypertrophy and nucleus thickening.
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Comment
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Two different mechanisms of atrial ruptures have been suggested in the reviewed literature: (1) The first is intrathoracic compression of the heart between sternum and posterior thoracic wall [3]. This usually results in complete rupture leading to pericardial tamponade or exsanguination through an additional pericardial laceration into the pleural space [3, 4] or mediastinal compression [5]. (2) The other mechanism discussed [3, 4] is a rapid acceleration/deceleration trauma when the relatively mobile part of the heart is moving because of the inertial impulse and tears at the fixed venous insertions and great vessels while they are trying to keep the heart in place.
Direct penetration of heart chambers caused by rib fragments is very uncommon [3, 4]. We suppose that one of the above-mentioned mechanisms led to an incomplete rupture with bleeding into the right atrial wall. The so formed false aneurysm of the right atrium partly thrombosed and remained undetected before hospital admission of our patient.
As we know from congenital aneurysm of the atria, distention of the atrial wall may trigger atrial arrhythmias [6, 7]. The reported patient had atrial fibrillation preoperatively and converted to sinus rhythm afterward.
According to Miyamura and associates [6], atrial aneurysms can mimic cardiomyopathy with low left ventricular ejection fraction due to rhythm disturbances. In this patient cardiomyopathy was suspected because of the decreased left ventricular function preoperatively. We suppose that myocardial scar formations after multiple cardiac contusions during three episodes of blunt chest trauma may have had an additive effect.
We generally recommend a surgical approach via a median sternotomy for repair of traumatic cardiac lesions, because of the excellent exposure of all parts of the heart. In this special case we established extracorporeal circulation for further surgical options. Moreover, cardiopulmonary bypass is very helpful in acute trauma for fast circulatory recompensation and the repair of additional cardiac lesions such as ventricular ruptures.
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Footnotes
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Address reprint requests to Dr Cesnjevar, Abteilung fuer Herzchirurgie und Chirurgie der grossen thorakalen Gefaesse, Chirurgische Universitaetsklinik, Krankenhausstr 12, D-91054 Erlangen, Germany.
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References
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- Stone KS, Brown JW, Canal D, et al. Congenital aneurysm of the left atrial wall in infancy. Ann Thorac Surg 1990;49:476–8.[Abstract/Free Full Text]
- Maeda K, Yamashita C, Shida T, et al. Successful surgical treatment of dissecting left atrial aneurysm after mitral valve replacement. Ann Thorac Surg 1985;39:382–4.[Abstract/Free Full Text]
- Getz BS, Davies E, Steinberg SM, et al. Blunt cardiac trauma resulting in right atrial rupture. JAMA 1986;255:761–3.[Medline]
- Smith JM III, Grover FL, Marcos JJ, et al. Blunt traumatic rupture of the atria. J Thorac Cardiovasc Surg 1976;71:617–20.[Abstract]
- Sethia B. Traumatic atrial rupture without haemopericardium. Injury 1980;12:187–8.[Medline]
- Miyamura H, Nakagomi M, Eguchi S, et al. Successful surgical treatment of incessant automatic atrial tachycardia with atrial aneurysm. Ann Thorac Surg 1990;50:476–8.[Abstract/Free Full Text]
- Scalia GM, Stafford WJ, Burstow DJ, et al. Successful treatment of incessant atrial flutter with excision of congenital giant right atrial aneurysm diagnosed by transesophageal echocardiography. Am Heart J 1995;129:834–5.[Medline]
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Resection of Congenital Intrapericardial Right Atrial Aneurysm
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Abstract
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