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Ann Thorac Surg 2002;73:1981-1983
© 2002 The Society of Thoracic Surgeons

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Case report

Aneurysm of the left atrial appendage

^a Division of Surgery, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil

Accepted for publication December 5, 2001.

* Address reprint requests to Dr Pomerantzeff, Division of Surgery, Heart Institute (InCor), University of São Paulo Medical School, av Dr Enéas de Carvalho Aguiar, 44, Cerqueira César, CEP: 05403-000, São Paulo, Brazil
e-mail: dclpablo{at}incor.usp.br

	Abstract

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We present the case of a 33-year-old woman with atrial tachyarrhythmias and chest pain. The transthoracic echocardiography demonstrated an intrapericardial liquid mass confirmed as an aneurysm of the left atrial appendage by a nuclear magnetic imaging study. Aneurysmectomy was performed with the assistance of cardiopulmonary bypass with a bilateral submammary skin incision and subsequent median sternotomy. The patient had an uneventful postoperative course. We suggest aneurysmectomy aided by cardiopulmonary bypass as a safer method of treatment for this rare cardiac anomaly.

	Introduction

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Intrapericardial aneurysms of the left atrial appendage (LAA) are rare cardiac anomalies. However, they must always be considered in the presence of atrial tachyarrhythmias, systemic embolism, and cardiomegaly. Once an LAA aneurysm is diagnosed, aneurysmectomy must be performed to prevent stroke or sudden death.

A 33-year-old woman presented with recurrent episodes of severe palpitations associated with periods of chest pain occurring during the previous 10 months. Physical examination and laboratory findings were unremarkable. Her electrocardiogram was normal, but the 24-hour Holter study indicated 2 episodes of atrial tachyarrhythmias. The chest roentgenogram demonstrated an unusually prominent left heart border with mild cardiomegaly. The transthoracic echocardiogram revealed an intrapericardial mediastinal liquid mass of 9.5 cm x 5.5 cm without thrombi. The magnetic resonance study (Fig 1) confirmed the presence of the mass, interpreting is as a pericardial-celomic cyst. Surgical resection of the mass was indicated. A bilateral submamarian skin incision was performed (Fig 2), followed by a median sternotomy. A giant left atrial appendage aneurysm was visualized posterolaterally with intact overlying pericardium and without the presence of any pericardial adherences. No other cardiac anomalies were detected. The aneurysmectomy was performed using cardiocirculatory bypass. We did not find thrombi or any inflammatory signs in the left atrial body and in the LAA (Fig 3).

View larger version (89K): [in this window] [in a new window]   Fig 1. Magnetic resonance image (transverse plane) demonstrating the left atrial appendage aneurysm (arrows).

View larger version (94K): [in this window] [in a new window]   Fig 2. Submammarian incision and median sternotomy.

View larger version (110K): [in this window] [in a new window]   Fig 3. Left atrial appendage aneurysm resected.

	Comment

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LAA aneurysms are an unusual cardiac anomaly. The cause of this rare anomaly is congenital [1], probably because of a histologic structural deficiency in the atrial appendage wall. The true LAA aneurysm appears in the absence of other associated cardiac and pericardial pathologies, such as mitral valvular disease, partial agenesis of the pericardium, endocarditis, and tuberculosis.

The age of onset of symptoms is variable. Generally symptoms appear during the second or third decade of life. Sex is not a predominant factor. LAA appears almost in equal proportions in both men and women. The most frequent symptoms are palpitations [2], progressive dyspnea, and atypical chest pain episodes [3] that may be caused by the compression of the left coronary artery or any of its divisions. An electrocardiogram and a 24-hour Holter study must be performed. A chest roentgenogram must also form part of the primary routine examination. It may show an unspecific cardiomegaly with an unusual prominent left heart border. A transthoracic echocardiogram or, even better, a transesophageal color Doppler echocardiogram [4], which has been considered the best examination for diagnosing LAA aneurysms, may demonstrate the exchange of blood between the two chambers [5]. Other imaging studies, such as radionuclide scintiscanning, thoracic computed tomographic scan, magnetic resonance imaging of the chest, and angiocardiography will help confirm the diagnosis and eliminate other pathologic conditions such as cardiac or mediastinal tumors, pericardial cysts, acquired left atrial enlargement secondary to mitral valvular disease, left atrial herniation in the presence of any pericardial defect, and anomalous pulmonary venous drainage [1]. If left untreated, the chances of systemic embolism originating from a thrombus in the LAA are greater, leading to sudden death, stroke, or important neurologic sequelae. Anticoagulation with warfarin (Coumadin) is indicated to prevent formation of thrombi in the presence of arrhythmias, but the definitive treatment must be surgical resection.

Aneurysmectomy must be performed as the treatment of choice, even in the asymptomatic patient, because of the high risk of systemic embolism. Median sternotomy aided by cardiopulmonary bypass is the most accepted approach, uniformly considered safer and more successful, especially in cases of giant aneurysms with thrombi. Left lateral thoracotomy without cardiopulmonary bypass [2] and the use of stapling devices [6] associated with intraoperative transesophageal echocardiography have been reported as operative techniques with good results for the resection of LAA aneurysms.

If the aneurysms are promptly diagnosed and surgically resected in patients with isolated LAA aneurysms, the outcome is good with a total disappearance of the symptoms.

	References

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1. Gold J.P., Afifi H.Y., Ko W., et al. Congenital giant aneurysms of the left atrial appendage: diagnosis and management. J Card Surg 1996;11:147-150.[Medline]
2. Zhao J., Ge Y., Yan H., et al. Treatment of congenital aneurysms of the left atrium and left atrial appendage. Tex Heart Inst J 1999;26:136-139.[Medline]
3. Frambach P.J., Geskes G.G., Cheriex E.C., et al. Giant intrapericardial aneurysm of the left atrial appendage. Eur Heart J 1990;11:848-853.[Abstract/Free Full Text]
4. Comess K.A., Labate D.P., Winter J.A., et al. Congenital left atrial appendage aneurysm with intact pericardium: diagnosis by transesophageal echocardiography. Am Heart J 1990;120:992-996.[Medline]
5. Foale R.A., Gibson T.C., Guyer D.E., et al. Congenital aneurysms of the left atrium: recognition by cross-sectional echocardiography. Circulation 1982;66:1065-1069.[Abstract/Free Full Text]
6. Burke R.P., Mark J.B., Collins J.J., Jr, et al. Improved surgical approach to left atrial appendage aneurysm. J Card Surg 1992;7:104-107.[Medline]

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