Ann Thorac Surg 2004;77:721-723
© 2004 The Society of Thoracic Surgeons
Case report
Left atrial appendage aneurysm in a child
Yoshihisa Tanoue, MDa,
Hideaki Kado, MDa*,
Yuichi Shiokawa, MDa,
Koichi Sagawa, MDa
a Departments of Cardiovascular Surgery and Pediatric Cardiology, Fukuoka Children's Hospital Medical Center, Fukuoka, Japan
Accepted for publication April 8, 2003.
* Address reprint requests to Dr Kado, Department of Cardiovascular Surgery, Fukuoka Children's Hospital Medical Center, 2-5-1 Tojin-machi, Chuo-ku, Fukuoka 810-0063, Japan
e-mail: kado.h{at}fukuoka-child.jp
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Abstract
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We report a case of left atrial appendage aneurysm in a 1-year-old child. The patient was asymptomatic, and a mediastinal liquid mass that was confirmed to be an aneurysm of the left atrial appendage was incidentally revealed by transthoracic echocardiography. Aneurysmectomy was performed during cardioplegic arrest under the support of cardiopulmonary bypass. The postoperative course was uneventful.
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Introduction
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Aneurysm of left atrial appendage is a very rare anomaly. Some cases involving surgical treatment with or without the support of cardiopulmonary bypass have been reported. The cause of this rare anomaly is congenital [1], but there are a few case reports of this anomaly in children. We report a case of left atrial appendage aneurysm in a 1-year-old child. Aneurysmectomy was performed during cardioplegic arrest under the support of cardiopulmonary bypass.
A 1-year-old boy was admitted to our hospital for an asymptomatic aneurysm of the left atrium, which was unexpectedly found by transthoracic echocardiography in another hospital. Physical examination revealed a well-developed child with a body weight of 10.4 kg and a height of 82.0 cm. Chest radiography showed a protruding shadow above the left side of the heart. Transthoracic echocardiography demonstrated an abnormal cavity measuring 27 x 19 mm connected to the left atrial appendage at the lateral side of the left ventricle (Fig 1).
Cardiac catheterization was performed before the surgical procedure to confirm the diagnosis of left atrial appendage aneurysm.
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Fig 1. Transthoracic echocardiogram showing an aneurysm connected with the left atrial appendage at the lateral side of the left ventricle. (LA = left atrium; LAAA = aneurysm of the left atrial appendage; LV = left ventricle; RA = right atrium; RV = right ventricle.)
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A standard median sternotomy was performed. The 29 x 22-mm aneurysm connected to the left atrial appendage had overlying pericardium and no adherences; its free wall was thin, suggesting a fibrous change from the white surface (Fig 2).
Aortic and bicaval cannulations were performed, and cardiopulmonary bypass was instituted. After cross-clamping the ascending aorta, cardiac arrest was achieved by cold crystalloid cardioplegia. Aneurysmectomy was performed without clamping the left atrium, and the stump of the left atrial appendage was sutured in a linear fashion. Thrombi or any inflammatory signs were not seen in the aneurysm or in the left atrium, and no other cardiac anomalies were found. His heart beat recovered spontaneously after the aortic cross-clamp was released, and weaning from cardiopulmonary bypass was smooth. The cardiopulmonary bypass time was 30 minutes and the aortic cross-clamp time was 11 minutes. Blood transfusion was not performed. The patient was extubated 3 hours after operation in the intensive care unit, and had an uneventful postoperative course.
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Fig 2. Operative findings (A) after incising the pericardium and (B) after drawing the aneurysm. (Ao = ascending aorta; LA = left atrium; LAAA = aneurysm of the left atrial appendage; LAD = left anterior descending coronary artery; MPA = main pulmonary artery; RA = right atrium; RV = right ventricle.)
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Comment
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We report the surgical repair of a left atrial appendage aneurysm in a 1-year-old child. This is a very rare anomaly, especially during childhood. The present case involved an asymptomatic patient, and the aneurysm was incidentally found by transthoracic echocardiography. Although the cause of left atrial appendage aneurysm is congenital, symptoms generally appear during the second or third decade of life [1]. Noninvasive examination with echocardiography and magnetic resonance imaging can aid in early diagnosis. Because the risk of surgical resection is low and its outcome is good, it is ideal to perform this operation before the appearance of critical symptoms, such as palpitation due to arrhythmia [1–4], progressive dyspnea [4], atypical chest pain caused by the compression of the left coronary artery [2], and stroke or sudden death due to systemic embolism [5].
In the present case, aneurysmectomy was performed during cardiac arrest under the support of cardiopulmonary bypass. The left atrium was not clamped to prevent injury and kink of the coronary artery, and to preclude embolism during the procedure. Resection without cardiopulmonary bypass by left thoracotomy has been reported to produce good results [4, 6]. However, authentic resection during cardiac arrest under the support of cardiopulmonary bypass by median sternotomy is a safe method, especially in children.
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References
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- Gold J.P., Afifi H.Y., Ko W., Horner N., Hahn R. Congential giant aneurysms of the left atrial appendage: diagnosis and management. J Card Surg 1996;11:147-150.[Medline]
- Pomerantzeff P.M., Freyre H.M., de Almeida Brandao C.M., Pereira Barreto A.C., Almeida de Oliveira S. Aneurysm of the left atrial appendage. Ann Thorac Surg 2002;73:1981-1983.[Abstract/Free Full Text]
- Pome G., Pelenghi S., Grassi M., Vignati G., Pellegrini A. Congenital intrapericardial aneurysm of the left atrial appendage. Ann Thorac Surg 2000;69:1569-1571.[Abstract/Free Full Text]
- Zhao J., Ge Y., Yan H., Pan Y., Liao Y. Treatment of congenital aneurysms of the left atrium and left atrial appendage. Tex Heart Inst J 1999;26:136-139.[Medline]
- Victor S., Nayak V.M. Aneurysm of the left atrial appendage. Tex Heart Inst J 2001;28:111-118.[Medline]
- Burke R.P., Mark J.B., Collins J.J., Jr, Cohn L.H. Improved surgical approach to left atrial appendage aneurysm. J Card Surg 1992;7:104-107.[Medline]
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Abstract
Introduction
