Giant right atrium due to rheumatic tricuspid valve stenosis

Abstract

Fig. 1. Chest X-ray revealed cardiomegaly that mimics paracardiac mass. A 65 year old female with a known history of rheumatic heart disease was referred to our cardiology department because of progressive dyspnea, lower extremity edema and palpitation. Physical examination revealed mild respiratory distress with 25 breaths/min. Her pulse rate was 110 beats per minute, blood pressure 90/45 mm Hg and oxygen saturation 85% while she was breathing ambient air. Her neck veins were distended with raised jugular venous pressure. Cardiac auscultation revealed a diastolic heart murmur over the right sternal borders. An electrocardiogram showed atrial fibrillation with rapid ventricular response. Hematological and biochemical parameters were normal. Chest X-ray showed cardiomegaly that mimics paracardiac mass (Fig. 1). Echocardiography revealed enlarged right atrium which had linear dimensions of 95 ∗ 90 mm with severe tricuspid stenosis (the gradientwas found to be 25 and therewas severe tricuspid stenosis with amean gradient of 17mmHg). Therewas no biochemical or CT evidence of carcinoid heart disease, Ebstein's anomaly and severe left sided valvular heart disease. Rheumatic tricuspid stenosis was diagnosed and surgery was planned. However, patient refused the surgery. She was discharged from hospital 6 days after admission (Figs. 2 and 3, Movie 1). Right atrial dilatation due to tricuspid stenosis is very rare and clinical presentation varies widely, approximately half of patients are asymptomatic at the time of diagnosis [1,2]. Reported symptoms commonly include atrial fibrillation and right heart failure. This situation must be distinguished from more common structural lesions, such as Ebstein's anomaly, mitral, aortic valve disease and left sided heart failure. The treatment of tricuspid stenosis is still controversial [1,3–6].