Small Left Atrium Research Articles

The Operative Problem of Small Left Atrium in Total Anomalous Pulmonary Venous Connection: Report of 5 Patients

A moderately small left atrium is a common finding in total anomalous pulmonary venous connection (TAPVC). In most patients in whom the common pulmonary vein is anastomosed to the left atrium, the small size of this chamber does not interfere with good operative results. Recently a patient was encountered in whom the left atrium measured less than 2 cm in its greatest dimension. This atrium was too small to take an anastomosis with the common pulmonary vein. Therefore the common pulmonary vein was anastomosed primarily to the right atrium, the floor of the fossa ovalis was excised, and a pericardial conduit was constructed. Subsequently, 4 additional patients have been similarly treated. The problem of small left atrium in TAPVC is discussed.

Congenital aortic valve disease with rupture of mitral chordae tendineae.

A new clinical entity is described in which free aortic regurgitation from congenital aortic valve disease caused rupture of the chordae to the anterior leaflet of the mitral valve in 7 men aged 45 to 63 years (mean 52 years); 2 of the patients also had rupture of chordae to the posterior leaflet. Comparing these patients with those with ruptured mitral chordae in association with rheumatic heart disease and patients with spontaneous chordal rupture, differences were evident. No patient had a history of rheumatic fever and none had active infection. The typical clinical presentation was of acute mitral regurgitation into a small left atrium, with severe pulmonary oedema which was often resistant to medical treatment. The cause of chordal rupture in these patients was in part the result of progressive left ventricular dilatation, of direct trauma to the anterior cusp of the mitral valve, and possibly of a genetic factor. The anatomical features of both aortic and mitral valves are described, and in 3 histology of the mitral valve was available; 2 had myxomatous degeneration similar to that seen in patients with spontaneous chordal rupture, and in 1 there was degeneration of collagen tissue. All patients were treated surgically but the mortality was high (5 out of 7,70%). Early operation with replacement of the aortic and mitral valves is recommended if this high mortality is to be reduced.

Cardioversion following prosthetic mitral valve replacement.

Direct current conversion of atrial fibrillation has been attempted in 60 consecutive patients following prosthetic mitral valve replacement (Starr-Edwards prosthesis). Sinus rhythm was attained and persisted for at least 24 hours after the procedure in 68% (41 patients) and 40% of the entire group (24 patients) were still in normal sinus rhythm an average of 10 months later. Successful initial conversion and persistence of sinus rhythm occurred most frequently in patients whose duration of atrial fibrillation was less than 5 years and who had a small left atrium. Results differed little whether conversion was attempted 7 to 21 days or 1 to 15 months after open valve replacement. Atrial disease associated with a long period of antecedent atrial fibrillation and marked left atrial enlargement appeared to be the most important factors responsible for persistence of atrial fibrillation or early relapse. Attempts at cardioversion are recommended for all patients with persistent atrial fibrillation following mitral valve replacement in view of the high success rate and the safety of the procedure.

SEVERE MITRAL REGURGITATION SECONDARY TO RUPTURED CHORDAE TENDINEAE.

Fifteen cases of severe mitral regurgitation secondary to ruptured chordae tendineae have been reviewed, eight of whom underwent open-heart surgery to correct their lesions. Three patients are living at this time with two being markedly improved. Cardiac catheterization was performed in six prior to surgery. Progressive deterioration within the year following the onset of difficulty or sudden worsening of previous cardiac symptoms characterized the usual clinical course. The apical systolic murmur, always loud, was conspicuously harsh and radiated to the base of the heart, simulating aortic stenosis when the mural cusp was ruptured. Although strongly suggesting the diagnosis, the sudden onset of an apical systolic murmur could be documented in only three instances. The presence of a small left atrium radiographically with tall left atrial "v" waves and marked reflux of contrast material into a paradoxically pulsating left atrium also pointed to the correct diagnosis. Various technics of surgical repair and problems influencing survival of patients in the present series are discussed.

Technique and sequelae of catheterization of the left side of the heart

Left heart catheterization is an investigation which has much to offer in the accurate diagnosis and study of mitral and aortic valvular disease. It is a practical procedure which carries a reasonably low risk. However, left heart catheterization has been connected with some complications, and several of these can be avoided. Some complications cannot be avoided. Therefore we only advise a left heart catheterization where its diagnostic help is found necessary for the decision of an eventual surgical exploration. We believe a chest surgeon should perform the puncture and he should be equipped to perform a thoracotomy and defibrillation. In our group of 150 cases of mitral stenosis major complications were observed in eleven cases or 7 per cent. No death occurred in this group and no patient had persistent sequelae. In our seventeen cases of aortic valvular disease there were three major complications. In such cases with a small left atrium the puncture may be performed with the aid of fluoroscopy. We have had the most severe complications in this group, i.e. cardiac tamponade with ventricular fibrillation. When angiocardiography is performed it is most important to have the patient well oxygenated during and after the anesthesia. The complications, which have occurred in this group seem to be more related to the anesthesia than to the actual injection of contrast media. The complication frequency could probably be lowered with a thinner needle. But, as we consider, it is essential to perform pressure measurements in the left ventricle and angiocardiography we will continue to use the technique outlined.