Giant left atrial appendage

A 30-year-old woman presented with a history of palpitations for 15 years and dyspnoea on exertion for 6 years. Her symptomatic status had worsened from New York Heart Association (NYHA) class 2 to NYHA class 3 in the last 1 year. On clinical examination, she had evidence of congestive cardiac failure and rheumatic mitral valve disease. ECG showed right axis deviation, left ventricular hypertrophy and atrial fibrillation (AF) with controlled ventricular rate. Her chest x-ray (figure 1) showed cardiomegaly and a hump-like convexity at the left cardiac border suggestive of an enlarged left atrial appendage (LAA). Transthoracic echocardiogram revealed dilation of all cardiac chambers with a markedly enlarged left atrium (LA, 12 cm). The mitral valve was thick and fibrosed with the posterior mitral leaflet being restricted. There was a mild anterior mitral leaflet prolapse with subvalvular disease. Tricuspid valve annulus was enlarged; aortic and pulmonary valves were structurally normal. LAA was unusually dilated with the base of the appendage measuring 5.6 cm (figures 2 and 3). Colour Doppler imaging showed sever eccentric mitral regurgitation that was directed towards the LAA (figure 4; see online video clip). There was moderate tricuspid regurgitation with a right ventricular systolic pressure of 60 mm Hg. On the basis of echocardiographic findings, the patient successfully underwent LAA ligation along with mitral valve replacement.