A new surgical technique for left atrial reduction in giant left atrium

Abstract

Objective: The study objective was to evaluate the safety and clinical and echocardiographic outcomes of a new surgical technique in adult patients diagnosed with a giant left atrium.

Methods: We analyzed a cohort of patients who underwent left atrium reduction surgery between January 2016 and June 2020 performed by a specialized surgical team in 2 national reference centers in Lima, Peru. We assessed the major adverse valvular-related events and the New York Heart Association functional class as primary clinical outcomes. Also, our primary echocardiographic endings were the diameter, area, and volume of the left atrium. We assessed these variables at 3 time periods: baseline (t0), perioperative period (t1), and extended follow-up (t2: 12 ± 3.4 months). We carried out descriptive and bivariate exploratory statistical analysis for dependent measures.

Results: We included 17 patients, 70.6% of whom were women. Rheumatic mitral valve disease (76.5%) was the main etiology. We performed 14 (82.4%) mitral valve replacements and 3 repairs. Major adverse valvular-related events occurred in 1 patient (5.9%) (hemorrhagic stroke) at t1. A significant reduction in the size of the left atrium was observed: diameter (77 mm vs 48 mm, P < .001), area (75 cm² vs 31 cm², P < .001), and volume (332 cm³ vs 90 cm³, P < .001). Compared with t0 and t1, these echocardiographic findings remained without significant changes during t2.

Conclusions: Our surgical left atrium reduction technique was associated with improved clinical functionality and reduced left atrium measures in patients with a giant left atrium undergoing mitral valve surgery.

Keywords: CPB, cardiopulmonary bypass; GLA, giant left atrium; IQR, interquartile range; LA, left atrium; MAVRE, major adverse valvular-related events; MV, mitral valve; NYHA, New York Heart Association; RHD, rheumatic heart disease; SR, sinus rhythm; atrial fibrillation; developing countries; giant left atrium; left atrial reduction surgery; mitral valve disease.

Graphical abstract

We observed a significant decrease in LA volume after reduction surgery.

Figure 1

Surgical technique. A, Diagram showing our LA reduction technique, resection through the oblique sinus and between the pulmonary veins (blue arrow), LA roof resection (red arrow), and LA appendage excision and closure (yellow arrow). B, Sketch diagram showing the tissue resected. C, The inferior edge of left atriotomy extended across the obliquus sinus in the LA inferior wall between the left and right pulmonary veins. D, LA inferior wall sutured with 4/0 polypropylene. E, Left atriotomy extended superiorly below the superior vena cava across the LA roof. We resected a longitudinal segment 1- to 1.5-cm wide and closed it with 4/0 polypropylene continuous sutures. AA, Ascending aorta; SVC, superior vena cava; MV, mitral valve; IVC, inferior vena cava; URPV, upper right pulmonary vein; ULPV, upper left pulmonary vein; LAA, left auricular apendix; ILPV, inferior left pulmonary vein; IRPV, inferior right pulmonary vein.

Figure 2

Postoperative results in 17 patients undergoing MV surgery and LA reduction with our technique.

Figure 3

A and B, Preoperative transthoracic echocardiography and thoracic x-ray showing extreme LA dilatation. C and D, Significant postoperative LA reduction in the same patient. E, Hematoxylin–eosin stain: Low-power photomicrograph exhibiting myocyte vacuolization with myocardial lymphocytic inflammation. F, Masson's trichrome stain: moderate myocardial interstitial fibrosis (pericellular-type fibrosis). LA, Left atrium.