J INVASIVE CARDIOL 2018;30(6):E52-E53.
Key words: valve surgery, mitral valve replacement
A 67-year old female, who recently immigrated to the United States from Guinea, with past medical history of hypertension and rate controlled atrial fibrillation on warfarin therapy was admitted for decompensated congestive heart failure (CHF). She had experienced symptoms of dyspnea with exertion, fatigue, and chest pain for 1 year, with recent worsening of symptoms over the last 4 weeks. On physical examination, she had an irregular rhythm with a grade III/IV systolic murmur radiating to the axilla, a laterally displaced point of maximum impulse, and bibasilar rales.
Chest x-ray showed marked cardiomegaly with pulmonary edema and no evidence of chest wall deformity (Figure 1). Atrial fibrillation was noted on electrocardiogram without significant ischemic changes. She responded to intravenous diuretics, which improved her CHF symptoms. Transthoracic echocardiogram demonstrated rheumatic mitral valve disease with severe stenosis (valve area 0.9, cm2), moderate to severe mitral regurgitation and a massively dilated left atrium (Figure 2). There was also severe tricuspid regurgitation with a reduced left ventricular (LV) ejection fraction of 50%. Left atrial diameter was 8.8 cm and LV end-diastolic diameter was 6.7 cm.
Cardiothoracic surgery consultation was obtained and the patient accepted for mitral and tricuspid valve surgery. Coronary angiogram was performed for presurgical evaluation. All major coronary arteries had mild luminal irregularities in a right dominant circulation; however, the mid left anterior descending artery was noted to have diastolic compression against the 5th and 6th ribs, secondary to lateral displacement of the LV from the severely enlarged left atrium (Figures 3A and 3B; Video 1).
The patient underwent mitral valve replacement with a bioprosthetic porcine valve, tricuspid valve annuloplasty, and left atrial appendage ligation with good result and an uncomplicated postoperative course. Extrinsic coronary compression is a rare finding and usually occurs in the setting of cardiac chamber remodeling or enlargement. There are no randomized data regarding appropriate therapy; however, correcting the underlying cause of chamber enlargement would be the first priority. In our case, the patient underwent mitral valve replacement for severe rheumatic mitral stenosis, which would optimistically allow for attenuation of left atrial size and relief of coronary compression. However, percutaneous coronary intervention has been reported as a treatment option as well. Herein, we describe a case of massive cardiac chamber enlargement with consequential diastolic compression of the LAD.
Watch the accompanying video here.
From Deborah Heart and Lung Center, Division of Interventional Cardiology and Endovascular Medicine, Browns Mills, New Jersey.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript accepted February 1, 2018.
Address for correspondence: Vincent Varghese, DO, Deborah Heart and Lung Center, Division of Interventional Cardiology and Endovascular Medicine, 200 Trenton Road, Browns Mills, NJ 08015. Email: VargheseV@Deborah.org