Introduction
Left atrial appendage aneurysms are extremely rare and may arise congenitally or as a result of inflammatory conditions, degenerative changes, or mitral valve pathologies. Prompt intervention is generally recommended upon detection, as it can lead to arrhythmias or thrombus formation in affected patients. Most cases are asymptomatic, and the condition is often identified during evaluations for unrelated issues. In symptomatic cases, non-specific complaints such as palpitations, shortness of breath, and chest pain may be observed. In this article, we aim to present the congenital left atrial appendage aneurysm detected in an asymptomatic 7-year-old girl and its surgical treatment.
Case report
The 7-year-old girl, who had no complaints, was referred to the paediatric cardiology clinic after an enlarged heart appearance was detected on a chest X-ray (Figure 1 (a) ). Physical examination revealed no cardiac murmurs or abnormal cardiovascular findings. The echocardiography showed a normal sinus rhythm. The chest radiograph demonstrated a prominence on the left cardiac silhouette. Echocardiographic examination revealed a left atrial aneurysm measuring 7 x 4 x 4 cm (Figure 1 (b) ). No other cardiac pathology was detected. CT imaging revealed that the aneurysmal left atrial appendage exerted pressure on the left ventricle.(Figure-1 (c) ). The patient underwent surgery through median sternotomy. After resecting the thymus, the pericardium was incised, revealing no abnormalities. The left atrial appendage aneurysm was explored without the need for cardiopulmonary bypass (Figure 2 (a) ). A vascular clamp was applied to the aneurysm’s neck, followed by continuous suturing to secure it. The left atrial appendage aneurysm was excised (Figure 2 (b) ). No thrombus was observed inside the aneurysm. The patient was extubated on the operating table and taken to the ICU for monitoring. On the first postoperative day, the patient was transferred to the ward. No pathology was detected in the control echocardiographic evaluation in the ward. The patient was discharged with recovery on the 4th postoperative day.
Imaging findings: ( a ) Telecardiogram showing left atrial bulging; ( b ) Transthoracic echocardiogram showing the aneurysm; ( c ) CT angiography demonstrating the aneurysm.
Operative findings: ( a ) Intraoperative image of the aneurysm; ( b ) Excised specimen.
Discussion
Fry initially described congenital left atrial appendage aneurysm in 1953. Reference Fry1 This pathology, typically detected incidentally, often leads to non-specific complaints such as palpitations and shortness of breath, starting in the 20s. In the paediatric patient group, although rarely, it can be associated with heart failure, shortness of breath, and cardiac tamponade symptoms. In one-third of the cases, thrombus is observed inside the left atrial appendage during surgery. Reference Park, Lee, Han, Kim, Shin and Kim2 The following diagnostic criteria for congenital left atrial aneurysm were proposed: (i) the origin from an otherwise normal left atrium, (ii) a well-defined communication with the left atrium, (iii) intrapericardial location, and (iv) displacement or distortion of the left ventricle by the aneurysm. Reference Foale, Gibson, Guyer, Gillam, King and Weyman3 Another diagnostic criterion is the linear measurement of the aneurysm exceeding 3 cm. Reference Ulucam, Muderrisoglu and Sezgin4 Transthoracic echocardiography, transesophageal echocardiography, CT, or MRI imaging can be used in the diagnosis. Untreated aneurysms can lead to atrial fibrillation, supraventricular tachycardia, and related thromboembolic events. Even without arrhythmia, they can serve as a source of thromboembolism due to the slowing of intracardiac flow. Consequently, timely surgical intervention is advised upon diagnosis. Reference Wang, Li and Zhang5 Surgical approach, especially with cardiopulmonary bypass, is considered safer for aneurysms containing thrombus or those with a wide neck connecting to the left atrium. Nonetheless, those with narrow-necked aneurysms may undergo surgery without the use of cardiopulmonary bypass. Reference Zhao, Ge, Yan, Pan and Liao6 An approach to the left atrium through left thoracotomy is also possible, but in our case, we chose median sternotomy due to the patient’s age and the risk of not being able to tolerate the positioning of the heart without cardiopulmonary bypass (CPB) support. We did not use CPB support during the manipulation of the left atrial appendage, as there were no hemodynamic changes. Since there was no need for CPB support, we extubated the patient on the operating table after a relatively short surgery at normothermia and discharged her in good health on postoperative day 4. In conclusion, left atrial appendage aneurysms can cause arrhythmias or serve as a source of thromboembolism even without arrhythmia. Therefore, early surgical intervention is recommended even in asymptomatic patients.
