https://orcid.org/0000-0002-5571-7549
A 61-year-old man with hypertension, type 2 diabetes, and coronary artery bypass grafting 4 years ago presented with a 1-month of recurrent intrusive angina and exertional breathlessness. Haemoglobin was 126 g/L, D-dimer 458 μg/L (normal range 270–750), hs-troponin T level was 172 ng/L (normal < 14), and NT-proBNP was 294 ng/L. Coronary angiogram showed no angiographic cause for the symptoms. Transthoracic echocardiogram revealed a large echogenic mass that almost completely obliterated the left atrium, resulting in functional mitral stenosis (Panel A, Supplementary data online, Videos S1–S3). Axial computed tomography chest demonstrated a 5 × 5 × 6.5 cm soft tissue mass and bilateral pleural effusions. (Panel B) With suspected left atrial tumour and evidence of heart failure, he proceeded to urgent surgical intervention. Interatrial septal incision was made, revealing a large intramural haematoma extending to the posterolateral aspect of the left atrium. The haematoma was evacuated, and histopathological examination showed atrial myocardium with intramural haemorrhage, and endocardial fibrosis with accompanying reactive stromal changes. (Panels C and D) There was no histological evidence of neoplasia. The patient’s symptoms improved post-operatively. Left atrial dissection is a recognized rare complication of mitral valve surgery, where haematoma typically accumulates in the posterior left atrial wall within a contained atrioventricular injury. With absence of previous surgery or blunt trauma, left atrial dissection could also rarely be a consequence of myocardial infarction or infective endocarditis. Subacute left atrial dissection should be considered as a cause of recurrent angina. Prompt surgical exploration is indicated particularly when occlusion of valve orifice is threatened, or acute heart failure develops.
Supplementary data are available at European Heart Journal - Cardiovascular Imaging online.
