Bi-Atrial Compression Due to Ascending and Descending Aortic Aneurysms

J INVASIVE CARDIOL 2017;29(10):E151-E152.

Key words: aortic aneurysm, left atrial compression, right atrial compression, dyspnea

Aortic aneurysms compressing an atrium causing symptoms are uncommon. We describe a case of bi-atrial compression due to ascending and descending aneurysms leading to dyspnea.

An 89-year-old male with a history of hypertension, coronary artery bypass graft surgery, and descending thoracic aortic aneurysm repair with an endograft placement was admitted with a chief complaint of increasing dyspnea on exertion over a period of 2 months. Physical exam revealed an S4 gallop, an aortic systolic murmur, jugular venous distension, and mild bi-basilar crackles. He was treated with intravenous diuretics with improvement in his dyspnea. 

A transthoracic echocardiogram performed demonstrated an ejection fraction of 40% with anterior wall hypokinesis, pseudonormal mitral inflow pattern, and no significant valve lesions. Also noted on the apical four-chamber view was a large ascending aortic aneurysm that was compressing the right atrium, as well as a large descending aortic aneurysm that contained an endograft compressing the left atrium (Figure 1). A computerized tomography scan of the chest was then performed, which revealed the ascending aortic aneurysm measuring 7.1 cm in diameter compressing the right atrium and the descending aortic aneurysm measuring 8.8 cm in diameter  compressing the left atrium (Figure 2). In view of the advanced age of the patient, he was managed conservatively. 

Compression of an atrium by an aortic aneurysm has been previously described.^1,2 Compression of both atria due to ascending and descending aneurysms is uncommon. Mild compression is most commonly asymptomatic. However, when the compression is significant, it may lead to syncope, dyspnea, or palpitations/arrhythmias.³ The dyspnea in the present case was most likely multifactorial, which included systolic and diastolic dysfunction, with the compression of the atria contributing to it. Transthoracic echocardiography is the diagnostic tool of choice in these cases. Contrast echocardiography may aid in the diagnosis by differentiating the compressing mass to be vascular, such as the aorta versus other structures.⁴

References

1.    Celenk MK, Ozeke O, Selcuk MT, Selcuk H, Cagli K. Left atrial compression by thoracic aneurysm mimicking congestive heart failure. Echocardiography. 2005;22:677-678.

2.    Sadaniantz A, Pyne CT. Obstruction of left atrial filling by a large descending thoracic aortic aneurysm detected by pulsed Doppler echocardiography. Echocardiography. 1994;11:323-326.

3.    Maybrook RJ, Afzal MR, Parashar S, et al. Intrinsis and extrinsic cardiac pseudotumors: echocardiographic evaluation and review of the literature. Echocardiography. 2016;33:117-132.

4.    Stoupakis G, Fuhrman MA, Dabu L, Knezevic D, Saric M. The use of contrast echocardiography in the diagnosis of an unusual cause of congestive heart failure: achalasia. Echocardiography. 2004;21:149-152.

From the Columbia University Division of Cardiology at the Mount Sinai Heart Institute, Miami Beach, Florida. 

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 April 17, 2017.

Address for correspondence: Orlando Santana, MD, Director, Echocardiography Laboratory, Columbia University Division of Cardiology, Mount Sinai Heart Institute, 4300 Alton Road, Miami Beach, FL 33140. Email: osantana@msmc.com