biatrial enlargement: an unusual cause of massive cardiomegaly · an unusual cause of massive...
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Biatrial enlargement: an unusual cause of massivecardiomegalyTanupreet Sethi,1 Ajit Pal Singh,2 Vivek Singla,2 Yadvinder Singh2
1Department of Radiology,Kempegowda Institute ofMedical Sciences, Bengaluru,Karnataka, India2Department of Cardiology,Sri Jayadeva Institute ofCardiovascular Sciences andResearch, Bengaluru,Karnataka, India
Correspondence toVivek Singla,[email protected]
To cite: Sethi T, Singh AP,Singla V, et al. BMJ CaseRep Published online:[please include Day MonthYear] doi:10.1136/bcr-2012-008320
DESCRIPTIONA 50-year-old woman presented with complaints ofprogressive breathlessness and easy fatiguability overthe past 2 years. Jugular venous pressure was raisedwith absence of a wave. Cardiac auscultationrevealed two distinct mid-diastolic murmurs at theapex and a left lower sternal border with an ejectionsystolic murmur at the right second intercostalspace. The ECG performed showed atrial fibrillationwith a fast ventricular rate. Rate control wasachieved with amiodarone infusion and intravenousdiuretic therapy was instituted. Chest radiograph(figure 1) showed evidence of gross cardiomegaly(cardiothoracic ratio=0.8) with the left heart bordertouching the left lateral chest wall. Enlargement ofthe left atrium was evidenced by straightening of theleft heart border, double density sign and splayingof the carina. Widening of the right heart bordersuggested right atrial enlargement. There was con-spicuous absence of pulmonary congestion dispro-portionate to the severe symptomatic status. Aorticknuckle calcification was seen. A transthoracic echo-cardiogram (figures 2 and 3A–D) diagnosed the con-dition as chronic rheumatic heart disease withsevere stenotic lesions of the mitral, tricuspid andaortic valves and mild regurgitation at the threevalves. The left atrium measured 8.5 cm×5.8 cm inarea while the right atrium measured 50.3 cm2.Predominant biatrial enlargement can present as
an unusual cause of massive cardiomegaly. Causes of
biatrial enlargement include restrictive cardiomyop-athy, rheumatic heart disease, isolated mitral insuffi-ciency and constrictive pericarditis.1 2 Cliniciansand radiologists should consider this possibilitywhile interpreting massive cardiomegaly on chestradiographs.
Learning points
▸ Biatrial enlargement can present as massivecardiomegaly on a chest radiograph.
▸ Common causes of biatrial enlargement includerestrictive cardiomyopathy, rheumatic heartdisease and constrictive pericarditis.
▸ Two-dimensional Doppler echocardiographyhelps in delineating the definitive diagnosis.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peerreviewed.
REFERENCES1 Rogers WR, Wittels B. Extreme bilateral atriomegaly; review of the
literature and report of a case. Circulation 1957;15:434–41.2 Ceylan N, Bayraktaroğlu S, Nalbantgil S, et al. Massive bilateral
atriomegaly filling thoracic cavity. Anadolu Kardiyol Derg 2011;11:E1–2.
Figure 1 Chest radiograph showing massivecardiomegaly with signs of biatrial enlargement. Verticalarrow depicts carinal splaying, suggesting left atrialenlargement. Horizontal arrow shows aortic knucklecalcification.
Figure 2 Transthoracic two-dimensionalechocardiogram in a subcostal view depicting chamberenlargement as seen in the chest radiograph. LA, leftatrium; LV, left ventricle; RA, right atrium; RV, rightventricle.
Sethi T, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2012-008320 1
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Figure 3 (A) Transthoracicechocardiogram in an apicalfour-chamber view showing sizes ofthe two atria. (B) Continuous-waveDoppler across the tricuspid valvedepicting severe tricuspid stenosis withmild regurgitation. (C)Continuous-wave Doppler across themitral valve depicting severe mitralstenosis with mild regurgitation. (D)Continuous-wave Doppler across theaortic valve depicting severe aorticstenosis with mild regurgitation.
2 Sethi T, et al. BMJ Case Rep 2013. doi:10.1136/bcr-2012-008320
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