Giant Aneurysm of the Right Atrial Appendage

Abstract

A 52-year-old man was referred to our hospital to be evaluated for a heart transplant. He had a history of multiple admissions due to heart failure. His physical examination revealed: jugular distension, hepatomegaly, and peripheral edema. The electrocardiogram showed sinus rhythm with right axis deviation. A chest x-ray revealed cardiomegaly. Transthoracic echocardiography showed an aneurysmal dilatation of the right atrial appendage (RAA) with intracavity thrombus (Fig. 1). The right ventricular ejection fraction was impaired, with moderate tricuspid regurgitation, and pulmonary hypertension. A nuclear resonance image confirmed a giant appendage aneurysm with the intracavity thrombus and right ventricular dysfunction (Figs. 2 and 3). A 64-slice multidetector computed tomography ruled out chronic pulmonary Figure 1. Four-chamber echocardiography: RA = right atrial; RV = right ventricle.thromboembolism, and an aneurysmatic cavity was three-dimensionally reconstructed (Fig. 4). A cardiac catheterization was performed. The pulmonary arterial systolic pressure was 73 mmHg, the diastolic pressure was 28 mmHg, and the mean pressure was 42 mmHg. The left ventricle end-diastolic pressure was 25 mmHg. The cardiac index was 2.9 liter/min per meter square.Approximately 100 cases of right atrium abnormalities have been reported in the literature. 1 Giant RAA is a very rare anomaly discovered accidentally by an enlarged silhouette on a chest x-ray; an associated atrial septal defect has been reported. 2,3 Slightly less than half of the cases have symptomatic arrhythmias. The optimal treatment is controversial; a conservative approach is recommended in the absence of symptoms, leaving surgical treatment to symptomatic cases. Figure 2. Steady-state free precession (SSFP-b) images in systole, four-chamber view: RA = right atrial; RV = right ventricle; and T = thrombus. 95

Right Atrial Appendage Aneurysm: A Systematic Review

“…12 In patients with difficult TTE images and or unclear diagnosis, TEE with contrast study and has been reported to increase sensitivity for diagnosing RAAA, however, the sensitivity was still low at 33%. 10 Risk factors associated with adverse outcomes including thromboembolic and arrhythmic complications included large RAAA size, large right atrial size, and associated congenital cardiac defects. 13 Both the modalities are useful in confirming the connection of the aneurysm to the RAA and studying its relation to other structures like descending thoracic aorta.…”

“…CT angiography and MRI are excellent adjuvant imaging tools, in patients in whom the diagnosis is not clear on TEE, with high sensitivity and specificity. 3,6,9,10 Periodic monitoring of RAAA in asymptomatic patients with cardiac MRI or CT for evidence of enlarging RAAA has been shown to be a useful tool in selecting patients for early surgical intervention. 2 A 24-hour Holter recording should be requested in patients complaining of palpitations and/or normal ECG for the evaluation of atrial tachyarrhythmias.…”

A Case of Right Atrial Appendage Aneurysm in a 62‐Year‐Old Man

“…Clinical presentations of RAAA mainly include supraventricular arrhythmia, intracavity thrombosis, and space‐occupying effects such as compression of the tricuspid annulus or compression of the right ventricular outflow tract (RVOT) . Moreover, there have been cases accompanied with right ventricular (RV) dysfunction and pulmonary hypertension (PH), although it remains unclear whether such manifestations were related to the aneurysm. However, clinical characteristics may depend on the location and size of the aneurysm, and some cases are asymptomatic …”

“…There is no evidence to suggest that aneurysmectomy and anticoagulation are needed in all situations . However, potential risks of thrombosis and embolism were documented in previous reports . For conservatively treated cases, follow‐up examinations of EKG, Holter and echocardiography are greatly important.…”

“…4 However, potential risks of thrombosis and embolism were documented in previous reports. 2,3 For conservatively treated cases, follow-up examinations of 3D reconstruction image showed that the RCA stenosis was distal to the aneurysm (the aneurysm marked by white arrows, and the RCA stenosis marked by the black arrow). B. CT angiography showing the RCA stenosis (marked by black arrows).…”