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Asian Cardiovasc Thorac Ann 2001;9:226-228
© 2001 Asia Publishing EXchange Pte Ltd

CASE STUDY

Resection of Congenital Intrapericardial Right Atrial Aneurysm

Yavuz Besogul, MD, Bülent Tünerir, MD, Celal Kirdar, MD1, Bilgin Timuralp, MD2, Recep Aslan, MD

Department of Cardiovascular and Thoracic Surgery
2 Department of Cardiology Osmangazi University Medical School and Research Hospital Eskisehir, Turkey
1 Department of Cardiology State Hospital Eskisehir, Turkey
For reprint information contact: Bülent Tünerir, MD Tel: 90 222 232 1386 Fax: 90 222 220 4830 email: btunerir{at}ogu.edu.tr Hasan Polatkan Bulvari Akin Sitesi, No. 122/A, D:19, Eskisehir 26120, Turkey.

   Abstract
TOP
 Abstract
INTRODUCTION
 CASE REPORT
 DISCUSSION
 REFERENCES
 
A 16-year-old male was investigated for exercise-induced dyspnea and paroxysmal palpitations. There was no prominent right heart border in a chest radiograph. A congenital intrapericardial right atrial aneurysm was diagnosed from 2-dimensional echocardiographic findings of a large echo-free space close to the right atrium, and confirmed by magnetic resonance imaging and surgical pathology. Successful repair was achieved on a beating heart with a brief period of on-pump support. Postoperatively, the symptoms disappeared completely.


   INTRODUCTION
TOP
 Abstract
 INTRODUCTION
CASE REPORT
 DISCUSSION
 REFERENCES
 
Intrapericardial aneurysm of the right atrium is a very rare cardiac anomaly that can be congenital or acquired.1–3 It arises infrequently from the right atrial free wall and more commonly from the right atrial appendage (diverticulum).1–4 Symptoms may be present or absent, and it can be treated successfully by surgical repair.1,2–5


   CASE REPORT
TOP
 Abstract
 INTRODUCTION
 CASE REPORT
DISCUSSION
 REFERENCES
 
A 16-year-old male who had suffered exercise-induced dyspnea and palpitations for 2 years, was referred with a diagnosis of atrial aneurysm and atrial septal defect. Physical examination revealed a chest deformity and normal cardiac findings. Unusually, there was no prominent right heart border on his chest radiograph, but there was a moderate pectus carinatum deformity. Routine biochemical screening including thyroid status was normal. Intermittent 12-lead electrocardiograms were normal, but 24-hour Holter monitoring showed episodes of atrial fibrillation with a rapid ventricular response; an electrophysiological study confirmed these signs. Cross-sectional echocardiography in the parasternal long-axis view demonstrated an atypical right atrium enlarged to an area of 38.2 cm2 (Figure 1Go). There was no thrombus in the atrial space. Contrast echocardiography did not reveal an atrial septal defect. Cardiac catheterization and angiography showed normal hemodynamics of the right atrium and coronary arteries. Because of insufficient contrast volume, an aneurysm could not be demonstrated angiographically. Diagnosis of a right atrial aneurysm was confirmed by magnetic resonance imaging. Because the patient was symptomatic, it was decided to carry out surgical resection of the aneurysm. We prefer to repair right atrial aneurysms on a beating heart to minimize the side effects of extracorporeal circulation.



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  		Figure 1. Two-dimensional echocardiographic view of the right atrial aneurysm. LA = left atrium, LV = left ventricle, RA = right atrium, RV = right ventricle.

 
After a median sternotomy, arterial cannulation was performed via the aortic root and venous return was supplied by direct superior vena caval cannulation and femoral cannulation with a long 24F silicon chest tube extended into the inferior vena caval orifice. After pericardiectomy, a very large thick-walled right atrial aneurysm was observed (Figure 2Go). The superior and inferior venae cavae were snared to prevent venous return. The heart was supported by a centrifugal pump with a membrane oxygenator, without crossclamping. Mean arterial pressure was maintained at 80 mm Hg. Neither hypothermia nor circulatory arrest was employed. A right atriotomy was performed between the superior vena cava-atrial groove and the inferior vena cava. There was no atrial septal defect, abnormal venous return, or thrombus. The tricuspid valve was evaluated and found to be normal. A large portion (approximately 14 x 8 cm) of the free wall of the aneurysm was resected. The edges were closed with a double layer of 3/0 propylene sutures (Figure 3Go). Centrifugal pump support was used for only 10 minutes. After atrial closure, the vena caval snares were removed and the sternum was closed as usual. Postoperative echocardiography showed a normal right atrium with an area of 16.6 cm2. The patient had an uneventful postoperative course with normal sinus rhythm, and he was discharged from the hospital symptom-free without any medication. He remained well during one year of follow-up that included 24-hour Holter monitoring.



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  		Figure 2. Operative photograph of the right atrial aneurysm.

 


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  		Figure 3. Operative photograph of the right atrium after resection of the aneurysm.

 

   DISCUSSION
TOP
 Abstract
 INTRODUCTION
 CASE REPORT
 DISCUSSION
REFERENCES
 
Acquired aneurysm of the right atrium is usually associated with previous trauma.3 It is sometimes asymptomatic but may present with arrhythmias or dyspnea, as in our patient.5,6 The diagnosis is usually suggested by the appearance of an abnormal cardiac shadow on a plain chest radiograph. However, the right heart border was not abnormal in this case and angiography failed to show an atrial aneurysm. Two-dimensional echocardiography can provide information regarding right atrial size and configuration, and may establish the diagnosis of right atrial aneurysm.7

Right and left atrial aneurysms frequently cause atrial fibrillation that is associated with significant symptoms and morbidity. Palpitations, presyncope, dyspnea, and exercise intolerance may be caused by a poorly controlled ventricular response rate at rest or during exercise. The irregular ventricular response is a consequence of the rapid atrial rhythm that results in beat-to-beat variability of ventricular filling.8 Atrial fibrillation is associated with loss of a regular cardiac rhythm and thromboembolism. Generally, surgical treatment of the atrial aneurysm eliminates these complications. The prognosis of con-genital right atrial aneurysm after surgical treatment is excellent. Our patient has been symptom-free without medication for 12 months postoperatively. The case highlights the importance of noninvasive methods of diagnosis of right atrial aneurysm and the possibility of successful surgical repair on a beating heart with a brief period of support with a centrifugal pump.


   REFERENCES
TOP
 Abstract
 INTRODUCTION
 CASE REPORT
 DISCUSSION
 REFERENCES
 

  1. Morrow AG, Behrendt DM. Congenital aneurysm (diverticulum) of the right atrium. Circulation 1968; 38:124–8.[Abstract/Free Full Text]

  2. Miyamura H, Nakagomi M, Eguchi S, Aizawa Y. Successful surgical treatment of incessant automatic atrial tachycardia with atrial aneurysm. Ann Thorac Surg 1990;250:476–8.[Abstract]

  3. Von der Emde J, Cesnjevar RA, Kretschmer S, Janssen GH, Wittekind C. Posttraumatic aneurysm of the right atrium. Ann Thorac Surg 1996;62;1507–9.[Abstract/Free Full Text]

  4. Domanski M, Surowka J. Aneurysm or diverticulum of the right atrium. Pol Tyg Lek 1981;36:973–4.[Medline]

  5. Zeebregts CJAM, Hensens AG, Lacquet LK. Asymptomatic right atrial aneurysm: fortuitous finding and resection. Eur J Cardio-thorac Surg 1997;11:591–3.[Abstract]

  6. Varghese PJ, Simon AL, Rosenquist GC, Berger M, Rowe RD, Bender HW. Multiple saccular congenital aneurysm of the atria causing persistent atrial tachyarrhythmia in an infant. Pediatrics 1969;44:429–33.[Abstract/Free Full Text]

  7. Gross B, Petrikovsky B, Challenger M. Prenatal diagnosis of an aneurysm of the right atrium. Prenat Diagn 1996;16:1043–5.[Medline]

  8. Ferguson TB, Cox JL. Surgical treatment of arrhythmias. In: Edmunds LH, editor. Cardiac surgery in the adult. New York: McGraw-Hill, 1997:737–92.





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