Case report
Left atrium and pulmonary artery compression due to aortic aneurysm causing heart failure symptoms
Compressão do átrio esquerdo e artéria pulmonar por um aneurisma da aorta causando sintomas de insuficiência cardíaca
Antonio José Lagoeiro Jorge
, Wolney de Andrade Martins, Victor M. Moutinho, Juliano M. Rezende, Patricia Y. Alves, Humberto Villacorta, Pedro F. Silveira, Antonio A. Couto
Corresponding author
Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brasil
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array:2 [ "paginaInicial" => "539.e1" "paginaFinal" => "539.e3" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Antonio José Lagoeiro Jorge, Wolney de Andrade Martins, Victor M. Moutinho, Juliano M. Rezende, Patricia Y. Alves, Humberto Villacorta, Pedro F. Silveira, Antonio A. Couto" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Antonio José Lagoeiro" "apellidos" => "Jorge" "email" => array:1 [ 0 => "lagoeiro@globo.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Wolney de Andrade" "apellidos" => "Martins" ] 2 => array:2 [ "nombre" => "Victor M." "apellidos" => "Moutinho" ] 3 => array:2 [ "nombre" => "Juliano M." "apellidos" => "Rezende" ] 4 => array:2 [ "nombre" => "Patricia Y." "apellidos" => "Alves" ] 5 => array:2 [ "nombre" => "Humberto" "apellidos" => "Villacorta" ] 6 => array:2 [ "nombre" => "Pedro F." "apellidos" => "Silveira" ] 7 => array:2 [ "nombre" => "Antonio A." "apellidos" => "Couto" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brasil" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Compressão do átrio esquerdo e artéria pulmonar por um aneurisma da aorta causando sintomas de insuficiência cardíaca" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1189 "Ancho" => 1584 "Tamanyo" => 135215 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Venous computed tomography angiography of the chest.</p> <p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">DAo: descending thoracic aorta; PAT: pulmonary artery truncus; RPA: right pulmonary artery; SVC: superior vena cava; TAA: thoracic aortic aneurysm.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Patients with thoracic aortic aneurysm (TAA) are mostly asymptomatic and TAA is rarely related to heart failure (HF). TAA may present acutely with rupture or dissection, or chronically, with symptoms related to surrounding structures.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Extrinsic compression of the left atrium (LA) and the pulmonary vessels is an uncommon cause of hemodynamic compromise and may be secondary to the involvement of mediastinal structures, including TAA. This compression can lead to increased atrial and pulmonary artery pressures and may consequently cause pulmonary hypertension or pulmonary edema.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> We report the case of a patient with type A TAA with right pulmonary artery and LA compression, who had HF with preserved ejection fraction (HFpEF) and acute pulmonary edema (APE).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">An 80-year-old female patient, with a previous diagnosis of hypertension and HFpEF, was hospitalized with dry cough, progressive dyspnea on exertion, New York Heart Association (NYHA) functional class III/IV, orthopnea and lower limb edema. She also reported moderate atypical chest pain and dysphagia for solids.</p><p id="par0015" class="elsevierStylePara elsevierViewall">On physical examination, blood pressure was 162/82 mmHg; heart rate was 88 bpm and respiratory rate was 27 ipm. Pathological jugular venous distention was present. The patient had a regular heart rhythm, with no murmurs; fine crackles in both lung bases and bilateral lower limb edema (++/4+).</p><p id="par0020" class="elsevierStylePara elsevierViewall">Complete right bundle branch block was observed on the electrocardiogram. Chest radiography showed cardiomegaly, mediastinal widening, and left pleural effusion that resolved with medical treatment. (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). Echocardiogram revealed left ventricular ejection fraction of 72%, increased LA, TAA diameter of 7.2 cm, moderate pericardial effusion with no signs of restriction, and left pleural effusion.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Twelve hours after admission she progressed with APE, which was controlled with medication. Seventy-two hours later she had atrial fibrillation without hemodynamic impairment. Clinical improvement occurred following drug treatment and she was discharged in NYHA class II.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Echocardiogram one week later showed giant TAA with left atrial compression, diastolic dysfunction and preserved left ventricular ejection fraction, without pericardial or pleural effusion. (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>)</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Chest angiography was performed and revealed a giant 8.3×7.7-cm TAA, which compressed the right pulmonary artery, the left and right atriums, the right ventricle and the esophagus, without any evidence of dissection (<a class="elsevierStyleCrossRefs" href="#fig0015">Figures 3 and 4</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Her clinical status significantly improved after administration of carvedilol, enalapril and furosemide. Correcting the TAA surgically was proposed; however, the patient and her family opted for conservative treatment.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">The ascending aorta measures about 5<span class="elsevierStyleHsp" style=""></span>cm in length and is connected to the right with the superior vena cava and right atrium; to the left with the pulmonary artery and posteriorly to the left atrium and the right pulmonary artery.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The compression of surrounding structures, particularly the LA, rarely causes hemodynamic effects.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The few reports of HF caused by TAA are mainly associated with aneurysms with dissection.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,3–5</span></a> TAA complications are related to the compression of neighboring structures or a dissecting aneurysm. A large ascending aortic aneurysm can compress vessels, leading to hypertension and pulmonary edema, as in this patient.</p><p id="par0055" class="elsevierStylePara elsevierViewall">HFpEF management has limitations related to comorbidities and the lack of strong evidence for specific treatment. It is reasonable to assume that AF triggered the HF decompensation.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In this case, it is important to note that there was no aneurysm dissection, clinical status stabilized and functional class improved with pharmacological treatment. Furthermore, it is worth highlighting that this is an unusual and unexpected cause of HF symptoms.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Aneurysm repair surgery was not performed due to a shared decision between the patient, her family and the physician, prioritizing the patient's quality of life.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1059618" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1008526" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1059619" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1008527" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-10-29" "fechaAceptado" => "2017-04-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1008526" "palabras" => array:4 [ 0 => "Thoracic aortic aneurysm" 1 => "Heart failure" 2 => "Pulmonary edema" 3 => "Left atrium" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec1008527" "palabras" => array:4 [ 0 => "Aneurisma da aorta torácica" 1 => "Insuficiência cardíaca" 2 => "Edema pulmonar" 3 => "Átrio esquerdo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patients with thoracic aortic aneurysm (TAA) are mostly asymptomatic and TAA is rarely related to heart failure (HF). We report the case of an 80-year-old female patient, with type A TAA without dissection, with right pulmonary artery and left atrium compression, who presented with HF, preserved ejection fraction and acute pulmonary edema.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Pacientes com aneurisma da aorta torácica (AAT) são geralmente assintomáticos e o AAT é raramente associado à insuficiência cardíaca (IC). Nós relatamos o caso de uma paciente feminina, 80 anos, com um AAT tipo A sem sinais de dissecção, que apresentou compressão do átrio esquerdo e da artéria pulmonar direita e desenvolvimento de IC com fração de ejeção preservada e edema agudo de pulmão.</p></span>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 673 "Ancho" => 1400 "Tamanyo" => 95871 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Chest radiography: (A) mediastinal enlargement and left pleural and pericardial effusion; (B) After medical treatment: thoracic aortic aneurysm.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 892 "Ancho" => 2334 "Tamanyo" => 163296 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Echocardiogram with Doppler</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">IVS: interventricular septum; LA: left atrium; LV: left ventricle; RV: right ventricle.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1189 "Ancho" => 1584 "Tamanyo" => 131875 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Chest computed tomography angiography with contrast.</p> <p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">DAo: descending thoracic aorta; LA: left atrium; PAT: pulmonary artery truncus; TAA: thoracic aortic aneurysm.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1189 "Ancho" => 1584 "Tamanyo" => 135215 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Venous computed tomography angiography of the chest.</p> <p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">DAo: descending thoracic aorta; PAT: pulmonary artery truncus; RPA: right pulmonary artery; SVC: superior vena cava; TAA: thoracic aortic aneurysm.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rare case of heart failure caused by compression of the left atrium by a thoracic aortic aneurysm" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "N.M. Gandhi" 1 => "M. Greaves" 2 => "N.H. Brooks" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Heart" "fecha" => "2004" "volumen" => "90" "paginaInicial" => "e9" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14729814" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary edema due to extreme left atrial compression" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. DeLuca" 1 => "S. Daniels" 2 => "N. Pathak" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "N Engl J Med." "fecha" => "1991" "volumen" => "88" "paginaInicial" => "37" "paginaFinal" => "38" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Images in cardiovascular medicine. An uncommon complication of nondissected ascending aortic aneurysm" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E. Antón" 1 => "M. Echeverría" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.104.483495" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2005" "volumen" => "112" "paginaInicial" => "e116" "paginaFinal" => "e117" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16129804" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "e4-6" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Left atrial compression by dissecting aneurysm of the ascending aorta" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Walpot" 1 => "B. Amsel" 2 => "W.H. Pasteuning" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "J Am Soc Echocardiogr." "fecha" => "2007" "volumen" => "10" "paginaInicial" => "1220" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Left atrial compression by thoracic aneurysm mimicking congestive heart failure" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M.K. Celenk" 1 => "O. Ozeke" 2 => "M.T. Selcuk" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1540-8175.2005.40083.x" "Revista" => array:6 [ "tituloSerie" => "Echocardiography" "fecha" => "2005" "volumen" => "22" "paginaInicial" => "677" "paginaFinal" => "678" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16174123" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003700000006/v3_201807150625/S2174204918302071/v3_201807150625/en/main.assets" "Apartado" => array:4 [ "identificador" => "9919" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003700000006/v3_201807150625/S2174204918302071/v3_201807150625/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204918302071?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 8 | 6 | 14 |
| 2024 October | 45 | 34 | 79 |
| 2024 September | 73 | 26 | 99 |
| 2024 August | 55 | 29 | 84 |
| 2024 July | 46 | 27 | 73 |
| 2024 June | 43 | 20 | 63 |
| 2024 May | 51 | 30 | 81 |
| 2024 April | 42 | 32 | 74 |
| 2024 March | 50 | 21 | 71 |
| 2024 February | 50 | 27 | 77 |
| 2024 January | 45 | 23 | 68 |
| 2023 December | 43 | 28 | 71 |
| 2023 November | 46 | 23 | 69 |
| 2023 October | 39 | 21 | 60 |
| 2023 September | 39 | 17 | 56 |
| 2023 August | 44 | 21 | 65 |
| 2023 July | 33 | 16 | 49 |
| 2023 June | 45 | 13 | 58 |
| 2023 May | 78 | 27 | 105 |
| 2023 April | 67 | 3 | 70 |
| 2023 March | 107 | 23 | 130 |
| 2023 February | 75 | 15 | 90 |
| 2023 January | 59 | 11 | 70 |
| 2022 December | 62 | 22 | 84 |
| 2022 November | 72 | 31 | 103 |
| 2022 October | 89 | 21 | 110 |
| 2022 September | 68 | 47 | 115 |
| 2022 August | 66 | 33 | 99 |
| 2022 July | 62 | 33 | 95 |
| 2022 June | 72 | 24 | 96 |
| 2022 May | 64 | 30 | 94 |
| 2022 April | 59 | 28 | 87 |
| 2022 March | 51 | 37 | 88 |
| 2022 February | 51 | 25 | 76 |
| 2022 January | 81 | 18 | 99 |
| 2021 December | 53 | 30 | 83 |
| 2021 November | 50 | 35 | 85 |
| 2021 October | 96 | 37 | 133 |
| 2021 September | 57 | 28 | 85 |
| 2021 August | 79 | 30 | 109 |
| 2021 July | 49 | 20 | 69 |
| 2021 June | 44 | 12 | 56 |
| 2021 May | 67 | 39 | 106 |
| 2021 April | 102 | 37 | 139 |
| 2021 March | 72 | 20 | 92 |
| 2021 February | 71 | 19 | 90 |
| 2021 January | 51 | 10 | 61 |
| 2020 December | 62 | 11 | 73 |
| 2020 November | 64 | 18 | 82 |
| 2020 October | 53 | 18 | 71 |
| 2020 September | 70 | 12 | 82 |
| 2020 August | 66 | 12 | 78 |
| 2020 July | 75 | 13 | 88 |
| 2020 June | 82 | 17 | 99 |
| 2020 May | 63 | 2 | 65 |
| 2020 April | 52 | 17 | 69 |
| 2020 March | 80 | 8 | 88 |
| 2020 February | 193 | 16 | 209 |
| 2020 January | 74 | 6 | 80 |
| 2019 December | 73 | 9 | 82 |
| 2019 November | 66 | 12 | 78 |
| 2019 October | 53 | 5 | 58 |
| 2019 September | 82 | 9 | 91 |
| 2019 August | 55 | 6 | 61 |
| 2019 July | 69 | 13 | 82 |
| 2019 June | 67 | 12 | 79 |
| 2019 May | 63 | 10 | 73 |
| 2019 April | 54 | 12 | 66 |
| 2019 March | 119 | 12 | 131 |
| 2019 February | 117 | 10 | 127 |
| 2019 January | 131 | 6 | 137 |
| 2018 December | 102 | 13 | 115 |
| 2018 November | 88 | 10 | 98 |
| 2018 October | 131 | 28 | 159 |
| 2018 September | 52 | 16 | 68 |
| 2018 August | 54 | 16 | 70 |
| 2018 July | 49 | 23 | 72 |
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