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[page 70]                                                             [Emergency Care Journal 2023; 19:11431]

                             Emergency Care Journal 2023; volume 19:11431

Question
Why was the plan for chest drain insertion cancelled?
A. The right sided pleural effusion is too small.
B. There is an aortic aneurysm.
C. There is a giant left atrium.
D. There is a diaphragmatic hernia.

A simple pleural effusion or not? 
Victoria Wen Yeng Teoh, Mohd Adli Deraman, Alexander Loch

Department of Cardiology, University Malaya Medical Centre, Kuala Lumpur, Malaysia 

Correspondence: Alexander Loch, Department of Cardiology,
University Malaya Medical Centre, 59100 Kuala Lumpur, Malaysia.
Tel.: +603.7949 4422 - Fax: +603-7956 2253. 
E-mail: alexander.loch@ummc.edu.my 

Key words: echocardiography, clinical competence, heart valve
prosthesis.

Conflict of interest: the authors declare no potential conflict of inter-
est and they confirm accuracy.

Ethical approval: the institution does not require ethical approval for
reporting individual cases provided the cases are sufficiently
anonymized.

Informed consent: written informed consent was obtained from the
patient for the anonymized information to be published in this article.

Availability of data and materials: all data generated or analyzed
during this study are included in this published article.

Received for publication: 24 April 2023.
Accepted for publication: 29 May 2023.

This work is licensed under a Creative Commons Attribution 4.0
License (by-nc 4.0).

©Copyright: the Author(s), 2023
Licensee PAGEPress, Italy
Emergency Care Journal 2023; 19:11431
doi:10.4081/ecj.2023.11431

Publisher's note: all claims expressed in this article are solely those of
the authors and do not necessarily represent those of their affiliated
organizations, or those of the publisher, the editors and the reviewers.
Any product that may be evaluated in this article or claim that may be
made by its manufacturer is not guaranteed or endorsed by the publisher.

Figure 1. A 60-year-old man presented with a 2-week history of
progressive dyspnea and bilateral leg edema. He had undergone a
prosthetic mitral valve replacement 9 years earlier. The patient was
in respiratory distress (respiratory rate 32/min, oxygen saturation
86% on air, heart rate 124/min, blood pressure 109/56 mmHg).
Examination revealed bilateral lung crackles and reduced air entry
with dullness to percussion and elevated jugular venous pressure.
The electrocardiogram showed sinus tachycardia. A chest X-ray
(CXR) (Figure 1) and bedside lung ultrasonography were per-
formed (Figure 2A). A diagnosis of a large pleural effusion was
made and urgent thoracocentesis was considered in view of the
patient’s respiratory distress. A repeat ultrasonographic scan with
adjusted angulation to identify the most suitable entry point for the
chest drain (Figure 2B) yielded new results that led to the cancel-
lation of the thoracocentesis. 

Figure 2. Bedside lung ultrasonography.

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Answer: C
The CXR suggested the presence of large pleural effusion. The

image quality is poor with regard to semi-erect positioning. Sternal
wires and a ball-in-cage mitral prosthesis are present. Lung ultra-
sound (Figure 2A) was initially suggestive of a right-sided pleural
effusion. Only repeated ultrasound scanning prior to the planned
thoracocentesis revealed a well-delineated structure within the tho-
racic cavity with color Doppler flow signals (Figure 2B and 3A).
The features were indicative of a vascular structure, actually a
giant left atrium. 

A giant left atrium is defined as one that touches the right lat-
eral side of the chest wall on a CXR.1,2 It is a rare condition with a
reported incidence of 0.3%. It is commonly associated with rheu-
matic mitral valve disease,1 mitral valve prolapse,3 hypertrophic
cardiomyopathy4 and cardiac amyloidosis.5 It can mimic mediasti-
nal tumors and pleural effusions.6 It has been described in both
adult and pediatric populations.7 Thrombus formation within and
embolism are significant complications.8 Left atrial volume reduc-
tion surgery can be performed particularly in the context of com-
pressive symptoms.9 The condition is often accompanied by atrial
fibrillation.10 Prior to thoracocentesis, it is always necessary to
observe with color Doppler the blood flow within suspicious vas-
cular structures in multiple imaging planes to identify an aneurysm
or an enlarged cardiac chamber. 

A Computed Tomography Pulmonary Angiography (CTPA;
Figure 3B) and formal echocardiography (Figure 3 C-D) con-
firmed an extremely enlarged left atrium with an anteroposterior
diameter of 10.5 cm in the parasternal long axis view and a diam-
eter of 15.4 cm from the atrioventricular plane to the roof of the
atrium. The estimated left atrial volume was 890 mL. The left ven-
tricular ejection fraction was 52%. 

The learning point is that ultrasonographic appearance of a
fluid collection within the chest could represent a vascular struc-
ture. Multi-plane color doppler imaging is essential to avoid cata-
strophic iatrogenic injury.

References
1. El Maghraby A, Hajar R. Giant left atrium: a review. Heart

Views 2012;13:46-52.
2. Tung R, DeSanctis R. Images in clinical medicine. Giant left

atrium. N Engl J Med 2004;351:1437.
3. Loch A, Sadiq MA, Wan Ahmad WA. Giant left atrium in a

patient with prosthetic mitral valve. Eur Heart J 2013;34:981.
4. Yuksel UC, Kursaklioglu H, Celik T. Apical hypertrophic car-

diomyopathy with giant left atrium. Arq Bras Cardiol
2007;88:e47.

5. Cheng Z, Fang Q, Liu Y. Cardiac amyloidosis with giant atria.
Heart. 2010;96:1820.

6. Rimon D, Cohen L, Rosenfeld J. Thrombosed giant left atrium
mimicking a mediastinal tumor. Chest 1977;71:406-8.

7. Li D, Bai Z, An Q, Lin K. Giant left atrium in a 9-year-old
child. Int J Cardiol 2015;197:167-9.

8. Schvartzman PR, White RD. Giant left atrium. Circulation.
2001;104:E28-9.

9. Apostolakis E, Shuhaiber JH. The surgical management of
giant left atrium. Eur J Cardiothorac Surg 2008;33:182-9014.

10. Owen I, Fenton WJ. A case of extreme dilatation of the left
auricle of the heart. Transactions of the Clinical Society of
London. 1901;34:183-91.

                                                                                                 Images In Emergency

                                                                         [Emergency Care Journal 2023; 19:11431]                                                        [page 71]

Figure 3. Giant left atrium. (A) lung ultrasound with color
Doppler. (B) CTPA. * - prosthetic mitral valve; # - pleural effusion.
(C-D) echocardiography.

Online supplementary materials
Video 1. Supplementary digital contents.

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