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British Heart Journal, 1971, 33, 799-802.

Dysphagia due to left atrial enlargement

after mitral Starr valve replacement
M. H. Chesshyre and M. V. Braimbridge
From the Department of Cardiothoracic Surgery, St. Thomas' Hospital, London S.E.s

A patient is described who developed dysphagia after a Starr mitral valve replacement. The onset
of dysphagia was associated with shift of the oesophagus from right to left, suggesting that this
position of the oesophagus may be important in the development of dysphagia due to enlarged
left atrium.

Dysphagia due to left atrial enlargement has she was found to have mitral stenosis, and a
become well recognized, but such dysphagia closed mitral valvotomy was performed. Initially
after mitral Starr valve replacement has not she was greatly improved, but her dyspnoea
previously been described. The patient de- gradually returned and by the time of admission
scribed here may throw light on the reason her effort intolerance was much increased and was
accompanied by orthopnoea, paroxysmal noc-
why these cases of enlarged left atrium develop turnal dyspnoea, and angina. On examination she
dysphagia, a complication that has been had the signs of mitral stenosis and incompetence
shown to be due not merely to the size of the - a moderately loud pansystolic murmur and an
left atrium. opening snap o-o8 sec after the second sound
followed by a long mitral diastolic murmur. The
electrocardiogram showed atrial fibrillation with
Case report a normal electrical axis and no evidence of
A woman of 6o developed increasing dyspnoea ventricular hypertrophy.
from the age of 35 until she was 44, at which time On the plain chest x-ray there was moderate
FIG. I (a) Preoperative penetrated posteroanterior chest x-ray showing moderate (Grade 2)
enlargement of the left atrium. (b) Postoperative x-ray showing that the left atrium has not
increased in size.
(a) (b)
goo Chesshyre and Braimbridge

(a) (b)
FIG . 2 (a) Barium swallow taken preoperatively showing displacement on the oesophagus
posteriorly and to the right, with no sign of obstruction. (b) Lateral view.

enlargement of the ventricular mass, pulmonary been carried out outside the pericardium. An
artery, and right atrium. The penetrated film oesophagoscopy was performed and pieces of
showed moderate enlargement of the left atrium solid food were removed, the oesophagus itself
(Fig. ia), and a barium swallow showed indenta- showing only slight inflammation of the mucous
tion of the oesophagus by the enlarged left atrium, membrane at the site of the obstruction. The
the oesophagus being displaced to the right of the chest x-ray showed no increase in the size of the
midline (Fig. 2a and b). At cardiac catheterization left atrium (Fig. ib). Her dysphagia was slightly
the pulmonary artery pressure was 50/35 mmHg improved and she was sent out for convalescence.
with a mean of 40 mmHg and a mean indirect left She quickly reverted to being unable to swallow
atrial pressure of 30 mmHg. At operation a at all, and six weeks later she was readmitted.
median sternotomy was performed with the Barium swallow now showed a definite stricture,
patient lying on her back; the clinical and x-ray which had not been present two months pre-
findings were confirmed and the mitral valve was viously, at the upper level of the segment com-
excised and replaced with a Starr prosthesis. pressed by the left atrium where the oesophagus
After operation she made a good recovery from was crossing the vertebral column (Fig. 3b). On
the cardiac point of view, but she had difficulty in tipping the patient, there was no evidence of
swallowing solids which appeared to stick at the gastro-oesophageal reflux.
level of the manubrium, but had no trouble with Attempts to dilate the stricture with mercury
liquids. She was being given oral slow release bougies were unsuccessful, and she required two
potassium, both slow K and Sandoz K 4 times a subsequent dilatations at oesophagoscopy before
day. On barium swallow the oesophagus was seen she could swallow. The cause of the stricture was
to be obstructed with a flattened, narrowed section not clear, but it had developed since operation
where the left atrium was pressing on it. The and was exactly at the point where the oesophagus
position of the oesophagus had changed it was
passed between the vertebral column and left
now displaced to the left of the midline (Fig. 3a), atrium. Biopsy showed squamous epithelium
in spite of the fact that no surgical manoeuvre had below the stricture.
Dysphagia due to left atrial enlargement after mitral Starr valve replacement 8oi

(a) (b)
FIG. 3 (a) Postoperative barium swallow showing obstruction due to pressure from the left
atrium. The oesophagus has moved to the left of the midline. (b) Two months later a stricture
has developed at the upper level of the segment compressed by the left atrium where the
oesophagus is crossing the vertebral column.

Discussion 15 cases of massive dilatation of the left

Despite the frequency of mitral valve disease auricle. In only 3 of them was the oesophagus
with enlarged left atrium, dysphagia is only displaced to the left and all 3 developed
rarely a complication. It is not simply a matter dysphagia. Of 20 published cases of dysphagia
of size, as in some cases of the largest left due to left atrial enlargement, the oesophagus
atria recorded dysphagia does not occur was displaced to the left in 6, to the right in 3,
(Tinney, Schmidt, and Smith, 1943). and in the other i i the position was not
There must therefore be other contributory stated (Table).
factors. Lee, Freeman, and Olson (I968) have
suggested the presence of cardiac failure as
one such factor, and in their case report, and TABLE 20 recorded cases of dysphagia due
several others of dysphagia due to left atrial to left atrial enlargement showing side to
enlargement, cardiac failure was present. which oesophagus was deviated
After it had been successfully treated medic-
ally, dysphagia disappeared (Dines and No. of cases
Anderson, I966; Parsonnet, Bernstein, and Left Right Not
Martland, I946; Tinney et al., I943; Bloom- stated
field, I940).
Lee and his co-workers considered atrial Bedford (I927) I'
Bishop and Babey (1936) I
fibrillation to be a contributory factor also, as Bloomfield (I940) I -
all the cases recorded have been in atrial Daley and Franks (I949) 3 - 2
fibrillation. Dines and Anderson (I966) - - 2
The position of the oesophagus may be a Lee et al. (I968) - - I
Le Roux and Williams (I969) - - I
factor in the development of dysphagia. Newton and Levine (1942) - I -
Usually an enlarged left atrium displaces the Nichols and Ostrum (1932) - 2
oesophagus posteriorly and to the right of the Parsonnet et al. (I946) - I
midline (Tinney et al., I943; Daley and Rosler and Weiss (I925) 2 -
Shaw (1924) - I
Franks, 1949), but occasionally it is deviated Tinney et al. (I943) - I
to the left. Daley and Franks (I949) recorded
802 Chesshyre and Braimbridge

In the patient described here the oesopha- Bloomfield, A. L. (I940). Dysphagia with disorders of
gus was initially to the right of the midline, the heart and great vessels. American J7ournal of the
Medical Sciences, 200, 289.
but when dysphagia developed after operation Daley, R., and Franks, R. (I949). Massive dilatation of
it was found to have become displaced to the the left auricle. Quarterly Journal of Medicine, i8,
left. There was no increase in the size of the 8i.
left atrium on chest x-ray examination, so it Dines, D. E., and Anderson, M. W. (I966). Giant left
can only be assumed that it was the change in atrium as a cause of dysphagia. Annals of Internal
position of the oesophagus which brought on Medicine, 65, 758.
Lee, R. V., Freeman, W. A., and Olson, R. J. (I968).
the dysphagia and the development of the Dysphagia associated with left atrial enlargement
stricture. The left is perhaps a less favourable and atrial fibrillation. Rocky Mountain Medical
side for the oesophagus as it becomes com- Journal, 65, no. 5 (May), p. 43.
pressed as it crosses between the aorta and the Le Roux, B. T., and Williams, M. A. (I969). Dysphagia
vertebral bodies, whereas on the right there megalatriensis. Thorax, 24, 603.
is more room for it to expand. Newton, F. C., and Levine, S. A. (I942). Decompres-
sion of the chest for dysphagia due to marked
This patient developed a benign stricture cardiac enlargement. Journal of Thoracic Surgery,
at the point where the oesophagus passed 12, 15I.
between the left atrium and vertebral column. Nichols, C. F., and Ostrum, H. W. (1932). Unusual
The oesophagus was lined with squamous dilatation of the left auricle. American Heart
epithelium throughout, which excluded a Journal, 8, 205.
Parsonnet, A. E., Bernstein, A., and Martland, H. S.
columnar lined oesophagus with reflux of (1946). Massive left auricle with special reference
gastric contents as the cause. Presumably the to its etiology and mechanism. American Heart
stricture was secondary to the irritation of Journal, 31, 438.
slow release potassium and food held up at Rosler, H., and Weiss, K. (I925). t'ber die Verander-
this point. ung des Osophagusverlaufes durch den ver-
grosserten linken Vorhog. Fortschritte auf dem
Gebiete der Rontgenstrahlen, 33, 717.
References Shaw, H. B. (1924). A case of horizontal dilatation of
Bedford, D. E. (1927). Extreme dilatation of the left the left auricle. Lancet, 2, 493.
auricle to the right. American Heart_Journal, 3, I27. Tinney, W. S., Schmidt, H. W., and Smith, H. L.
Bishop, L. F., and Babey, A. (1936). Massive left (1943). Dysphagia: the result of pressure from a
auricle. Journal of the American Medical Association, dilated left auricle. Proceedings of the Staff Meetings
Io6, 462. of the Mayo Clinic, I8, 476.