Giant left atrium: look before you leap into invasive procedures

Description 

A 67-year-old woman with history of mechanical mitral valve replacement for severe rheumatic mitral stenosis and permanent atrial fibrillation on warfarin presented with worsening dyspnoea and bilateral lower extremity swelling over the past 3 weeks. Physical examination revealed hypoxaemia with an oxygen saturation of 85% on room air, jugular venous distension, absent breath sound at right middle and lower lung zones, a crisp prosthetic valve click with a grade 1/6 holosystolic murmur at the apex and 2+ lower extremity oedema. Laboratory showed a brain natriuretic peptide of 799 pg/mL and an international normalized ratio of 2.7. A venous blood gas revealed respiratory acidosis with PaCO₂ of 75 mm Hg. Chest X-ray (CXR) revealed cardiomegaly and complete opacification of right mid-to-lower lung zones (figure 1). Concerned for massive right-sided pleural effusion or right thoracic mass, a CT of the chest (figure 2) was performed, which showed massive left atrial...

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