A case report: cardiac dysphagia — a ghost of the past?

Background Rheumatic heart disease has become rare in developed countries and physicians have grown unfamiliar with the disease and its clinical course. The mitral valve is most commonly affected leading to mitral regurgitation and/or stenosis. The chronic volume and/or pressure overload leads to atrial remodelling and enlargement, driving the development of atrial fibrillation and thromboembolic events. Case Summary A 87-year-old patient with a history of rheumatic mitral stenosis and mitral valve replacement was admitted to the neurology department for vertigo. A stroke was suspected and she underwent a transoesophageal echocardiogram which was complicated by dysphagia. Oesophageal manometry and CT revealed oesophagogastric junction outflow obstruction due to extrinsic compression by a giant left atrium. Discussion Dysphagia due to a giant left atrium is rare. Various diagnostic criteria exist and the prevalence thus depends on which criterium is used. It is mostly encountered in rheumatic mitral disease, although there are reports of non-rheumatic etiology. When the left atrium assumes giant proportions it can compress adjacent intrathoracic structures. Compression of the oesophagus can lead to dysphagia, as in our case. A transoesophageal echocardiogram in these cases is relatively contraindicated and should only be performed if there is considerable reason to believe that it may change patient management.