Biatrial enlargement: an unusual cause of massive cardiomegaly.

To cite: Sethi T, Singh AP, Singla V, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2012008320 DESCRIPTION A 50-year-old woman presented with complaints of progressive breathlessness and easy fatiguability over the past 2 years. Jugular venous pressure was raised with absence of a wave. Cardiac auscultation revealed two distinct mid-diastolic murmurs at the apex and a left lower sternal border with an ejection systolic murmur at the right second intercostal space. The ECG performed showed atrial fibrillation with a fast ventricular rate. Rate control was achieved with amiodarone infusion and intravenous diuretic therapy was instituted. Chest radiograph (figure 1) showed evidence of gross cardiomegaly (cardiothoracic ratio=0.8) with the left heart border touching the left lateral chest wall. Enlargement of the left atrium was evidenced by straightening of the left heart border, double density sign and splaying of the carina. Widening of the right heart border suggested right atrial enlargement. There was conspicuous absence of pulmonary congestion disproportionate to the severe symptomatic status. Aortic knuckle calcification was seen. A transthoracic echocardiogram (figures 2 and 3A–D) diagnosed the condition as chronic rheumatic heart disease with severe stenotic lesions of the mitral, tricuspid and aortic valves and mild regurgitation at the three valves. The left atrium measured 8.5 cm×5.8 cm in area while the right atrium measured 50.3 cm. Predominant biatrial enlargement can present as an unusual cause of massive cardiomegaly. Causes of biatrial enlargement include restrictive cardiomyopathy, rheumatic heart disease, isolated mitral insufficiency and constrictive pericarditis. 2 Clinicians and radiologists should consider this possibility while interpreting massive cardiomegaly on chest radiographs.