Giant left atrium associated with mitral valve prolapse.

Valve Prolapse To the Editor: I thoroughly enjoyed Hurst’s dissertation on the etiology of a giant left atrium1 and concurred that a giant left atrium seldom results from severe mitral regurgitation due to a nonrheumatic cause such as mitral valve prolapse. Although I would never dare to challenge Dr Hurst on anything he said or wrote, because I consider him not only as the master clinician of the century but also as my mentor, I thought it might be of interest to point out that there were 2 cases reported in the literature of a giant left atrium associated with mitral valve prolapse.2,3 The presentation in both cases was the Ortner syndrome. Ortner4 in 1897 described 2 patients with mitral stenosis and hoarseness of voice. Although he attributed the hoarseness to paralysis of the left vocal cord due to compression of the left recurrent laryngeal nerve between the enlarged left atrium and the arch of the aorta, his explanation has been questioned by subsequent workers. According to a literature review, Sengupta et al5 concluded that the etiology of left recurrent laryngeal nerve paralysis was compression of the nerve between the enlarged tense left pulmonary artery and the aorta at the ligamentum arteriosum. That is the reason why Ortner syndrome may also occur in primary pulmonary hypertension, Eisenmenger syndrome due to atrial septal defect where the left atrium is not enlarged, and even aortic aneurysms with encroachment of aorticopulmonary window and resultant compression of the left recurrent laryngeal nerve.5 Finally, I wish to echo Hurst’s teaching that a giant left atrium is more commonly associated with mitral regurgitation than mitral stenosis and rheumatic than nonrheumatic cause of mitral regurgitation. However, like everything in medicine, there may always be exceptions. That is the reason why rare cases of a giant left atrium due to nonrheumatic etiology became the subject of case reports in the medical literature.2,3