Massive left atrial wall calcification, or porcelain atrium, is very rare. We describe a case of an unusual pattern of cardiac calcification demonstrated on routine preoperative chest X-ray for cataract surgery in a 71-year-old Nigerian woman. Past medical history was significant for mitral stenosis and atrial fibrillation. Radiographic imaging revealed curvilinear high density areas of calcification outlining the left atrium on the chest X-ray. Noncontrast CT scan of the thorax confirmed the left atrial distribution of calcification and, thus, the diagnosis of porcelain left atrium.
Massive calcification of the left atrial walls, also known as a porcelain atrium, is a rare condition. Though without immediate clinical sequela, its existence yields important implications in the setting of mitral valve surgery [
A 71-year-old Nigerian female, with past medical history of rheumatic valvular disease with mitral stenosis, and atrial fibrillation, presented for routine preoperative chest X-ray for cataract surgery. The patient was asymptomatic, and otherwise in reasonably good health. A recent echocardiogram confirmed severe left atrial and left ventricular enlargement; the mitral valve area was found to be 0.7 cm2 (normal 3-4 cm2), consistent with mitral valve stenosis. Incidental findings on the chest X-ray revealed an unusual pattern of curvilinear cardiac calcification (Figures
A 71-year-old woman with known mitral stenosis and atrial fibrillation underwent routine preoperative screening for cataract surgery. The chest X-ray showed curvilinear dense calcifications on both the frontal ((a), arrows) and lateral ((b), arrows) views. A follow up noncontrast CT of the chest better localized these calcifications on axial images ((c), (d), white arrows), coronal image (e) and sagittal image (f), as being in the wall of the left atrium. The interatrial septum ((c), black thin arrow) and mitral valve annulus ((d), thin black arrow) were not calcified. The coronal (e) and sagittal (f) images show a pattern of calcification very similar to the one seen on the frontal (a) and lateral (b) chest X-rays. Incidental right pleural effusion and liver cysts were also shown.
Cardiac and pericardial calcifications have been well described in the literature. Left atrial calcifications are a less commonly encountered subset of these. Calcifications of the left atrium can involve the left atrial appendage, left atrial free wall, or mitral valve apparatus, and in more severe cases it may involve all three sites [
Calcification of the left atrium has a predilection for females with an age range of late 50’s to early 60’s. Review of the literature revealed that almost all of the patients with left atrial calcification were found to be in chronic atrial fibrillation, and the interatrial septum was uninvolved, as seen with our patient. In addition, these patients are usually found to have undergone at least one previous operation [
Various imaging techniques may be used to aid in the diagnosis of a porcelain atrium. Chest X-ray imaging demonstrates mural calcifications that appear as a thin curvilinear density tracing the outline of the left atrium in part or completely [
Calcification of the left atrial wall or appendage or both constitutes a major complication and risk to mitral valve surgery due to difficulty in entering the left atrium, potential embolization, and impaired hemostasis [
Two specific imaging findings need to be taken into account prior to any surgery, as they may be contraindicatory to proceed with surgery. First, the presence of a coconut atrium (calcified interatrial wall) will significantly complicate surgery and increase mortality [
Porcelain atrium is a rare entity. Familiarity with the radiographic features of this unique distribution of calcium, in the correct clinical setting, will allow prompt recognition when interpreting chest X-rays and CT images. Mitral valvular calcification is commonly associated, as well as a history of rheumatic heart disease. Calcification of the interatrial septum and/or caseous necrosis of the mitral annulus could be potential contraindications for mitral valve surgery. Neither was present in our patient.