Progressive Giant Left Atrium After Valve Surgery With Preserved Hemodynamics

Background: Giant left atrium (GLA) is a rare complication of rheumatic heart disease that may continue to enlarge despite successful valve surgery. Case Summary: A 69-year-old man with rheumatic valvular disease and previous mechanical mitral and aortic valve replacement developed progressive GLA and heart failure symptoms. Redo aortic valve replacement was performed for prosthetic dysfunction. Long-term follow-up demonstrated progressive atrial enlargement (indexed left atrial volume up to 1,172 mL/m2), mediastinal displacement, and pulmonary compression. Despite these findings, right heart catheterization confirmed normal pulmonary artery and filling pressures, with preserved left ventricular ejection fraction and sustained clinical stability. Discussion: GLA is typically associated with pulmonary hypertension and heart failure progression. This case is notable for extreme progressive atrial remodeling over 2 decades despite correction of the underlying valve disease, while preserving pulmonary hemodynamics and ventricular function. Take-Home Messages: Progressive GLA may remain compatible with prolonged survival after successful valve surgery when ventricular function and pulmonary hemodynamics are preserved. Long-term multimodality imaging and invasive hemodynamic assessment are essential for patient management.