Coconut left atrium: A curious case report
A 60 year old gentleman presented with history of dyspnea on effort of 20 years duration. He had atrial fibrillation with fast ventricular rate and in NYHA Class III on presentation. The first heart sound was variable followed by loud pulmonary component of the second heart sound. A pansystolic murmur was noted at the apex radiating posteriorly along with the characteristic diastolic murmur of mitral stenosis in the left lateral position.

Chest skiagram showed a peculiar type of calcification resembling a ' COCONUT ′ in postero-anterior view and lateral skiagram showing C-shaped calcification of the left atrium. The same was confirmed by non-contrast CT scan. Physicians proceeded with an echocardiogram which confirmed the findings (calcific mitral valve with significant mitral stenosis, mitral regurgitation and moderate pulmonary hypertension). The patient was stabilized medically and later successfully underwent mitral valve replacement with endoatrioectomy.

3 patterns of left atrial calcification have been described in literature till now: Type A - Confined to left atrial appendage; Type B - Limited to free wall of left atrium and mitral valve; and Type C - Confined to posterior wall of left atrium in the area of McCallum's patch.
The major challenges from a surgical point of view are (1) the ideal approach to the mitral valve, (2) post-operative hemostasis, and (3) potential risk for systemic embolization.

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