Dysphagia Megalatriensis From Massive Left Atrial Enlargement

Dysphagia megalatriensis, or esophageal compression from a dilated left atrium, is rare and often mistaken for primary esophageal disease. Recognition is crucial, as definitive therapy targets cardiac pathology.

A 63-year-old man with heart failure with reduced ejection fraction, implantable cardioverter-defibrillator placement, and left ventricular thrombus on apixaban presented with progressive dysphagia and weight loss. Given prior esophageal stricture, a barium swallow showed midesophageal narrowing. Upper endoscopy showed extrinsic compression, chest computed tomography showed left atrial enlargement causing esophageal impingement, and echocardiography showed an ejection fraction of 17% with severe left ventricular dilatation, severe mitral and tricuspid regurgitation, and severe pulmonary hypertension.

Given end-stage biventricular dysfunction, severe valvular disease, and prohibitive surgical risk, the patient was not a candidate for valvular intervention. Management focused on heart failure optimization, dietary modification, and supportive multidisciplinary care.

Early recognition prevents unnecessary interventions and shifts focus to supportive strategies in advanced, nonsurgical patients.