Porcelain left atrium, from stone to function - a surgical challenge

Long-standing rheumatic heart disease (RHD) remains the most common cause of mitral stenosis (MS) in developing countries, leading to chronic pressure overload, left atrial (LA) dilation, and a predisposition to thrombus formation due to blood stasis; in rare cases, the LA wall undergoes extensive calcification, a condition known as "porcelain left atrium" (PLA), which further complicates surgical intervention. Presenting a case of a 49-year-old, emaciated, 30-kg female, who presented with severe dyspnea of New York Heart Association (NYHA) class IV. Massively dilated LA with extensive calcification was noticed in the chest x-ray, and echocardiography revealed a 65-mm LA filled with a large thrombus, severe MS, thickened and calcified mitral leaflets, and moderate tricuspid regurgitation (TR). Intraoperatively, a large thrombus was found in the LA in various stages of organisation, with the outermost layer calcified and adherent to the LA wall. The thrombus was meticulously removed, and mitral valve replacement (MVR) was performed using a 29-mm TTK Chitra monoleaflet mechanical prosthetic valve. She was discharged on the seventh postoperative day following an uneventful course. This case emphasises the rare but significant surgical difficulties associated with extensive LA calcification. It highlights the need for prudent preoperative assessment, meticulous surgical technique, and individualised management for better patient outcomes.