<![CDATA[Giant left atrium (GLA) is an uncommon but notable manifestation of advanced rheumatic heart disease (RHD), particularly in patients with longstanding rheumatic mitral stenosis. Extreme atrial remodeling may be associated with intracavitary blood stasis, pulmonary hypertension, and progressive right-sided cardiac involvement. A 50-year-old woman with congestive heart failure secondary to RHD presented with intermittent dyspnea, easy fatigability, and palpitations. Electrocardiography revealed atrial fibrillation (AF), and chest radiography demonstrated cardiomegaly with pulmonary vascular congestion. Echocardiography showed severe rheumatic mitral stenosis (MS) with mild mitral regurgitation and a Wilkins score of 9. The left atrium was markedly enlarged, measuring 7.0 cm, with a left atrial volume index (LAVI) of 239 mL/m² and spontaneous echo contrast without identifiable thrombus. Additional findings included mild aortic regurgitation, moderate tricuspid regurgitation, mild pulmonary regurgitation, a D-shaped left ventricle during systole and diastole, isolated post-capillary pulmonary hypertension, and reduced right ventricular systolic function despite preserved left ventricular systolic function. This case demonstrated the progression of chronic rheumatic mitral obstruction from sustained left atrial pressure overload to extreme atrial remodeling, blood stasis, pulmonary hypertension, and right ventricular involvement. Preserved left ventricular systolic function may coexist with substantial advanced hemodynamic impairment. Mitral valve replacement with left atrial reduction and left atrial appendage occlusion was recommended. This case highlights the central role of comprehensive echocardiography in identifying the structural, hemodynamic, and thromboembolic consequences of severe rheumatic MS with GLA. Echocardiography provided essential information for individualized therapeutic decision-making.]]>
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