“Coconut" Atrium: A case report and review of the literature

  • J A Okeniyi Obafemi Awolowo University http://orcid.org/0000-0001-9492-5263
  • A J Bonde Krishna Institute of Medical Sciences Hospital
  • G Vejendla Krishna Institute of Medical Sciences Hospital
  • C S Matcha Krishna Institute of Medical Sciences Hospital
Keywords: Atrium of stone, Coconut heart, Dystrophic cardiac calcification, Left atrial calcification, Porcelain atrium, Porcelain heart, Stone heart


“Coconut atrium” or complete dystrophic left atrial wall calcification is rare and occurs almost exclusively in the middle-aged and the elderly, often following chronic conditions such as rheumatic heart disease, end-stage renal disease and tuberculosis. Hyperparathyroidism, lipid storage disease and use of xenografts are known causes of incomplete intra-cardiac dystrophic calcification in older children. The present report describes a rare case of cardiac calcification demonstrated by Trans-thoracic 2-D Echocardiography in a two-year old Indian boy who presented at a private hospital in Hyderabad, India with breathlessness. Unfortunately, his parents declined further extensive investigations and treatment, but this case was instructive due to the rarity of complete dystrophic left atrial wall calcification, the exclusion of the common known aetiologies and the extremely young age of the patient.

Author Biographies

J A Okeniyi, Obafemi Awolowo University
Department of Paediatrics and Child Health, Reader.
A J Bonde, Krishna Institute of Medical Sciences Hospital
Paediatrics and Consultant Paediatrician
G Vejendla, Krishna Institute of Medical Sciences Hospital
Paediatrics and Consultant Paediatric Cardiologist
C S Matcha, Krishna Institute of Medical Sciences Hospital
Cardiology and Echocardiographer


1. Anandan PK, Shukkarbhai PJ, Bhatt P, Manjunath CN. Coconut atrium. Eur Heart J Cardiovasc Imaging 2015; 16 (7): 814.

2. Onishi T, Idei Y, Otsui K, Iwata S, Suzuki A, Ozawa T, et al. Coconut atrium in long-standing rheumatic valvular heart disease. Am J Case Rep 2015; 16: 191 – 95.

3. Choi EK, Ro JY, Ayala AG. Calcified amorphous tumor of the heart: case report and review of the literature. Methodist Debakey Cardiovasc J 2014; 10 (1): 38 – 40.

4. Jones C, Lodhi AM, Cao LB, Chagarlamudi AK, Movahed A. Atrium of stone: A case of confined left atrial calcification without hemodynamic compromise. World J Clin Cases 2014; 2 (5): 142 –45.

5. Germino J, Pipavath SN. Severe left atrium calcification (heart within a heart). J Thorac Cardiovasc Surg 2014; 148 (2): 733 – 34.

6. Leacock K, Duerinckx AJ, Davis B. Porcelain atrium: a case report with literature review. Case Rep Radiol 2011; 2011: 501396.

7. Lee WJ, Son CW, Yoon JC, Jo HS, Son JW, Park KH, et al. Massive left atrial calcification associated with mitral valve replacement. J Cardiovasc Ultrasound 2010; 18 (4): 151 –3.

8. Meyners W, Peters S. A coconut left atrium 23 years after mitral valve replacement for chronic mitral stenosis. Z Kardiol 2003; 92 (1): 82 – 3.

9. Del Campo C, Weinstein P, Kunnelis C, DiStefano P, Ebers GM. Coconut atrium: transmural calcification of the entire left atrium. Tex Heart Inst J 2000; 27 (1): 49 – 51.

10. Vijayvergiya R, Jeevan H, Grover A. Left atrial calcification in rheumatic heart disease: a rare presentation. Heart 2006; 92 (9): 1218.

11. Tsumaru S, Minakata K, Yamazaki K, Nakamura M, Sakaguchi H, Sakata R. Redo mitral valve replacement in patient with "coconut atrium". Ann Thorac Surg 2015; 99 (4): 1454.

12. Dattilo G, Anfuso C, Casale M, Giugno V, Camarda L, Laganà N, et al. Calcific left atrium: A rare consequence of endocarditis. World J Cardiol 2014; 6 (9): 1038 –40.

13. Jenkins NP, Brooks NH, Greaves M. Coconut atrium following thoracic radiotherapy. Heart 2004; 90 (12): 1376.

14. Catellier MJ, Chua GT, Youmans G, Waller BF. Calcific Deposits in the Heart. Clin Cardiol 1990; 13 (4): 287-94.

15. Ananthakrishna R, Moorthy N. Dystrophic myocardial calcification. Indian Heart J 2016; 68: s180 – s181.

16. Thandroyen FT, Whitton IN, Pirie D, Rogers MA, Mitha AS. Severe calcification of glutaraldehyde-preserved porcine xenografts in children. Am J Cardiol 1980; 45 (3): 690 – 96.

17. Shah S, Misri A, Bhat M, Maheshwari S. Gaucher’s disease type III C: Unusual cause of intracardiac calcification. Ann PediatrCardiol 2008; 1(2): 144 –46.

18. Civilibal M, Caliskan S, Adaletli I, Oflaz H, Sever L, Candan C, et al. Coronary artery calcifications in children with end-stage renal disease. Pediatr Nephrol 2006; 21: 1426-33.

19. Perkins KW, McInnes IWS, Blackburn CRB, Beal RW. Idiopathic haemochromatosis in children: Report of a family. Am J Med 1965; 39 (1): 118–26.

20. Ávila-Vanzzini N, Trevethan-Cravioto S, Lopez-Mora E, Herrera-Bello H, Soto-Abraham V, Martínez-Rios MA. Heart calcification (idiopathic cardiac osseous metaplasia): A case report. Arch Cardiol Mex 2014; 84: 140– 42.

21. Daniel Gräfe. Ped(z): Pediatric calculator©. 2008 - 2017. https://www.pedz.de/en/welcome.html

22. Ekery DL, Davidoff R. Aortic regurgitation: quantitative methods by echocardiography. Echocardiography 2000; 17(3): 293 – 302.

23. Gowda RM, Boxt LM. Calcifications of the heart. Radiol Clin N Am 2004; 42: 603–17.

24. Harthorne JW, Seltzer RA, Austen WG. Left atrial calcification. Review of literature and proposed management. Circulation 1966; 34 (2): 198–210.

25. Reddy D, Madansein R. Cracking the coconut: extensive calcification of the left atrium. Ann Thorac Surg 2013; 96 (6): 2249.

26. Vallejo JL, Merino C, González-Santos JM, Bastida E, Albertos J, Riesgo MJ, et al. Massive calcification of the left atrium: surgical implications. Ann Thorac Surg 1995; 60 (5): 1226– 29.

27. Akita M, Urashima K, Hagiwara S, Inamura J. An unusual ectopic calcification in the left atrium. Eur J Cardiothorac Surg 2012; 41 (2): 450.

28. Jørgensen M, Gill S, Thomassen A, Søndergaard EV, Diederichsen LP, Diederichsen AC. Coconut atrium: an exotic source of cardiac emboli. Int J Cardiol 2014; 177 (3): e97 – e98.

29. Warren BA, Yong JL. Calcification of the aortic valve: its progression and grading. Pathology 1997; 29 (4): 360 – 68.

30. Warc C. Clinical significance of the bicuspid aortic valve. Heart 2000; 83: 81–5.