Dysphagia Megalatriensis From Massive Left Atrial Enlargement

BACKGROUND: 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. CASE SUMMARY: 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. DISCUSSION: 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. TAKE-HOME MESSAGE: Early recognition prevents unnecessary interventions and shifts focus to supportive strategies in advanced, nonsurgical patients.