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Inverted Left Atrial Appendage Masquerading as a Left Atrial Mass Abstract

An inverted left atrial appendage after cardiac surgery is a rare finding and can be misinterpreted as a thrombus, mass, or vegetation. We report a case where intraoperative transesophageal echocardiography assisted in making an accurate diagnosis. Keywords: De‑airing, inverted left atrial appendage, left ventricular vent

Introduction It is uncommon to discover a new left atrial mass postheart surgery. In addition to the usual differentials such as thrombus, vegetation, or tumors such as myxoma, we report a case of inverted left atrial appendage (LAA) that masqueraded as a left atrium (LA) mass.

Case Report A 39‑year‑old female patient with severe calcific aortic stenosis was planned for aortic valve replacement. Transesophageal echocardiography (TEE) done intraoperatively showed severe aortic stenosis with a peak gradient of 74 mmHg and moderate aortic regurgitation. During the surgery, a left ventricular vent was placed through a right superior pulmonary vein to prevent distension of the left ventricle due to the moderate aortic regurgitation [Figure 1]. After aortic valve replacement was done and the heart was beating adequately, the

left ventricular vent was removed, following which a homogeneous hyperechogenic ovoid mass was seen in the LA on TEE [Figures 2 and 3]. The mass appeared to be attached to the anterolateral wall of the LA above the mitral annulus and prolapsed into the mitral valve. The surgeon was alerted about the suspected mass. The LA was externally inspected, and it was found that there was inversion of LAA. Digital manipulation and eversion of LAA were done by the surgeon after which the mass disappeared on TEE [Figure 4]. Patient was successfully weaned off bypass.

Suresh Kumaran, Gladdy George, AV Varsha, Raj Sahajanandan Department of Anaesthesia, Christian Medical College and Hospital, Vellore, Tamil Nadu, India

Discussion When a new LA mass is discovered intraoperatively on TEE, it is usually assumed to be a clot, tumor, or vegetation.[1] Inversion of the LAA after cardiac surgery is a rare finding. It can occur during weaning from cardiopulmonary bypass (CPB) while the heart is still empty. The likely cause is due to the negative pressure created by the left ventricular vent introduced during surgery. It is also possible that the appendage may

Address for correspondence: Dr. Suresh Kumaran, Department of Anaesthesia, Christian Medical College and Hospital, Vellore ‑ 632 004, Tamil Nadu, India. E‑mail: [email protected] com

Access this article online Website: www.annals.in Figure 1: Mid-esophageal two-chamber view showing left ventricular vent across the left atrium into the left ventricle This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact: [email protected]

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DOI: 10.4103/aca.ACA_192_16 PMID: *** Figure 2: Mid-esophageal four-chamber view showing left atrium mass abutting into the mitral valve

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How to cite this article: Kumaran S, George G, Varsha AV, Sahajanandan R. Inverted left atrial appendage masquerading as a left atrial mass. Ann Card Anaesth 2017;20:248-9.

© 2017 Annals of Cardiac Anaesthesia | Published by Wolters Kluwer - Medknow

Kumaran, et al.: Inverted left atrial appendage

Figure 3: Mid-esophageal long axis view showing the left atrium mass

invert during the de‑airing maneuvers.[2] On TEE, it can give a “crooked finger”[2] or tongue‑like appearance.[3] Apart from causing confusion in the diagnosis, it can cause mitral valve obstruction and impaired ventricular filling[4] and necrosis and rupture of the left atrial wall.[3,4] Inability to identify the mass as an inverted LAA can result in unnecessary return to CPB, surgical intervention, and additional ischemia time. The key to recognizing an inverted LAA is being aware of its existence, especially when it newly appears postsurgery and knowledge of its position which is located just superior to the mitral valve and inferior to the pulmonary veins.[3] It generally everts spontaneously once the heart is filled. Other methods to correct it are by Valsalva maneuver, digital manipulation, or pulling by forceps.[5] Rarely, LA appendage ligation might be required.[3] This case highlights the invaluable use of intraoperative TEE which enabled an inverted LAA to be identified immediate postsurgery which otherwise would have gone undetected causing confusion in diagnosis postoperatively and unnecessary resurgery.

Annals of Cardiac Anaesthesia | Volume 20 | Issue 2 | April-June 2017

Figure 4: Mid-esophageal long axis view after eversion of the left atrial appendage

Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

References 1. Allen BS, Ilbawi M, Hartz RS, Kumar S, Thoele D. Inverted left atrial appendage: An unrecognized cause of left atrial mass. J Thorac Cardiovasc Surg 1997;114:278‑80. 2. Bouzas‑Mosquera A, Alvarez‑García N, Cuenca‑Castillo JJ. Inverted left atrial appendage. Heart 2008;94:1064. 3. Leong MC, Latiff HA, Hew CC, Mazlan SL, Osman H. Inverted left atrial appendage masquerading as a cardiac mass. Echocardiography 2013;30:E33‑5. 4. Molaei A, Tabib A, Meraji M, Shemirani RH. Inverted left atrial appendage: A  cause of left ventricularinflow obstruction. Iran Cardiovasc Res J 2010;4:139‑41. 5. Chikwe J, Fischer GW, Adams DH. Inverted left atrial appendage. J Am Coll Cardiol 2009;54:e7.

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Inverted left atrial appendage masquerading as a left atrial mass.

An inverted left atrial appendage after cardiac surgery is a rare finding and can be misinterpreted as a thrombus, mass, or vegetation. We report a ca...
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