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(Circulation. 2005;111:e178-e179.)
© 2005 American Heart Association, Inc.

Images in Cardiovascular Medicine

Inverted Left Atrial Appendage Ligation Mimicking Thrombus

Monvadi B. Srichai, MD; Brian Griffin, MD; Michael Banbury, MD; Ellen Mayer Sabik, MD

From the Departments of Cardiovascular Medicine (M.B.S., B.G., E.M.S.) and Cardiothoracic Surgery (M.B.), Cleveland Clinic Foundation, Cleveland, Ohio.

Correspondence to Ellen Mayer Sabik, MD, Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F15, Cleveland, OH 44195. E-mail mayere{at}ccf.org

A 37-year-old man with a history of rheumatic heart disease who previously had undergone mitral and aortic valve replacement was referred to our institution for reoperation for paravalvular mitral regurgitation (MR). He presented with recurrent heart failure symptoms, and an outside transesophageal echocardiogram (TEE) demonstrated moderately severe paravalvular MR as well as a mobile mass attached to the limbus of the left atrium. The patient had been taking warfarin for the past 1 years since placement of the 2 mechanical valves. He otherwise had been well with no history of thromboembolic events or febrile illnesses. Clinical examination demonstrated moderate congestive heart failure with sinus tachycardia. Preoperative TEE demonstrated evidence of a mechanical bileaflet mitral valve prosthesis with paravalvular MR (Figure 1) and large, mobile masses located at the orifice of the left atrial appendage (LAA) (Figure 2). Although a presumptive diagnosis of left atrial thrombi was made on the basis of the location and anatomic features of the masses, the history of therapeutic anticoagulation, in addition to the presence of high-velocity flow into the LAA from the paravalvular MR jet, appeared discordant with the diagnosis. Intraoperatively, the patient was discovered to have an inverted LAA (Figure 3) from prior ligation, with no evidence of thrombus or vegetations within the left atrial cavity. The patient underwent repair of his mitral valve prosthesis and resection of the LAA tissue with an uneventful postoperative course.

View larger version (37K): [in this window] [in a new window]   Figure 1. Two-dimensional TEE images at midesophageal level, with transducer rotated to 77°, are shown at end-diastole (A), end-systole (B), and with color Doppler (C and D). Mechanical prosthesis is shown in mitral valve position, with small discontinuity between valve and annulus laterally, leading to paravalvular MR (arrows).

View larger version (28K): [in this window] [in a new window]   Figure 2. Two-dimensional TEE images at midesophageal level, with transducer rotated to 72°, at end-diastole (A) and end-systole (B), demonstrate mobile mass located near limbus of left atrium (arrows). Further rotation of transducer to 109° (C) reveals multiple masses in same area (arrows). Color Doppler echocardiography (D) demonstrates direction of high-flow paravalvular MR toward masses (arrow).

View larger version (94K): [in this window] [in a new window]   Figure 3. Intraoperative surgical view of left atrial cavity with inverted LAA.

	Footnotes

 
The online-only Data Supplement, which contains 4 movies, is available with this article at http://www.circulationaha.org.

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Circulation 2005 111: 1729. [Full Text]

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This Article Full Text (PDF) Data Supplement Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Srichai, M. B. Articles by Sabik, E. M. Search for Related Content PubMed PubMed Citation Articles by Srichai, M. B. Articles by Sabik, E. M. Related Collections Echocardiography CV surgery: valvular disease CV surgery: other Related Article