Inverted Left Atrial Appendage Ligation Mimicking Thrombus
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 1½ 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.
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