Decapitate or Strangulate?
A 79-year-old woman with paroxysmal atrial fibrillation and severe mitral regurgitation underwent a mitral valve plasty and suture ligation of the left atrial appendage. Because of the patient's refractoriness to antiarrhythmic drugs, a transcutaneous pulmonary vein isolation was scheduled 17 months after the initial surgery. During the selective angiography (Figure 1) of the right superior pulmonary vein a saccular structure was surprisingly visualized, anteriorly and superiorly located to the mitral ring, corresponding to the previously presumed excluded left atrial appendage. A computed tomography scan, performed 2 days before ablation, also revealed that the left atrial appendage was not excluded (Figure 2). An incomplete exclusion of the left atrial appendage could correspond to a proembolic status, and can be documented by transesophageal echocardiography. Fortunately, oral anticoagulation has never been interrupted in our patient, and no thromboembolic complications have occurred. Different epicardial, endocardial, and combined epicardial-endocardial methods are currently being clinically investigated to close the left atrial appendage to ensure a true closure or excision of the left atrial appendage.
- © 2011 American Heart Association, Inc.