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INTERESTING IMAGE  
Year : 2011  |  Volume : 14  |  Issue : 2  |  Page : 150-151
Left juxtaposed atrial appendages in a patient with dextrocardia and tricuspid atresia: TEE images


1 Department of Cardiac Anaesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
2 Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

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Date of Web Publication25-May-2011
 

How to cite this article:
Nath MP, Makhija N, Kiran U, Dhawan N, Velayoudam D. Left juxtaposed atrial appendages in a patient with dextrocardia and tricuspid atresia: TEE images. Ann Card Anaesth 2011;14:150-1

How to cite this URL:
Nath MP, Makhija N, Kiran U, Dhawan N, Velayoudam D. Left juxtaposed atrial appendages in a patient with dextrocardia and tricuspid atresia: TEE images. Ann Card Anaesth [serial online] 2011 [cited 2019 Jul 22];14:150-1. Available from: http://www.annals.in/text.asp?2011/14/2/150/81572


A 1½-year-old boy with the diagnosis of cyanotic congenital heart disease, dextrocardia, and tricuspid atresia was scheduled for bidirectional Glenn procedure. Preoperative two-dimensional transthoracic echocardiography (TTE) demonstrated tricuspid atresia with a single atrial septal defect and multiple ventricular septal defects. The right ventricle was small. There was subvalvular and valvular pulmonary stenosis with a gradient of 60 mm of Hg. The pulmonary arteries were adequate and confluent. Cardiac catheterization confirmed the echocardiography findings. Left ventriculography suggested normal left ventricular function. Aorta and pulmonary arteries were filled from the same injection. Aorta was anterior to the pulmonary artery. Aortic root angiography revealed normal coronaries and one large major aortopulmonary collateral.

Bidirectional Glenn procedure was performed through median sternotomy on cardiopulmonary bypass. Peroperatively, there was dextrocardia with both left and right atrial appendages juxtaposed on the left side with distinct morphological characteristics [Figure 1]. The aorta was arising anterior to the pulmonary artery. Transesophageal echocardiography (TEE) revealed both atrial appendages on the left side [Figure 2]. Right atrial appendage was confirmed by pushing fluid through the central venous catheter placed in the right internal jugular vein [Figure 3]. Postoperatively, patient remained on mechanical ventilation for 8 hours in the intensive care unit, shifted to ward on third postoperative day (POD), and discharged on sixth POD.
Figure 1: Intraoperative photograph showing right atrial appendage (RAA) juxtaposed on the left. LAA - left atrial appendage, RV - right ventricle

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Figure 2: Transesophageal four-chamber view with both left and right atrial appendages on the left side. RA - right atrium, RV - right ventricle, LV - left ventricle, RAA - right atrial appendage, LAA - left atrial appendage

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Figure 3: Transesophageal four-chamber view. Right atrial appendage (RAA) confirmed by presence of fluid pushed through right internal jugular vein. LAA - left atrial appendage, RA - right atrium, LV - Left ventricle

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Developmentally, juxtaposed atrial appendages (JAA) is a consequence of ectopic origin of the atrial appendage rudiment, and is a marker for the presence of cyanotic congenital heart disease. [1] Left juxtaposition is more frequently seen and associated with more morbid anatomy than right juxtaposition. [2] Left-sided JAA is more common than right-sided JAA by a ratio of 6 : 1 to 8 : 1. [3] Left JAA is most commonly associated with transposition of great vessels, and these patients are likely to have coexistent right ventricular inflow stenosis or atresia. [2] However, association of JAA with isolated tricuspid atresia and dextrocardia is uncommon. Other common associated anomalies include ventricular septal defect (88%), atrial septal defect (78%), bilateral conus (77%), small or absent right ventricle (71%), and pulmonary or aortic outflow obstruction (52%, 38%). [3]

The importance of diagnosis of this malformation in the preintervention period is to avoid mistaking the orifice of the right atrial appendage for an atrial septal defect during surgery or in the patent foramen ovale during balloon atrial septostomy. It also helps in preoperative planning in Senning, Mustard, or Fontan procedures. [4]

The diagnostic TTE feature of a left juxtaposed right atrial appendage is the alteration of the plane of the interatrial septum on a high parasternal short-axis view. [4] The diagnosis of JAA can be made by angiocardiography, but only when special emphasis is placed on identifying this anomaly. [5]

Recognition of juxtaposition with TTE can be difficult in older children or patients with poor acoustic windows. TEE is the considered technique of choice for identifying this anomaly. TEE features of left juxtaposition of atrial appendage include right lateral deviation of the inferior and posterior portion of the atrial septum, a more frontal orientation of anterosuperior part of atrial septum forming the floor and the posterior wall of the junction of right-sided atrial appendage with the venous component of the atrial cavity. The two atrial appendages, each with its own morphology, are visualized on the same side either in superior-inferior positions or side to side. The association of ostium secundum type septal defect may be difficult to recognize. When scanning on transesophageal four-chamber view, characteristically, there is malorientation of the atrial septum. The abnormal orientation of the atrial septum may give false impression of an atrial septal defect at the junction of atrial appendage with the venous cavity. [6]

 
   References Top

1.Melhuish BP, Van Praagh R. Juxtaposition of the atrial appendages: A sign of severe cyanotic congenital heart disease. Br Heart J 1968;30:269-84.  Back to cited text no. 1
    
2.Leu MR, Chiu IS, Hung CR, Wu MH. Surgical implications of juxtaposed atrial appendages and the associated anomalies. The Ann Thorac Surg 1992;54:134-6.  Back to cited text no. 2
    
3.Mathew R, Replogle R, Thilenius OG, Arcilla RA. Right juxtaposition of the atrial appendages. Chest 1975;67:483-6.  Back to cited text no. 3
    
4.Rice MJ, Seward JB, Hagler DJ, Edwards WD, Julsrud PR, Tajk AJ. Left juxtaposed atrial appendages: diagnostic two-dimentional echocardiographic features. J Am Coll Cardiol 1983;1:1330-6.  Back to cited text no. 4
    
5.Hunter AS, Henderson CB, Urquhart W, Farmer MB. Left-sided juxtaposition of the atrial appendages: report of four cases diagnosed by cardiac catheterization and angiocardiography. Br Heart J 1973;35:1184-89.  Back to cited text no. 5
    
6.Stûmper O, Rijlaarsdam M, Vargas-Barron J, Romero A, Hess J, Sutherland GR. The assessment of juxtaposed atrial appendages by transesophageal echocardiography. Int Cardiol 1990; 29:365-71.  Back to cited text no. 6
    

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Correspondence Address:
Neeti Makhija
7th Floor, Department of Cardiac Anaesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.81572

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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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