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LETTER TO EDITOR  
Year : 2014  |  Volume : 17  |  Issue : 4  |  Page : 320-321
An uncommon presentation of partially ligated left atrial appendage on transesophageal echocardiography


Department of Cardiac Anesthesia, Cardio Neuro Sciences Center, All India Institute of Medical Sciences, New Delhi, India

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Date of Web Publication1-Oct-2014
 

How to cite this article:
Singh SP, Hasija S, Chauhan S. An uncommon presentation of partially ligated left atrial appendage on transesophageal echocardiography. Ann Card Anaesth 2014;17:320-1

How to cite this URL:
Singh SP, Hasija S, Chauhan S. An uncommon presentation of partially ligated left atrial appendage on transesophageal echocardiography. Ann Card Anaesth [serial online] 2014 [cited 2020 Sep 27];17:320-1. Available from: http://www.annals.in/text.asp?2014/17/4/320/142079


The Editor,

An 18-year-old female weighing 42 kg diagnosed with severe mitral stenosis was scheduled for mitral valve replacement (MVR). An intraoperative transesophageal echocardiographic (TEE) examination revealed thickening of both the anterior and posterior mitral leaflets, and severe, Grade IV subvalvular disease. The mitral valve area measured 1.0 cm 2 by planimetry. There was no mitral or tricuspid valve regurgitation. The mean gradient across the mitral valve was 12 mmHg. The left atrium measured 5.0 × 4.0 cm. The left ventricular ejection fraction was 60%. No thrombus was detected in the left atrium. The patient underwent MVR with 27 mm mechanical mitral valve prosthesis (St. Jude Medical Inc., MN USA) under standard moderate hypothermic cardiopulmonary bypass (CPB). Intravenous nitroglycerin and dopamine in doses of 0.5 and 5 μg/kg/min, respectively, were started at the time of rewarming and the patient was weaned off CPB without any difficulty. TEE examination showed normal functioning of the mitral valve prosthesis and left ventricular ejection fraction of 55%. Additionally, a homogenous density was detected in the left atrial appendage (LAA) [Figure 1]; Video 1]. The homogenous density initially was considered a thrombus. However, the echotexture of the mass was considered different from that of a thrombus. Discussion with the surgeon revealed that the LAA was not completely ligated. On direct inspection, the LAA appeared wide and "fern-like" [Figure 2]. The incomplete ligature of the LAA has left a part of appendage patent, which was seen in the backdrop of the remaining collapsed appendage (homogeneous density on ultrasound). The LAA was again ligated, completely.
Figure 1: Mid-esophageal view showing a homogenous echodensity in the left atrial appendage and mitral valve prosthesis

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Figure 2: Photograph showing the ligated and patent portions of left atrial appendage

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]




The incidence of LAA ligation after MVR surgery varies from 28% to 51% [1],[2] and that of an incompletely ligated LAA is as high as 36%. [3] Conventionally, the incompletely ligated LAA is diagnosed by color flow Doppler, that demonstrates a to-and-fro jet traversing the separation between the LAA and the left atrial body. [3] Left atrial thrombus and LA myxoma are the common causes of a LAA echodensity. [4] In our patient, the incompletely ligated LAA masqueraded as a thrombus. In the absence of TEE, the LAA may have been left partially patent that may serve as a potential site for thrombus formation. Additionally, during follow-up echocardiographic examinations this echodensity would have caused a diagnostic dilemma and mistaken for a thrombus especially with transthoracic echocardiography where imaging of LAA is not appropriate always. [5] This echodensity will also be important in the setting of a prosthetic valve thrombosis where a true thrombus can develop at the annulus or on any of the leaflets and shall be indistinguishable from the present echodensity.

 
   References Top

1.García-Fernández MA, Pérez-David E, Quiles J, Peralta J, García-Rojas I, Bermejo J, et al. Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: A transesophageal echocardiographic study. J Am Coll Cardiol 2003;42:1253-8.  Back to cited text no. 1
    
2.Bando K, Kobayashi J, Hirata M, Satoh T, Niwaya K, Tagusari O, et al. Early and late stroke after mitral valve replacement with a mechanical prosthesis: Risk factor analysis of a 24-year experience. J Thorac Cardiovasc Surg 2003;126:358-64.  Back to cited text no. 2
    
3.Katz ES, Tsiamtsiouris T, Applebaum RM, Schwartzbard A, Tunick PA, Kronzon I. Surgical left atrial appendage ligation is frequently incomplete: A transesophageal echocardiograhic study. J Am Coll Cardiol 2000;36:468-71.  Back to cited text no. 3
    
4.Malik L, Borgohain S, Gupta A, Grover V, Gupta VK. Left atrial appendage myxoma masquerading as left atrial appendage thrombus. Asian Cardiovasc Thorac Ann 2013;21:205-7.  Back to cited text no. 4
    
5.de Bruijn SF, Agema WR, Lammers GJ, van der Wall EE, Wolterbeek R, Holman ER, et al. Transesophageal echocardiography is superior to transthoracic echocardiography in management of patients of any age with transient ischemic attack or stroke. Stroke 2006;37:2531-4.  Back to cited text no. 5
    

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Correspondence Address:
Sarvesh Pal Singh
Department of Cardiac Anesthesia, Cardio Neuro Sciences Center, All India Institute of Medical Sciences, New Delhi 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.142079

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