Year : 2014  |  Volume : 17  |  Issue : 1  |  Page : 42--43

Real and pseudo clot in left atrial appendage

Monish S Raut1, Arun Maheshwari1, Sujay Shad2,  
1 Department of Cardiac Anaesthesia, Sir Ganga Ram Hospital, New Delhi, India
2 Department of Cardiac Surgery, Sir Ganga Ram Hospital, New Delhi, India

Correspondence Address:
Monish S Raut
Department of Cardiac Anaesthesia, Sir Ganga Ram Hospital, New Delhi

How to cite this article:
Raut MS, Maheshwari A, Shad S. Real and pseudo clot in left atrial appendage.Ann Card Anaesth 2014;17:42-43

How to cite this URL:
Raut MS, Maheshwari A, Shad S. Real and pseudo clot in left atrial appendage. Ann Card Anaesth [serial online] 2014 [cited 2020 May 27 ];17:42-43
Available from:

Full Text

The Editor,

A 55-year-old male patient presented with retrosternal chest pain with ST elevation in anterolateral leads and atrial fibrillation (AF) on electrocardiogram. Transthoracic echocardiography (TTE) revealed hypokinetic anterior wall with left ventricular ejection fraction 48% and no evidence of clot in cardiac chambers. Coronary angiography showed triple vessel disease and patient was scheduled for off pump coronary artery bypass grafting (CABG). Transesophageal echocardiography (TEE) during pre-bypass period revealed a freely mobile clot in left atrial appendage [LAA; [Figure 1], [Video 1] [MULTIMEDIA:1]. After discussing TEE finding with the operating surgeon, it was decided to proceed for CABG on cardiopulmonary bypass (CPB) and three grafts were anastomosed to diseased coronary vessels, and the LAA clot was removed. After separation from CPB, 2D-TEE showed clot like shadow in LAA [Figure 2], [Video 2] [MULTIMEDIA:2]. While speculating whether it was an inadequate removal of LAA clot or new clot formation, the operating surgeon inspected outer surface of the LAA wall and found a part of the LAA inverted. The inverted left atrial wall tissue spontaneously everted with the improved cardiac filling and the image disappeared on TEE imaging.{Figure 1}{Figure 2}

LA clot is commonly observed in patients with AF. Such finding can be missed during TTE examination as would have occurred in this case. It is advisable to perform TEE examination pre-operatively in patients with AF to rule out LAA clot so that surgery can be planned accordingly. Inversion of the LAA tissue after cardiac surgery mimicking a LA mass is rare. It is mostly recognized during weaning from CPB while the heart is still empty. [1],[2] The LAA generally everts spontaneously once the heart is filled. [2] Apart from causing confusion in the diagnosis, it can cause mitral valve obstruction and impaired ventricular filling. [1],[3] Inability to identify such a mass as an inverted LAA can result in unnecessary surgical intervention, unnecessary return to CPB and additional ischemic time. [4],[5] The key to recognize inverted LAA is being aware of its existence and considering its possibility in the differential diagnosis of a newly appearing LA mass. [6] 3D-echocardiography can help in differentiating the inverted LAA and clot. Failure of an appendage to evert upon LA filling can be corrected by Valsalva maneuver, digital manipulation, pulling by forceps; occasionally, LA appendage ligation might be required. [7]


1Aronson S, Ruo W, Sand M. Inverted left atrial appendage appearing as a left atrial mass with transesophageal echocardiography during cardiac surgery. Anesthesiology 1992;76:1054-5.
2Toma DM, Stewart RB, Miyake-Hull CY, Otto CM. Inverted left atrial appendage mimicking a left atrial mass during mitral valve repair. J Am Soc Echocardiogr 1995;8:557-9.
3Danford DA, Cheatham JP, Van Gundy JC, Mohiuddin SM, Fleming WH. Inversion of the left atrial appendage: Clinical and echocardiographic correlates. Am Heart J 1994;127:719-21.
4Slavik Z, Salmon AP, Lamb RK. Unusual left atrial mass following cardiac surgery in an infant. Eur J Cardiothorac Surg 1994;8:566-7.
5Minich LL, Hawkins JA, Tani LY, Judd VE, McGough EC. Inverted left atrial appendage presenting as an unusual left atrial mass. J Am Soc Echocardiogr 1995;8:328-30.
6Cohen AJ, Tamir A, Yanai O, Houri S, Schachner A. Inverted left atrial appendage presenting as a left atrial mass after cardiac surgery. Ann Thorac Surg 1999;67:1489-91.
7Smiles GS, Basu R, Mitchell IM. Inversion of the left atrial appendage: A complication of cardiac surgery. Heart Lung Circ 2012;21:117-9.