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Ann Thorac Surg 1999;67:1492-1493
© 1999 The Society of Thoracic Surgeons

Case Reports

Inverted left atrial appendage: an unusual complication in cardiac surgery

Keiichi Fujiwara, MDa, Yasuaki Naito, MDa, Yasuzo Noguchi, MDa, Hiroki Hayashi, MDa, Shigeru Uemura, MDa

a Department of Thoracic and Cardiovascular Surgery, and Pediatrics, Wakayama Medical College, Wakayama, Japan

Accepted for publication October 31, 1998.

Address reprint requests to Dr Fujiwara, Department of Thoracic and Cardiovascular Surgery, Wakayama Medical College, 811-1, Kimiidera, Wakayama, Japan, 640-0012
e-mail: fujiwara{at}mail-wakayama.med.ac.jp


   Abstract
Top
 Abstract
Introduction
 Patient 1
 Patient 2
 Comment
 References
 
Two patients with an inverted left atrial appendage after cardiac surgery were presented. Magnetic resonance imaging is one of the useful methods to establish an accurate diagnosis of this complication. In 1 patient, it repaired spontaneously without surgical intervention.


   Introduction
Top
 Abstract
 Introduction
Patient 1
 Patient 2
 Comment
 References
 
Inverted left atrial appendage is a rare complication in cardiac surgery, and only 10 cases have been previously reported [1–7]. We present 2 infants with an inerted left atrial appendage after cardiac surgery, and their echocardiographic and magnetic resonance imaging (MRI) findings are reviewed.


   Patient 1
Top
 Abstract
 Introduction
 Patient 1
Patient 2
 Comment
 References
 
A 3-month-old boy with a ventricular septal defect and moderate mitral regurgitation was referred to our department for an intracardiac repair. Performing cardiopulmonary bypass with moderate hypothermia, a patch closure of the ventricular septal defect and mitral annuloplasty was performed. During the cardiopulmonary bypass, a left atrial vent was inserted from the right upper pulmonary vein. After bypass, the hemodynamics were satisfactory. The left atrial pressure monitor catheter was not inserted into the left atrium. On the second postoperative day, a transthoracic echocardiography was performed during routine examination in the intensive care unit, and it revealed an abnormal homogenous mass in the left atrial cavity (Fig 1). The mass was attached to left atrial posterior wall and moved to the mitral annulus during contraction. This finding indicated thrombus in the left atrium. Heparinization was started (activated coagulating time [ACT]: approximately 200 sec). However, the regression of its size was not recognized by repeat transthoracic echocardiography. On the fourth postoperative day, the patient was taken back to the operating room. Performing cardiopulmonary bypass, the left atrium was opened via the atrial septal approach. No thrombus was noted. A trabeculated and purplish mass (Fig 2) was observed, identified as an inverted left atrial appendage, and was everted. Postoperative course was uneventful. Postoperative echocardiography revealed no abnormal mass in the left atrial cavity.



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  		Fig 1. Postoperative echocardiogram (patient 1). It demonstrates a homogenous and hinged-like mass in the left atrium.

 


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  		Fig 2. Operative view (patient 1). Inverted left atrial appendage with a trabeculated purplish surface is observed in the left atrial cavity.

 

   Patient 2
Top
 Abstract
 Introduction
 Patient 1
 Patient 2
Comment
 References
 
A 10-day-old boy with simple transposition of the great arteries was subjected to an arterial switch operation. Postoperative cardiac function was stable with a small dosage of catecholamine infusion. On the first postoperative day, echocardiography was performed as a routine examination to access cardiac function after removal of the left atrial pressure monitor catheter. It showed a homogenous mass in the left atrial cavity, originating from the left atrial appendage. It looked like the shape seen in patient 1. As a thrombus in the left atrial cavity could not be excluded, anticoagulant therapy with heparin was started. One month after the operation, MRI (Fig 3) revealed that the mass originated from the position of left atrial appendage and the left atrial appendage was absent. This finding suggested an inverted left atrial appendage. The patient was discharged without any surgical intervention. During the 6-month follow-up period, no episode of thromboembolism was observed and it repaired spontaneously.



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  		Fig 3. Postoperative MRI (patient 2). A mass in the left atrial cavity is observed, and the left atrial appendage is not seen in the normal position.

 

   Comment
Top
 Abstract
 Introduction
 Patient 1
 Patient 2
 Comment
References
 
Echocardiography is a useful technique to detect masses in the cardiac cavity. The differential diagnosis of left atrial mass usually involves thrombus, vegetation, and cardiac tumor, and rarely, an inverted left atrial appendage and a remnant of the pulmonary vein. Recently, transthoracic and/or esophageal echocardiography is routinely performed preoperatively in cardiac surgery. Therefore, a newly developed mass in the left atrium after cardiac surgery excludes cardiac tumor from these differential diagnoses. Minich and associates [4] described a broad base of the thumb-like mass, its hinge-type motion, and absence of normal left atrial appendage were characteristic of an inverted left atrial appendage, which may demonstrate a "crooked finger" appearance [3]. In the first case, transthoracic echocardiography revealed a homogenous thumb-like and mobile mass. However, the base was not broad. So this abnormal mass was suspected to be thrombus. Allen and associates [6] suggested that transesophageal echocardiography easily demonstrated left atrial appendage. We did not perform transesophageal echocardiography in these 2 patients. In patient 2, MRI revealed a mass in the left atrium and absence of a left atrial appendage. The MRI is useful in diagnosing the inverted left atrial appendage.

Inverted left atrial appendage is caused by an excess negative pressure of the left atrial venting or surgical inversion for evacuation of air during surgery. As we did not routinely perform the invertion of left atrium surgically, it may have been due to the former cause in our patients.

As it is difficult to establish an accurate diagnosis for inverted left atrial appendage, in 8 of 10 reported cases [1–7], it was confirmed surgically. In these cases, it was repaired or excised surgically. The natural course of inverted left atrial appendage has not been clarified. In only 1 case reported by Allen and associates [6], the diagnosis of inverted left atrial appendage was established by echocardiography, and surgical intervention was not performed. In this case, the condition was absent at 1-year follow-up without any complications. They suggested that it may be untreated because of a totally endotheliarized surface and improvement with time. In patient 2, no embolic episode was recognized during the follow-up periods, echocardiography showed reduction of its size, and it disappeared. If the inverted left atrial appendage is accurately diagnosed, further surgery may be unnecessary. During cardiac operations, the surgeon should confirm the presence of a left atrial appendage. Furthermore, cardiac surgeons and cardiologists must recognize an inverted left atrial appendage as a left atrial mass lesion.


   References
Top
 Abstract
 Introduction
 Patient 1
 Patient 2
 Comment
 References
 

  1. Aronson S., Ruo W., Sand M. Inverted left atrial appendage as a left atrial mass with transesophageal echocardiography during cardiac surgery. Anesthesiology 1992;76:1054-1055.[Medline]
  2. Slavik Z., Salmon A.P., Lamb R.K. Unusual left atrial mass following cardiac surgery in an infant. Eur J Cardio-thorac Surg 1994;8:566-567.[Abstract]
  3. Danford D.A., Cheatham J.P., Van Gundy J.C., Mohiuddin S.M., Fleming W.H. Inversion of the left atrial appendage: clinical and echocardiographic correlates. Am Heart J 1994;127:719-721.[Medline]
  4. Minich L.L., Hawkins J.A., Tani L.Y., Judd V.E., McGough E.C. Inverted left atrial appendage presenting as an usual left atrial mass. J Am Soc Echocardiogr 1995;8:328-330.[Medline]
  5. Toma D.M., Stewart R.B., Miyake-Hull C.Y., Otto C.M. Inverted left atrial appendage mimicking a left atrial mass during mitral repair. J Am Soc Echocardiogr 1995;8:557-559.[Medline]
  6. Allen B.S., Ilbawi M., Harz R.S., Kumar S., Thoele D. Inverted left atrial appendage. An unrecognized cause of left atrial mass. J Thorac Cardiovasc Surg 1997;114:278-280.[Free Full Text]
  7. Corno A.F. Inverted left atrial appendage. J Thorac Cardiovasc Surg 1998;115:1223-1224.[Free Full Text]

Related Article

Antonio F. Corno
Ann. Thorac. Surg. 1999 67: 1493-1494. [Extract] [Full Text] [PDF]




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