https://orcid.org/0000-0003-1710-6189
A 68-year-old female was diagnosed with cardiogenic shock due to acute myocardial infarction and its complication, ventricular septal rupture (VSR). After the introduction of extracorporeal membrane oxygenation and Impella CP (Abiomed, Danvers, MA, USA), percutaneous coronary intervention was performed for total occlusion of the left anterior descending artery. Haemodynamics were stabilized with the mechanical circulatory supports, leading to a decision to proceed with elective VSR closure. Pre-operative transoesophageal echocardiography (TEE) after 14 days of presentation revealed a large mobile mass in the left atrial appendage (LAA), initially thought to be a thrombus. Another possibility was an inverted LAA. Inverted LAA reportedly arises under conditions that create negative pressures to left atrium (LA) and deform LAA, such as under cardiac surgery with cardiopulmonary bypass and under left ventricular assist device management. Since the decrease in the suction force of Impella was possible to correct the inversion, the process of reducing its flow rate was observed with TEE. The large mobile mass at the flow rate of 2.0 L/min turned to be a pouch-like structure, the normal appearance of LAA, at 0.0 L/min (Panels A–F; see Supplementary data online, Videos S1–S6). Thus, inverted LAA should be suspected when an LA mass appears during Impella management. This phenomenon can be diagnosed by observing with TEE, the process of relieving negative pressures in LA by transiently reducing Impella flow. Furthermore, the absence of a thrombus in LAA had better be confirmed with TEE before introducing Impella, which can otherwise disseminate the thrombus by inverting LAA.
Supplementary data are available at European Heart Journal - Cardiovascular Imaging online.
Funding: None declared.
Data availability: No new data were generated or analysed in support of this research.
Author notes
Conflict of interest: None declared.
