https://orcid.org/0000-0002-1044-0750
A 56-year-old man with severe aortic stenosis underwent mechanical aortic valve replacement. After establishing cardioplegic arrest, a left ventricular vent was placed through the right superior pulmonary vein. The aortic valve was replaced through an oblique aortotomy. Following closure of the aortotomy, the left ventricular vent was placed on suction. The aortic cross-clamp was released, and sinus rhythm re-established. After adequate de-airing, the left ventricular vent was removed.
Post-bypass transoesophageal echocardiogram (TEE) unexpectedly demonstrated a phallus-like structure (arrowhead) arising lateral to the mitral valve (MV), prolapsing in and out across the MV orifice (Panels A–C; Supplementary data online, Video). Based on the shape and location of the structure, inversion of a windsock-shaped left atrial appendage (LAA; Panel D, asterisk) was suspected, presumably due to the negative-pressure suction created by the left ventricular vent through the left atrium (LA). Ultimately, this was corrected by lifting the apex of the heart. The resultant increase in intracardiac pressure gently reverted the appendage. Final TEE imaging (Panels D–F) demonstrated normal LAA configuration and MV function.
Left atrial appendage inversion is an uncommon intraoperative finding. It typically occurs as a result of negative-pressure environment created by a left ventricular vent or following left ventricular assist device implantation, presumably related to excessive volume unloading from high device speed.1 While spontaneous resolution commonly occurs intraoperatively as intracardiac volumes replenishes, persistent LAA inversion may result in MV inflow obstruction and functional stenosis.1 Thus, prompt recognition is important in case that manual eversion is required intraoperatively to restore normal LAA configuration.
Left atrial appendage inversion detected during post-bypass transoesophageal echocardiogram. LA, left atrium; MV, mitral valve; LAA, left atrial appendage.
Supplementary data are available at European Heart Journal online.
All authors declare no disclosure of interest for this contribution.
No data were generated or analysed for or in support of this paper.
