Inversion of the Left Atrial Appendage: A Complication of Cardiac Surgery

Left Atrial Appendage Inversion Presenting as Acute Right Ventricular Failure after Left Ventricular Assist Device Implantation

“…The LAA inversion associated with CPB is usually diagnosed early by intraoperative TEE during or immediately after weaning off CPB. 3 , 4 , 5 , 9 , 10 In our case, initial intraoperative TEE after LVAD placement demonstrated no mass. Moreover, acute RV failure was seen 3 days later, suggesting that LAA inversion was unrelated to perioperative maneuvers and most likely due to negative pressure induced by the presence of LVAD.…”

“…Since then, there have been several other case reports on intraoperative discovery of LAA mass following aortic valve replacement, mitral valve repair, and, more recently, LVAD implantation. 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 The current prevailing theory is that the most likely cause of left atrial inversion is the intracardiac negative pressure environment created by an LV vent or as part of deairing maneuvers following cardiopulmonary bypass (CPB). 1 , 4 , 5 , 6 The appendage usually spontaneously reverts to its anatomical position as the increasing left atrial pressure in atrial diastole counteracts this negative pressure.…”

Clinical Significance of Acquired Left Atrial Shadow

“…4 If the inverted appendage cannot be everted spontaneously, then the valsalva maneuver, pulling by forceps, and digital manipulation can help in correction. 5 It is essential to be aware not only of left atrial shadow but also to know its impact on the perioperative course. I was very much interested to read the article, "Pulmonary artery catheter use during cardiac surgery in the United States, 2010 to 2014."…”

Left Atrial Appendage and Echocardiography

“…4,5 If it is not corrected after filling of the heart during weaning from CPB, the Valsalva maneuver or pulling it by finger or by forceps can be tried. 6 Perioperatively, the anesthesiologist must be aware of such an inverted left atrial appendage masquerading as a clot or thrombus.…”