key: cord-0719654-h7st8a7b
authors: Maddali, Dr. Madan Mohan; Munasinghe, Dr. Thushara Dharshana
title: JCVA-D-21-00741R1: A left atrial mass after COVID-19 and cardiac surgery
date: 2021-07-28
journal: J Cardiothorac Vasc Anesth
DOI: 10.1053/j.jvca.2021.07.037
sha: b140941aa3448161e163d1cc4c36e29267ec5f15
doc_id: 719654
cord_uid: h7st8a7b

When a new left atrial mass is encountered following open-heart surgery, it is important to be aware of the possibility of a left atrial invagination prior to resorting to drastic measures especially in the critical period after separation from cardiopulmonary bypass. Intraoperative transesophageal echocardiography is of immense value and the mass has to be evaluated in multiple views before arriving at a definitive diagnosis.

transesophageal echocardiography is of immense value and the mass has to be evaluated in multiple views before arriving at a definitive diagnosis.

A 3-month -old-girl [weight: 4.3kg; height: 55cms] with trisomy-21 was taken to the operating room for repair of an atrioventricular canal defect. Transthoracic echocardiography reported situs solitus; atrioventricular and ventriculoarterial concordant connections; normal systemic and pulmonary venous drainage; a 3.9 mm primum defect with a left to right shunt; a large size [26 mm] inlet ventricular septal defect with left to right shunt; a large patent ductus arteriosus with a bi-directional shunt; and good biventricular function with a normal sized coronary sinus. The baby was previously hospitalized for COVID-19 seven weeks before surgery. A deep venous thrombosis was identified ten days before surgery, which was initially treated with intravenous heparin and subsequently transitioned to low molecular weight heparin. Transesophageal echocardiography prior to cardiopulmonary bypass The authors previously reported an invagination of left atrial appendage probably due to a left atrial vent that was inserted through a patent foramen ovale during the repair of a child with Tetralogy of Fallot. 1 With this in mind, as well as the finding that the newly encountered left atrial opacity had the same echo density as the surrounding cardiac tissues, a careful examination of the appendage with minimal disturbance to the hemodynamic parameters was done. This revealed an inversion of the left atrial appendage and it was immediately restored to its normal configuration. The transesophageal echocardiography following this maneuver showed the disappearance of the mass. However, the left atrial appendage appeared to be collapsed with the imaging of an echo dense "Coumadin ridge".

The alternative diagnosis is a left atrial thrombus that often is a major source of concern especially after cardiac surgery that may necessitate immediate corrective measures. 

Acquired Left Atrial Opacity

Two-dimensional echocardiographic diagnosis of left-atrial thrombus in rheumatic heart disease. A clinicopathologic study

Inverted left atrial appendage presenting as a left atrial mass after cardiac surgery

Figure-4. Mid-esophageal 4-chamber view by transesophageal echocardiography showing the

Mid-esophageal aortic long axis videoclip by transesophageal echocardiography demonstrating the left atrial mass

atrial appendage if not restored to its normal configuration may result in necrosis and rupture leading to a pericardial tamponade. In addition, an unresolved inversion may pose a postoperative diagnostic conundrum.

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.