Inversion of the Left Atrial Appendage

An 8-year-old girl with hypoplastic left heart syndrome underwent orthotopic heart transplantation for end-stage right ventricular dysfunction, after previous surgical palliations with the modified Norwood and Glenn procedures. The donor heart was transplanted into the recipient with the use of a bicaval anastomosis. Postoperative transesophageal echocardiography was noteworthy for a prominent tubular-shaped structure within the left atrium (Figure 1A through 1C and Movies I and II in the online-only Data Supplement), in proximity to the mitral valve orifice. Doppler color-flow mapping suggested no flow within the structure. The patient’s marginal hemodynamic status after separation from cardiopulmonary bypass resulted in a decision to pursue delayed sternal closure, and the structure was not addressed at the time of transplantation.Figure 1. Multiplane transesophageal still-frame echocardiographic images from the midesophageal 0° 4-chamber view ( A ), midesophageal 71° view focusing on the right ventricular outflow tract ( B ), and midesophageal 109° view focusing on the left ventricular outflow tract ( C ) with Doppler color-flow mapping. In each image, the inverted left atrial appendage is the tubular structure denoted with an asterisk. Note the absence of color flow through the inverted left atrial appendage in C . D , Transthoracic still-frame echocardiographic image …