Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 1214 1216
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Diagnostic Dilemma
A left Atrial Mass After COVID-19 and Cardiac
Surgery
Madan Mohan Maddali, MD ,
Thushara Dharshana Munasinghe, DA
Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, Muscat, Oman
Key Words: echocardiography; transesophageal; heart atria/diagnostic imaging; heart diseases/surgery; infant; intraoperative care/methods
A three-month-old girl (weight: 4.3 kg; height: 55 cm) with
trisomy-21 was taken to the operating room for repair of an
atrioventricular canal defect. The transthoracic echocardio-
gram reported situs solitus; atrioventricular and ventriculoarte-
rial 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 bidi-
rectional shunt; and good biventricular function with a nor-
mal-sized coronary sinus. The baby previously was
hospitalized for Coronavirus disease 2019 (COVID-19) seven
weeks before surgery. A deep venous thrombosis was identi-
fied ten days before surgery, which initially was treated with
intravenous heparin and subsequently transitioned to low-
molecular-weight heparin. The transesophageal echocardiog-
raphy before cardiopulmonary bypass confirmed the previous
findings (Fig 1, Video 1). The intracardiac repair was per-
formed on cardiopulmonary bypass, and the left heart cham-
bers were vented for better visualization of the cardiac
structures, with a left atrial vent that was inserted through the
foramen ovale. After separation from cardiopulmonary bypass,
an echo-dense mass was visualized in the left atrium (Figs 2
and 3; Videos 2 and 3). The peak and mean pressure gradients
across the mitral valve were assessed by a pulse-wave Doppler
(Fig 4). What is the diagnosis?
Institutional ethical committee approval: SRC#CR25/2021.
1
Address correspondence to Madan Mohan Maddali, MD, Senior Consultant
in Anesthesia, National Heart Center, Royal Hospital, P.B.No: 1331, P.C: 111,
Seeb, Muscat, Sultanate of Oman.
E-mail address: madanmaddali@hotmail.com (M.M. Maddali).
https://doi.org/10.1053/j.jvca.2021.07.037
1053-0770/Ó 2021 Elsevier Inc. All rights reserved.
1
Diagnosis: Left Atrial Appendage Inversion
In view of the baby’s medical history of recovery from
COVID-19 infection and deep vein thrombosis, the dilemma
was that this mass might be a thrombus with the potential for
systemic embolization. If that were the diagnosis, it meant
reheparinization, reinstitution of cardiopulmonary bypass,
and reversing the atrial septation, for inspecting the left
atrial chamber under cardioplegic arrest would have been
required.
The authors previously reported an invagination of a 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 distur-
bance to the hemodynamic parameters was done. This revealed
an inversion of the left atrial appendage and it was restored
immediately to its normal configuration. The transesophageal
echocardiogram after 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 was a left atrial thrombus that
often is a major source of concern, especially after cardiac sur-
gery that may necessitate immediate corrective measures. The
features of a left atrial thrombus may include: a relatively
well-defined border; mobility throughout the cardiac cycle;
demonstrable in more than one echocardiographic view;
 M.M. Maddali and T.D. Munasinghe / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 1214 1216 1215

Fig 1. Midesophageal four-chamber two-dimensional and color Doppler blood flow images by transesophageal echocardiography displaying the anatomy.

displays a constant and reproducible position in the left atrial
cavity; and demonstrates a surface attachment to the left atrial
wall in at least one echocardiographic view, with an echo den-
sity that is different from that of the adjoining cardiac struc-
tures.2 In contrast, a left atrial inversion displays an echo
density that is similar to that of the surrounding cardiac struc-
tures. Left atrial inversion may be seen in the midesophageal
four-chamber view as a mass just superior to the mitral valve
but inferior to the pulmonary veins.3
An iatrogenic inversion of the left atrial appendage may
occur during open cardiac surgery as a result of excessive neg-
ative pressure applied to a left ventricular vent. It also may
occur if digital insertion into the left atrial chamber is used to
help dislodge trapped air as part of deairing maneuvers at the
time of release of the aortic crossclamp. An iatrogenic inver-
sion of the left 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.

Fig 2. Midesophageal four-chamber two-dimensional and color Doppler blood flow images by transesophageal echocardiography showing a mass in the left
atrium.
1216 M.M. Maddali and T.D. Munasinghe / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 1214 1216

Fig 3. Midesophageal aortic long-axis view by transesophageal echocardiography demonstrating the left atrial mass.

Fig 4. Midesophageal four-chamber view by transesophageal echocardiography showing the pulse-wave Doppler signal across the left ventricular inflow.

Conflict of Interest References

None.
Supplementary materials
Supplementary material associated with this article can be
found in the online version at doi:10.1053/j.jvca.2021.07.037.
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Cardiothorac Vasc Anesth 2016;30:e32–4.
2 Shrestha NK, Moreno FL, Narciso FV, et al. Two-dimensional echocardio-
graphic diagnosis of left-atrial thrombus in rheumatic heart disease. A clini-
copathologic study. Circulation 1983;67:341–7.
3 Cohen AJ, Tamir A, Yanai O, et al. Inverted left atrial appendage presenting as
a left atrial mass after cardiac surgery. Ann Thorac Surg 1999;67:1489–91.