Advertisement

Left Atrial Appendage Confusion: A Mobile Echodensity in a Patient With Endocarditis

Published:January 11, 2022DOI:https://doi.org/10.1053/j.jvca.2022.01.008
      A 50-YEAR-OLD, 70- kg, 172- cm man with known bicuspid aortic valve disease and severe aortic insufficiency presented to the authors’ institution with a 3-day history of “pulsating” chest pain, dyspnea with exertion, and bilateral lower extremity swelling. The patient previously was hospitalized on several occasions for the treatment of recurrent Streptococcus cristatus bacteremia originating from poor dentition. He also was receiving apixaban for the treatment of a cephalic vein thrombosis. The physical examination was notable for sinus tachycardia (122 beats/min), grade III/VI systolic and diastolic murmurs heard best at the left sternal border, bilateral lower extremity pitting edema, and red petechiae on both hands and feet. The patient was anemic (hemoglobin of 8.0 g/dL) and had renal insufficiency (serum creatinine concentration of 1.66 mg/dL). Leukocytosis was present (11.8 103/µL). The plasma brain natriuretic peptide level was markedly elevated (20,063 pg/mL). An increase in high-sensitivity troponin concentration also was observed. An electrocardiogram revealed sinus tachycardia and low-voltage QRS complexes, but acute ST-segment changes were absent. Transthoracic echocardiogram revealed vegetations on both the aortic and mitral valves, resulting in severe regurgitation. Transesophageal echocardiography (TEE) also was performed as part of the diagnostic evaluation, and the following images were obtained (Fig. 1-3; Videos 1-3). What is the diagnosis?
      Fig 1
      Fig 1Midesophageal right ventricular inflow-outflow transesophageal echocardiography view.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Cardiothoracic and Vascular Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Kerut EK.
        Anatomy of the left atrial appendage.
        Echocardiography. 2008; 25: 669-673
        • Ernst G
        • Stöllberger C
        • Abzieher F
        • et al.
        Morphology of the left atrial appendage.
        Anat Rec. 1995; 242: 553-561
        • Shirani J
        • Alaeddini J.
        Structural remodeling of the left atrial appendage in patients with chronic non-valvular atrial fibrillation: Implications for thrombus formation, systemic embolism, and assessment by transesophageal echocardiography.
        Cardiovasc Pathol. 2000; 9: 95-101
        • Ho SY
        • Cabrera JA
        • Sanchez-Quintana D.
        Left atrial anatomy revisited.
        Circ Arrhythm Electrophysiol. 2012; 5: 220-228
        • Veinot JP
        • Harrity PJ
        • Gentile F
        • et al.
        Anatomy of the normal left atrial appendage: A quantitative study of age-related changes in 500 autopsy hearts: Implications for echocardiographic examination.
        Circulation. 1997; 96: 3112-3115
        • Meissner I
        • Whisnant JP
        • Khandheria BK
        • et al.
        Prevalence of potential risk factors for stroke assessed by transesophageal echocardiography and carotid ultrasonography: The SPARC study. Stroke prevention: Assessment of risk in a community.
        Mayo Clin Proc. 1999; 74: 862-869
        • Giove GC
        • Singla I
        • Mishra J
        • et al.
        Transesophageal echocardiographic finding of left atrial appendage lobe mimicking a mass lesion.
        Echocardiography. 2011; 28: 684-685
        • Su P
        • McCarthy KP
        • Ho SY.
        Occluding the left atrial appendage: Anatomical considerations.
        Heart. 2008; 94: 1166-1170
        • Beigel R
        • Wunderlich NC
        • Ho SY
        • et al.
        The left atrial appendage: Anatomy, function, and noninvasive evaluation.
        JACC Cardiovasc Imaging. 2014; 7: 1251-1265
        • Penmasta S
        • Silbiger JJ.
        The transverse and oblique sinuses of the pericardium: Anatomic and echocardiographic insights.
        Echocardiography. 2019; 36: 170-176
        • Stöllberger C
        • Ernst G
        • Bonner E
        • et al.
        Left atrial appendage morphology: Comparison of transesophageal images and postmortem casts.
        Z Kardiol. 2003; 92: 303-308
        • Chirillo F
        • Fusaro M
        • Morana G
        • et al.
        An intriguing intracardiac mass in a woman with atrial fibrillation.
        Heart. 2016; 102: 693-727
        • Skolnick AH
        • Perk G
        • Kronzon I.
        Fibrinous material in a pericardial effusion mimicking intraatrial thrombus.
        Echocardiography. 2008; 25: 639-641
        • Chhabra L
        • Goyal A
        • Mwansa V
        • et al.
        Transverse sinus fat pad may masquerade as left atrial appendage thrombus.
        J Electrocardiol. 2019; 56: 43-45