J Thorac Cardiovasc Surg 1998;115:1224
© 1998 Mosby, Inc.
Inverted left atrial appendage
Bradley S. Allen, MD,
Michel Ibawi, MD
Reply to the Editor:
We thank Dr. Corno for his informative response to our report. We acknowledge that most of the inferences in both our experiences are rather anecdotal, based on only a few cases, and therefore cannot be totally substantiated. However, on the basis of our encounter with four cases, two of which were previously reported, echocardiography has been very helpful in making the diagnosis. This does not mean that it is the imaging method of choice or that magnetic resonance is not a good alternative. An echocardiogram, however, is easier to perform in children and is cheaper. Therefore, it should be used initially to help in establishing the diagnosis. Corno acknowledges the efficacy of echocardiography and recommends its use to eliminate the postoperative occurrence of an inverted appendage by identifying it during the operation. We agree with this assertion, because we were able to make the diagnosis in the operating room in our last patient. As stated in our manuscript, we further agree with Corno that this complication may result from deairing procedures, but we believe that left ventricular vent suction is more likely to be the cause.
We, however, strongly disagree with Corno's contention that an inverted atrial appendage needs to be removed to prevent embolization or postoperative arrhythmias. There is no evidence or physiologic mechanism to support either contention. Thrombosis leading to embolization is unlikely to occur on normal atrial tissue. The problem with the left atrial appendage is that it promotes thrombus formation because of its long cylindrical shape and because it is out of the path of blood flow, leading to stagnation. Thus an inverted left atrial appendage is likely to decrease the incidence of thrombus formation, rather than increase it. We therefore strongly believe than an inverted left atrial appendage does not need to be surgically removed if the definitive diagnosis can be made. Futhermore, as occurred in our patient, it may get better with time because of increased left atrial pressure. In contrast to Corno, we believe that to justify reoperative surgery, one must be able to document a risk that is greater than the risk of the operation.
Department of SurgeryDivision of Cardiothoracic SurgeryUniversity of Illinois,
Chicago, IL 6061212/8/87799
