3D imaging of left atrial dissection: a case report.

BACKGROUND

Left atrial dissection (LAD) is an uncommon but potentially devastating complication of cardiac surgery. Though surgical and conservative treatment strategies have been reported, the choice depends on each clinical situation. Especially in sensitive cases, the decision could be difficult, where the detailed assessment of the multiple imaging modalities is mandatory.

CASE PRESENTATION

Open surgical total arch replacement (TAR) was performed on a male patient aged 79 years old, who had severe chronic obstructive pulmonary disease (COPD) and a history of aortofemoral bypass for abdominal aortic aneurysm and arteriosclerosis obliterans (ASO). During the weaning off the cardiopulmonary bypass (CPB), LAD was detected on intraoperative transesophageal echocardiography (TEE). It was 18 × 26 mm and full of hematoma with the TEE. Due to the patient's frailty and not to elongate the CPB duration, we selected a conservative strategy. The patient was extubated on postoperative day (POD) 1 and transferred from ICU to the ward on POD 3. On POD 7, ECG-gated 3D-CT was performed, on which LAD occupied 26% of the left atrial volume. It also revealed the opening of the pulmonary veins and the proximity of the LAD and the coronary sinus (CS). The cause of the LAD was considered to be the CS perforation with a retrograde cardioplegic cannula. A follow-up 3D-TEE was performed on POD 15, where the hematoma inside the LAD was absorbed. He was discharged home at POD 23. With transthoracic echocardiography, LAD itself disappeared after 3 months.

CONCLUSION

3D imaging, such as 3D-TEE and 3D-CT, is valuable in the assessment of the volume and quality of LAD. Furthermore, it clarifies the exact position and configuration of LAD, which help in assessing the etiology, predicting the hemodynamic disturbance, and determining the treatment strategy. They are potent tools, especially in complex cases.