The Double-Orifice Left Atrial Appendage: Multimodality and Virtual Transillumination Imaging

•LAA membranes are exceedingly rare with variable morphologies.•Thromboembolic risk LAA remains unknown.•Use of 3D TEE transillumination may assist in visualization and understanding. The left atrial appendage (LAA) is a small pouch extending from the atrium that embryologically derived primitive atrium. It predominant source thromboemboli patients fibrillation (AF) without rheumatic heart disease.1Naksuk N. Padmanabhan D. Yogeswaran V. Asirvatham S.J. Left appendage: embryology, anatomy, physiology, arrhythmia, therapeutic intervention.JACC Clin Electrophysiol. 2016; 2: 403-412Google Scholar,2Blackshear J.L. Odell J.A. Appendage obliteration to reduce stroke cardiac surgical fibrillation.Ann Thorac Surg. 1996; 61: 755-759Google Scholar We present rarely reported case an double-orifice membrane as imaged using three-dimensional (3D) transesophageal echocardiography (TEE) computed tomography (CCT). A 63-year-old man history persistent AF rate-related cardiomyopathy was referred for radiofrequency ablation. patient treated systemic anticoagulation therapy. He had no any or invasive procedures. presented preprocedural CCT. Two-dimensional revealed thin linear echodensity traversing ostium, color Doppler demonstrated blood flow between (Figure 1, Video 1). Three-dimensional photorealistic light transparency (TrueVue; Philips Healthcare) along “chicken wing” morphology, at ostium two distinct orifices 2, 2).Figure 2Double-orifice on TEE. (A) TEE, en face display TrueVue positioned inside body, transilluminating LAA. (B) anatomy LAA, demonstrating chicken-wing morphology. MV, Mitral valve; Pulm., pulmonary.View Large Image Figure ViewerDownload Hi-res image Download (PPT) There thrombus Preprocedural CCT contrast also performed 3), orifice areas 15.2 24.4 mm2 volume rendering multiplanar reconstruction imaging. underwent successful ablation has been maintained oral embolic events. Developmental abnormalities but have reported, ranging congenital absence LAA3Saleh M. Balakrishnan R. Castillo Kontak L. Benenstein Chinitz L.A. Donnino et al.Congenital absense visualized by adult patients.Echocardiography. 2015; 32: 1206-1210Google aneurysm.4Chowdhury U.K. Seth S. Govindappa Jagia P. Malhotra Congenital aneurysm: report brief review literature.Heart, Lung Circulation. 2009; 18: 412-416Google reports involving orifice.4Chowdhury Although there formal definition currently, these be complete partial obstructive nonobstructive. Recent demonstrate clinical utility improving anatomic details echocardiography.5Italiano G. Fusini Mantegazza Tamborini Muratori Ghulam Ali al.Novelties transthoracic echocardiography.J Med. 2021; 10: 408Google Scholar,6Cotella J.I. Yamat Henry M.P. Addetia K. Lang R.M. Clinical imaging.CASE. 2022; 6: 394-399Google enhances detection edges allows pool imaging, which enables views (Video 3). postulate diagnosis characterization membranes. suggested physiology similar failed ligation percutaneous exclusion/occlusion device leak, possibly promoting stasis clot formation,7Cresti A. Solari Gismondi A.L. Baratta De Sensi F. Breschi al.Incidence relevance membranes: new disease?.Eur Heart J Cardiovasc Imaging. 23: 673-679Google effects size emptying velocities unknown. In our patient, associated thrombus, he continued long-term after Last, it unknown whether association if found incidentally when evaluated because sampling bias. Given rarity, significance unknown, management unclear. Further research required classify various morphologies, follow longitudinal outcomes, analyze tissue histopathology. multimodality imaging due two-dimensional This such could contribute future understanding this entity.