Left atrial dissection: taken from darkness by transoesophageal echocardiography

Introduction Left atrial dissection (LATD) is an infrequent (incidence 0.16%) however serious condition (mortality 13.8%). Methods The authors present three-LATD between 2016 and 2018 (from 2475 cardiac-surgery cases). Results Case 1 - A 57-year-old female with severe mitral regurgitation (P2 prolapse) was admitted for elective mitral valve repair (MVr). After two unsuccessful MVr attempts due to systolic anterior motion, a mitral valve replacement (MVR) was performed. LATD was diagnosed on the transoesophageal echocardiography (TOE). Conservative approach was decided based on the patient stability. However, LATD increased on the TOE and surgical treatment was required. She was successfully weaned form cardiopulmonary bypass (CPB) and transferred to the intensive care unit (ICU) stable on inotropes. Unfortunately, the patient died thirteen days after surgery due to airway and respiratory complications. A post-mortem study confirmed the patency of cardiac sutures. Case 2 - A 74-year-old male with severe mitral regurgitation (P2-P3 prolapse) was admitted for elective mitral valve repair and pulmonary vein ablation. A LATD associated to intra and peri- annular leaks was diagnosed on the post- repair TOE. Surgical treatment on CPB was required. The LATD was repaired and MVR was performed. The patient was weaned form CPB and transferred to the ICU on Right-Ventricular Assistance Device (RVAD) and inotropes due to RV failure. He was successfully weaned from RVAD and then discharged from hospital two months after the initial surgery. Case 3 - A 85-year-old female with severe aortic and moderate mitral regurgitation was admitted for elective aortic valve replacement and MVr. A LATD was diagnosed on the post-CPB TOE without affecting pulmonary-vein drainage or left atrial filling. Conservative approach was decided based on patient's stability. Consecutive TOE controls showed no changes. Therefore, he was transferred to the ICU and discharged from hospital one month after surgery. Discussion As in the authors’ three-case series, this infrequent cardiac-surgery complication has been mainly related to mitral valve surgery (56.3%). Treatment depends on patients’ clinical status, left-atrial filing impairment and LATD progression on TOE. Both surgical and conservative treatments have been reported successfully. Therefore, TOE is paramount in order to diagnosed and deal with this condition.