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Peer-reviewedCC BY-NC-ND 4.0JACC Case Reports

Elongated Channels Between Surgically Excluded LAA and LA

  • Parsa Asachi1
  • Alan Vainrib1
  • Didier F. Loulmet1
  • Ali Hage1
  • Anthony Aizer1
  • Larry A. Chinitz1
  • Richard Ro1
  • Muhamed Saric1
  1. 1Leon H. Charney Division of Cardiology, NYU Grossman School of Medicine, NYU Langone Health, New York, New York, USA
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Abstract

Background: Systematic left atrial appendage (LAA) exclusion during mitral valve surgery reduces thromboembolic risk in patients with pre- or postoperative atrial fibrillation. Rare residual LAA-left atrial (LA) communications may occasionally occur after surgical exclusion and increase thromboembolic risk, particularly in patients not receiving anticoagulation.

Case Series: Among more than 2,000 robotic mitral valve surgeries performed at NYU Langone Health from 2010 to 2025, LAA closure with LA posterior wall plication was performed using a continuous back-and-forth suture technique. We identified 4 patients with elongated residual LAA-LA communications that were occult on transesophageal echocardiography (TEE) but clearly visualized by cardiac computed tomography angiography (CCTA). TEE demonstrated persistent echolucency and color Doppler flow within the excluded LAA without a visible communication entrance. A tubular channel extending from the LAA, termed the “panhandle sign,” was consistently observed. CCTA identified the communication orifices and guided successful transcatheter vascular plug closure.

Conclusions: Rare elongated residual LAA-LA communications may be missed on routine TEE after LAA exclusion with LA plication. Persistent LAA flow and echolucency should prompt CCTA to detect occult communications and guide percutaneous closure. The “panhandle sign” may represent an imaging marker specific to our institutional extended-suture technique that facilitates earlier recognition.

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Cite

BibTeXRIS
BibTeX
@article{asachi2026elongated,
  title = {{Elongated Channels Between Surgically Excluded LAA and LA}},
  author = {Parsa Asachi and Alan Vainrib and Didier F. Loulmet and Ali Hage and Anthony Aizer and Larry A. Chinitz and Richard Ro and Muhamed Saric},
  journal = {JACC Case Reports},
  year = {2026},
  month = sep,
  doi = {10.1016/j.jaccas.2026.110207},
  url = {https://doi.org/10.1016/j.jaccas.2026.110207},
  note = {CC BY-NC-ND 4.0},
}
RIS
TY  - JOUR
TI  - Elongated Channels Between Surgically Excluded LAA and LA
AU  - Parsa Asachi
AU  - Alan Vainrib
AU  - Didier F. Loulmet
AU  - Ali Hage
AU  - Anthony Aizer
AU  - Larry A. Chinitz
AU  - Richard Ro
AU  - Muhamed Saric
PY  - 2026
DA  - 2026/09/02
JO  - JACC Case Reports
DO  - 10.1016/j.jaccas.2026.110207
UR  - https://doi.org/10.1016/j.jaccas.2026.110207
AB  - Background: Systematic left atrial appendage (LAA) exclusion during mitral valve surgery reduces thromboembolic risk in patients with pre- or postoperative atrial fibrillation. Rare residual LAA-left atrial (LA) communications may occasionally occur after surgical exclusion and increase thromboembolic risk, particularly in patients not receiving anticoagulation.  Case Series: Among more than 2,000 robotic mitral valve surgeries performed at NYU Langone Health from 2010 to 2025, LAA closure with LA posterior wall plication was performed using a continuous back-and-forth suture technique. We identified 4 patients with elongated residual LAA-LA communications that were occult on transesophageal echocardiography (TEE) but clearly visualized by cardiac computed tomography angiography (CCTA). TEE demonstrated persistent echolucency and color Doppler flow within the excluded LAA without a visible communication entrance. A tubular channel extending from the LAA, termed the “panhandle sign,” was consistently observed. CCTA identified the communication orifices and guided successful transcatheter vascular plug closure.  Conclusions: Rare elongated residual LAA-LA communications may be missed on routine TEE after LAA exclusion with LA plication. Persistent LAA flow and echolucency should prompt CCTA to detect occult communications and guide percutaneous closure. The “panhandle sign” may represent an imaging marker specific to our institutional extended-suture technique that facilitates earlier recognition.
SN  - 2666-0849
ER  -