Graphical Abstract
We fully agree that one of the main lessons from this case is the potentially deceptive nature of early hemodynamic stability. Despite the absence of overt clinical deterioration, serial transesophageal echocardiography (TEE) demonstrated progressive expansion of the false lumen (FL) with increasing impairment of left ventricular (LV) inflow.1 These findings anticipated clinical deterioration and reinforced our belief that management should be guided by anatomical evolution rather than clinical status alone. TEE should therefore be regarded not only as a diagnostic modality but also as the cornerstone of continuous anatomical and hemodynamic monitoring, enabling timely recognition of disease progression.2
We also appreciate the emphasis on multimodality imaging. The success of the procedure relied on the complementary strengths of 3-dimensional TEE and cardiac computed tomography. Beyond procedural planning and device selection, multimodality imaging elucidated the hemodynamic implications of left atrial dissection (Figure 1). Progressive expansion of the FL impaired left atrial reservoir function, compromising LV diastolic filling. Persistent systolic run-off from the LV into the FL reduced effective forward stroke volume. At the same time, the residual interatrial septal fenestration partially decompressed the FL, likely accounting for the initial preservation of hemodynamic stability despite ongoing anatomical progression.
Figure 1.
Hemodynamic Implications of Left Atrial Dissection
FL = false lumen; IAS = interatrial septum; LA = left atrium; LV = left ventricle.
These findings show that the hemodynamic consequences of left atrial dissection extend beyond cavity expansion and reflect the interplay among impaired atrial compliance, LV volume loss, and dynamic intracardiac shunting.
Finally, closure of the residual interatrial communication was a key procedural step. Once LV run-off into the FL had been abolished, the residual interatrial septal fenestration became the principal source of FL pressurization, emphasizing the dynamic nature of intracardiac flow after structural intervention and the importance of continuous imaging guidance. Although this complication remains exceptionally rare, our case underscores how understanding its hemodynamic mechanisms, integrated with Heart Team decision-making, multimodality imaging, and transcatheter intervention, can enable successful treatment of carefully selected patients with prohibitive surgical risk.
Footnotes
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors thank Dr Mustafa for his thoughtful comments and interest in our report. His observations provide an opportunity to emphasize further key lessons from the management of this rare and life-threatening complication.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
References
- 1.Cristiano M., Santoro G., Romano A., et al. Percutaneous closure of an atrioventricular groove rupture causing a left atrial dissection after cardiac surgery. JACC Case Rep. 2026;31(29) doi: 10.1016/j.jaccas.2026.108577. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Fukuhara S., Dimitrova K.R., Geller C.M., Hoffman D.M., Ko W., Tranbaugh R.F. Left atrial dissection: etiology and treatment. Ann Thorac Surg. 2013;95(5):1557–1562. doi: 10.1016/j.athoracsur.20612.12.041. [DOI] [PubMed] [Google Scholar]