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.
Key words: atrial appendage anatomy, cardiac computed tomography, endocardial suture technique, residual communication, transesophageal echocardiography, vascular plug intervention
Visual Summary
Left atrial appendage (LAA) exclusion includes surgical and percutaneous approaches such as excision, epicardial clipping or suturing, endocardial suturing, and device-based occlusion.1 Among anticoagulated patients with preoperative atrial fibrillation, Third Left Atrial Appendage Occlusion Study III demonstrated that surgical LAA closure significantly reduces thromboembolic events.2 Despite these benefits, incomplete LAA exclusion remains an important clinical concern and may maintain a thromboembolic risk when residual LAA-left atrial (LA) communication persists.3 Percutaneous occlusion using closure devices of these LAA-LA communications has been shown to be safe and effective in prior reports.4,5
Robotic mitral valve (MV) surgery with endocardial suture closure of the LAA has demonstrated high procedural success rates6,7 in contrast to those of traditional open endocardial LAA ligation.3 In addition, our institution uniquely uses an extended suture-line technique combining LAA closure with LA plication to further reduce stroke risk, an approach that has not previously been described in the literature (Supplemental Figure 1). This approach uses a double suture line to close the LAA, with a running suture from right to left followed by an interlocking back-and-forth suture from left to right. The suture also plicates the posterior LA wall between the left inferior pulmonary vein and mitral annulus, improving MV exposure by preventing LAA intumescence while simultaneously achieving LAA closure and LA size reduction. Because this posterior wall segment contributes substantially to LA dilation, its plication may further reduce LA size. Although the continuous back-and-forth suture may rarely create a residual channel between the LAA and LA, the fibrous LAA-LA junction should permit tighter suture tensioning and minimize this risk.
With an institutional experience of more than 2,000 patients undergoing this approach, we present 4 cases of a rare tubular communication following robotic endocardial LAA suture closure with LA plication during MV surgery. These cases illustrate the evolution of our recognition of findings incompletely characterized on transesophageal echocardiography (TEE) to identification of imaging features prompting multimodality evaluation. This series also demonstrates successful transcatheter vascular plug occlusion of these communications, although their clinical significance remains uncertain.
Patient 1
A 61-year-old man with a history of MV repair with surgical LAA suture exclusion and LA plication was referred for TEE to evaluate LAA closure. Shortly after surgery, he presented with slurred speech and was diagnosed with an acute left middle cerebral artery infarction. There was no atrial fibrillation on long-term cardiac monitoring.
Preprocedural TEE demonstrated an elongated channel extending from the LAA with no spontaneous echo contrast or thrombus within the LAA (Figures 1A and 1B). Standard imaging planes revealed persistent LAA color flow Doppler despite no obvious communication (Figures 1C and 1D) (Video 1). Intravenous administration of an ultrasound-enhancing agent demonstrated opacification of the LAA (Figures 1E and 1F), with contrast agent entering the LAA from the posterior aspect, implying a distal communication outside of the standard views (Video 2). The patient underwent preprocedural cardiac computed tomography angiography (CCTA) for detailed anatomical characterization of the atypical communication in preparation for eventual transcatheter occlusion.
Figure 1.
Ultrasound-Enhancing Agent Opacification of the LAA
(A and B) Transesophageal echocardiography of the left atrial appendage (LAA) at 135° showing an elongated channel extending from the LAA. (C and D) Multiple transesophageal echocardiography views of the LAA and channel showing persistent color flow Doppler signal within the LAA and no flow crossing the LAA into the left atrium (LA) at the expected suture closure site. (E and F) Intravenous ultrasound-enhancing agent is shown flowing into the LAA posteriorly (circles), suspected to be from a posterior communication because of the direction of contrast agent inflow. Notice there is no contrast agent flowing from the expected site.
Patient 2
A 73-year-old man with prior robotic MV repair with LAA suture closure and LA plication and paroxysmal atrial fibrillation was referred for TEE to assess for LAA exclusion in hopes of discontinuing anticoagulation while undergoing facial radiation therapy for melanoma.
TEE at a multiplane angle of 135° of the LAA revealed an elongated tubular channel, similar to that observed in the prior case (Figure 2A). Color flow Doppler of the expected suture line did not demonstrate any flow across the channel despite persistent flow within the echolucent LAA, suggesting occult communication (Figure 2B, Video 3). CCTA confirmed a patent tubular channel connecting the LAA to the LA, depicting the “panhandle” morphology in 3 dimensions (Figures 2C and 2D). The LA entrance was located near the P2 to P3 junction and measured 9 × 5 mm (Figures 2E and 2F). Although the potential thromboembolic risk associated with this residual communication is uncertain, the patient was referred for transcatheter occlusion of the residual LAA communication.
Figure 2.
Characterization of the “Panhandle” Sign
(A) Transesophageal echocardiography of the left atrial appendage (LAA) at 135° clearly showing the tubular channel forming the “panhandle” sign with the LAA. (B) Transesophageal echocardiography of the LAA and channel showing persistent color flow Doppler signal within the LAA and no signal crossing the LAA into the left atrium (LA). (C) Three-dimensional reconstructed cardiac computed tomography angiography on 3mensio structural heart software (Pie Medical Imaging) at left anterior oblique (LAO) 152° and cranial (CRA) 30° projection visualizing the elongated LAA-LA channel extending from the LAA (highlighted) and coursing parallel to the mitral annuloplasty band. (D) Transesophageal echocardiography “panhandle” configuration matched to 3-dimensional cardiac computed tomography angiography orientation, demonstrating morphologic similarity. (E) 3-dimensional reconstructed cardiac computed tomography angiography on 3mensio demonstrating the oval-shaped LA entrance of the LAA-LA communication. (F) The LA orifice measured 9 × 5 mm. LLPV = left lower pulmonary vein; LUPV = left upper pulmonary vein.
Patient 3
A 69-year-old woman with prior robotic MV repair with LAA suture closure and LA plication and paroxysmal atrial fibrillation presented with recurrent falls attributed to gait instability from newly diagnosed amyotrophic lateral sclerosis. Given her increased risk of bleeding, she was initially referred for TEE to assess her LAA to guide anticoagulation management. TEE revealed the “panhandle” sign, but no clear communication was identified despite persistent color flow Doppler within the echolucent LAA. She was referred for CCTA to identify the occult communication.
CCTA clearly demonstrated the “panhandle” morphology of the LAA channel (Figure 3A) and revealed an irregularly shaped LA orifice to the channel lying posterior to the P2 scallop (Figures 3B to 3C). The LA orifice to the channel measured 4 × 7 mm (Figure 3C).
Figure 3.
Identification of the LAA-LA Channel Entrance
(A) Three-dimensional reconstructed cardiac computed tomography angiography on 3mensio structural heart software at left anterior oblique (LAO) 133° and cranial (CRA) 15° projection visualizing the tubular left atrial appendage–left atrium (LAA-LA) channel arising from the LAA (highlighted) coursing relatively parallel to the mitral annuloplasty band. (B and C) 3-dimensional reconstructed cardiac computed tomography angiography on 3mensio at multiple views revealing the irregularly shaped LA entrance of the LAA-LA communication. (D) The LA orifice measured 4 × 7 mm at its widest dimensions. RAO = right anterior oblique; abbreviations as in Figure 2.
Despite an indeterminate thromboembolic risk, the patient was referred for transcatheter occlusion of the residual LAA communication, which was conducted with multimodality imaging guidance. CCTA showed the channel neck adjacent to and parallel with the posterior aspect of the annuloplasty band, which was used as a landmark on fluoroscopy. Visualization of the LAA channel was achieved with contrast agent injection, and a guidewire was advanced to its neck using the mitral annuloplasty band as a fluoroscopic landmark (Figures 4A and 4B, Video 4). A 10-mm Amplatzer Vascular Plug (AVP) II (Abbott) was deployed at the neck of the channel with postdeployment contrast agent injection demonstrating complete occlusion (Figures 4C and 4D). At 1-month follow-up, CCTA confirmed there was no significant gap around the occlusion device (Figure 5), and anticoagulation was discontinued.
Figure 4.
Fluoroscopy Images During Transcatheter Closure of the Residual Left Atrial Appendage–Left Atrium Communication
(A) Contrast agent injection into the left atrium demonstrating the tubular left atrial appendage–left atrium channel (circle), with the mitral annuloplasty band used as a fluoroscopic landmark to align the guidewire. (B) Advancement and anchoring of the guidewire within the left atrial appendage–left atrium channel, with contrast agent injection confirming position within the channel. (C) Deployment of 10-mm Amplatzer Vascular Plug II device within the neck of the channel. (D) Detachment and release of the Amplatzer Vascular Plug II device.
Figure 5.
CCTA Follow-Up 1 Month After Device Deployment
At 1-month follow-up, cardiac computed tomography angiography demonstrated no significant gap around the Amplatzer Vascular Plug II device in multiple 2-dimensional planes (A to C) and 3-dimensional reconstruction on 3mensio (D). Abbreviations as in Figure 2.
Patient 4
A 68-year-old woman with a history of atrial fibrillation and prior robotic MV repair with LAA suture closure and LA plication underwent TEE to evaluate for LAA exclusion and potential discontinuation of anticoagulation because of increased bleeding risk.
TEE of the LAA was notable for the “panhandle” sign (Figure 6A). Immediately, an obvious communication was shown between the posterior aspect of the LAA and the LA with bidirectional flow on color Doppler (Figure 6B, Video 5). Despite the “panhandle” configuration, the distal suture lines were not interrogated because of the presence of an obvious communication. The patient was referred for transcatheter occlusion. Subsequent preoperative CCTA revealed 2 distinct sites of residual communication (Figure 6D). The dominant orifice was located near the mitral P2 segment at the distal end of the suture line not assessed on TEE, measuring approximately 9 × 7 mm (Figure 6E). The smaller communication coursed along the posterior aspect of the LAA, measuring approximately 4 × 3 mm (Figure 6F).
Figure 6.
Identification of Two LAA-LA Communications
(A) Two-dimensional transesophageal echocardiography of the left atrial appendage (LAA) at 135° demonstrating the “panhandle” sign. (B) 2-dimensional transesophageal echocardiography at 0° at the plane of P2 of the mitral valve revealing a clear color flow Doppler jet crossing the oversewn LAA into the left atrium (LA). (C) 2-dimensional cardiac computed tomography angiography at left anterior oblique (LAO) 42° and caudal (CAU) 40° projection now revealing 2 LAA-LA communications with contrast agent opacification in the LAA. “LA Orifice 1” creates a “speech bubble” sign with the LAA. (D) Three-D-reconstructed cardiac computed tomography angiography on 3mensio structural heart software at LAO 65° and CAU 11° displaying the 2 LA orifices. (E) The more proximal orifice, “LA Orifice 1,” measures 4 × 3 mm. (F) The distal, dominant “LA Orifice 2” measures 9 × 7 mm. Abbreviations as in Figures 2 and 3.
Transcatheter occlusion of the residual LAA communications was performed with multimodality imaging guidance. An 8-mm AVP IV (Abbott) was deployed at the smaller, posterior LAA communication (Figure 7A and 7B), and a second AVP IV was deployed within the channel (Figure 7C). After deployment, dense spontaneous echo contrast (“smoke”) was noted in the LAA, indicating successful occlusion (Figure 7D). Anticoagulation was discontinued 10 weeks postprocedure.
Figure 7.
Three-Dimensional Transesophageal Echocardiography During Transcatheter Closure of the Residual Left Atrial Appendage–Left Atrium (LAA-LA) Communication
(A) 3-dimensional transesophageal echocardiography guiding placement of the guidewire into the smaller, proximal orifice (“LA Orifice 1”) of the LAA-LA communication. (B) Two-dimensional transesophageal echocardiography confirming precise placement of the 8-mm Amplatzer Vascular Plug IV device within the orifice. (C) Three-dimensional transesophageal echocardiography guiding placement of the guidewire into the larger, distally located orifice (“LA Orifice 2”) of the LAA-LA communication adjacent to the first Amplatzer Vascular Plug IV device. (D) Two-dimensional transesophageal echocardiography confirming deployment of the second 8-mm Amplatzer Vascular Plug IV device within the channel, occluding the second LA orifice. Spontaneous echo contrast is noted within the LAA, supporting successful occlusion of the residual LAA communications.
Discussion
This series describes an uncommon form of incomplete LAA exclusion following our institution's extended LAA closure and LA plication technique. The central observation across all 4 patients was persistent color Doppler flow within an echolucent LAA despite the absence of a clearly visualized communication along the expected closure line on routine TEE.
In the first patient, this discrepancy raised suspicion for a residual communication that could not be identified using standard imaging planes. Administration of an ultrasound-enhancing agent demonstrated contrast agent entering the LAA from a posterior location, suggesting a distal communication along the elongated channel. Because the entry site could not be clearly defined, CCTA was pursued. This case highlighted an important limitation of TEE in patients undergoing our unique LAA closure technique, in which the suture line extends beyond the native LAA margins because of concomitant LA plication (Supplemental Figure 1), leaving portions of the closure not routinely assessed on TEE.
As additional patients were evaluated, a recurring morphologic pattern became apparent. The presence of an elongated tubular channel extending from the LAA led to recognition of a distinct imaging finding that we termed the “panhandle” sign. This morphology is best appreciated at a multiplane angle of approximately 135°, where the tubular extension (the “handle”) from the LAA (the “pan”) becomes more apparent. Importantly, the “panhandle” sign served as a secondary indicator of a residual communication in addition to persistent color Doppler flow within an echolucent LAA. Although observed consistently in our series, this morphology may be specific to our LAA closure-LA plication technique. Notably, all 4 distal communications occurred at the distal end of the LA plication suture line (Supplemental Figure 1). Given the limited number of cases, no common LA or LAA morphology associated with residual communication formation could be identified, and the mechanism and timing of channel formation remain uncertain.
These cases also highlighted several technical limitations of TEE for identifying these communications. Distal residual communications often require a high, posteriorly directed insonation angle, which can limit image quality and make detection challenging. In addition, color flow Doppler assessment may be unreliable because the Doppler jet can lie parallel to the ultrasound beam or become obscured by transmitral flow. TEE nevertheless remains an appropriate initial imaging modality because it provides dynamic assessment of residual flow, thrombus, spontaneous echo contrast, and concomitant valvular pathology without radiation or contrast agent exposure. When TEE demonstrates persistent color Doppler flow within the LAA, the “panhandle” sign, or otherwise suspicious or inconclusive findings, CCTA provides comprehensive 3-dimensional interrogation of the suture line and may identify occult or multiple communications, as demonstrated in the fourth case. These findings also suggest that routine postbypass TEE interrogation of the surgically excluded LAA may be advantageous, even when direct surgical inspection suggests complete closure. The proposed diagnostic pathway is depicted in the Visual Summary. The fourth case also demonstrated the “speech bubble” sign, previously described by Nakayama et al,8 involving the more proximal communication at the native LAA margins.
Beyond diagnosis, CCTA was crucial for preprocedural planning and follow-up after occlusion of these communications, consistent with prior studies evaluating residual leaks after LAA closure.9,10 Transcatheter occlusion requires careful assessment of channel anatomy and its relationship to adjacent structures, which CCTA readily provided. In particular, CCTA defined the relationship between the communication and the mitral annuloplasty band, which subsequently served as a fluoroscopic landmark for catheter alignment. Unlike broad peri-device leaks, these distal tubular communications typically have narrow channels well suited for vascular plug or coil occlusion. Device selection should favor oversizing relative to the smallest channel diameter to ensure stable anchoring without protrusion into the LA or LAA. After device deployment, the proceduralist may use dense spontaneous echo contrast developing within the LAA as a marker of successful LAA communication occlusion, as demonstrated in the fourth case.
Although concern for thromboembolic risk motivated closure in these patients, the true stroke risk associated with incomplete LAA exclusion using this technique remains unknown, particularly given the small residual channels and the uncertain likelihood of retrograde thromboembolism from the LAA into the systemic circulation. Management is therefore currently extrapolated from other forms of incomplete LAA exclusion.3 Likewise, the prevalence of these communications following our surgical technique remains undefined but is likely low, given our institutional experience of more than 2,000 robotic MV procedures. Further investigation is needed to clarify their incidence, mechanism of formation, natural history, and clinical consequences.
Conclusions
These cases describe an uncommon form of incomplete LAA exclusion following our institution's extended LAA closure and LA plication technique. Persistent color Doppler flow within an echolucent LAA, despite the absence of a clearly visualized communication along the expected closure line, was the key finding prompting further evaluation with multimodality imaging. As experience accumulated, recognition and dissemination of a recurring imaging pattern, which we termed the “panhandle” sign, facilitated earlier suspicion of distal residual communications and more targeted diagnostic evaluation. Although this morphology is likely specific to our surgical technique, these cases illustrate how institutional pattern recognition can improve detection of previously underrecognized postoperative findings. Our experience further highlights the limitations of standard TEE alone for identifying complex or occult residual communications and the importance of CCTA in diagnosis, procedural planning, and follow-up. The mechanism, prevalence, and clinical significance of these uncommon LAA-LA communications remain uncertain and warrant further investigation.
Visual Summary.
Diagnostic Pathway of Elongated LAA-LA Communications Formed After Robotic LAA Suture Closure and LA Plication
After endocardial suture closure of the LAA with LA plication, a channel between the LAA and LA is likely formed post-bypass. Identification of persistent color Doppler flow within the echolucent LAA along with the "Panhandle" sign should prompt multimodality imaging. LAA-LA = left atrial appendage–left atrium; LIPV = left inferior pulmonary vein; MV = mitral valve.
Funding Support and Author Disclosures
Dr Chinitz has received honoraria from and served as a consultant for Abbott. Dr Aizer has received electrophysiology fellowship support from Abbott, Biosense Webster, Boston Scientific, and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Take-Home Messages
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Residual LAA–left atrial communications may very infrequently form after robotic endocardial suture closure despite apparently successful exclusion on routine transesophageal echocardiography, particularly when elongated distal channels are present because of extended-suture closure techniques.
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Persistent color flow Doppler within the LAA remnant or visualization of an elongated tubular channel from the LAA, the “panhandle” sign in our cases, should prompt rigorous higher-angle interrogation of the distal suture line with color flow Doppler and multimodality imaging with cardiac computed tomography angiography.
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These tubular residual communications often demonstrate a defined axis and narrow neck that are well suited for transcatheter vascular plug occlusion when appropriately characterized by cardiac computed tomography angiography.
Footnotes
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.
Appendix
For supplemental videos and a figure, please see the online version of this paper.
Appendix
Transesophageal Echocardiography Views of the Left Atrial Appendage Showing Persistent Color Flow Doppler Signal Within the Left Atrial Appendage and No Flow Crossing the Left Atrial Appendage Into the Left Atrium at the Expected Suture Closure Site
Intravenous Ultrasound-Enhancing Agent Is Shown Flowing Into the Left Atrial Appendage Posteriorly, Suspected to Be From a Posterior Communication Because of the Direction of Contrast Agent Inflow
Transesophageal Echocardiography of the Left Atrial Appendage Showing Persistent Color Flow Doppler Signal Within the Left Atrial Appendage and No Signal Crossing the Left Atrial Appendage Into the Left Atrium
Fluoroscopy Videos During Transcatheter Closure of the Residual Left Atrial Appendage–Left Atrium Communication Using a 10-mm Amplatzer Vascular Plug II
Transesophageal Echocardiography at 0° at the Plane of P2 of the Mitral Valve Revealing a Clear Color Flow Doppler Jet Crossing the Oversewn Left Atrial Appendage Into the Left Atrium
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Associated Data
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Supplementary Materials
Transesophageal Echocardiography Views of the Left Atrial Appendage Showing Persistent Color Flow Doppler Signal Within the Left Atrial Appendage and No Flow Crossing the Left Atrial Appendage Into the Left Atrium at the Expected Suture Closure Site
Intravenous Ultrasound-Enhancing Agent Is Shown Flowing Into the Left Atrial Appendage Posteriorly, Suspected to Be From a Posterior Communication Because of the Direction of Contrast Agent Inflow
Transesophageal Echocardiography of the Left Atrial Appendage Showing Persistent Color Flow Doppler Signal Within the Left Atrial Appendage and No Signal Crossing the Left Atrial Appendage Into the Left Atrium
Fluoroscopy Videos During Transcatheter Closure of the Residual Left Atrial Appendage–Left Atrium Communication Using a 10-mm Amplatzer Vascular Plug II
Transesophageal Echocardiography at 0° at the Plane of P2 of the Mitral Valve Revealing a Clear Color Flow Doppler Jet Crossing the Oversewn Left Atrial Appendage Into the Left Atrium