Staged hybrid ablation in left atrial appendage aneurysm a rare cause of refractory atrial tachyarrhythmia - a case report

LAAA is a rare cardiac anomaly which can be congenital or acquired in origin. Because most cases are asymptomatic, it is typically diagnosed incidentally in 2nd to 3rd decades of life. We present a case of 28-year-old male with refractory atrial tachyarrhythmias and significantly reduced exercise tolerance. The informed consent was given by patient for this manuscript. We present a case of 28-year-old male with refractory atrial tachyarrhythmias, and significantly reduced exercise tolerance after an episode of COVID respiratory infection. He was referred by primary care physician for management of AF with CHA2DS2Vasc score zero. He had documented AF and AFL resistant to both chemical and electrical cardioversion. Initial portable focused TTE documented borderline reduced LVEF in context of AFL. Electrophysiological study confirmed diagnosis of typical atrial flutter. Successful radiofrequency ablation of cavo-tricuspid isthmus resulted in bidirectional isthmus conduction block. However, patient developed AF which was electrically cardioverted at the end of procedure. Patient was discharged on Bisoprolol, Ramipril and Apixaban and outpatient cardiac MRI was organised to look for post COVID myocardial scarring. Patient had recurrence of symptoms, this time it was due to AF. Multimodal imaging led to discovery of LAAA, which after discussion in MDT he was accepted for and managed with surgical resection of LAAA with concomitant Cox Maze IV procedure. On 9 months post operative follow up patient is maintaining sinus rhythm and has completely returned to baseline activities. A young patient with refractory atrial arrhythmia should be referred for multimodal cardiovascular imaging to rule out any structural heart disease. LAAA is rare and can be managed conservatively, but surgical excision is most reported and appears to favour arrythmia free survival.