Management
Given the large LAAA with concomitant arrhythmias and risk of thromboembolism, the patient was advised to undergo surgery for removal of the aneurysm. There is potential risk of a perioperative thromboembolic event with minimally invasive surgical approach due to less controlled manipulation of the aneurysm during resection. The size of aneurysm and presence of thrombus by CT determined our surgical approach to be median sternotomy with cardiac arrest during cardiopulmonary bypass (CPB). This approach would give us the most controlled and low risk scenario during resection. The patient was placed on CPB after direct cannulation of ascending aorta and cannulation of right atrium via right common femoral vein approach. The aorta was cross clamped and Del Nido antegrade cardioplegia was delivered to the aortic root. Once the heart was decompressed, the large LAAA was visualized (Figure 5) and careful dissection was performed along the neck of the aneurysm. A 50 mm AtriCure clip was placed across base of the LAA and the aneurysm was resected (Figure 5, Video 1). Histopathological examination confirmed a thin walled LAAA.