Case report:
A previously fit and well 29 years old female, presented to our hospital with gradually progressive shortness of breath and pedal oedema, after giving birth to a child 2 months ago. 2D Echo revealed an ejection fraction less than 10% with dilated ventricles. A diagnosis of peripartum cardiomyopathy was made and she was commenced on heart failure medications. Patient had poor response to medical management and suffered a cardiac arrest in the hospital. Post successful resuscitation, it was decided to consider her for heart transplant. Considering the COVID epidemic and paucity of available donors, it was decided to support her mechanically with a left ventricular assist device (LVAD). After an uneventful LVAD (HVAD, HeartWare, Medtronics Inc, Minnesota MN, USA) implantation via midline sternotomy and standard cardiopulmonary bypass, device was activated and the revolutions on the pump were steadily increased to 2600 RPM for de-airing on cardiopulmonary bypass. The power on the LVAD device increased to a maximum of 7.5 Watts and the flows dropped. As the de-airing proceeded a suspicious hyper-echoic mass was noted in the left atrium on TEE leading to confusion of a LA clot. Inversion of left atrial appendage was suspected since the pre-CPB trans-esophageal echocardiogram showed no LA clot and it was unlikely that a new clot would form in an anticoagulated patient on CPB. The LVAD flows were reduced and re-examination of the left atrium by the surgeon revealed an inverted appendage, which was promptly everted with help of a forceps. LA mass disappeared, LVAD flows stabilised and the power utilization immediately dropped to 3.2 Watts. The patient made an uneventful recovery and was discharged from the hospital within 2 weeks of surgery.