The missing left atrial appendage

A 34 year old man underwent a transesophageal echocardiogram (TEE) prior to implantation of a biventricular ICD and DC cardioversion, to exclude left atrium and left atrial appendage thrombus. He had a history of repaired tetralogy of Fallot as a child, Stickler syndrome, atrial flutter and was status post recent mitral valve replacement, pulmonary valve replacement and tricuspid valve repair. The left atrial appendage was not visualized on TEE. A cardiac CT clarified that there was a left atrial appendage and provided an explanation as to why it was not visualized on TEE, highlighting the importance of multimodality imaging in patients with complex congenital heart disease.