'Floating' left atrial appendage in an infant with chylopericardium.

To cite: Vijayalakshmi IB, Agrawal N, Mallikarjun K, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013200275 DESCRIPTION We present an interesting image of a ‘floating left atrial (LA) appendage’ in a 5-month-old female infant with pericardial tamponade. Clinical features of respiratory distress, lethargy and difficulty in suckling were present and the jugular venous pressure ( JVP) was raised, although the wave forms were not easily assessable due to the child being in respiratory distress and uncooperative. The echocardiographic evaluation revealed the signs of tamponade along with another interesting finding that the left atrial appendage (LAA) was elongated and membrane like and was freely moving and ballooning with atrial contraction in the pericardial fluid around it as though ‘floating’. Cath tracings were not performed as the first priority was an emergency lifesaving pericardiocentesis. There was another abnormal bulge posterolaterally. The other cardiac chambers were normal and there was no obvious echocardiographic evidence of any pressure overload of LA in the form of LA dilation (figures 1 and 2; see videos 1–4). Pericardiocentesis revealed the presence of chylous fluid. (figure 3). CT confirmed the finding and revealed no mediastinal or cardiac mass and no obvious thoracic duct anomaly (figure 4). The child was planned for conservative management followed by thoracic duct ligation if required in view of the high surgical risk in exploratory thoracotomy in absence of a definite diagnosis and a definitive understanding of the pathophysiology. On follow-up at 1 month the appendicular abnormality had recovered completely and the fluid had decreased. This is an unusual interesting image of membranous LAA in an infant with large chylous PE.