**Introduction/Hypothesis:**
Background: LV-LAA fistula is a rare complication following mitral valve surgery and, to our knowledge, has only been reported once in the literature. It may present with nonspecific symptoms of mitral valve regurgitation or a decline in cardiac function, but it can also be clinically silent. Diagnosis largely depends on advanced cardiac imaging with cardiac CT/MR and echocardiography.

**Methods**
Case: A 72-year-old woman presents for atrial flutter evaluation and ablation workup and was found to have a large fistula connecting the LV to LAA, with resulting enlargement of the LAA to 1.9 x 2 cm. She had an extensive cardiac surgical history dating back to 2000, when she had her first mitral valve surgery for mitral valve regurgitation (MVR) and subsequently had two additional mitral valve replacements in 2004 and 2005. She underwent left atrial appendage clipping during one of the prior cardiac surgeries. The LV-LAA fistula was deemed unamenable to percutaneous or surgical management, and the patient was followed over time with cardiac CT and echocardiography. In March 2018, surveillance revealed an increased size of the LAA and resulting “systolic posterosuperior motion” of the bioprosthetic mitral valve leaflet secondary to turbulent flow from the LV into the LAA with worsening mitral regurgitation. She also experienced worsening dyspnea with a decline in ejection fraction to 34%. She underwent extensive cardiac surgery with mitral valve replacement, tricuspid valve repair, and repair of the LV-LAA fistula. Post-op imaging showed a decreased size of the LAA, resolution of MVR, and an increase in EF to 51%.

**Results**
Discussion: LV-LAA are extremely rare and are thought to be caused primarily by surgical technique. Forceful retraction of the LV, extensive papillary muscle resection, and impingement by a prosthesis strut may all be implicated. Complications include large pericardial effusion, rupture, and acute/chronic heart failure. In our patient with extensive cardiac surgery history, it is likely to have been multifactorial. Advanced cardiac imaging is crucial in managing LV-LAA fistula and assesses size, location, and cardiac function over time. Annual imaging showed stability of her fistula and LAA size, and conservative management was continued. Ultimately, she became symptomatic with a measurable decline in cardiac function and underwent surgical repair. Percutaneous repair has also been reported in the literature. To date, the patient tolerated surgery well and has trivial MVR with stable size of her LAA.

**Conclusion**
Conclusion: Our case highlights the utility of cardiac imaging in managing LV-LAA fistula. To our knowledge, this is the first case of longitudinal imaging follow-up and demonstrated that while stable over time, they may eventually become symptomatic and require correction. We pursued annual imaging follow-up, though no official criteria exist due to the rarity of this entity. Patients should be managed based on the clinical picture, and repair may be done surgically or percutaneously.



The Great Ventricular Escape: A Rare Case of Left Ventricule to Left Atrial Appendage Fistula.

This course will explore basic and cutting-edge imaging techniques to improve patient care and hone individual skills in performance and interpretation of echocardiography, nuclear cardiology, cardiac computed tomography, and cardiovascular magnetic resonance imaging. Days will reinforce how cardiovascular imaging may improve comprehension in ischemic heart disease, structural heart disease, cardiomyopathies, and heart failure. Experts will utilize novel techniques to reinforce key topics including taped interventional cases and a strong emphasis on case presentations.