forced separation of the left atrial ( la ) wall layers by blood , is known as left atrial dissection ( latd ) . latd is a rare and severe complication of cardiac surgery1 ) occurring in up to 0.84% of mitral valve replacements ( mvr).2 ) other rarer causes include mitral valve ( mv ) repair , aortic valve ( av ) surgeries , myocardial infarction , percutaneous coronary intervention , cardiac mass excision , left ventricular ( lv ) aneurysm repair , coronary artery bypass graft ( cabg ) , blunt cardiac trauma , pulmonary vein cannulation , infective endocarditis ( ie ) and spontaneous occurrence.1 ) it is most frequently associated with atrioventricular junction injuries . however , there are other less common cases including those remote from the atrioventricular junction.1 ) we report a case of infected latd after cabg , mvr , av and ascending aortic root replacement which was presented with disseminated intravascular coagulation ( dic ) and septicemia . to the best of our knowledge , this is the first report of la dissecting flap associated with infective vegetations which was identified by transesophageal echocardiography ( tee ) . a 69-year - old man was admitted in our hospital due to fever , chill , orthopnea and paroxysmal nocturnal dyspnea . in physical examination , he had undergone a major cardiac surgery including cabg , mvr , aortic valve replacement ( avr ) and ascending aorta replacement due to severe coronary artery disease , significant valvular heart disease ( rheumatic ) and aneurysmally dilated ascending aorta , 75 days prior to his recent admission . an electrocardiogram revealed atrial fibrillation rhythm , normal axis and non - specific st - t changes in inferior and lateral leads ( fig . transthoracic echocardiography followed by tee showed normal lv size with preserved systolic function , bioprosthetic mv with acceptable hemodynamic and mobility and no paravalvular regurgitation . there was normal functioning ascending aorta dacron tube graft without leakage from proximal and distal part of prosthesis . two homogenous particles ( 1.18  0.4 cm and 0.9  0.58 cm ) were attached to the dissecting flaps which were highly suggestive for vegetations and ie ( fig . 2 , 3 , and 4 , supplementary movie 1 , 2 , and 3 ) . laboratory tests showed severe coagulopathy , high levels of fibrin degradation products , leukocytosis ( white blood cells count : 26700/cm , predominantly poly morphonucleated ) , severe anemia , thrombocytopenia , elevated liver enzymes and serum creatinine levels . he suffered from tonic - clonic seizures , diminished consciousness , widespread mucosal bleeding and oliguria . he received infusion of fresh frozen plasma , packed cells , valproic acid , diazepam and phenytoin . based on his poor general condition , cardiac surgery was not performed and finally he expired from multi organ failure . latd is defined as a gap from the mitral annular area to the la wall , developing a new cavity with or without connection into the true la . the false chamber presents as an echolucent area and may cause partial elimination of atrial cavity.3 ) similar to what happens in aortic dissection , the false chamber may be compressed during ventricular systole as la is being filled.4 ) the etiology of latd after mvr is unknown . suggested causes include : inappropriate suturing of the annulus to the prosthesis , inadvertent trauma to the posterior part of mitral annulus , intense debridement of the annulus , intense tension on posterior annulus sutures and inadvertent injury to the la endocardium during atrial thrombectomy.5 ) suggested etiologies for latd after avr are division of the non - coronary aortic annulus and entrance into the la wall due to removal of calcification or inadvertent incision of lv outflow tract.2 ) la wall is formed by two muscular layers that are longitudinally and circumferentially aligned . disruption in this site may be a predisposing factor for latd.2 ) in our case , dissecting flap was remote from the atrioventricular junction . time to presentation of latd after mvr ranged from 1 day to 9 years.3 ) in our patient , it was diagnosed after seventy five days . reported clinical presentations include : acute low output syndrome and congestive heart failure in the immediate post - operative period , symptoms of moderate cardiac failure , persistent fever or it may be an incidental finding during routine echocardiography assessment.3 ) our patient presented as persistent fever and progressive dyspnea . dyspnea might be caused by bilateral severe pneumonia with parapneumonic effusion , septicemia and dic . tee clearly improved the diagnostic capacity of echocardiography as a technique of choice in the semi - invasive diagnosis of latd.3 ) latd usually requires surgical treatment to stop blood flow to the false chamber.3 ) rupture of atrial wall with fistula formation into the la or rupture into the pericardial space with bleeding or tamponade may occur . also , pulmonary vein obstruction with reduced blood return and pulmonary edema have been reported.3 ) in patients with latd and no or minimal symptoms , close follow - up is recommended.5 ) in conclusion , previous cardiac surgery seems to be the main risk factor for developing latd . our study showed that a complicated infective flap in la wall can be a source for producing septic systemic emboli and dic . to the best of our knowledge , this form of la dissecting flap has not been reported in the literature previously .
left atrial dissection ( latd ) , defined as the forced separation of the left atrial ( la ) wall layers by blood , is a rare and severe complication of cardiac surgery . 
 it is most frequently associated with atrioventricular junction injuries . 
 we report a case of infected latd after coronary artery bypass graft , mitral valve replacement , aortic valve replacement and ascending aortic root replacement . 
 the patient was presented with septicemia and disseminated intravascular coagulation . to the best of our knowledge , 
 this is the first case report of la dissecting flap concomitant with attached infective vegetations identified by transesophageal echocardiography .