While the prevalence of LHAS was initially estimated to be around 2-8% in the general population, recent studies have found this figure to be as high as 43% in cardiac surgery patients. A higher prevalence has been found in patients who are obese, Caucasian, in the sixth and seventh decade of life, and women. Although LHAS is frequently a benign finding, the disorder can rarely present with a wide range of cardiac complications, including atrial arrhythmias. We present a case of large LHAS diagnosed incidentally on pre-operative imaging with subsequent successful completion of a CABG procedure. Our patient initially presented with multiple ectopic rhythm disturbances, which have been reported in association with LHAS, and sinus bradycardia in the postoperative period managed with dual chamber pacing. Our patient’s risk factors for this pathology include obesity, female sex, Caucasian race, age in the sixth-seventh decade, and coronary artery disease. As the prevalence of this disorder seems to be higher than that initially thought, it is critical for anesthesiologists to account for its potential complications in the perioperative period. Perioperative arrhythmias have been shown to prolong hospital stays and are associated with increased morbidity and mortality among patients. Arrhythmias arising under general anesthesia and in the postoperative period can be severe. While atrial arrhythmias are typically well tolerated in younger patient populations, they have been associated with life-threatening hemodynamic instability in elderly patients, the age demographic commonly presenting with LHAS. Although not displayed here, a bubble study is also to be considered as this pathology has also been associated with a patent foramen ovale (PFO). Other considerations include potential challenges with numerous surgical approaches and percutaneous interventions. Namely transseptal catheterization or bicaval cannulation.

Anesthesiologists must be aware of these potential risks and be prepared to identify and collaborate on the medical management of challenging arrhythmias or structural heart obstacles throughout the perioperative period.

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