Echocardiography. 2018;1–3. wileyonlinelibrary.com/journal/echo | 1 © 2018 Wiley Periodicals, Inc. 1 | INTRODUCTION The left atrial appendage (LAA) plays a predominant role in intra- cardiac thrombus formation in the setting of non-valvular atrial fibrillation (NVAF). 1 Thrombi from this region of the left atrium (LA) are a leading cause of cardio-embolic events. 2 The absence of the LAA appears to be a rare pathology. The diagnosis of this structural abnormality is challenging and may require various dif- ferent imaging modalities. We present one such rare case of an individual being evaluated for a Watchman™ left atrial appendage closure (LAAC) device where the absence of the LAA was detected on transesophageal echocardiography (TEE) and subsequently confirmed with left atrial angiography and cardiac computed to- mography (CT). 2 | CASE REPORT A 79-year-old female with history of stable chronic obstructive pulmonary disease, hypertension, hyperlipidemia, diabetes melli- tus, heart failure with preserved ejection fraction and a ten-year history of persistent NVAF presented to the electrophysiology clinic for LAAC evaluation due to lower gastrointestinal bleeding needing transfusion and intolerance to therapeutic anticoagula- tion. During her initial evaluation, a TEE showed no evidence of a LAA. TEE demonstrated lack of a LAA at its expected origin from the LA on a short-axis view of the LA adjacent to the aortic valve (Figure 1, Movie S1). TEE was used to search the entire contents of the LA walls for the LAA. However, the LAA was not found. The three-dimensional (3D) TEE en-face view of the expected origin of the LAA helped to confirm this anomaly (Figure 2, Movie S2). Received: 11 May 2018 | Revised: 9 August 2018 | Accepted: 12 September 2018 DOI: 10.1111/echo.14151 CASE REPORT A curious case of an absent left atrial appendage Narayana Sarma V. Singam MD 1 | Rakesh Gopinathannair MD, MA 1 | Jeffrey M. Stidam MD 2 | Naresh K. Solankhi MD 2 | Matthew Bessen MD 2 | Marcus F. Stoddard MD 1 1 Division of Cardiology, University of Louisville, Louisville, Kentucky 2 KentuckyOne Health, Louisville, Kentucky Correspondence Marcus F. Stoddard, Division, Cardiovascular Medicine, University of Louisville, Louisville, KY. Email: mfstod01@louisville.edu The left atrial appendage (LAA) in the setting of non-valvular atrial fibrillation (NVAF) is the predominant location for intracardiac thrombus formation. An absent LAA is a very rare congenital cardiac anomaly. We present a case of a 79-year-old female with NVAF, high CHADS2VASC2 score, and high bleeding risk who presented for elective Watchman™ left atrial appendage closure device implant. A pre-procedural transesophageal echocardiography showed an absent LAA. This finding was con- firmed with cardiac computed tomography and a left atrial angiogram. The patient was discharged on medical therapy with close outpatient follow-up. KEYWORDS angiography, atrial fibrillation, computed tomography, congenital heart defects, left atrial appendage function, transesophageal echocardiography FIGURE 1 Transesophageal echocardiography short-axis view of the left atrium (LA). The expected opening (arrow) of the left atrial appendage between the aortic valve and the pulmonic vein (PV) is not present