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Zhu X, Li W, Chu H, Zhong L, Wang C, Li J, Liang P, Wang L, Shi L. Catheter ablation in combined procedures is associated with residual leaks. Front Cardiovasc Med 2023; 9:1091049. [PMID: 36818912 PMCID: PMC9928718 DOI: 10.3389/fcvm.2022.1091049] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 12/28/2022] [Indexed: 02/05/2023] Open
Abstract
Objectives To compare patients with atrial fibrillation (AF) undergoing left atrial appendage closure (LAAC) with catheter ablation (CA) and those without CA. Background The CA of AF may cause ridge edema, which may affect the safety of LAAC. Methods Patients with AF (N = 98) who underwent LAAC (combined CA + LAAC procedure group; N = 51) or alone (LAAC group; N = 47) received pre-procedural, intra-procedural, and 6 week post-procedural transesophageal echocardiography (TEE). The depth and ostial diameter of LAA, device compression, residual leak, and ridge thickness were evaluated in the patients who had undergone combined and alone procedures, as well as images of LAA and primary clinical characteristics. Results A residual leak was identified in 27 patients at 6 weeks after implantation by TEE (19 in the combined procedures group and eight in the alone group; p = 0.04). The combined procedure group had a significantly higher rate of a new residual leak than the alone group (25.5 vs. 8.5%; p = 0.03). Meanwhile, compared with at the time of implant, a smaller amount of device compression ratio was significant after 6 weeks (22.44 ± 3.90 vs. 19.59 ± 5.39; p = 0.03). There was no significant difference between both groups in all-cause mortality, cardiovascular mortality, and TIA/stroke/system embolism. Conclusion The combined procedures of CA and LAAC for AF are feasible and safe; however, during the follow-up period, we found that the resolution of ridge edema caused by CA might cause an increased residual leak and a smaller device compression ratio.
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Affiliation(s)
- Xuefeng Zhu
- Department of Cardiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Wenjing Li
- Doppler Ultrasonic Department, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Hongxia Chu
- Department of Cardiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Lin Zhong
- Department of Cardiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Chunxiao Wang
- Department of Cardiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Jianping Li
- Doppler Ultrasonic Department, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Pingping Liang
- Department of Cardiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Lihong Wang
- Doppler Ultrasonic Department, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Lei Shi
- Doppler Ultrasonic Department, Yantai Yuhuangding Hospital, Yantai, Shandong, China
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Hang D, Schmitt MC, Gonzalez LS, Zdanovec A, Pagel PS. Left Atrial Appendage Confusion: A Mobile Echodensity in a Patient With Endocarditis. J Cardiothorac Vasc Anesth 2022; 36:2829-2832. [PMID: 35144871 DOI: 10.1053/j.jvca.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Dustin Hang
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI.
| | - Michael C Schmitt
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Laura S Gonzalez
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Amber Zdanovec
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Paul S Pagel
- Anesthesiology Service, the Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
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Pour-Ghaz I, Heckle MR, Maturana M, Seitz MP, Zare P, Khouzam RN, Kabra R. Percutaneous Left Atrial Appendage Closure: Review of Anatomy, Imaging, and Outcomes. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2022; 24:41-59. [DOI: 10.1007/s11936-022-00958-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 11/29/2022]
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Deng B, Nie R, Qiu Q, Wei Y, Liu Y, Lv H, Zheng S, Wang J. 3D transesophageal echocardiography assists in evaluating the morphology, function, and presence of thrombi of left atrial appendage in patients with atrial fibrillation. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:876. [PMID: 34164510 PMCID: PMC8184463 DOI: 10.21037/atm-21-1981] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Left atrial appendage (LAA) is significantly more likely to form thrombi in patients with atrial fibrillation (AFib). Two-dimensional transesophageal echocardiography (2D TEE) is considered the gold standard for assessing and studying LAA morphology and anatomy. However, 2D TEE can only visualize one plane at any given time. Real-time three-dimensional echocardiography (RT-3D TEE) imaging can preserve spatial and temporal resolution, which is a safe, accurate, and reproducible imaging modality. There are few reports of the usage of RT-3D TEE to study LAA in AFib patients. In our research, RT-3D TEE helps to provide detailed LAA information and identifying the presence or absence of thrombi from pectinate muscles in paroxysmal and long-standing AFib patients. Methods LAA morphology was analyzed in detail by 2D TEE and RT-3D TEE in 320 patients with paroxysmal or long-standing AFib. The LAA flow pattern, as maximal LAA emptying flow velocity (LAAeV), was retrieved from 2D and 3D TEE imaging. LAA morphological parameters, spontaneous echo contrast (SEC), and thrombi were also detected by 2D and 3D TEE in all patients. In addition, LAA lobes and types were classified according to the morphology by 3D TEE, and the relationship between LAA types and the incidence of thrombi was evaluated. Results Long-standing AFib had greater enlargement of LAAs (orifice diameters and area), significantly more severe SEC, and a higher thrombi clot incidence rate by 3D-TEE compared with paroxysmal AFib patients (P<0.05). In addition, cauliflower morphology in long-standing AFib patients was associated with a higher LAA thrombus (OR 2.1, 95% CI: 1.1–8.5, P=0.031) and increased prevalence of SEC. Moreover, the uncertainty of thrombi detection was significantly decreased by 3D TEE compared with 2D TEE (P<0.001), and the certainty of thrombi detection by 3D TEE also decreased slightly (P=0.06). Conclusions RT-3D TEE is a safe and real-time option for the evaluation of LAA morphology and function. Long-standing AFib has greater LAA and SEC, as well as a higher incidence of thrombi than the paroxysmal group. Cauliflower LAA type was associated with a higher prevalence of SEC and thrombi.
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Affiliation(s)
- Bingqing Deng
- Cardiovascular Department, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ruqiong Nie
- Cardiovascular Department, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qiong Qiu
- Cardiovascular Department, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yulin Wei
- Cardiovascular Department, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yingmei Liu
- Cardiovascular Department, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hanlu Lv
- Cardiovascular Department, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shaoxin Zheng
- Cardiovascular Department, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jingfeng Wang
- Cardiovascular Department, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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5
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Schlett CL, Heidt MC, Jörg A, Soschynski M, Buss SJ, Korosoglou G, Bamberg F, Kauczor HU, Mohrs OK. [Value of dual-energy computed tomography for detection of left atrial appendage thrombus]. Radiologe 2020; 60:1162-1168. [PMID: 33237385 DOI: 10.1007/s00117-020-00774-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Contrast-enhanced computed tomography (CT) is a convenient method to visualize left atrial appendage (LAA) thrombi. We determined whether diagnostic accuracy improves by including dual-energy as compared to transesophageal echocardiography (TEE). Furthermore, the influence of protocol parameters on radiation dose were quantified. METHODS Patients were assigned to the different CT protocols. All CTs were assessed qualitatively for presence of LAA thrombi and dual-energy CT scans quantitatively for iodine concentration. TEE was assessed qualitatively for the presence of thrombi. RESULTS Of 32 enrolled patients, 6 had a thrombus in TEE. Qualitative CT assessment yielded 83% sensitivity and 88% specificity. In the 26 patients who underwent dual-energy CT, median iodine concentration was 8.6 mg/cm3 and significantly lower in patients with than without LAA thrombi ; furthermore, it provided value for detecting LAA thrombi (AUC: 0.950 vs 0.867 for combined vs. only qualitative assessment, p = 0.04). The median radiation dose was 1.83 mSv; independently lower in scanning only LAA and with prospective gating , while arrhythmia and dual-energy did not contribute independently. CONCLUSION CT provides good diagnostic accuracy for detecting LAA thrombi, which can further be improved if iodine density measurements by dual-energy are incorporated. With an optimized protocol, reasonably low radiation dose can be achieved.
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Affiliation(s)
- C L Schlett
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hugstetter Str. 55, 79106, Freiburg im Breisgau, Deutschland.
- Sektion für Herz‑, Gefäß- und Thoraxbildgebung, Universitäts-Herzzentrum Freiburg - Bad Krozingen, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland.
| | - M C Heidt
- Kardiovaskuläres Zentrum Darmstadt, Alice-Krankenhaus, Darmstadt, Deutschland
| | - A Jörg
- Sektion Computertomographie, SIEMENS Healthineers AG, Erlangen, Deutschland
| | - M Soschynski
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hugstetter Str. 55, 79106, Freiburg im Breisgau, Deutschland
- Sektion für Herz‑, Gefäß- und Thoraxbildgebung, Universitäts-Herzzentrum Freiburg - Bad Krozingen, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - S J Buss
- Abteilung für Kardiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - G Korosoglou
- Abteilung für Kardiologie und Gefäßmedizin, GRN-Krankenhaus Weinheim, Weinheim, Deutschland
| | - F Bamberg
- Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Hugstetter Str. 55, 79106, Freiburg im Breisgau, Deutschland
| | - H-U Kauczor
- Abteilung für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - O K Mohrs
- Abteilung für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
- Abteilung für kardiovaskuläre Bildgebung am Alice-Krankenhaus, Radiologie Darmstadt, Darmstadt, Deutschland
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6
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Bosi GM, Cook A, Rai R, Menezes LJ, Schievano S, Torii R, Burriesci G. Computational Fluid Dynamic Analysis of the Left Atrial Appendage to Predict Thrombosis Risk. Front Cardiovasc Med 2018; 5:34. [PMID: 29670888 PMCID: PMC5893811 DOI: 10.3389/fcvm.2018.00034] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 03/20/2018] [Indexed: 11/13/2022] Open
Abstract
During Atrial Fibrillation (AF) more than 90% of the left atrial thrombi responsible for thromboembolic events originate in the left atrial appendage (LAA), a complex small sac protruding from the left atrium (LA). Current available treatments to prevent thromboembolic events are oral anticoagulation, surgical LAA exclusion, or percutaneous LAA occlusion. However, the mechanism behind thrombus formation in the LAA is poorly understood. The aim of this work is to analyse the hemodynamic behaviour in four typical LAA morphologies - "Chicken wing", "Cactus", "Windsock" and "Cauliflower" - to identify potential relationships between the different shapes and the risk of thrombotic events. Computerised tomography (CT) images from four patients with no LA pathology were segmented to derive the 3D anatomical shape of LAA and LA. Computational Fluid Dynamic (CFD) analyses based on the patient-specific anatomies were carried out imposing both healthy and AF flow conditions. Velocity and shear strain rate (SSR) were analysed for all cases. Residence time in the different LAA regions was estimated with a virtual contrast agent washing out. CFD results indicate that both velocity and SSR decrease along the LAA, from the ostium to the tip, at each instant in the cardiac cycle, thus making the LAA tip more prone to fluid stagnation, and therefore to thrombus formation. Velocity and SSR also decrease from normal to AF conditions. After four cardiac cycles, the lowest washout of contrast agent was observed for the Cauliflower morphology (3.27% of residual contrast in AF), and the highest for the Windsock (0.56% of residual contrast in AF). This suggests that the former is expected to be associated with a higher risk of thrombosis, in agreement with clinical reports in the literature. The presented computational models highlight the major role played by the LAA morphology on the hemodynamics, both in normal and AF conditions, revealing the potential support that numerical analyses can provide in the stratification of patients under risk of thrombus formation, towards personalised patient care.
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Affiliation(s)
- Giorgia Maria Bosi
- UCL Mechanical Engineering, University College London, London, United Kingdom
| | - Andrew Cook
- UCL Institute of Cardiovascular Science & Great Ormond Street Hospital for Children, London, United Kingdom
| | - Rajan Rai
- UCL Mechanical Engineering, University College London, London, United Kingdom
| | - Leon J Menezes
- Biomedical Research Centre, NIHR University College London Hospitals, London, United Kingdom
| | - Silvia Schievano
- UCL Institute of Cardiovascular Science & Great Ormond Street Hospital for Children, London, United Kingdom
| | - Ryo Torii
- UCL Mechanical Engineering, University College London, London, United Kingdom
| | - Gaetano Burriesci
- UCL Mechanical Engineering, University College London, London, United Kingdom.,Bioengineering Group, Ri.MED Foundation, Palermo, Italy
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7
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Chen J, Zhang H, Zhu D, Wang Y, Byanju S, Liao M. Cardiac MRI for detecting left atrial/left atrial appendage thrombus in patients with atrial fibrillation. Herz 2018; 44:390-397. [DOI: 10.1007/s00059-017-4676-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 11/14/2017] [Accepted: 12/21/2017] [Indexed: 01/04/2023]
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8
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Akin I, Nienaber CA. Left atrial appendage occlusion: A better alternative to anticoagulation? World J Cardiol 2017; 9:139-146. [PMID: 28289527 PMCID: PMC5329740 DOI: 10.4330/wjc.v9.i2.139] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 11/20/2016] [Accepted: 12/01/2016] [Indexed: 02/06/2023] Open
Abstract
Non-valvular atrial fibrillation is associated with a significantly increased risk of embolic stroke due to blood clot forming predominantly in the left atrial appendage (LAA). Preventive measures to avoid embolic events are permanent administration of anticoagulants or surgical closure of the LAA. Various clinical trials provide evidence about safety, effectiveness and therapeutic success of LAA occlusion using various cardiac occluder devices. The use of such implants for interventional closure of the LAA is likely to become a valuable alternative for stroke prevention, especially in patients with contraindication for oral anticoagulation as safety, clinical benefit and cost-effectiveness of LAA occlusion has recently been demonstrated.
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Affiliation(s)
- Ibrahim Akin
- Ibrahim Akin, Medical Faculty Mannheim, University Heidelberg, 68167 Mannheim, Germany
| | - Christoph A Nienaber
- Ibrahim Akin, Medical Faculty Mannheim, University Heidelberg, 68167 Mannheim, Germany
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9
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Beigel R, Wunderlich NC, Ho SY, Arsanjani R, Siegel RJ. The left atrial appendage: anatomy, function, and noninvasive evaluation. JACC Cardiovasc Imaging 2015; 7:1251-65. [PMID: 25496544 DOI: 10.1016/j.jcmg.2014.08.009] [Citation(s) in RCA: 317] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 08/12/2014] [Accepted: 08/20/2014] [Indexed: 12/23/2022]
Abstract
The left atrial appendage (LAA) is a finger-like extension originating from the main body of the left atrium. Atrial fibrillation (AF) is the most common clinically important cardiac arrhythmia, occurring in approximately 0.4% to 1% of the general population and increasing with age to >8% in those >80 years of age. In the presence of AF thrombus, formation often occurs within the LAA because of reduced contractility and stasis; thus, attention should be given to the LAA when evaluating and assessing patients with AF to determine the risk for cardioembolic complications. It is clinically important to understand LAA anatomy and function. It is also critical to choose the optimal imaging techniques to identify or exclude LAA thrombi in the setting of AF, before cardioversion, and with current and emerging transcatheter therapies, which include mitral balloon valvuloplasty, pulmonary vein isolation, MitraClip (Abbott Laboratories, Abbott Park, Illinois) valve repair, and the implantation of LAA occlusion and exclusion devices. In this review, we present the current data regarding LAA anatomy, LAA function, and LAA imaging using the currently available noninvasive imaging modalities.
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Affiliation(s)
- Roy Beigel
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; The Heart Institute, Sheba Medical Center, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Siew Yen Ho
- Cardiac Morphology Unit, Royal Brompton Hospital, London, England
| | - Reza Arsanjani
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Robert J Siegel
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Sakr SA, El-Rasheedy WA, Ramadan MM, El-Menshawy I, Mahfouz E, Bayoumi M. Association between left atrial appendage morphology evaluated by trans-esophageal echocardiography and ischemic cerebral stroke in patients with atrial fibrillation. Int Heart J 2015; 56:329-334. [PMID: 25912903 DOI: 10.1536/ihj.14-374] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The left atrial appendage (LAA) represents one of the major sources of cardiac thrombi responsible for embolic stroke in patients with atrial fibrillation (AF). The aim of the present study was to evaluate LAA structure and functions by transesophageal echocardiography (TEE) in patients with AF to investigate the possible association between the different LAA morphologies and the patients' history of ischemic cerebral stroke. We included 50 patients with non-valvular AF (29 chronic, 21 paroxysmal), 24 patients (13 men) without stroke; and 26 patients (9 men) with a history of ischemic stroke. All patients underwent TEE evaluation of LAA morphology and functions. Compared to patients without stroke, patients with ischemic stroke had significantly higher CHADS2 scores (4.19 ± 0.89 versus 1.67 ± 1.13; P < 0.001) and C-reactive protein levels (8.3 ± 1.6 versus 7.6 ± 0.83 mg/L; P = 0.023), and lower peak filling (21.7 ± 11.3 versus 31.2 ± 9.5 cm/second; P = 0.033) and emptying (22.2 ± 9.7 versus 33.4 ± 13.4 cm/second, P = 0.030) velocities. Triangular LAA morphology had a higher prevalence in patients with stroke (36% versus 12% in non-stroke group); and in half of them an LAA thrombus was present. LAA thrombi were detected in 9 patients (18%) with stroke and in 5 patients (10%) without stroke. On multivariate logistic regression analysis, age (OR = 1.202 [1.042-1.585]; P = 0.041), LAA orifice diameter (OR = 1.275 [1.102-1.748]; P = 0.028), and triangular LAA morphology (OR = 4.53 [1.629-8.381]; P = 0.011) were significantly and independently associated with ischemic stroke in AF patients. LAA morphology evaluated by TEE may be useful for predicting ischemic cerebral stroke in patients with non-valvular AF, especially in those with a low CHADS2 score.
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Affiliation(s)
- Sherif A Sakr
- Department of Cardiology, Faculty of Medicine, Mansoura University
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Cabrera JA, Saremi F, Sánchez-Quintana D. Left atrial appendage: anatomy and imaging landmarks pertinent to percutaneous transcatheter occlusion. Heart 2014; 100:1636-50. [DOI: 10.1136/heartjnl-2013-304464] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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12
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Ren JF, Callans DJ, Marchlinski FE. What Is the Natural Relationship Between Left Atrial Appendage Morphology and History of Stroke? J Am Coll Cardiol 2013; 61:689-90. [DOI: 10.1016/j.jacc.2012.09.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Accepted: 09/11/2012] [Indexed: 10/27/2022]
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13
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Dössel O, Krueger MW, Weber FM, Wilhelms M, Seemann G. Computational modeling of the human atrial anatomy and electrophysiology. Med Biol Eng Comput 2012; 50:773-99. [PMID: 22718317 DOI: 10.1007/s11517-012-0924-6] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 05/21/2012] [Indexed: 01/08/2023]
Abstract
This review article gives a comprehensive survey of the progress made in computational modeling of the human atria during the last 10 years. Modeling the anatomy has emerged from simple "peanut"-like structures to very detailed models including atrial wall and fiber direction. Electrophysiological models started with just two cellular models in 1998. Today, five models exist considering e.g. details of intracellular compartments and atrial heterogeneity. On the pathological side, modeling atrial remodeling and fibrotic tissue are the other important aspects. The bridge to data that are measured in the catheter laboratory and on the body surface (ECG) is under construction. Every measurement can be used either for model personalization or for validation. Potential clinical applications are briefly outlined and future research perspectives are suggested.
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Affiliation(s)
- Olaf Dössel
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology, Karlsruhe, Germany.
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Analysis of left atrial appendix by dual-source CT coronary angiography: morphologic classification and imaging by volume rendered CT images. Eur J Radiol 2010; 80:e346-50. [PMID: 21126840 DOI: 10.1016/j.ejrad.2010.11.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Accepted: 11/03/2010] [Indexed: 11/22/2022]
Abstract
AIM We investigated the evaluability of left atrial appendix by dual source coronary CT angiography and analyzed morphologic features. MATERIALS AND METHODS We included 106 consecutive patients who underwent coronary CT angiography for various indications. Technical parameters were slice thickness 0.6 mm, reconstruction interval 0.3mm, gantry rotation time 165 ms. Images were reconstructed from 10% to 100% R-R intervals at 10% intervals to evaluate the left atrial appendix and 4-D inspace software was used for analysis. We recorded the R-R intervals when the left atrial appendix was at maximum and minimum volume. We also evaluated visibility of appendix at R-R intervals. Maximum appendix volume was calculated. Atrial appendices were classified morphologically based on number of chambers (types 1-3) seen on volume rendered images. RESULTS There were 60 male and 46 female patients in the study group and, mean age was 55±13. Mean heart rate was 72 (ranges 47-110). Left atrial was evaluable at maximum and minimum volume by coronary CT angiography in all patients. We noted types 1-3 appendix in 29 (27%), 73 (69%), and 4 (4%) patients, respectively. Mean R-R intervals at maximum and minimum volume were 40%±6 (95% CI; 28-52%) and 95%±5 (95% CI; 85-5%), respectively. Mean appendix maximum volume was 7±4 cm3. Appendix contours were mildly, moderately and severely irregular in 10 (9%), 58 (55%), 38 (36%) patients, respectively. CONCLUSION Left atrial appendix was visualized in all patients independent of heart rate at maximum and minimum volumes. Volume rendered CT images can allow excellent depiction of left atrial appendix morphology and classification. Presence of moderate and severe irregularity of appendix contour in most of the patients may be the cause of slow flow. This morphologic appearance may be the underlying reason for the propensity to atrial appendix thrombus formation.
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15
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Khattab AA, Meier B. Transcatheter left atrial appendage exclusion, gold or fool's gold? Eur Heart J Suppl 2010. [DOI: 10.1093/eurheartj/suq008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Willens HJ, Qin JX, Keith K, Torres S. Diagnosis of a bilobed left atrial appendage and pectinate muscles mimicking thrombi on real-time 3-dimensional transesophageal echocardiography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2010; 29:975-980. [PMID: 20498471 DOI: 10.7863/jum.2010.29.6.975] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Transesophageal echocardiography (TEE)-guided cardioversion is an established strategy for managing atrial arrhythmias and is commonly used as an alternative to the conventional approach of administering several weeks of anticoagulation before cardioversion. However, the safety of this approach depends on the exclusion of left atrial appendage (LAA) thrombi with a high level of diagnostic confidence. The objective of this case series is to explore the use of real-time 3-dimensional (RT3D) TEE in the precardioversion evaluation of patients with complex anatomy in their LAAs. METHODS We used RT3D TEE to further assess the LAAs of 3 patients being evaluated for cardioversion who had inconclusive 2-dimensional (2D) TEE studies because of complex anatomic variants of the LAA. We imaged the LAA using the 3D zoom mode and rotated this image to view the LAA en face from the perspective of its ostium. Further cropping was performed as needed. RESULTS In all 3 patients, the additional views of the appendage obtained by RT3D TEE were decisive in excluding contraindications to cardioversion. The unique en face view of the LAA acquired with 3D TEE, which was previously unobtainable using 2D TEE, was particularly useful. In 1 patient, a bilobed LAA mimicked a thrombus. In 2 other patients, prominent pectinate muscles masqueraded as thrombi. CONCLUSIONS Three-dimensional TEE is valuable for the precardioversion evaluation of patients with complex anatomic variants of the LAA.
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Affiliation(s)
- Howard J Willens
- Department of Medicine, Division of Cardiology, University of Miami Miller School of Medicine, Miami, Florida, USA.
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Leithäuser B, Park JW. Cardioembolic stroke in atrial fibrillation-rationale for preventive closure of the left atrial appendage. Korean Circ J 2009; 39:443-58. [PMID: 19997539 PMCID: PMC2790130 DOI: 10.4070/kcj.2009.39.11.443] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Atrial fibrillation is the most common cardiac arrhythmias, and a major cause of morbidity and mortality due to cardioembolic stroke. The left atrial appendage is the major site of thrombus formation in non-valvular atrial fibrillation. Loss of atrial systole in atrial fibrillation and increased relative risk of associated stroke point strongly toward a role for stasis of blood in left atrial thrombosis, although thrombus formation is multifactorial, and much more than blood flow irregularities are implicated. Oral anticoagulation with vitamin-K-antagonists is currently the most effective prophylaxis for stroke in atrial fibrillation. Unfortunately, this treatment is often contraindicated, particularly in the elderly, in whom risk of stroke is high. Moreover, given the risk of major bleeding, there is reason to be skeptical of the net benefit when warfarin is used in those patients. This work reviews the pathophysiology of cardioembolic stroke and critically spotlights the current status of preventive anticoagulation therapy. Various techniques to exclude the left atrial appendage from circulation were discussed as a considerable alternative for stroke prophylaxis.
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Affiliation(s)
- Boris Leithäuser
- Asklepios General Hospital Harburg, 1st Medical Department, Cardiology, Intensive Care Medicine, Hamburg, Germany
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Abstract
Atrial structures are important in the current era of cardiac interventions using percutaneous transcatheter procedures. Understanding their locations and component parts helps to reduce risks of procedural-related damage. The general arrangement of the myofibers that make up the atrial walls is reviewed to provide a morphologic basis for atrial conduction and potential substrates of arrhythmias. The right atrium, dominated by its appendage, is characterized by having an extensive array of pectinate muscles. These extend almost perpendicularly from the terminal crest. The left atrium has relatively smooth walls and a small tubular-shaped appendage. The myofibers show changes in orientations when traced through the thickness of the walls. Extensions of atrial myocardium onto the pulmonary veins and the superior caval vein are common. Apart from Bachmann's bundle, there are other muscular bridges of variable numbers and sizes that provide interatrial connections, connections between the left atrium and the coronary sinus, and connections between the muscular sleeves of the right pulmonary veins and the right atrium. The purpose of this review is to summarize the three-dimensional arrangement of gross atrial structures, the myoarchitecture and variations in muscular interatrial connections. These are important features in intra- and interatrial conduction.
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Affiliation(s)
- S Y Ho
- Cardiac Morphology Unit, National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, Dovehouse Street, London, United Kingdom.
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HILL JOHNN. Detection of Thrombus Before Ablation for Atrial Fibrillation: Focus Determines Reality. J Cardiovasc Electrophysiol 2008; 19:359-61. [DOI: 10.1111/j.1540-8167.2007.01082.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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GOTTLIEB ILAN, PINHEIRO AURÉLIO, BRINKER JEFFA, CORRETTI MARYC, MAYER SUSANA, BLUEMKE DAVIDA, LIMA JOAOA, MARINE JOSEPHE, BERGER RONALDD, CALKINS HUGH, ABRAHAM THEODOREP, HENRIKSON CHARLESA. Diagnostic Accuracy of Arterial Phase 64-Slice Multidetector CT Angiography for Left Atrial Appendage Thrombus in Patients Undergoing Atrial Fibrillation Ablation. J Cardiovasc Electrophysiol 2008; 19:247-51. [DOI: 10.1111/j.1540-8167.2007.01043.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Duerinckx AJ, Vanovermeire O. Accessory appendages of the left atrium as seen during 64-slice coronary CT angiography. Int J Cardiovasc Imaging 2007; 24:215-21. [PMID: 17577678 DOI: 10.1007/s10554-007-9240-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2007] [Accepted: 05/17/2007] [Indexed: 11/29/2022]
Abstract
PURPOSE To document the frequency and variations in number and anatomical shape of accessory appendages of the left atrium as seen on 64-slice cardiac CT. METHODS AND MATERIALS Retrospective review of the anatomy of the left atrium as depicted by cardiac CT using the acquisition protocol designed for coronary CT Angiography and performed in 166 patients over a 6-month period with a 64-slice ECG-gated CT scanner (Siemens Medical Solutions). The local IRB provided a waiver of informed consent for this retrospective study. Structures less than 5 mm in shape were excluded, as well as large accessory pulmonary veins. RESULTS Seventeen (17) of 166 patients (10%) had 18 accessory left atrial appendages (only one patient had two). Fifteen (15) accessory appendages were located along the right upper atrial wall and measured 0.9 x 0.6 x 0.5 cm(3) +/- 0.2 x 0.2 x 0.1 (Type 1). Three (3) were located along the left lower atrial wall, and were larger (0.9-2.5 cm cross-section) (Type 2). The right upper accessory appendages were mostly shaped like small diverticuli and the left lower ones were shaped like flat cauliflower expansions. CONCLUSIONS Accessory left atrial appendages were visualized in 10% of 166 patients during 64-slice coronary CT angiography.
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Affiliation(s)
- Andre J Duerinckx
- Department of Radiology, The MetroHealth System, Cleveland, OH 44109, USA.
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Schneider B, Stöllberger C, Schneider B. Diagnosis of Left Atrial Appendage Thrombi by Multiplane Transesophageal Echocardiography Interlaboratory Comparative Study. Circ J 2007; 71:122-5. [PMID: 17186989 DOI: 10.1253/circj.71.122] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Transesophageal echocardiography (TEE) is regarded as the method of choice for imaging left atrial appendage thrombi (LAAT). However, the interobserver variability among 2 independent echocardiographic laboratories in diagnosing LAAT by multiplane TEE has not yet been assessed. METHODS AND RESULTS The videorecordings of 50 patients in atrial fibrillation (25 from each laboratory) were blindly reviewed by 1 experienced observer from each institution. LAAT were assessed as present, absent or questionable. Indications for TEE were: cardioversion (n=17), valve disease (n=13), endocarditis (n=12), or embolism (n=8). The prevalence of LAAT was 10% (observer 1) vs 12% (observer 2). A questionable LAAT was assessed in 6% vs 12% and a LAAT was excluded in 84% vs 76%, respectively. By head-to-head comparison, disagreement occurred in 11 cases (22%, kappa=0.5). Discrepant results were not related to the echocardiographic equipment. Problems occurred because of reverberation artifacts of the ridge between the left atrial appendage and left upper pulmonary vein (n=5), and in differentiating LAAT from spontaneous echocardiographic contrast (n=4) or an echogenic atrioventricular groove (n=1). The differentiation of pectinate muscles from LAAT was the reason for disagreement in only 1 case. Eliminating the category of questionable thrombi increased the kappa value to 0.65. In 5 patients undergoing cardiac surgery, both observers had agreed on the presence (n=1) or absence (n=4) of LAAT, and intraoperatively the results of TEE were confirmed. CONCLUSION Even with multiplane TEE, interobserver variability among 2 independent echocardiographic laboratories for diagnosing LAAT remains high because of problems in differentiating LAAT from spontaneous echocardiographic contrast and reverberation artifacts.
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Affiliation(s)
- Birke Schneider
- Sana Kliniken Lübeck, Klinik für Kardiologie, Kronsforder Allee, Germany.
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Mohrs OK, Nowak B, Petersen SE, Welsner M, Rubel C, Magedanz A, Kauczor HU, Voigtlaender T. Thrombus Detection in the Left Atrial Appendage Using Contrast-Enhanced MRI: A Pilot Study. AJR Am J Roentgenol 2006; 186:198-205. [PMID: 16357402 DOI: 10.2214/ajr.04.1504] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Left atrial thrombi are an important cause for embolism-related morbidity and mortality. Transesophageal echocardiography (TEE), the clinical reference, is semiinvasive; thus, we aimed to assess the value of contrast-enhanced cardiovascular MRI for the detection of thrombus in the left atrial appendage. CONCLUSION The image quality was good for both 2D perfusion (grade 4 +/- 1) and 3D turbo fast low-angle shot (FLASH) (grade 4 +/- 1, n.s.). Compared with TEE, 2D perfusion, 3D turboFLASH, and the combination of both techniques yielded sensitivities of 47/35/44%, specificities of 50/67/67%, positive predictive values of 73/75/80%, and negative predictive values of 25/27/29%, respectively. The size of the thrombus was overestimated by 2D perfusion (66%) and by 3D turboFLASH (25%) and agreement for location and shape of thrombus was 50% and 75% for 2D perfusion and 75% and 50% for 3D turboFLASH, respectively. The TEE thrombus size was significantly larger in patients with true-positive diagnoses by 2D perfusion (148%) and by 3D turboFLASH (151%) when compared with patients with false-negative diagnoses (p < 0.05 for both). No such difference was found for image quality, time delay between TEE and MRI examination, and location and shape of thrombi. Contrast-enhanced MRI lacks diagnostic accuracy for the detection of thrombi in the left atrial appendage. Future technical improvements are essential to establish this technique as a noninvasive alternative to TEE.
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Affiliation(s)
- Oliver K Mohrs
- Cardiovascular Center Bethanien (CCB), Im Pruefling 23, D-60389 Frankfurt/Main, Germany.
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Abstract
This article reviews common cardiovascular pathologies that can be noted first on plain film when previously unsuspected, and then illustrates how cross-sectional imaging can provide the follow-up information needed to make a diagnosis. First reviewed are the normal cardiac structures and contours as seen on the plain film of the chest, followed by specific types of pathologies as seen in older adults; patients with lung cancer invading the heart, pericardium, or large vessels; and postsurgical and posttraumatic findings. Also provided is a review of non-cardiac-related areas of plain film and cross-sectional imaging correlation. It is hoped that the reader gains a better understanding and appreciation for the great value of cross-sectional imaging, and the power of the plain film in helping detect and recognize thoracic pathology.
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Affiliation(s)
- André J Duerinckx
- Radiology Service, Veterans Affairs North Texas Healthcare System, Dallas, TX 75126, USA.
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