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Bshennaty A, Vogl BJ, Bavo AM, Sularz A, Kramer AD, Jia Y, De Beule M, Nielsen-Kudsk JE, De Backer O, Alkhouli M, Hatoum H. Understanding the role of the left atrial appendage on the flow in the atrium. Catheter Cardiovasc Interv 2024. [PMID: 39033333 DOI: 10.1002/ccd.31153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 07/10/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND The exclusion/occlusion of the left atrial appendage (LAA) is a treatment option for atrial fibrillation (AF) patients who are at high risk of stroke and high risk of bleeding. As the role of the LAA is not well understood or explored, this study aims to assess its role on flow dynamics in the left atrium. METHODS Computational fluid dynamics (CFD) simulations were carried out for nine AF patients before and after LAA exclusion. The flow parameters investigated included the LA velocities, Time Averaged Wall Shear Stress (TAWSS), Oscillatory Shear Index (OSI), Relative Residence Time (RRT), and Pressure in the LA. RESULTS This study shows that, on average, a decrease in TAWSS (1.82 ± 1.85 Pa to 1.27 ± 0.96 Pa, p < 0.05) and a slight increase in OSI (0.16 ± 0.10 to 0.17 ± 0.10, p < 0.05), RRT (1.87 ± 1.84 Pa-1 to 2.11 ± 1.78 Pa-1, p < 0.05), and pressure (-19.2 ± 6.8 mmHg to -15.3 ± 8.3 mmHg, p < 0.05) were observed in the LA after the exclusion of the LAA, with a decrease in low-magnitude velocities. CONCLUSION The exclusion of the LAA seems to be associated with changes in LA flow dynamics. Further studies are needed to elucidate the clinical implications of these changes.
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Affiliation(s)
- Ahmad Bshennaty
- Department of Biomedical Engineering, Michigan Technological University, Houghton, Michigan, USA
| | - Brennan J Vogl
- Department of Biomedical Engineering, Michigan Technological University, Houghton, Michigan, USA
| | | | - Agata Sularz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Yuheng Jia
- Department of Cardiology, Copenhagen University Hospital, Denmark
| | | | | | - Ole De Backer
- Department of Cardiology, Copenhagen University Hospital, Denmark
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hoda Hatoum
- Department of Biomedical Engineering, Michigan Technological University, Houghton, Michigan, USA
- Health Research Institute, Center of Biocomputing and Digital Health and Institute of Computing and Cybersystems, Michigan Technological University, Houghton, Michigan, USA
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Nicol E, Karim N, Semple T, Baleswaran S, Owen R, Riad O, Markides V, Padley SPG, Wong T. Left Atrial Appendage Pseudothrombus Is Associated With Stroke History in Patients With Atrial Fibrillation Undergoing Cardiac Computed Tomography. J Am Heart Assoc 2024; 13:e030147. [PMID: 38842331 PMCID: PMC11255678 DOI: 10.1161/jaha.123.030147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 02/28/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND In nonvalvular atrial fibrillation (NVAF), the left atrial appendage (LAA) is the source of thrombus in up to 90% of patients. LAA pseudothrombus (LAAPT), defined as a filling defect on the initial but not the 60-second delayed acquisition on cardiovascular computed tomography scan (CCT), is a recognized phenomenon in NVAF, with unknown clinical relevance. We aimed to determine the relationship between LAAPT and history of stroke in patients with NVAF. METHODS AND RESULTS The study included 213 consecutive patients with NVAF undergoing CCT who were assessed for LAAPT. LA and LAA dimensions and LAA morphology correlated with clinical demographics including cardiovascular risk factors, history of stroke, thromboembolic stroke, and transient ischemic attack. Mean age (±SD) was 65.1±10.5 years (range 31-89) and 150 of 213 (70.4%) were men. LAAPT was present in 59 of 213 (27.7%) patients. Greater mean LAA ostium area (5.7 versus 4.5, P<0.001), greater mean LAA ostium area:curved length (0.11 versus 0.08, P<0.001), increased LAA volume (14.0 versus 10.2, P<0.001), and lower mean LAA tortuosity index (1.17 versus 1.38, P<0.001) were all associated with the presence of LAAPT. On multivariable analysis, LAAPT on CCT (odds ratio [OR], 3.20 [95% CI, 1.40-7.20]; P<0.006) and higher CHA2DS2-VASc score (OR, 1.65 [95% CI, 1.16-2.35]; P=0.01) were associated with all strokes, with LAAPT remaining a statistically significant risk factor even after adjustment for CHA2DS2-VASc score. CONCLUSIONS LAAPT on CCT is common in patients with NVAF. It has a strong positive association with stroke prevalence, even after adjustment for CHA2DS2-VASc score. LAAPT on CCT may potentially allow further stratification for stroke risk, additive to the CHA2DS2-VASc score.
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Affiliation(s)
- Edward Nicol
- Cardiology DepartmentRoyal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation TrustLondonUK
- Radiology DepartmentRoyal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation TrustLondonUK
- School of Biomedical Engineering and Imaging SciencesKing’s CollegeLondonUK
| | - Nabeela Karim
- Heart Rhythm Centre, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation TrustLondonUK
| | - Tom Semple
- Radiology DepartmentRoyal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation TrustLondonUK
| | | | - Ruth Owen
- London School of Hygiene & Tropical MedicineUniversity of LondonLondonUK
| | - Omar Riad
- Heart Rhythm Centre, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation TrustLondonUK
- Cardiology department, faculty of MedicineAin Shams UniversityCairoEgypt
| | - Vias Markides
- Cardiology DepartmentRoyal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation TrustLondonUK
| | - Simon P. G. Padley
- Radiology DepartmentRoyal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation TrustLondonUK
| | - Tom Wong
- Heart Rhythm Centre, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation TrustLondonUK
- School of Cardiovascular Medicine and Sciences, Faculty of Life Sciences & MedicineKing’s College LondonLondonUK
- National Heart and Lung InstituteFaculty of Medicine, Imperial CollegeLondonUK
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3
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Nagasaka T, Nakamura M. Left Atrial Appendage Closure: A Narrative Review. Cardiol Ther 2023; 12:615-635. [PMID: 37938523 DOI: 10.1007/s40119-023-00337-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/09/2023] [Indexed: 11/09/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and the cause of thromboembolic events in elderly patients worldwide. AF is associated with a significantly increased risk of morbidity and mortality due to cardiac emboli, primarily from left atrial appendage (LAA) thrombus. Oral anticoagulation therapy is the standard treatment to effectively reduce the risk of thromboembolic events in patients with AF. However, anticoagulation treatment increases bleeding risk. LAA closure (LAAC) has recently been introduced as a feasible mechanical preventive intervention for thromboembolic events while minimizing the risk of bleeding. Transcatheter LAAC devices have evolved in the past decade, and several ongoing trials have demonstrated the improvements of safety and outcomes in newer generation devices. This review summarizes the current perspectives and outcomes regarding LAAC as an alternative to pharmacologic therapy.
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Affiliation(s)
- Takashi Nagasaka
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Mamoo Nakamura
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Aarnink E, Zabern M, Boersma L, Glikson M. Mechanisms and Prediction of Ischemic Stroke in Atrial Fibrillation Patients. J Clin Med 2023; 12:6491. [PMID: 37892626 PMCID: PMC10607686 DOI: 10.3390/jcm12206491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/06/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in adults worldwide and represents an important burden for patients, physicians, and healthcare systems. AF is associated with substantial mortality and morbidity, due to the disease itself and its specific complications, such as the increased risk of stroke and thromboembolic events associated with AF. The temporal relation between AF episodes and stroke is nonetheless incompletely understood. The factors associated with an increased thromboembolic risk remain unclear, as well as the stroke risk stratification. Therefore, in this review, we intend to expose the mechanisms and physiopathology leading to intracardiac thrombus formation and stroke in AF patients, together with the evidence supporting the causal hypothesis. We also expose the risk factors associated with increased risk of stroke, the current different risk stratification tools as well as future prospects for improving this risk stratification.
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Affiliation(s)
- Errol Aarnink
- Department of Cardiology, St. Antonius Hospital, 3435 CM Nieuwegein, The Netherlands
| | - Maxime Zabern
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
| | - Lucas Boersma
- Department of Cardiology, St. Antonius Hospital, 3435 CM Nieuwegein, The Netherlands
- Department of Cardiology, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
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Mantini C, Corradi F, Ricci F, Jensen B, Tana C, Di Mascio V, Mastrodicasa D, Bucciarelli B, Procaccini L, Saba L, Marco Tana, Cademartiri F, De Caterina R. A highly-detailed anatomical study of left atrial auricle as revealed by in-vivo computed tomography. Heliyon 2023; 9:e20575. [PMID: 37842578 PMCID: PMC10568352 DOI: 10.1016/j.heliyon.2023.e20575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 09/19/2023] [Accepted: 09/29/2023] [Indexed: 10/17/2023] Open
Abstract
The left atrial auricle (LAA) is the main source of intracardiac thrombi, which contribute significantly to the total number of stroke cases. It is also considered a major site of origin for atrial fibrillation in patients undergoing ablation procedures. The LAA is known to have a high degree of morphological variability, with shape and structure identified as important contributors to thrombus formation. A detailed understanding of LAA form, dimension, and function is crucial for radiologists, cardiologists, and cardiac surgeons. This review describes the normal anatomy of the LAA as visualized through multiple imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI), and echocardiography. Special emphasis is devoted to a discussion on how the morphological characteristics of the LAA are closely related to the likelihood of developing LAA thrombi, including insights into LAA embryology.
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Affiliation(s)
- Cesare Mantini
- Department of Neuroscience, Imaging and Clinical Sciences, “G. D'Annunzio” University, Chieti, Italy
| | | | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, “G. D'Annunzio” University, Chieti, Italy
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Bjarke Jensen
- Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Claudio Tana
- Geriatrics Clinic, SS. Annunziata Hospital of Chieti, 66100, Chieti, Italy
| | - Valeria Di Mascio
- Department of Neuroscience, Imaging and Clinical Sciences, “G. D'Annunzio” University, Chieti, Italy
| | | | - Benedetta Bucciarelli
- Department of Pediatrics, Politechnic University of Marche, G. Salesi Children's Hospital, Ancona, Italy
| | | | - Luca Saba
- Department of Radiology, University Hospital of Cagliari, Cagliari, Italy
| | - Marco Tana
- Internal Medicine Unit and Department of Vascular Medicine and Cardiovascular Ultrasound, SS. Annunziata Hospital of Chieti, Italy
| | | | - Raffaele De Caterina
- Cardiology, University of Pisa and University Cardiology Division, Pisa University Hospital, Pisa, Italy
- Fondazione Villa Serena per la Ricerca, Città Sant’Angelo-Pescara, Italy
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6
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Cresti A, Camara O. Left Atrial Thrombus-Are All Atria and Appendages Equal? Card Electrophysiol Clin 2023; 15:119-132. [PMID: 37076224 DOI: 10.1016/j.ccep.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Although the left atrial appendage (LAA) seems useless, it has several critical functions that are not fully known yet, such as the causes for being the main origin of cardioembolic stroke. Difficulties arise due to the extreme range of LAA morphologic variability, making the definition of normality challenging and hampering the stratification of thrombotic risk. Furthermore, obtaining quantitative metrics of its anatomy and function from patient data is not straightforward. A multimodality imaging approach, using advanced computational tools for their analysis, allows a complete characterization of the LAA to individualize medical decisions related to left atrial thrombosis patients.
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Affiliation(s)
- Alberto Cresti
- Cardiology Department, Misericordia Hospital, Azienda Sanitaria Toscana SudEst, Via Senese, Grosseto 58100, Italy
| | - Oscar Camara
- BCN MedTech, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Tànger 122, Barcelona 08018, Spain.
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Tian X, Wang C, Gao D, Gao BL, Li CY. Morphological changes in the orifices of the left atrial appendage and left atrium in patients with atrial fibrillation. Quant Imaging Med Surg 2022; 12:5371-5382. [PMID: 36465818 PMCID: PMC9703112 DOI: 10.21037/qims-22-218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 09/14/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND As an integral part of the left atrium (LA), the left atrial appendage (LAA) plays an important role in atrial fibrillation (AF). However, the relationship between LAA remodeling and AF has not been clearly defined. This retrospective case-control study aimed to assess the morphological and functional features of the LA and the LAA in AF patients using images obtained by computed tomography angiography (CTA). METHODS A total of 140 AF patients and 64 patients without AF or other cardiovascular diseases who underwent CTA scans between September 2016 and August 2017 were enrolled in this observational study as the experimental and the control groups, respectively. The major and minor axes, area, and perimeter of the LAA orifice, the LAA depth, and the volume of both the LAA and LA were analyzed. The data of the AF group and the control group were compared. The t-test was used to analyze the normally distributed data, and the Wilcoxon rank-sum test was used for abnormally distributed data. The best critical value of predictors of AF was calculated using receiver operating characteristic (ROC) curve analysis. The correlation of the LAA volume change with the major and minor axes, area, and perimeter of the LAA orifice, and the LAA depth were analyzed using the Pearson correlation coefficient. RESULTS The LAA orifice's minor axis, LAA volume, and LA volume were significantly greater (P=0.004, P=0.010, and P<0.001, respectively) in patients with AF than in those without AF. The LAA volume [95% confidence interval (CI): 1.01 to 1.30; P=0.038] and LA volume (95% CI: 1.03 to 1.07; P<0.001) were significantly independent predictors of AF. An LAA volume of 8.75 mL had the highest predictive value for AF [area under the curve (AUC), 0.612], with a sensitivity of 76.6% and a specificity of 48.6%. In contrast, an LA volume of 97.15 mL had the highest predictive value for AF (AUC, 0.771), with a sensitivity of 90.6% and a specificity of 53.6%. The change of LAA volume was positively weakly correlated with the area and perimeter of the LAA orifice (r=0.1703 and r=0.1378, respectively). The LAA emptying fraction was negatively correlated with the major axis and the area of the LAA orifice. The major and minor axes, area, and perimeter of the LAA orifice, and LAA depth were significantly greater in female than in male patients (P=0.003, P=0.003, P=0.001, P=0.019, and P<0.001, respectively). CONCLUSIONS The AF patients had a longer minor axis of the LAA orifice than that of the control group, resulting in a more circular LAA orifice. The LAA orifice area and perimeter were positively correlated with LAA volume change. The LAA orifice major and minor axes, area, and perimeter, and the LAA depth of the female patients were significantly greater than those of their male counterparts in AF patients.
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Affiliation(s)
- Xin Tian
- Department of Medical Imaging, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Cen Wang
- Radiology Department, Beijing Nuclear Industry Hospital, Beijing, China
| | - Duo Gao
- Department of Medical Imaging, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Bu-Lang Gao
- Department of Medical Imaging, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Cai-Ying Li
- Department of Medical Imaging, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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8
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Wang B, Wang Z, Chu H, He B, Fu G, Feng M, Du X, Liu J, Yu Y. Long-term safety and efficacy of left atrial appendage closure in patients with small appendage orifices measured with transesophageal echocardiography. Clin Cardiol 2022; 46:134-141. [PMID: 36378742 PMCID: PMC9933104 DOI: 10.1002/clc.23950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 10/12/2022] [Accepted: 10/30/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The Watchman device is the most widely used occluder but is indicated in atrial fibrillation (AF) patients with a maximal left atrial appendage (LAA) orifice diameter between 17 and 31 mm. We aimed to compare the long-term safety and efficacy of left atrial appendage closure (LAAC) between patients with a small LAA (<17 mm) and those with an indicated LAA (17-31 mm) measured by transesophageal echocardiography (TEE). METHODS A total of 369 AF patients treated with LAAC between March 2015 and February 2019 were included and divided into two groups based on the maximal LAA orifice diameter measured by TEE: small LAA group (n = 22) and indicated LAA group (n = 347). Periprocedural complications and long-term clinical outcomes were compared. RESULTS The Watchman device was successfully implanted in all patients. Mean device compression was higher in the small LAA group. Four patients (1.2%) in the indicated LAA group experienced pericardial effusion, and none experienced pericardial effusion in the small LAA group. Device-related thrombus was detected in one (4.5%) patient in the small LAA group and five (1.4%) in the indicated LAA group (p = .310). After a mean follow-up period of 4.1 ± 1.6 years, one patient in the small LAA group (4.5%; 1.1/100 person-years) and four in the indicated LAA group (1.2%; 0.3/100 person-years) suffered an ischemic stroke (p = .266). CONCLUSIONS The safety and efficacy of LAAC with the Watchman device were comparable between patients with small and indicated LAA orifice diameters measured by TEE.
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Affiliation(s)
- Binhao Wang
- Arrhythmia CenterNingbo First HospitalNingboChina,Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang ProvinceNingboChina
| | - Zhao Wang
- Department of UltrasonographyNingbo First HospitalNingboChina
| | - Huimin Chu
- Arrhythmia CenterNingbo First HospitalNingboChina,Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang ProvinceNingboChina
| | - Bin He
- Arrhythmia CenterNingbo First HospitalNingboChina,Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang ProvinceNingboChina
| | - Guohua Fu
- Arrhythmia CenterNingbo First HospitalNingboChina,Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang ProvinceNingboChina
| | - Mingjun Feng
- Arrhythmia CenterNingbo First HospitalNingboChina,Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang ProvinceNingboChina
| | - Xianfeng Du
- Arrhythmia CenterNingbo First HospitalNingboChina,Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang ProvinceNingboChina
| | - Jing Liu
- Arrhythmia CenterNingbo First HospitalNingboChina,Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang ProvinceNingboChina
| | - Yibo Yu
- Arrhythmia CenterNingbo First HospitalNingboChina,Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang ProvinceNingboChina
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Corti M, Zingaro A, Dede' L, Quarteroni AM. Impact of atrial fibrillation on left atrium haemodynamics: A computational fluid dynamics study. Comput Biol Med 2022; 150:106143. [PMID: 36182758 DOI: 10.1016/j.compbiomed.2022.106143] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 08/30/2022] [Accepted: 09/18/2022] [Indexed: 11/28/2022]
Abstract
We analyse the haemodynamics of the left atrium, highlighting differences between healthy individuals and patients affected by atrial fibrillation. The computational study is based on patient-specific geometries of the left atria to simulate blood flow dynamics. We design a novel procedure to compute the boundary data for the 3D haemodynamic simulations, which are particularly useful in absence of data from clinical measurements. With this aim, we introduce a parametric definition of atrial displacement, and we use a closed-loop lumped parameter model of the whole cardiovascular circulation conveniently tuned on the basis of the patient's characteristics. We evaluate several fluid dynamics indicators for atrial haemodynamics, validating our numerical results in terms of clinical measurements; we investigate the impact of geometric and clinical characteristics on the risk of thrombosis. To highlight the correlation of thrombus formation with atrial fibrillation, according to medical evidence, we propose a novel indicator: age stasis. It arises from the combination of Eulerian and Lagrangian quantities. This indicator identifies regions where slow flow cannot properly rinse the chamber, accumulating stale blood particles, and creating optimal conditions for clots formation.
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Affiliation(s)
- Mattia Corti
- MOX-Dipartimento di Matematica, Politecnico di Milano, Piazza Leonardo da Vinci 32, Milan, 20133, Italy.
| | - Alberto Zingaro
- MOX-Dipartimento di Matematica, Politecnico di Milano, Piazza Leonardo da Vinci 32, Milan, 20133, Italy
| | - Luca Dede'
- MOX-Dipartimento di Matematica, Politecnico di Milano, Piazza Leonardo da Vinci 32, Milan, 20133, Italy
| | - Alfio Maria Quarteroni
- MOX-Dipartimento di Matematica, Politecnico di Milano, Piazza Leonardo da Vinci 32, Milan, 20133, Italy; Institute of Mathematics, École Polytechnique Fédérale de Lausanne, Station 8, Av. Piccard, Lausanne, CH-1015, Switzerland (Professor Emeritus)
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10
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Cherry Kemmerling E. In Vitro Pressure Measurements Across an Interatrial Shunt for HFpEF Treatment. Cardiovasc Eng Technol 2022; 13:662-672. [PMID: 35106722 DOI: 10.1007/s13239-021-00607-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/15/2021] [Indexed: 01/27/2023]
Abstract
PURPOSE Preserved ejection fraction heart failure (HFpEF) can be treated by installing a shunt in the interatrial septum, which relieves excess pressure in the left atrium by allowing blood to flow from left to right. This technique has proven effective in clinical trials, but the details of the flow through the shunted heart are not well understood. The current study aims to collect quantitative data on the relationship between pressure and flow rate in such shunts. METHODS An in vitro, shunted double atrium flow phantom was fabricated and used to investigate the relationship between pressure drop and flow across an interatrial shunt. Flow rate was controlled and the resulting pressure drop across the shunt was measured for a variety of flow cases, including steady and pulsatile flow, flow rate waveforms typical of healthy and failing hearts, and low and high heart rates. RESULTS The results show a positive relationship between shunt flow rate and pressure drop which is more pronounced in steady flow than in pulsatile flow. Increasing heart rate increases the time-averaged pressure drop across the shunt but not the maximum pressure drop. For steady-flow cases, large changes in pressure drop resulting from moderate changes in flow rate suggest a flow regime transition during parts of the cardiac cycle. Comparison of time-averaged pulsatile flow pressure measurements with steady-flow measurements and two analytical plate-orifice models suggests that none approximate pulsatile flow accurately. CONCLUSIONS The flow rate/pressure drop relationship across an in vitro model of an interatrial shunt has been measured for a variety of physiologically relevant cases. Among other things, the results suggest that steady flow approximations to the heart's pulsatile flow should be used with caution and simplified theoretical models do not approximate the flow rate/pressure drop relationship accurately.
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Mendez K, Kennedy DG, Wang DD, O’Neill B, Roche ET. Left Atrial Appendage Occlusion: Current Stroke Prevention Strategies and a Shift Toward Data-Driven, Patient-Specific Approaches. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100405. [PMID: 39131471 PMCID: PMC11308563 DOI: 10.1016/j.jscai.2022.100405] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/08/2022] [Accepted: 06/14/2022] [Indexed: 08/13/2024]
Abstract
The left atrial appendage (LAA) is a complex structure with unknown physiologic function protruding from the main body of the left atrium. In patients with atrial fibrillation, the left atrium does not contract effectively. Insufficient atrial and LAA contractility predisposes the LAA morphology to hemostasis and thrombus formation, leading to an increased risk of cardioembolic events. Oral anticoagulation therapies are the mainstay of stroke prevention options for patients; however, not all patients are candidates for long-term oral anticoagulation. Percutaneous occlusion devices are an attractive alternative to long-term anticoagulation therapy, although they are not without limitations, such as peri-implant leakage and device-related thrombosis. Although efforts have been made to reduce these risks, significant interpatient heterogeneity inevitably yields some degree of device-anatomy mismatch that is difficult to resolve using current devices and can ultimately lead to insufficient occlusion and poor patient outcomes. In this state-of-the-art review, we evaluated the anatomy of the LAA as well as the current pathophysiologic understanding and stroke prevention strategies used in the management of the risk of stroke associated with atrial fibrillation. We highlighted recent advances in computed tomography imaging, preprocedural planning, computational modeling, and novel additive manufacturing techniques, which represent the tools needed for a paradigm shift toward patient-centric LAA occlusion. Together, we envisage that these techniques will facilitate a pipeline from the imaging of patient anatomy to patient-specific computational and bench-top models that enable customized, data-driven approaches for LAA occlusion that are engineered specifically to meet each patient's unique needs.
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Affiliation(s)
- Keegan Mendez
- Harvard/MIT Health Sciences and Technology Program, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Darragh G. Kennedy
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Department of Biomedical Engineering, Columbia University, New York, New York
| | | | | | - Ellen T. Roche
- Harvard/MIT Health Sciences and Technology Program, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts
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12
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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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13
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Machino-Ohtsuka T, Nakagawa D, Albakaa NK, Nakatsukasa T, Kawamatsu N, Sato K, Yamamoto M, Yamasaki H, Ishizu T, Ieda M. Clinical Characteristics of Non-Valvular Atrial Fibrillation Patients With a Large Left Atrial Appendage Ostium-Limiting Percutaneous Closure. Circ J 2022; 86:1263-1272. [PMID: 35786689 DOI: 10.1253/circj.cj-22-0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The left atrial appendage (LAA) is a therapeutic target for preventing cardioembolic stroke in patients with non-valvular atrial fibrillation (NVAF). A large LAA ostium limits percutaneous LAA closure. This study investigated the characteristics and factors associated with a large LAA ostium in Japanese patients with NVAF.Methods and Results: In 1,102 NVAF patients, the maximum LAA diameter was measured using transesophageal echocardiography (TEE). A large LAA ostium was defined by a maximum diameter of >30 mm. Forty-four participants underwent repeated TEEs, and changes in LAA size under lasting AF were assessed. A large LAA ostium was observed in 3.1% of all participants and 8.9% of patients with long-standing persistent AF (LSAF). The large LAA group had greater CHA2DS2-VASc (P=0.024) and HAS-BLED scores (P=0.046) and a higher prevalence of LAA thrombus (P=0.004) than did the normal LAA group. LSAF, moderate or severe mitral regurgitation, left atrial volume ≥42 mL/m2, E/E' ratio ≥9.5, and left ventricular mass ≥85 mg/m2were independently associated with a large LAA ostium (P<0.001, P<0.001, P=0.009, P=0.009, and P=0.032, respectively). In 44 patients with lasting AF, the LAA ostial diameter increased over time (P<0.001). CONCLUSIONS NVAF patients with a large LAA ostium may have a higher risk of stroke and bleeding. LSAF and factors leading to LA overload may be closely associated with LAA ostial dilatation and can promote it.
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Affiliation(s)
| | - Daishi Nakagawa
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Noor K Albakaa
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Naoto Kawamatsu
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Kimi Sato
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Hiro Yamasaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Tomoko Ishizu
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Masaki Ieda
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
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14
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Wang L, Wang Z, Fang R, Li ZY. Evaluation of Stroke Risk in Patients With Atrial Fibrillation Using Morphological and Hemodynamic Characteristics. Front Cardiovasc Med 2022; 9:842364. [PMID: 35571199 PMCID: PMC9098797 DOI: 10.3389/fcvm.2022.842364] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background It is well known that the thrombus triggering stroke in patients with atrial fibrillation (AF) mainly comes from the left atrial appendage (LAA). This study aims to characterize the morphological and hemodynamic parameters and evaluate their differences between AF patients with and without a stroke history. Methods Cardiac CT images were obtained from AF patients with (n = 10) and without a history of stroke (n = 10). 3D models of the left atrium (LA) were reconstructed by processing the CT image, and the LA/LAA morphological parameters were measured. Computational fluid dynamics (CFD) simulations were performed to calculate the hemodynamic parameters in LA. The species-transport model and discrete phase model (DPM) were applied to analyze blood residual ratio and particle residual ratio, two qualitative parameters for thrombus formation and flow-out potential, respectively. Results There were significant differences in LAA actual depth (p = 0.002), and direct length (p = 0.049) between the non-stroke and stroke groups. Significant differences were also found in certain hemodynamic parameters. The blood residual ratio in LAA was significantly smaller in the stroke group than in the non-stroke group (p < 0.05). Moreover, the particle residual ratio within LAA was significantly smaller in the stroke groups than in the non-stroke group (p < 0.05). Conclusion There are significant differences in both morphological and hemodynamic parameters between AF patients with and without a stroke history. A high blood residual ratio in LAA confirms that thrombus is more likely to form in AF patients. A significantly smaller particle residual ratio in the stroke group may suggest the thrombus formed with LAA is more likely to flow out of LAA, leading to a higher risk of stroke. The proposed morphological and hemodynamic parameters may be additional risk factors that can be used to better risk stratify AF patients.
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Affiliation(s)
- Lingfeng Wang
- School of Biological Science and Medical Engineering, Southeast University, Nanjing, China
| | - Zidun Wang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Runxin Fang
- School of Biological Science and Medical Engineering, Southeast University, Nanjing, China
| | - Zhi-Yong Li
- School of Biological Science and Medical Engineering, Southeast University, Nanjing, China
- School of Mechanical, Medical and Process Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- *Correspondence: Zhi-Yong Li,
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15
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Cresti A, Camara O. Left Atrial Thrombus-Are All Atria and Appendages Equal? Interv Cardiol Clin 2022; 11:121-134. [PMID: 35361457 DOI: 10.1016/j.iccl.2021.11.005] [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: 06/14/2023]
Abstract
Although the left atrial appendage (LAA) seems useless, it has several critical functions that are not fully known yet, such as the causes for being the main origin of cardioembolic stroke. Difficulties arise due to the extreme range of LAA morphologic variability, making the definition of normality challenging and hampering the stratification of thrombotic risk. Furthermore, obtaining quantitative metrics of its anatomy and function from patient data is not straightforward. A multimodality imaging approach, using advanced computational tools for their analysis, allows a complete characterization of the LAA to individualize medical decisions related to left atrial thrombosis patients.
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Affiliation(s)
- Alberto Cresti
- Cardiology Department, Misericordia Hospital, Azienda Sanitaria Toscana SudEst, Via Senese, Grosseto 58100, Italy
| | - Oscar Camara
- BCN MedTech, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Tànger 122, Barcelona 08018, Spain.
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16
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Huang H, Chen L, Liu J, Wang W, Cao Y, Yuan B, Tao E, Fang Q, Tang L, Wang F, Wan L. Clinical application of percutaneous left atrial appendage occlusion guided only by transesophageal echocardiography without fluoroscopy and angiography in the patients with nonvalvular atrial fibrillation. J Card Surg 2022; 37:1479-1485. [PMID: 35355334 DOI: 10.1111/jocs.16463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/05/2022] [Accepted: 02/21/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIM The objective of this study was to understand the clinical efficacy and application of the percutaneous left atrial appendage occlusion (PLAAO) guided only by the transesophageal echocardiography (TEE) in patients with nonvalvular atrial fibrillation (NVAF), without using the fluoroscopy and angiography. METHODS During the time period of this study from June 2020 to June 2021, 32 patients underwent PLAAO and all underwent a TEE guided approach. The anatomical features of the left atrial appendage (LAA) were evaluated and observed by TEE before and during the procedure. LAA occluder device was selected for the appropriate size. Intraoperative TEE guided and monitored the process of PLAAO in real-time, and also evaluated the stability and tightness of the occluder device, following monitored postoperative complications. RESULTS The PLAAO procedure was successful in all the patients. No serious complications like dislocation of the occluder and embolism were seen. Postoperative TEE demonstrated that the PLAAO occluder devices were in a good position without residual shunting. CONCLUSIONS PLAAO only guided by TEE may become a safe and reliable surgical procedure, which can protect surgeons and patients from radiation, and can gradually become a novel surgical method of PLAAO with the practical application value.
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Affiliation(s)
- Huang Huang
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Li Chen
- Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Department of Ultrasound Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jichun Liu
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wenjun Wang
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yuanping Cao
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Bin Yuan
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Ende Tao
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Qiao Fang
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Liang Tang
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Fudong Wang
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Li Wan
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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17
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Kim WD, Cho I, Kim YD, Cha MJ, Kim SW, Choi Y, Shin SY. Improving Left Atrial Appendage Occlusion Device Size Determination by Three-Dimensional Printing-Based Preprocedural Simulation. Front Cardiovasc Med 2022; 9:830062. [PMID: 35252401 PMCID: PMC8889006 DOI: 10.3389/fcvm.2022.830062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/18/2022] [Indexed: 01/01/2023] Open
Abstract
Background The two-dimensional (2D)-based left atrial appendage (LAA) occluder (LAAO) size determination by using transesophageal echocardiography (TEE) is limited by the structural complexity and wide anatomical variation of the LAA. Objective This study aimed to assess the accuracy of the LAAO size determination by implantation simulation by using a three-dimensional (3D)-printed model compared with the conventional method based on TEE. Methods We retrospectively reviewed patients with anatomically and physiologically properly implanted the Amplatzer Cardiac Plug and Amulet LAAO devices between January 2014 and December 2018 by using the final size of the implanted devices as a standard for size prediction accuracy. The use of 3D-printed model simulations in device sizing was compared with the conventional TEE-based method. Results A total of 28 cases with the percutaneous LAA occlusion were reviewed. There was a minimal difference [−0.11 mm; 95% CI (−0.93, 0.72 mm); P = 0.359] between CT-based reconstructed 3D images and 3D-printed left atrium (LA) models. Device size prediction based on TEE measurements showed poor agreement (32.1%), with a mean difference of 2.3 ± 3.2 mm [95% CI (−4.4, 9.0)]. The LAAO sizing by implantation simulation with 3D-printed models showed excellent correlation with the actually implanted LAAO size (r = 0.927; bias = 0.7 ± 2.5). The agreement between the 3D-printed and the implanted size was 67.9%, with a mean difference of 0.6 mm [95% CI (−1.9, 3.2)]. Conclusion The use of 3D-printed LA models in the LAAO size determination showed improvement in comparison with conventional 2D TEE method.
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Affiliation(s)
- William D. Kim
- College of Medicine, Chung-Ang University, Seoul, South Korea
| | - Iksung Cho
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Doo Kim
- Department of Mechanical Engineering, Graduate School, Chung-Ang University, Seoul, South Korea
| | - Min Jae Cha
- Department of Radiology, Chung-Ang University Hospital, Seoul, South Korea
| | - Sang-Wook Kim
- Division of Cardiology, Chung-Ang University Hospital, Seoul, South Korea
- Heart Research Institute, Chung-Ang University Hospital, Seoul, South Korea
| | - Young Choi
- Department of Mechanical Engineering, Graduate School, Chung-Ang University, Seoul, South Korea
| | - Seung Yong Shin
- Division of Cardiology, Chung-Ang University Hospital, Seoul, South Korea
- *Correspondence: Seung Yong Shin
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18
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Pre-procedural determination of device size in left atrial appendage occlusion using three-dimensional cardiac computed tomography. Sci Rep 2021; 11:24107. [PMID: 34916575 PMCID: PMC8677741 DOI: 10.1038/s41598-021-03537-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 12/06/2021] [Indexed: 12/31/2022] Open
Abstract
The complex structure of the left atrial appendage (LAA) brings limitations to the two-dimensional-based LAA occlusion (LAAO) size prediction system using transesophageal echocardiography. The LAA anatomy can be evaluated more precisely using three-dimensional images from cardiac computed tomography (CT); however, there is lack of data regarding which parameter to choose from CT-based images during pre-procedural planning of LAAO. We aimed to assess the accuracy of measurements derived from cardiac CT images for selecting LAAO devices. We retrospectively reviewed 62 patients with Amplatzer Cardiac Plug and Amulet LAAO devices who underwent implantation from 2017 to 2020. The minimal, maximal, average, area-derived, and perimeter-derived diameters of the LAA landing zone were measured using CT-based images. Predicted device sizes using sizing charts were compared with actual successfully implanted device sizes. The mean size of implanted devices was 27.1 ± 3.7 mm. The perimeter-derived diameter predicted device size most accurately (mean error = − 0.8 ± 2.4 mm). All other parameters showed significantly larger error (mean error; minimal diameter = − 4.9 ± 3.3 mm, maximal diameter = 1.0 ± 2.9 mm, average diameter = − 1.6 ± 2.6 mm, area-derived diameter = − 2.0 ± 2.6 mm) than the perimeter-derived diameter (all p for difference < 0.05). The error for other parameters were larger in cases with more eccentrically-shaped landing zones, while the perimeter-derived diameter had minor error regardless of eccentricity. When oversizing was used, all parameters showed significant disagreement. The perimeter-derived diameter on cardiac CT images provided the most accurate estimation of LAAO device size regardless of landing zone eccentricity. Oversizing was unnecessary when using cardiac CT to predict an accurate LAAO size.
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19
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Effectiveness and safety of transcatheter left atrial appendage closure. J Cardiol 2021; 79:186-193. [PMID: 34565689 DOI: 10.1016/j.jjcc.2021.08.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 11/24/2022]
Abstract
Atrial fibrillation (AF) is responsible for cardiogenic stroke. Since left atrial appendage (LAA) is a cause of most of cardiac thrombus, LAA closure is an emerging novel stroke prevention procedure for patients with AF alternative to anticoagulation. WATCHMAN LAA Closure device (Boston Scientific, Marlborough, MA, USA) is the only approved device in the USA and Japan. The device is indicated in high bleeding risk and high stroke risk non-valvular AF patients. Cardiac tamponade, stroke, and device embolization are typical procedural complications. Procedural complication rate is reduced with implanters' experience and matured procedure steps. Several randomized trials demonstrated procedure safety and efficacy of the device. The device resulted in similar thromboembolic event rates but significantly reduced bleeding events compared to anticoagulants. After the procedure, optimal post procedural antithrombotic drug regimen has not been fully investigated. Also, device-related thrombosis can be a new issue. Modification of the device can improve issues, but not fully solve it. Tailor made treatment based on the individual risk by heart team communication with neurologists is essential to treat patients.
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20
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Rosati F, de Maat GE, Valente MAE, Mariani MA, Benussi S. Surgical clip closure of the left atrial appendage. J Cardiovasc Electrophysiol 2021; 32:2865-2872. [PMID: 34288215 PMCID: PMC9291484 DOI: 10.1111/jce.15181] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 07/02/2021] [Accepted: 07/16/2021] [Indexed: 12/17/2022]
Abstract
Atrial fibrillation (AF) is the most common atrial arrhythmia, but it is not a benign disease. AF is an important risk factor for thromboembolic events, causing significant morbidity and mortality. The left atrial appendage (LAA) plays an important role in thrombus formation, but the ideal management of the LAA remains a topic of debate. The increasing popularity of surgical epicardial ablation and hybrid endoepicardial ablation approaches, especially in patients with a more advanced diseased substrate, has increased interest in epicardial LAA management. Minimally invasive treatment options for the LAA offer a unique opportunity to close the LAA with a clip device. This review highlights morphologic, electrophysiologic, and surgical aspects of the LAA with regard to AF surgery, and aims to illustrate the importance of surgical clip closure of the LAA.
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Affiliation(s)
- Fabrizio Rosati
- Division of Cardiac Surgery, Spedali Civili Brescia University Hospital, Brescia, Italy
| | - Gijs E de Maat
- Department of Cardio-thoracic Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Mattia A E Valente
- Department of Cardio-thoracic Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Massimo A Mariani
- Department of Cardio-thoracic Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Stefano Benussi
- Division of Cardiac Surgery, Spedali Civili Brescia University Hospital, Brescia, Italy
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21
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Smit JM, Simon J, El Mahdiui M, Szaraz L, van Rosendael PJ, Kolassváry M, Szilveszter B, Delgado V, Merkely B, Maurovich-Horvat P, Bax JJ. Anatomical Characteristics of the Left Atrium and Left Atrial Appendage in Relation to the Risk of Stroke in Patients With Versus Without Atrial Fibrillation. Circ Arrhythm Electrophysiol 2021; 14:e009777. [PMID: 34279121 DOI: 10.1161/circep.121.009777] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Jeff M Smit
- Department of Cardiology, Leiden University Medical Center, the Netherlands (J.M.S., M.E.M., P.J.v.R., V.D., J.J.B.)
| | - Judit Simon
- Cardiovascular Imaging Research Group, Heart and Vascular Center (J.S., L.S., M.K., B.S., B.M., P.M.-H.), Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Mohammed El Mahdiui
- Department of Cardiology, Leiden University Medical Center, the Netherlands (J.M.S., M.E.M., P.J.v.R., V.D., J.J.B.)
| | - Lili Szaraz
- Cardiovascular Imaging Research Group, Heart and Vascular Center (J.S., L.S., M.K., B.S., B.M., P.M.-H.), Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Philippe J van Rosendael
- Department of Cardiology, Leiden University Medical Center, the Netherlands (J.M.S., M.E.M., P.J.v.R., V.D., J.J.B.)
| | - Márton Kolassváry
- Cardiovascular Imaging Research Group, Heart and Vascular Center (J.S., L.S., M.K., B.S., B.M., P.M.-H.), Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Balint Szilveszter
- Cardiovascular Imaging Research Group, Heart and Vascular Center (J.S., L.S., M.K., B.S., B.M., P.M.-H.), Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, the Netherlands (J.M.S., M.E.M., P.J.v.R., V.D., J.J.B.)
| | - Béla Merkely
- Cardiovascular Imaging Research Group, Heart and Vascular Center (J.S., L.S., M.K., B.S., B.M., P.M.-H.), Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Pál Maurovich-Horvat
- Cardiovascular Imaging Research Group, Heart and Vascular Center (J.S., L.S., M.K., B.S., B.M., P.M.-H.), Medical Imaging Centre, Semmelweis University, Budapest, Hungary.,Department of Radiology (P.M.-H.), Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, the Netherlands (J.M.S., M.E.M., P.J.v.R., V.D., J.J.B.).,Heart Center, University of Turku, Turku University Hospital, Finland (J.J.B.)
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22
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Sanatkhani S, Nedios S, Menon PG, Bollmann A, Hindricks G, Shroff SG. Subject-Specific Calculation of Left Atrial Appendage Blood-Borne Particle Residence Time Distribution in Atrial Fibrillation. Front Physiol 2021; 12:633135. [PMID: 34045972 PMCID: PMC8148016 DOI: 10.3389/fphys.2021.633135] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/24/2021] [Indexed: 11/13/2022] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia that leads to thrombus formation, mostly in the left atrial appendage (LAA). The current standard of stratifying stroke risk, based on the CHA2DS2-VASc score, does not consider LAA morphology, and the clinically accepted LAA morphology-based classification is highly subjective. The aim of this study was to determine whether LAA blood-borne particle residence time distribution and the proposed quantitative index of LAA 3D geometry can add independent information to the CHA2DS2-VASc score. Data were collected from 16 AF subjects. Subject-specific measurements included left atrial (LA) and LAA 3D geometry obtained by cardiac computed tomography, cardiac output, and heart rate. We quantified 3D LAA appearance in terms of a novel LAA appearance complexity index (LAA-ACI). We employed computational fluid dynamics analysis and a systems-based approach to quantify residence time distribution and associated calculated variable (LAA mean residence time, t m) in each subject. The LAA-ACI captured the subject-specific LAA 3D geometry in terms of a single number. LAA t m varied significantly within a given LAA morphology as defined by the current subjective method and it was not simply a reflection of LAA geometry/appearance. In addition, LAA-ACI and LAA t m varied significantly for a given CHA2DS2-VASc score, indicating that these two indices of stasis are not simply a reflection of the subjects' clinical status. We conclude that LAA-ACI and LAA t m add independent information to the CHA2DS2-VASc score about stasis risk and thereby can potentially enhance its ability to stratify stroke risk in AF patients.
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Affiliation(s)
- Soroosh Sanatkhani
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
| | - Sotirios Nedios
- Department of Electrophysiology, Massachusetts General Hospital, Boston, MA, United States
- Department of Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, Netherlands
| | - Prahlad G. Menon
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
| | - Andreas Bollmann
- Department of Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Sanjeev G. Shroff
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
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23
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Cresti A, Solari M, Gismondi AL, Baratta P, De Sensi F, Breschi M, Limbruno U. Incidence and clinical relevance of left atrial appendage membranes: a new congenital heart disease? Eur Heart J Cardiovasc Imaging 2021; 23:673-679. [PMID: 33948621 DOI: 10.1093/ehjci/jeab076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/12/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS Left atrial appendage (LAA) membranes are rare congenital anomalies. Those involving the appendage orifice may obstruct its emptying flows, thus promoting blood stasis and clot formation. However, the epidemiology of LAA membranes has never been studied and a correlation with appendage thrombosis has never been proved. Very few case reports described LAA membranes, therefore, their frequency and clinical significance are not known. Moreover, their presence and degree are of crucial importance in planning LAA percutaneous closure, a procedure whose indication is evolving, and whether their presence can represent technical issues during the device implantation is not known. This study aimed to evaluate the incidence and the clinical significance of LAA membranes. METHODS AND RESULTS A population of 6030 consecutive transoesophageal echo (TOE) studies has been retrospectively reviewed in order to find those patients in whom an LAA membrane has been found. A literature research has been performed to review previous described cases. Among 6030 TOE cases, an LAA membrane has been described in 6 (prevalence of 1/1000). In one case, the membrane was associated to a severe LAA hypoplasia and in another case to an LAA thrombus (these represent the first cases ever described). All patients had an atrial fibrillation (AF) history and two were in AF during the TOE exam. CONCLUSION LAA membranes are rare congenital abnormalities occasionally discovered during a TOE exam, frequently in patients affected by AF. In half of the cases, they obstruct the LAA flow, thus theoretically pre-disposing to clot formation. They may be rarely associated to an appendage hypoplasia. During a TOE exam, cardiac imagers should always rule out their presence.
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Affiliation(s)
- Alberto Cresti
- Department of Cardiology , Misericordia Hospital, Azienda Sanitaria Toscana Sudest, Via Senese, 58100 Grosseto Italy
| | - Marco Solari
- Department of Cardiology , Misericordia Hospital, Azienda Sanitaria Toscana Sudest, Via Senese, 58100 Grosseto Italy
| | - Anna Laura Gismondi
- Department of Biotechnologies, Division of Cardiology, University of Siena, Viale Bracci, 53100 Siena, Italy
| | - Pasquale Baratta
- Department of Cardiology , Misericordia Hospital, Azienda Sanitaria Toscana Sudest, Via Senese, 58100 Grosseto Italy
| | - Francesco De Sensi
- Department of Cardiology , Misericordia Hospital, Azienda Sanitaria Toscana Sudest, Via Senese, 58100 Grosseto Italy
| | - Marco Breschi
- Department of Cardiology , Misericordia Hospital, Azienda Sanitaria Toscana Sudest, Via Senese, 58100 Grosseto Italy
| | - Ugo Limbruno
- Department of Cardiology , Misericordia Hospital, Azienda Sanitaria Toscana Sudest, Via Senese, 58100 Grosseto Italy
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Rashid HN, Layland J. Modification of the left atrial appendage and its role in stroke risk reduction with non-valvular atrial fibrillation. IJC HEART & VASCULATURE 2021; 32:100688. [PMID: 33354620 PMCID: PMC7744943 DOI: 10.1016/j.ijcha.2020.100688] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/21/2020] [Accepted: 11/27/2020] [Indexed: 12/30/2022]
Abstract
Atrial fibrillation is one of the most common cardiovascular disorders encountered by clinicians in clinical practice. Patients with atrial fibrillation are at risk of cerebrovascular and systemic embolic events, which may be attenuated by commencement of anticoagulation therapy. Even so, due to extremely high bleeding risk certain patients may not be suitable for long-term anticoagulation therapy. The left atrial appendage is a common site for thrombus formation in patients with atrial fibrillation. Left atrial appendage exclusion, either surgical or percutaneous, has been performed to ostensibly reduce the risk of cerebrovascular events and potentially minimise or omit anticoagulation therapy in select patients. This review summarises the role of the left atrial appendage in cerebrovascular events, current evidence with modification of the left atrial appendage and future trials that may change practice with these procedures.
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Key Words
- ACC, American College of Cardiology
- AF, Atrial fibrillation
- AHA, American Heart Association
- Atrial fibrillation
- DRT, Device related thrombus
- ESC, European Society of Cardiology
- FDA, Food and Drug Administation
- HR, Hazard ratio
- LAA, Left atrial appendage
- LAAE, Left atrial appendage exclusion
- LGE, Late gadolinium enhancement
- Left atrial appendage occluder
- Left atrial appendage occlusion
- OAC, Oral anticoagulation
- OR, Odds ratio
- Stroke
- TOE, Trans-oesopheageal echocardiogram
- Thrombosis
- Watchman device
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Affiliation(s)
- Hashrul N. Rashid
- Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia
- Department of Cardiovascular Research, Peninsula Health, Melbourne, Australia
| | - Jamie Layland
- Department of Cardiovascular Research, Peninsula Health, Melbourne, Australia
- Peninsula Clinical School, Monash University, Melbourne, Australia
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Negrotto SM, Lugo RM, Metawee M, Kanagasundram AN, Chidsey G, Baker MT, Michaud GF, Piana RN, Benjamin Shoemaker M, Ellis CR. Left atrial appendage morphology predicts the formation of left atrial appendage thrombus. J Cardiovasc Electrophysiol 2021; 32:1044-1052. [PMID: 33512055 DOI: 10.1111/jce.14922] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 12/15/2020] [Accepted: 01/03/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nonchicken wing left atrial appendage (LAA) morphology is associated with higher risk for stroke in patients with atrial fibrillation (AF) than chicken wing (CW) morphology. OBJECTIVE Assess whether LAA morphology predicts the formation of LAA thrombus independent of age, sex, presenting rhythm, left ventricular ejection fraction (LVEF), or anticoagulant use. METHODS A cross-sectional analysis was performed on patients prospectively enrolled in the Vanderbilt LAA Registry or presenting for transesophageal echocardiogram (TEE) between January 1, 2015, and November 1, 2017 (n = 306). Two physicians independently reviewed TEEs interpreted as having LAA thrombus. Determination of LAA morphology, ejection velocity, and presence of thrombus (n = 102) were based on 0°, 45°, 90°, and 135° TEE views. The control cohort (n = 204) included consecutive AF patients undergoing TEE without LAA thrombus. RESULTS LAA morphology in patients with LAA thrombus was: 35% windsock, 47% broccoli, and 12% CW. Windsock (odds ratio [OR], 4.0; 95% confidence interval [CI]: 1.7-9.3, p = .001) and broccoli (OR, 6.6; 95% CI: 2.6-16.6; p < .001) morphology were higher risk for thrombus compared to CW. Female sex predicted higher-odds for LAA thrombus (OR, 2.6; 95% CI: 1.4-4.8; p = .002) as did LAA-EV < 20 cm/s (OR, 11.12; 95% CI: 5.6-22.1). Anticoagulation use (OR, 0.5; 95% CI: 0.3-0.9; p = .03) and higher LVEF (OR, 0.95; 95% CI: 0.93-0.98; p < .001) were associated with lower risk. In patients with a CW morphology who had LAA thrombus, 4 of the 7 had an LAA-EV < 20 cm/s and acute systolic heart failure with LVEF < 30% or active malignancy. In multivariable linear regression analysis controlling for presenting rhythm, anticoagulant use, age, sex, and LVEF, CW morphology appears relatively protective from LAA thrombus (p = .001). CONCLUSION CW LAA morphology appears relatively protective against the formation of LAA thrombus.
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Affiliation(s)
- Sara M Negrotto
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ricardo M Lugo
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mohamed Metawee
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Arvindh N Kanagasundram
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Geoffrey Chidsey
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael T Baker
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gregory F Michaud
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert N Piana
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Moore Benjamin Shoemaker
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher Randall Ellis
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Xia L. Left atrial appendage closure using the Watchman device in patients with off-label anatomy: "No man left behind". Cardiol J 2020; 27:95-96. [PMID: 32103485 DOI: 10.5603/cj.2020.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 01/19/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Linying Xia
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004 Shaanxi, China.
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27
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Karim N, Ho SY, Nicol E, Li W, Zemrak F, Markides V, Reddy V, Wong T. The left atrial appendage in humans: structure, physiology, and pathogenesis. Europace 2019; 22:5-18. [DOI: 10.1093/europace/euz212] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/12/2019] [Indexed: 01/01/2023] Open
Abstract
Abstract
For many years, the left atrial appendage (LAA) was considered a dormant embryological remnant; however, it is a structurally complex and functional organ that contributes to cardiac haemodynamic changes and volume homeostasis through both its contractile properties and neurohormonal peptide secretion. When dysfunctional, the LAA contributes to thrombogenesis and subsequent increased predisposition to cardioembolic events. Consequently, the LAA has gained much attention as a therapeutic target to lower this risk. In addition, attention has focused on the LAA in its role as an electrical trigger for atrial tachycardia and atrial fibrillation with ablation of the LAA to achieve electrical isolation showing promising results in the maintenance of sinus rhythm. This in-depth review explores the structure, physiology and pathophysiology of the LAA, as well as LAA intervention and their sequelae.
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Affiliation(s)
- Nabeela Karim
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Siew Yen Ho
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Edward Nicol
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Wei Li
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Filip Zemrak
- Barts Heart Centre, St. Bartholomew’s Hospital, Barts Health NHS Trust, London, UK
| | - Vias Markides
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Vivek Reddy
- Helmsley Centre for Cardiac Electrophysiology, Mount Sinai Hospital, New York City, NY, USA
| | - Tom Wong
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
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28
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Toy D, Naeger DM. Pre and Post Procedure Imaging of the Watchman® Device with Cardiac Computed Tomography Angiography. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:61. [DOI: 10.1007/s11936-019-0767-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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29
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Ramchand J, Harb SC, Miyasaka R, Kanj M, Saliba W, Jaber WA. Imaging for Percutaneous Left Atrial Appendage Closure: A Contemporary Review. STRUCTURAL HEART-THE JOURNAL OF THE HEART TEAM 2019. [DOI: 10.1080/24748706.2019.1643957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Jay Ramchand
- Section of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Serge C. Harb
- Section of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rhonda Miyasaka
- Section of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mohamed Kanj
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Walid Saliba
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wael A. Jaber
- Section of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
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30
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Xia L, Liu Y, Tao L. Kissing-Watchman technique applied in single-lobulated left atrial appendage anatomy with giant ostia. Cardiol J 2019; 27:78-80. [PMID: 31313275 DOI: 10.5603/cj.a2019.0070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/08/2019] [Accepted: 07/04/2019] [Indexed: 11/25/2022] Open
Affiliation(s)
- Linying Xia
- Department of Cardiology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032 Shaanxi, China.,Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710004 Shaanxi, China
| | - Yi Liu
- Department of Cardiology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032 Shaanxi, China
| | - Ling Tao
- Department of Cardiology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032 Shaanxi, China.
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31
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Alsagheir A, Koziarz A, Belley-Côté EP, Whitlock RP. Left Atrial Appendage Occlusion: A Narrative Review. J Cardiothorac Vasc Anesth 2019; 33:1753-1765. [DOI: 10.1053/j.jvca.2019.01.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Indexed: 12/21/2022]
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32
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Tan NY, Yasin OZ, Sugrue A, El Sabbagh A, Foley TA, Asirvatham SJ. Anatomy and Physiologic Roles of the Left Atrial Appendage: Implications for Endocardial and Epicardial Device Closure. Interv Cardiol Clin 2019. [PMID: 29526287 DOI: 10.1016/j.iccl.2017.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The left atrial appendage has been implicated as a major nidus for thrombus formation, particularly in atrial fibrillation. This discovery has prompted substantial interest in the development of left atrial appendage exclusion devices aimed at decreasing systemic thromboembolism risk. Its deceptively simple appearance belies the remarkable complexity that characterizes its anatomy and physiology. We highlight the key anatomic features and variations of the left atrial appendage as well as its relationships with surrounding structures. We also summarize crucial anatomic factors that should be taken into account by the interventional cardiologist when planning for or performing left atrial appendage exclusion procedures.
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Affiliation(s)
- Nicholas Y Tan
- Department of Internal Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Omar Z Yasin
- Department of Internal Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Alan Sugrue
- Department of Cardiovascular Diseases, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Abdallah El Sabbagh
- Department of Cardiovascular Diseases, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Thomas A Foley
- Department of Cardiovascular Diseases, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN 55905, USA.
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33
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Wu L, Liang E, Fan S, Zheng L, Du Z, Liu S, Hu F, Fan X, Chen G, Ding L, Yao Y. Relation of Left Atrial Appendage Morphology Determined by Computed Tomography to Prior Stroke or to Increased Risk of Stroke in Patients With Atrial Fibrillation. Am J Cardiol 2019; 123:1283-1286. [PMID: 30709597 DOI: 10.1016/j.amjcard.2019.01.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/06/2019] [Accepted: 01/09/2019] [Indexed: 11/29/2022]
Abstract
Left atrial appendage (LAA) morphology is considered to be associated with ischemic stroke, non-Chicken Wing LAA morphology increases the risk of thromboembolic events. However, existing classification of LAA morphology remains not well quantifiable and therefore may leave room for substantial subjective interpretation. This study aimed to assess interobserver and intraobserver agreements in LAA morphology and its real value in stroke prediction. A total of 2,264 atrial fibrillation patients who underwent computed tomography to explore the LAA anatomy were enrolled. All computed tomography images were given to 3 reviewers to judge the LAA morphology independently. A consensus between all 3 reviewers was only reached in 655 cases (28.9%). In which, 86 patients had previous stroke. Poor intraobserver consistency was observed between 2 times of reading in all the 3 reviewers (Kappa = 0.368, p = 0.014; Kappa = 0.350, p = 0.014; Kappa = 0.333, p = 0.015). Multivariate analysis showed that persistent atrial fibrillation (odds ratio [OR] 1.679; 95% confidence interval [CI] 1.031 to 2.736; p = 0.037), female gender (OR 1.761; 95% CI 1.037 to 2.994; p = 0.036) and age (OR 1.029; 95% CI 1.004 to 1.056; p = 0.025) were associated with previous stroke. LAA morphology was not associated with previous stroke and non-Chicken Wing LAA morphology did not increase the risk of stroke (OR 1.392; 95% CI 0.847 to 2.288; p = 0.192). In conclusion, high interobserver and intraobserver variabilities suggested that existing classification of LAA morphology was unreliable, the interpretation of the relation between LAA morphology and stroke needs caution.
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Affiliation(s)
- Lingmin Wu
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Erpeng Liang
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Siyang Fan
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Lihui Zheng
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhongpeng Du
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Shangyu Liu
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Feng Hu
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xiaohan Fan
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Gang Chen
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Ligang Ding
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yan Yao
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
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Jia D, Jeon B, Park HB, Chang HJ, Zhang LT. Image-Based Flow Simulations of Pre- and Post-left Atrial Appendage Closure in the Left Atrium. Cardiovasc Eng Technol 2019; 10:225-241. [PMID: 30953246 DOI: 10.1007/s13239-019-00412-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 03/28/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE For patients with atrial fibrillation, the left atrial appendage (LAA) is often the site of thrombus formation due to low atrial ejection fraction that triggers strokes and other thromboembolic events. Recently introduced percutaneous LAA occlusion procedure is known to reduce LAA-induced strokes. Despite having the procedure, there are still 11% of the patients who continue to suffer from future strokes or transient ischemic attacks, not accounting for the procedural related complications. The high failure rate is largely due to the variabilities in LAA's shape, size, and contractility which may result in ineffectiveness of this procedure. To correctly identify the candidates and evaluate the effectiveness of the procedure, we rely on patient-specific CT scans which provides the exact LA and LAA geometries and predictive hemodynamic analysis to assist in evaluating quantitative flow parameters pre- and post-LAA occlusion procedures. Hemodynamic parameters are critical to predict adverse hemodynamic flow patterns in LAA as well as the effectiveness of LAA closure in individual patient. The aim of this paper is to establish an image-based patient-specific computational fluid dynamic (CFD) simulation framework specific to the prediction of treatment outcomes of LAA closure with atrial fibrillation. This framework utilizes automated LA/LAA image segmentation which yields significant reduction in image processing. One set of patient data with successful procedure outcome is used to illustrate the potential of the proposed framework. METHODS The proposed LAA occlusion simulation framework is composed of several components: (1) a novel image segmentation procedure, which is fully-automated to identify LA/LAA geometries from CT images, (2) a finite-element mesh generation procedure which transforms the surface geometry into a 3-D volume mesh and properly identified boundary planes, (3) performing CFD simulations with atrial fibrillation flow boundary conditions, and (4) analyzing flow characteristics (velocity, flow patterns, streamlines, vortices) within the LA for before and after LAA closure. RESULTS Based on the LA/LAA segmentation of a 65 year old female patient with chronic atrial fibrillation, a CFD analysis was pursued to examine flow characteristics upon LAA closure. The results showed that the flow velocity magnitudes were significantly reduced by a maximum factor of 2.21, flow streamlines were greatly stabilized, and mitral outflow appeared to be more organized. Vortices were dramatically reduced in size, number, intensity, as well as duration. During diastole, the peak vortex diameter was reduced from 2.8 to 1.5 cm, while the vortex duration was reduced from 0.210 to 0.135 s. These flow characteristics all indicated a reduced risk in future thrombus formation and strokes based on the established relationship between flow and thrombus formation. For the patient case under study, the effectiveness of the procedure is predicted and found to be consistent with the actual procedural outcome. CONCLUSIONS This framework successfully predicted patient-specific outcome of a LAA closure procedure for one patient with atrial fibrillation. It can be further developed into a useful tool for pre-procedural planning and candidate selection. More patient data are necessary for further validation studies.
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Affiliation(s)
- Dongjie Jia
- Department of Mechanical, Aerospace & Nuclear Engineering, Rensselaer Polytechnic Institute, Troy, NY, 12180, USA
| | - Byunghwan Jeon
- Brain Korea 21 PLUS Project for Medical Science, Yonsei University, Seoul, South Korea
- Yonsei-Cedars Sinai Integrative Cardiovascular Imaging Research Center, Yonsei University Health System, Seoul, South Korea
| | - Hyung-Bok Park
- Yonsei-Cedars Sinai Integrative Cardiovascular Imaging Research Center, Yonsei University Health System, Seoul, South Korea
- Division of Cardiology, Department of Internal Medicine, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, South Korea
| | - Hyuk-Jae Chang
- Yonsei-Cedars Sinai Integrative Cardiovascular Imaging Research Center, Yonsei University Health System, Seoul, South Korea
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, South Korea
| | - Lucy T Zhang
- Department of Mechanical, Aerospace & Nuclear Engineering, Rensselaer Polytechnic Institute, Troy, NY, 12180, USA.
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Electrical isolation of the left atrial appendage increases the risk of ischemic stroke and transient ischemic attack regardless of postisolation flow velocity. Heart Rhythm 2019; 15:1746-1753. [PMID: 30502771 DOI: 10.1016/j.hrthm.2018.09.012] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Electrical isolation of the left atrial appendage (LAA) is associated with a lower rate of atrial fibrillation (AF) recurrence in patients undergoing radiofrequency catheter ablation. However, LAA isolation can significantly impair LAA contractility. OBJECTIVE This study was performed to evaluate whether electrical isolation of the LAA is associated with an increased risk of ischemic stroke or transient ischemic attack (TIA). METHODS Consecutive patients with AF undergoing radiofrequency catheter ablation at Korea University Medical Center Anam Hospital were analyzed. RESULTS Of 2352 patients, 39 (1.7%) had LAA isolation. Patients with LAA isolation had a significantly higher rate of ischemic stroke or TIA than did those without LAA isolation (log-rank, P < .001; hazard ratio 23.6; P < .001). There were significant differences in the baseline characteristics of the 2 groups, including type of AF (34 [87.2%] and 911 [39.4%] patients with and without LAA isolation had nonparoxysmal AF, respectively). After multivariate adjustment, LAA isolation was found to be a significant risk factor for ischemic stroke or TIA (adjusted hazard ratio 11.3; P < .001). Propensity score-matched analysis also revealed an increased risk of ischemic stroke or TIA in patients with LAA isolation compared with those without LAA isolation (log-rank, P = .001). The LAA flow velocity of post-LAA isolation status was not significantly different between patients who did and did not experience ischemic stroke or TIA (30.3 ± 17.7 cm/s vs 33.9 ± 17.9 cm/s; P = .608). CONCLUSION A significantly increased risk of ischemic stroke or TIA was observed in patients with electrical isolation of the LAA. In addition, postisolation LAA flow velocity is not a reliable marker to predict future ischemic events.
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Impact of anatomical features of the left atrial appendage on outcomes after cryoablation for atrial fibrillation. J Cardiovasc Comput Tomogr 2019; 13:105-112. [PMID: 30639114 DOI: 10.1016/j.jcct.2019.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 11/20/2018] [Accepted: 01/03/2019] [Indexed: 11/22/2022]
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Left atrial appendage-beyond being a thrombus-spreading tiger. J Interv Card Electrophysiol 2018; 53:283-284. [PMID: 30225533 DOI: 10.1007/s10840-018-0450-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
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Asmarats L, Bernier M, O'Hara G, Paradis JM, O'Connor K, Beaudoin J, Bilodeau S, Cavalcanti R, Champagne J, Rodés-Cabau J. Hemodynamic impact of percutaneous left atrial appendage closure in patients with paroxysmal atrial fibrillation. J Interv Card Electrophysiol 2018; 53:151-157. [PMID: 29869301 DOI: 10.1007/s10840-018-0387-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/23/2018] [Indexed: 10/14/2022]
Abstract
PURPOSE Percutaneous left atrial appendage (LAA) closure has become a valid alternative to anticoagulation therapy for the prevention of thromboembolic events in patients with atrial fibrillation (AF). However, scarce data exist on the impact of LAA closure on left atrial and ventricular function. We sought to assess the acute hemodynamic changes associated with percutaneous LAA closure in patients with paroxysmal AF. METHODS The study population consisted of 31 patients (mean age 73 ± 10 years; 49% women) with paroxysmal AF who underwent successful percutaneous LAA closure. All patients were in sinus rhythm and underwent 2D transthoracic echocardiography at baseline and the day after the procedure. A subset of 14 patients underwent preprocedural cardiac computed tomography (CT) with 3D LA and LAA reconstruction. RESULTS Left ventricular systolic function parameters and LA volumetric indexes remained unchanged after the procedure. No significant changes in left ventricular stroke volume (72.4 ± 16.0 vs. 73.3 ± 15.7 mL, p = 0.55) or LA stroke volume (total 15.6 ± 4.2 vs. 14.6 ± 4.2 mL, p = 0.21; passive 9.0 ± 2.8 vs. 8.3 ± 2.6 mL, p = 0.31; active 10.3 ± 5.6 vs. 10.0 ± 6.4 mL, p = 0.72) occurred following LAA closure. Mean ratio of LAA to LA volume by 3D CT was 10.2 ± 2.3%. No correlation was found between LAA/LA ratio and changes in LA stroke volume (r = 0.35, p = 0.22) or left ventricular stroke volume (r = 0.28, p = 0.33). CONCLUSIONS The LAA accounts for about 10% of the total LA volume, but percutaneous LAA closure did not translate into any significant changes in LA and left ventricular function.
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Affiliation(s)
- Lluis Asmarats
- Quebec Heart & Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec, G1V 4G5, Canada
| | - Mathieu Bernier
- Quebec Heart & Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec, G1V 4G5, Canada
| | - Gilles O'Hara
- Quebec Heart & Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec, G1V 4G5, Canada
| | - Jean-Michel Paradis
- Quebec Heart & Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec, G1V 4G5, Canada
| | - Kim O'Connor
- Quebec Heart & Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec, G1V 4G5, Canada
| | - Jonathan Beaudoin
- Quebec Heart & Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec, G1V 4G5, Canada
| | - Sylvie Bilodeau
- Quebec Heart & Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec, G1V 4G5, Canada
| | - Rafael Cavalcanti
- Quebec Heart & Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec, G1V 4G5, Canada
| | - Jean Champagne
- Quebec Heart & Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec, G1V 4G5, Canada
| | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, 2725 chemin Ste-Foy, Quebec City, Quebec, G1V 4G5, Canada.
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García-Isla G, Olivares AL, Silva E, Nuñez-Garcia M, Butakoff C, Sanchez-Quintana D, G Morales H, Freixa X, Noailly J, De Potter T, Camara O. Sensitivity analysis of geometrical parameters to study haemodynamics and thrombus formation in the left atrial appendage. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2018; 34:e3100. [PMID: 29737037 DOI: 10.1002/cnm.3100] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 04/02/2018] [Accepted: 04/15/2018] [Indexed: 06/08/2023]
Abstract
The left atrial appendage (LAA) is a complex and heterogeneous protruding structure of the left atrium (LA). In atrial fibrillation patients, it is the location where 90% of the thrombi are formed. However, the role of the LAA in thrombus formation is not fully known yet. The main goal of this work is to perform a sensitivity analysis to identify the most relevant LA and LAA morphological parameters in atrial blood flow dynamics. Simulations were run on synthetic ellipsoidal left atria models where different parameters were individually studied: pulmonary veins and mitral valve dimensions; LAA shape; and LA volume. Our computational analysis confirmed the relation between large LAA ostia, low blood flow velocities and thrombus formation. Additionally, we found that pulmonary vein configuration exerted a critical influence on LAA blood flow patterns. These findings contribute to a better understanding of the LAA and to support clinical decisions for atrial fibrillation patients.
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Affiliation(s)
- Guadalupe García-Isla
- BCN-MedTech, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
| | - Andy Luis Olivares
- BCN-MedTech, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
| | - Etelvino Silva
- Arrhythmia Unit, Department of Cardiology, Cardiovascular Center, Aalst, Belgium
| | - Marta Nuñez-Garcia
- BCN-MedTech, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
| | - Constantine Butakoff
- BCN-MedTech, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
| | | | - Hernán G Morales
- Medisys, Philips Research, Paris, France
- Centro de Fisiologia del Ejercicio, Facultad de Ciencias, Universidad Mayor, Santiago de Chile, Chile
| | - Xavier Freixa
- Department of Cardiology, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Jérôme Noailly
- BCN-MedTech, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
| | - Tom De Potter
- Arrhythmia Unit, Department of Cardiology, Cardiovascular Center, Aalst, Belgium
| | - Oscar Camara
- BCN-MedTech, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
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Zhang J, Cui CY, Huang DQ, Liu YY, Qin YY, Zhang LZ, Liu L. Evaluation of the left atrial appendage by real time three-dimensional transesophageal echocardiography online. Echocardiography 2018; 35:991-998. [PMID: 29676485 DOI: 10.1111/echo.13870] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The objective of this study was to evaluate the feasibility of online real time three-dimensional transesophageal echocardiography (RT3DTEE) in the measurement of left atrial appendage (LAA) orifice size. We also analyzed the correlation between LAA ejection fraction (EF) and its peak empty velocity (PEV). METHODS There were 91 subjects enrolled in this study, with 46 patients with AF and 45 individuals with sinus rhythm (SR). RT3DTEE was performed by four methods including iSlice and iCrop online and QLAB software 3DQ and GI-3DQ off-line which were used to measure LAA orifice area, long diameter, short diameter, depth in the largest LAA, and number of LAA lobes. These LAA parameters achieved by the four methods were compared, respectively. GI-3DQ off-line was used to measure LAA end-diastolic and end-systolic volumes to calculate EF of LAA. Two-dimensional (2D) TEE was applied to measure PEV of LAA. The correlation between EF and PEV was analyzed. RESULTS There were no significant differences in all LAA parameters between any two RT3DTEE methods (All P > .05). There was a significant and positive correlation between PEV and EF (r = .423, P = .000). There were statistical differences in LAA EF and PEV between patients with AF and SR individuals (0.38 ± 0.12 vs 0.61 ± 0.07, 35.7 ± 12.1 vs 49.5 ± 10.0 cm/s, P = .000). CONCLUSION Using online RT3DTEE for measuring LAA orifice size is feasible, and online RT3DTEE is more convenient than offline RT3DTEE. EF is positively correlated with PEV. LAA function is significantly decreased in patients with AF.
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Affiliation(s)
- Juan Zhang
- Department of Cardiovascular Ultrasound, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Cun-Ying Cui
- Department of Cardiovascular Ultrasound, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Dan-Qing Huang
- Department of Cardiovascular Ultrasound, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yuan-Yuan Liu
- Department of Cardiovascular Ultrasound, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yun-Yun Qin
- Department of Cardiovascular Ultrasound, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Lian-Zhong Zhang
- Department of Cardiovascular Ultrasound, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Lin Liu
- Department of Cardiovascular Ultrasound, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, Henan, China
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Echocardiographic Imaging for Left Atrial Appendage Occlusion: Transesophageal Echocardiography and Intracardiac Echocardiographic Imaging. Interv Cardiol Clin 2018. [PMID: 29526290 DOI: 10.1016/j.iccl.2018.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Left atrial appendage occlusion (LAAO) is a rapidly evolving technology. Multi-modality imaging and understanding of left atrial appendage anatomy are sure to advance. Two-dimensional and 3-dimensional transesophageal echocardiography with fluoroscopy are the mainstay for LAAO image-guided therapy. Key to successful LAAO is an understanding of the transseptal puncture, LAAO size selection for the device-specific landing zone, and postdeployment evaluation for leak and complications. With advancements in computed tomography, there may be a greater role for intracardiac echocardiographic imaging in specific types of LAAO anatomy and devices.
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Luani B, Groscheck T, Genz C, Tanev I, Rauwolf T, Herold J, Medunjanin S, Schmeisser A, Braun-Dullaeus RC. Left atrial enlargement and clinical considerations in patients with or without a residual interatrial shunt after closure of the left atrial appendage with the WATCHMAN™-device. BMC Cardiovasc Disord 2017; 17:294. [PMID: 29233088 PMCID: PMC5727646 DOI: 10.1186/s12872-017-0728-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 12/04/2017] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Interventional closure of the left atrial appendage (LAA) in patients with non-valvular atrial fibrillation, high thromboembolic and bleeding risk or bleeding history is an alternative therapeutic strategy to oral anticoagulation. It is not known if the exclusion of the LAA from the blood circulation affects the left atrial volume (LAV) and consequently its prognostic value or the circulatory performance of the heart in humans. METHODS We aimed to prospectively assess potential changes in baseline LAV, left ventricular ejection fraction (LVEF), NT-proBNP-level and the covered distance in the 6-min walk-test 6 weeks and 6 months after LAA closure with the WATCHMAN™ device. We used serial 3-dimensional transthoracic and transesophageal echocardiography to assess LAV, residual interatrial shunt and device performance in 58 consecutive patients with successful LAA closure. RESULTS Accurate 3D-echocardiographic data for LAV measurements were evaluable for 51 (91%) patients. Maximum LAV (LAVmax) at baseline was 102.8 ± 30.8 ml and increased significantly to 107.7 ± 32.8 ml after 6 weeks (p < 0.01) and 113.5 ± 34.2 ml after 6 months (p < 0.01). Minimal LAV (LAVmin) increased from 76.9 ± 29.5 ml at baseline to 81.8 ± 30.2 ml after 45 days (p < 0.01) and 82.1 ± 33.3 ml after 6 months (p < 0.01). Similarly, their indexes to BSA (LAVImax and LAVImin) increased significantly, as well. Patients without a residual left-to-right interatrial shunt showed a significantly higher increase in LAVmax or LAVmin. Baseline LVEF, NT-proBNP-level or the distance covered at the 6-min walk test did not significantly change 6 weeks or 6 months after LAA closure. CONCLUSIONS LAVmax and LAVmin increase significantly after interventional LAA closure. LA enlargement does not correlate with clinical progression of heart failure. Persistent left-to-right interatrial shunt counteracts the LA enlargement. A reduced LA compliance after exclusion of the LAA from the blood circulation with consecutive increase in LA pressure may be a potential cause of LA enlargement and warrants further investigation. TRIAL REGISTRATION German Clinical Trials Register ID: DRKS00010768 ; Registration Date 07.07.2016.
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Affiliation(s)
- Blerim Luani
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr. 44, 39120 Magdeburg, Germany
| | - Thomas Groscheck
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr. 44, 39120 Magdeburg, Germany
| | - Conrad Genz
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr. 44, 39120 Magdeburg, Germany
| | - Ivan Tanev
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr. 44, 39120 Magdeburg, Germany
| | - Thomas Rauwolf
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr. 44, 39120 Magdeburg, Germany
| | - Joerg Herold
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr. 44, 39120 Magdeburg, Germany
| | - Senad Medunjanin
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr. 44, 39120 Magdeburg, Germany
| | - Alexander Schmeisser
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr. 44, 39120 Magdeburg, Germany
| | - Rüdiger C. Braun-Dullaeus
- Department of Internal Medicine, Division of Cardiology and Angiology, Magdeburg University, Leipzigerstr. 44, 39120 Magdeburg, Germany
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Rigatelli G, Zuin M, Dell'Avvocata F. Atrial fibrillation and patent foramen potentially share same atrial flow dynamic profile and thrombotic mechanism. Eur J Intern Med 2017; 44:e20-e21. [PMID: 28750795 DOI: 10.1016/j.ejim.2017.07.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 07/18/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Gianluca Rigatelli
- Section of Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, Rovigo, Italy.
| | - Marco Zuin
- Department of Cardiology, Rovigo General Hospital, Rovigo, Italy; Section of Internal and Cardiopulmonary Medicine, Department of Medical Science, University of Ferrara, Ferrara, Italy
| | - Fabio Dell'Avvocata
- Section of Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, Rovigo, Italy
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Lempereur M, Aminian A, Dulgheru R, De Potter T, Oury C, Lancellotti P. Role of Imaging in Left Atrial Appendage Occlusion. INTERNATIONAL JOURNAL OF CARDIOVASCULAR PRACTICE 2017. [DOI: 10.21859/ijcp-020203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Casu G, Gulizia MM, Molon G, Mazzone P, Audo A, Casolo G, Di Lorenzo E, Portoghese M, Pristipino C, Ricci RP, Themistoclakis S, Padeletti L, Tondo C, Berti S, Oreglia JA, Gerosa G, Zanobini M, Ussia GP, Musumeci G, Romeo F, Di Bartolomeo R. ANMCO/AIAC/SICI-GISE/SIC/SICCH Consensus Document: percutaneous occlusion of the left atrial appendage in non-valvular atrial fibrillation patients: indications, patient selection, staff skills, organisation, and training. Eur Heart J Suppl 2017; 19:D333-D353. [PMID: 28751849 PMCID: PMC5520759 DOI: 10.1093/eurheartj/sux008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia and its prevalence is increasing due to the progressive aging of the population. About 20% of strokes are attributable to AF and AF patients are at five-fold increased risk of stroke. The mainstay of treatment of AF is the prevention of thromboembolic complications with oral anticoagulation therapy. Drug treatment for many years has been based on the use of vitamin K antagonists, but recently newer and safer molecules have been introduced (dabigatran etexilate, rivaroxaban, apixaban, and edoxaban). Despite these advances, many patients still do not receive adequate anticoagulation therapy because of contraindications (relative and absolute) to this treatment. Over the last decade, percutaneous closure of left atrial appendage, main site of thrombus formation during AF, proved effective in reducing thromboembolic complications, thus offering a valid medical treatment especially in patients at increased bleeding risk. The aim of this consensus document is to review the main aspects of left atrial appendage occlusion (selection and multidisciplinary assessment of patients, currently available methods and devices, requirements for centres and operators, associated therapies and follow-up modalities) having as a ground the significant evolution of techniques and the available relevant clinical data.
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Affiliation(s)
- Gavino Casu
- CCU-Cardiology Department, Ospedale San Francesco Nuoro, Via Mannironi, 1 Nuoro, Italy
- Corresponding author. Tel: +393356623601, Fax: +390784240376,
| | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi, Catania”, Italy
| | - Giulio Molon
- Cardiology Unit Ospedale Sacro Cuore, Negrar (Verona), Italy
| | - Patrizio Mazzone
- Arrhythmology and Electrophysiology Unit, Ospedale San Raffaele, Milan, Italy
| | - Andrea Audo
- Cardiac Surgery Unit, Ospedale Civile SS. Antonio e Biagio, Alessandria, Italy
| | - Giancarlo Casolo
- Cardiology Department, Nuovo Ospedale Versilia, Lido di Camaiore (Lucca), Italy
| | | | | | | | - Renato Pietro Ricci
- CCU-Cardiology Department Presidio Ospedaliero San Filippo Neri, Rome, Italy
| | - Sakis Themistoclakis
- Electrophysiology and Electrostimulation Department, Ospedale dell’Angelo, Venice Mestre, Italy
| | - Luigi Padeletti
- Experimental and Clinical Medicine Department, Università degli Studi, Florence, Italy
| | - Claudio Tondo
- Arrhythmology Unit, Centro Cardiologico Monzino, Milan, Italy
| | - Sergio Berti
- Diagnostic and Interventional Cardiology Department, Fondazione Toscana “G. Monasterio”, Ospedale del Cuore, Massa, Italy
| | | | - Gino Gerosa
- Cardiac Surgery Unit—Centro V. Gallucci, Azienda Ospedaliera di Padova, Padua, Italy
| | - Marco Zanobini
- Cardiac Surgery Unit, Centro Cardiologico Monzino, Milan, Italy
| | - Gian Paolo Ussia
- Systems Medicine Department, Università degli Studi di Roma “Tor Vergata”, Rome, Italy
| | | | - Francesco Romeo
- Cardiology and Interventional Cardiology, Policlinico “Tor Vergata”, Rome, Italy
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Assessment of the left atrial appendage structure and morphology: comparison of real-time three-dimensional transesophageal echocardiography and computed tomography. Int J Cardiovasc Imaging 2016; 33:623-633. [PMID: 28012051 DOI: 10.1007/s10554-016-1044-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 12/16/2016] [Indexed: 02/05/2023]
Abstract
In this study, the left atrial appendage (LAA) structure and morphology were assessed using real-time three-dimensional transesophageal echocardiography (RT3D-TEE) and enhanced cardiac computed tomography (CT) scanning, and the two measurements obtained using these different techniques were compared. Two hundred nonvalvular atrial fibrillation (NVAF) patients who were prepared to undergo radiofrequency ablation were enrolled, and 62 controls were enrolled prospectively. RT3D-TEE and CT were performed, and the following parameters were measured: LAA orifice diameter, area, depth, maximum volume, and emptying velocity. The differences between the NVAF patients and controls were compared, and the differences and correlations in the LAA parameters between the two imaging techniques were assessed. The NVAF patients had significantly bigger orifice sizes, orifice areas, and maximum volumes, and lower emptying rates. The AF cohort had roughly equal proportions of the four morphological types, whereas the controls predominantly had the windsock type. A Bland-Altman analysis demonstrated that the LAA measurements obtained using RT3D-TEE were lower than those obtained with the CT. However, linear regression analysis showed the good correlations between the RT3D-TEE and CT measurements of the LAA orifice area, depth and volume (r = 0.86, 0.63, and 0.75, respectively). The use of RT3D-TEE for the visualization and quantitative analysis of LAA parameters is feasible, and the obtained measurements correlate well with those obtained with cardiac CT. This technique may be an ideal tool for guiding LAA occlusion procedures, and combining these two methods may enhance the accuracy of LAA measurements.
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Structural Comparison between the Right and Left Atrial Appendages Using Multidetector Computed Tomography. BIOMED RESEARCH INTERNATIONAL 2016; 2016:6492183. [PMID: 27900330 PMCID: PMC5120179 DOI: 10.1155/2016/6492183] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 10/05/2016] [Accepted: 10/16/2016] [Indexed: 11/18/2022]
Abstract
The three-dimensional (3D) structures of the right atrial appendage (RAA) and left atrial appendage (LAA) were compared to clarify why thrombus formation less frequently occurs in RAA than in LAA. Morphological differences between RAA and LAA of 34 formalin-preserved cadaver hearts were investigated. Molds of RAA and LAA specimens were made and the neck areas, volumes of the atrial appendages (AA), and amount of pectinate muscles (PMs) were analyzed using multidetector computed tomography. In RAA, most PMs were connected to one another and formed a “dendritic” appearance and the inner surface area was smaller than in LAA. RAA had smaller volumes and larger neck areas than LAA. The ratios of the neck area/volume were larger and the amounts of PMs were smaller in RAA than in LAA. The volumes, neck areas, and amount of PMs of RAA were significantly correlated with those of LAA. According to the 3D structure, RAA appears to be suited for a more favorable blood flow, which may explain why the thrombus formation is less common in RAA than in LAA. Examining not only LAA but also RAA by transesophageal echocardiography may be useful in high-risk patients of thrombus formation in LAA because the volume, neck area, and amount of PMs of LAA reflect the shape of RAA.
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Di Biase L, Burkhardt JD, Mohanty P, Mohanty S, Sanchez JE, Trivedi C, Güneş M, Gökoğlan Y, Gianni C, Horton RP, Themistoclakis S, Gallinghouse GJ, Bailey S, Zagrodzky JD, Hongo RH, Beheiry S, Santangeli P, Casella M, Dello Russo A, Al-Ahmad A, Hranitzky P, Lakkireddy D, Tondo C, Natale A. Left Atrial Appendage Isolation in Patients With Longstanding Persistent AF Undergoing Catheter Ablation. J Am Coll Cardiol 2016; 68:1929-1940. [DOI: 10.1016/j.jacc.2016.07.770] [Citation(s) in RCA: 234] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 07/14/2016] [Accepted: 07/27/2016] [Indexed: 10/20/2022]
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Abuderman A, Abbas M. Morphological changes evaluation of left atrial appendage in patients with ischaemic heart disease. Biomed J 2016; 39:277-282. [PMID: 27793270 PMCID: PMC6139875 DOI: 10.1016/j.bj.2016.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 12/10/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Since the majority of morphological changes evaluation of myocardium in ischaemic heart disease was in animal model, we detected the importance to evaluate such changes in human patients to gain insights into the targets of cellular damage and to reconcile or refine those experiments. METHODS Tissue sections from left atrial appendage of the heart were carefully dissected from seventy five patients underwent conventional coronary artery bypass grafting at the cardiothoracic surgical department, Manchester Royal Infirmary. Tissue was fixed, sectioned, stained and six random sections were photographed and the images were assessed and quantified using Image Analyser Pro-Plus software, version 4.1. Arterioles, venules, intermediate sized vessels, and capillaries were directly counted within the highlighted area of myocardium under LM. Ultra-thin sections were imaged in a Tecnai 12 Biotwin transmission electron microscope at a magnification of ×4200 and photographed by a camera with a black and white film to quantify different structures of myocardium. RESULTS The arteriole wall to lumen ratio was significantly increased in ischaemic heart disease patients 18.57 ± 2.89 compared to controls 8.3 ± 1.57, (P < 0.01). The regression analysis between vascular density and cardiomyocyte size demonstrated a significant inverse correlation between transverse cardiomyocyte diameter and arteriole, capillary and total vessel density (P < 0.01, 0.04, 0.02), respectively. Lumen area of the distal myocardial capillary was significantly reduced in IHD patients compared to controls (P < 0.01). CONCLUSION These results elucidate the morphological changes in the myocardial microvasculature of patients with ischaemic heart disease and its pathological magnitudes.
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Affiliation(s)
- Abdulwahab Abuderman
- Department of Basic Medical Sciences, College of Medicine, Prince Sattam bin Abdulaziz University, Kharj, Saudi Arabia; Al-Farabi College of Medicine, Al-Farabi Colleges, Riyadh, Saudi Arabia.
| | - Mohammed Abbas
- Department of Medical Laboratory, Allied Health Division, College of Health Sciences, University of Bahrain, Manama, Bahrain
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