1
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Higa S. Editorial to "Association of Left Atrial Appendage Morphology and Function With Stroke and Transient Ischemic Attack in Atrial Fibrillation Patients". Am J Cardiol 2024; 222:184-186. [PMID: 38657852 DOI: 10.1016/j.amjcard.2024.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 04/19/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Satoshi Higa
- Cardiac Electrophysiology and Pacing Laboratory, Division of Cardiovascular Medicine, Makiminato Central Hospital, Okinawa, Japan.
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2
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Zingaro A, Ahmad Z, Kholmovski E, Sakata K, Dede' L, Morris AK, Quarteroni A, Trayanova NA. A comprehensive stroke risk assessment by combining atrial computational fluid dynamics simulations and functional patient data. Sci Rep 2024; 14:9515. [PMID: 38664464 PMCID: PMC11045804 DOI: 10.1038/s41598-024-59997-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
Stroke, a major global health concern often rooted in cardiac dynamics, demands precise risk evaluation for targeted intervention. Current risk models, like theCHA 2 DS 2 -VASc score, often lack the granularity required for personalized predictions. In this study, we present a nuanced and thorough stroke risk assessment by integrating functional insights from cardiac magnetic resonance (CMR) with patient-specific computational fluid dynamics (CFD) simulations. Our cohort, evenly split between control and stroke groups, comprises eight patients. Utilizing CINE CMR, we compute kinematic features, revealing smaller left atrial volumes for stroke patients. The incorporation of patient-specific atrial displacement into our hemodynamic simulations unveils the influence of atrial compliance on the flow fields, emphasizing the importance of LA motion in CFD simulations and challenging the conventional rigid wall assumption in hemodynamics models. Standardizing hemodynamic features with functional metrics enhances the differentiation between stroke and control cases. While standalone assessments provide limited clarity, the synergistic fusion of CMR-derived functional data and patient-informed CFD simulations offers a personalized and mechanistic understanding, distinctly segregating stroke from control cases. Specifically, our investigation reveals a crucial clinical insight: normalizing hemodynamic features based on ejection fraction fails to differentiate between stroke and control patients. Differently, when normalized with stroke volume, a clear and clinically significant distinction emerges and this holds true for both the left atrium and its appendage, providing valuable implications for precise stroke risk assessment in clinical settings. This work introduces a novel framework for seamlessly integrating hemodynamic and functional metrics, laying the groundwork for improved predictive models, and highlighting the significance of motion-informed, personalized risk assessments.
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Affiliation(s)
- Alberto Zingaro
- ADVANCE, Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles St., Baltimore, MD, 21218, USA.
- MOX, Laboratory of Modeling and Scientific Computing, Dipartimento di Matematica, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133, Milan, Italy.
- ELEM Biotech S.L., Pier07, Via Laietana, 26, 08003, Barcelona, Spain.
| | - Zan Ahmad
- ADVANCE, Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles St., Baltimore, MD, 21218, USA
- Department of Applied Mathematics and Statistics, Johns Hopkins University, 100 Wyman Park Dr, Baltimore, MD, 21211, USA
| | - Eugene Kholmovski
- ADVANCE, Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles St., Baltimore, MD, 21218, USA
- Department of Radiology, University of Utah, 30 N Mario Capecchi Dr., Salt Lake City, UT, 84112, USA
| | - Kensuke Sakata
- ADVANCE, Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles St., Baltimore, MD, 21218, USA
| | - Luca Dede'
- MOX, Laboratory of Modeling and Scientific Computing, Dipartimento di Matematica, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133, Milan, Italy
| | - Alan K Morris
- Scientific Computing and Imaging Institute, University of Utah, 72 Central Campus Dr., Salt Lake City, UT, 84112, USA
| | - Alfio Quarteroni
- MOX, Laboratory of Modeling and Scientific Computing, Dipartimento di Matematica, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133, Milan, Italy
- Institute of Mathematics, École Polytechnique Fédérale de Lausanne, Station 8, Av. Piccard, 1015, Lausanne, Switzerland
| | - Natalia A Trayanova
- ADVANCE, Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles St., Baltimore, MD, 21218, USA
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3
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Noubiap JJ, Nyaga UF, Middeldorp ME, Stokes MB, Sanders P. Cardiac imaging correlates and predictors of stroke in patients with atrial fibrillation: a meta-analysis. J Cardiovasc Med (Hagerstown) 2024; 25:280-293. [PMID: 38407860 DOI: 10.2459/jcm.0000000000001608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
BACKGROUND New nonclinical parameters are needed to improve the current stroke risk stratification schemes for patients with atrial fibrillation. This study aimed to summarize data on potential cardiac imaging correlates and predictors of stroke or systemic embolism in patients with atrial fibrillation. METHODS MEDLINE, EMBASE, and Web of Science were searched to identify all published studies providing relevant data through 16 November 2022. Random effects meta-analysis method was used to pool estimates. RESULTS We included 64 studies reporting data from a pooled population of 56 639 patients. Left atrial spontaneous echo-contrast [adjusted odds ratio (aOR) 3.32, 95% confidence interval (CI) 1.98-5.49], nonchicken wing left atrial appendage (LAA) morphology (aOR 2.15, 95% CI 1.11-4.18), left atrial enlargement (aOR 2.12, 95% CI 1.45-3.08), and higher LAA orifice diameter (aOR 1.56, 95% CI 1.18-2.05) were highly associated with stroke. Other parameters associated with stroke included higher left atrial sphericity (aOR 1.14, 95% CI 1.01-1.29), higher left atrial volume (aOR 1.03, 95% CI 1.01-1.04), higher left atrial volume index (aOR 1.014, 95% CI 1.004-1.023), lower left atrial reservoir strain [adjusted hazard ratio (aHR) 0.86, 95% CI 0.76-0.98], higher left ventricular mass index (aOR 1.010, 95% CI 1.005-1.015) and E / e' ratio (aOR 1.12, 95% CI 1.07-1.16). There was no association between LAA volume (aOR 1.37, 95% CI 0.85-2.21) and stroke. CONCLUSION These cardiac imaging parameters identified as potential predictors of thromboembolism may improve the accuracy of stroke risk stratification schemes in patients with atrial fibrillation. Further studies should evaluate the performance of holistic risk scores including clinical factors, biomarkers, and cardiac imaging.
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Affiliation(s)
- Jean Jacques Noubiap
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
| | | | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Smidt Heart Institute, Cedar-Sinai Medical Centre, Los Angeles, California, USA
| | - Michael B Stokes
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
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4
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Zingaro A, Ahmad Z, Kholmovski E, Sakata K, Dede’ L, Morris AK, Quarteroni A, Trayanova NA. A comprehensive stroke risk assessment by combining atrial computational fluid dynamics simulations and functional patient data. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.01.11.575156. [PMID: 38293150 PMCID: PMC10827064 DOI: 10.1101/2024.01.11.575156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Stroke, a major global health concern often rooted in cardiac dynamics, demands precise risk evaluation for targeted intervention. Current risk models, like the CHA2DS2-VASc score, often lack the granularity required for personalized predictions. In this study, we present a nuanced and thorough stroke risk assessment by integrating functional insights from cardiac magnetic resonance (CMR) with patient-specific computational fluid dynamics (CFD) simulations. Our cohort, evenly split between control and stroke groups, comprises eight patients. Utilizing CINE CMR, we compute kinematic features, revealing smaller left atrial volumes for stroke patients. The incorporation of patient-specific atrial displacement into our hemodynamic simulations unveils the influence of atrial compliance on the flow fields, emphasizing the importance of LA motion in CFD simulations and challenging the conventional rigid wall assumption in hemodynamics models. Standardizing hemodynamic features with functional metrics enhances the differentiation between stroke and control cases. While standalone assessments provide limited clarity, the synergistic fusion of CMR-derived functional data and patient-informed CFD simulations offers a personalized and mechanistic understanding, distinctly segregating stroke from control cases. Specifically, our investigation reveals a crucial clinical insight: normalizing hemodynamic features based on ejection fraction fails to differentiate between stroke and control patients. Differently, when normalized with stroke volume, a clear and clinically significant distinction emerges and this holds true for both the left atrium and its appendage, providing valuable implications for precise stroke risk assessment in clinical settings. This work introduces a novel framework for seamlessly integrating hemodynamic and functional metrics, laying the groundwork for improved predictive models, and highlighting the significance of motion-informed, personalized risk assessments.
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Affiliation(s)
- Alberto Zingaro
- ADVANCE, Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles St., 21218, Baltimore, MD, USA
- MOX, Laboratory of Modeling and Scientific Computing, Dipartimento di Matematica, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133, Milano, Italy
- ELEM Biotech S.L., Pier07, Via Laietana, 26, 08003, Barcelona, Spain
| | - Zan Ahmad
- ADVANCE, Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles St., 21218, Baltimore, MD, USA
- Department of Applied Mathematics and Statistics, Johns Hopkins University, 100 Wyman Park Dr, 21211, Baltimore, MD, USA
| | - Eugene Kholmovski
- ADVANCE, Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles St., 21218, Baltimore, MD, USA
- Department of Radiology, University of Utah, 30 N Mario Capecchi Dr., 84112, Salt Lake City, UT, USA
| | - Kensuke Sakata
- ADVANCE, Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles St., 21218, Baltimore, MD, USA
| | - Luca Dede’
- MOX, Laboratory of Modeling and Scientific Computing, Dipartimento di Matematica, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133, Milano, Italy
| | - Alan K. Morris
- Scientific Computing and Imaging Institute, University of Utah, 72 Central Campus Dr., 84112, Salt Lake City, UT, USA
| | - Alfio Quarteroni
- MOX, Laboratory of Modeling and Scientific Computing, Dipartimento di Matematica, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133, Milano, Italy
- Institute of Mathematics, École Polytechnique Fédérale de Lausanne, Station 8, Av. Piccard, CH-1015 Lausanne, Switzerland (Professor Emeritus)
| | - Natalia A. Trayanova
- ADVANCE, Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles St., 21218, Baltimore, MD, USA
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5
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Sulague RM, Whitham T, Danganan LML, Effiom V, Candelario K, Latif N, Hameed I. The Left Atrial Appendage and Atrial Fibrillation-A Contemporary Review. J Clin Med 2023; 12:6909. [PMID: 37959374 PMCID: PMC10650862 DOI: 10.3390/jcm12216909] [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: 10/02/2023] [Revised: 10/28/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023] Open
Abstract
In patients with atrial fibrillation, the left atrial appendage may serve as the site of thrombus formation due to stasis that occurs within the appendage because of its shape and trabeculations. Although thrombus formation can be reduced by using anticoagulants, this may be contraindicated in some patients. The need for a better alternative treatment prompted the study of left atrial appendage occlusion for thromboembolism prophylaxis. Due to this, procedures that excise or occlude the left atrial appendage have gained attention because of their ability to prevent thromboembolic events. This article provides a comprehensive review of the left atrial appendage and its associated procedures' clinical utility.
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Affiliation(s)
- Ralf Martz Sulague
- Graduate School of Arts and Sciences, Georgetown University, Washington, DC 20057, USA;
| | - Tarik Whitham
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH 44272, USA;
| | | | - Victory Effiom
- College of Medical Sciences, University of Calabar, Calabar 540271, Nigeria;
| | - Katherine Candelario
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, 330 Cedar Street, New Haven, CT 06510, USA; (K.C.); (N.L.)
| | - Nida Latif
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, 330 Cedar Street, New Haven, CT 06510, USA; (K.C.); (N.L.)
| | - Irbaz Hameed
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, 330 Cedar Street, New Haven, CT 06510, USA; (K.C.); (N.L.)
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Ouchi K, Sakuma T, Higuchi T, Yoshida J, Narui R, Nojiri A, Yamane T, Ojiri H. Prediction of spontaneous echocardiographic contrast within the left atrial appendage in cardiac computed tomography of patients with atrial fibrillation. Heart Vessels 2023; 38:1138-1148. [PMID: 37029248 DOI: 10.1007/s00380-023-02263-8] [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: 04/20/2022] [Accepted: 03/23/2023] [Indexed: 04/09/2023]
Abstract
This study aimed to assess the predictors of spontaneous echocardiographic contrast (SEC) using left atrial appendage (LAA) findings in cardiac computed tomography (CT) of patients with atrial fibrillation (AF). We retrospectively analyzed cardiac CT findings of the LAA, including morphology, volume, and filling defects, of 641 patients who underwent transesophageal echocardiography (TEE) prior to pulmonary vein isolation (PVI) from January 6, 2013 through December 16, 2019 at our institution. We investigated potential associated factors that might be predictors of SEC using cardiac CT findings and computed a receiver operator characteristic, choosing a threshold value at which the likelihood of SEC could be predicted based on the LAA volume indexed for body size. SEC correlated significantly with indexed LAA volume (P < 0.001; odds ratio [OR], 1.31; 95% confidence interval [CI], 1.17-1.48) of 7.75 cm3/m2 or greater (sensitivity, 76.0%; specificity, 57.7%), LAA early filling defect (P = 0.005; OR, 2.72; 95% CI, 1.35-5.48), a history of persistent AF (P < 0.001; OR, 3.81; 95% CI, 1.86-7.80), and LAA flow velocity (P < 0.001; OR, 0.97; 95% CI, 0.96-0.99). Findings of LAA in cardiac CT can allow for the noninvasive estimation of SEC to determine the need for additional TEE investigation and the need to obtain additional information for risk stratification and management of thromboembolic events in patients with AF.
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Affiliation(s)
- Kotaro Ouchi
- Department of Radiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan.
| | - Toru Sakuma
- Department of Radiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Takahiro Higuchi
- Department of Radiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Jun Yoshida
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Ryosuke Narui
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Ayumi Nojiri
- Department of Laboratory Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Teiichi Yamane
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Hiroya Ojiri
- Department of Radiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
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7
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Zhou F, Yuan Z, Liu X, Yu K, Li B, Li X, Liu X, Cheng G. Evaluation of atrial anatomical remodeling in atrial fibrillation with machine-learned morphological features. Int J Comput Assist Radiol Surg 2023; 18:603-610. [PMID: 36272019 DOI: 10.1007/s11548-022-02776-z] [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: 05/22/2022] [Accepted: 10/05/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE To elucidate the role of atrial anatomical remodeling in atrial fibrillation (AF), we proposed an automatic method to extract and analyze morphological characteristics in left atrium (LA), left atrial appendage (LAA) and pulmonary veins (PVs) and constructed classifiers to evaluate the importance of identified features. METHODS The LA, LAA and PVs were segmented from contrast computed tomography images using either a commercial software or a self-adaptive algorithm proposed by us. From these segments, geometric and fractal features were calculated automatically. To reduce the model complexity, a feature selection procedure is adopted, with the important features identified via univariable analysis and ensemble feature selection. The effectiveness of this approach is well illustrated by the high accuracy of our models. RESULTS Morphological features, such as LAA ostium dimensions and LA volume and surface area, statistically distinguished ([Formula: see text]) AF patients or AF with LAA filling defects (AF(def+)) patients among all patients. On the test set, the best model to predict AF among all patients had an area under the receiver operating characteristic curve (AUC) of 0.91 (95% CI, 0.8-1) and the best model to predict AF(def+) among all patients had an AUC of 0.92 (95% CI, 0.81-1). CONCLUSION This study automatically extracted and analyzed atrial morphology in AF and identified atrial anatomical remodeling that statistically distinguished AF or AF(def+). The importance of identified atrial morphological features in characterizing AF or AF(def+) was validated by corresponding classifiers. This work provides a good foundation for a complete computer-assisted diagnostic workflow of predicting the occurrence of AF or AF(def+).
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Affiliation(s)
- Fanli Zhou
- Department of Radiology, Peking University Shenzhen Hospital, Futian, Shenzhen, 518036, Guangdong, China.
- Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Nanshan, Shenzhen, 518055, Guangdong, China.
| | - Zhidong Yuan
- Department of Radiology, Peking University Shenzhen Hospital, Futian, Shenzhen, 518036, Guangdong, China
| | - Xianglin Liu
- Center for Artificial Intelligence, Peng Cheng Laboratory, Nanshan, Shenzhen, 518066, Guangdong, China
| | - Keyan Yu
- Department of Radiology, Peking University Shenzhen Hospital, Futian, Shenzhen, 518036, Guangdong, China
| | - Bowei Li
- Department of Radiology, Peking University Shenzhen Hospital, Futian, Shenzhen, 518036, Guangdong, China
| | - Xingyan Li
- Ultrasound Department, Chenzhou No. 1 People's Hospital, Beihu, Chenzhou, 424300, Hunan, China
| | - Xin Liu
- Paul C. Lauterbur Research Center for Biomedical Imaging, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Nanshan, Shenzhen, 518055, Guangdong, China
| | - Guanxun Cheng
- Department of Radiology, Peking University Shenzhen Hospital, Futian, Shenzhen, 518036, Guangdong, China.
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Liu XW, Yan LQ, Wang GS, Sun YH, Bao WJ, Zhang HW, Yang L, Chen C, Li MY, Yang L, Zhang XQ, Tian X, Li CY. Left atrial appendage filling defects restricted to the early phase of cardiac computed tomography is significantly associated with ischemic stroke. Clin Imaging 2023; 98:16-21. [PMID: 36989887 DOI: 10.1016/j.clinimag.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/01/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023]
Abstract
PURPOSE To investigate the relationship between filling defects in the left atrial appendage restricted to the early phase of cardiac computed tomography (CCT), and ischemic stroke in patients with atrial fibrillation (AF). MATERIALS AND METHODS A total of 152 patients with non-valvular AF were retrospectively enrolled and divided into two groups according to the stroke history, as confirmed by brain computed tomography (CT) or magnetic resonance imaging (MRI), as the non-stroke group (n = 89) and stroke group (n = 63), respectively. The numbers of patients with filling defects in the early phase of CCT images without thrombi were recorded. Morphological parameters of the LAA were measured for all participants. All patients with early-phase filling defects (n = 44) were assigned to two groups according to ischemic stroke history: the filling defects with stroke group (n = 28) and the filling defects without stroke group (n = 16). The clinical characteristics and LAA morphological parameters were compared. RESULTS Univariate analysis showed that compared with the non-stroke group,LAA volume index and age were higher in the stroke group, and the ratio of early phase filling defect in LAA, hypertension and diabetes were also higher, in the meanwhile the LVEF and BMI were lower (P < 0.05).After adjusting confounding factors by the multivariate logistic regression analysis, filling defect was significantly related with stroke [odds ratio (OR): 4.339, 95% confidence interval (CI): 1.951-9.653, P = 0.000]. LAA morphological parameters were not significantly different between the filling defects with stroke group and the group without stroke. CONCLUSION AF patients with LAA non-thrombotic filling defects in the early-phase of CCT had an increased risk of ischemic stroke compared to those without filling defects. This finding may help to optimize stroke risk stratification in patients with AF.
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Al WA, Yun ID, Chun EJ. Centerline depth world for left atrial appendage orifice localization using reinforcement learning. Comput Med Imaging Graph 2023; 106:102201. [PMID: 36848765 DOI: 10.1016/j.compmedimag.2023.102201] [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: 03/21/2022] [Revised: 02/16/2023] [Accepted: 02/16/2023] [Indexed: 02/27/2023]
Abstract
Left atrial appendage (LAA) occlusion (LAAO) is a minimally invasive implant-based method to prevent cardiovascular stroke in patients with non-valvular atrial fibrillation. Assessing the LAA orifice in preoperative CT angiography plays a crucial role in choosing an appropriate LAAO implant size and a proper C-arm angulation. However, accurate orifice localization is hard because of the high anatomic variation of LAA, and unclear position and orientation of the orifice in available CT views. With the major research focus being on LAA segmentation, the only existing computational method for orifice localization utilized a rule-based decision. Nonetheless, using such a fixed rule may yield high localization error due to the varied anatomy of LAA. While deep learning-based models usually show improvements under such variation, learning an effective localization model is difficult because of the tiny orifice structure compared to the vast search space of CT volume. In this paper, we propose a centerline depth-based reinforcement learning (RL) world for effective orifice localization in a small search space. In our scheme, an RL agent observes the centerline-to-surface distance and navigates through the LAA centerline to localize the orifice. Thus, the search space is significantly reduced facilitating improved localization. The proposed formulation could result in high localization accuracy compared to the expert annotations. Moreover, the localization process takes about 7.3 s which is 18 times more efficient than the existing method. Therefore, this can be a useful aid to physicians during the preprocedural planning of LAAO.
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Affiliation(s)
- Walid Abdullah Al
- Division of Computer Engineering, Hankuk University of Foreign Studies, Yongin, South Korea
| | - Il Dong Yun
- Division of Computer Engineering, Hankuk University of Foreign Studies, Yongin, South Korea.
| | - Eun Ju Chun
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, South Korea
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10
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Guo T, Xu Y, Dong Y, Yu S. Study on the correlation between false-positive filling defect in LAA CT and LAA structure in patients with atrial fibrillation based on TEE. Ann Noninvasive Electrocardiol 2022; 28:e13027. [PMID: 36547015 PMCID: PMC9833370 DOI: 10.1111/anec.13027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 11/15/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE This study aims to explore the actual meaning of "false positive filling defect" in left atrial appendage (LAA) computed tomography (CT) in patients with atrial fibrillation (AF), with transesophageal echocardiography (TEE) as the gold standard. METHODS Patients with AF undergoing cardiac CT angiography and TEE examinations for proposed radiofrequency catheter ablation between October 2020 and October 2021 were selected as the study subjects. Transesophageal echocardiography was taken as the "gold standard," and spontaneous echocardiographic contrast (SEC) and thrombus events were defined as positive events. The CT manifestations were classified into three groups (true positive, false positive, and true negative) to evaluate the differences in left atrium (LA) anterior-posterior diameter (LAAP), LA anterior wall thickness, and LAA orifice long diameter and short diameter, area, and depth between the three groups. RESULTS (1) There was no statistical difference in LA anterior wall thickness between the three groups (p > .05); there was a statistical difference in LAAP (only) between the true-positive group and the true-negative group (p < .05). (2) There was a statistical difference in LAA orifice long diameter, short diameter, and area between the true-positive group and the true-negative group as well as between the false-positive group and the true-negative group (p < .05). (3) There was a statistical difference in LAA depth between the true-positive group and the false-positive group as well as between the true-positive group and the true-negative group (p < .05). (4) The area under the receiver operator characteristic curve (AUC) of LAA depth affecting the LAA thrombus and SEC was 0.863 (confidence interval = 0.718-1.000), the sensitivity was 77.8%, and the specificity was 90.6% for predicting the occurrence of LAA thrombus and SEC in patients with nonvalvular AF (NVAF) and an LAA depth of ≥50.84 mm. CONCLUSIONS There was a difference in LAA diameter between the TEE-based CT false-positive group and the other groups. A "CT false positive" is an objectively existing state, and CT might be able to identify the LAA hemodynamic disorder earlier than TEE. Furthermore, a CT + TEE combined application could more accurately evaluate LAA hemodynamics in patients with AF.
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Affiliation(s)
- Tian‐Jiao Guo
- Hebei Medical UniversityShijiazhuangChina,Department of Diagnostic CTCangzhou Central HospitalCangzhouChina
| | - Yan‐Feng Xu
- Department of Diagnostic CTCangzhou Central HospitalCangzhouChina
| | - Ya‐Peng Dong
- Department of Diagnostic CTCangzhou Central HospitalCangzhouChina
| | - Shu‐Jing Yu
- Hebei Medical UniversityShijiazhuangChina,Department of Diagnostic CTCangzhou Central HospitalCangzhouChina
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11
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Takaya Y, Nakayama R, Yokohama F, Toh N, Nakagawa K, Miyamoto M, Ito H. Left atrial appendage morphology with the progression of atrial fibrillation. PLoS One 2022; 17:e0278172. [PMID: 36449497 PMCID: PMC9710751 DOI: 10.1371/journal.pone.0278172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 11/10/2022] [Indexed: 12/02/2022] Open
Abstract
Left atrial appendage (LAA) size is crucial for determining the indication of transcatheter LAA closure. The aim of this study was to evaluate the differences in LAA morphology according to the types of atrial fibrillation (AF). A total of 299 patients (mean age: 67 ± 13 years) who underwent transesophageal echocardiography (TEE) were included. Patients were classified into non-AF (n = 64), paroxysmal AF (n = 86), persistent AF (n = 87), or long-standing persistent AF (n = 62). LAA morphology, including LAA ostial diameter and depth, was assessed using TEE. Patients with long-standing persistent AF had larger LAA ostial diameter and depth and lower LAA flow velocity. The maximum LAA ostial diameter was 19 ± 4 mm in patients with non-AF, 21 ± 4 mm in patients with paroxysmal AF, 23 ± 5 mm in patients with persistent AF, and 26 ± 5 mm in patients with long-standing persistent AF. LAA ostial diameter was increased by 2 or 3 mm with the progression of AF. LAA ostial diameter was correlated with LA volume index (R = 0.37, P < 0.01) and the duration of continuous AF (R = 0.30, P < 0.01), but not with age or the period from the onset of AF. In conclusion, LAA size was increased with the progression of AF.
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Affiliation(s)
- Yoichi Takaya
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
- * E-mail:
| | - Rie Nakayama
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Fumi Yokohama
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Norihisa Toh
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masakazu Miyamoto
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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12
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Fang R, Li Y, Wang J, Wang Z, Allen J, Ching CK, Zhong L, Li Z. Stroke risk evaluation for patients with atrial fibrillation: Insights from left atrial appendage. Front Cardiovasc Med 2022; 9:968630. [PMID: 36072865 PMCID: PMC9441763 DOI: 10.3389/fcvm.2022.968630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/27/2022] [Indexed: 11/13/2022] Open
Abstract
Left atrial appendage (LAA) is believed to be a common site of thrombus formation in patients with atrial fibrillation (AF). However, the commonly-applied stroke risk stratification model (such as. CHA2DS2-VASc score) does not include any structural or hemodynamic features of LAA. Recent studies have suggested that it is important to incorporate LAA geometrical and hemodynamic features to evaluate the risk of thrombus formation in LAA, which may better delineate the AF patients for anticoagulant administration and prevent strokes. This review focuses on the LAA-related factors that may be associated with thrombus formation and cardioembolic events.
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Affiliation(s)
- Runxin Fang
- School of Biological Science and Medical Engineering, Southeast University, Nanjing, China
| | - Yang Li
- Zhongda Hospital, The Affiliated Hospital of Southeast University, Nanjing, China
| | - Jun Wang
- First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Zidun Wang
- First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - John Allen
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Chi Keong Ching
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- National Heart Centre Singapore, Singapore, Singapore
| | - Liang Zhong
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- National Heart Centre Singapore, Singapore, Singapore
| | - Zhiyong 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: Zhiyong Li
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13
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Miki Y, Uchida Y, Tanaka A, Tobe A, Sakakibara K, Kataoka T, Niwa K, Furusawa K, Ichimiya H, Watanabe J, Kanashiro M, Ishii H, Ichimiya S, Murohara T. Clinical Significance of the Left Atrial Appendage Orifice Area. Intern Med 2022; 61:1801-1807. [PMID: 34776484 PMCID: PMC9259814 DOI: 10.2169/internalmedicine.8301-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective The left atrial appendage (LAA) is one of the major sources of cardiac thrombus formation. Three-dimensional transesophageal echocardiography (TEE) made it possible to perform a detailed evaluation of the LAA morphologies. This study aimed to evaluate the clinical implications of the LAA orifice area. Methods A total of 149 patients who underwent TEE without significant valvular disease were studied. The LAA orifice area was measured using three-dimensional TEE. The patients were divided into two groups according to the LAA orifice area (large LAA orifice group, ≥median value, and small LAA orifice group). The clinical characteristics and echocardiographic findings were evaluated. Results The median LAA orifice area among all patients was 4.09 cm2 (interquartile range 2.92-5.40). The large LAA orifice group were older (67.2±10.4 vs. 62.4±15.3 years, p=0.02), more often had hypertension (66.7% vs. 44.6%, p=0.007), and atrial fibrillation (70.7% vs. 39.2%, p<0.001) than the small LAA orifice group. Regarding the TEE findings, the LAA flow velocity was significantly lower (33.7±20.0 vs. 50.2±24.3, p<0.001) and spontaneous echo contrast was more often observed (21.3% vs. 8.1%, p=0.02) in the large LAA orifice group. Multivariate models demonstrated that atrial fibrillation was an independent predictor of the LAA orifice area. In the analysis of atrial fibrillation duration, the LAA orifice area tended to be larger as patients had a longer duration of atrial fibrillation. Conclusion Our findings indicated that a larger LAA orifice area was associated with the presence of atrial fibrillation and high thromboembolic risk based on TEE findings. A continuation of the atrial fibrillation rhythm might lead to the gradual expansion of the LAA orifice.
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Affiliation(s)
- Yusuke Miki
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
- Department of Cardiology, Yokkaichi Municipal Hospital, Japan
| | - Yasuhiro Uchida
- Department of Cardiology, Yokkaichi Municipal Hospital, Japan
| | - Akihito Tanaka
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | - Akihiro Tobe
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | - Keisuke Sakakibara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | - Takashi Kataoka
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | - Kiyoshi Niwa
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | - Kenji Furusawa
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
| | | | - Junji Watanabe
- Department of Cardiology, Yokkaichi Municipal Hospital, Japan
| | | | - Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
- Department of Cardiology, Fujita Health University Bantane Hospital, Japan
| | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan
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Dudziñska-Szczerba K, Kułakowski P, Michałowska I, Baran J. Association Between Left Atrial Appendage Morphology and Function and the Risk of Ischaemic Stroke in Patients with Atrial Fibrillation. Arrhythm Electrophysiol Rev 2022; 11:e09. [PMID: 35846423 PMCID: PMC9272406 DOI: 10.15420/aer.2022.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 04/22/2022] [Indexed: 12/03/2022] Open
Abstract
AF is the most common cardiac arrhythmia and has been identified as an independent risk factor for stroke. The European Society of Cardiology guidelines recommend a thromboembolic event risk assessment based on the CHA2DS2-VASc score. However, stroke also occurs in some patients with a low CHA2DS2-VASc score. Therefore, it is necessary to find new factors to improve thromboembolic risk stratification in AF patients. Over 90% of embolic strokes are caused by thrombi originating from the left atrial appendage (LAA). Thus, certain anatomical or functional parameters of the LAA could potentially be used to predict cardioembolic stroke. Studies have suggested that some of these factors, such as LAA morphology, number of LAA lobes, LAA dimensions, LAA volume, distance from the LAA ostium to the first bend of LAA, LAA orifice diameter, extent of LAA trabeculations, LAA takeoff, LAA flow velocity and LAA strain rate, are independently associated with a higher risk of stroke in a population of patients with AF and improve the performance of the CHA2DS2-VASc score. However, the results are conflicting and, so far, no new parameter has been added to the CHA2DS2-VASc score.
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Affiliation(s)
| | - Piotr Kułakowski
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
| | | | - Jakub Baran
- Division of Clinical Electrophysiology, Department of Cardiology Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
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15
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Left Atrial Appendage Depth and Tachycardia Bradycardia Syndrome as Important Predictors of Left Atrial Appendage Thrombus in Patients with Nonvalvular Atrial Fibrillation. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:4632823. [PMID: 35401785 PMCID: PMC8986422 DOI: 10.1155/2022/4632823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/24/2022] [Accepted: 03/05/2022] [Indexed: 11/17/2022]
Abstract
Background Atrial fibrillation (AF) is the most common heart rhythm disorder that has been shown to be associated with a significant increase in stroke and systemic embolism risk. The left atrial appendage (LAA) is a finger-like extension originating from the left atrium; the formation of thrombus in LAA is the main reason of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (NVAF). This study is aimed at finding out the risk of left atrial appendage thrombus (LAAT) in patients with nonvalvular atrial fibrillation (NVAF). Method We retrospectively examined the clinic and left atrial computer tomography angiography (CTA) features of patients assessed in Zhengzhou No. 7 People's Hospital between January 2020 and January 2021 derivation. Student's t-test, chi-square test, receiver operating characteristics (ROC) curves, and logistic regression analysis were used to identify predictors of LAAT. Result Of 480 patients included in the analysis, LAAT was found in approximately 9.2% of all patients. Univariate demographic predictors of LAAT included left atrium top and bottom diameter (LTD), left atrial appendage depth (LAAD), CHA2DS2-VASc, tachycardia bradycardia syndrome (TBS), and nonparoxysmal atrial fibrillation (PAF). In a multiple logistic regression analysis, the independent predictors of thrombus were LAAD > 23.45 mm (odds ratio: 4.216, 95% CI: 1.869-9.510, P = 0.001), TBS (odds ratio: 4.076, 95% CI: 1.655-10.038, P = 0.002), and non-PAF (odds ratio: 2.896, 95% CI: 1.183-7.094, P = 0.02). Conclusion In NVAF patients with LAAT, evidence suggested that larger LAAD, non-PAF, and TBS present a high risk of LAAT. This is the first report demonstrating that the LAAD and TBS are associated with LAAT in patients with NVAF.
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16
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Alinezhad L, Ghalichi F, Ahmadlouydarab M, Chenaghlou M. Left atrial appendage shape impacts on the left atrial flow hemodynamics: A numerical hypothesis generating study on two cases. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 213:106506. [PMID: 34752960 DOI: 10.1016/j.cmpb.2021.106506] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 10/25/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND OBJECTIVES The left atrial appendage (LAA) is the most common region for thrombus formation in atrial fibrillation (AF). Morphological parameters such as shape, size, and LAA volume can cause insufficient effectiveness of available therapeutic options. This study aimed to examine blood flow inside LAA and its removal effects. Computational fluid dynamic (CFD) simulations were carried out on two patients with different morphologies. METHODS Two patients' CT was used to reconstruct the 3D geometries of the left atrium (LA) and left atrial appendage (LAA). Then, the geometries were refined in the mentioned software, and the LAA in some models was removed. Next, in generated 3D volume mesh, sinus rhythm (SR) and atrial fibrillation (AF) outflow velocity were imposed at the mitral valve as boundary conditions. Finally, CFD simulation was conducted to analyzing blood flow within LA with/without LA. RESULTS The results confirmed that velocity and vorticity decreased under AF conditions inside the LA domain for both patients. However, removing LAA may cause unpredictable consequences, due to different shape and volume of LAA. LAA removal had insignificant effects on velocity and vorticity within LA in SR-mitral outflow. However, removing LAA increased the blood flow rate by 9.15% and vorticity by 7.27% for patient one under AF rhythm (SR)-outflow. In contrast, for patient two, LAA removal in both AF and SR decreased velocity and vorticity within the LA domain. In SR-mitral outflow, velocity dropped by 18.8 %, and vorticity by 13.2%. Also, under AF velocity and vorticity decreased by 23.33% and 18.6% respectively. Meanwhile, the results indicated that the vorticity magnitude increased inside the LAA under AF associated with the risk of thrombus formation, particularly for patient one under AF. The distal part of LAA in both patients was the most common region for blood stasis because of the lowest velocity magnitude. CONCLUSION Overall, the morphology of LAA could be the critical parameter to determine the possibility of thrombosis formation, particularly under AF conditions. High volume, low blood flow velocity and two-lobe-appendage are more likely to have blood stasis. Furthermore, the morphology difference can affect the LAA removal result and make it more complicated. So, it could be challenging to generalize LAA removal as a therapeutic option for different patients. The implication of this CFD observation needs more investigation.
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Affiliation(s)
- Lida Alinezhad
- Department of Biomedical Engineering, Division of Biomechanics, Sahand University of Technology, Tabriz, Iran
| | - Farzan Ghalichi
- Department of Biomedical Engineering, Division of Biomechanics, Sahand University of Technology, Tabriz, Iran
| | - Majid Ahmadlouydarab
- Faculty of Chemical & Petroleum Engineering, University of Tabriz, Tabriz, Iran.
| | - Maryam Chenaghlou
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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17
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Fang P, Wei Y, Wang J, Wang X, Yang H. Post-angiography Retention of the Contrast Agent in the Left Atrial Appendage Is Associated With Risk of Cardioembolic Stroke in Patients With Atrial Fibrillation: A Retrospective Study. Front Cardiovasc Med 2021; 8:753949. [PMID: 34778408 PMCID: PMC8581209 DOI: 10.3389/fcvm.2021.753949] [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: 08/05/2021] [Accepted: 10/07/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Atrial fibrillation (AF) represents an important risk factor for cardioembolic stroke, and most atrial thrombi originate from the left atrial appendage (LAA). Although the CHA2DS2-VASc score is widely used to estimate the risk of cardioembolic stroke in AF patients, yet greatly affected by many factors. This study was undertaken to determine the association between contrast agent retention in LAA after LAA angiography and risks of cardioembolic stroke in patients with AF. Methods: This is a retrospective study. The demographic and clinical data of AF patients undergone left atrial appendage occlusion (LAAO) with or without catheter radiofrequency ablation were retrospectively analyzed. The patients were classified into either stroke or non-stroke group by the history with cardioembolic stroke or transient ischemic attack (TIA). Results: Sixty-two consecutive patients undergone LAAO were finally included, in whom 31 AF patients had a history of cardioembolic stroke or TIA (one TIA), and significantly higher CHA2DS2-VASc score (4.2 ± 1.4 vs. 3.3 ± 1.3; P = 0.006) as well as incidence of contrast agent retention in LAA (n = 20 vs. n = 7; P = 0.001) compared to the patients in non-stroke group. In addition, the relative proportion of distinctive morphological types of LAA was significantly different between groups (P < 0.001). Multivariate logistic regression analysis showed that higher CHA2DS2-VASc scores (OR = 1.7, 95% CI: 1.0-3.0, P = 0.046) and LAA contrast agent retention (OR = 5.1, 95% CI: 1.1-23.9, P = 0.002) were associated with increased risks of cardioembolic stroke. The patients with Windsock type LAA (OR = 7.8, 95% CI: 1.1-57.2, P = 0.044) and Cauliflower LAA (OR = 20.2, 95% CI: 3.2-125.5, P = 0.001) were more prone to cardioembolic stroke compared to those with Chicken Wing type LAA. Conclusion: Left atrial appendage contrast agent retention after LAA angiography is associated with the risks of cardioembolic stroke in patients with AF, and cardioembolic stroke is more seen in AF patients with Windsock or Cauliflower type LAA.
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Affiliation(s)
- Ping Fang
- Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, China
| | - Youquan Wei
- Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, China
| | - Jinfeng Wang
- Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, China
| | - Xianghai Wang
- Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, China
| | - Hao Yang
- Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, China
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Wei Y, Cui M, Liu S, Yu H, Feng J, Gao W, Li L. Increased hemoglobin A1c level associates with low left atrial appendage flow velocity in patients of atrial fibrillation. Nutr Metab Cardiovasc Dis 2021; 31:3176-3183. [PMID: 34629254 DOI: 10.1016/j.numecd.2021.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/15/2021] [Accepted: 07/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS High hemoglobin A1c (HbAlc) level is associated with increased cardiovascular disease risk and thromboembolic events [1]. The study sought to explored the association between HbAlc and left atrial appendage flow velocity (LAAV) among non-valvular atrial fibrillation (AF) patients. METHODS AND RESULTS A total of 249 consecutive non-valvular AF patients who underwent transesophageal echocardiography (TEE) were divided into two subgroups according to the median of LAAV level (<45 cm/s, ≥45 cm/s). Blood samples and other baseline clinical data of all patients were collected and analyzed. The low LAAV group included 126 patients and the high LAAV group included 123 patients. Patients in the low LAAV group were older and had a higher percentage of persistent AF, chronic heart failure, and higher CHA2DS2-VASc score (P < 0.05). HbAlc level in the low LAAV group was significantly higher than the high LAAV group [6.1 (5.7-6.5)% vs 5.9 (5.6-6.2)%, P = 0.010]. The low LAAV group had larger left atrial diameter (LAD), left atrial area (LAA), higher left atrial pressure (LAP), and lower left ventricular ejection fraction (LVEF) (P < 0.05). Spearman rank correlation analysis showed that the HbAlc level was negatively correlated with LAAV (r = -0.211, P = 0.001). Multivariate analysis indicated that female gender (OR = 2.233, 95% CI 1.110-4.492, P = 0.024), persistent AF (OR = 6.610, 95% CI 3.109-14.052, P < 0.001), and HbAlc (OR = 1.903, 95% CI 1.092-3.317, P = 0.023) were independent factors that associated with low LAAV in AF patients. CONCLUSION Increased HbAlc level is associated with decreased LAAV and may reflect a low contractile function of the left atrial appendage.
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Affiliation(s)
- Ying Wei
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China
| | - Ming Cui
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China
| | - Shuwang Liu
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China
| | - Haiyi Yu
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China
| | - Jieli Feng
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China
| | - Wei Gao
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China
| | - Lei Li
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China.
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Ouchi K, Sakuma T, Higuchi T, Yoshida J, Narui R, Nojiri A, Yamane T, Ojiri H. Filling defects in the left atrial appendage restricted to the early phase of cardiac computed tomography as a potential risk of left atrial appendage dysfunction. J Cardiol 2021; 79:211-218. [PMID: 34610891 DOI: 10.1016/j.jjcc.2021.09.011] [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: 07/21/2021] [Revised: 08/19/2021] [Accepted: 09/06/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Filling defects within the left atrial appendage (LAA) restricted to the early phase of computed tomography (CT) are not highly specific to the presence of thrombosis. The true significance of LAA early filling defects without thrombus remains uncertain. We evaluated the predictors of LAA early filling defects on echocardiography and cardiac CT findings in patients with atrial fibrillation (AF). METHODS Cardiac CT findings of 641 patients with AF who underwent transesophageal echocardiography prior to pulmonary vein isolation from 6 January 2013 to 16 December 2019 at our institution were retrospectively analyzed. We investigated potential predictors of LAA early filling defects and computed the receiver operator characteristics, choosing a threshold value at which the likelihood of LAA early filling defects could be predicted. RESULTS Early filling defects within the LAA correlated significantly with a history of persistent AF [p = 0.014; odds ratio (OR), 2.36; 95% confidence interval (CI), 1.19-4.66), low left ventricular ejection fraction (p = 0.009; OR, 2.62; 95% CI, 1.28-5.38), diminished LAA flow velocity (p < 0.001; OR, 0.97; 95% CI, 0.96-0.99) below 45.3 cm/s (sensitivity, 63.6%; specificity, 72.4%), and increased indexed LAA volume (p = 0.001; OR, 1.18; 95% CI, 1.07-1.30) ≥7.64 cm3/m2 (sensitivity, 70.5%; specificity, 69.0%). CONCLUSION Early filling defects within the LAA on cardiac CT were associated with LAA function including risk factors for thrombus development, which could lead to noninvasive estimation of LAA function and additional information for risk stratification of thromboembolic events in patients with AF.
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Affiliation(s)
- Kotaro Ouchi
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan.
| | - Toru Sakuma
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Higuchi
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Jun Yoshida
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ryosuke Narui
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ayumi Nojiri
- Department of Laboratory Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Teiichi Yamane
- Department of Cardiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroya Ojiri
- Department of Radiology, The Jikei University School of Medicine, Tokyo, Japan
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Seguchi R, Ohtsuka T, Ishikawa N, Watanabe G. Bilateral endoscopic technique for left atrial appendectomy and robot-assisted mitral valve repair. Interact Cardiovasc Thorac Surg 2021; 34:326-328. [PMID: 34535996 PMCID: PMC8782230 DOI: 10.1093/icvts/ivab250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 08/04/2021] [Accepted: 08/13/2021] [Indexed: 11/30/2022] Open
Abstract
We report a bilateral thoracoscopic technique in which robot-assisted mitral
valve repair was achieved concomitantly with stapler division of the large left
atrial appendage. The patient was a 65-year-old male with severe mitral
regurgitation, paroxysmal atrial fibrillation and a large-sized atrial
appendage. Closure of the appendage was completed off-pump using a left
thoracoscopic stapler-division technique previous to right thoracoscopic
robot-assisted mitral valve repair and cryoablation. Complete closure of the
appendage was confirmed in thoracoscopic views. The bilateral thoracoscopic
technique could be preferable for the minimally invasive treatment of mitral
valvular disease and concomitant large-sized atrial appendage management.
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Affiliation(s)
- Ryuta Seguchi
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Tokyo, Japan
| | - Toshiya Ohtsuka
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Tokyo, Japan
| | - Norihiko Ishikawa
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Tokyo, Japan
| | - Go Watanabe
- Department of Cardiovascular Surgery, NewHeart Watanabe Institute, Tokyo, Japan
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Cohen A, Donal E, Delgado V, Pepi M, Tsang T, Gerber B, Soulat-Dufour L, Habib G, Lancellotti P, Evangelista A, Cujec B, Fine N, Andrade MJ, Sprynger M, Dweck M, Edvardsen T, Popescu BA. EACVI recommendations on cardiovascular imaging for the detection of embolic sources: endorsed by the Canadian Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2021; 22:e24-e57. [PMID: 33709114 DOI: 10.1093/ehjci/jeab008] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/07/2021] [Indexed: 12/28/2022] Open
Abstract
Cardioaortic embolism to the brain accounts for approximately 15-30% of ischaemic strokes and is often referred to as 'cardioembolic stroke'. One-quarter of patients have more than one cardiac source of embolism and 15% have significant cerebrovascular atherosclerosis. After a careful work-up, up to 30% of ischaemic strokes remain 'cryptogenic', recently redefined as 'embolic strokes of undetermined source'. The diagnosis of cardioembolic stroke remains difficult because a potential cardiac source of embolism does not establish the stroke mechanism. The role of cardiac imaging-transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac computed tomography (CT), and magnetic resonance imaging (MRI)-in the diagnosis of potential cardiac sources of embolism, and for therapeutic guidance, is reviewed in these recommendations. Contrast TTE/TOE is highly accurate for detecting left atrial appendage thrombosis in patients with atrial fibrillation, valvular and prosthesis vegetations and thrombosis, aortic arch atheroma, patent foramen ovale, atrial septal defect, and intracardiac tumours. Both CT and MRI are highly accurate for detecting cavity thrombosis, intracardiac tumours, and valvular prosthesis thrombosis. Thus, CT and cardiac magnetic resonance should be considered in addition to TTE and TOE in the detection of a cardiac source of embolism. We propose a diagnostic algorithm where vascular imaging and contrast TTE/TOE are considered the first-line tool in the search for a cardiac source of embolism. CT and MRI are considered as alternative and complementary tools, and their indications are described on a case-by-case approach.
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Affiliation(s)
- Ariel Cohen
- Assistance Publique-Hôpitaux de Paris, Saint-Antoine and Tenon Hospitals, Department of Cardiology, and Sorbonne University, Paris, France.,INSERM unit UMRS-ICAN 1166; Sorbonne-Université, Paris, France
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Mauro Pepi
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20141, Milan, Italy
| | - Teresa Tsang
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bernhard Gerber
- Service de Cardiologie, Département Cardiovasculaire, Cliniques Universitaires St. Luc, Division CARD, Institut de Recherche Expérimental et Clinique (IREC), UCLouvainAv Hippocrate 10/2803, B-1200 Brussels, Belgium
| | - Laurie Soulat-Dufour
- Assistance Publique-Hôpitaux de Paris, Saint-Antoine and Tenon Hospitals, Department of Cardiology, and Sorbonne University, Paris, France.,INSERM unit UMRS-ICAN 1166; Sorbonne-Université, Paris, France
| | - Gilbert Habib
- Aix Marseille Univ, IRD, MEPHI, IHU-Méditerranée Infection, APHM, La Timone Hospital, Cardiology Department, Marseille, France
| | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, CHU SartTilman, Liège, Belgium.,Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy
| | - Arturo Evangelista
- Servei de Cardiologia. Hospital Universitari Vall d'Hebron-VHIR. CIBER-CV. Pº Vall d'Hebron 119. 08035. Barcelona. Spain
| | - Bibiana Cujec
- Division of Cardiology, University of Alberta, 2C2.50 Walter Mackenzie Health Sciences Center, 8440 112 St NW, Edmonton, Alberta, Canada T6G 2B7
| | - Nowell Fine
- University of Calgary, Libin Cardiovascular Institute, South Health Campus, 4448 Front Street Southeast, Calgary, Alberta T3M 1M4, Canada
| | - Maria Joao Andrade
- Maria Joao Andrade Cardiology Department, Hospital de Santa Cruz-Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos 2790-134 Carnaxide, Portugal
| | - Muriel Sprynger
- Department of Cardiology-Angiology, University Hospital Liège, Liège, Belgium
| | - Marc Dweck
- British Heart Foundation, Centre for Cardiovascular Science, Edinburgh and Edinburgh Imaging Facility QMRI, University of Edinburgh, United Kingdom
| | - Thor Edvardsen
- Faculty of medicine, Oslo University, Oslo, Norway and Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Bogdan A Popescu
- Cardiology Department, University of Medicine and Pharmacy 'Carol Davila', Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C. C. Iliescu', Sos. Fundeni 258, sector 2, 022328 Bucharest, Romania
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Coronary CTA to Investigate Predictive Value of Left Atrial Appendage for Cardiogenic Stroke in Patients with Nonvalvular Atrial Fibrillation. BIOMED RESEARCH INTERNATIONAL 2021; 2020:7351876. [PMID: 33123585 PMCID: PMC7584971 DOI: 10.1155/2020/7351876] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 09/25/2020] [Accepted: 09/29/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE To investigate the predictive value of changes in LAA size and function for cardiogenic stroke (CS) in patients with NVAF by coronary CTA examination. Materials and Method. 179 patients with NVAF were selected and grouped according to the outbreak of acute ischemic stroke and TIA within 2 years after coronary CTA examination. Those who met the criteria for CS were selected as cases (87 patients), and those neither stroke nor TIA as controls (92 patients). LAA size of selected patients was measured and data postprocessing was performed. The differences of baseline data and LAA parameters between groups were analyzed. The impacts of BMI, hyperlipidemia, the duration of AF, the LAAOA Index, and the LAAEF on CS were assessed by binary logistic regression. The predictive abilities of LAAOA Index, LAAEF, and the combined predictor were assessed by ROC curves. RESULTS Proportions of BMI ≥ 25, prevalence of hyperlipidemia, duration of AF, and LAAODmax, LAAODmin, LAAOA, LAAVmax, and LAAVmin with their correction index were greater in cases than controls. The LAAEF was lower in cases than that in controls. The binary logistic regression model showed an increase in LAAOA Index (P = 0.005) and a decrease in LAAEF (P < 0.001) were independent risk factors for CS. ROC curve analysis showed that the optimal cutoff values of LAAOA Index and LAAEF to predict CS were 3.16 cm2/m2 and 38.71%, with AUC value of 0.712 and 0.734, respectively. The LAAOA Index-LAAEF combined predictor (AUC value = 0.786) was likely superior to either LAAOA Index or LAAEF. CONCLUSIONS Coronary CTA can provide additional valuable parameters, as a by-product of coronary artery assessment without additional radiation dose, for the risk assessment of CS in patients with NVAF. Coronary CTA may make up for the limitation of single indicator of CHA2DS2-VASc in guiding anticoagulation program, to reduce the incidence of embolism and bleeding events.
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Rajiah P, Alkhouli M, Thaden J, Foley T, Williamson E, Ranganath P. Pre- and Postprocedural CT of Transcatheter Left Atrial Appendage Closure Devices. Radiographics 2021; 41:680-698. [PMID: 33939541 DOI: 10.1148/rg.2021200136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Transcatheter left atrial appendage (LAA) closure is an alternative to long-term anticoagulation therapy in selected patients with nonvalvular atrial fibrillation who have an increased risk for stroke. LAA closure devices can be implanted by means of either an endocardial or a combined endocardial and epicardial approach. Preprocedural imaging is key to identifying contraindications, accurately sizing the device, and minimizing complications. Transesophageal echocardiography (TEE) has been the reference standard imaging modality to assess the anatomy for LAA closure and to provide intraprocedural guidance. However, CT has emerged as a less-invasive alternative to TEE for pre- and postprocedural imaging. CT is comparable to TEE for exclusion of thrombus but is superior to TEE for the delineation of complex LAA anatomy, measurement for device sizing, and evaluation of pulmonary venous and extracardiac structures. CT provides accurate measurements of the LAA ostial diameter, landing zone diameter, and LAA length, which are vital for accurate sizing of the device. CT allows evaluation of the relationship with the pulmonary veins and other adjacent structures that can be injured during the procedure. CT also simulates procedural fluoroscopic angles and provides evaluation of the interatrial septum, which is punctured during LAA closure. CT also provides a more convenient method for the evaluation of postprocedural complications such as incomplete closure, peridevice leaking, device-related thrombus, and device dislodgement. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Prabhakar Rajiah
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Mohamad Alkhouli
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Jeremy Thaden
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Thomas Foley
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Eric Williamson
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Praveen Ranganath
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
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Dudzińska-Szczerba K, Michałowska I, Piotrowski R, Sikorska A, Paszkowska A, Stachnio U, Kowalik I, Kułakowski P, Baran J. Assessment of the left atrial appendage morphology in patients after ischemic stroke - The ASSAM study. Int J Cardiol 2021; 330:65-72. [PMID: 33524464 DOI: 10.1016/j.ijcard.2021.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 12/12/2020] [Accepted: 01/13/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The ASSAM study was designed to evaluate the association between left atrial appendage (LAA) morphology and stroke risk in patients with atrial fibrillation (AF). METHODS The study included 85 randomly chosen AF patients with acute ischemic stroke matched with 84 AF without stroke. All patients had left atrial (LA) computed tomography performed to analyze LAA anatomy. RESULTS Patients in the stroke group had a larger LAA volume (10.22 [7.83-13.62] vs. 9.33 cm3 [7.33-11.47], p = 0.046], greater distance from LAA ostium to the first LAA bend (9.25 ± 3.85 vs. 7.23 ± 2.95 mm, p = 0.0002), and more frequently had round LAA ostium shape (11.8 vs. 1.2%, p = 0.005). According to a multivariable model, significant predictors of ischemic stroke were distance from LAA ostium to the first LAA bend (OR 1.202 [1.065-1.356], p = 0.003), LAA ostium round shape of (OR 16.813 [1.857-152.231], p = 0.012), LAA ostium surface area (OR 0.612 [0.457-0.819], p = 0.009), and cactus LAA morphology (OR 2.739 [1.176-6.380], p = 0.016). After adjusting for CHA2DS2-VASc score, only the distance from LAA ostium to the first LAA bend remained a significant risk factor for stroke (OR 1.154 [1.014-1.314], p = 0.03). CONCLUSIONS The distance from LAA ostium to the first bend of the LAA was independently associated with stroke risk in patients with AF. Whether this parameter may help improve identification of patients at risk of ischemic stroke, needs to be confirmed in larger studies.
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Affiliation(s)
- Katarzyna Dudzińska-Szczerba
- Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Grenadierów 51/59, 04-073 Warsaw, Poland
| | - Ilona Michałowska
- Department of Radiology, Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland.
| | - Roman Piotrowski
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Grenadierów 51/59, 04-073 Warsaw, Poland
| | - Agnieszka Sikorska
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Grenadierów 51/59, 04-073 Warsaw, Poland
| | - Agnieszka Paszkowska
- Department of Therapy and Neurological Rehabilitation, Grochowski Hospital, Grenadierów 51/59, 04-073 Warsaw, Poland
| | - Urszula Stachnio
- Department of Therapy and Neurological Rehabilitation, Grochowski Hospital, Grenadierów 51/59, 04-073 Warsaw, Poland
| | - Ilona Kowalik
- Heart Arrhythmia Ward, II Department of Coronary Artery Disease, Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland.
| | - Piotr Kułakowski
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Grenadierów 51/59, 04-073 Warsaw, Poland.
| | - Jakub Baran
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Grenadierów 51/59, 04-073 Warsaw, Poland
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A Predictor for Defects in Filling of the Left Atrial Appendage on Cardiac Computed Tomography in Patients With Atrial Fibrillation. J Comput Assist Tomogr 2020; 44:284-288. [DOI: 10.1097/rct.0000000000000984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Anan AR, Fareed J, Suhaib J, Rafat R, Murad D, Isam B, Tariq M, Patricia E, Alexander E, Vaidya V, Peter A N, Abhishek D. Left Atrial Appendage Morphology as a Determinant for Stroke Risk Assessment in Atrial Fibrillation Patients: Systematic Review and Meta-Analysis. J Atr Fibrillation 2019; 12:2183. [PMID: 32002111 DOI: 10.4022/jafib.2183] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 02/14/2019] [Accepted: 03/26/2019] [Indexed: 12/23/2022]
Abstract
Background Atrial fibrillation (AF) is a leading source of emboli that precipitate cerebrovascular accident (CVA) which is correlated with left atrial appendage (LAA) morphology. We aimed to elaborate the relationship between CVA and LAA morphology in AF patients. Methods Medline and EMBASE databases were thoroughly searched between 2010-2018 for studies that included atrial fibrillation patients and classified them into two groups based on CVA occurrence. Four different LAA morphologies (Chicken wing CW, Cauliflower, cactus and windsock) were determined in each group by 3D TEE, MDCT or CMRI. New Castle Ottawa Scale was used to appraise the quality of included studies. The risk of CVA before cardiac ablation and/or LAA intervention in CW patients was compared to each type of non-CW morphologies. The extracted data was statistically analyzed in the form of forest plot by measuring the risk ratio (RR) using REVMAN software. P value and I square were used to assess the heterogeneity between studies. Results PRISMA diagram was illustrated showing 789 imported studies for screening. Three duplicates were removed, and the rest were arbitrated by 2 reviewers yielding 12 included studies with 3486 patients including 1551 with CW, 442 with cauliflower, 732 with cactus 765 with windsock. The risk of CVA in CW patients was reduced by 41% relative to non-CW patients (Total RR=0.59 (0.52-0.68)). Likewise, the risk of CVA in CW patients was less by 46%, 35% and 31% compared to cauliflower (Total RR =0.54(0.46-0.64)), cactus (Total RR =0.65(0.55-0.77)) and windsock (Total RR =0.69(0.58-0.83)) patients respectively. Low levels of heterogeneity were achieved in all comparisons (I square <35% and p value > 0.1). Conclusions Patients with non-CW morphologies (cauliflower, cactus and windsock) show a higher incidence of CVA than CW patients. For that reason, LAA appendage morphology could be useful for risk stratification of CVA in AF patients.
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Affiliation(s)
- Abu Rmilah Anan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Jumah Fareed
- Rutgers-Robert Wood Johnson Universty Hospital, New Brunswick, NJ, USA
| | | | | | | | - Bsisu Isam
- Jordan University Hospital, Amman, Jordan
| | | | - Erwin Patricia
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Egbe Alexander
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Vaibha Vaidya
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | | | - Deshmukh Abhishek
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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Glassy MS, Wung W, Westcott S, Smith TW, Fan D, Rogers JH, Singh GD. Watchman Occlusion in Long-Standing Persistent Atrial Fibrillation. JACC Cardiovasc Interv 2019; 12:1018-1026. [DOI: 10.1016/j.jcin.2019.04.007] [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: 01/09/2019] [Revised: 03/05/2019] [Accepted: 04/02/2019] [Indexed: 11/24/2022]
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Thoracoscopic stapler-and-loop technique for left atrial appendage closure in nonvalvular atrial fibrillation: Mid-term outcomes in 201 patients. Heart Rhythm 2018; 15:1314-1320. [DOI: 10.1016/j.hrthm.2018.05.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Indexed: 12/12/2022]
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29
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Hozawa M, Morino Y, Matsumoto Y, Tanaka R, Nagata K, Kumagai A, Tashiro A, Doi A, Yoshioka K. 3D-computed tomography to compare the dimensions of the left atrial appendage in patients with normal sinus rhythm and those with paroxysmal atrial fibrillation. Heart Vessels 2018; 33:777-785. [DOI: 10.1007/s00380-018-1119-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 01/05/2018] [Indexed: 10/18/2022]
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30
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Delgado V, Di Biase L, Leung M, Romero J, Tops LF, Casadei B, Marrouche N, Bax JJ. Structure and Function of the Left Atrium and Left Atrial Appendage. J Am Coll Cardiol 2017; 70:3157-3172. [DOI: 10.1016/j.jacc.2017.10.063] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 10/22/2017] [Indexed: 12/12/2022]
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31
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Chen Z, Bai W, Li C, Wang H, Tang H, Qin Y, Rao L. Left Atrial Appendage Parameters Assessed by Real-Time Three-Dimensional Transesophageal Echocardiography Predict Thromboembolic Risk in Patients With Nonvalvular Atrial Fibrillation. JOURNAL OF ULTRASOUND IN MEDICINE 2017; 36:1119-1128. [PMID: 28233335 DOI: 10.7863/ultra.16.05070] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 08/12/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVES In nonvalvular atrial fibrillation (NVAF) patients, the effect of left atrial appendage (LAA) morphology, structure, and hemodynamic characteristics evaluated by real-time 3D transesophageal echocardiography (RT3D-TEE) on thromboembolic risk has not been elucidated. METHODS A total of 444 NVAF patients who underwent clinically indicated RT3D-TEE were enrolled in the study. The orifice size, orifice area, depth, and volume measurements of the LAA were assessed using Philips QLAB 9.0. The LAA characteristics were compared among different CHA2 DS2 -VASc thromboembolic risk subgroups, as well as between the thromboembolic event and nonevent groups. RESULTS The orifice size, orifice area, and end-diastolic volumes of the LAA were increased with an increasing CHA2 DS2 -VASc risk score in the NVAF patients, whereas the emptying rate was decreased. The NVAF patients with LAA thrombus exhibited a significantly increased end-diastolic volume (7.39 ± 3.47 versus 5.21 ± 2.59 mL, P = .003) and higher prevalence of the cauliflower shaped LAA (64.3% versus 25%, P = .004) compared with those without thrombus. Logistic regression indicated that the LAA end-diastolic volume (P = .002; odds ratio 1.556; 95% confidence interval 1.176-2.057) and cauliflower shape (P = .001; odds ratio, 10.177; 95% confidence interval, 2.458-42.140) were independent predictors of thromboembolic events in patients with NVAF following adjustment for the CHA2 DS2 -VASc score. CONCLUSIONS The LAA end-diastolic volume and cauliflower phenotype predict thromboembolic events independent of the CHA2 DS2 -VASc score, and these data improve stroke prediction in NVAF patients.
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Affiliation(s)
- Zhongxiu Chen
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Wenjuan Bai
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Chen Li
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Hui Wang
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Hong Tang
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yupei Qin
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Li Rao
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Commonly Used Echocardiographic Diastolic Function Parameters and Left Atrial Appendage Thrombus. J Am Soc Echocardiogr 2017; 30:198. [DOI: 10.1016/j.echo.2016.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Indexed: 11/24/2022]
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33
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Whisenant B, Orford J. From Good to Great. JACC Cardiovasc Interv 2016; 9:2341-2342. [DOI: 10.1016/j.jcin.2016.08.029] [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: 08/10/2016] [Accepted: 08/20/2016] [Indexed: 11/30/2022]
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Gan L, Yu L, Xie M, Feng W, Yin J. Analysis of real-time three dimensional transesophageal echocardiography in the assessment of left atrial appendage function in patients with atrial fibrillation. Exp Ther Med 2016; 12:3323-3327. [PMID: 27882157 PMCID: PMC5103785 DOI: 10.3892/etm.2016.3745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 09/20/2016] [Indexed: 11/06/2022] Open
Abstract
The aim of the study was to examine changes in left atrial appendage volume (LAA-V) in patients with non-valvular atrial fibrillation (AF) using real-time three-dimensional transesophageal echocardiography (RT3D-TEE) and evaluate the prediction value on the high risk of thrombosis of LAA. Using RT3D-TEE we measured: i) LAA peak empty velocity (LAA-PEV), ii) LAA-V including LAA end-diastolic volume (LAA-EDV) and end-systolic volume (LAA-ESV). We also calculated LAA ejection fraction (LAA-EF). RT3D-TEE was applied in 20 control cases and 74 patients with non-valvular AF. According to the presence of thrombosis, 74 patients were divided into the no thrombosis group (NTH group, n=52) and thrombosis group (TH group, n=22). Our results showed that there were significant differences in LAA-V and LAA-EF values in different groups (P<0.05). LAA-EDV moderately correlated with LAA-PEV (r=-0.531, P<0.001) while LAA-ESV demonstrated a strong correlation with LAA-PEV (r=-0.741, P<0.001). LAA-EF also showed a strong correlation with LAA-PEV (r=0.693, P<0.001). Through receiver operating characteristic (ROC) curves, the cut-off values of LAA-EDV and LAA-ESV in thrombosis of LAA were 18.45 and 9.69 ml, respectively. RT3D-TEE effectively evaluated the LAA-V, LAA-PEV and LAA-EF parameters, and proved to be valuable in the process of evaluation of thrombosis of LAA.
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Affiliation(s)
- Lin Gan
- Department of Ultrasound Imaging, Xiangyang Hospital Affiliated to Hubei University of Medicine, Xiangyang, Hubei 441000, P.R. China
| | - Lan Yu
- Department of Ultrasound Imaging, Xiangyang Hospital Affiliated to Hubei University of Medicine, Xiangyang, Hubei 441000, P.R. China
| | - Manying Xie
- Department of Ultrasound Imaging, Xiangyang Hospital Affiliated to Hubei University of Medicine, Xiangyang, Hubei 441000, P.R. China
| | - Wei Feng
- Department of Ultrasound Imaging, Xiangyang Hospital Affiliated to Hubei University of Medicine, Xiangyang, Hubei 441000, P.R. China
| | - Jiabao Yin
- Department of Ultrasound Imaging, Xiangyang Hospital Affiliated to Hubei University of Medicine, Xiangyang, Hubei 441000, P.R. China
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Bisbal F, Gómez-Pulido F, Cabanas-Grandío P, Akoum N, Calvo M, Andreu D, Prat-González S, Perea RJ, Villuendas R, Berruezo A, Sitges M, Bayés-Genís A, Brugada J, Marrouche NF, Mont L. Left Atrial Geometry Improves Risk Prediction of Thromboembolic Events in Patients With Atrial Fibrillation. J Cardiovasc Electrophysiol 2016; 27:804-10. [PMID: 27027899 DOI: 10.1111/jce.12978] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 02/25/2016] [Accepted: 03/02/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Left atrial (LA) sphericity (LASP) is a new remodeling parameter based on LA shape analysis, with independent predictive value for recurrence after atrial fibrillation (AF) ablation. OBJECTIVES To evaluate the association between LASP and thromboembolic events (TE) in patients with AF. METHODS Twenty-nine AF patients and prior TE and 29 age- and gender-matched controls were included. LASP was calculated using a 3D-LA reconstruction. The LA appendage (LAA) volume and morphology were assessed. ROC curve analysis was performed for LASP, LA volume, LAA volume, and CHAD/CHA2 D-VASc scores (Stroke2 -the grouping variable-was excluded). RESULTS Mean age of the study population was 61 ± 11 years (79.3% males, 53.4% hypertension, 8.6% diabetes). Patients with prior TE had higher LASP than those without (82.5 ± 3.3% vs. 80.2 ± 3.1%, P = 0.008); there were no differences in CHAD or CHA2 D-VASc scores, LA volume, LAA volume, or LAA morphology. The C-statistic was higher for LASP (0.71) than for other tested variables (CHAD score = 0.58, CHA2 D-VASc score = 0.59, LA volume = 0.50, LAA volume = 0.46; P < 0.01 for all vs. LASP). The best cutoff value for LASP was 83.6% (sensitivity 0.52, specificity 0.90). Logistic regression analysis showed predictive value for LASP (OR 1.26 per each 1% increase [1.85-52.20], P = 0.013), but not for clinical risk scores. The addition of LASP to the CHAD and CHA2 D-VASc scores increased the predictive value over the risk scores alone (P = 0.004), and reclassified 45.5% of patients with CHAD = 0 (no anticoagulation indicated) to moderate-risk (anticoagulation indicated). CONCLUSION LA sphericity is associated with prior TE in AF patients and improves the performance of the CHAD and CHA2 D-VASc scores alone.
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Affiliation(s)
- Felipe Bisbal
- Heart Institute - Hospital Universitari Germans Trias I Pujol, Badalona, Spain
| | | | | | - Nazem Akoum
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Mireia Calvo
- Atrial Fibrillation Unit (UFA) - Hospital Clínic, Barcelona, Spain
| | - David Andreu
- Atrial Fibrillation Unit (UFA) - Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Susanna Prat-González
- Atrial Fibrillation Unit (UFA) - Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Rosario J Perea
- Atrial Fibrillation Unit (UFA) - Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Roger Villuendas
- Heart Institute - Hospital Universitari Germans Trias I Pujol, Badalona, Spain
| | - Antonio Berruezo
- Atrial Fibrillation Unit (UFA) - Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Marta Sitges
- Atrial Fibrillation Unit (UFA) - Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Antoni Bayés-Genís
- Heart Institute - Hospital Universitari Germans Trias I Pujol, Badalona, Spain
| | - Josep Brugada
- Atrial Fibrillation Unit (UFA) - Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Nassir F Marrouche
- Comprehensive Arrhythmia Research and Management (CARMA) Center - University of Utah, Salt Lake City, Utah, USA
| | - Lluís Mont
- Atrial Fibrillation Unit (UFA) - Hospital Clínic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques Agustí Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Anselmino M, Gili S, Castagno D, Ferraris F, Matta M, Rovera C, Giustetto C, Gaita F. Do left atrial appendage morphology and function help predict thromboembolic risk in atrial fibrillation? J Cardiovasc Med (Hagerstown) 2016; 17:169-76. [DOI: 10.2459/jcm.0000000000000305] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kreidieh B, Valderrábano M. Malignant Left Atrial Appendage Morphology and Embolization Risk in Atrial Fibrillation. HeartRhythm Case Rep 2016; 1:406-410. [PMID: 26918230 PMCID: PMC4762447 DOI: 10.1016/j.hrcr.2015.02.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Bahij Kreidieh
- Methodist DeBakey Heart Vascular Center, Houston Methodist Hospital
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Wunderlich NC, Beigel R, Swaans MJ, Ho SY, Siegel RJ. Percutaneous interventions for left atrial appendage exclusion: options, assessment, and imaging using 2D and 3D echocardiography. JACC Cardiovasc Imaging 2016; 8:472-488. [PMID: 25882576 DOI: 10.1016/j.jcmg.2015.02.002] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 01/22/2015] [Accepted: 02/05/2015] [Indexed: 12/26/2022]
Abstract
Percutaneous left atrial appendage (LAA) exclusion is an evolving treatment to prevent embolic events in patients with nonvalvular atrial fibrillation. In the past few years multiple percutaneous devices have been developed to exclude the LAA from the body of the left atrium and thus from the systemic circulation. Two- and 3-dimensional transesophageal echocardiography (TEE) is used to assess the LAA anatomy and its suitability for percutaneous closure to select the type and size of the closure device and to guide the device implantation procedure in conjunction with fluoroscopy. In addition, 2- and 3-dimensional TEE is also used to assess the effectiveness of device implantation acutely and on subsequent follow-up examination. Knowledge of the implantation options that are currently available along with their specific characteristics is essential for choosing the appropriate device for a given patient with a specific LAA anatomy. We present the currently available LAA exclusion devices and the echocardiographic imaging approaches for evaluation of the LAA before, during, and after LAA occlusion.
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Affiliation(s)
| | - Roy Beigel
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; The Heart Institute, Sheba Medical Center, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Siew Yen Ho
- Cardiac Morphology Unit, Royal Brompton Hospital, London, United Kingdom
| | - Robert J Siegel
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Kreidieh B, Rojas F, Schurmann P, Dave AS, Kashani A, Rodríguez-Mañero M, Valderrábano M. Left Atrial Appendage Remodeling After Lariat Left Atrial Appendage Ligation. Circ Arrhythm Electrophysiol 2015; 8:1351-8. [DOI: 10.1161/circep.115.003188] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 10/14/2015] [Indexed: 01/02/2023]
Abstract
Background—
Left atrial appendage (LAA) ligation with the Lariat device is being used for stroke prevention in atrial fibrillation. Residual leaks into the LAA are commonly reported after the procedure. Little is known about the anatomic LAA remodeling after Lariat ligation.
Methods and Results—
In an exploratory study, we evaluated LAA 3-dimensional geometry via computed tomographic scan in 31 consecutive patients before Lariat closure and after a minimum of 30 days post procedure. Thirteen patients were classified as unfavorable cases based on anatomic criteria. Our population had an average age of 70±12 years, a mean CHADS2 (congestive heart failure, hypertension, age>75, diabetes mellitus, history of stroke) score of 3.2±1.2, a mean CHADS2VASC (CHADS2 in addition to female sex, ages 65–75, as well as double impact of age >75, vascular disease) of 4.2±1.5, and a mean HASBLED (hypertension, abnormal renal/liver function, stroke, bleeding predisposition/history, labile international normalized ratio, elderly, drugs/alcohol) bleeding score of 4.0±1.1. Successful suture deployment was achieved in all cases, but 3 patients had intraprocedural residual flow into the LAA (leak). On follow-up, 10 patients (32%) had recanalized residual LAA cavities, which were morphologically similar to the original LAA, albeit significantly smaller in volume (22.5±13.3% of the original volume). Recanalization was not associated with age, sex, comorbid conditions, stroke or bleeding risk scores, follow-up interval, baseline LAA volume, or morphology. Unfavorable cases had anatomic outcomes comparable with those of the anatomically favorable population. No patients have exhibited thromboembolism after 842±338 days post ligation.
Conclusions—
Incomplete LAA ligation after Lariat is common. However, the remodeled LAA cavity is dramatically reduced. Diminished cavity size and tightening of the LAA orifice may play a role in the reduction of thrombus formation.
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Affiliation(s)
- Bahij Kreidieh
- From the Division of Cardiac Electrophysiology, Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX
| | - Francia Rojas
- From the Division of Cardiac Electrophysiology, Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX
| | - Paul Schurmann
- From the Division of Cardiac Electrophysiology, Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX
| | - Amish S. Dave
- From the Division of Cardiac Electrophysiology, Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX
| | - Amir Kashani
- From the Division of Cardiac Electrophysiology, Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX
| | - Moisés Rodríguez-Mañero
- From the Division of Cardiac Electrophysiology, Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX
| | - Miguel Valderrábano
- From the Division of Cardiac Electrophysiology, Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, TX
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Beigel R, Wunderlich NC, Ho SY, Arsanjani R, Siegel RJ. The left atrial appendage: anatomy, function, and noninvasive evaluation. JACC Cardiovasc Imaging 2015; 7:1251-65. [PMID: 25496544 DOI: 10.1016/j.jcmg.2014.08.009] [Citation(s) in RCA: 289] [Impact Index Per Article: 32.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 08/12/2014] [Accepted: 08/20/2014] [Indexed: 12/23/2022]
Abstract
The left atrial appendage (LAA) is a finger-like extension originating from the main body of the left atrium. Atrial fibrillation (AF) is the most common clinically important cardiac arrhythmia, occurring in approximately 0.4% to 1% of the general population and increasing with age to >8% in those >80 years of age. In the presence of AF thrombus, formation often occurs within the LAA because of reduced contractility and stasis; thus, attention should be given to the LAA when evaluating and assessing patients with AF to determine the risk for cardioembolic complications. It is clinically important to understand LAA anatomy and function. It is also critical to choose the optimal imaging techniques to identify or exclude LAA thrombi in the setting of AF, before cardioversion, and with current and emerging transcatheter therapies, which include mitral balloon valvuloplasty, pulmonary vein isolation, MitraClip (Abbott Laboratories, Abbott Park, Illinois) valve repair, and the implantation of LAA occlusion and exclusion devices. In this review, we present the current data regarding LAA anatomy, LAA function, and LAA imaging using the currently available noninvasive imaging modalities.
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Affiliation(s)
- Roy Beigel
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; The Heart Institute, Sheba Medical Center, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Siew Yen Ho
- Cardiac Morphology Unit, Royal Brompton Hospital, London, England
| | - Reza Arsanjani
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Robert J Siegel
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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41
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Bardia A, Montealegre-Gallegos M, Mahmood F, Owais K, Pal A, Matyal R. Left atrial size: an underappreciated perioperative cardiac risk factor. J Cardiothorac Vasc Anesth 2014; 28:1624-32. [PMID: 25307502 DOI: 10.1053/j.jvca.2014.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Amit Bardia
- Departments of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mario Montealegre-Gallegos
- Departments of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Hospital México C.C.S.S., Universidad de Costa Rica, San José, Costa Rica
| | - Feroze Mahmood
- Departments of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Khurram Owais
- Departments of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Anam Pal
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Robina Matyal
- Departments of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Taina M, Korhonen M, Haataja M, Muuronen A, Arponen O, Hedman M, Jäkälä P, Sipola P, Mustonen P, Vanninen R. Morphological and volumetric analysis of left atrial appendage and left atrium: cardiac computed tomography-based reproducibility assessment. PLoS One 2014; 9:e101580. [PMID: 24988467 PMCID: PMC4079282 DOI: 10.1371/journal.pone.0101580] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 06/07/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Left atrial appendage (LAA) dilatation and morphology may influence an individual's risk for intracardiac thrombi and ischemic stroke. LAA size and morphology can be evaluated using cardiac computed tomography (cCT). The present study evaluated the reproducibility of LAA volume and morphology assessments. METHODS A total of 149 patients (47 females; mean age 60.9±10.6 years) with suspected cardioembolic stroke/transient ischemic attack underwent cCT. Image quality was rated based on four categories. Ten patients were selected from each image quality category (N = 40) for volumetric reproducibility analysis by two individual readers. LAA and left atrium (LA) volume were measured in both two-chamber (2CV) and transversal view (TV) orientation. Intertechnique reproducibility was assessed between 2CV and TV (200 measurement pairs). LAA morphology (A = Cactus, B = ChickenWing, C = WindSock, D = CauliFlower), LAA opening height, number of LAA lobes, trabeculation, and orientation of the LAA tip was analysed in all study subjects by three individual readers (447 interobserver measurement pairs). The reproducibility of volume measurements was assessed by intra-class correlation (ICC) and the reproducibility of LAA morphology assessments by Cohen's kappa. RESULTS The intra-observer and interobserver reproducibility of LAA and LA volume measurements was excellent (ICCs>0.9). The LAA (ICC = 0.954) and LA (ICC = 0.945) volume measurements were comparable between 2CV and TV. Morphological classification (ĸ = 0.24) and assessments of LAA opening height (ĸ = 0.1), number of LAA lobes (ĸ = 0.16), trabeculation (ĸ = 0.15), and orientation of the LAA tip (ĸ = 0.37) was only slightly to fairly reproducible. CONCLUSIONS LA and LAA volume measurements on cCT provide excellent reproducibility, whereas visual assessment of LAA morphological features is challenging and results in unsatisfactory agreement between readers.
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Affiliation(s)
- Mikko Taina
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Miika Korhonen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Mika Haataja
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Antti Muuronen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Otso Arponen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Marja Hedman
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Pekka Jäkälä
- NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Petri Sipola
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Pirjo Mustonen
- Department of Cardiology, Keski-Suomi Central Hospital, Jyväskylä, Finland
| | - Ritva Vanninen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
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Abdelmoneim SS, Mulvagh SL. Techniques To Improve Left Atrial Appendage Imaging. J Atr Fibrillation 2014; 7:1059. [PMID: 27957080 DOI: 10.4022/jafib.1059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 06/11/2014] [Accepted: 06/12/2014] [Indexed: 01/20/2023]
Abstract
The clinical importance of the left atrial appendage (LAA) is increasingly recognized. The assessment of the unique anatomy and function of the LAA is especially important in the setting of atrial fibrillation (AF). AF is the most commonly occurring cardiac arrhythmia, and the association of LAA thrombi and AF has been well established. Transesophageal echocardiography (TEE) is a widely available imaging tool to exclude the potential presence of LAA thrombus prior to cardioversion in patients with AF. Commercially available products containing microbubbles to enhance ultrasound images, termed "ultrasound contrast agents" (UCA) are indicated for use with transthoracic echocardiography to improve cardiac structure and function assessment, but can also be used with TEE as an adjunctive tool to assess the LAA. Integrative multimodality imaging techniques can be used in evaluation of the LAA as indicated in various clinical scenarios including: stroke risk assessment, decision-making prior to cardioversion in AF, placement and assessment percutaneous transcatheter LAA occlusion procedures, and assessment of results of procedural or surgical exclusion of LAA. In this article, various imaging techniques that are available for non-invasive visualization of the LAA will be reviewed along with the clinical importance of assessment of LAA anatomy and function.
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Affiliation(s)
- Sahar S Abdelmoneim
- Mayo Clinic Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Division of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States; Division of Cardiovascular Medicine, Assiut University, Assiut, Egypt
| | - Sharon L Mulvagh
- Mayo Clinic Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Division of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, United States
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Kanmanthareddy A, Reddy YM, Vallakati A, Earnest MB, Nath J, Ferrell R, Dawn B, Lakkireddy D. Embryology and Anatomy of the Left Atrial Appendage: Why Does Thrombus Form? Interv Cardiol Clin 2014; 3:191-202. [PMID: 28582164 DOI: 10.1016/j.iccl.2013.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The left atrial appendage (LAA) is a long tubular structure that opens into the left atrium. In patients with atrial fibrillation, the LAA develops mechanical dysfunction and fibroelastotic changes on the endocardial surface. The complex anatomy of the LAA makes it a good site for relative blood stasis. In addition, systemic factors exacerbate the hypercoagulable state, eventually resulting in endothelial dysfunction, release of tissue factor, and production of inflammatory cytokines and oxidative free radicals, and eventually initiating the coagulation cascade. Thus, the LAA is susceptible to thrombus formation and is the most common source of systemic thromboembolism.
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Affiliation(s)
- Arun Kanmanthareddy
- Division of Cardiovascular Medicine, Mid-America Cardiology, University of Kansas Hospital, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Yeruva Madhu Reddy
- Division of Cardiovascular Medicine, University of Kansas Hospital, Kansas City, KS 66160, USA
| | - Ajay Vallakati
- Division of Cardiology, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH 44109, USA
| | - Matthew B Earnest
- Mid-America Cardiology, University of Kansas Hospital, Kansas City, KS 66160, USA
| | - Jayant Nath
- Division of Cardiovascular Medicine, Mid-America Cardiology, University of Kansas Hospital, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Ryan Ferrell
- Division of Cardiovascular Medicine, Mid-America Cardiology, University of Kansas Hospital, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Buddhadeb Dawn
- Division of Cardiovascular Medicine, Mid-America Cardiology, University of Kansas Hospital, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Dhanunjaya Lakkireddy
- Division of Cardiology, Mid-America Cardiology, Center for Excellence in Atrial Fibrillation & Electrophysiology Research, Bloch Heart Rhythm Center, KU Cardiovascular Research Institute, University of Kansas Hospital, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA.
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Tanaka K, Koga M, Ohyama S, Tokunaga K, Sato K, Suzuki R, Minematsu K, Toyoda K. Evaluation of the left atrial appendage by real-time three-dimensional transesophageal echocardiography for acute stroke patients. ACTA ACUST UNITED AC 2014. [DOI: 10.3995/jstroke.36.260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Taina M, Vanninen R, Hedman M, Jäkälä P, Kärkkäinen S, Tapiola T, Sipola P. Left atrial appendage volume increased in more than half of patients with cryptogenic stroke. PLoS One 2013; 8:e79519. [PMID: 24223960 PMCID: PMC3817123 DOI: 10.1371/journal.pone.0079519] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 09/26/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Ischemic strokes without a well-defined etiology are labeled as cryptogenic, and account for 30-40% of strokes in stroke registries. The left atrial appendage (LAA) is the most typical origin for intracardiac thrombus formation when associated with atrial fibrillation. Here, we examined whether increased LAA volume detected with cardiac computed tomography (cCT) constitutes a risk factor in cryptogenic stroke patients. METHODS This study included 82 stroke/TIA patients (57 males; mean age, 58 years) with a diagnosis of cryptogenic stroke after extensive radiological and cardiological investigations. Cases were classified using the TOAST criteria modified by European Association of Echocardiography recommendations for defining cardiac sources of embolism. Forty age- and gender-matched control subjects without cardiovascular diseases were selected for pair-wise comparisons (21 males; mean age, 54 years). LAA volume adjusted for body surface area was measured three dimensionally by tracing the LAA borders on electrocardiogram-gated CT slices. RESULTS In control subjects, mean LAA volume was 3.4±1.1 mL/m(2). Mean+2SD, which was considered the upper limit for normal LAA volume was 5.6 mL/m(2). In paired Student t-test between the patient group and matched controls, LAA volume was 67% larger in cryptogenic stroke/TIA patients (5.7±2.0 mL/m(2) vs. 3.4±1.1 mL/m(2); P<0.001). Forty-five (55%) patients with cryptogenic stroke/TIA had enlarged LAA. CONCLUSION LAA is significantly enlarged in more than half of patients with cryptogenic stroke/TIA. LAA thrombosis may contribute to the pathogenesis of stroke in patients considered to have cryptogenic stroke after conventional evaluation.
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Affiliation(s)
- Mikko Taina
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- * E-mail:
| | - Ritva Vanninen
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Marja Hedman
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Pekka Jäkälä
- NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Unit of Neurology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | | | - Tero Tapiola
- Department of Neurology, North Kymi Hospital, Kouvola, Finland
| | - Petri Sipola
- Department of Clinical Radiology, Kuopio University Hospital, Kuopio, Finland
- Unit of Radiology, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
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