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Oliva A, Ioppolo AM, Chiarito M, Cremonesi A, Azzano A, Miccichè E, Mangiameli A, Ariano F, Ferrante G, Reimers B, Garot P, Amabile N, Mehran R, Condorelli G, Stefanini G, Cao D. Left Atrial Appendage Closure Compared With Oral Anticoagulants for Patients With Atrial Fibrillation: A Systematic Review and Network Meta-Analysis. J Am Heart Assoc 2024:e034815. [PMID: 39119987 DOI: 10.1161/jaha.124.034815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 07/12/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Percutaneous left atrial appendage closure (LAAC) has been suggested as an alternative to long-term oral anticoagulation for nonvalvular atrial fibrillation, but comparative data remain scarce. We aimed to assess ischemic and bleeding outcomes of LAAC compared with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) for the prevention of cardioembolic events in patients with atrial fibrillation. METHODS AND RESULTS Embase and MEDLINE were searched for randomized trials comparing LAAC, VKAs, and DOACs. The primary efficacy end point was any stroke or systemic embolism. Treatment effects were calculated from a network meta-analysis and ranked according to the surface under the cumulative ranking curve. Seven trials and 73 199 patients were included. The risk of the primary end point was not statistically different between LAAC versus VKAs (odds ratio [OR], 0.92 [95% CI, 0.62-1.50]) and LAAC versus DOACs (OR, 1.11 [95% CI, 0.71-1.73]). LAAC and DOACs resulted in similar risk of major or minor (OR, 0.93 [95% CI, 0.61-1.42]) and major bleeding (OR, 0.92 [95% CI, 0.58-1.46]); however, after exclusion of procedural bleeding, bleeding risk was significantly lower in those undergoing LAAC. Both LAAC and DOACs reduced the risk of all-cause death compared with VKAs (LAAC versus VKAs: OR, 0.70 [95% CI, 0.53-0.91]; DOACs versus VKAs: OR, 0.90 [95% CI, 0.85-0.95], respectively). DOACs ranked as the best treatment for stroke or systemic embolism prevention (66.9%) and LAAC for reducing major bleeding (63.9%) and death (96.4%). CONCLUSIONS As a nonpharmacological alternative to oral anticoagulation for atrial fibrillation, LAAC showed similar efficacy and safety compared with VKAs or DOACs. Prospective confirmation from larger studies is warranted.
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Affiliation(s)
- Angelo Oliva
- Cardiovascular Department Humanitas Gavazzeni Hospital Bergamo Italy
- Department of Biomedical Sciences Humanitas University Pieve Emanuele MI Italy
- Cardio Center Humanitas Clinical and Research Hospital IRCCS Rozzano Italy
| | | | - Mauro Chiarito
- Department of Biomedical Sciences Humanitas University Pieve Emanuele MI Italy
- Cardio Center Humanitas Clinical and Research Hospital IRCCS Rozzano Italy
| | - Alberto Cremonesi
- Cardiovascular Department Humanitas Gavazzeni Hospital Bergamo Italy
- Department of Biomedical Sciences Humanitas University Pieve Emanuele MI Italy
| | - Alessia Azzano
- Cardiovascular Department Humanitas Gavazzeni Hospital Bergamo Italy
| | - Eligio Miccichè
- Cardiovascular Department Humanitas Gavazzeni Hospital Bergamo Italy
| | - Andrea Mangiameli
- Cardiovascular Department Humanitas Gavazzeni Hospital Bergamo Italy
| | - Francesco Ariano
- Cardiovascular Department Humanitas Gavazzeni Hospital Bergamo Italy
| | - Giuseppe Ferrante
- Department of Biomedical Sciences Humanitas University Pieve Emanuele MI Italy
- Cardio Center Humanitas Clinical and Research Hospital IRCCS Rozzano Italy
| | - Bernhard Reimers
- Department of Biomedical Sciences Humanitas University Pieve Emanuele MI Italy
- Cardio Center Humanitas Clinical and Research Hospital IRCCS Rozzano Italy
| | - Philippe Garot
- Institut Cardiovasculaire Paris Sud (ICPS), Hôpital Privé Jacques Cartier Ramsay-Santé Massy France
| | - Nicolas Amabile
- Institut Cardiovasculaire Paris Sud (ICPS), Hôpital Privé Jacques Cartier Ramsay-Santé Massy France
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY USA
| | - Gianluigi Condorelli
- Department of Biomedical Sciences Humanitas University Pieve Emanuele MI Italy
- Cardio Center Humanitas Clinical and Research Hospital IRCCS Rozzano Italy
| | - Giulio Stefanini
- Department of Biomedical Sciences Humanitas University Pieve Emanuele MI Italy
- Cardio Center Humanitas Clinical and Research Hospital IRCCS Rozzano Italy
| | - Davide Cao
- Cardiovascular Department Humanitas Gavazzeni Hospital Bergamo Italy
- Department of Biomedical Sciences Humanitas University Pieve Emanuele MI Italy
- Institut Cardiovasculaire Paris Sud (ICPS), Hôpital Privé Jacques Cartier Ramsay-Santé Massy France
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2
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Nardi E, Santoro C, Prastaro M, Canonico ME, Paolillo S, Gargiulo G, Gargiulo P, Parlati ALM, Basile C, Bardi L, Giuliano M, Esposito G. Crosslink between atrial fibrillation and cancer: a therapeutic conundrum. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2024; 10:48. [PMID: 39113118 PMCID: PMC11304574 DOI: 10.1186/s40959-024-00243-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 06/21/2024] [Indexed: 08/10/2024]
Abstract
Atrial fibrillation (AF) is more common in patients with malignancies than in general population. The pathophysiological processes include the pro-inflammatory condition and the exaggerated inflammatory reaction to chemotherapy, radiotherapy, and surgery interventions. Thus, it is pivotal to decrease morbidity and mortality in this group by providing appropriate care and prevention. In this subset, the risk of thromboembolic and bleeding events is high and the common risk score such as CHA2DS2-VASc and HAS-BLED employed in non-oncologic patients have limited evidence in cancer patients. A paucity of evidence in the setting in individuals having both malignancies and atrial fibrillation entangle the clinician when it comes to therapeutic management. Tailored management is recommended of anticoagulation treatment could be difficult, and there is. In this review, we try to explain the mechanism of AF in cancer patients as well as its management in this setting.
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Affiliation(s)
- Ermanno Nardi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy.
| | - Maria Prastaro
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Mario Enrico Canonico
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Paola Gargiulo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Antonio L M Parlati
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Christian Basile
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Luca Bardi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Mario Giuliano
- Department of Clinical Medicine and Surgery, University Federico II Rare Tumors Coordinating Center of Campania Region (CRCTR), Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
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3
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Wang E, Sadleir P, Sourinathan V, Weerasooriya R, Playford D, Joshi P. Thoracoscopic Left Atrial Appendage Occlusion with the AtriClip PRO2: An Experience of 144 Patients. Heart Lung Circ 2024; 33:1215-1220. [PMID: 38604885 DOI: 10.1016/j.hlc.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 12/30/2023] [Accepted: 02/13/2024] [Indexed: 04/13/2024]
Abstract
AIM To report the clinical outcomes of thoracoscopic left atrial appendage occlusion (LAAO) with the AtriClip PRO2 device (Atricure Inc, Mason, OH, USA). Stroke risk reduction with LAAO in patients with atrial fibrillation is now well-established. Many surgical and percutaneous techniques have been used, with varying rates of success. The percutaneous devices have had issues with procedural complications and peridevice flow. Thoracoscopic AtriClip offers an epicardial linear closure of the appendage at its ostium. This study sought to evaluate its safety and efficacy in achieving complete LAA closure. METHOD This is a prospective series of thoracoscopic AtriClip PRO2 as a standalone procedure or a thoracoscopic AtriClip deployed as an adjunct to minimal access cardiac and thoracic surgery. Study ethical approval was granted by the hospital Human Research Ethics Committee. RESULTS In total, 144 thoracoscopic AtriClip procedures were conducted by a single surgeon from 2017 to 2022, 56 standalone and 88 concomitant. There was no mortality or major morbidities. A 100% success in complete LAA closure was observed, with 87% complete follow-up imaging. For patients that underwent standalone AtriClip after cessation of anticoagulation, no thromboembolic phenomena were seen in the 180 patient-years of follow-up. CONCLUSIONS This study demonstrates that thoracoscopic placement of AtriClip is safe and effective in achieving consistent and complete LAAO. Future randomised trials will be useful to compare outcomes with percutaneous devices.
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Affiliation(s)
- Edward Wang
- Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Paul Sadleir
- Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia; Heart Rhythm Clinic, Hollywood Private Hospital, Perth, WA, Australia
| | - Vijay Sourinathan
- Heart Rhythm Clinic, Hollywood Private Hospital, Perth, WA, Australia
| | - Rukshen Weerasooriya
- Heart Rhythm Clinic, Hollywood Private Hospital, Perth, WA, Australia; Faculty of Medicine, The University of Western Australia, Perth, WA, Australia
| | - David Playford
- School of Medicine, The University of Notre Dame Australia, Perth, WA, Australia
| | - Pragnesh Joshi
- Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia; Heart Rhythm Clinic, Hollywood Private Hospital, Perth, WA, Australia; Faculty of Medicine, The University of Western Australia, Perth, WA, Australia.
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4
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Nasr GH, Rushworth PM, Donaldson DM. Left Atrial Appendage Closure: Therapy Overview and Future Perspective. Cardiol Clin 2024; 42:389-401. [PMID: 38910023 DOI: 10.1016/j.ccl.2024.02.018] [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] [Indexed: 06/25/2024]
Abstract
The left atrial appendage (LAA) has gained increasing attention in the field of cardiology as a potential site for intervention in patients with atrial fibrillation (AF) and an elevated risk of thromboembolic events. Left atrial appendage occlusion (LAAO) has emerged as a promising therapeutic strategy to mitigate the risk of stroke and systemic embolism, especially in individuals who are unsuitable candidates for long-term anticoagulation therapy. This review aims to provide a comprehensive analysis of the current state of LAAO, encompassing its anatomic considerations, procedural techniques, clinical outcomes, and future directions.
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Affiliation(s)
- George H Nasr
- Division of Cardiology, University of California, Irvine, 101 The City Drive South Suite 407, Orange, CA 92868, USA
| | - Parker M Rushworth
- Division of Cardiology, University of California, Irvine, 101 The City Drive South Suite 407, Orange, CA 92868, USA
| | - David M Donaldson
- Division of Cardiology, University of California, Irvine, 101 The City Drive South Suite 407, Orange, CA 92868, USA.
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Anwar AM. Morphological and functional assessment of the left atrial appendage in daily practice: a comprehensive approach using basic and advanced echocardiography with practical tips. J Cardiovasc Imaging 2024; 32:12. [PMID: 39069633 DOI: 10.1186/s44348-024-00017-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 02/13/2024] [Indexed: 07/30/2024] Open
Abstract
Cardioembolic stroke is the most serious and life-threatening complication of atrial fibrillation (AF), with an associated mortality up to 30% at 12 months. Approximately 47% of thrombi in valvular AF and 91% of thrombi in nonvalvular AF are localized in the left atrial appendage (LAA). Therefore, identification or exclusion of LAA thrombi is critical in many clinical situations. It is essential to assess LAA morphology and function using imaging modalities (particularly echocardiography) before, during, and after interventional procedures such as AF ablation and LAA occlusion. This review article describes the anatomical, physiological, and pathological background of the LAA, followed by an assessment of different echocardiographic modalities. Many practical points are included to improve the diagnostic accuracy and to minimize errors during image acquisition and interpretation. In each clinical scenario where LAA is the crucial target, specific and essential information and parameters are collected.
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Affiliation(s)
- Ashraf M Anwar
- Department of Cardiology, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia.
- Department of Cardiology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
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6
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Wyatt B, McIntosh G, Campbell A, Little M, Rogers L, Wyatt B. Simulating left atrial arrhythmias with an interactive N-body model. J Electrocardiol 2024; 86:153762. [PMID: 39059214 DOI: 10.1016/j.jelectrocard.2024.153762] [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: 10/17/2023] [Revised: 05/31/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Heart disease and strokes are leading global killers. While atrial arrhythmias are not deadly by themselves, they can disrupt blood flow in the heart, causing blood clots. These clots can travel to the brain, causing strokes, or to the coronary arteries, causing heart attacks. Additionally, prolonged periods of elevated heart rates can lead to structural and functional changes in the heart, ultimately leading to heart failure if untreated. The left atrium, with its more complex topology, is the primary site for complex arrhythmias. Much remains unknown about the causes of these arrhythmias, and computer modeling is employed to study them. METHODS We use N-body modeling techniques and parallel computing to build an interactive model of the left atrium. Through user input, individual muscle attributes can be adjusted, and ectopic events can be placed to induce arrhythmias in the model. Users can test ablation scenarios to determine the most effective way to eliminate these arrhythmias. RESULTS We set up muscle conditions that either spontaneously generate common arrhythmias or, with a properly timed and located ectopic event, induce an arrhythmia. These arrhythmias were successfully eliminated with simulated ablation. CONCLUSIONS We believe the model could be useful to doctors, researchers, and medical students studying left atrial arrhythmias.
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Affiliation(s)
- Bryant Wyatt
- Tarleton State University, Department of Mathematics,1333 W Washington St, Stephenville, TX 76401, United States of America.
| | - Gavin McIntosh
- Tarleton State University, Department of Mathematics,1333 W Washington St, Stephenville, TX 76401, United States of America
| | - Avery Campbell
- Oncor Electric Delivery, 1616 Woodall Rodgers Fwy, Dallas, TX 75202, United States of America
| | - Melanie Little
- MD Anderson School of Health Professions, 1515 Holocombe Blvd, Houston, TX 77030, United States of America
| | - Leah Rogers
- Tarleton State University, Department of Mathematics,1333 W Washington St, Stephenville, TX 76401, United States of America
| | - Brandon Wyatt
- Biosense Webster, 31 Technology Dr. Suite 200, Irvine, CA 92618, United States of America
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7
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Bshennaty A, Vogl BJ, Bavo AM, Sularz A, Kramer AD, Jia Y, De Beule M, Nielsen-Kudsk JE, De Backer O, Alkhouli M, Hatoum H. Understanding the role of the left atrial appendage on the flow in the atrium. Catheter Cardiovasc Interv 2024. [PMID: 39033333 DOI: 10.1002/ccd.31153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 07/10/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND The exclusion/occlusion of the left atrial appendage (LAA) is a treatment option for atrial fibrillation (AF) patients who are at high risk of stroke and high risk of bleeding. As the role of the LAA is not well understood or explored, this study aims to assess its role on flow dynamics in the left atrium. METHODS Computational fluid dynamics (CFD) simulations were carried out for nine AF patients before and after LAA exclusion. The flow parameters investigated included the LA velocities, Time Averaged Wall Shear Stress (TAWSS), Oscillatory Shear Index (OSI), Relative Residence Time (RRT), and Pressure in the LA. RESULTS This study shows that, on average, a decrease in TAWSS (1.82 ± 1.85 Pa to 1.27 ± 0.96 Pa, p < 0.05) and a slight increase in OSI (0.16 ± 0.10 to 0.17 ± 0.10, p < 0.05), RRT (1.87 ± 1.84 Pa-1 to 2.11 ± 1.78 Pa-1, p < 0.05), and pressure (-19.2 ± 6.8 mmHg to -15.3 ± 8.3 mmHg, p < 0.05) were observed in the LA after the exclusion of the LAA, with a decrease in low-magnitude velocities. CONCLUSION The exclusion of the LAA seems to be associated with changes in LA flow dynamics. Further studies are needed to elucidate the clinical implications of these changes.
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Affiliation(s)
- Ahmad Bshennaty
- Department of Biomedical Engineering, Michigan Technological University, Houghton, Michigan, USA
| | - Brennan J Vogl
- Department of Biomedical Engineering, Michigan Technological University, Houghton, Michigan, USA
| | | | - Agata Sularz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Yuheng Jia
- Department of Cardiology, Copenhagen University Hospital, Denmark
| | | | | | - Ole De Backer
- Department of Cardiology, Copenhagen University Hospital, Denmark
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hoda Hatoum
- Department of Biomedical Engineering, Michigan Technological University, Houghton, Michigan, USA
- Health Research Institute, Center of Biocomputing and Digital Health and Institute of Computing and Cybersystems, Michigan Technological University, Houghton, Michigan, USA
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8
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Lu X, Wang X, Wang Q, Song T, Liu G, Liu A, Shi X, Guo J, Chen T. Efficiency of optimal fluoroscopic projection angle defined by computed tomography angiography for left atrial appendage closure. Hellenic J Cardiol 2024; 78:50-59. [PMID: 37717695 DOI: 10.1016/j.hjc.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/24/2023] [Accepted: 09/12/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND Left atrial appendage (LAA) closure (LAAC) procedures are conventionally performed using empirical fluoroscopic viewing angles. However, because the LAA is a highly variable anatomical structure, these angles cannot depict the LAA in the optimal position. The present study aimed to assess the efficiency of using a novel optimal fluoroscopic projection angle (OPA) for LAAC and to validate its feasibility. METHODS The OPAs of the derivation cohort were acquired using cardiac computed tomography angiography (CCTA) to assess its superiority for depicting LAA depth versus traditional working angles (TAs) of RAO 30°, CAU 20°. The practicability of OPA-guided LAAC was demonstrated by comparison between clinical data from the validation cohort and those from a propensity-score matched (PSM) control group, as well as randomized controlled studies investigating LAAC. RESULTS Of 705 patients in the derivation cohort, the median OPA was RAO 46°, CAU 31°. Compared with TA, the OPA depicted a longer mean (±SD) LAA depth (5.1 ± 4.4) mm and a larger orifice diameter (1.1 ± 1.1 mm), (P < 0.0001 for both). All 38 OPA-guided LAACs were successful, with a shorter mean procedure duration (42.9 ± 12.3 min versus [vs.] 107.2 ± 41.5 min; P < 0.0001) and reduced device consumption (1.08 vs. 1.5 per case), compared with the PSM control group. At the 3-month follow-up, the incidence of peri-device leak was 52.6% (20/38) detected by CCTA, with a mean leakage of 1.6 ± 0.8 mm. CONCLUSION By unfolding the LAA depth and orifice diameter for a better view, OPA demonstrated the potential to optimize LAAC procedural efficiency, although further larger-scale studies are required to confirm this.
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Affiliation(s)
- Xu Lu
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China; Outpatient Department, The 44th Sanatorium of Retired Cadres in Haidian District, No. 19 Dahuisi Road, Haidian District, Beijing 100081, China.
| | - Xinyan Wang
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China.
| | - Qingsong Wang
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China.
| | - Tingting Song
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China.
| | - Ge Liu
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China.
| | - Ao Liu
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China.
| | - Xiangmin Shi
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China.
| | - Jun Guo
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China.
| | - Tao Chen
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China.
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9
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Jing M, Xi H, Liu Q, Zhu H, Sun Q, Zhang Y, Liu X, Ren W, Deng L, Zhou J. Correlation between left atrial appendage morphology based on fractal dimension quantification and its hemodynamic parameters in patients with atrial fibrillation. Clin Radiol 2024:S0009-9260(24)00334-9. [PMID: 39054176 DOI: 10.1016/j.crad.2024.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/24/2024] [Accepted: 05/01/2024] [Indexed: 07/27/2024]
Abstract
AIMS To investigate the relationship between left atrial appendage (LAA) morphology, quantified based on fractal dimension (FD), and LAA hemodynamic parameters in patients with atrial fibrillation (AF), in an effort to reveal the effect of LAA shape on blood flow. MATERIALS AND METHODS 225 patients with AF who underwent cardiac computed tomography angiography (CTA) and transesophageal echocardiography (TEE) were enrolled. LAA morphology was quantified based on FD on cardiac CTA images, and LAA hemodynamic parameters, including injection fraction (EF), filling peak flow velocity (FV), maximum speed of emptying (PEV), and wall motion velocity (WMV), were assessed using TEE. RESULTS We divided the patients with AF into two groups based on a mean LAA FD of 1.32: the low FD group (n=124) and the high FD group (n=101). Compared to the low FD group, there were more patients with LAA circulatory stasis/thrombus (P=0.008) in the high FD group, as well as lower LAA FV (P=0.004), LAA PEV (P=0.007), and LAA WMV (P=0.007). LAA FD was an independent and significant determinant of LAA EF (β = -11.755, P=0.001), LAA FV (β = -17.364, P=0.004), LAA PEV (β = -18.743, P<0.001), and LAA WMV (β = -7.740, P=0.001) in multiple linear regression analysis. CONCLUSIONS LAA FD is an essential determinant of LAA hemodynamic parameters, suggesting that the relatively complex morphology of the LAA may influence its hemodynamics, which can correlate with embolic events.
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Affiliation(s)
- M Jing
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China; Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China; Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - H Xi
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China; Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China; Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - Q Liu
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China; Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China; Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - H Zhu
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China; Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China; Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - Q Sun
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China; Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China; Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - Y Zhang
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China; Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China; Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - X Liu
- Ultrasound Medical Center, Lanzhou University Second Hospital, Lanzhou, China
| | - W Ren
- GE Healthcare, Computed Tomography Research Center, Beijing, China
| | - L Deng
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China; Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China; Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China
| | - J Zhou
- Department of Radiology, Lanzhou University Second Hospital, Lanzhou, China; Second Clinical School, Lanzhou University, Lanzhou, China; Key Laboratory of Medical Imaging of Gansu Province, Lanzhou, China; Gansu International Scientific and Technological Cooperation Base of Medical Imaging Artificial Intelligence, Lanzhou, China.
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10
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Ma C, Wu S, Liu S, Han Y. Chinese guidelines for the diagnosis and management of atrial fibrillation. Pacing Clin Electrophysiol 2024; 47:714-770. [PMID: 38687179 DOI: 10.1111/pace.14920] [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: 11/22/2023] [Accepted: 11/30/2023] [Indexed: 05/02/2024]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of the guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice timely and fully, the Chinese Society of Cardiology of Chinese Medical Association and the Heart Rhythm Committee of Chinese Society of Biomedical Engineering jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2‑VASc‑60 stroke risk score based on the characteristics of the Asian AF population. The guidelines also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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Affiliation(s)
- Changsheng Ma
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shulin Wu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shaowen Liu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Yaling Han
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
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11
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Agarwal PP, Nasr LA, Ghoshhajra BB, Brown RKJ, Collier P, De Cecco CN, Fuss C, Goldstein JN, Kallianos K, Malik SB, Maroules CD, Meyersohn NM, Nazarian S, Scherer MD, Singh S, Tailor TD, Tong MS, Koweek LM. ACR Appropriateness Criteria® Preprocedural Planning for Left Atrial Procedures in Atrial Fibrillation. J Am Coll Radiol 2024; 21:S237-S248. [PMID: 38823947 DOI: 10.1016/j.jacr.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
This document summarizes the relevant literature for the selection of preprocedural imaging in three clinical scenarios in patients needing endovascular treatment or cardioversion of atrial fibrillation. These clinical scenarios include preprocedural imaging prior to radiofrequency ablation; prior to left atrial appendage occlusion; and prior to cardioversion. The appropriateness of imaging modalities as they apply to each clinical scenario is rated as usually appropriate, may be appropriate, and usually not appropriate to assist the selection of the most appropriate imaging modality in the corresponding clinical scenarios. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Layla A Nasr
- Research Author, Allegheny Health Network Imaging Institute, Pittsburgh, Pennsylvania
| | | | - Richard K J Brown
- University of Utah, Department of Radiology and Imaging Sciences, Salt Lake City, Utah; Commission on Nuclear Medicine and Molecular Imaging
| | | | | | - Cristina Fuss
- Oregon Health & Science University, Portland, Oregon
| | - Jennifer N Goldstein
- ChristianaCare Health System, Newark, Delaware; Society of General Internal Medicine
| | | | - Sachin B Malik
- VA Palo Alto Health Care System, Palo Alto, California; Stanford University, Stanford, California
| | | | | | - Saman Nazarian
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Heart Rhythm Society
| | - Markus D Scherer
- Sanger Heart and Vascular Institute, Charlotte, North Carolina; Society of Cardiovascular Computed Tomography
| | - Simranjit Singh
- Indiana University School of Medicine, Indianapolis, Indiana; American College of Physicians
| | - Tina D Tailor
- Duke University Medical Center, Durham, North Carolina
| | - Matthew S Tong
- Ohio State University, Columbus, Ohio; Society for Cardiovascular Magnetic Resonance
| | - Lynne M Koweek
- Specialty Chair, Duke University Medical Center, Durham, North Carolina
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12
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Yuan Y, Zhu Y, Wu D, Wang J, Lin S, Zhu Y, Xu Y, Wu F. The Relationship Between Cardiac CT-based Left Atrial Structure and Epicardial Adipose Tissue and Postablation Atrial Fibrillation Recurrence Within 2 Years. J Thorac Imaging 2024:00005382-990000000-00140. [PMID: 38800955 DOI: 10.1097/rti.0000000000000789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
PURPOSE The aim of this study was to explore the association of cardiac CT-based left atrium (LA) structural and functional parameters and left atrial epicardial adipose tissue (LA-EAT) parameters with postablation atrial fibrillation (AF) recurrence within 2 years. MATERIALS AND METHODS Contrast-enhanced cardiac CT images of 286 consecutive AF patients (median age: 65 y; 97 females) who underwent initial ablation between June 2018 and June 2020 were retrospectively analyzed. Structural and functional parameters of LA, including maximum and minimum volume and ejection fraction of LA and left atrial appendage (LAA), and LA-EAT volume, were measured. The body surface area indexed maximum and minimum volume of LA (LAVImax, LAVImin) and LAA (LAAVImax, LAAVImin), and LA-EAT volume index (LA-EATVI) were calculated. Independent predictors of AF recurrence were determined using Cox regression analysis. The clinical predictors were added to the imaging predictors to build a combined model (clinical+imaging). The predictive performance of the clinical, imaging, and combined models was assessed using the area under the receiver operating characteristics curve (AUC). RESULTS A total of 108 (37.8%) patients recurred AF within 2 years after ablation at a median follow-up of 24 months (IQR=11, 32). LA and LAA size and LA-EAT volume were significantly increased in patients with AF recurrence (P<0.05). After the multivariable regression analysis, LA-EATVI, LAAVImax, female sex, AF duration, and stroke history were independent predictors for AF recurrence. The combined model exhibited superior predictive performance compare to the clinical model (AUC=0.712 vs. 0.641, P=0.023) and the imaging model (AUC=0.712 vs. 0.663, P=0.018). CONCLUSION Cardiac CT-based LA-EATVI and LAAVImax are independent predictors for postablation AF recurrence within 2 years and may provide a complementary value for AF recurrence risk assessment.
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Affiliation(s)
- Yuan Yuan
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University
- Department of Radiology, The Affiliated Cancer Hospital of Nanjing Medical University, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, Nanjing, Jiangsu Province
| | - Yinsu Zhu
- Department of Radiology, The Second Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology, Baotou, Inner Mongolia
| | - Dandan Wu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University
| | - Jun Wang
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University
| | | | - Yaxin Zhu
- United Imaging Healthcare Co. Ltd, Shanghai, China
| | - Yi Xu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University
| | - Feiyun Wu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University
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13
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Chen T, Lu X, Wang X, Chen Q, Zhao R, Zhang W, Song T, Guo J, Chen Y. Peri-device leakage and delayed endothelialization of the Watchman device: a computed tomography study. Eur Radiol 2024:10.1007/s00330-024-10778-5. [PMID: 38780765 DOI: 10.1007/s00330-024-10778-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/13/2024] [Accepted: 03/19/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES This study aimed to explore the endothelialization process and assess the potential association between endothelialization and peri-device leak (PDL) following Watchman implantation via a quantitative method. METHODS This is a single-center retrospective study of consecutive patients undergoing LAAO between December 2015 and November 2021. Device endothelialization, compared between PDL and non-PDL group, were quantitatively analyzed based on hypoattenuated thickening in cardiac computed tomography angiography (CCTA). Advancement in endothelialization over time were explored using the Cochran-Armitage test and generalized estimating equation approach. Potential risk factors of delayed endothelialization were analyzed using the Cox proportional-hazards model. RESULTS A total of 172 patients (mean age, 68 years ± 10 [standard deviation], 114 men) were finally included. The average endothelialization ratio of the study population was 89.8 ± 7.2 percent. In the follow-up period of postprocedural 3 months to more than 12 months, an incremental trend of endothelialization over time was observed with the ratio of 85.8 ± 8.0, 89.6 ± 7.6, 92.2 ± 4.5, 94.3 ± 2.9 percent, respectively (p < 0.0001). Notably, patients without PDL exhibited a swifter advancement in endothelialization compared to those with PDL, irrespective of device size. The multivariable Cox regression model showed that PDL (HR = 2.113, 95%CI: 1.300-3.435, p = 0.003), DSP (HR = 1.717, 95%CI: 1.113-2.647, p = 0.014) were independent risk factors of delayed endothelialization. CONCLUSION CCTA holds promise as an effective means of quantitatively assessing device endothelialization. Endothelialization advanced gradually over time, with PDL potentially impeding device endothelialization. CLINICAL RELEVANCE STATEMENT A comprehensive understanding of the correlation between endothelialization ratio, time, and residual shunt can establish a more dependable foundation for determining the appropriate anticoagulation treatment following left atrial appendage closure. KEY POINTS Current recommendations for postleft atrial appendage occlusion anti-platelet and anticoagulation therapy are based on animal studies. Cardiac computed tomography angiography (CCTA) combined with the UNet neural network model enables the quantitative assessment of device endothelialization. This technique will allow for additional studies to better understand device endothelialization to optimize treatments in this population.
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Affiliation(s)
- Tao Chen
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China
| | - Xu Lu
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China
- Outpatient Department, The 44th Sanatorium of Retired Cadres in Haidian District, 19 Dahuisi Road, Haidian District, Beijing, 100086, China
| | - Xinyan Wang
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China
| | - Qi Chen
- Department of Health Statistics, Naval Medical University, 800 Xiangyin Road, Yangpu District, Shanghai, 200433, China
| | - Runtao Zhao
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China
| | - Wei Zhang
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China
| | - Tingting Song
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China
| | - Jun Guo
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China.
| | - Yundai Chen
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China
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14
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Zhuo W, Wang B, Fu G, Yu Y, Feng M, Liu J, Du X, Chu H. Impact of left atrial appendage orifice diameter on the safety and efficacy of left atrial appendage closure using the LAmbre device. J Formos Med Assoc 2024; 123:600-605. [PMID: 38238125 DOI: 10.1016/j.jfma.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 12/02/2023] [Accepted: 01/05/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND The diameter and shape of the left atrial appendage (LAA) orifices may influence occluder selection and the outcomes of left atrial appendage closure (LAAC) procedure. This study aimed to evaluate the impact of LAA orifice diameter on the safety and efficacy of LAAC using the LAmbre device. METHODS A total of 133 patients with nonvalvular atrial fibrillation (AF) who underwent LAAC with the LAmbre device between June 2018 and June 2020 were included in this study. The patients were categorized into two groups based on the maximal diameter of the LAA orifice: the large LAA group (n = 45) with a maximal orifice diameter of ≥31 mm, and the normal LAA group (n = 88) with a maximal orifice diameter of <31 mm. The study assessed periprocedural characteristics and long-term clinical follow-up. RESULTS Successful implantation of the LAmbre device was observed in all patients. The incidence of periprocedural peridevice leakage (PDL) was significantly higher in the large LAA group (P < 0.001), while the incidence of acute pericardial effusion (PE) during the procedure was comparable between the two groups (P = 1.000). After a mean follow-up period of 4.8 ± 1.7 years, three patients in the large LAA group developed delayed PE, while no patients in the normal LAA group did (P = 0.037). Additionally, a larger LAA maximal orifice diameter was associated with a higher prevalence of PDL (P = 0.001) and PE (including both acute and delayed PE) (P = 0.027). The optimal cutoff value of the LAA maximal orifice diameter for predicting PDL and PE after LAAC with the LAmbre device was determined to be 30 mm. CONCLUSION The findings suggest that the LAmbre device is a safe and feasible option for occluding the LAA, regardless of its orifice diameter. However, it is important to note that a larger LAA orifice diameter may increase the risk of PDL and delayed PE.
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Affiliation(s)
- Weidong Zhuo
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China; Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, China
| | - Binhao Wang
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China; Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, China
| | - Guohua Fu
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China; Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, China
| | - Yibo Yu
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China; Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, China
| | - Mingjun Feng
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China; Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, China
| | - Jing Liu
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China; Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, China
| | - Xianfeng Du
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China; Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, China
| | - Huimin Chu
- Arrhythmia Center, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China; Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang Province, China.
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15
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Troisi F, Guida P, Vitulano N, Quadrini F, Di Monaco A, Patti G, Grimaldi M. Atrial Thrombosis Prevalence Before Cardioversion or Catheter Ablation of Atrial Fibrillation: An Updated Systematic Review and Meta-Analysis of Direct Oral Anticoagulants Versus Vitamin K Antagonists. Am J Cardiol 2024; 218:77-85. [PMID: 38458580 DOI: 10.1016/j.amjcard.2024.02.042] [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: 12/12/2023] [Revised: 01/21/2024] [Accepted: 02/17/2024] [Indexed: 03/10/2024]
Abstract
Left atrial or left atrial appendage thrombosis (LAT) is contraindicated for cardiac ablation (CA) or cardioversion (CV) of atrial fibrillation (AF). This study was aimed to compare the frequency of LAT detected by transesophageal echocardiography (TEE) before CA or CV in patients with AF treated with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs). We searched PubMed, Scopus, Web of Science, and Cochran Library databases from inception through July 13, 2023 to select studies reporting data on LAT identification before CA or CV using TEE in patients with AF treated with DOACs or VKAs. Pooled odds ratios (ORs) with 95% confidence interval were calculated with a random-effects model. Studies retrieved were 50 (38 observational), 29 on CA, 15 on CV, and 6 on both procedures (17,096 patients on DOACs and 13,666 on VKAs). The overall prevalence of LAT was smaller in DOACs than in VKAs, with an OR of 0.66 (0.52 to 0.84), confirmed at sensitivity analysis and in most subgroups. This finding was consistent for the 3 most reported DOACs: the pooled OR for LAT was 0.68 (0.50 to 0.90) in apixaban, 0.67 (0.51 to 0.88) in dabigatran, 0.61 (0.43 to 0.89) in rivaroxaban, and 1.10 (0.74 to 1.64) in edoxaban (not significant). In conclusion, in this large meta-analysis in patients with AF, the prevalence of LAT by TEE evaluation performed before CV or CA appears lower in those treated with DOACs than in those on VKAs. Additional research may help in better understanding differences between these classes of anticoagulant drugs in the setting of protection against AF-related left atrial thrombotic formation.
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Affiliation(s)
- Federica Troisi
- Cardiology Department, Regional General Hospital "F. Miulli," Bari, Italy.
| | - Pietro Guida
- Cardiology Department, Regional General Hospital "F. Miulli," Bari, Italy
| | - Nicola Vitulano
- Cardiology Department, Regional General Hospital "F. Miulli," Bari, Italy
| | - Federico Quadrini
- Cardiology Department, Regional General Hospital "F. Miulli," Bari, Italy
| | - Antonio Di Monaco
- Cardiology Department, Regional General Hospital "F. Miulli," Bari, Italy; Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Giuseppe Patti
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy; Division of Cardiology, AOU Maggiore della Carità, Novara, Italy
| | - Massimo Grimaldi
- Cardiology Department, Regional General Hospital "F. Miulli," Bari, Italy
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16
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Liu X, Xu Y. A device-related fistula between coronary artery and left atrial appendage following left atrial appendage closure: Case presentation. J Cardiovasc Electrophysiol 2024; 35:1046-1049. [PMID: 38468182 DOI: 10.1111/jce.16224] [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: 01/10/2024] [Revised: 02/06/2024] [Accepted: 02/12/2024] [Indexed: 03/13/2024]
Abstract
INTRODUCTION Left atrial appendage (LAA) closure (LAAC) is considered a viable alternative to anticoagulation therapy for stroke prevention in nonvalvular atrial fibrillation, we report a case with a less common shunt resulting from a device-related coronary artery-appendage fistula (CAAF) following LAAC. METHODS AND RESULTS A 67-year-old male with a history of LAAC was referred to our emergency room with recurrent chest pain and palpitations and was diagnosed with ischemic angina pectoris. Subsequent coronary angiography (CAG) revealed 70% in-stent restenosis and an abnormal shunt of contrast originating from the left circumflex artery (LCA) to the LAA tip which did not exist before. The restenosis was successfully dilated using a drug-coated balloon, the procedure was safely completed without pericardial effusion. The patient had been implanted with a LAmbre occluder (Lifetech Scientific Corp.) in the previous LAAC procedure. This occluder had a lobe-disk design, and the distal umbrella was not fully opened after release, particularly in the lower portion. This could make the hooks embedded on the umbrella contact the LAA wall more tightly, possibly resulting in microperforation and coincidental impingement of the LCA. The epicardial adipose and hyperplastic tissue then chronically wrapped the perforated site, prevented blood outflow into the epicardium, and ultimately formed a CAAF. CONCLUSION CAAF is a rare complication after LAAC but may be underestimated, especially for lobe-disk designed occluders. Therefore, CAG is perhaps necessary to detect this complication.
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Affiliation(s)
- Xiaohua Liu
- Department of Cardiology, Hangzhou First People's Hospital, Hangzhou, China
| | - Yizhou Xu
- Department of Cardiology, Hangzhou First People's Hospital, Hangzhou, China
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17
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Dell'Angela L, Nicolosi GL. Lights and shadows on left atrial appendage occlusion: mind the gap in knowledge and think twice on long-term outcomes. J Cardiovasc Med (Hagerstown) 2024; 25:345-352. [PMID: 38477853 DOI: 10.2459/jcm.0000000000001610] [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: 03/14/2024]
Abstract
Ischemic stroke prevention represents a crucial concern in health systems, being associated with high morbidity and mortality. Atrial fibrillation is associated with 15-20% of ischemic strokes, in the presence of thrombus in the left atrial appendage in 90% of patients with nonvalvular atrial fibrillation. Oral anticoagulation represents the standard of care. However, left atrial appendage occlusions have been developed for selected patients with nonvalvular atrial fibrillation. With regard to the latter, particularly, some important concerns have been raised on the selection of patients potentially amenable to the procedure, seemingly emphasizing a gap in knowledge, real-life clinical practice, and current management guidelines. In light of the recent evidence regarding the current indications for management of left atrial appendage in presence of nonvalvular atrial fibrillation, the purpose of this critical review is to highlight the blind spots of left atrial appendage occlusion indications, taking into account the evidence-based mid- to long-term outcomes. Apparently, many unsolved concerns and problems are still present, mainly including mid- and long-term device-related potential complications, the possibility of concurrent sources of embolization, ethical and economic issues. Furthermore, larger, well designed, long-term, multicentric, and more inclusive studies, as well as shared/integrated registries are needed, aiming at comparing direct oral anticoagulation with left atrial appendage occlusion in the long run.
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Affiliation(s)
- Luca Dell'Angela
- Cardio-Thoracic and Vascular Department, Cardiology Division, Gorizia & Monfalcone Hospital, ASUGI, Gorizia
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18
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Pradella M, Baraboo JJ, Maroun A, Liu SZ, DiCarlo AL, Chu SH, Hwang JM, Collins MA, Passman R, Heckbert SR, Greenland P, Markl M. Associations between 3D-based Left Atrial Volumetric and Blood Flow Parameters in a Single-Site Cohort of the Multi-Ethnic Study of Atherosclerosis. Radiol Cardiothorac Imaging 2024; 6:e230148. [PMID: 38451190 PMCID: PMC11056754 DOI: 10.1148/ryct.230148] [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: 06/06/2023] [Revised: 01/03/2024] [Accepted: 01/18/2024] [Indexed: 03/08/2024]
Abstract
Purpose To investigate associations between left atrial volume (LAV) and function with impaired three-dimensional hemodynamics from four-dimensional flow MRI. Materials and Methods A subcohort of participants from the Multi-Ethnic Study of Atherosclerosis from Northwestern University underwent prospective 1.5-T cardiac MRI including whole-heart four-dimensional flow and short-axis cine imaging between 2019 and 2020. Four-dimensional flow MRI analysis included manual three-dimensional segmentations of the LA and LA appendage (LAA), which were used to quantify LA and LAA peak velocity and blood stasis (% voxels < 0.1 m/sec). Short-axis cine data were used to delineate LA contours on all cardiac time points, and the resulting three-dimensional-based LAVs were extracted for calculation of LA emptying fractions (LAEFtotal, LAEFactive, LAEFpassive). Stepwise multivariable linear models were calculated for each flow parameter (LA stasis, LA peak velocity, LAA stasis, LAA peak velocity) to determine associations with LAV and LAEF. Results This study included 158 participants (mean age, 73 years ± 7 [SD]; 83 [52.5%] female and 75 [47.4%] male participants). In multivariable models, a 1-unit increase of LAEFtotal was associated with decreased LA stasis (β coefficient, -0.47%; P < .001), while increased LAEFactive was associated with increased LA peak velocity (β coefficient, 0.21 cm/sec; P < .001). Furthermore, increased minimum LAV indexed was most associated with impaired LAA flow (higher LAA stasis [β coefficient, 0.65%; P < .001] and lower LAA peak velocity [β coefficient, -0.35 cm/sec; P < .001]). Conclusion Higher minimum LAV and reduced LA function were associated with impaired flow characteristics in the LA and LAA. LAV assessment might therefore be a surrogate measure for LA and LAA flow abnormalities. Keywords: Atherosclerosis, Left Atrial Volume, Left Atrial Blood Flow, 4D Flow MRI Supplemental material is available for this article. © RSNA, 2024.
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Affiliation(s)
- Maurice Pradella
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Justin J. Baraboo
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Anthony Maroun
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Sophia Z. Liu
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Amanda L. DiCarlo
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Stanley H. Chu
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Julia M. Hwang
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Mitchell A. Collins
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Rod Passman
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Susan R. Heckbert
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Philip Greenland
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
| | - Michael Markl
- From the Department of Radiology (M.P., J.J.B., A.M., S.Z.L., A.L.D.,
S.H.C., J.M.H., M.A.C., M.M.), Department of Medicine, Division of Cardiology
(R.P., P.G.), and Department of Preventive Medicine (P.G.), Northwestern
University Feinberg School of Medicine, 737 N Michigan Ave, Suite 1600, Chicago,
IL 60611; Department of Radiology, University Hospital Basel, University of
Basel, Basel, Switzerland (M.P.); and Department of Epidemiology, University of
Washington, Seattle, Wash (S.R.H.)
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19
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Wang W, Chen LY, Walker RF, Alonso A, Norby FL, Lakshminarayan K, Lutsey PL. Percutaneous left atrial appendage occlusion and risk of stroke, hospitalized bleeding and death in Medicare beneficiaries. Pharmacoepidemiol Drug Saf 2024; 33:e5786. [PMID: 38565524 PMCID: PMC10996071 DOI: 10.1002/pds.5786] [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: 09/18/2023] [Revised: 02/12/2024] [Accepted: 03/15/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE Among patients with atrial fibrillation (AF), a nonpharmacologic option (e.g., percutaneous left atrial appendage occlusion [LAAO]) is needed for patients with oral anticoagulant (OAC) contraindications. Among beneficiaries in the Medicare fee-for-service coverage 20% sample databases (2015-18) who had AF and an elevated CHA2DS2-VASc score, we assessed the association between percutaneous LAAO versus OAC use and risk of stroke, hospitalized bleeding, and death. METHODS Patients undergoing percutaneous LAAO were matched to up to five OAC users by sex, age, date of enrollment, index date, CHA2DS2-VASc score, and HAS-BLED score. Overall, 17 156 patients with AF (2905 with percutaneous LAAO) were matched (average ± SD 78 ± 6 years, 44% female). Cox proportional hazards model were used. RESULTS Median follow-up was 10.3 months. After multivariable adjustments, no significant difference for risk of stroke or death was noted when patients with percutaneous LAAO were compared with OAC users (HRs [95% CIs]: 1.14 [0.86-1.52], 0.98 [0.86-1.10]). There was a 2.94-fold (95% CI: 2.50-3.45) increased risk for hospitalized bleeding for percutaneous LAAO compared with OAC use. Among patients 65 to <78 years old, those undergoing percutaneous LAAO had higher risk of stroke compared with OAC users. No association was present in those ≥78 years. CONCLUSION In this analysis of real-world AF patients, percutaneous LAAO versus OAC use was associated with similar risk of death, nonsignificantly elevated risk of stroke, and an elevated risk of bleeding in the post-procedural period. Overall, these results support results of randomized trials that percutaneous LAAO may be an alternative to OAC use for patients with contraindications.
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Affiliation(s)
- Wendy Wang
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Lin Yee Chen
- Lillehei Heart Institute and Department of Medicine (Cardiovascular Division), University of Minnesota Medical School, Minneapolis, Minnesota
| | - Rob F. Walker
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Faye L. Norby
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | - Kamakshi Lakshminarayan
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
- Department of Neurology, University of Minnesota, Minneapolis Minnesota
| | - Pamela L. Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota
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20
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MA CS, WU SL, LIU SW, HAN YL. Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. J Geriatr Cardiol 2024; 21:251-314. [PMID: 38665287 PMCID: PMC11040055 DOI: 10.26599/1671-5411.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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21
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Gupta S, Lutnik M, Cacioppo F, Lindmayr T, Schuetz N, Tumnitz E, Friedl L, Boegl M, Schnaubelt S, Domanovits H, Spiel A, Toth D, Varga R, Raudner M, Herkner H, Schwameis M, Niederdoeckl J. Computed Tomography to Exclude Cardiac Thrombus in Atrial Fibrillation-An 11-Year Experience from an Academic Emergency Department. Diagnostics (Basel) 2024; 14:699. [PMID: 38611612 PMCID: PMC11011443 DOI: 10.3390/diagnostics14070699] [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: 03/01/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Computed tomography (CT) could be a suitable method for acute exclusion of left atrial appendage thrombus (LAAT) prior to cardioversion of atrial fibrillation (AF) and atrial flutter (AFL) at the emergency department. Our aim was to present our experiences with this modality in recent years. METHODS This registry-based observational study was performed at the Department of Emergency Medicine at the Medical University of Vienna, Austria. We studied all consecutive patients with AF and AFL who underwent CT between January 2012 and January 2023 to rule out LAAT before cardioversion to sinus rhythm was attempted. Follow-ups were conducted by telephone and electronic medical records. The main variables of interest were the rate of LAAT and ischemic stroke at follow-up. RESULTS A total of 234 patients (143 [61%] men; median age 68 years [IQR 57-76], median CHA2DS2-VASc 2 [IQR 1-4]) were analyzed. Follow-up was completed in 216 (92%) patients after a median of 506 (IQR 159-1391) days. LAAT was detected in eight patients (3%). A total of 163 patients (72%) in whom LAAT was excluded by CT were eventually successfully cardioverted to sinus rhythm. No adverse events occurred during their ED stay. All patients received anticoagulation according to the CHA2DS2-VASc risk stratification, and no patient had suffered an ischemic stroke at follow-up, resulting in an incidence risk of ischemic strokes of 0% (95% CI 0.0-1.2%). CONCLUSION LAAT was rare in patients admitted to the ED with AF and AFL who underwent cardiac CT prior to attempted cardioversion. At follow-up, no patient had suffered an ischemic stroke. Prospective studies need to show whether this strategy is suitable for the acute treatment of symptomatic AF in the emergency setting.
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Affiliation(s)
- Sophie Gupta
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (S.G.); (F.C.); (T.L.); (N.S.); (E.T.); (L.F.); (M.B.); (S.S.); (H.D.); (H.H.); (J.N.)
| | - Martin Lutnik
- Department of Clinical Pharmacology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Filippo Cacioppo
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (S.G.); (F.C.); (T.L.); (N.S.); (E.T.); (L.F.); (M.B.); (S.S.); (H.D.); (H.H.); (J.N.)
| | - Teresa Lindmayr
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (S.G.); (F.C.); (T.L.); (N.S.); (E.T.); (L.F.); (M.B.); (S.S.); (H.D.); (H.H.); (J.N.)
| | - Nikola Schuetz
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (S.G.); (F.C.); (T.L.); (N.S.); (E.T.); (L.F.); (M.B.); (S.S.); (H.D.); (H.H.); (J.N.)
| | - Elvis Tumnitz
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (S.G.); (F.C.); (T.L.); (N.S.); (E.T.); (L.F.); (M.B.); (S.S.); (H.D.); (H.H.); (J.N.)
| | - Lena Friedl
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (S.G.); (F.C.); (T.L.); (N.S.); (E.T.); (L.F.); (M.B.); (S.S.); (H.D.); (H.H.); (J.N.)
| | - Magdalena Boegl
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (S.G.); (F.C.); (T.L.); (N.S.); (E.T.); (L.F.); (M.B.); (S.S.); (H.D.); (H.H.); (J.N.)
- Clinical Division of Gynaecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Sebastian Schnaubelt
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (S.G.); (F.C.); (T.L.); (N.S.); (E.T.); (L.F.); (M.B.); (S.S.); (H.D.); (H.H.); (J.N.)
| | - Hans Domanovits
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (S.G.); (F.C.); (T.L.); (N.S.); (E.T.); (L.F.); (M.B.); (S.S.); (H.D.); (H.H.); (J.N.)
| | - Alexander Spiel
- Department of Emergency Medicine, Clinic Ottakring, Vienna Healthcare Group, 1160 Vienna, Austria;
| | - Daniel Toth
- Department of Radiology, Medical University of Vienna, 1090 Vienna, Austria; (D.T.); (R.V.); (M.R.)
| | - Raoul Varga
- Department of Radiology, Medical University of Vienna, 1090 Vienna, Austria; (D.T.); (R.V.); (M.R.)
| | - Marcus Raudner
- Department of Radiology, Medical University of Vienna, 1090 Vienna, Austria; (D.T.); (R.V.); (M.R.)
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (S.G.); (F.C.); (T.L.); (N.S.); (E.T.); (L.F.); (M.B.); (S.S.); (H.D.); (H.H.); (J.N.)
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (S.G.); (F.C.); (T.L.); (N.S.); (E.T.); (L.F.); (M.B.); (S.S.); (H.D.); (H.H.); (J.N.)
| | - Jan Niederdoeckl
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria; (S.G.); (F.C.); (T.L.); (N.S.); (E.T.); (L.F.); (M.B.); (S.S.); (H.D.); (H.H.); (J.N.)
- Department of Clinical Pharmacology, Medical University of Vienna, 1090 Vienna, Austria;
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22
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Daxer B, Radner W, Fischer F, Cocoșilă AL, Ettl A. Aetiology, Diagnosis and Treatment of Arterial Occlusions of the Retina-A Narrative Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:526. [PMID: 38674172 PMCID: PMC11052062 DOI: 10.3390/medicina60040526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/28/2024]
Abstract
Arterial occlusions of the retina are potentially sight-threatening diseases which often result in profound visual loss. The aim of this narrative review is to provide an overview of the aetiology, discuss major risk factors, describe the management and systemic assessments and evaluate existing therapies. For this review, an extensive literature search in PubMed was performed. Emboli from the heart or the carotid arteries can cause ophthalmic artery occlusion (OAO), central retinal artery occlusion (CRAO) and branch retinal artery occlusion (BRAO). Most patients with arterial occlusions have vascular risk factors such as arterial hypertension, hyperhomocysteinaemia, carotid stenosis and atrial fibrillation, which also increase the risk of cerebral stroke and myocardial infarction. Therapies such as ocular massage, thrombolysis and anterior chamber paracentesis have been suggested but are still equivocal. However, it is evident that retinal artery occlusion should be immediately treated and accompanied by interdisciplinary collaboration, since early diagnosis and the proper treatment of possible risk factors are important to reduce the risk of further damage, recurrences, other vascular diseases and mortality.
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Affiliation(s)
- Barbara Daxer
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500 Krems, Austria
- Department of Ophthalmology and Orbital Surgery, University Hospital St. Pölten, Dunantplatz 1, 3100 St. Pölten, Austria
| | - Wolfgang Radner
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500 Krems, Austria
- Department of Ophthalmology and Orbital Surgery, University Hospital St. Pölten, Dunantplatz 1, 3100 St. Pölten, Austria
- Austrian Academy of Ophthalmology, Mollgasse 11, 1180 Vienna, Austria
| | - Florian Fischer
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500 Krems, Austria
- Department of Ophthalmology and Orbital Surgery, University Hospital St. Pölten, Dunantplatz 1, 3100 St. Pölten, Austria
| | - Andreea-Liliana Cocoșilă
- Faculty of Medicine and Pharmacy, University of Oradea, 1 Decembrie Square 10, 410068 Oradea, Romania
| | - Armin Ettl
- Karl Landsteiner University of Health Sciences, Dr. Karl-Dorrek-Straße 30, 3500 Krems, Austria
- Department of Ophthalmology and Orbital Surgery, University Hospital St. Pölten, Dunantplatz 1, 3100 St. Pölten, Austria
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23
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Ge L, Xu Y, Li J, Li Y, Xi Y, Wang X, Wang J, Mu Y, Wang H, Lu X, Guo J, Chen Z, Chen T, Chen Y. The impact of contrast retention on thrombus formation risks in patients with atrial fibrillation: A numerical study. Heliyon 2024; 10:e26792. [PMID: 38434273 PMCID: PMC10907767 DOI: 10.1016/j.heliyon.2024.e26792] [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: 01/25/2024] [Accepted: 02/20/2024] [Indexed: 03/05/2024] Open
Abstract
Background Contrast retention (CR) is an important predictor of left atrial appendage thrombus (LAAT) and stroke in patients with non-valvular atrial fibrillation (AF). We sought to explore the underlying mechanisms of CR using computational fluid dynamic (CFD) simulations. Methods A total of 12 patients with AF who underwent both cardiac computed tomography angiography (CTA) and transesophageal echocardiography (TEE) before left atrial appendage occlusion (LAAO) were included in the study. The patients were allocated into the CR group or non-CR group based on left atrial appendage (LAA) angiography. Patient-specific models were reconstructed to evaluate time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI), relative residence time (RRT), and endothelial cell activation potential (ECAP). Additionally, the incidence of thrombosis was predicted using residence time (RT) at different time-points. Results TAWSS was lower [median (Interquartile Range) 0.27 (0.19-0.47) vs 1.35 (0.92-1.79), p < 0.001] in LAA compared to left atrium. In contrast, RRT [1438 (409.70-13869) vs 2.23 (1.81-3.14), p < 0.001] and ECAP [122.70 (30.01-625.70) vs 0.19 (0.16-0.27), p < 0.001)] was higher in the LAA. The patients in the CR group had significantly higher RRT [(mean ± SD) 16274 ± 11797 vs 639.70 ± 595.20, p = 0.009] and ECAP [610.80 ± 365.30 vs 54.26 ± 54.38, p = 0.004] in the LAA compared to the non-CR group. Additionally, patients with CR had a wider range of thrombus-prone regions [0.44(0.27-0.66)% vs 0.05(0.03-0.27)%, p = 0.009] at the end of the 15th cardiac cycle. Conclusions These findings suggest that CR might be an indicator of high-risk thrombus formation in the LAA. And CT-based CFD simulation may be a feasible substitute for the evaluation of LAA thrombotic risk in patients with AF, especially in patients with CR.
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Affiliation(s)
- Lan Ge
- Medical School of Chinese PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
| | - Yawei Xu
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Jun Li
- Medical School of Chinese PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
| | - Yuan Li
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Yifeng Xi
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Xinyan Wang
- Medical School of Chinese PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
| | - Jing Wang
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
| | - Yang Mu
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
| | - Hongsen Wang
- Medical School of Chinese PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
| | - Xu Lu
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
| | - Jun Guo
- Medical School of Chinese PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
| | - Zengsheng Chen
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Tao Chen
- Medical School of Chinese PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
| | - Yundai Chen
- Medical School of Chinese PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
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Ashraf T, Aamir KF, Nadeem A, Murtaza S, Akhtar P, Haque SY, Ghaffar R, Hassan MU, Tipoo FA. Left atrial appendage thrombus with severe mitral stenosis: Responders and non-responders to anticoagulation. Rev Port Cardiol 2024:S0870-2551(24)00070-2. [PMID: 38401704 DOI: 10.1016/j.repc.2023.12.007] [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: 04/01/2023] [Revised: 11/30/2023] [Accepted: 12/02/2023] [Indexed: 02/26/2024] Open
Abstract
INTRODUCTION AND OBJECTIVE Mitral stenosis (MS) is one of the most frequently observed valvular heart lesions in developing countries and is due to different etiologies. The effects of anticoagulation in different types of left atrial appendage (LAA) are unknown. The current study aimed to determine the resolution of LAA thrombus on transesophageal echocardiography (TEE) after three months of optimal anticoagulation in patients with different types of LAA at baseline cardiac computed tomography of patients with severe MS. METHODS This prospective cohort study observed the frequency of LAA thrombus resolution after three months of anticoagulation therapy in patients with severe MS. The response rate in different morphologies of LAA and locations was also assessed. Thrombus resolution after three months of warfarin therapy was assessed on repeat TEE. RESULTS A total of 88 patients were included, mean age 37.95±11.87 years. Repeat TEE showed thrombus resolution in only 27.3% of patients. The rate of thrombus resolution was 8/12 (66.7%), 4/28 (14.3%), 8/36 (22.2%), and 4/12 (33.3%) for patients with cactus, cauliflower, chicken wing, and windsock LAA type, respectively. The resolution rate was 0/12 (0%), 4/44 (9.1%), and 20/32 (62.5%) for patients with thrombus in the base, body, and tip of the LAA, respectively. CONCLUSION The cactus type of LAA morphology and thrombus at the LAA tip responded well to three months of anticoagulation, however, patients with thrombus in the LAA base and body and cauliflower and chicken wing morphology were non-responders and could benefit from early referral for surgical management.
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Affiliation(s)
- Tariq Ashraf
- Karachi Institute of Heart Diseases, Karachi, Pakistan.
| | | | - Asif Nadeem
- Armed Forces Institute of Cardiology & National Institute of Heart Diseases (AFIC-NIHD), Rawalpindi, Pakistan
| | | | - Parveen Akhtar
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
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Li X, Feng S, Ren Z, Wu J, Zhou L, Yang H, Zheng Y, Meng W, Zhang J, Su Y, Jiang Y, Xu J, Sun H, Xu Y, Zhao D, Yin X. Long-term outcomes of left atrial appendage closure with or without concomitant pulmonary vein isolation:a propensity score matching analysis based on CLACBAC study. BMC Cardiovasc Disord 2024; 24:85. [PMID: 38310248 PMCID: PMC10837861 DOI: 10.1186/s12872-024-03725-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 01/11/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND The combined procedure of left atrial appendage closure (LAAC) with concomitant pulmonary vein isolation (PVI) has demonstrated its efficacy and safety. However, there is still a lack of comparative investigations regarding the long-term benefits of the combined procedure when compared to LAAC alone. Our study aims to assess the long-term outcomes of combined procedure of LAAC with concomitant PVI in comparison with a propensity matched LAAC alone group. METHODS Propensity score matching (PSM) was employed to rectify covariate imbalances, resulting in the inclusion of 153 comparable patients from the initial cohort of 333 non-valvular atrial fibrillation (AF) patients. Clinical outcomes, encompassing thrombotic events, major cardiocerebrovascular adverse events (MACCE), re-hospitalization due to cardiovascular disease (CVD), and atrial tachycardia (AT), were juxtaposed between the two groups. Bleeding events and peri-device complications, such as residual flow, device-related thrombus, and device replacement, were also compared. Additionally, a patients group underwent PVI alone was included for comparing AF recurrence rates between the PVI alone group and the combined group. RESULTS Following PSM, 153 patients (mean age 70.3 ± 8.9, 62.7% men) were included, with 102 undergoing the combined procedure and 51 undergoing LAAC alone. No significant differences were found in baseline characteristics between the two groups. The mean follow-up time was 37.6 ± 7.9 months, and two patients were lost to follow-up in the combined procedure group. Thrombotic events were observed in 4 (7.8%) patients in the LAAC alone group and 4 (4.0%) in the combined group (Log-rank p = 0.301). The proportion of patients experiencing MACCE, re-hospitalization due to CVD, and AT between the two groups was comparable, as were bleeding events and peri-device complications. Among patients from the combined procedure group without AF recurrence, a significant difference was noted in prior-procedure left ventricular ejection fraction (LVEF) and LVEF at the 12th month after the procedure (57.2% ± 7.1% vs. 60.5% ± 6.5%, p = 0.002). CONCLUSION The concomitant PVI and LAAC procedure did not increase procedure-related complications, nor did it confer significant benefits in preventing thrombotic events or reducing other cardiovascular events. However, the combined procedure improved heart function, suggesting potential long-term benefits.
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Affiliation(s)
- Xiang Li
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
- Department of Nursing, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200092, China
| | - Shiyu Feng
- Tongji University School of Medicine, Shanghai, 200092, China
| | - Zhongyuan Ren
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Jiayu Wu
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
- School of Medicine, Anhui University of Science and Technology, Anhui province, Huainan, China
| | - Lili Zhou
- School of Clinical Medicine, Shanghai University of Medicine and Health Sciences, Shanghai, 201318, China
| | - Haotian Yang
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Yixing Zheng
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Weilun Meng
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Jun Zhang
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Yang Su
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Yan Jiang
- Tongji University School of Medicine, Shanghai, 200092, China
- Department of Nursing, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200092, China
| | - Jun Xu
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Hui Sun
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
- Department of Cardiology, Shanghai Tenth People's Hospital Chongming Branch, Shanghai, 202157, China
| | - Yawei Xu
- Tongji University School of Medicine, Shanghai, 200092, China.
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China.
| | - Dongdong Zhao
- Tongji University School of Medicine, Shanghai, 200092, China.
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China.
| | - Xiaobing Yin
- Tongji University School of Medicine, Shanghai, 200092, China.
- Department of Nursing, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200092, China.
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Valvez S, Oliveira-Santos M, Gonçalves L, Amaro AM, Piedade AP. Preprocedural Planning of Left Atrial Appendage Occlusion: A Review of the Use of Additive Manufacturing. 3D PRINTING AND ADDITIVE MANUFACTURING 2024; 11:333-346. [PMID: 38389681 PMCID: PMC10880654 DOI: 10.1089/3dp.2022.0373] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
Stroke is a significant public health problem, with non-valvular atrial fibrillation (NVAF) being one of its main causes. This cardiovascular arrhythmia predisposes to the production of intracardiac thrombi, mostly formed in the left atrial appendage (LAA). When there are contraindications to treatment with oral anticoagulants, another therapeutic option to reduce the possibility of thrombus formation in the LAA is the implantation of an occlusion device by cardiac catheterization. The effectiveness of LAA occlusion is dependent on accurate preprocedural device sizing and proper device positioning at the LAA ostium, to ensure sufficient device anchoring and avoid peri-device leaks. Additive manufacturing, commonly known as three-dimensional printing (3DP), of LAA models is beginning to emerge in the scientific literature to address these challenges through procedural simulation. This review aims at clarifying the impact of 3DP on preprocedural planning of LAA occlusion, specifically in the training of cardiac surgeons and in the assessment of the perfect adjustment between the LAA and the biomedical implant.
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Affiliation(s)
- Sara Valvez
- Department of Mechanical Engineering, CEMMPRE, ARISE, University of Coimbra, Coimbra, Portugal
| | | | - Lino Gonçalves
- CBR, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Ana M. Amaro
- Department of Mechanical Engineering, CEMMPRE, ARISE, University of Coimbra, Coimbra, Portugal
| | - Ana P. Piedade
- Department of Mechanical Engineering, CEMMPRE, ARISE, University of Coimbra, Coimbra, Portugal
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Karmegaraj B. Three-dimensional high-definition live tissue virtual dissection of mirror-image dextrocardia with thoracic-abdominal discordance in a fetus. Echocardiography 2024; 41:e15788. [PMID: 38400626 DOI: 10.1111/echo.15788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
Three-dimensional virtual dissection using high-definition live tissue rendering ultrasound tool of a 23-week gestation fetus with situs solitus, mirror image dextrocardia, ventricular septal defect, aortic override, and pulmonary atresia.
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Affiliation(s)
- Balaganesh Karmegaraj
- Sowmi Pediatric Heart Centre, Swasthik Fetal Heart Unit, Tirunelveli, Tamil Nadu, India
- Fetal Cardiology Division, Department of Paediatric Cardiology, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
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28
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Chen J, Chiu F, Chang S, Cheng H, Huang P, Wu C, Wang Y, Hwang J, Tsai C. Pattern of Endothelialization in Left Atrial Appendage Occluder by Optic Coherence Tomography: A Pilot Study. J Am Heart Assoc 2024; 13:e030080. [PMID: 38156658 PMCID: PMC10863799 DOI: 10.1161/jaha.123.030080] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 10/03/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Implantation of the left atrial appendage occluder (LAAO) has been proven to prevent stroke effectively in patients with atrial fibrillation who cannot tolerate anticoagulants. Incomplete endothelization of LAAO may cause device-related thrombus, and currently no good image modality exists to clearly see LAAO endothelialization. We aimed to use coronary optic coherence tomography (OCT) to visualize LAAO endothelialization. METHODS AND RESULTS We enrolled 14 patients (72.8±9.4 years old) undergoing pulmonary vein isolation with a preexisting LAAO implanted more than 1 year ago (5 Watchman and 9 Amulet). After pulmonary vein isolation, we did OCT via steerable sheath and coronary guiding catheter to adjust OCT probe location and injected contrast medium to visualize the LAAO surface. In vitro testing was also performed to see the bare occluder. In vitro OCT showed the surface of the bare device as an interrupted granule pattern, which included the Watchman surface polytetrafluoroethylene membrane string, Amulet disc metal strut, and inner polytetrafluoroethylene membrane string. In the implanted Watchman, OCT showed endothelialization as a smooth surface layer with noninterrupted coarser granules. In the implanted Amulet, OCT showed endothelialization as thin (early) or thick (late) endothelialization layer covering struts with OCT shadows. Among patients with Watchman, 2 showed no, 2 early, and 1 complete endothelialization. Among patients with Amulet, 2 showed no, 3 early, and 4 late endothelialization. CONCLUSIONS We demonstrated the feasibility of OCT to visualize LAAO endothelization with high resolution. Further studies are needed to determine antithrombotic regimens if incomplete endothelization is detected. A new OCT catheter may be designed specifically for LAAO.
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Affiliation(s)
- Jien‐Jiun Chen
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and Hospital Yun‐Ling BranchDou‐Liu CityTaiwan
| | - Fu‐Chun Chiu
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and Hospital Yun‐Ling BranchDou‐Liu CityTaiwan
| | - Sheng‐Nan Chang
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and Hospital Yun‐Ling BranchDou‐Liu CityTaiwan
| | - Hsiao‐Liang Cheng
- Department of AnesthesiaNational Taiwan University HospitalTaipeiTaiwan
| | - Pang‐Shuo Huang
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and Hospital Yun‐Ling BranchDou‐Liu CityTaiwan
| | - Cho‐Kai Wu
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and HospitalTaipeiTaiwan
| | - Yi‐Chih Wang
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and HospitalTaipeiTaiwan
| | - Juey‐Jen Hwang
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and HospitalTaipeiTaiwan
| | - Chia‐Ti Tsai
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and HospitalTaipeiTaiwan
- Graduate Institute of Clinical MedicineNational Taiwan University College of Medicine, Cardiovascular Center, National Taiwan University HospitalTaipeiTaiwan
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29
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Fukui N, Kanahashi T, Matsubayashi J, Imai H, Yoneyama A, Otani H, Yamada S, Takakuwa T. Morphogenesis of the pulmonary vein and left atrial appendage in human embryos and early fetuses. J Anat 2024; 244:142-158. [PMID: 37559438 PMCID: PMC10734654 DOI: 10.1111/joa.13941] [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: 03/21/2023] [Revised: 07/15/2023] [Accepted: 07/28/2023] [Indexed: 08/11/2023] Open
Abstract
The left atrium wall has several origins, including the body, appendage, septum, atrial-ventricular canal, posterior wall, and venous component. Here, we describe the morphogenesis of left atrium based on high-resolution imaging (phase-contrast X-ray computed tomography and magnetic resonance imaging). Twenty-three human embryos and 19 fetuses were selected for this study. Three-dimensional cardiac images were reconstructed, and the pulmonary veins and left atrium, including the left atrial appendage, were evaluated morphologically and quantitatively. The positions of the pericardial reflections were used as landmarks for the border of the pericardial cavity. The common pulmonary vein was observed in three specimens at Carnegie stages 17-18. The pericardium was detected at the four pulmonary veins (left superior, left inferior, right superior, and right inferior pulmonary veins) at one specimen at Carnegie stage 18 and all larger specimens, except the four samples. Our results suggest that the position of the pericardial reflections was determined at two pulmonary veins (right and left pulmonary vein) and four pulmonary veins almost simultaneously when the dorsal mesocardial connection between the embryo and heart regressed. The magnetic resonance images and reconstructed heart cavity images confirmed that the left atrium folds were present at the junction between the body and venous component. Three-dimensional reconstruction showed that the four pulmonary veins entered the dorsal left atrium tangentially from the lateral to the medial direction. More specifically, the right pulmonary veins entered at a greater angle than the left pulmonary veins. The distance between the superior and inferior pulmonary veins was shorter than that between the left and right pulmonary veins. Three-dimensional reconstruction showed that the venous component increased proportionally with growth. No noticeable differences in discrimination between the right and left parts of the venous component emerged, while the junction between the venous component and body gradually became inconspicuous but was still recognizable by the end of the observed early fetal period. The left superior pulmonary vein had the smallest cross-sectional area and most flattened shape, whereas the other three were similar in area and shape. The left atrial appendage had a large volume in the center and extended to the periphery as a lobe-like structure. The left atrial appendage orifice increased in the area and tended to become flatter with growth. The whole left atrium volume^(1/3) increased almost proportionally with growth, parallel to the whole heart volume. This study provided a three-dimensional and quantitative description of the developmental process of the left atrium, comprising the venous component and left atrial appendage formation, from the late embryonic to the early fetal stages.
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Affiliation(s)
- Narumi Fukui
- Human Health Science, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Toru Kanahashi
- Human Health Science, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Jun Matsubayashi
- Center for Clinical Research and Advanced Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Hirohiko Imai
- Department of Systems Science, Kyoto University Graduate School of Informatics, Kyoto, Japan
| | | | - Hiroki Otani
- Department of Developmental Biology, Faculty of Medicine, Shimane University, izumo, Japan
| | - Shigehito Yamada
- Human Health Science, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Congenital Anomaly Research Center, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tetsuya Takakuwa
- Human Health Science, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Malhotra P. Use of Computed Tomography for Left Atrial Appendage Occlusion Procedure Planning and Post-Procedure Assessment. Interv Cardiol Clin 2024; 13:19-28. [PMID: 37980064 DOI: 10.1016/j.iccl.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Transcatheter left atrial appendage occlusion (LAAO) is an alternative to systemic anticoagulation in patients with non-valvular atrial fibrillation with increased risk for thromboembolic events. Pre- and post-procedural imaging is essential for technical success, allowing practitioners to identify contraindications, select appropriate devices, and recognize procedural complications. Although transesophageal echocardiography has traditionally served as the preeminent imaging modality in LAAO, cardiac computed tomography imaging has emerged as a noninvasive surrogate given its excellent isotropic spatial resolution, multiplanar reconstruction capability, rapid temporal resolution, and large field of view.
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Affiliation(s)
- Pankaj Malhotra
- Department of Imaging, Mark Taper Imaging Center, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Taper M335, Los Angeles, CA 90048, USA; Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA.
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31
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Rana MA, Yoon S, Dallan LAP, Tashtish N, Attizzani GF, Rashid I, Rajagopalan S, Arruda M, Filby SJ. Midterm follow-up after computed tomography angiography planned left atrial appendage closure. Catheter Cardiovasc Interv 2024; 103:129-136. [PMID: 37786977 DOI: 10.1002/ccd.30843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/25/2023] [Accepted: 08/31/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND While studies have shown the advantages of computed tomography angiography (CTA) over transesophageal echocardiography (TEE) in left atrial appendage closure (LAAC) preprocedural planning for WATCHMAN™ legacy and FLX devices, there has been no reported long-term data for this approach. OBJECTIVES We sought to evaluate long-term outcomes using CTA-based preprocedural planning for LAAC using the WATCHMAN™ device. METHODS A prospective analysis of 231 consecutive patients who underwent LAAC in a single, large academic hospital in the United States was conducted over a 5-year period. CTA-guided preprocedural planning was performed in all. Procedural success, adverse events, length of procedure, number of devices used, and length of stay were evaluated. Rates of death, cerebral embolism, systemic embolism, and major and minor bleeding were recorded. Adjusted predicted stroke and major bleeding rates were derived from CHA2DS2-Vasc and HAS-BLED scores, respectively. RESULTS From January 26, 2017, to November 23, 2021, 231 patients underwent LAAC with CTA preprocedural planning by two operating physicians. The mean age of patients was 76.5 ± 8.4. 59.7% of patients were male. Mean CHA2DS2VASc and HAS-BLED scores were 4.5 ± 1.4 and 3.9 ± 0.9, respectively. All procedures were performed with intracardiac echo (100%). The procedural success rate was 99.1%. The CTA sizing strategy accurately predicted the implant size in 93.5% of patients. Mean number of devices used was 1.10 ± 0.3. Peri-procedural complication rate was 2.2%. 6 patients were lost to follow-up. Mean follow-up was 608.94 days with a total of 377.04 patient years. Median follow-up period of 368 days (interquartile range: 209-1067 days). There were 51 deaths from all causes (13.52 per 100 patient-years), 10 cases of cerebral embolism (2.65 per 100 patient-years), 2 cases of systemic embolism (0.53 per 100 patient-years), 17 cases of major bleeding (4.50 per 100 patient-years), and 31 cases of minor bleeding (8.2 per 100 patient-years). All-cause mortality at 1, 2, and 3 years was 12.7%, 20.9%, and 29.2%, respectively. CV event rates at 1, 2, and 3 years were 2.1%, 6.6%, and 10.5%, respectively. CONCLUSIONS CTA-based preprocedural planning is accurate in predicting device size for LAAC and associated with excellent clinical outcomes at 5 years.
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Affiliation(s)
- Mohammad Atif Rana
- Division of Cardiology, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sunghan Yoon
- Division of Cardiology, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Luis Augusto Palma Dallan
- Division of Cardiology, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Nour Tashtish
- Division of Cardiology, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Guilherme F Attizzani
- Division of Cardiology, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Imran Rashid
- Division of Cardiology, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sanjay Rajagopalan
- Division of Cardiology, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Mauricio Arruda
- Division of Cardiology, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Steven J Filby
- Division of Cardiology, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Balaji N, Adams A, Dixit P, Mahmood R, Weisman D. Successful occlusion of left atrial appendage after failed surgical ligation utilizing 4-dimensional intracardiac echocardiography. HeartRhythm Case Rep 2023; 9:919-921. [PMID: 38204825 PMCID: PMC10774586 DOI: 10.1016/j.hrcr.2023.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Affiliation(s)
- Nivedha Balaji
- Department of Graduate Medical Education, Internal Medicine, Northeast Georgia Medical Center, Gainesville, Georgia
| | - Alex Adams
- Department of Graduate Medical Education, Cardiovascular Disease, Northeast Georgia Medical Center, Gainesville, Georgia
| | - Priyadarshini Dixit
- Department of Graduate Medical Education, Cardiovascular Disease, Northeast Georgia Medical Center, Gainesville, Georgia
| | - Riaz Mahmood
- Department of Graduate Medical Education, Cardiovascular Disease, Northeast Georgia Medical Center, Gainesville, Georgia
| | - David Weisman
- Georgia Heart Institute, Northeast Georgia Health System, Gainesville, Georgia
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Ding X, Xiang K, Qian C, Hou X, Wu F. Intracardiac echocardiography is a promising strategy for guiding closure of the left atrial appendage. Health Sci Rep 2023; 6:e1762. [PMID: 38116174 PMCID: PMC10728371 DOI: 10.1002/hsr2.1762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/09/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
Background and Aims Percutaneous transcatheter left atrial appendage (LAA) closure (LAAC) is an effective approach for preventing ischemic stroke in nonvalvular atrial fibrillation patients. Intracardiac echocardiography (ICE), a new imaging modality, is a promising strategy for guiding LAAC. This review highlights the various strategies for ICE-guided-LAAC as an option for clinical policy. Methods A comprehensive literature search was conducted of PubMed, ScienceDirect, Ovid Web of Science, SpringerLink, and other notable databases to identify recent peer-reviewed clinical trials, reviews, and research articles related to ICE and its application in the guidance of LAAC. Results Various methods are used to evaluate the spatial structure and dimensions of the LAA. The main techniques for guiding LAAC are transesophageal echocardiography (TEE), cardiac computed tomography (CTA), and ICE. Among these techniques, the advantages of ICE typically include (1) multiangle and real-time assessment of intracardiac structure, (2) a reduction in procedural fluoroscopy, (3) reduced operation time and improved workflow in the catheterization laboratory, and (4) the avoidance of general anesthesia and the early detection of complications. Conclusion ICE is a promising strategy for the guidance of LAAC. Among the most advanced and recent technological innovations in cardiovascular imaging in general and volume imaging in particular, ICE offers greater efficacy and safety.
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Affiliation(s)
- Xueyan Ding
- Department of CardiologySir Run Run Shaw Hospital Zhejiang University School of MedicineHangzhouZhejiangP.R. China
| | - Kefa Xiang
- Department of Cardiology, The 72nd Group Army HospitalHuzhou UniversityHuzhouZhejiangP.R. China
| | - Congli Qian
- Department of Cardiology, The 72nd Group Army HospitalHuzhou UniversityHuzhouZhejiangP.R. China
| | - Xu Hou
- Bengbu Medical CollegeBengbuAnhuiP.R. China
| | - Feng Wu
- Department of Cardiology, The 72nd Group Army HospitalHuzhou UniversityHuzhouZhejiangP.R. China
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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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35
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Liu J, Yu T, Tan C, Li H, Zheng Y, Zheng S, Wen K, Wang J, Geng D, Zhou S. How the trabeculae protrude within the left atrial appendage is the key factor affecting thrombosis in patients with atrial fibrillation. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023; 39:2259-2267. [PMID: 37665485 DOI: 10.1007/s10554-023-02933-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 08/13/2023] [Indexed: 09/05/2023]
Abstract
The left atrial appendage (LAA) is a major site of thrombosis in patients with non-valvular atrial fibrillation. The myocardial trabeculae within the LAA have a peculiar tendency to protrude but its relationship to thrombosis remains unknown. This study aimed to investigate the relationship between the condition of trabeculae protrusion and LAA thrombosis. This retrospective study consecutively selected patients diagnosed with non-valvular atrial fibrillation and prepared for radiofrequency ablation from January 2011 to May 2020. Patients were divided into the thrombus group (n = 43), the sludge group (n = 35), and the normal group (n = 407) according to whether the thrombus or sludge was present. The trabeculae protruding angle (TPA), which was measured by the CT scans, was used to quantify the trabeculae protrusion condition. Patients' clinical data, TPA, LAA emptying velocity, and other factors were collected and compared among the three groups. A total of 485 patients were enrolled. The range of TPA was between 0 and 158 degrees, with an average of 89.3 ± 35.6 degrees. The TPA was significantly greater in the thrombus (109.3 ± 14.8 degrees) and sludge groups (110.8 ± 12.8 degrees) than in the normal group (85.3 ± 37.1). The incidence of LAA thrombus and sludge increased with increasing TPA. Multivariate regression analysis showed that the TPA was an independent risk factor for LAA thrombus (OR = 1.046, 95%CI: 1.020-1.073, p < 0.001) and sludge (OR = 1.035, 95%CI: 1.017-1.053, p < 0.001). Further analysis revealed that the TPA was negatively correlated with LAA emptying velocity but its effect on promoting thrombosis was not only mediated by slowing down the flow velocity. The TPA can well reflect the condition of trabeculae protrusion. This study revealed that the TPA was an independent risk factor for LAA thrombus or sludge, providing a potential indicator for future thrombosis risk assessment.
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Affiliation(s)
- Juanzhang Liu
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, People's Republic of China
| | - Taihui Yu
- Department of Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, People's Republic of China
| | - Chaodi Tan
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, People's Republic of China
| | - Hongwei Li
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, People's Republic of China
| | - Yuping Zheng
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, People's Republic of China
| | - Shaoxin Zheng
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, People's Republic of China
| | - Kexin Wen
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, People's Republic of China
| | - Jingfeng Wang
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, People's Republic of China.
| | - Dengfeng Geng
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, People's Republic of China.
| | - Shuxian Zhou
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, People's Republic of China.
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Cui J, Du X, He L, Xia SJ, Tang RB, Sang CH, Long DY, Dong JZ, Ma CS. Impact of pre-ablation left appendage flow velocities on long term recurrence of catheter ablation for paroxysmal atrial fibrillation. Pacing Clin Electrophysiol 2023; 46:1412-1418. [PMID: 37736872 DOI: 10.1111/pace.14828] [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: 04/04/2023] [Revised: 07/27/2023] [Accepted: 09/07/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Despite undergoing a single ablation, many patients with paroxysmal atrial fibrillation (PAF) experience a gradually increasing recurrence rate. This study aims to examine the relationship between left atrial appendage emptying velocity (LAAeV) and filling velocity (LAAfV) profiles and 3-year recurrence of AF after ablation. METHODS We conducted a prospective study of 658 consecutive PAF patients who underwent their first ablation between January 2018 and December 2019. We collected the clinical and echocardiographic characteristics of the patients. LAAeV and LAAfV were obtained from a transesophageal echocardiogram (TEE) before catheter ablation. Patients were followed at regular intervals to monitor for the primary outcome of AF recurrence. RESULTS After a median follow-up period of 35.3 months (range, 10.7-36.3), 288 patients (43.8%) experienced AF recurrence after catheter ablation. Patients who experienced AF recurrence had decreased LAAeV and LAAfV (LAAeV: 56.5 ± 21.2 vs. 59.6 ± 20.7 cm/s, p = .052; LAAfV: 47.5 ± 17.9 vs. 51.7 ± 18.2, p = .003). Kaplan-Meier analysis showed that patients in the low LAAeV (<55 cm/s) group had a poorer event-free survival rate than those in the high LAAeV (≥55 cm/s) group (log-rank p = .012). Patients with LAAfV <48 cm/s had a significantly higher risk of AF recurrence than those with LAAfV ≥48 cm/s (log-rank p = .003). In the multivariable model, low LAAfV pre-ablation in TEE-guided was significantly independently associated with 3-year recurrence after single radiofrequency ablation in patients with PAF, along with LA dimension and duration of AF. CONCLUSION This study found an independent association between low LAAfV pre-ablation in TEE-guided and 3-year recurrence after single radiofrequency ablation in patients with PAF.
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Affiliation(s)
- Jing Cui
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Xin Du
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Liu He
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Shi-Jun Xia
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Ri-Bo Tang
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Cai-Hua Sang
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - De-Yong Long
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Jian-Zeng Dong
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Chang-Sheng Ma
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing, China
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Li Y, Jiang L, Wang L, Yin X, Han Q, Feng Y. Left atrial appendage thrombus in an elderly patient with atrial fibrillation during non-cardiac surgery- a case report. BMC Anesthesiol 2023; 23:335. [PMID: 37803283 PMCID: PMC10557309 DOI: 10.1186/s12871-023-02286-8] [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: 04/21/2023] [Accepted: 09/16/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Perioperative newly developed left atrial appendage (LAA) thrombus is a rare but extremely challenging event for anesthesia management. It's important to identify and diagnose thrombosis in high-risk populations promptly. CASE PRESENTATION In the case of an elderly patient with atrial fibrillation undergoing non-cardiac surgery, we recorded the findings before and after thrombosis during the operation using transesophageal echocardiography (TEE). Through timely detection of the thrombus and proactive management, a satisfactory therapeutic effect was ultimately achieved. CONCLUSIONS Clinicians should be aware of the potential risk of LAA clot formation during surgery, even if it was not detected preoperatively. And TEE is valuable for monitoring newly developed perioperative thrombosis.
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Affiliation(s)
- Yaru Li
- Department of Anesthesiology, Peking University People's Hospital, 11 Xi Zhi Men South Street, Beijing, 100044, China
| | - Luyang Jiang
- Department of Anesthesiology, Peking University People's Hospital, 11 Xi Zhi Men South Street, Beijing, 100044, China.
| | - Lu Wang
- Department of Anesthesiology, Peking University People's Hospital, 11 Xi Zhi Men South Street, Beijing, 100044, China
| | - Xinrui Yin
- Department of Anesthesiology, Peking University People's Hospital, 11 Xi Zhi Men South Street, Beijing, 100044, China
| | - Qiaoyu Han
- Department of Anesthesiology, Peking University People's Hospital, 11 Xi Zhi Men South Street, Beijing, 100044, China
| | - Yi Feng
- Department of Anesthesiology, Peking University People's Hospital, 11 Xi Zhi Men South Street, Beijing, 100044, China
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38
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Li F, Li Y, Zhang X, Yang Y. Hairpin-curved shape of the left atrial appendage causing the misdiagnosis of coronary artery aneurysm. Asian J Surg 2023; 46:4614-4615. [PMID: 37302891 DOI: 10.1016/j.asjsur.2023.05.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 05/12/2023] [Indexed: 06/13/2023] Open
Affiliation(s)
- Fangya Li
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Yuman Li
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China
| | - Xiaowei Zhang
- Jingshan Union Hospital, Union Hospital, Huazhong University of Science and Technology, Jingshan, 431800, China.
| | - Yali Yang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, 430022, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, 430022, China.
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39
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Mantini C, Corradi F, Ricci F, Jensen B, Tana C, Di Mascio V, Mastrodicasa D, Bucciarelli B, Procaccini L, Saba L, Marco Tana, Cademartiri F, De Caterina R. A highly-detailed anatomical study of left atrial auricle as revealed by in-vivo computed tomography. Heliyon 2023; 9:e20575. [PMID: 37842578 PMCID: PMC10568352 DOI: 10.1016/j.heliyon.2023.e20575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 09/19/2023] [Accepted: 09/29/2023] [Indexed: 10/17/2023] Open
Abstract
The left atrial auricle (LAA) is the main source of intracardiac thrombi, which contribute significantly to the total number of stroke cases. It is also considered a major site of origin for atrial fibrillation in patients undergoing ablation procedures. The LAA is known to have a high degree of morphological variability, with shape and structure identified as important contributors to thrombus formation. A detailed understanding of LAA form, dimension, and function is crucial for radiologists, cardiologists, and cardiac surgeons. This review describes the normal anatomy of the LAA as visualized through multiple imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI), and echocardiography. Special emphasis is devoted to a discussion on how the morphological characteristics of the LAA are closely related to the likelihood of developing LAA thrombi, including insights into LAA embryology.
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Affiliation(s)
- Cesare Mantini
- Department of Neuroscience, Imaging and Clinical Sciences, “G. D'Annunzio” University, Chieti, Italy
| | | | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, “G. D'Annunzio” University, Chieti, Italy
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Bjarke Jensen
- Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Claudio Tana
- Geriatrics Clinic, SS. Annunziata Hospital of Chieti, 66100, Chieti, Italy
| | - Valeria Di Mascio
- Department of Neuroscience, Imaging and Clinical Sciences, “G. D'Annunzio” University, Chieti, Italy
| | | | - Benedetta Bucciarelli
- Department of Pediatrics, Politechnic University of Marche, G. Salesi Children's Hospital, Ancona, Italy
| | | | - Luca Saba
- Department of Radiology, University Hospital of Cagliari, Cagliari, Italy
| | - Marco Tana
- Internal Medicine Unit and Department of Vascular Medicine and Cardiovascular Ultrasound, SS. Annunziata Hospital of Chieti, Italy
| | | | - Raffaele De Caterina
- Cardiology, University of Pisa and University Cardiology Division, Pisa University Hospital, Pisa, Italy
- Fondazione Villa Serena per la Ricerca, Città Sant’Angelo-Pescara, Italy
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40
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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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Schilling J, Lin JP, Mankad SV, Krishnam MS, Ning M, Patel PM, Kim CK, Kapoor R, Di Tullio MR, Jung J, Kim JK, Fisher MJ. The 2022 FASEB Virtual Catalyst Conference on the Cardiac Interatrial Septum and Stroke Risk, December 7, 2022. FASEB J 2023; 37:e23122. [PMID: 37606555 DOI: 10.1096/fj.202300897] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 05/09/2023] [Accepted: 07/20/2023] [Indexed: 08/23/2023]
Abstract
There is emerging evidence that the cardiac interatrial septum has an important role as a thromboembolic source for ischemic strokes. There is little consensus on treatment of patients with different cardiac interatrial morphologies or pathologies who have had stroke. In this paper, we summarize the important background, diagnostic, and treatment considerations for this patient population as presented during the Federation of American Societies for Experimental Biology (FASEB) Virtual Catalytic Conference on the Cardiac Interatrial Septum and Stroke Risk, held on December 7, 2022. During this conference, many aspects of the cardiac interatrial septum were discussed. Among these were the embryogenesis of the interatrial septum and development of anatomic variants such as patent foramen ovale and left atrial septal pouch. Also addressed were various mechanisms of injury such as shunting physiologies and the consequences that can result from anatomic variants, as well as imaging considerations in echocardiography, computed tomography, and magnetic resonance imaging. Treatment options including anticoagulation and closure were addressed, as well as an in-depth discussion on whether the left atrial septal pouch is a stroke risk factor. These issues were discussed and debated by multiple experts from neurology, cardiology, and radiology.
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Affiliation(s)
- Jonathan Schilling
- Department of Medicine, University of California, Irvine, California, USA
| | - Jeannette P Lin
- Department of Cardiology, University of California, Los Angeles, California, USA
| | - Sunil V Mankad
- Department of Cardiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mayil S Krishnam
- Department of Radiology, Stanford University, Stanford, California, USA
| | - MingMing Ning
- Cardio-Neurology Clinic, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pranav M Patel
- Division of Cardiology, Department of Medicine, University of California, Irvine, California, USA
| | - Chi Kyung Kim
- Department of Neurology, Korea University College of Medicine, Seoul, South Korea
| | - Ruchi Kapoor
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Marco R Di Tullio
- Division of Cardiology, Department of Medicine, Columbia University, New York, New York, USA
| | - Jinman Jung
- Department of Neurology, Korea University Ansan Hospital, Ansan, South Korea
| | - Jin Kyung Kim
- Division of Cardiology, Department of Medicine, University of California, Irvine, California, USA
| | - Mark J Fisher
- Departments of Neurology, Anatomy & Neurobiology, and Pathology & Laboratory Medicine, University of California, Irvine, California, USA
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42
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Bäck S, Skoda I, Lantz J, Henriksson L, Karlsson LO, Persson A, Carlhäll CJ, Ebbers T. Elevated atrial blood stasis in paroxysmal atrial fibrillation during sinus rhythm: a patient-specific computational fluid dynamics study. Front Cardiovasc Med 2023; 10:1219021. [PMID: 37649669 PMCID: PMC10463733 DOI: 10.3389/fcvm.2023.1219021] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/31/2023] [Indexed: 09/01/2023] Open
Abstract
Introduction Atrial fibrillation (AF) is associated with an increased risk of stroke, often caused by thrombi that form in the left atrium (LA), and especially in the left atrial appendage (LAA). The underlying mechanism is not fully understood but is thought to be related to stagnant blood flow, which might be present despite sinus rhythm. However, measuring blood flow and stasis in the LAA is challenging due to its small size and low velocities. We aimed to compare the blood flow and stasis in the left atrium of paroxysmal AF patients with controls using computational fluid dynamics (CFD) simulations. Methods The CFD simulations were based on time-resolved computed tomography including the patient-specific cardiac motion. The pipeline allowed for analysis of 21 patients with paroxysmal AF and 8 controls. Stasis was estimated by computing the blood residence time. Results and Discussion Residence time was elevated in the AF group (p < 0.001). Linear regression analysis revealed that stasis was strongest associated with LA ejection ratio (p < 0.001, R2 = 0.68) and the ratio of LA volume and left ventricular stroke volume (p < 0.001, R2 = 0.81). Stroke risk due to LA thrombi could already be elevated in AF patients during sinus rhythm. In the future, patient specific CFD simulations may add to the assessment of this risk and support diagnosis and treatment.
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Affiliation(s)
- Sophia Bäck
- Unit of Cardiovascular Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | - Iulia Skoda
- Department of Cardiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Jonas Lantz
- Unit of Cardiovascular Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
| | - Lilian Henriksson
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
- Department of Radiology, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Lars O. Karlsson
- Department of Cardiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Anders Persson
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
- Department of Radiology, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Carl-Johan Carlhäll
- Unit of Cardiovascular Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
- Department of Clinical Physiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Tino Ebbers
- Unit of Cardiovascular Sciences, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Center for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
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Norozi K, Subasri M, Diaz LA, Honjo O. Left atrial appendage aneurysm in pediatrics: Case study and literature review. Front Cardiovasc Med 2023; 10:1211619. [PMID: 37636313 PMCID: PMC10449248 DOI: 10.3389/fcvm.2023.1211619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/28/2023] [Indexed: 08/29/2023] Open
Abstract
Left atrial appendage aneurysm (LAAA) is a rare cardiac pathology that is often identified in adulthood. There are a myriad of presentations related to atrial appendage enlargement, but most are asymptomatic. Pediatric cases of LAAA are extremely rare. We report a case of an incidental giant LAAA found in a healthy 6-year-old boy. He was successfully treated with surgical resection. A review of the literature shows that the presentation of LAAA in pediatrics likely involves cardiac or respiratory symptoms but can also be incidental findings. Similar to adults, diagnosis requires cardiac imaging, with echocardiography being the mainstay. Surgical intervention is indicated in symptomatic and most asymptomatic patients to prevent complications. More research is warranted into the optimal timing of surgery and alternative surgical approaches for complex cases.
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Affiliation(s)
- Kambiz Norozi
- Department of Paediatrics, University of Western Ontario, London, ON, Canada
- Division of Pediatric Cardiology, Department of Paediatrics, London Health Sciences Centre, London, ON, Canada
- Pediatric Cardiopulmonary Research Laboratory, London Health Sciences Centre, London, ON, Canada
- Children Health Research Institute, London, ON, Canada
- Department of Paediatric Cardiology, Medical School Hannover, Hannover, Germany
| | - Mathushan Subasri
- Division of Pediatric Cardiology, Department of Paediatrics, London Health Sciences Centre, London, ON, Canada
- Pediatric Cardiopulmonary Research Laboratory, London Health Sciences Centre, London, ON, Canada
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Luis Altamirano Diaz
- Department of Paediatrics, University of Western Ontario, London, ON, Canada
- Division of Pediatric Cardiology, Department of Paediatrics, London Health Sciences Centre, London, ON, Canada
- Pediatric Cardiopulmonary Research Laboratory, London Health Sciences Centre, London, ON, Canada
- Children Health Research Institute, London, ON, Canada
| | - Osami Honjo
- Department of Surgery, The Hospital for Sick Children, Toronto, ON, Canada
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44
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Zhang Z, Zhu J, Wu M, Neidlin M, Wu WT, Wu P. Computational modeling of hemodynamics and risk of thrombosis in the left atrial appendage using patient-specific blood viscosity and boundary conditions at the mitral valve. Biomech Model Mechanobiol 2023; 22:1447-1457. [PMID: 37389735 DOI: 10.1007/s10237-023-01731-4] [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: 12/06/2022] [Accepted: 05/23/2023] [Indexed: 07/01/2023]
Abstract
Hemodynamics play a vital role for the risk of thrombosis in the left atrial appendage (LAA) and left atrium (LA) for patients with atrial fibrillation. Accurate prediction of hemodynamics in the LA can provide important guidance for assessing the risk of thrombosis in the LAA. Patient specificity is a crucial factor in representing the true hemodynamic fields. In this study, we investigated the effects of blood rheology (as a function of hematocrit and shear rate), as well as patient-specific mitral valve (MV) boundary conditions (MV area and velocity profiles measured by ultrasound) on the hemodynamics and thrombosis potential of the LAA. Four scenarios were setup with different degrees of patient specificity. Though using a constant blood viscosity can classify the thrombus and non-thrombus patients for all the hemodynamic indicators, the risk of thrombosis was underestimated for all patients compared with patient-specific viscosities. The results with least patient specificities showed that patients prone to thrombosis predicted by three hemodynamic indicators were inconsistent with clinical observations. Moreover, though patients had the same MV inlet flow rate, different MV models lead to different trends in the risk of thrombosis in different patients. We also found that endothelial cell activation potential and relative residence time can effectively distinguish thrombus and non-thrombus patients for all the scenarios, relatively insensitive to patient specificities. Overall, the findings of this study provide useful insights on patients-specific hemodynamic simulations of the LA.
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Affiliation(s)
- Zijian Zhang
- Artificial Organ Technology Laboratory, School of Mechanical and Electrical Engineering, Soochow University, Suzhou, China
| | - Jiade Zhu
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Min Wu
- Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China.
| | - Michael Neidlin
- Department of Cardiovascular Engineering, Medical Faculty, Institute of Applied Medical Engineering, RWTH Aachen University, Aachen, Germany
| | - Wei-Tao Wu
- School of Mechanical Engineering, Nanjing University of Science and Technology, Nanjing, China
| | - Peng Wu
- Artificial Organ Technology Laboratory, School of Mechanical and Electrical Engineering, Soochow University, Suzhou, China.
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Honnekeri B, Fava AM, Reyaldeen R, Kanj M, Alvarez P, Xu B. Prominent para-cardiac fat mimicking left atrial appendage thrombus on echocardiography: Utility of cardiac computed tomography. Echocardiography 2023; 40:875-878. [PMID: 37199004 DOI: 10.1111/echo.15595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 05/03/2023] [Indexed: 05/19/2023] Open
Abstract
Transesophageal echocardiography is the most frequently used imaging modality for exclusion of left atrial appendage thrombus prior to cardioversion. Echocardiographers should be aware of rare conditions that may mimic left atrial appendage thrombus. Here, we describe a rare case of prominent para-cardiac fat mimicking left atrial appendage thrombus on transesophageal echocardiographic imaging. Multimodality imaging with cardiac computed tomography was instrumental in providing further anatomical delineation and characterization of the echodensity as prominent para-cardiac fat in this case.
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Affiliation(s)
- Bianca Honnekeri
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Agostina M Fava
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Reza Reyaldeen
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mohamed Kanj
- Section of Electrophysiology, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Paulino Alvarez
- Section of Heart Failure and Cardiac Transplantation, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bo Xu
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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46
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Castellani C, Gao Y, Kim H, Thompson C, Ning J, Lohr N, Welsh A, Berger M. Left atrial appendage structural characteristics predict thrombus formation. J Cardiovasc Electrophysiol 2023; 34:1683-1689. [PMID: 37403777 DOI: 10.1111/jce.15994] [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: 03/06/2023] [Revised: 06/12/2023] [Accepted: 06/21/2023] [Indexed: 07/06/2023]
Abstract
INTRODUCTION Nonvalvular atrial fibrillation (NVAF) is a highly prevalent arrhythmia where loss of synchronized atrial contraction increases the risk of intracardiac thrombus particularly within the left atrial appendage (LAA). Anticoagulation is the mainstay of stroke prevention based on the CHA2 DS2 -VASc score; however, it does not account for LAA structural characteristics. METHODS The research comprises a retrospective matched case-control study of 196 subjects with NVAF who underwent transesophageal echo (TEE). The control group, without thrombus (n = 117), was selected from two different groups, both pools had: NVAF and CHA2 DS2 -VASc score ≥ 3. One group underwent screening TEE before Watchman closure device placement from January 2015 to December 2019 (n = 74) the second underwent TEE before cardioversion from February to October 2014 (n = 43). The study group, with thrombus (n = 79), included patients with NVAF, TEE study performed between February 2014 and December 2020, and LAA thrombus. The propensity score method was utilized to determine the matched controls while accounting for confounding from prognostic variables resulting in 61 matched pairs included in the analysis data set. LAA ostial area (OA) (calculated from orthogonal measurements 0°, 90° or 45°, 135°), LAA maximal depth, and peak LAA outflow velocity were measured. RESULTS Patient characteristics and TEE data were collected and compared using the t test or χ2 analysis. We observed a lower LAA peak exit velocity in the thrombus group as compared to the control group. Additionally, we found that patients in the thrombus group had smaller LAA OA at 0° and 90°, at 45° and 135°, using largest diameter, as well as using aggregate OA, and smaller maximum LAA depth compared to patients in the control group. Candidate conditional logistic regression models for the outcome of the presence of thrombus were evaluated. Statistical results from the best-fitting conditional regression model were calculated showing a significant association between aggregate OA and LAA exit velocity with presence of thrombus. CONCLUSION Utilizing LAA structural characteristics to predict thrombus formation may help refine current cardioembolic stroke (CES) risk estimation.
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Affiliation(s)
- Carson Castellani
- Department of Medicine, Medical College of Wisconsin Affiliated Hospitals, Milwaukee, Wisconsin, USA
| | - Yan Gao
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Colton Thompson
- Department of Medicine, University of Wisconsin Hospital, Madison, Wisconsin, USA
| | - John Ning
- Department of Medicine, Medical College of Wisconsin Affiliated Hospitals, Milwaukee, Wisconsin, USA
| | - Nicole Lohr
- Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Aimee Welsh
- Department of Medicine, Medical College of Wisconsin Affiliated Hospitals, Milwaukee, Wisconsin, USA
| | - Marcie Berger
- Department of Medicine, Medical College of Wisconsin Affiliated Hospitals, Milwaukee, Wisconsin, USA
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Li X, Cai Y, Chen X, Ming Y, He W, Liu J, Pu H, Chen X, Peng L. Radiomics Based on Single-Phase CTA for Distinguishing Left Atrial Appendage Thrombus from Circulatory Stasis in Patients with Atrial Fibrillation before Ablation. Diagnostics (Basel) 2023; 13:2474. [PMID: 37568837 PMCID: PMC10417448 DOI: 10.3390/diagnostics13152474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/14/2023] [Accepted: 07/20/2023] [Indexed: 08/13/2023] Open
Abstract
Differentiation of left atrial appendage thrombus (LAAT) and left atrial appendage (LAA) circulatory stasis is difficult when based only on single-phase computed tomography angiography (CTA) in routine clinical practice. Radiomics provides a promising tool for their identification. We retrospectively enrolled 204 (training set: 144; test set: 60) atrial fibrillation patients before ablation, including 102 LAAT and 102 circulatory stasis patients. Radiomics software was used to segment whole LAA on single-phase CTA images and extract features. Models were built and compared via a multivariable logistic regression algorithm and area under of the receiver operating characteristic curves (AUCs), respectively. For the radiomics model, radiomics clinical model, radiomics radiological model, and combined model, the AUCs were 0.82, 0.86, 0.90, 0.93 and 0.82, 0.82, 0.84, 0.85 in the training set and the test set, respectively (p < 0.05). One clinical feature (rheumatic heart disease) and four radiological features (transverse diameter of left atrium, volume of left atrium, location of LAA, shape of LAA) were added to the combined model. The combined model exhibited excellent differential diagnostic performances between LAAT and circulatory stasis without increasing extra radiation exposure. The single-phase, CTA-based radiomics analysis shows potential as an effective tool for accurately detecting LAAT in patients with atrial fibrillation before ablation.
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Affiliation(s)
- Xue Li
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, China; (X.L.); (X.C.); (W.H.); (J.L.); (H.P.)
| | - Yuyan Cai
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China;
| | - Xiaoyi Chen
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, China; (X.L.); (X.C.); (W.H.); (J.L.); (H.P.)
| | - Yue Ming
- West China School of Medicine, Sichuan University, Chengdu 610041, China;
| | - Wenzhang He
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, China; (X.L.); (X.C.); (W.H.); (J.L.); (H.P.)
| | - Jing Liu
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, China; (X.L.); (X.C.); (W.H.); (J.L.); (H.P.)
| | - Huaxia Pu
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, China; (X.L.); (X.C.); (W.H.); (J.L.); (H.P.)
| | - Xinyue Chen
- CT Collaboration, Siemens Healthineers, Chengdu 610041, China;
| | - Liqing Peng
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, China; (X.L.); (X.C.); (W.H.); (J.L.); (H.P.)
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Miyauchi S, Tokuyama T, Takahashi S, Hiyama T, Okubo Y, Okamura S, Miyamoto S, Oguri N, Takasaki T, Katayama K, Miyauchi M, Nakano Y. Relationship Between Fibrosis, Endocardial Endothelial Damage, and Thrombosis of Left Atrial Appendage in Atrial Fibrillation. JACC Clin Electrophysiol 2023; 9:1158-1168. [PMID: 37495324 DOI: 10.1016/j.jacep.2023.01.029] [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: 10/25/2022] [Revised: 01/23/2023] [Accepted: 01/26/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Left atrial appendage (LAA) thrombus (LAAT) and ischemic stroke are considered important in atrial cardiomyopathy with progressive atrial fibrosis and endocardial endothelial damage. OBJECTIVES This study aimed to obtain histological evidence to clarify the association between LAA fibrosis and endocardial endothelial damage with LAAT, ischemic stroke, and clinical risk factors. METHODS Ninety-six patients with atrial fibrillation (AF) scheduled to undergo LAA excision during surgery were enrolled. They underwent transesophageal echocardiography before the surgery to validate the LAA function/morphology and LAAT presence or absence. The resected LAAs were subjected to Azan-Mallory staining and CD31 immunohistochemistry to quantify the degree of fibrosis and endocardial endothelial damage staged as F1-F4 and E1-E4 per the quantiles. RESULTS Patients with an LAAT and/or ischemic stroke history had higher fibrosis degrees (18.4% ± 9.9% vs 10.4% ± 7.0%, P < 0.0001) and lower CD31 expressions (0.27 [IQR: 0.05-0.57] vs 1.02 [IQR: 0.49-1.65]; P < 0.0001). Also, higher CHADS2 was associated with a higher degree of fibrosis and lower CD31 expression. Multivariate logistic regression analysis revealed that endothelial damage (E4) was associated with an LAAT and/or ischemic stroke history independent of AF type (paroxysmal or nonparoxysmal) with an OR of 3.47. Among patients with nonparoxysmal AF, fibrosis (F4, OR: 3.66), endothelial damage (E4, OR: 4.62), and LAA morphology (non-chicken-wing, OR: 3.79) were independently associated with LAAT and/or stroke. The degree of fibrosis correlated significantly with endothelial damage (R = -0.38, P = 0.0001). CONCLUSIONS These histological findings may be essential in considering the pathophysiology of LAAT and stroke within the atrial cardiomyopathy context.
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Affiliation(s)
- Shunsuke Miyauchi
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan; Division of Medicine, Health Service Center, Hiroshima University, Higashihiroshima, Japan
| | - Takehito Tokuyama
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toru Hiyama
- Division of Medicine, Health Service Center, Hiroshima University, Higashihiroshima, Japan
| | - Yousaku Okubo
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Sho Okamura
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shogo Miyamoto
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Naoto Oguri
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Taiichi Takasaki
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Keijiro Katayama
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Mutsumi Miyauchi
- Department of Oral and Maxillofacial Pathobiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yukiko Nakano
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
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Penfold MP, Haq IU, Connolly HM, Dearani JA, Schaff HV, Miranda WR, Asirvatham SJ, Killu AM, Arghami A, Stephens EH. Atrial Appendage Aneurysms: Natural History and Outcomes. World J Pediatr Congenit Heart Surg 2023; 14:474-480. [PMID: 36972504 DOI: 10.1177/21501351231162909] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
BACKGROUND Left (LAAA) and right atrial appendage aneurysms (RAAA) are rare entities, and their natural history, management, and long-term outcomes are not well studied. METHODS This retrospective review includes all patients from 2000 to 2021 with atrial appendage aneurysms at our institution identified using an electronic search tool. LAAA and RAAA were confirmed using multimodality imaging and intraoperative findings. RESULTS We identified 13 (87%) patients with LAAA and 2 (13%) with RAAA. At diagnosis, 11 (73%) were female, mean age was 51.4 ± 18.8 years, and ejection fraction 56.5 ± 13.1%. Three (20%) patients had congenital heart disease including 2 (13%) with atrioventricular septal defects and 1 (7%) with congenitally corrected transposition. LAAA/RAAA was diagnosed due to new-onset atrial fibrillation (AF) in 6 (40%) patients and embolic stroke in 2 (13%). Ten patients had preexisting AF diagnosed 2.9 ± 1.4 years earlier at a mean age of 50.2 ± 15.5 years. Thrombus within the aneurysm was identified in 2 (15%) LAAA patients. All patients were on anticoagulation and follow-up of the cohort from diagnosis was 7.1 ± 6.2 years. Eleven (73%) patients were surgically managed with 7 (64%) lesions excised, 1 (9%) stapled, and 3 (27%) ligated. Postoperative complications occurred in 2 (18%) patients with 1 (7%) developing tricuspid regurgitation and another with pericardial effusion and tamponade. CONCLUSIONS Atrial appendage aneurysm is a rare disease and nearly half of patients present with AF. Surgical treatment with concomitant AF ablation is a reasonable and safe management option.
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Affiliation(s)
| | - Ikram-Ul Haq
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Samuel J Asirvatham
- Department of Pediatrics, Mayo Clinic, Rochester, MN, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ammar M Killu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
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Fernandes R, Torres HR, Oliveira B, Azevedo J, Fan K, Lee AP, Vilaca JL, Morais P. Deep learning networks in the segmentation of the left atrial appendage in 2D ultrasound: A comparative analysis. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023; 2023:1-4. [PMID: 38083227 DOI: 10.1109/embc40787.2023.10340937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Left atrial appendage (LAA) is the major source of thromboembolism in patients with non-valvular atrial fibrillation. Currently, LAA occlusion can be offered as a treatment for these patients, obstructing the LAA through a percutaneously delivered device. Nevertheless, correct device sizing is a complex task, requiring manual analysis of medical images. This approach is sub-optimal, time-demanding, and highly variable between experts. Different solutions were proposed to improve intervention planning, but, no efficient solution is available to 2D ultrasound, which is the most used imaging modality for intervention planning and guidance. In this work, we studied the performance of recently proposed deep learning methods when applied for the LAA segmentation in 2D ultrasound. For that, it was created a 2D ultrasound database. Then, the performance of different deep learning methods, namely Unet, UnetR, AttUnet, TransAttUnet was assessed. All networks were compared using seven metrics: i) Dice coefficient; ii) Accuracy iii) Recall; iv) Specificity; v) Precision; vi) Hausdorff distance and vii) Average distance error. Overall, the results demonstrate the efficiency of AttUnet and TransAttUnet with dice scores of 88.62% and 89.28%, and accuracy of 88.25% and 86.30%, respectively. The current results demonstrate the feasibility of deep learning methods for LAA segmentation in 2D ultrasound.Clinical relevance- Our results proved the clinical potential of deep neural networks for the LAA anatomical analysis.
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