Left atrial appendage morphology assessment for risk stratification of embolic stroke in patients with atrial fibrillation: A meta-analysis

Lupercio, Florentino; Ruiz, Juan Carlos; Briceño, David; Romero, Jorge; Villablanca, Pedro A.; Berardi, Cecilia; Faillace, Robert T.; Krumerman, Andrew; Fisher, John D.; Ferrick, Kevin J.; García, Mario J.; Natale, Andrea; Biase, Luigi Di

doi:10.1016/j.hrthm.2016.03.042

Cited by 117 publications

(57 citation statements)

References 31 publications

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“…Some of them had tried different types of anticoagulants. The morphologic characteristics of LA and LAA of these patients had many of the features previously described in ‘malignant LAA’ except for the ‘non‐chicken‐wing’ morphology . Interestingly, in our study 90% of patients had ‘chicken‐wing’ LAA.…”

Section: Discussionsupporting

confidence: 71%

Oral anticoagulation and left atrial appendage closure: a new strategy for recurrent cardioembolic stroke

Masjuán

Salido

DeFelipe

et al. 2019

Euro J of Neurology

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Background and purpose There are no recommendations regarding how to treat cardioembolic recurrent strokes when patients are well anticoagulated. We evaluated the safety and efficacy of combining oral anticoagulation (OAC) with percutaneous left atrial appendage closure (LAAC) in patients with well‐anticoagulated atrial fibrillation (AF) with recurrent strokes. Methods In an explorative, prospective, observational study, LAAC was performed in patients with AF with at least two ischaemic strokes in the previous year, despite good anticoagulation using the Amplatzer Cardiac Plug (St Jude Medical, St Paul, MN, USA) or Amulet Abbot device (Abbot Vascular, Santa Clara, CA, USA). We recorded age, type of AF, CHA2DS2‐VASC and HAS‐BLED scores, types of OAC and risk factors. After closure, treatment with aspirin (100 mg/day) was continued for 3 months in combination with indefinite OAC. Clinical status, recurrent embolisms and bleeding complications were recorded during follow‐up. Results A total of 19 patients were included (mean age, 72.1 ± 9.6 years; mean CHA2DS2‐VASC score, 5.3 ± 1.48; mean number of previous strokes, 2.78 ± 1.15). Thirteen had spontaneous echocardiographic contrast and all had dilatation of the left atrium. Eighteen patients had a multilobulated left atrial appendage, 17 with ‘chicken‐wing’ morphology and one patient had a left atrial appendage thrombus. There were no complications during the procedure. Only one patient had a transient ischaemic attack and no major bleeding occurred during a mean follow‐up of 17.4 ± 11.5 months. Conclusion Combination therapy with indefinite OAC plus LAAC in patients with AF with recurrent strokes despite good anticoagulation should be considered in order to prevent a new stroke.

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Section: Discussionsupporting

confidence: 71%

Oral anticoagulation and left atrial appendage closure: a new strategy for recurrent cardioembolic stroke

Masjuán

Salido

DeFelipe

et al. 2019

Euro J of Neurology

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“…Recent reports have suggested an association of the LAA morphology with the risk of clot formation, indicating the Chicken wing morphology as the least critical when compared to the non-Chicken wing shapes, although quantification of the risks are different in the literature, depending on the population examined (16). In particular, the Cauliflower shape appears to be associated with higher risk of thrombus development (17).…”

Section: Introductionmentioning

confidence: 99%

Computational Fluid Dynamic Analysis of the Left Atrial Appendage to Predict Thrombosis Risk

Bosi

Cook

Rai

et al. 2018

Front. Cardiovasc. Med.

115

114

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During Atrial Fibrillation (AF) more than 90% of the left atrial thrombi responsible for thromboembolic events originate in the left atrial appendage (LAA), a complex small sac protruding from the left atrium (LA). Current available treatments to prevent thromboembolic events are oral anticoagulation, surgical LAA exclusion, or percutaneous LAA occlusion. However, the mechanism behind thrombus formation in the LAA is poorly understood. The aim of this work is to analyse the hemodynamic behaviour in four typical LAA morphologies - “Chicken wing”, “Cactus”, “Windsock” and “Cauliflower” - to identify potential relationships between the different shapes and the risk of thrombotic events. Computerised tomography (CT) images from four patients with no LA pathology were segmented to derive the 3D anatomical shape of LAA and LA. Computational Fluid Dynamic (CFD) analyses based on the patient-specific anatomies were carried out imposing both healthy and AF flow conditions. Velocity and shear strain rate (SSR) were analysed for all cases. Residence time in the different LAA regions was estimated with a virtual contrast agent washing out. CFD results indicate that both velocity and SSR decrease along the LAA, from the ostium to the tip, at each instant in the cardiac cycle, thus making the LAA tip more prone to fluid stagnation, and therefore to thrombus formation. Velocity and SSR also decrease from normal to AF conditions. After four cardiac cycles, the lowest washout of contrast agent was observed for the Cauliflower morphology (3.27% of residual contrast in AF), and the highest for the Windsock (0.56% of residual contrast in AF). This suggests that the former is expected to be associated with a higher risk of thrombosis, in agreement with clinical reports in the literature. The presented computational models highlight the major role played by the LAA morphology on the hemodynamics, both in normal and AF conditions, revealing the potential support that numerical analyses can provide in the stratification of patients under risk of thrombus formation, towards personalised patient care.

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“…Patients with chicken wing LAA morphology were shown to less likely develop an embolic event even after controlling for comorbidities and CHADS 2 score [27]. This was confirmed in a recent meta-analysis [28]. Large LAA neck diameter and LAA depth as well as extensive LAA trabeculations may also be predictors of thromboembolic events [29].…”

Section: International Journal Of Cardiovascular Practicementioning

confidence: 78%

Role of Imaging in Left Atrial Appendage Occlusion

Lempereur

Aminian

Potter

et al. 2017

ijcp

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Percutaneous left atrial appendage (LAA) occlusion is now a valid alternative to longterm oral anticoagulation in patients with non-valvular atrial fibrillation at high thromboembolism risk, especially for patients who are considered ineligible for anticoagulation. The most frequently used occluders worldwide include the WATCHAMN (Boston Scientific, Natick, MA, USA) and the Amplatzer Cardiac Plug or Amulet (St. Jude Medical/Abbott, St Paul, MN, USA) devices. Multimodality imaging is key in the understanding of 3D aspects of the LAA and surrounding structures anatomy. Imaging is essential for procedural planning, during each step of the procedure and for device surveillance after implantation. Multimodality imaging, including 2D/3D echocardiography, fluoroscopy, and cardiac computed tomography can increase the safety and efficacy of the procedure.

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Left atrial appendage morphology assessment for risk stratification of embolic stroke in patients with atrial fibrillation: A meta-analysis

Cited by 117 publications

References 31 publications

Oral anticoagulation and left atrial appendage closure: a new strategy for recurrent cardioembolic stroke

Oral anticoagulation and left atrial appendage closure: a new strategy for recurrent cardioembolic stroke

Computational Fluid Dynamic Analysis of the Left Atrial Appendage to Predict Thrombosis Risk

Role of Imaging in Left Atrial Appendage Occlusion

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