Atrium Appendage Research Articles

Impact of left atrial appendage closure on left atrial function: insights from the OCEAN-LAAC registry

Abstract Background Percutaneous left atrium appendage closure (LAAC) is an effective therapy to prevent thromboembolic events among patients with atrial fibrillation (AF) (Ref 1). However, since the left atrium appendage (LAA) potentially serves as a part of the left atrium (LA) volume and a buffer for increasing LA pressure, this procedure may impair LA compliance (Ref 2). Purpose In this study, we sought to investigate the effect of LAAC on LA function. Methods/Results The OCEAN-LAAC registry is an ongoing, multicentre Japanese registry including patients who underwent LAAC in Japan (Ref 3). Among 225 patients from the registry, LA volume index (LAVI) and tricuspid regurgitation pressure gradient (TRPG) at baseline and 6 months after the procedure were analysed. In the overall population, no significant increase in LAVI (Abstract Picture 1A) and TRPG (Abstract Picture 1B) was observed (LAVI baseline vs 6 months, 55.0 [44.0, 70.0] ml/m2 vs 55.0 [42.0, 75.6] ml/m2; P = 0.31; TRPG, 25.0 [20.3, 32.0] mmHg vs 25.0 [20.0, 32.0] mmHg; P = 0.85). However, particular patients underwent an increase in LAVI (Abstract Picture 1C), and multivariable analysis showed smaller LAVI and elevated TRPG at baseline, rather than any procedural factors, were significantly associated with an increase in LAVI (Odds ratio (OR) for baseline LAVI: 0.98 [95% confidential interval (CI): 0.97 - 0.996]; OR for baseline TRPG: 1.04 [95% CI: 1.00 - 1.08]). A 5 ml/m2 increase in LAVI at a 6-month follow-up was significantly associated with subsequent heart failure hospitalization (HFH) (Hazard ratio: 3.37 [95% CI: 1.18 - 9.65]) (Abstract Picture 2A). However, this predictive value was not observed in patients with lower LAVI (≤ 55 ml/m2) at baseline; instead, it was observed in those with a baseline LAVI over 55 ml/m² (Abstract Picture 2B). Conclusions In summary, our study did not elucidate the negative impact of LAAC on LA function, yet demonstrated an increase in LAVI at 6 month follow-up was frequently observed in patients with lower LAVI and higher TRPG at baseline. Additionally, increase in LAVI was significantly associated with subsequent HFH, which was more evident in patients with higher LAVI at baseline.

Distinctive Deposition Patterns of Sporadic Transthyretin-Derived Amyloidosis in the Atria: A Forensic Autopsy-Based Study.

Left-to-right differences in the histopathologic patterns of transthyretin-derived amyloid (ATTR) deposition in the atria of older adults have not yet been investigated. Hence, this study evaluated heart specimens from 325 serial autopsy subjects. The amount of ATTR deposits in the seven cardiac regions, including both sides of atria and atrial appendages, was evaluated semiquantitatively. Using digital pathology, we quantitatively evaluated the immunohistochemical deposition burden of ATTR in the myocardium. We identified 20 sporadic ATTR cardiac amyloidosis cases (nine males). All patients had ATTR deposition in the left atrial regions of the myocardium. In the semiquantitative analysis, 14 of the 20 cases showed more severe ATTR deposition on the left atrial regions than on the right side, with statistically significant differences in the pathology grading (p < 0.01 for both the atrium and atrial appendage). Quantitative analysis further supported the difference. Moreover, six had ATTR deposition in the epineurium and/or neural fibers of the atria. Cluster analysis revealed that ATTR deposition in the myocardium was significantly more severe in males than in females. The heterogeneous distribution of amyloid deposits between atria revealed in this study may impair the orderly transmission of the cardiac conduction system and induce arrhythmias, which may be further aggravated by additional neuropathy in the advanced phase. This impairment could be more severe among males. These findings emphasize that atrial evaluation is important for individuals with sporadic ATTR cardiac amyloidosis, particularly for early detection.

A novel score to predict left atrial appendage thrombus and sludge in patients with persistent atrial fibrillation on chronic anticoagulants

Abstract Introduction Left atrium (LA) and left atrial appendage (LAA) thrombus may occur during atrial fibrillation (AF) and atrial flutter (AFl), and potentially cause main embolic events. Sludge is a pre-thrombotic condition, associated with long term adverse outcomes. Current guidelines do not recommend to perform transesophageal echocardiography (TEE) before cardioversion (CV) of patients with persistent AF/AFl when at least 3 weeks of anticoagulation are administered with appropriate compliance. Instead, they suggest TEE before atrial ablations (Abl), even in anticoagulated patients. Evidence to support these approaches are weak and conflicting, due to not infrequent occurrence of peri-procedural stroke and several reports of not negligible prevalence of LAA thrombus finding. Purpose Aim of the study was to evaluate the real prevalence of LAA thrombus and sludge in a retrospective cohort of consecutive anticoagulated patients with persistent AF and AFl, who underwent TEE before a scheduled cardioversion or catheter ablation. Moreover, clinical and echocardiographic characteristics were analyzed to develop a score that could predict the individual risk of combined thrombus/sludge. Methods We conducted a retrospective, monocentric, observational study, recruiting 1037 consecutive patients with persistent AF/AFl referred to our center for CV or Abl. TEE had been always performed to rule out thrombus and sludge before procedures. We collected data about patients characteristics, medication and compliance, electrographic and echocardiographic findings and type of scheduled procedure. Data was compared in univariate and multivariate analysis to identify possible predictors of LAA thrombus and sludge, and we used the last significant results to create a predictive score with logistic regression analysis. We identified best cutoff value with ROC curve. Results 767 patients were included in final dataset. Mean CHA2DS2-VASc was 3.2. LA/LAA thrombus and sludge were identified in 63 subjects (8.21%), 17 thrombi (2.21%) and 45 sludge (5.86%). Presence of valvular AF (+1), previous stroke or TIA (+1.5), heart failure history (+1), ventricular systolic (LVEF &amp;lt; 45%)(+0.5) and diastolic (Lateral E/e’ &amp;gt; 9) dysfunctions (+1) were significantly associated to higher risk of thrombus/sludge occurrence, meanwhile AFl (-1) was associated to lower risk. A novel score, called HEELP score, was developed based on these variables, and a threshold of 1 point showed high sensitivity (89%) and remarkable negative predictive value (98%). Conclusion Thrombus and sludge prevalence is not infrequent in anticoagulated patients with persistent AF/AFl. A strategy to perform TEE before procedures in patients with high risk features according to our score could be effective in preventing main embolic events, but it has to be validated in further studies.LAA empty (1), sludge (2), thrombus (3)HEELP score

Quantitative Analysis of Epicardial Adipose Tissue: 120K Shades of Heart

Background: Epicardial adipose tissue (EAT) is the fat deposited between the myocardium and epicardium. Due to its unique anatomical position, EAT has both protective and harmful effects on the heart, influencing conditions such as coronary artery disease, atrial fibrillation, and heart failure. This study aimed to quantify the amount of EAT by analyzing the color shades of the heart's anterior surface during coronary artery bypass grafting (CABG) procedures. Objective: To assess the number of color shades in different sub-regions of the heart and quantify EAT using real-time 2D images captured during CABG procedures, and to correlate these findings with clinical conditions and risk factors. Methods: The study was conducted at Rehman Medical Institute, Peshawar, from October 2023 to April 2024. Images were captured using an iPhone 11 with a 12-megapixel camera during CABG procedures, specifically before cannulation, after opening the pericardium, and tucking the pericardium to the skin on a beating heart. Photographs were taken at a 90-degree angle and one-foot distance during systole, including surrounding tissues and a self-retaining retractor with a ruler for measurement reference. The images from three patients were processed to form the "HEART ANTERIOR VIEW THROUGH STERNOTOMY (HATS)" dataset. The data were cleaned and standardized for consistency. The surgical team annotated and labeled the images using the LabelMe tool, identifying the full heart region and its sub-regions: Aorta, Right Ventricle (RV) Myocardium, RV and Pulmonary Artery (PA) Epicardial Fat, and Right Atrium (RA) Appendage. Image segmentation techniques isolated the heart region and identified fat deposits. The total area of fat on the anterior surface of RV, PA, and RA was quantified using appropriate algorithms. Pixel analysis was conducted to determine the color shades, with each pixel having three color channels (Red, Green, Blue) and 256 intensity values per channel. Results: The total pixel count for the full image (heart and surrounding region) was 1600x1200 for Patient 1, 480x624 for Patient 2, and 480x848 for Patient 3. The heart regions contained 218,864 pixels (Patient 1), 44,020 pixels (Patient 2), and 77,919 pixels (Patient 3). The EAT areas were found to be 158,213 pixels (Patient 1), 35,608 pixels (Patient 2), and 52,723 pixels (Patient 3). The percentage areas of the sub-regions varied, with RV and PA Epicardial Fat comprising 72.3%, 80.9%, and 67.7% of the heart regions for Patients 1, 2, and 3, respectively. The top 100 color shades were identified, with unique colors in the Aorta (23,323), Appendage (7,030), Epicardial Fat (80,257), and Myocardium (10,131). Conclusion: The study demonstrated that EAT and the color shades of heart sub-regions could be accurately quantified using advanced imaging and computational techniques. These findings provide valuable insights into the correlation between EAT and cardiac risk factors, enhancing the ability to predict postoperative morbidity and mortality and enabling early interventions to improve patient outcomes.

MRI Investigation of the Association of Left Atrial and Left Atrial Appendage Hemodynamics with Silent Brain Infarction.

Left atrial (LA) myopathy is thought to be associated with silent brain infarctions (SBI) through changes in blood flow hemodynamics leading to thrombogenesis. 4D-flow MRI enables in-vivo hemodynamic quantification in the left atrium (LA) and LA appendage (LAA). To determine whether LA and LAA hemodynamic and volumetric parameters are associated with SBI. Prospective observational study. A single-site cohort of 125 Participants of the multiethnic study of atherosclerosis (MESA), mean age: 72.3 ± 7.2 years, 56 men. 1.5T. Cardiac MRI: Cine balanced steady state free precession (bSSFP) and 4D-flow sequences. Brain MRI: T1- and T2-weighted SE and FLAIR. Presence of SBI was determined from brain MRI by neuroradiologists according to routine diagnostic criteria in all participants without a history of stroke based on the MESA database. Minimum and maximum LA volumes and ejection fraction were calculated from bSSFP data. Blood stasis (% of voxels <10 cm/sec) and peak velocity (cm/sec) in the LA and LAA were assessed by a radiologist using an established 4D-flow workflow. Student's t test, Mann-Whitney U test, one-way ANOVA, chi-square test. Multivariable stepwise logistic regression with automatic forward and backward selection. Significance level P < 0.05. 26 (20.8%) had at least one SBI. After Bonferroni correction, participants with SBI were significantly older and had significantly lower peak velocities in the LAA. In multivariable analyses, age (per 10-years) (odds ratio (OR) = 1.99 (95% confidence interval (CI): 1.30-3.04)) and LAA peak velocity (per cm/sec) (OR = 0.87 (95% CI: 0.81-0.93)) were significantly associated with SBI. Older age and lower LAA peak velocity were associated with SBI in multivariable analyses whereas volumetric-based measures from cardiac MRI or cardiovascular risk factors were not. Cardiac 4D-flow MRI showed potential to serve as a novel imaging marker for SBI. 3 TECHNICAL EFFICACY: Stage 2.

Perioperative Treatment with Rivaroxaban and Dabigatran on Changes of Coagulation and Platelet Activation Biomarkers following Left Atrial Appendage Closure.

Insufficient data exist regarding the investigation of the impact of novel oral anticoagulants (NOACs) on coagulation activation biomarkers in the context of left atrial appendage closure (LAAC) and device-related thrombosis (DRT). The study was designed to investigate the changes and presence of coagulation activation biomarkers between different antithrombotic strategies following LAAC. A total of 120 nonvalvular atrial fibrillation patients intolerant of long-term anticoagulants, who underwent successful WATCHMAN closure implantation, were enrolled (rivaroxaban, n = 82; dabigatran, n = 38). Blood samples were obtained from left atrium (LA) and left atrial appendage (LAA) during the operation and fasting blood samples on the same day of LAAC and 45 days after discharge. The biochemical indicators, thrombin-antithrombin complex (TAT), soluble P-selectin (sP-selectin), von Willebrand factor (vWF), and CD40 ligand (CD40L), were measured by enzyme-linked immunosorbent assay. The primary endpoints of this study were the efficacy and safety characteristics of different antithrombotic strategies, including DRT incidence, stroke or transient ischemic attack, systemic embolism, and clinical major and nonmajor bleeding complications during the follow-up of 180 days. The results revealed that TAT, vWF, sP-selectin, and CD40L levels in vein were significantly reduced by 2.4% (p = 0.043), 5.0% (p < 0.001), 8.7% (p < 0.001), and 2.5% (p = 0.043) from their baseline levels after rivaroxaban treatment. Conversely, no significant changes were detected in the dabigatran group. Furthermore, the plasma levels of platelet activation biomarkers (CD40L and sP-selectin) in both LA and LAA groups were significantly lower after anticoagulation with rivaroxaban, as compared to dabigatran treatment (CD40L: 554.62 ± 155.54 vs. 445.02 ± 130.04 for LA p = 0.0013, 578.51 ± 156.28 vs. 480.13 ± 164.37 for LAA p = 0.0052; sP-selectin: 2849.07 ± 846.69 vs. 2225.54 ± 799.96 for LA p = 0.0105, 2915.52 ± 1402.40 vs. 2203.41 ± 1061.67 for LAA p = 0.0022). Notably, the present study suggests that rivaroxaban may be more effective in the prevention of DRT for patients undergoing LAAC.

On the importance of fundamental computational fluid dynamics toward a robust and reliable model of left atrial flows.

Computational fluid dynamics (CFD) studies of left atrial flows have reached a sophisticated level, for example, revealing plausible relationships between hemodynamics and stresses with atrial fibrillation. However, little focus has been on fundamental fluid modeling of LA flows. The purpose of this study was to investigate the spatiotemporal convergence, along with the differences between high- (HR) versus normal-resolution/accuracy (NR) solution strategies, respectively. Rigid wall CFD simulations were conducted on 12 patient-specific left atrial geometries obtained from computed tomography scans, utilizing a second-order accurate and space/time-centered solver. The convergence studies showed an average variability of around 30% and 55% for time averaged wall shear stress (WSS), oscillatory shear index (OSI), relative residence time (RRT), and endothelial cell activation potential (ECAP), even between intermediate spatial and temporal resolutions, in the left atrium (LA) and left atrial appendage (LAA), respectively. The comparison between HR and NR simulations showed good correlation in the LA for WSS, RRT, and ECAP ( ), but not for OSI ( ). However, there were poor correlations in the LAA especially for OSI, RRT, and ECAP ( .55, .63, and .61, respectively), except for WSS ( ). The errors are comparable to differences previously reported with disease correlations. To robustly predict atrial hemodynamics and stresses, numerical resolutions of 10 M elements (i.e., .5 mm) and 10 k time-steps per cycle seem necessary (i.e., one order of magnitude higher than normally used in both space and time). In conclusion, attention to fundamental numerical aspects is essential toward establishing a plausible, robust, and reliable model of LA flows.

The role of epicardial fat radiomic profiles for atrial fibrillation identification and recurrence risk with coronary CT angiography.

Fat radiomic profile (FRP) was a promising imaging biomarker for identifying increased cardiac risk. We hypothesize FRP can be extended to fat regions around pulmonary veins (PV), left atrium (LA), and left atrial appendage (LAA) to investigate their usefulness in identifying atrial fibrillation (AF) and the risk of AF recurrence. We analysed 300 individuals and grouped patients according to the occurrence and types of AF. We used receiver operating characteristic and survival curves analyses to evaluate the value of imaging biomarkers, including fat attenuation index (FAI) and FRP, in distinguishing AF from sinus rhythm and predicting post-ablation recurrence. FRPs from AF-relevant fat regions showed significant performance in distinguishing AF and non-AF with higher AUC values than FAI (peri-PV: FRP = 0.961 vs FAI = 0.579, peri-LA: FRP = 0.923 vs FAI = 0.575, peri-LAA: FRP = 0.900 vs FAI = 0.665). FRPs from peri-PV, peri-LA, and peri-LAA were able to differentiate persistent and paroxysmal AF with AUC values of 0.804, 0.819, and 0.694. FRP from these regions improved AF recurrence prediction with an AUC of 0.929, 0.732, and 0.794. Patients with FRP cut-off values of ≥0.16, 0.38, and 0.26 had a 7.22-, 5.15-, and 4.25-fold higher risk of post-procedure recurrence, respectively. FRP demonstrated potential in identifying AF, distinguishing AF types, and predicting AF recurrence risk after ablation. FRP from peri-PV fat depot exhibited a strong correlation with AF. Therefore, evaluating epicardial fat using FRP was a promising approach to enhance AF clinical management. The role of epicardial adipose tissue (EAT) in AF had been confirmed, we focussed on the relationship between EAT around pulmonary arteries and LAA in AF which was still unknown. Meanwhile, we used the FRP to excavate more information of EAT in AF.

Modified Haller Index is inversely associated with asymptomatic status in atrial fibrillation patients undergoing electrical cardioversion: a preliminary observation.

No previous study evaluated the possible influence of chest wall conformation on symptoms perception in atrial fibrillation (AF) patients candidates for electrical cardioversion (ECV). We aimed at evaluating the anthropometric and clinical characteristics of patients with persistent AF undergoing ECV, categorized according to the presence or absence of symptoms. This study retrospectively analyzed a series of persistent AF patients scheduled for early ECV who underwent pre-procedural clinical evaluation, MHI (the ratio of chest transverse diameter over the distance between sternum and spine) assessment, transthoracic and transesophageal echocardiography implemented with strain analysis of both left atrium and left atrial appendage. Thromboembolic risk and burden of comorbidities were assessed by CHA<inf>2</inf>DS<inf>2</inf>-VASc Score and Charlson Comorbidity Index (CCI), respectively. The independent predictors of "asymptomatic AF" were assessed. A total of 25 asymptomatic and 90 symptomatic AF patients were retrospectively examined. Compared to symptomatic AF patients, those asymptomatic were significantly older (78.4±3.8 vs. 71.0±7.7 years, P<0.001), predominantly males (84 vs. 44.4%, P<0.001), with significantly lower MHI (2.0±0.1 vs. 2.4±0.1, P<0.001), higher CHA<inf>2</inf>DS<inf>2</inf>-VASc Score (5.8±1.1 vs. 3.6±1.1, P<0.001) and CCI (6.8±1.4 vs. 2.3±0.9, P<0.001), and greater impairment in biventricular systolic function and atrio-auricolar myocardial strain indices. On multivariate logistic regression analysis, CHA<inf>2</inf>DS<inf>2</inf>-VASc Score (OR=2.65, 95% CI: 1.53-4.60) and CCI (OR=2.36, 95% CI: 1.16-4.66) were linearly associated with the endpoint "asymptomatic AF," whereas MHI (OR 0.76, 95% CI 0.59-0.97) was inversely associated with the asymptomatic status. A MHI <2.2 was the best cut-off for detecting asymptomatic AF patients. MHI is inversely associated with asymptomatic status in persistent AF patients undergoing ECV. MHI assessment might represent an innovative practical approach to AF patients.

Thoracoscopic ablation of persistent atrial fibrillation after left atrial appendage occluder implantation: a case report

A clinical case of successful radiofrequency thoracoscopic ablation of persistent atrial fibrillation after implantation of an occluder in the left atrium appendage is presented.

Validation of a predictive model of the left atrium appendage thrombosis in patients with nonvalvular atrial fibrillation

Aim: To test the previously developed predictive model on a test set, including patients with non-valvular atrial fibrillation (AF).Material and Methods. A predictive model was previously developed on a training set of 638 patients with non-valvular AF. The test set included 175 randomly selected patients with non-valvular AF hospitalized at the Tyumen Cardiology Research Center for radiofrequency ablation (RFA) or electrical cardioversion in 2018-2021. The quality of the predictive model was assessed using ROC analysis.Results. Arterial hypertension, coronary heart disease, congestive chronic heart failure, and persistent AF were more common in patients of both sets with left atrial appendage (LAA) thrombosis. Patients of the training and test sets with LAA thrombus had more pronounced structural changes in the heart cavities and similar changes in the geometry of the heart: normal left ventricle (LV) geometry was less common and eccentric LV hypertrophy was more common. According to the results of a previous retrospective analysis of the data, independent predictors of LAA thrombosis were persistent type of AF, left atrium size, and eccentric LV hypertrophy. Based on the data gathered, a predictive model LAA thrombosis was developed as an equation that includes 3 variables. The cut-off point for calculating the probability of LAA thrombosis is 0.07. Applying this model on a test set showed the good quality of the model: the area under the curve obtained using ROC analysis was 0.750 (p &lt; 0.001). At the same time, the sensitivity and specificity of this model for the detection of LAA thrombosis were 72.3% and 71%, respectively.Conclusion. The evaluation of the quality of the LAA thrombosis predictive model developed on the training set confirmed its good quality on a similar test set of patients with non-valvular AF hospitalized for RFA or electrical cardioversion.

Prediction of low left atrial appendage velocity from echocardiographic left atrial function parameters in patients with atrial fibrillation undergoing catheter ablation

Abstract Funding Acknowledgements Type of funding sources: None. Background Decreased left atrial appendage velocity (LAAV) measured by transesophageal echocardiography is considered a significant risk factor for the presence of thrombus in both the left atrium (LA) and left atrial appendage (LAA). Purpose The aim of the study was to assess the role of echocardiographic LA function parameters in predicting low left atrial appendage velocity (LAAV) in patients with persistent atrial fibrillation (AF) undergoing catheter ablation. Methods We prospectively enrolled consecutive patients with persistent AF undergoing transesophageal echocardiography (TEE) directly before first AF ablation in 2019–2022. All patients underwent conventional two-dimensional (2D) echocardiography and 2D speckle tracking echocardiography on the day of ablation. Patients were divided into two groups according to the presence or absence of decreased LAAV≤25cm/s at TEE. Results Out of total 150 patients enrolled in the study, 29.3% (n=44) had a reduced LAAV ≤25cm/s. Patients with decreased LAAV value exhibited significantly lower left atrial reservoir and conduit strain (LASr and LAScd) (p&amp;lt;0.001 for both); LA emptying fraction (p&amp;lt;0.001) and average e’ value (p&amp;lt;0.001). At the same time, this group presented higher LA stiffness index (LASI) (defined as E/e' ratio/LASr) (p&amp;lt;0.001); LA and right atrial area (p = 0.002 and 0.004 respectively); LA volume index (p&amp;lt;0.001) and E/e’ ratio (p&amp;lt;0.001). In multivariable logistic regression analysis only LASI and LAVI remained significant predictors of the lower LAAV (odds ratio (OR) for LASI 3.065, 95% confidence interval(CI) 1.415–6.639, p&amp;lt;0.001; for LAVI OR 1.05 (1.011–1.091). The diagnostic accuracy of these two parameters in predicting low LAAV value calculated as the area under receiver operating characteristic curves (ROC) were 0.809 (95% CI 0.726–0.892) for LASI and 0.755 (CI 0.676–0.835) for LAVI. A ROC analysis found a LASI threshold of 1.6 with 64% sensitivity and 90% specificity and LAVI threshold of 44.47ml/m2 with 91% sensitivity and 53% specificity in predicting reduced LAAV defined as ≤ 25cm/s. Conclusions Among all noninvasive parameters assessed by conventional 2D and 2D speckle tracking echocardiography, LASI and LAVI were found to be the best predictors of reduced LAAV in patients with persistent non-valvular AF undergoing TEE before catheter ablation, with good sensitivity and specificity.

P299 WATCHMAN DEVICE THROMBOSIS FOLLOWING THE PERCUTANEOUS CLOSURE OF THE LEFT ATRIUM APPENDAGE: A "CUL–DE–SAC" IN THE ANTITHROMBOTIC STRATEGY

Abstract Background The percutaneous closure of the left atrium appendage (LAA) is a valuable therapeutic tool in patients with atrial fibrillation (AF) who have contraindications to anticoagulant drugs. However, the procedure can lead to complications and the device positioning determines a risk of thrombosis that can‘t be underestimated, especially during the first period from the intervention. Clinical Case In this report we propose the case of a 72 years old man in chronic therapy with NOAC (non–vitamin K antagonist oral anticoagulants) for a paroxysmal AF (CHA2DS2–VASC = 3), that presented intracranial hemorrhage after 3 years due to a cerebral arteriovenous malformation. This condition represents an absolute contraindication to anticoagulant therapy, because of the high hemorrhagic risk, and led to the percutaneous device positioning (WATCHMAN 24 mm) for LAA closure. After the implantation procedure we started a single antiplatelet therapy (SAPT) with clopidogrel 75 mg for 6 months. At one month follow–up a trans–esophageal echocardiogram (TEE) showed the presence of a swinging samll trombotic formation (4x2,5 mm) attached to the device. At that time antithrombotic therapy with enoxaparin 6000 IU was started, in addition to SAPT. Ten days later, another TEE showed the thrombus resolution and we decided to continue with clopidogrel alone. No relevant clinical events were observed to the subsequent follow–up. Discussion Current recommendations suggest double antiplatelet therapy (DAPT) for 1–6 months followed by SAPT, in patients who have absolute contraindication to anticoagulant drugs, or SAPT for at least 1 month in those who have an extreme hemorrhagic risk. LAA closure device thrombosis affects 3% of patients and represents an independent predictor of cerebral ischemic events, according to various registers and meta–analyses. This event determines an indication to anticoagulant therapy in patients who would have an absolute contraindication, creating a difficult management that assume clinical relevance. In our experience a 10 days therapy with heparin added to SAPT led to thrombosis resolution. However the therapeutic management of these complications is currently not standardized and more studies are needed.

E-3 | Do Patients With Dilated Left Atrium Appendage Orifice Require More Joules for Direct Current Cardioversion to Restore Sinus Rhythm?

E-3 | Do Patients With Dilated Left Atrium Appendage Orifice Require More Joules for Direct Current Cardioversion to Restore Sinus Rhythm?

Novel scale for predicting thrombosis of the left atrium and its appendage before catheter ablation or cardioversion in patients with nonvalvular atrial fibrillation or atrial flutter

Aim. To study the potential of predicting thrombosis of the left atrium (LA) and/or LA appendage (LAA) before catheter ablation (CA) or elective cardioversion in patients with nonvalvular atrial fibrillation (NAF) or atrial flutter (AFL) using indicators available in routine practice.Material and methods. In this single-center retrospective study, the medical records of 1994 patients with nAF or AFL for the period 2014-2019 were analyzed, who underwent transesophageal echocardiography before CA or elective CV. LA/LAA thrombus was found in 33 (1,6%) patients. For the comparison group, 167 patients were randomly selected without LA/LAA thrombosis. Demographic, anamnestic, clinical, laboratory data, results of transthoracic echocardiography, as well as the CHA2DS2-VASc-RAF (CHA2DS2-VASc plus 2 points for an estimated glomerular filtration rate &lt;56 ml/min/1,73 m2, 4 points for persistent AF (lasting &gt;7 days), 10 points for persistent AF).Results. The mean age of the patients was 60,3±10,9 years (men, 55%). There were more patients with NAF (87,5%), hospitalized for CV (84,0%). Multivariate analysis revealed that the severity of symptoms associated with arrhythmia was associated with the detection of a LA/LAA thrombus (odds ratio (OR) for EHRA class 3-4 14,29 at 95% confidence interval (CI): 3,3-61,8; p&lt;0,0001), left ventricular ejection fraction &lt;48% (OR, 7,83; 95% CI: 1,2-53,05; p=0,035) and total CHA2DS2-VASc-RAF score (OR, 1,29 at 95% CI: 1,08-1,5; p=0,004). Sup­ple­mentation of the CHA2DS2-VASc-RAF with new independent predictors of LA/LAA thrombosis did not lead to a significant increase in the area under the characteristic curve, which was 0,83 (95% CI: 0,76-0,91) and 0,87 (95% CI: 0,80-0,94), respectively (p=0,13). The OR of LA/LAA thrombosis with a total score CHA2DS2-VASc-RAF &gt;3 was 12,8 (95% CI: 3,8-43,9; p&lt;0,0001), while the sensitivity, specificity, positive and negative predictive value — 90,6, 57,1, 30,2 and 96,7% respectively. The OR of thrombosis of LA/LAA with a CHA2DS2-VASc-RAF score &gt;8 was 25,8 (95% CI: 5,9-112,3; p&lt;0,0001), while sensitivity, specificity, positive and negative predictive value — 93,5, 64,0, 34,9 and 97,9%, respectively.Conclusion. When predicting LA/LAA thrombosis, detected during transesophageal echocardiography before CA or elective CV in patients with NAF or AFL who did not have a pronounced structural heart pathology and severe concomitant diseases, taking into account the severity of symptoms associated with arrhythmia and a reduced left ventricular ejection fraction (&lt;48%) in addition to the risk stratification scale for LA/LAA thrombosis CHA2DS2-VASc-RAF did not lead to an increase in the area under the characteristic curve, but made it possible to increase the OR of LA/LAA thrombosis detection by 2 times and increase the sensitivity, specificity, positive and negative predictive value.

A bailout procedure with a surgical stapler for unsuccessful left atrium appendage clipping in minimally invasive cardiac surgery

A bailout procedure with a surgical stapler for unsuccessful left atrium appendage clipping in minimally invasive cardiac surgery

CT-criteria for left atrium appendage thrombus detection

&lt;b&gt;Objective: &lt;/b&gt;Atrial fibrillation is strongly associated with stroke and accounts for 60% of cardioembolic stroke. Assessing thromboembolic risk is important for patients with atrial fibrillation. Approximately 90% of all thrombus are localized in the left atrium appendage (LAA). This study aimed to determine the efficacy of cardiac computed tomography (CT) for LAA thrombus detection.&lt;br /&gt; &lt;b&gt;Material and methods:&lt;/b&gt; This retrospective study included 292 patients. LAA thrombus was confirmed or excluded by cardiac CT with the reference to transesophageal echocardiography (TEE). We excluded patients with allergic reactions to iodide, increased creatinine levels, thyroid disease (hyperthyroidism), pregnancy, and age &amp;lt;18 years.&lt;br /&gt; &lt;b&gt;Results:&lt;/b&gt; According to the cardiac CT, 103 of 292 people had LAA thrombus, while according to TEE, only 48 of patients had LAA thrombus. The sensitivity and specificity of CT were 97.7% and 77%, respectively. The sensitivity and specificity of the CT was higher in 2016–2020, when the delayed phase was added to the standard protocol, compared to 2012–2015 years. Older age, higher BMI, higher CHA&lt;sub&gt;2&lt;/sub&gt;DS&lt;sub&gt;2&lt;/sub&gt;-VASc and HAS-BLED scores, and larger LA and LVESV were significantly associated with LAA thrombus detection on cardiac CT. Higher LVESV and LVEDV indexes (LVESVI and LVEDVI) and lower LV ejection fraction measured by TEE were also predictors of LAA thrombus detection by cardiac CT.&lt;br /&gt; &lt;b&gt;Conclusion:&lt;/b&gt; Our findings show that cardiac CT has high sensitivity and specificity for excluding or confirming LAA thrombus, and can also be exclusively used to determine the presence or absence of a thrombus.

Treatment results of cardiac tamponade due to thoracic trauma at Jeju Regional Trauma Center, Korea: a case series.

The purpose of this study was to report the treatment results of patients with traumatic cardiac tamponade after the opening of Jeju Regional Trauma Center. We analyzed the treatment outcomes of patients with traumatic cardiac tamponade who were treated at Jeju Regional Trauma Center from January 2018 to August 2022. Seven patients with traumatic cardiac tamponade were treated. The male to female ratio was 1.33:1 (four male and three female patients) and the average age was 60.3±7.2 years. The mechanism of injury was blunt trauma in six cases and penetrating injury in one case. Upon arrival at the emergency department, pericardiostomy was performed in four cases, and an emergency operation was performed in six cases. Pericardiostomy alone was performed in one patient, who had cardiac tamponade due to extrapericardial suprahepatic inferior vena cava rupture. The causes of cardiac tamponade were right atrium appendage rupture in one case, right ventricle rupture in one case, inferior vena cava rupture in two cases, right atrium and left atrium rupture in one case, both atria and left ventricle rupture in one case, and intercostal artery rupture in one case. In three cases, intraoperative cardiopulmonary bypass was required. Two of the seven patients died (mortality rate, 28.5%). Relatively favorable treatment results were observed for traumatic cardiac tamponade patients after Jeju Regional Trauma Center was established.

Incidental Thrombus in Left Atrium Appendage Detected by Intracardiac Echocardiography.

Incidental Thrombus in Left Atrium Appendage Detected by Intracardiac Echocardiography.

Echocardiographic predictors of thrombus in left atrial appendage-The role of novel transthoracic parameters.

The left atrium appendage thrombus (LAAT) formation is a complex process. A CHA2DS2-VASc scale is an established tool for determining the thromboembolic risk and initiation of anticoagulation treatment in patients with atrial fibrillation or flutter (AF/AFL). We aimed to identify whether any transthoracic echocardiography (TTE) parameters could have an additional impact on LAAT detection. That is a sub-study of multicenter, prospective, observational study LATTEE (NCT03591627), which enrolled 3,109 consecutive patients with AF/AFL referred for transesophageal echocardiography (TEE) before cardioversion or ablation. LAAT was diagnosed in 8.0% of patients. The univariate logistic regression analysis [based on pre-specified in the receiver operating characteristic (ROC) analysis cut-off values with AUC ≥ 0.7] identified left ventricular ejection fraction (LVEF) ≤ 48% and novel TTE parameters i.e., the ratios of LVEF and left atrial diameter (LAD) ≤ 1.1 (AUC 0.75; OR 5.64; 95% CI 4.03-7.9; p < 0.001), LVEF to left atrial area (LAA) ≤ 1.7 (AUC 0.75; OR 5.64; 95% CI 4.02-7.9; p < 0.001), and LVEF to indexed left atrial volume (LAVI) ≤ 1.1 (AUC 0.75, OR 6.77; 95% CI 4.25-10.8; p < 0.001) as significant predictors of LAAT. In a multivariate logistic regression analysis, LVEF/LAVI and LVEF/LAA maintained statistical significance. Calculating the accuracy of the abovementioned ratios according to the CHA2DS2-VASc scale values revealed their highest predictive power for LAAT in a setting with low thromboembolic risk. Novel TTE indices could help identify patients with increased probability of the LAAT, with particular applicability for patients at low thromboembolic risk.