Heart Rhythm. The assessment of suspected thrombus formation in the left atrial appendage has emerged as one of the most common indications to utilise transoesophageal echocardiography. Clinical electrophysiology. Functional assessment of atrial appendages and diverticula was not performed in this study, and future studies may be necessary to evaluate whether functional behavior may allow differentiation between diverticula and accessory appendages. The roles these structures may have in the development of atrial fibrillation or an increased prevalence of thromboembolic disease remains unclear and may need to be evaluated in future studies. 2, NO. METHODS AND RESULTS: Twenty-two (22) patients (73±8 years, 55% male) with atrial fibrillation requiring anticoagulation at high bleeding risk underwent LAA closure (WATCHMAN device). Left atrial appendage. The following are key points to remember from these expert recommendations about cardiac computed tomography (CT) for planning transcatheter left atrial appendage occlusion (LAAO): One rather unexplored area is that of anatomic variants of the left atrium. (2014) Anadolu kardiyoloji dergisi : AKD = the Anatolian journal of cardiology. We investigated whether the use of 3D-printed left atrial appendage (LAA) models based on preprocedural computed tomography (CT) permits accurate device sizing. A dual-phase cardiac CT protocol for complete delineation of left atrial appendage (LAA) anatomy and thrombus exclusion prior to AF ablation or LAA device exclusion. Is the left atrial appendage more than a simple appendage?. [4] examined 120 consecutive patients and found 27 left atrial diverticula in 20 patients (16.7% of all patients). Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. The left atrial appendage is a finger like, trabecularized structure which originates supralaterally in the left atrium. [1] describe a case with semicircular arrangement of accessory appendages along the line of fusion between the primitive embryonic atrium and pulmonary veins. 5A, 5B, 5C). (2017) Journal of cardiothoracic surgery. It lies over the left atrioventricular groove, and partially covers the left coronary artery in it. 39 (9): 1443-9. 2014;7 (12): 1251-65. Moderators: Shakeel Qureshi, Evelina Children's Hospital, London, United Kingdom. 14 (3): 256-60. Diverticula have also been associated with occurrence of supraventricular arrhythmia, which is believed to be produced by a large area of abnormal atrial wall [10, 11]. The lesion has previously been attributed to an entrapment of the developing atria to one side of the outflow tract during an early stage of cardiogenesis [8]. Image reconstruction was performed at a phase start of 65% of the R peak to R peak interval (equivalent to a phase center definition as used by other vendors of approximately 75%) but was repeated at various other phases throughout the cardiac cycle if motion artifact was present. 6. The location was characterized as based on an atrial wall (superior, inferior, right lateral, or left lateral wall) and further subdivided into anterior, posterior, superior, or inferior position at the respective wall where applicable. Though this structure is not necessary to survival, it plays a role in lowering the blood pressure against the left side of the left atrium. (2002) Journal of the American College of Cardiology. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Role of Ct Imaging in Left Atrial Appendage Occlusionother Section Atrial appendage thrombosis is seen in a variety of clinical settings and can result in severe morbidity or even death from embolic events. In patients with a history of atrial fibrillation, we recorded whether the patient had undergone a pulmonary vein isolation procedure and, if so, whether it was successful in restoring sinus rhythm. Characterization of the atrial appendage using TEE is performed using four main viewing angles: 0°, 45°, 90°, and 135°.4 From these views, maximal LAA length and width are ascertained, and a device is chosen based on the manufacturer’s sizing guide in the instructions for use.4 The appendage must be at least as deep as the size of the measured ostia to ensure safe implantation, otherwise, the patient will b… Echocardiographically derived measures of LAA contractility and flow characteristics are highly predictive of future thromboembolic stroke risk. Because the study was designed as an observational prevalence study, we cannot assess the association of the left atrial structures described in our study with other relevant clinical and electrophysical information. The cardiac CTA examinations were evaluated for presence of any other congenital abnormality including, but not limited to, patent foramen ovale, atrial septal defect, ventricular septal defect, transposition of the great vessels, and subaortic membranes. Although in the former case no thrombus was found in the surgical specimen of the diverticulum, thrombus formation and embolization appeared plausible because of low flow and turbulence within the sac-shaped structure. In terms of the atrial diverticula, in both genders the widths were similar (men, 6.2 ± 2.4 mm; women, 5.8 ± 2.7 mm; p = 0.41), but men tended to have longer atrial diverticula than women (men, 6.7 ± 2.6 mm; women, 4.9 ± 1.8 mm; p = 0.002). Copyright © 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. Two orthogonal planes were generated for measurement purposes: one orthogonal to the long axis of the diverticulum (parallel to the ostium at the widest diameter) and the other along the long axis at the widest diameter. The left atrial appendage (LAA) is a finger-like extension originating from the main body of the left atrium. One patient underwent pulmonary vein isolation, which resulted in restoration of sinus rhythm. One hundred twenty-one patients had one or more left atrial accessory appendages (n = 20), left atrial diverticula (n = 81), or both (n = 20). JACC: CLINICAL ELECTROPHYSIOLOGY VOL. CT = computed tomography LAA = left atrial appendage LA = left atrium LOM = ligament of Marshall LSPV = left superior pulmonary vein LV = left ventricle PA = pulmonary artery PV = pulmonary vein TEE = transesophageal echocardiography Naksuk et al. J. Its superior (S) and posterior (P) walls are shown by double-headed arrows. An atrial diverticulum was identified if the structure had a saclike shape with a broad-based ostium and a smooth contour to its body (Fig. Additionally, cases of electric dissociation within left atrial appendage accessory lobes have been described in which the accessory lobe was fibrillating (pulsed-wave Doppler sonography), whereas the remainder of the atrium, pulmonary vein, and right atrium appeared to be in sinus rhythm [12]. J Atr Fibrillation, 8 (2015), pp. Our data show that left atrial accessory appendages and diverticula can be found in more than one fifth of subjects undergoing cardiac CTA and are more common in men. 10. 53 The lateral course passes over the tip of the left atrial appendage, whereas the posteroinferior course passes over the roof of the appendage os. 8. MATERIALS AND METHODS. Coll. ... Anomalous pulmonary venous anatomy. Seven patients with left atrial diverticula or left atrial accessory appendages had atrial fibrillation with atrial enlargement. CT data sets were evaluated using axial, sagittal, coronal, and interactive multiplanar reconstructions; maximum intensity projections (MIPs); and interactive volume rendering. Atrial fibrillation (AF) is the most common clinically important cardiac arrhythmia, occurring in approximately 0.4% to 1% of the general population and increasing with age to >8% in those > … The LAA shape and presence or absence of pectinate muscles and their size were also recorded. 26 (9): 921-64. 6A, 6B, 6C and 7A, 7B). Expert Recommendations on Cardiac Computed Tomography for Planning Transcatheter Left Atrial Appendage Occlusion. This study aimed to assess the prevalence, location, and size of left atrial accessory appendages and diverticula in a general population. The multilobulated architecture, frequent variant anatomy, and pectinate muscles make securing several orthogonal views essential for detection or exclusion of pathology. Comparisons between the dimensions and prevalence of left atrial accessory appendages and left atrial diverticula in men and women were performed using independent two-sample Student's t tests. Patient, left atrial, and left atrial appendage parameters and their correlation with magnitude of discrepancy between measurements on 2D-TOE vs. CT (maximum LAA orifice diameters). Cardiac CT Illustrates the Relationship Between the LCX Anteroinferior to the LAA (A) Note the persistent left-sided superior vena cava ... S.J. This matches the common locations of left atrial accessory append ages as observed in our study. RESULTS. Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation? These structures are not associated with other cardiac congenital abnormalities in the majority of cases. Two cases have been associated with clinical events. Table 3 summarizes the sizes of both accessory appendages and diverticula. Eur Heart J Cardiovasc Imaging 2015;16(11):1198–1206. Of accessory appendages, 34% were inferior posterior, 32% were left inferior, 18% were superior anterior, 14% were inferior posterior, and 2% were right inferior posterior. This finding was first described by Dixon [6] in 1954 and is associated with congenital cardiac anomalies such as severe conotruncal abnormalities, especially transposition of the aorta [6, 7]. Additionally, anteroposterior measurements of the left atrium in axial views were obtained (> 40 mm was considered enlarged). Duerinckx and Vanovermeire [3] found that only 10% (17 of 166) of patients had accessory left atrial appendages or diverticula (one patient had both) compared with 23% in this study. The presence, type, and location of left atrial appendages and diverticula were recorded. Crossref, Medline, Google Scholar; 3. ECG-based tube current modulation was used when appropriate. Its small, parallel-running … Whether there is any pathologic value remains uncertain. The informed consent requirement was waived. Bakalli A, Kamberi L, Pllana E, Zahiti B, Dragusha G, Brovina A. However, to our knowledge, the prevalence and morphologic appearance of accessory left atrial appendages and diverticula in vivo have not been described to date. Although the rate of major procedural complications 2012;60 (6): 531-8. 12 (1): 15. Cardiac CT angiography for device surveillance after endovascular left atrial appendage closure. KEY POINTS: • Variations in normal left atrial appendage in vivo anatomy and function remain largely unknown. Four patients with left atrial diverticula or accessory appendages had prior noncryptogenic strokes. The left atrium (LA in red) is located superior and posterior to the right atrium. 7. Most of the accessory appendages had a left lateral inferior location, whereas most of the diverticula had a superior anterior location (Figs. Unless contraindicated, cardiac CTA was performed after vasodilation with oral nitroglycerin and administration of IV metoprolol in patients with heart rates of 60 beats per minute or more. 3. elevated left atrial pressures may affect LAA morphology, contractile function, and outflow velocities, elevated end-diastolic diameter associated with LAA dilation and thrombogenesis, initial identification of the LAA, which will be a roughly crescentic shaped extrusion from the anterolateral left atrium, anterior extension typically parallels LUPV, variation may occur, including a posterolateral course, assess for gross LAA structural abnormalities, including dilation or aneurysm, ostium typically measures between 1.0 and 2.5 cm, mid-oesophageal left atrial appendage (LAA) view, spontaneous echo contrast (SEC) or uniformly echogenic luminal densities representing thrombus should be specifically sought, rough estimation of contractile status should also be noted, a pulsed wave Doppler sample volume should be advanced toward the identified blood flow (no more than 1-2 cm within the LAA), four deflections may be observed in sinus rhythm, positive deflection representing early diastolic filling, with a peak between 20 and 40 cm/second, followed by the markedly positive late diastolic LAA contraction, with a velocity of 50–60 cm/s, subsequent negative deflection of similar amplitude represents LAA filling, variable, undulating systolic reflection waves follow, bidirectional velocities measured > 40 cm/s amplitude reassuring for normal LAA contractile function, and low risk for thrombus, whereas velocities < 20 cm/s are concerning, maybe used to measure orifice width and the depth of the LAA. Cardiac computed tomography (CCT) is a well-established technique for the evaluation of left atrial and pulmonary vein anatomy [1, 2].CCT images may be integrated with electrophysiological mapping to guide radiofrequency catheter ablation of atrial fibrillation (AF) [].In addition, CCT has been regarded as an emerging noninvasive imaging modality for the detection of left atrial appendage … JACC Cardiovasc Imaging. Cardiac CT angiography (CTA) provides important new noninvasive insights into subtle details of cardiac anatomy and morphology. Finally, left atrial enlargement was more common in patients with diverticula (32%) compared with those with accessory appendages (20%) or without either lesion (24%; p = 0.19). Routine retrospectively gated contrast-enhanced cardiac 64-MDCT was performed in 530 consecutive patients for a period of 5 months at the Massachusetts General Hospital CT laboratory. The absence of pathologic proof is a limitation. The “Misty Mesentery”: Mesenteric Panniculitis and Its Mimics. Presence and size of either structure within the left atrium were recorded. CSI Focus LAA: anatomy and imaging. If classification as either left atrial diverticulum or left atrial accessory appendage was difficult, consensus was achieved based on best judgement (classification as left atrial accessory appendage if the lesion resembled cauliflower or the left atrial appendage proper or had obvious pectinate muscles). 81-87. All cases were reviewed at 65%, but readers had the option to review other phases if image degradation from motion or other artifact was present. Atrial fibrillation (AF) is the most common clinically important cardiac arrhythmia, occurring in approximately 0.4% to 1% of the general population and increasing with … Speaker Edward Nicol However, consideration of the development of the outflow pathways of the normal human heart suggests that this event would be improbable because the atrial appendages form after the definitive relationship between the atria and outflow tract is established [8]. The potential association with atrial enlargement, embolic disease, arrhythmias, and other conditions is not sufficiently assessed and may need to be investigated in future studies. Left atrial appendage anatomy and endovascular closure. CONCLUSION. 38 (2): 90-4. CT and MRI Assessment of the Aortic Root and Ascending Aorta, Review. Left atrial diverticula are more commonly found than are accessory appendages. In those patients with a history of stroke, further medical history was reviewed regarding severity of left ventricular function, presence of large-artery atherosclerotic disease, nonatherosclerotic vasculopathies, or hypercoagulable disorders. 9. Data on mitral or aortic valve disease were confirmed by reviewing reports of previous echocardiograms, if present. Imaging Pulmonary Infection: Classic Signs and Patterns, Structured Review. Accessory left atrial appendages tend to be smaller than diverticula and are more commonly found on the left lateral atrial wall. Address correspondence to S. Abbara ([email protected]). All coronary CTA imaging was performed with a 64-MDCT scanner (Sensation 64, Siemens Healthcare) using retrospective gating. 5. Evaluation of the left atrial appendage should be accompanied by a structural and functional assessment of related structures, including the 10: Specific assessment of the left atrial appendage may then proceed with the following views 12: Some authors report that the presence of trabeculations and a smaller left atrial appendage orifice diameter may be associated with greater stroke prevalence in atrial fibrillation; i.e. 2. 2A, 2B and 3A, 3B). Thrombus in the left atrial appendage may cause embolism producing ischemic stroke and infarction of other organs including the spleen, bowel and kidneys. Even though both structures seem to be present in any location within the left atrium, there is a preference of accessory appendages to be in the left lateral inferior section of this cardiac chamber. Contrast-enhanced image acquisition was performed during a single breath-hold. Catheter Cardiovasc Interv. Table 2 summarizes the locations within the left atrium of both the accessory appendages and diverticula. 8. Hence ablation is often attempted on the posterior aspect of this structure (ie, the anterior wall of the left PV antrum). One case was reported in association with severe mitral regurgitation, suggesting that finding may play a role in the formation of left atrial diverticula [9]. The left phrenic nerve takes an anterior (18%), lateral (59%), or posteroinferior (23%) course on the fibrous pericardium overlying the left heart. Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM, Reeves ST, Shanewise JS, Siu SC, Stewart W, Picard MH. Atrial fibrillation (AF) is the most common clinically important cardiac arrhythmia, occurring in approximately 0.4% to 1% of the general population and increasing with age to >8% in those >80 years of age. A p value of less than 0.05 was considered statistically significant. Descriptive statistics were calculated. Beigel R, Wunderlich NC, Ho SY et-al. There was a statistically significant difference in length (p = 0.0009) and in width (p = 0.0001) between accessory appendages and diverticula, the latter being larger in both dimensions. Methods A total of 104 left atrial diverticula were found in 101 patients (19% of examined population) and 44 accessory appendages in 40 patients (8% of population) (Figs. Furthermore, the differentiation of an accessory left atrial appendage from left atrial diverticula may be difficult because the defining features may be subtle, and some lesions may express features of both appendages and diverticula. AsirvathamA review of the relevant embryology, pathohistology, and anatomy of the left atrial appendage for the invasive cardiac electrophysiologist. The left atrial appendage (LAA) is a highly complex anatomical structure distinct from the rest of the left atrium from an embryologic, anatomic, and pathophysiologic standpoint. Four main morphological types have been described: 1. chicken wing: 48% 2. cactus: 30% 3. windsock: 19% 4. cauliflower: 3%. While this is a well-known complication of atrial fibrillation, LAA dysfunction is a strong independent risk factor for ischaemic stroke and TIA. Heart. Recent studies have demonstrated that pre-procedural CT reconstruction is useful to classify a wide range of variations in morphology of the left atrial appendage. We also aimed to evaluate the potential clinical relevance of the presence of these structures. The left atrial appendage is a small structure that resembles a finger coming off the left atrium of the human heart. The left atrial appendage (LAA) is a complex structure that develops in the 3rd week of gestation, arising from the left and superior side of the primary atrial tube. We also reviewed the patients' medical histories for presence of mitral or aortic valve disease, strokes, and atrial fibrillation. Axial, sagittal, coronal, and interactive multiplanar reconstructions as well as maximum intensity projections and interactive volume-rendering images were generated in ventricular diastole. However, variations in normal in vivo anatomy and function according to age and gender remain largely unknown. Imaging parameters included a slice collimation of 64 × 0.6 mm, gantry rotation time of 330 milliseconds with a tube voltage of 100–120 kV and effective tube current of 750–850 mAs. None of these structures revealed any presence of thrombus. (2013) Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography. Assessing Anatomy for Left Atrial Appendage Closure L eft atrial appendage (LAA) closure is now a com-mercially available alternative means of thrombo-prophylaxis in atrial fibrillation patients who are not ideal candidates for oral anticoagulation. The left atrial appendage: anatomy, function, and noninvasive evaluation. Chen Y, Mou Y, Jiang LJ, Hu SJ. 4. Four main morphological types have been described: It is derived from the left wall of the primary atrium, which forms during the fourth week of embryonic development. Di Biase L, Santangeli P, Anselmino M et-al. 2013;10 (12): 1843-9. 11.1 Conventional left atrial anatomy (LAA). Left Atrial Appendage: Embryology, Anatomy, Physiology, Arrhythmia and Therapeutic Intervention. The purpose of this study is to describe the prevalence, morphology, size, and location of left atrial abnormalities including diverticula and accessory appendages in consecutive patients undergoing cardiac-gated CT for coronary artery evaluation. Check for errors and try again. OBJECTIVE. Although this theory has promoted the idea that juxtaposition of the atrial appendages is an entity that should be reinterpreted as an accessory appendage or atrial diverticulum [8], it appears that the descriptions of accessory atrial appendages in juxtaposition, as opposed to those described in this study, refer to distinct rare malformations that are associated with congenital heart disease. The contrast volume was individually adapted to match the scan duration and the selected contrast flow rates. Few recent case reports and smaller series have described the presence of atrial accessory appendages [1–3]. Session Prognosis and management in atrial fibrillation . Demirçelik MB, Çetin M, Çiçekcioğlu H, Uçar Ö, Duran M. Effect of left ventricular diastolic dysfunction on left atrial appendage function and thrombotic potential in nonvalvular atrial fibrillation. Our data show that left atrial accessory appendages and diverticula can be found in more than one fifth of subjects undergoing cardiac CTA and are more common in men. Lee et al. However, correlations between these measurements remain inadequately assessed. There was a statistically significant difference in the prevalence of left atrial diverticula in men compared with women (19.0% vs 7.9%, p < 0.001) but not in the prevalence of left atrial accessory appendages (8.0% vs 6.2%, p = 0.16). Of these patients, 408 (77%; 256 men, 63%; 152 women, 37%) had neither a left atrial diverticulum nor an accessory appendage, whereas 121 patients (23%; 96 men, 79%; 25 women 21%) were found to have accessory appendages or diverticula. Table 1 summarizes the characteristics of the group with atrial diverticula or accessory appendages. 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