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PubMed2005

Three unusual myxomas originating from the left atrial appendage: a case report.

Most left atrial appendage masses have been reported to be thrombus, particularly in the presence of atrial fibrillation. The presence of any mass other than thrombus is extremely rare in the left atrial appendage. This report presents the rare case of a 70-year-old woman presenting with paroxysmal atrial fibrillation and syncope who was given the diagnosis of having 3 myxomas originating from the left atrial appendage. The diagnosis was established by the help of transesophageal echocardiography and confirmed by histologic examination after operation. The advantage of transesophageal echocardiography in this case and for patients with atrial fibrillation is emphasized.

Aged↗
PubMed1994

Influence of acutely altered loading conditions on left atrial appendage flow velocities.

OBJECTIVES: The purpose of this study was to identify the effects of altered loading conditions on left atrial appendage flow velocities. BACKGROUND: Although studies have suggested that Doppler analysis of left atrial appendage blood flow may have clinical utility, the hemodynamic and cardiac mechanical determinants of left atrial appendage flow are poorly understood. METHODS: Transesophageal Doppler echocardiography was performed in eight atrially paced anesthetized dogs instrumented with sonomicrometers on the left atrial appendage and the left ventricular minor axis and with left atrial and left ventricular micromanometers. Left atrial appendage emptying and filling velocities corresponding to early and late ventricular diastole, respectively, were measured using volume expansion and phenylephrine infusion. RESULTS: Volume infusion caused a significant decrease in the early to late emptying and filling ratios (mean +/- SD 0.85 +/- 0.24 vs. 0.46 +/- 0.17 and 0.80 +/- 0.50 vs. 0.40 +/- 0.20, both p < 0.05). By contrast, phenylephrine infusion did not significantly alter either filling or emptying ratio. The independent determinants of each flow wave were identified with multiple regression analysis: early emptying velocity--time constant of left ventricular relaxation, left ventricular end-systolic dimension and aortic pressure (r = 0.75, p < 0.001); late emptying velocity--left ventricular peak positive time derivative of left ventricular pressure (dP/dt) and fractional shortening (r = 0.74, p < 0.001); early filling velocity--left atrial appendage shortening fraction (r = 0.45, p = 0.01) and late filling velocity--left atrial appendage lengthening rate and left ventricular fractional shortening (r = 0.56, p < 0.01). CONCLUSIONS: These results indicate that 1) both the magnitude and the pattern of left atrial appendage emptying and filling velocities are dependent on loading conditions, and 2) left atrial appendage velocities are influenced to a greater extent by changes in left ventricular than in left atrial appendage function. These findings may have implications for the pathogenesis of left atrial appendage thrombi.

Animals↗
PubMed2005

The use of anatomic M-mode echocardiography to determine the left atrial appendage functions in patients with sinus rhythm.

Left atrial appendage (LAA) contractile dysfunction is associated with thrombus formation and systemic embolism. LAA function is determined by its flow velocities and fractional area change. This study was performed in order to determine the LAA functions with the anatomic M-mode echocardiography (AMME). Our study comprised 74 patients who had sinus rhythm and underwent transesophageal echocardiography (TEE) for various reasons. LAA fractional change (LAAFAC) was measured by manual planimetry in a transverse basal short-axis approach and LAA emptying and filling velocities also were measured. The AMME values were determined by an M-mode cross section from a cursor placed beneath the orifice of the LAA in transverse basal short-axis imaging. From these values LAA fractional shortening (LAAFS) and ejection fraction (LAAEF) were calculated. LAAEF was calculated by the Teicholz method. The comparisons were conducted, and no correlations between the LAA late filling and the anatomic M-mode values were found (for LAAFS r = 0.18; P > 0.05 and for LAAEF r = 0.19; P > 0.05). There were significant but poor correlations among the LAA late emptying with the anatomic M-mode measurements (for LAAFS r = 0.26; P < 0.05 and for LAAEF r = 0.30; P < 0.01), whereas, there were significant and good correlations between the LAAFAC and the anatomic M-mode values (for LAAFS r = 0.75; P < 0.01 and for LAAEF r = 0.78; P < 0.01). There were significant differences between the valvular heart disease group and the normal group, and between the valvular heart disease group and the ASD group (for LAAFAC P < 0.01, for LAAEF P < 0.01, for LAAFS P < 0.01). There was no difference between the normal group and the ASD group. Our study showed that the LAAEF and LAAFS in patients with sinus rhythm obtained via anatomical M-mode echocardiography is a new method, which can be used instead of left atrial appendage area change.

Adult↗
PubMed2006

Evaluation of a novel device for left atrial appendage exclusion: the second-generation atrial exclusion device.

BACKGROUND: The left atrial appendage is a frequent source of thromboemboli in patients with atrial fibrillation. Exclusion of the left atrial appendage may reduce the risk of stroke in patients with atrial fibrillation. The atrial exclusion device, previously developed to perform left atrial appendage exclusion on a beating heart, was modified to accommodate different anatomic patterns of the human left atrial appendage and to ensure uniform pressure and occlusion. The purpose of this study was to evaluate this second-generation atrial exclusion device during a midterm period in a canine model. METHODS: Ten mongrel dogs (mean weight 28.9 +/- 4.6 kg) were used in this study. The atrial exclusion device, constructed from two parallel and rigid titanium tubes and two nitinol springs with a knit-braided polyester fabric, was implanted at the base of the left atrial appendage through a left thoracotomy on a beating heart using a specially designed delivery tool. Dogs were evaluated at 30 days (n = 4) and 90 days (n = 6) by epicardial echocardiography, left atrial and coronary angiography, gross pathology, and histologic inspection. RESULTS: Device implantation was performed without complications in all dogs. Complete left atrial appendage exclusion without device migration or hemodynamic instability was confirmed, and there was no damage to the left circumflex artery or pulmonary artery. Macroscopic and microscopic assessments revealed favorable biocompatibility during midterm follow-up. CONCLUSION: The atrial exclusion device enabled rapid, reliable, and safe exclusion of the left atrial appendage. Clinical application may provide a new therapeutic option for reducing the risk of stroke in patients with atrial fibrillation.

Animals↗
PubMedDate not supplied

Thrombus formation in the left atrial appendage in the course of atrial fibrillation.

BACKGROUND: Thromboembolism in patients with nonvalvular atrial fibrillation is secondary to emboli arising from atrial cavities, particularly left atrial appendage. Stroke Prevention Atrial Fibrillation (SPAF) III study showed washing flow, left appendage ejection fraction, natural echocontrast, and left appendage volume and morphology, as risk parameters of thromboembolism. METHODS: The authors examined 69 patients by transesophageal echocardiography, subdividing them into 3 groups: 26 patients in sinus rhythm in Group A (Gr.A), 22 patients in atrial fibrillation without thrombi in the left atrial appendage in Group B (Gr.B), 21 patients with tromboembolism and with thrombus in the left atrial appendage (Gr.C). RESULTS: Atrial volume in sinus rhythm (SR) patients (41.9 +/- 23.4 cm3) was lower than the one in Gr.B (86.2 +/- 47.9 cm3, p < 0.001) and Gr.C (78.6 +/- 28.5 cm3, p < 0.01), whereas no difference was found between Gr.B and Gr.C (86.2 vs. 78.6 cm3; p > 0.05). No difference was found between Gr.A and Gr.B left atrial appendage fraction (31.8% versus 29.1%, p > 0.05), whereas it was found related to Gr.C (31.8% versus 15.4% p < 0.01). Flow velocity within left atrial appendage was significantly higher in Gr.A in relation to the other two groups (p < 0.001); flow velocity in Gr.B was lower than in Gr.A but higher than in Gr.C and in all cases such differences were statistically significant (p < 0.001). Gr.A flow duration was approximately twice as much compared to the one in Gr.B (616.8 +/- 94.1 msec vs. 483.3 +/- 172.6 msec, p < 0.01), whereas it was approximately four times higher compared to the one in Gr.C (616.8 +/- 94.1 msec vs. 165.7 +/- 53.7 msec; p < 0.001). Such duration, if related to the corresponding cardiac cycle, indicates the percentage of time during which blood flows through a cycle within the left atrial appendage; this value is about 85% of cardiac cycle in Gr.A, while it is 65% in Gr.B (p < 0.01) and about 21% in Gr.C (p < 0.001). CONCLUSIONS: Such results add a new parameter to the ones suggested in the SPAF III study for the evaluation of TE risk, that is flow duration measurement within the left atrial appendage, and its ratio to the cardiac cycle. The availability to measure this parameter, by recording the transesophageal pulse wave sample volume positioned in the atrial appendage, makes the evaluation of TE risk more reliable.

Atrial Appendage↗
PubMed1996

Patterns of Doppler-measured blood flow velocity in the normal and fibrillating human left atrial appendage.

Doppler measurement of left atrial appendage (LAA) blood velocity during transesophageal echocardiography has been proposed as a method of assessing LAA contractile function and thromboembolic risk. Clinical and echocardiographic determinants of five LAA Doppler blood velocity patterns were examined in 40 patients with a history of atrial fibrillation (AF), in 10 control subjects, and in 5 patients aged </=60 years having sinus rhythm and left ventricular hypertrophy. In sinus rhythm, two blood velocity patterns were differentiated by the extent of passive emptying of the LAA, which was related to age and left ventricular early diastolic filling properties. In AF, three blood velocity patterns were differentiated by the relative preservation of LAA mechanical function during fibrillatory activity. LAA contractile function is an important but not the sole determinant of blood flow in the normal and fibrillating human LAA.

Adult↗
PubMed2006

Transesophageal echocardiographic assessment of right atrial appendage anatomy and function: comparison with the left atrial appendage and implications for local thrombus formation.

OBJECTIVES: We sought to define right atrial appendage (RAA) anatomic and functional parameters in a consecutive series of participants and to compare these measures with left atrial appendage (LAA) indices among patients with in sinus rhythm and atrial fibrillation (AF). BACKGROUND: With AF, both atria are fibrillating, yet the vast majority of thrombi are located within the LAA. Transesophageal echocardiography provides anatomic and functional information regarding both the LAA and the RAA. METHODS: In a consecutive series of 92 patients (48 men; age 61 +/- 17 years) referred for transesophageal echocardiography, RAA and LAA anatomy (width, length, area) and ejection velocity were measured at two orientations (RAA, 90 and 135 degrees; LAA, 0 and 90 degrees). RESULTS: RAA anatomic measures were similar for both imaging planes, whereas LAA area was larger at 90 degrees. There was a modest correlation between RAA and LAA anatomic measures (area: r = 0.58, P = .001). RAA neck width was substantially greater than LAA neck width (P < .0001) whereas appendage area was similar (P = not significant) and RAA neck width/area was greater than LAA neck width/area (P < .0001). AF was associated with approximately 50% decline in ejection velocity for both the LAA and the RAA with an increase in LAA area (P = .006 vs sinus), but similar anatomic remodeling was not found for the RAA (P = not significant vs sinus). CONCLUSION: In this consecutive series of patients undergoing transesophageal echocardiography, RAA anatomic and functional parameters were found to be independent of imaging plane, with anatomic measures demonstrating a correlation with LAA measures. Although AF is associated with depressed RAA and LAA ejection velocities, anatomic RAA remodeling appears to be absent. The larger RAA width and lack of anatomic remodeling may partially explain the substantially lower prevalence of RAA thrombus found among patients with AF.

Adult↗
PubMed2006

Mitral annular systolic velocity reflects the left atrial appendage function in mitral stenosis.

BACKGROUND: Left atrial appendage (LAA) dysfunction is an independent predictor of thromboembolism in mitral stenosis (MS). OBJECTIVES: To investigate whether there is a relation between annular velocities obtained by tissue Doppler imaging and LAA function and to determine if the annular velocities can predict the presence of the inactive LAA in MS. METHODS: Eighty-five MS patients and 80 healthy controls were evaluated by transthoracic echocardiography and all patients underwent transesophageal echocardiography. The annular systolic (S-wave) and diastolic (E- and A-waves) velocities were recorded. Inactive LAA was defined as LAA emptying velocity <25 cm/sec. Patients were divided into three groups; group I (n = 43): sinus rhythm (SR) and LAA emptying velocity > or =25 cm/sec, group II (n = 15): SR and LAA emptying velocity <25 cm/sec and group III (n = 27): atrial fibrillation. RESULTS: Thrombus was detected in 12 patients and spontaneous echo contrast (SEC) was detected in 48 patients. Both S-wave and peak LAA emptying velocities were decreasing, while SEC frequency and density were increasing from group I to group III. There was a positive correlation between LAA emptying and S-wave velocities (P < 0.001, r = 0.682). Multivariate regression analysis showed that only S-wave is the independent predictor of inactive LAA (P = 0.001, odds ratio = 0.143, 95% CI = 0.047-0.434). In patients with SR, the cutoff value of S-wave was 13.5 cm/sec for the prediction of the presence of inactive LAA (sensitivity: 95.3%, specificity: 93.3%). CONCLUSIONS: S-wave is an independent predictor of inactive LAA and a useful parameter in estimating inactive LAA in MS with SR.

Adult↗
PubMedDate not supplied

Spontaneous inversion of left atrial appendage.

Inversion of the left atrial appendage is a rare phenomenon and frequently occurs as a complication following cardiac operations. Spontaneous inversion is even rarer, and so far, only three cases have been reported. We report an additional case of spontaneous inversion in 4-month female with Down's syndrome, hypothyroidism, and complete atrioventricular canal defect.

Atrial Appendage↗
PubMed1985

[Congenital aneurysm of the left atrial appendage].

Congenital aneurysm of the left atrial appendage is a rare anomaly, usually presenting in adult life. We report the case of a 31-year-old woman with a marked prominence of the upper left heart border at the chest X-ray in whom the diagnosis of congenital aneurysm of the left atrial appendage was confirmed by cross-sectional echocardiography and computed tomography. Up to few years ago angiography was considered the method of choice in establishing the diagnosis. Cross-sectional echocardiography has recently become a safe and reliable method for diagnosing congenital aneurysm of the left atrium and should be considered in any case with abnormality of the profile of left atrium on the chest radiography.

Adult↗
PubMed2005

Left atrial appendage aneurysm.

Aneurysms of the left atrial appendage are exceedingly rare. Patients most commonly present with atrial tachyarrhythmias and thromboembolism. Resection of the aneurysm is usually curative. We present a case report of a 60-year-old female with a long-standing history of atrial arrhythmias found to have a large left atrial appendage aneurysm with additional bi-atrial enlargement and a family history of atrial arrhythmias. The patient was successfully treated with resection of the aneurysm and a Cox-Maze III procedure.

Arrhythmias, Cardiac↗
PubMed2001

Pulmonary venous drainage into the left atrial appendage facilitates transplantation of the left lung with difficult exposure.

Heterotopic implantation of the pulmonary venous confluence into the left atrial appendage during left lung transplantation is a reasonable alternative technique to reestablish venous drainage when exposure of the native left pulmonary veno-atrial connection may be problematic. We used this approach in a 39-year-old woman with chronic bronchiectasis who underwent bilateral sequential lung transplantation through a clam-shell approach. Dense hilar scarring and a small left atrial size made exposure of the native left pulmonary veno-atrial connection difficult.

Adult↗
PubMed2004

Transesophageal investigation of surgically ligated left atrial appendage.

Surgical ligation of the left atrial appendage is often performed during heart surgery for various diseases like mitral prosthesis implantation, mitral valve repair, and even coronary artery revascularization, mainly to prevent thrombus formation and systemic embolism in patients with atrial fibrillation. However surgical ligation is sometimes incomplete, thereby exposing the patient to residual embolic risk. We report two cases of surgical ligation of the left atrial appendage focusing on the transesophageal echographic aspects of complete or incomplete closure of the appendage.

Aged↗
PubMed1981

Congenital aneurysm of left atrial appendage.

Congenital aneurysm of the left atrial appendage is a rare anomaly, usually presenting in adult life. The case reported is that of a 55-year-old man who died of cerebral embolism originating from a thrombus in a congenital aneurysm of the left atrial appendage. The cardiac silhouette 11 years previously had suggested a cardiac tumour or a pericardial cyst. As judged frm 14 published cases, the major manifestations of these aneurysms are an abnormal cardiac silhouette in the x-ray, supraventricular tachycardia, and systemic embolism. Angiocardiography appears to be the method of choice in establishing the diagnosis. Resection of th aneurysm is the recommended form of treatment.

Adult↗
PubMed2002

Assessment of the left atrial appendage mechanical function by three-dimensional echocardiography.

AIMS: We evaluated the feasibility of three-dimensional echocardiography, in the assessment of left atrial appendage (LAA) function. METHODS AND RESULTS: Forty-five patients underwent multiplane transoesophageal echocardiography. In addition to Doppler and two-dimensional echocardiography, data for three-dimensional echocardiography reconstruction were obtained during transoesophageal echocardiography. Left atrial appendage ejection fraction based on three-dimensional echocardiography volume measurements (EFv) and two-dimensional echocardiography area measurements (EFa), coupled with other echocardiographic data, were related to left atrial appendage late peak emptying velocity, a frequently used indicator of left atrial appendage function. Multiple regression analysis has revealed a significant association of peak emptying velocity with EFv (P<0.0001), spontaneous echocardiographic contrast (P=0.001), tricuspid regurgitation (P=0.03) and left ventricular hypertrophy (P=0.05). No significant relation was observed between peak emptying velocity and EFa, presence or absence of atrial fibrillation, left ventricular dysfunction, mitral stenosis and insufficiency, left atrial dilatation, pulmonary venous peak systolic, diastolic and peak reverse flow velocity at atrial contraction as well as left atrial appendage volumes derived from two-dimensional echocardiography and three-dimensional echocardiography. In a simple linear correlation, the degree of association between peak emptying velocity and EFv was higher as between peak emptying velocity and EFa (r=0.7 vs 0.4, both P<0.001). Observer variabilities for calculating EFv were considerably lower than for two-dimensional echocardiography derived EFa. Ejection fractions determined by two-dimensional echocardiography area measurements at 45 degrees, 90 degrees and 135 degrees cutplane angulations were related to EFv only at 135 degrees. CONCLUSIONS: Left atrial appendage ejection fraction calculation by three-dimensional echocardiography is feasible, more accurate than by two-dimensional echocardiography and has lower observer variability. Furthermore, an optimal cutplane angulation of the left atrial appendage view at 135 degrees has been demonstrated.

Adult↗