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  •    Left Atrial Appendage Morphology and Silent Cerebral Ischemia in Patients with Atrial Fibrillation
    Ajay Vallakati , Metrohealth Medical Center, Case Western Reserve University, Ohio

    Turin, Italy: Patients with AF have 5 times increased risk of symptomatic stroke compared to the general population. A recent study showed there is a correlation between morphology of left atrial appendage (LAA) and risk of stroke in AF patients (1). Another study by the same group attempted to determine whether LAA morphology is related to burden of silent cerebral ischemia in patients with AF(2)

    This was a multicenter retrospective study in which 359 AF patients undergoing catheter ablation were screened. LAA morphology was assessed by cardiac magnetic resonance (MR) or computed tomography (CT) and classified into 1) cactus LAA 2) chicken wing LAA 3) wind sock LAA and 4) cauliflower LAA. Eleven patients were excluded due to poor quality of CT/MR images. Silent cerebral ischemia (SCI), defined as focal sharply demarcated hypertintense (on T2 FLAIR weighted) or iso-intense lesions (on T1-weighted), was assessed by cerebral MR. Dimensions of left atrium, LAA and its orifice as well as LAA peak flow speed were determined by echocardiography(TTE/TEE) and CT/MR.

    The frequency of different types of LAA was as follows: 1) cactus 52 (14.9%), 2) chicken wing type 177 (50.9%), 3) wind sock type 101 (29.0%) and cauliflower type 18 (5.2%). SCI was noted in 295 (84.8%) patients. Median SCI burden was 23 (IQR 6-43). SCI burden was divided into four quartiles (1st quartile - ? 6, 2nd quartile 7-23, 3rd quartile 24-43, 4th quartile ? 44).

    SCI burden was significantly related to LA antero-posterior (p=0.0035) and supero-inferior diameter (p=0.01).There was significant association of SCI burden with LAA type (p =0.28). Around 30% patients with cactus and chicken wing type LAA were in the 1st quartile in contrast to 14% and 17% patients with windsock and cauliflower types respectively. On the other hand, the percent of patients in fourth quartile were as follows (cactus – 17.3%, chicken wing-22%, windsock -27.7% and cauliflower 38.9%). Multivariate analysis showed there was significant positive correlation of SCI burden with age (p<0.001), windsock type ( p =0.005) , cauliflower type ( p=0026) and negative association with cactus type (p<0.001) and chicken wing type(p =0.021).

    The authors hypothesize that complex internal anatomy of cauliflower and windsock type LAA leads to increased blood stasis and thrombogenesis when compared simple LAA anatomy of chicken wing and cactus type LAA. As SCI has been shown to predict symptomatic strokes, the authors suggest that therapies directed at reduction/prevention of SCI may prevent early cerebral damage in AF patients. The authors state that more research to support this association between LAA morphology and thrombo-embolic events may improve risk stratification particularly in “low risk” AF patients.

    Reference: 1. Di Biase L, Santangeli P, Anselmino M et al. Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation?: results from a multicenter study. J Am Coll Cardiol. 2012 Aug 7;60(6):531-8.
    2.Anselmino M, Scaglione M, Di Biase L et al. Left atrial appendage morphology and silent cerebral ischemia in patients with atrial fibrillation. Heart rhythm : the official journal of the Heart Rhythm Society 2014;11:2-7.

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