Evaluation of left atrial appendage function and thrombi in patients with atrial fibrillation: from transthoracic to real time 3D transesophageal echocardiography

Abstract

The detection of embolic sources in patients with atrial fibrillation (AF) is important to guide anticoagulant therapy. Two-dimensional transesophageal echocardiography (TEE) is the gold standard to study left atrial appendage (LAA) anatomy and morphology, despite some false-positive diagnosis. We hypothesized that real time 3D TEE (RT3DTEE) is superior to 2DTEE in detecting and/or excluding LAA thrombi. We studied 93 patients with non-valvular AF (60 males, age = 67.1 ± 14.2 years) referred for electric cardioversion with transthoracic, 2DTEE and RT3DTEE. Before cardioversion, TTE allowed a confident measurement of emptying velocity of LAA (LAAeV) only in 59/93 patients (63%). On the contrary a good quality TEE LAAeV was obtained in all patients with 49/93 (53%) dysfunctional LAA (LAAeV < 40 cm/s). A subgroup of 5 patients (7.2% of the 69 effective cardioversion) presented a persistent dysfunction after cardioversion (with LAAeV values of <40 cm/s on the TEE post-CV). TEE allowed to observe a bilobed shape in 45 patients (48.4%) and three lobes in 22 patients (23.7%). In addition, besides to several additional findings, 2DTEE managed to detect thrombi with certainty in 8/93 patients (8.6%). In other 5 cases with diagnostic doubts for thrombi with 2DTEE (5/93 patients: 5.4%), the addition of the RT3DTEE mode allowed to discriminate with certainty the presence of just pectinate muscles in 4 patients RT3DTEE in patients with AF at risk of embolism is feasible, accurate and showed an additional diagnostic capability in the differential diagnosis of selected cases with suspected LAA thrombi.

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

“…In fact, though transthoracic (TTE) and transoesophageal echocardiography (TEE) are available in the clinic to measure the blood flow velocity in both the LA and the LAA, both techniques can only provide average information on the velocity magnitude and direction in the sampling volume, without being able to give detailed spatial 3D information on the local flow conditions (30, 31). Ideally, 4D flow MR could provide similar information as the CFD analysis, but the spatial resolution, typically larger than 1 mm voxel, is not sufficient to assess a small region such as the LAA, and is thus not yet suitable for clinical applications (32).…”

Numerical Simulation of the Influence of Geometric Configurations on Pressure Difference in the Intraventricular Tunnel

“…Some studies have demonstrated the effect of IVT morphology on the surgical outcome, however no study to our knowledge has ever included hemodynamic analysis of IVT morphology to investigate the effect of IVT morphology on the P. The main reason why we adopted the CFD analysis was that computational modeling enabled a quantitative analysis of fluiddynamic parameters, such as velocity streamlines and pressure, which were impossible to measure non-invasively in clinics with sufficient accuracy. In fact, although transthoracic (TTE) and transoesophageal echocardiography (TEE) are available in the clinic to measure the blood flow velocity in IVT, both techniques can only provide average information on the velocity magnitude and direction in the sampling volume, without being able to give detailed spatial 3D information on the local flow conditions (Fukuda et al, 2003;Dentamaro et al, 2017). Therefore, it is impossible to accurately evaluate the hemodynamics of IVT morphology.…”

Safety of Edoxaban 30 mg in Elderly Patients with Severe Renal Impairment

“…Additionally, elevated levels of inflammatory markers have been reported in CKD even in its early stages [18,19], underlining that inflammation plays a significant role in predicting progression of kidney dysfunction and in the pathogenesis of AF [20,21]. Imaging techniques such as echocardiography could be helpful to evaluate morphological and functional cardiac indicators of thromboembolic risk in patients with CKD [22][23][24], especially in cases of treatment with vitamin K antagonists out of therapeutic range or with NOACs in the presence of poor compliance [25,26].…”