Left atrial appendage morphology and risk of stroke following pulmonary vein isolation for drug-refractory atrial fibrillation in low CHA2DS2Vasc risk patients

Abstract

BackgroundCardiac CT angiography (CCTA) has become an important adjunct in the structural assessment of the pulmonary veins (PV) prior to pulmonary vein isolation (PVI). Published data is conflicting regarding a relationship between left atrial appendage (LAA) and the risk of ischemic stroke (CVA) following PVI. We investigated the associations of volumetric and morphologic left atrial (LA) and LAA measurements for CVA following PVI.MethodsWe retrospectively reviewed 332 consecutive patients with drug refractory atrial fibrillation who obtained cardiac CT angiogram (CCTA) prior to PVI. Baseline demographic data, procedural and lab details, and outcomes were obtained from abstraction of an electronic medical records system. LA, LAA, and PV volumes were measured using CCTA datasets utilizing a semi-automated 3D workstation application. LAA morphology was assigned utilizing volume rendered images as previously described.ResultsThe study cohort was 55 ± 13 years-old, 83.7% male, low CVA risk (median CHA2DS2Vasc 1; IQR 1, 3), and 30.4% were treated with novel oral anticoagulants. Chicken wing (CW) was the most common morphology (52%), followed by windsock (WS), cauliflower (CF), and cactus (CS) at 18, 9, and 2%, respectively. CVAs occurred in 4 patients following PVI with median time to CVA of 170.5 days. All CVAs were observed in CW morphology patients. When comparing CW morphology with non-CW morphology, CVAs occurred more frequently with the CW morphology (2.1% vs 0%, p = 0.03). This difference was not significant, though, after adjusting for CHA2DS2Vasc risk factors (p = 0.14).ConclusionThe CW morphology was observed more commonly in patients who experienced post-PVI CVA. After adjusting for CHA2DS2Vasc risk factors, CW morphology was not an independent predictor of post-PVI CVA. These findings should be interpreted in the setting of a low CVA event rate amongst a low risk population that was highly compliant with indicated anticoagulation therapy.

One-stop strategy for treatment of atrial fibrillation: feasibility and safety of combining catheter ablation and left atrial appendage closure in a single procedure

“…[ 29 ] In contrast, a study from the United States reported chicken wing type as the most common LAA morphology. [ 30 ] Racial differences as well as selective bias might contribute to the discrepancy which needs further verification.…”

Value of speckle tracking echocardiography for prediction of stroke risk in atrial fibrillation: Time to spare a stare outside the box?

“…On the other hand, there is a lack of evidence to support LAA closure in patients not suitable for anticoagulation . It may also be noted that even after pulmonary venous isolation (PVI), yet another invasive tool to maintain sinus rhythm, protection from stroke, may be lacking despite treatment with oral anticoagulation . PVI may lead to atrial fibrosis and atrial remodelling thereby acting as a trigger to sustain AF even after successful ablation .…”

“…14 It may also be noted that even after pulmonary venous isolation (PVI), yet another invasive tool to maintain sinus rhythm, protection from stroke, may be lacking despite treatment with oral anticoagulation. 16 PVI may lead to atrial fibrosis and atrial remodelling thereby acting as a trigger to sustain AF even after successful ablation. 17 The available data therefore indicate that there are some unmet needs in caring for subjects with AF.…”

Left atrial appendage thrombosis in atrial fibrillation - current status of the problem

“…Статистически значимой взаимосвязи морфологии УЛП и риска инсульта не выявили M.Korhonen et al [32]. В исследовании F.R.Kelly et al продемонстрировано, что анатомическая форма УЛП «куриное крыло» является независимым фактором риска развития ОНМК после операции изоляции легочных вен [33].…”