Modification of the left atrial appendage and its role in stroke risk reduction with non-valvular atrial fibrillation

Rashid, Hytham; Layland, Jamie

doi:10.1016/j.ijcha.2020.100688

Cited by 8 publications

(7 citation statements)

References 52 publications

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“…Yosefy et al [ 10 ] recently studied a cohort of patients in atrial fibrillation and reported in diabetics, but not in non-diabetics, the occurrence of remodeling of the LAA, which increases the risk for clot formation and thromboembolism. Remodeling of the LAA has previously been attributed to atrial fibrillation [ 11 – 13 ]. Does diabetes by itself predispose to LAA remodeling, unrelated to atrial fibrillation?…”

Section: Introductionmentioning

confidence: 99%

Diabetes induces remodeling of the left atrial appendage independently of atrial fibrillation in a rodent model of type-2 diabetes

Yosefy

Sharon

Yagil

et al. 2021

Cardiovasc Diabetol

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Background Diabetic patients have an increased predisposition to thromboembolic events, in most cases originating from thrombi in the left atrial appendage (LAA). Remodeling of the LAA, which predisposes to thrombi formation, has been previously described in diabetic patients with atrial fibrillation, but whether remodeling of the LAA occurs in diabetics also in the absence of atrial fibrillation is unknown. To investigate the contribution of diabetes, as opposed to atrial fibrillation, to remodeling of the LAA, we went from humans to the animal model. Methods We studied by echocardiography the structure and function of the heart over multiple time points during the evolution of diabetes in the Cohen diabetic sensitive rat (CDs/y) provided diabetogenic diet over a period of 4 months; CDs/y provided regular diet and the Cohen diabetic resistant (CDr/y), which do not develop diabetes, served as controls. All animals were in sinus rhythm throughout the study period. Results Compared to controls, CDs/y developed during the evolution of diabetes a greater heart mass, larger left atrial diameter, wider LAA orifice, increased LAA depth, greater end-diastolic and end-systolic diameter, and lower E/A ratio—all indicative of remodeling of the LAA and left atrium (LA), as well as the development of left ventricular diastolic dysfunction. To investigate the pathophysiology involved, we studied the histology of the hearts at the end of the study. We found in diabetic CDs/y, but not in any of the other groups, abundance of glycogen granules in the atrial appendages , atria and ventricles, which may be of significance as glycogen granules have previously been associated with cell and organ dysfunction in the diabetic heart. Conclusions We conclude that our rodent model of diabetes, which was in sinus rhythm, reproduced structural and functional alterations previously observed in hearts of human diabetics with atrial fibrillation. Remodeling of the LAA and of the LA in our model was unrelated to atrial fibrillation and associated with accumulation of glycogen granules. We suggest that myocardial accumulation of glycogen granules is related to the development of diabetes and may play a pathophysiological role in remodeling of the LAA and LA, which predisposes to atrial fibrillation, thromboembolic events and left ventricular diastolic dysfunction in the diabetic heart.

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Section: Introductionmentioning

confidence: 99%

Diabetes induces remodeling of the left atrial appendage independently of atrial fibrillation in a rodent model of type-2 diabetes

Yosefy

Sharon

Yagil

et al. 2021

Cardiovasc Diabetol

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“…Percutaneous or surgical LAAO minimizes the contractility of the LAA, which eventually reduces the risk of clot formation. Patients with non-valvular AF also have a 10% risk of intramural thrombus, which increases the need for modification of the LAA [49] . Patients with AF and a known history of atrial fibrosis have a high propensity for ischemic/hemorrhagic stroke and transient ischemic attacks.…”

Section: Discussionmentioning

confidence: 99%

Outcomes of cardiac surgery with left atrial appendage occlusion versus no Occlusion, direct oral Anticoagulants, and vitamin K Antagonists: A systematic review with Meta-analysis

Nso

Nassar

Lakhdar

et al. 2022

IJC Heart & Vasculature

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“…The extent to which the LA dilates secondary to impaired LV diastolic function is determined not only by LAP, but also intrinsic LA compliance, general hydration/volume status and compliance of the left atrial appendage to help off-load LAP [ 80 ]. Therefore, because the relationship between LA volume and pressure is not linear, a specific LAP does not correlate directly with a specific LA volume.…”

Section: Echocardiographic Measurements: Routine Supplementary and No...mentioning

confidence: 99%

The assessment of left ventricular diastolic function: guidance and recommendations from the British Society of Echocardiography

Robinson,

Ring,

Oxborough

et al. 2024

Echo Res Pract

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Impairment of left ventricular (LV) diastolic function is common amongst those with left heart disease and is associated with significant morbidity. Given that, in simple terms, the ventricle can only eject the volume with which it fills and that approximately one half of hospitalisations for heart failure (HF) are in those with normal/’preserved’ left ventricular ejection fraction (HFpEF) (Bianco et al. in JACC Cardiovasc Imaging. 13:258–271, 2020. 10.1016/j.jcmg.2018.12.035), where abnormalities of ventricular filling are the cause of symptoms, it is clear that the assessment of left ventricular diastolic function (LVDF) is crucial for understanding global cardiac function and for identifying the wider effects of disease processes. Invasive methods of measuring LV relaxation and filling pressures are considered the gold-standard for investigating diastolic function. However, the high temporal resolution of trans-thoracic echocardiography (TTE) with widely validated and reproducible measures available at the patient’s bedside and without the need for invasive procedures involving ionising radiation have established echocardiography as the primary imaging modality. The comprehensive assessment of LVDF is therefore a fundamental element of the standard TTE (Robinson et al. in Echo Res Pract7:G59–G93, 2020. 10.1530/ERP-20-0026). However, the echocardiographic assessment of diastolic function is complex. In the broadest and most basic terms, ventricular diastole comprises an early filling phase when blood is drawn, by suction, into the ventricle as it rapidly recoils and lengthens following the preceding systolic contraction and shortening. This is followed in late diastole by distension of the compliant LV when atrial contraction actively contributes to ventricular filling. When LVDF is normal, ventricular filling is achieved at low pressure both at rest and during exertion. However, this basic description merely summarises the complex physiology that enables the diastolic process and defines it according to the mechanical method by which the ventricles fill, overlooking the myocardial function, properties of chamber compliance and pressure differentials that determine the capacity for LV filling. Unlike ventricular systolic function where single parameters are utilised to define myocardial performance (LV ejection fraction (LVEF) and Global Longitudinal Strain (GLS)), the assessment of diastolic function relies on the interpretation of multiple myocardial and blood-flow velocity parameters, along with left atrial (LA) size and function, in order to diagnose the presence and degree of impairment. The echocardiographic assessment of diastolic function is therefore multifaceted and complex, requiring an algorithmic approach that incorporates parameters of myocardial relaxation/recoil, chamber compliance and function under variable loading conditions and the intra-cavity pressures under which these processes occur. This guideline outlines a structured approach to the assessment of diastolic function and includes recommendations for the assessment of LV relaxation and filling pressures. Non-routine echocardiographic measures are described alongside guidance for application in specific circumstances. Provocative methods for revealing increased filling pressure on exertion are described and novel and emerging modalities considered. For rapid access to the core recommendations of the diastolic guideline, a quick-reference guide (additional file 1) accompanies the main guideline document. This describes in very brief detail the diastolic investigation in each patient group and includes all algorithms and core reference tables.

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Modification of the left atrial appendage and its role in stroke risk reduction with non-valvular atrial fibrillation

Abstract: Highlights Evidence on surgical LAA excision has been limited to retrospective studies and registries. Surgical LAA excision is associated with high rates of post-operative atrial fibrillation burden. Watchman is equivalent to oral anticoagulants in high-bleeding risk AF patients.

Cited by 8 publications

References 52 publications

Diabetes induces remodeling of the left atrial appendage independently of atrial fibrillation in a rodent model of type-2 diabetes

Diabetes induces remodeling of the left atrial appendage independently of atrial fibrillation in a rodent model of type-2 diabetes

Outcomes of cardiac surgery with left atrial appendage occlusion versus no Occlusion, direct oral Anticoagulants, and vitamin K Antagonists: A systematic review with Meta-analysis

The assessment of left ventricular diastolic function: guidance and recommendations from the British Society of Echocardiography

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