Search Results (82)

Background: The term ‘left atrial appendage aneurysm’ (LAAA) has been recognized since 1962, when it was first described. It is an exceedingly rare pathology that can affect both adults and children. Often asymptomatic, it may be discovered incidentally. The anomaly consists of an exaggerated dilation of the primitive portion of the left atrium, resulting from pectinate muscle dysplasia or as a consequence of an obstructive lesion between the left atrium and the mitral valve. Surgical intervention represents a reliable strategy for preventing catastrophic complications such as stroke, thromboembolism, and rupture. This is a very rare condition, which is why we aimed to present a case report along with a review of the literature. Case presentation: We report the case of a 6-year-old asymptomatic girl in whom a giant left atrial appendage aneurysm was incidentally detected during a routine transthoracic echocardiogram, associated with a small atrial septal defect and a prothrombotic genetic profile. The aneurysm was successfully excised, and the atrial septal defect was closed. The postoperative course was uneventful, and the patient was discharged home on the 8th postoperative day. Conclusions: Left atrial appendage aneurysm is rare in children and often asymptomatic, yet it may be life-threatening due to stroke or thromboembolism. Fetal echocardiography may be considered in selected high-risk pregnancies, and routine postnatal assessment is advised, with surgical intervention recommended particularly for patients with risk factors for thrombus formation in the left atrium or its appendage. Full article

Background: Large vessel occlusion (LVO) strokes account for a significant proportion of ischemic strokes and are often cardioembolic in origin, particularly following atrial fibrillation (AF) with thrombus formation in the left atrial appendage (LAA). Although direct oral anticoagulation (DOAC) therapy reduces stroke risk in AF, anatomical and flow-related factors may still allow thrombi to form and persist, revealing the limitations of anticoagulation in high-risk patients. Examining structural and hemodynamic factors contributing to thrombus persistence is essential for optimizing patient management. Methods: We retrospectively analyzed 169 AF patients with LVO stroke who underwent cardiac CT (cCT) during acute stroke assessment. Patients were categorized based on the presence or absence of persistent LAA thrombi and further stratified by DOAC status. LAA volume, blood stasis and left ventricular (LV) diameter were measured. Thrombi were assessed using Hounsfield Unit (HU) analysis to evaluate potential differences in thrombus composition. Logistic regression analysis was performed to identify independent predictors of thrombus persistence with adjustment for DOAC therapy. Results: Persistent LAA thrombi were identified in 23 patients (13.6%). Patients with thrombi had significantly higher rates of stasis (p = 0.004), larger left ventricular diameters (p = 0.0019) and higher LAA volumes (p = 0.004). When adjusted for DOAC therapy, larger LAA volume (OR 1.05, p = 0.011), presence of LAA stasis (OR 6.14, p = 0.013) and increased LV diameter (OR 1.06, p = 0.006) were independent predictors of thrombus persistence. Thrombus size and HU values did not differ significantly between DOAC and non-DOAC groups. Notably, 30.4% of patients with persistent thrombi were on adequate DOAC therapy. Conclusions: LAA volume, stasis and LV enlargement predict thrombus persistence in the LAA of AF patients with LVO stroke, even under adequate DOAC therapy. These findings highlight the potential need for alternative antithrombotic strategies, including interventional LAA occlusion, and warrant further investigation into individualized stroke prevention in high-risk AF populations. Full article

Background: Cardiac surgery patients with pre- or post-operative atrial fibrillation are at an increased risk for thromboembolic stroke, often due left atrial appendage (LAA) thrombus. Surgical LAA exclusion (LAAE) can be performed and must be complete to avoid increased thrombus formation. Methods: This prospective, multi-center, post-market study (NCT05101993) evaluated the long-term safety and performance of the epicardial V-shape AtriClip device. Patients ≥18 years who had received V-shape AtriClip devices during non-emergent cardiac surgery consented to a prospective 12-month follow-up visit and LAA imaging. The primary performance was LAAE without residual left atrium-LAA communication, assessed by imaging at the last follow-up visit. The primary safety was device- or implant procedure-related serious adverse events (SAEs) (death, major bleeding, surgical site infection, pericardial effusion requiring intervention, myocardial infarction) within 30 days. Results: Of 155 patients from 11 U.S. centers, 151 patients had evaluable imaging. Complete LAAE was obtained in all patients. Primary performance in the intent-to-treat population was met, with 97% (95% CI 93.52%, 99.29%; p = 0.0001) complete LAAE. Primary safety was met, with 100% (95% CI 97.75%, 100%; p < 0.0001) of patients free from pre-defined SAEs within 30 days. One device-related SAE was reported, which resolved intraprocedurally. Conclusions: AtriClip V-Clip showed safe and successful LAAE through 12 months of follow-up. Full article

Background: Direct oral anticoagulants (DOACs) are generally preferred over warfarin for preventing arterial and venous thromboembolism. However, the efficacy and safety of DOACs in patients with extremely low body weight (BW) are uncertain. This study investigates anti-factor Xa (anti-FXa) activity of apixaban and compares it between patients with normal BW (>50 kg) and underweight (≤50 kg). Methods: We enrolled 150 patients on branded generic apixaban (Apixan^TM) for atrial fibrillation (AF), venous thromboembolism, and intracardiac thrombus. Anti-FXa activity of apixaban was measured at peak concentration (C_peak) and trough concentration (C_trough) after at least one week of therapy. Results: Mean age was 64.0 ± 12.7 years, with 53.3% being male. Mean BW was 61.3 ± 15.3 kg. Of the 150 patients, 132 (88%) had AF, and 43 (28.7%) had low BW. Overall, 87.3% and 84.7% of patients had C_trough and C_peak within the expected range. Underweight patients had significantly higher mean C_trough and C_peak than normal BW patients. A higher proportion of low-BW patients exceeded the expected C_peak range compared to normal-BW patients (25.6% vs. 3.7%, p < 0.001). Low BW was the only independent predictor of exceeding C_peak specified range (adjusted OR 4.87, 95% CI 1.31–18.15, p = 0.018). Conclusions: Most patients maintained apixaban levels within expected ranges, but those with low BW were more likely to exceed the specified range of C_peak. Full article

Background/Objectives: Extracellular volume (ECV) expansion reflects myocardial fibrosis and may play a role in subjects with severe aortic stenosis (AS) receiving transcatheter aortic valve implantation (TAVI). This study aimed to assess the relationship between cardiovascular risk factors (CVRF), AS severity and left ventricular myocardial ECV measured by cardiac computed tomography (CCT). Methods: 61 patients qualified for TAVI underwent pre-procedural CCT. CVRFs were recorded, including advanced age, male gender, obesity, hypertension, hypercholesterolemia, hypertriglyceridemia, type 2 diabetes, and smoking. The CCT protocol included non-contrast (for aortic valve calcium score, AVCS), angiographic (for vascular access planning), and delayed phases (for left atrial appendage thrombus assessment). ECV was calculated from attenuation values of the interventricular septum and left ventricular cavity assessed in native and delayed phases. Patients were stratified based on the presence/absence of individual CVRFs, median AVCS, and aortic valve area (AVA). Results: Mean ECV was higher in patients with hypertension (28.01% vs. 26.93%, p = 0.03), smokers (28.71% vs. 26.52%, p = 0.01), AVCS ≥ 2975 (28.08% vs. 26.95%, p = 0.02), and AVA < 0.95 cm² (28.63% vs. 26.53%, p = 0.01). Positive correlations were found between ECV and the number of CVRFs (r = 0.49, p = 0.01), BMI (r = 0.30, p = 0.01), systolic BP (r = 0.31, p = 0.02), and AVCS (r = 0.36, p = 0.01); AVA correlated negatively (r = −0.59, p = 0.01). Regression showed that hypertension, smoking, and smaller AVA were independent predictors of higher ECV. Conclusions: Among TAVI candidates, hypertension, smoking, and more advanced AS are independently associated with increased myocardial ECV on CCT. These findings may reflect subclinical myocardial remodeling and support the added diagnostic value of ECV in pre-TAVI assessment. Full article

Objective: This study aims to investigate the correlation between the morphological and functional characteristics of the left atrial appendage (LAA) and the incidence of thromboembolic events by transesophageal echocardiography (TEE) in patients with acute ischemic stroke. Methods: This cross-sectional study included 171 patients with acute ischemic stroke, running from November 2022 to September 2024. Transesophageal echocardiography was performed to evaluate the presence of LAA thrombus. Multivariable logistic regression analysis was performed to identify risk factors for LAA thrombus. Results: Of the 171 patients, 19 (11.1%) were found to have LAA thrombus. Multivariable logistic regression identified two independent predictors of LAA thrombus formation: (1) left atrial spontaneous echo contrast (OR = 8, 95% CI: 3–19, p < 0.001) and (2) atrial fibrillation (OR = 8, 95% CI: 1.057–76.095, p = 0.044). Conclusions: Left atrial spontaneous echo contrast and atrial fibrillation are independent predictors of LAA thrombus in patients with acute ischemic stroke. The use of transesophageal echocardiography for early detection of LAA thrombus may help improve treatment strategies and prevent recurrent strokes. Full article

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in adults and is associated with significant morbidity and mortality, including an increased risk of stroke, heart failure, dementia, and recurrent hospitalizations. As life expectancy rises, both the incidence and prevalence of AF continue to grow. Stroke prevention remains a cornerstone of AF management, with oral anticoagulation being the primary strategy to reduce thromboembolic risk. However, despite their advantages, direct oral anticoagulants do not completely eliminate the risk of bleeding complications. For patients in whom anticoagulation is contraindicated, poorly tolerated, or ineffective at preventing AF-related stroke, interventional alternatives have gained traction. The left atrial appendage (LAA), a primary site of thrombus formation in AF, can be occluded through a catheter-based procedure known as left atrial appendage closure (LAAC) or left atrial appendage occlusion (LAAO). This review aims to provide imaging specialists with a comprehensive understanding of their role in LAAC, underscoring the importance of a multidisciplinary approach to enhance patient selection, procedural success, and long-term efficacy. Full article

The CHA₂DS₂-VASc score is the most widely used and recognized method for stroke risk stratification in atrial fibrillation (AF) patients. However, some patients with low scores still experience strokes. Given that 90% of cardiogenic strokes are caused by thrombus in the left atrial appendage (LAA), it is essential to incorporate hemodynamic and geometric features of the LAA into existing risk stratification models. This review first evaluates current stroke and bleeding risk stratification strategies, then analyzes the geometric and hemodynamic parameters within the left atrium and LAA, and finally compares the methods and techniques available for acquiring these parameters. Through these retrospective analyses, insights and recommendations for the management of AF patients and stroke prevention are provided. Outlooks on future research directions, such as the exploration of the mechanism of thrombus detachment, are discussed. Full article

Background/Objectives: Atrial fibrillation is a frequent comorbidity amongst patients undergoing mitral valve transcatheter edge-to-edge repair (M-TEER) for mitral regurgitation. Left atrial appendage occlusion (LAAO) can be performed to reduce the risk of stroke in patients with atrial fibrillation. Both procedures require large-bore venous access, transseptal puncture, and real-time imaging of the left atrium. However, limited data exist evaluating the safety and feasibility of concomitant M-TEER and LAAO. Methods: We performed a retrospective review of all concomitant M-TEER and LAAO procedures at our institution between May 2019 and September 2024 to evaluate the safety and feasibility of this approach. Results: Concomitant left atrial appendage occlusion was successful in all 15 patients, requiring an additional 15 min (IQR 11–29) of procedural time. No patients died or had a major vascular complication. Routine transesophageal echocardiography performed within 90 days showed no device related thrombus, and no significant peri-device leak in any patients. Conclusions: Concomitant M-TEER and LAAO are feasible but additional prospective studies or randomized trials are needed to evaluate the potential clinical benefit. Full article

Background: Atrial septal defect (ASD) is a prevalent congenital heart condition, resulting in left-to-right shunting. Untreated ASDs may be associated with complications, including right-sided heart failure, pulmonary hypertension, and atrial arrhythmias. Percutaneous ASD closure, performed with various occluder devices, has become the preferred approach for symptomatic patients with suitable anatomy, yet data on device-specific efficacy and safety profiles remain limited. Methods: This study was a retrospective, single-center analysis involving patients who underwent percutaneous ASD closure between January 2000 and February 2023. Data on patient characteristics, indications for the procedure, procedural details, and clinical outcomes were extracted from electronic medical records. Endpoints included complications at the puncture site, pericardial effusion, atrial arrhythmias, device-related thrombus formation, and overall survival. Results: A total of 195 patients were included (mean age 53.6 ± 16.2 years; 60.5% female). Three different devices were used: Amplatzer ASD occluder (n = 111), Gore Septal Occluder (n = 67), and Occlutech ASD occluder (n = 17). Initial procedural success rate was 90.8%, with no significant differences observed between devices. Periprocedural complication rates were low and comparable across all devices. New-onset atrial fibrillation within the first month post-implantation occurred in 7.5% of patients with the Gore device, compared to 0.9% with the Amplatzer device (p = 0.03) and 0% with the Occlutech device. No statistically significant differences were observed among the devices regarding thrombus formation, late-onset pericardial effusion, device erosion, or stroke. Conclusions: Percutaneous ASD closure demonstrates high procedural success and low complication rates across different occluder devices, supporting its efficacy and safety as a treatment for adults. Although the Gore device showed a higher incidence of new-onset AF compared to the Amplatzer device, no significant differences were observed regarding thrombus formation, pericardial effusion, device erosion or stroke. Full article

Introduction: Due to the aging population, the number of elderly patients with atrial fibrillation and contraindications for anticoagulation due to bleeding complications is growing. After the epicardial ligation of the left atrial appendage (LAA), anticoagulation can be omitted. We present the single-center procedure data and long-term data of octogenarians being treated with LARIAT^®. Method: Out of 145 patients eligible for the epicardial ligation of the LAA, 45 were older than 80 y and included in this analysis. After successful ligation, patients were screened at 6 weeks of follow-up (FUP), at 12 weeks and after 12 months for transesophageal echocardiography (TOE) and clinical events. During long-term FUP, TOE sessions and clinical events for embolic events and death were documented. Results: The procedure was successful in 93% of patients, with a mean CHA₂DS₂VASC score of 4.6 and HASBLED score of 3.7 and a mean age of 82 y. One major complication occurred, with the laceration of the LAA and surgical closure of the LAA with an Atriclip. The 6-week FUP data were available in 39 patients, with the detection of four leaks (1–3 mm, median 2 mm) and three thrombi; one thrombus occurred at the site of a leak. The 12-week FUP (in 26 patients) showed that three leaks were closed, one leak persisted and one new thrombus developed at the site of the leak. All thrombi were resolved. The 12-month FUP showed the persistent resolution of three thrombi; one thrombus recurred after the withdrawal of the anticoagulant, and no new gap or thrombus could be detected. The long-term FUP (mean 38 months) was documented in 30 patients, with no new gaps and no new thrombi; one patient suffered from a stroke, with a good long-term result of LAA closure in TOE (stroke rate 1%/y, absolute risk reduction of 4.4% to a stroke rate of 5.4% related to the score, relative CHA₂DS₂VASC risk reduction of 88%). Eleven patients died: four in the first year of ligation and seven during long-term FUP. Conclusions: The epicardial ligation of the LAA for stroke prevention in octogenarians is highly safe and effective. Early TOE FUP is crucial for the detection of thrombi and establishing an optimal anticoagulation regime. No late development of thrombi or gaps can be observed at up to 5 years. Full article

With FDA-approved devices, left atrial appendage (LAA) occlusion has emerged as a well-established and rapidly growing approach to stroke prevention in patients with non-valvular atrial fibrillation. These devices are indicated for use in patients who are at increased risk of stroke and systemic embolism, as determined by CHA₂DS₂-VASc scores, and are suitable for anticoagulation therapy, with an appropriate rationale for seeking a non-pharmacologic alternative. This includes patients who may be unsuitable for long-term anticoagulation due to contra-indications. These devices, generally consisting of a nitinol-framed structure with a circular cross-section, are positioned within the LAA to obstruct the ostium, effectively preventing the thrombus from embolizing the brain. The initial clinical data from pivotal trials and observational registries indicated no strong correlation between peri-device leaks (PDLs) and adverse events. However, recent studies have shown that PDLs are associated with a higher risk of thrombo-embolic events, leading to renewed interest in managing PDLs. This paper reviews the occurrence of PDLs after percutaneous LAA occlusion using current FDA-approved devices, highlighting the need for non-circular occluders to better-accommodate the inherent variability in LAA anatomy. It also compares the benefits and limitations of emerging approaches still under investigation, focusing on addressing PDLs. Full article

Background: The safety and efficacy of electrophysiological (EP) procedures using ultrasound (US) guidance are being increasingly studied. We investigated if a systematic workflow with ultrasound guidance (the US4ABL), comprising four steps (transesophageal echocardiography (TEE) for left atrial thrombus exclusion, US of the groin vessels to guide femoral access, TEE-aided transseptal puncture, and transthoracic echocardiography (TTE) for exclusion of pericardial tamponade after the procedure), reduces the number of complications and fluoroscopy duration and dose. Methods: A total of 212 consecutive patients underwent left-sided ablations using the US4ABL workflow and were compared to a group of 299 patients who underwent the same type of ablations using post-procedural TTE to exclude tamponade (standard group: venous and/or arterial access by palpation and fluoroscopy, and pressure guided transseptal puncture). Complications, procedural duration, fluoroscopy duration, and dose were compared. Results: The cohort included 511 patients (42% female); 43.8% of patients suffered from paroxysmal atrial fibrillation (AF), 35.4% presented with persistent AF, 10.7% underwent the procedure was for atrial tachycardia, and 10% of patients had premature ventricular contractions. The complication rate in the US4ABL group was lower compared to the standard group: 0 complications vs. 11 complications (3.7%, mainly vascular and pericardial), respectively (p = 0.005). The procedure times were lower in the US4ABL group (p < 0.01), whereas the fluoroscopy time and dose did not differ significantly. Conclusions: A fully ultrasound-guided (US4ABL) workflow for left atrial and ventricular electrophysiology procedures reduces the complication rate and the procedure time. Full article

(1) Background: Cerebral magnetic resonance imaging has reported new cerebral ischemic lesions after left atrial appendage (LAA) closure in about one- third of patients. Stroke occurs predominantly periprocedurally. This study evaluated the characteristics of embolized debris captured by the SENTINEL^TM cerebral embolic protection system in patients undergoing LAA closure; (2) Methods: Sixty filters of 30 consecutive patients undergoing LAA closure with the WATCHMAN FLX^TM device were collected and captured debris was analyzed by histopathology and histomorphometry. Clinical outcome measures were disabling and non-disabling stroke within 72 h; (3) Results: In most filters, no material was captured. The predominant captured debris was acute or organized thrombi. The most common pattern was acute fibrin-rich thrombus, which was detected in 11/30 (33.3%) patients. Particles of heart tissue were seen in 6/30 (20%) patients, and foreign material was seen in one (3.3%) patient. The number of particles ranged from 0 to 52 per patient with a maximum of 31 in the distal and 21 in the proximal filter. Particle diameter ranged from 131 to 2614 µm. By logistic regression analysis, only protected time remained a multivariable predictor for larger particles (p = 0.039). There was no disabling or non-disabling stroke. Compared to transfemoral aortic valve replacement, the number of particles is only about 1.5%. (4) Conclusion: LAA occlusion with the WATCHMAN FLX^TM was associated with a very low number of embolized particles captured with the double-filter SENTINEL^TM embolic protection system and no periprocedural stroke. Full article

Background/Objectives: The risks of blood clot formation, stroke, heart failure (HF), and cardiovascular death are enhanced in individuals with atrial flutter (AFL). However, it remains unclear whether left atrial appendage thrombus (LAAT) in individuals with AFL with anticoagulation enhances the risk of cardiovascular morbidity and mortality. Thus, in the current trial, we aimed to evaluate the predictive role of LAAT for cardiovascular outcomes in individuals with AFL who were receiving anticoagulation and admitted for electrical cardioversion. Methods: Ninety patients were included in this prospective observational cohort study. The primary endpoint was the identification of LAAT by transesophageal echocardiographic examination. All participants were observed for a median of 2114.5 (interquartile range, 1487.5–2591) days to identify the secondary endpoints: cardiovascular death, transient ischemic attack (TIA), stroke, systemic thromboembolic complications, hospitalization due to HF, or myocardial infarction. Results: LAAT was identified in nine (10%) patients. No differences in cardiovascular outcomes between patients with and without LAAT were documented. However, a higher CHA₂DS₂-VASc score, previous myocardial infarction, and previous stroke/TIA/systemic thromboembolism were associated with significantly higher rates of hospitalization due to HF. Decreased left ventricular ejection fraction (LVEF) was associated with significantly higher rates of cardiovascular death, underscoring the significance of this marker in disease prognosis. Conclusions: The impact of LAAT on cardiovascular outcomes was insignificant. Higher CHA₂DS₂-VASc scores, previous myocardial infarction, previous stroke/TIA/systemic thromboembolism, and lower LVEF significantly affected long-term prognosis and were associated with a poor prognosis. Full article