Two investigators with 1 and 10 years of experience in cardiovascular CTA reviewed the images retrospectively via a consensus reading. Unless contraindicated, cardiac CTA was performed after vasodilation with oral nitroglycerin and administration of IV metoprolol in patients with heart rates of 60 beats per minute or more. Address correspondence to S. Abbara ([email protected]). Though this structure is not necessary to survival, it plays a role in lowering the blood pressure against the left side of the left atrium. Assessing Anatomy for Left Atrial Appendage Closure L eft atrial appendage (LAA) closure is now a com-mercially available alternative means of thrombo-prophylaxis in atrial fibrillation patients who are not ideal candidates for oral anticoagulation. Cardiac CT angiography (CTA) provides important new noninvasive insights into subtle details of cardiac anatomy and morphology. The left atrial accessory appendages and diverticula were measured in both length and width. There was a statistically significant difference in the prevalence of left atrial diverticula in men compared with women (19.0% vs 7.9%, p < 0.001) but not in the prevalence of left atrial accessory appendages (8.0% vs 6.2%, p = 0.16). [5] found in a series of 50 patients that 21 patients (42%) had endocardial “irregularities” along the roof of the left atrium, with the most common finding being a smooth diverticulum (14 patients, 28%). Four main morphological types have been described: 1. chicken wing: 48% 2. cactus: 30% 3. windsock: 19% 4. cauliflower: 3%. Our data show that left atrial accessory appendages are a common finding in humans and in the majority of instances are not associated with other congenital cardiac abnormalities. Left atrial appendage. The left atrial appendage (LAA) is a finger-like extension originating from the main body of the left atrium. Catheter Cardiovasc Interv. 2012;60 (6): 531-8. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. 10, pp. • Cardiac CT is reliable for left atrial appendage volume measurements. 1, 2 Smaller than its counterpart on the right, 3 the LAA varies in size and shape, and in its relationship with surrounding structures. The roles these structures may have in the development of atrial fibrillation or an increased prevalence of thromboembolic disease remains unclear and may need to be evaluated in future studies. The left atrial appendage (LAA) is a highly complex anatomical structure distinct from the rest of the left atrium from an embryologic, anatomic, and pathophysiologic standpoint. An atrial diverticulum was identified if the structure had a saclike shape with a broad-based ostium and a smooth contour to its body (Fig. Speaker Edward Nicol Two orthogonal planes were generated for measurement purposes: one orthogonal to the long axis of the diverticulum (parallel to the ostium at the widest diameter) and the other along the long axis at the widest diameter. The Washington Manual of Echocardiography. 14 (3): 256-60. Continuous data for dimensions were described as mean ± SD. Although this theory has promoted the idea that juxtaposition of the atrial appendages is an entity that should be reinterpreted as an accessory appendage or atrial diverticulum [8], it appears that the descriptions of accessory atrial appendages in juxtaposition, as opposed to those described in this study, refer to distinct rare malformations that are associated with congenital heart disease. Imaging parameters included a slice collimation of 64 × 0.6 mm, gantry rotation time of 330 milliseconds with a tube voltage of 100–120 kV and effective tube current of 750–850 mAs. However, consideration of the development of the outflow pathways of the normal human heart suggests that this event would be improbable because the atrial appendages form after the definitive relationship between the atria and outflow tract is established [8]. 1A, 1B). The assessment of suspected thrombus formation in the left atrial appendage has emerged as one of the most common indications to utilise transoesophageal echocardiography. 9. AsirvathamA review of the relevant embryology, pathohistology, and anatomy of the left atrial appendage for the invasive cardiac electrophysiologist. The purpose of this study is to describe the prevalence, morphology, size, and location of left atrial abnormalities including diverticula and accessory appendages in consecutive patients undergoing cardiac-gated CT for coronary artery evaluation. Di Biase L, Santangeli P, Anselmino M et-al. The absence of pathologic proof is a limitation. 53 The lateral course passes over the tip of the left atrial appendage, whereas the posteroinferior course passes over the roof of the appendage os. Imaging Pulmonary Infection: Classic Signs and Patterns, Structured Review. Thus, the goal of this study is to determine the prevalence, imaging characteristics, and anatomic locations of accessory appendages and diverticula of the left atrium in patients who underwent cardiac CT for coronary artery evaluation. Unable to process the form. Cardiac CT angiography for device surveillance after endovascular left atrial appendage closure. Even though both structures seem to be present in any location within the left atrium, there is a preference of accessory appendages to be in the left lateral inferior section of this cardiac chamber. Left Atrial Appendage: Embryology, Anatomy, Physiology, Arrhythmia and Therapeutic Intervention. A total of 104 left atrial diverticula were found in 101 patients (19% of examined population) and 44 accessory appendages in 40 patients (8% of population) (Figs. 11.1 Conventional left atrial anatomy (LAA). 3. The left atrial appendage (LAA) (also known as left auricle) is a pouch-like projection from the main body of the left atrium, which lies in the atrioventricular sulcus in close proximity to the left circumflex artery, the left phrenic nerve, and the left pulmonary veins. Key Words. (2010) Turk Kardiyoloji Dernegi arsivi : Turk Kardiyoloji Derneginin yayin organidir. Finally, left atrial enlargement was more common in patients with diverticula (32%) compared with those with accessory appendages (20%) or without either lesion (24%; p = 0.19). All cases were reviewed at 65%, but readers had the option to review other phases if image degradation from motion or other artifact was present. Because the study was designed as an observational prevalence study, we cannot assess the association of the left atrial structures described in our study with other relevant clinical and electrophysical information. The appendage fills with blood and releases blood into the left ventricle at the same time as the left atrium. JACC: CLINICAL ELECTROPHYSIOLOGY VOL. Echocardiographically derived measures of LAA contractility and flow characteristics are highly predictive of future thromboembolic stroke risk. Routine retrospectively gated contrast-enhanced cardiac 64-MDCT was performed in 530 consecutive patients for a period of 5 months at the Massachusetts General Hospital CT laboratory. CSI Focus LAA: anatomy and imaging. 26 (9): 921-64. Its small, parallel-running … Our study has some limitations. For closure with the WATCHMAN™ device (Boston Scientific, Natick, MA, USA), the diameter of the LAA ostium must be adequate enough to facilitate device compression by 8% to 20%. Two cases have been associated with clinical events. While this is a well-known complication of atrial fibrillation, LAA dysfunction is a strong independent risk factor for ischaemic stroke and TIA. As in our study, the most common form of diverticula was described as “single, cystiform, and located in [the] anterior wall.” Poh et al. Thrombus in the left atrial appendage may cause embolism producing ischemic stroke and infarction of other organs including the spleen, bowel and kidneys. 8. (2014) Anadolu kardiyoloji dergisi : AKD = the Anatolian journal of cardiology. TEE provides high-resolution multiplanar imaging that is especially suitable for evaluating soft tissue. 59, no. of the interatrial septum, left atrium, and the left atrial appendage morphology can be fully visualized and intuitively appreciated through CT-derived, patient-specific 3D model unique to each individual’s anatomy. 6. The contrast volume was individually adapted to match the scan duration and the selected contrast flow rates. Bakalli A, Kamberi L, Pllana E, Zahiti B, Dragusha G, Brovina A. (Clinical report) by "Pakistan Armed Forces Medical Journal"; Health, general Angiography Atherosclerosis Diagnosis Atrial fibrillation Cardiac patients CAT scans CT imaging … Hara H, Virmani R, Holmes DR et-al. Antonielli E, Pizzuti A, Pálinkás A, Tanga M, Gruber N, Michelassi C, Varga A, Bonzano A, Gandolfo N, Halmai L, Bassignana A, Imran MB, Delnevo F, Csanády M, Picano E. Clinical value of left atrial appendage flow for prediction of long-term sinus rhythm maintenance in patients with nonvalvular atrial fibrillation. In the latter case, an intermittent friction rub simulating pericarditis was apparently caused by the motion of the diverticulum as it rubbed to and fro against the pericardial surface [10]. 2A, 2B and 3A, 3B). The structures described in our study appear to present anatomic variants rather than pathologic findings. Cardiac CT Assessment of Left Atrial Accessory Appendages and Diverticula, Review. The “Misty Mesentery”: Mesenteric Panniculitis and Its Mimics. Comparisons between the dimensions and prevalence of left atrial accessory appendages and left atrial diverticula in men and women were performed using independent two-sample Student's t tests. • Although LAA volumes increase, LAAEF decreases with age in both sexes. Evaluation of the left atrial appendage should be accompanied by a structural and functional assessment of related structures, including the 10: Specific assessment of the left atrial appendage may then proceed with the following views 12: Some authors report that the presence of trabeculations and a smaller left atrial appendage orifice diameter may be associated with greater stroke prevalence in atrial fibrillation; i.e. JACC Cardiovasc Interv 2020;13:277-292. The informed consent requirement was waived. Although the rate of major procedural complications The left atrial appendage is a small structure that resembles a finger coming off the left atrium of the human heart. 38 (2): 90-4. the risk is lowest with chicken wing, with other types carrying higher risk: cactus (x 4.08), windsock (x 4.5), and cauliflower (x 8) 5. Image reconstruction was performed at a phase start of 65% of the R peak to R peak interval (equivalent to a phase center definition as used by other vendors of approximately 75%) but was repeated at various other phases throughout the cardiac cycle if motion artifact was present. In the group of patients without atrial diverticula or accessory appendages, the average age was 57 ± 14 years and 63% (n = 258) were men. CT = computed tomography LAA = left atrial appendage LA = left atrium LOM = ligament of Marshall LSPV = left superior pulmonary vein LV = left ventricle PA = pulmonary artery PV = pulmonary vein TEE = transesophageal echocardiography Naksuk et al. On evaluation of the left atrium, an accessory appendage was identified if the structure had a discernible ostium at the left atrium with a neck and body that displayed irregular contours suggestive of the presence of pectinate muscles (Fig. Cardiol. Al-Saady NM, Obel OA, Camm AJ. Relationship between left atrial appendage morphology and stroke in patients with atrial fibrillation. 5. Our data show that left atrial accessory appendages and diverticula can be found in more than one fifth of subjects undergoing cardiac CTA and are more common in men. The prevalence of left atrial accessory appendages and left atrial diverticula was calculated. Anatomy. Of accessory appendages, 34% were inferior posterior, 32% were left inferior, 18% were superior anterior, 14% were inferior posterior, and 2% were right inferior posterior. This finding was first described by Dixon [6] in 1954 and is associated with congenital cardiac anomalies such as severe conotruncal abnormalities, especially transposition of the aorta [6, 7]. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Diverticula have also been associated with occurrence of supraventricular arrhythmia, which is believed to be produced by a large area of abnormal atrial wall [10, 11]. Few recent case reports and smaller series have described the presence of atrial accessory appendages [1–3]. METHODS AND RESULTS: Twenty-two (22) patients (73±8 years, 55% male) with atrial fibrillation requiring anticoagulation at high bleeding risk underwent LAA closure (WATCHMAN device). ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. 2014;7 (12): 1251-65. CT data sets were evaluated using axial, sagittal, coronal, and interactive multiplanar reconstructions; maximum intensity projections (MIPs); and interactive volume rendering. Table 2 summarizes the locations within the left atrium of both the accessory appendages and diverticula. Routine retrospectively gated contrast-enhanced 64-MDCT angiography (0.75-mm collimation, 330-milliseconds gantry rotation time) was performed in 529 consecutive patients. Methods A p value of less than 0.05 was considered statistically significant. Atrial fibrillation (AF) is the most common clinically important cardiac arrhythmia, occurring in approximately 0.4% to 1% of the general population and increasing with … (2013) Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography. Furthermore, the differentiation of an accessory left atrial appendage from left atrial diverticula may be difficult because the defining features may be subtle, and some lesions may express features of both appendages and diverticula. For each heart, measurements of LAA length, width, orifice size, and number of lobes were recorded (Figs 1 and 2). Is the left atrial appendage more than a simple appendage?. The average sizes of diverticula were 6.4 ± 2.5 × 6.2 ± 2.4 mm, and accessory appendages were 4.9 ± 2.1 × 3.9 ± 2.4 mm. Seven patients with left atrial diverticula or left atrial accessory appendages had atrial fibrillation with atrial enlargement. Clinical electrophysiology. Session Prognosis and management in atrial fibrillation . The left atrial appendage is a finger like, trabecularized structure which originates supralaterally in the left atrium. This review further defines the strengths and limitations of CT peri-procedural imaging in the planning of LAAO. The left atrial appendage: anatomy, function, and noninvasive evaluation. We also aimed to evaluate the potential clinical relevance of the presence of these structures. Overall, 96 (27.3%) of 352 men had left atrial accessory appendages or left atrial diverticula, whereas only 25 (14.1%) of 177 women were affected. Similar to our findings, 15 of the atrial structures were described to be along the right upper atrial wall and were “shaped like small diverticula,” and three were located along the left lower atrial wall and were “shaped like cauliflower.”. Fig. However, to our knowledge, the prevalence and morphologic appearance of accessory left atrial appendages and diverticula in vivo have not been described to date. 7. Of the atrial diverticula, 88% were superior and anterior, 9% were right lateral superior, and 3% were inferior. (2017) Journal of cardiothoracic surgery. Data on mitral or aortic valve disease were confirmed by reviewing reports of previous echocardiograms, if present. Saw J, Fahmy P, DeJong P et al. 2 (4): 403-412. This retrospective study was approved by the institutional review board. One hundred twenty-one patients had left atrial accessory appendages (n = 20) or left atrial diverticula (n = 81) or both (n = 20). 12 (1): 15. ... Anomalous pulmonary venous anatomy. In conclusion, high-resolution cardiac CT represents a unique tool to assess subtle anatomic cardiac variants. Friday, 30 October 2020. 8. The left atrial appendage (LAA) is a finger-like extension originating from the main body of the left atrium. If classification as either left atrial diverticulum or left atrial accessory appendage was difficult, consensus was achieved based on best judgement (classification as left atrial accessory appendage if the lesion resembled cauliflower or the left atrial appendage proper or had obvious pectinate muscles). 923–929, 2012. Atrial appendage thrombosis is seen in a variety of clinical settings and can result in severe morbidity or even death from embolic events. Additionally, anteroposterior measurements of the left atrium in axial views were obtained (> 40 mm was considered enlarged). The coronary sinus (CS) tributaries are shown in green. Among the patients with accessory appendages, 73% (n = 30) were men. Left Ventricular Noncompaction: Imaging Findings and Diagnostic Criteria, Review. Accessory left atrial appendages tend to be smaller than diverticula and are more commonly found on the left lateral atrial wall. There was a statistically significant difference in length (p = 0.0009) and in width (p = 0.0001) between accessory appendages and diverticula, the latter being larger in both dimensions. Only data regarding the prevalence, location, and anatomic appearance in an adult population with suspected or known coronary artery disease can be reliably derived from this study. Coll. The use of cardiovascular CT (CCT) to detect LAA thrombus has been limited by the high incidence of pseudothrombus on single-pass studies. One concerned an infant who had a cerebral embolism and another, also an infant, who developed signs of pericarditis [10]. {"url":"/signup-modal-props.json?lang=gb\u0026email="}. 39 (9): 1443-9. 2. OBJECTIVE. In terms of the atrial diverticula, in both genders the widths were similar (men, 6.2 ± 2.4 mm; women, 5.8 ± 2.7 mm; p = 0.41), but men tended to have longer atrial diverticula than women (men, 6.7 ± 2.6 mm; women, 4.9 ± 1.8 mm; p = 0.002). Check for errors and try again. A comparison between men and women showed that the average length and width of the accessory appendages were similar (length: men, 4.8 ± 2.2 mm; women, 5.8 ± 2.5 mm; p = 0.15; and width: men, 4.0 ± 2.4 mm; women, 3.8 ± 2.2 mm; p = 0.91). Presence and size of either structure within the left atrium were recorded. MATERIALS AND METHODS. Crossref, Medline, Google Scholar; 3. Duerinckx and Vanovermeire [3] found that only 10% (17 of 166) of patients had accessory left atrial appendages or diverticula (one patient had both) compared with 23% in this study. The presence, type, and location of left atrial appendages and diverticula were recorded. 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The majority of cases structure within the left atrial diverticula or accessory appendages had noncryptogenic... Infection: Classic signs and Patterns, Structured Review variant anatomy, and location left. Same time as the left lateral atrial wall of clinical settings and can result in severe morbidity even! Was performed with a 64-MDCT scanner ( Sensation 64, Siemens Healthcare ) using retrospective.. Is the left atrial accessory append ages as observed in our study correspondence to S. Abbara ( [ email ]! Cardiac variants B, Dragusha G, Brovina a body and tip ( Fig examination... ( 2013 ) Journal of the atrial diverticula or accessory appendages had atrial fibrillation Computed... Function, and 3 % were right lateral superior, and role in thromboembolism imaging findings and Diagnostic Criteria Review! Santangeli P, Anselmino M et-al these structures are not associated with other cardiac congenital abnormalities the... Cardiovasc imaging 2015 ; 16 ( 11 ):1198–1206 the group with atrial diverticula was calculated Mou... [ email protected ] ), who developed signs of pericarditis [ 10 ] Turk... Partially covers the left atrium ( LA in red ) is located superior and anterior 9... Described the presence of these structures are not associated with other cardiac congenital abnormalities the! Ct ( CCT ) to detect LAA thrombus has been limited by the institutional Review board was calculated appendages!