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Dutta N, Das D, Chakraborty U, Das S, Sharma MK, Gajpal S, Chattopadhyay A, Ghosh S, Das JN. Double left atrial appendage: A diagnostic dilemma. Ann Pediatr Cardiol 2023; 16:378-380. [PMID: 38766452 PMCID: PMC11098290 DOI: 10.4103/apc.apc_136_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/19/2023] [Accepted: 01/11/2024] [Indexed: 05/22/2024] Open
Abstract
We report a unique intraoperative finding of an additional double left atrial appendage (LAA) during an arterial switch operation with ventricular septal defect closure in a 4-month-old girl. Immediately after the procedure, a prolapsing mass within the left atrium (LA) on the transesophageal echocardiogram raised concerns of a possible thrombus. The LAA was clearly visible with a pressure monitoring line which was put intraoperatively. To investigate further, cardiopulmonary bypass was resumed, and the heart was arrested and explored. There was an appendage-like structure, separate from the one that had the pressure monitoring line, which was inverted inside. It was pulled out from outside clearly establishing a double LAA. This report illustrates an example of a diagnostic dilemma caused by a double atrial appendage which was invaginated into LA masquerading as a mass or thrombus.
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Affiliation(s)
- Nilanjan Dutta
- Department of Cardiac Surgery, Narayana Superspeciality Hospital, Howrah, West Bengal, India
| | - Debasis Das
- Department of Cardiac Surgery, Narayana Superspeciality Hospital, Howrah, West Bengal, India
| | - Unmesh Chakraborty
- Department of Cardiac Surgery, Narayana Superspeciality Hospital, Howrah, West Bengal, India
| | - Shubhadeep Das
- Department of Pediatric Cardiac Intensive Care, Narayana Superspeciality Hospital, Howrah, West Bengal, India
| | - Manish Kumar Sharma
- Department of Cardiac Anaesthesia, Narayana Superspeciality Hospital, Howrah, West Bengal, India
| | - Shivani Gajpal
- Department of Cardiac Anaesthesia, Narayana Superspeciality Hospital, Howrah, West Bengal, India
| | - Amitabha Chattopadhyay
- Department of Pediatric Cardiology, Narayana Superspeciality Hospital, Howrah, West Bengal, India
| | - Sanjiban Ghosh
- Department of Pediatric Cardiology, Narayana Superspeciality Hospital, Howrah, West Bengal, India
| | - Jayita Nandy Das
- Department of Pediatric Cardiology, Narayana Superspeciality Hospital, Howrah, West Bengal, India
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2
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A puzzling CHD: a late diagnosis of left atrial isomerism. Cardiol Young 2023; 33:479-481. [PMID: 35801268 DOI: 10.1017/s1047951122002165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We present a case of a 41-year-old patient with an unknown complex cardiac anatomy, who was previously submitted to two cardiac surgeries. Using multimodality imaging, a retrospective diagnosis was established, revealing a heterotaxy syndrome (left isomerism).
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3
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Evans WN. Situs Deconstructed. Pediatr Cardiol 2023; 44:13-14. [PMID: 35841404 DOI: 10.1007/s00246-022-02968-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 07/05/2022] [Indexed: 01/24/2023]
Affiliation(s)
- William N Evans
- Congenital Heart Center Nevada, 3131 La Canada St. Ste 230, Las Vegas, NV, 89169, USA. .,Department of Pediatrics, Division of Pediatric Cardiology, Kirk Kerkorian School of Medicine at University of Nevada Las Vegas, 2040 W Charleston Blvd 3rd Floor, Las Vegas, NV, 89102, USA.
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4
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Fang R, Li Y, Wang J, Wang Z, Allen J, Ching CK, Zhong L, Li Z. Stroke risk evaluation for patients with atrial fibrillation: Insights from left atrial appendage. Front Cardiovasc Med 2022; 9:968630. [PMID: 36072865 PMCID: PMC9441763 DOI: 10.3389/fcvm.2022.968630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/27/2022] [Indexed: 11/13/2022] Open
Abstract
Left atrial appendage (LAA) is believed to be a common site of thrombus formation in patients with atrial fibrillation (AF). However, the commonly-applied stroke risk stratification model (such as. CHA2DS2-VASc score) does not include any structural or hemodynamic features of LAA. Recent studies have suggested that it is important to incorporate LAA geometrical and hemodynamic features to evaluate the risk of thrombus formation in LAA, which may better delineate the AF patients for anticoagulant administration and prevent strokes. This review focuses on the LAA-related factors that may be associated with thrombus formation and cardioembolic events.
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Affiliation(s)
- Runxin Fang
- School of Biological Science and Medical Engineering, Southeast University, Nanjing, China
| | - Yang Li
- Zhongda Hospital, The Affiliated Hospital of Southeast University, Nanjing, China
| | - Jun Wang
- First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Zidun Wang
- First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - John Allen
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Chi Keong Ching
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- National Heart Centre Singapore, Singapore, Singapore
| | - Liang Zhong
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
- National Heart Centre Singapore, Singapore, Singapore
| | - Zhiyong Li
- School of Biological Science and Medical Engineering, Southeast University, Nanjing, China
- School of Mechanical, Medical and Process Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- *Correspondence: Zhiyong Li
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5
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Evaluation and Interventional Management of Cardiac Dysrhythmias. Surg Clin North Am 2022; 102:365-391. [DOI: 10.1016/j.suc.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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6
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Spicer DE, Chowdhury UK, Anderson RH, Pandey NN, Sankhyan LK, George N, Goja S, Malik V. The surgical anatomy of hearts with isomeric atrial appendages-implications for surgical management. Eur J Cardiothorac Surg 2022; 62:6540686. [PMID: 35234855 DOI: 10.1093/ejcts/ezac139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/16/2022] [Accepted: 02/22/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The most severe combinations of cardiac malformations exist in individuals having jumbled-up thoracic and abdominal organs. These patients make up 2 distinct syndromes. As yet, the consensus is lacking on how best to describe the subsets. The subsets are frequently grouped together in terms of 'heterotaxy'. The surgical approaches to the subsets, however, are markedly different. We reviewed our experiences with regard to the anatomy as observed in the autopsy room, by the analysis of computed tomographic studies, and in the operating room, to assess whether the lesions might be segregated on the basis of isomerism of the atrial appendages. METHODS AND RESULTS A review of our findings from the examination of specimens from several archives, along with investigation of a large cohort of patients being prepared for surgical treatment, showed that individuals can uniformly be segregated into subgroups on the basis of isomeric arrangement of the atrial appendages. In all instances, this was made possible by using the criterion of the extent of the pectinate muscles within the appendages as judged relative to the atrial vestibules. Segregation on this basis, which correlated excellently with the bronchial arrangement, sets the scene for an appropriate description of the remainder of the heart, providing the cardiac surgeon with all the inferences required for appropriate surgical intervention. CONCLUSIONS When assessing individuals having the features of so-called 'heterotaxy', it is possible to segregate the groups into subsets of individuals having either isomeric right or left atrial appendages. This approach provides the framework for the assessment of appropriate surgical management.
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Affiliation(s)
- Diane E Spicer
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.,Department of Pediatric Cardiology, University of Florida, Gainesville, FL, USA
| | | | - Robert H Anderson
- Institute of Biomedical Sciences, Newcastle University, Newcastle-upon-Tyne, UK
| | - Niraj Nirmal Pandey
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Lakshmi Kumari Sankhyan
- Department of Cardiothoracic Surgery, All India Institute of Medical Sciences, Bilaspur, India
| | - Niwin George
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Shikha Goja
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Vishwas Malik
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
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7
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Verma M, Pandey NN, Kumar S, Ramakrishnan S, Jagia P. Juxtaposition of atrial appendages: Evaluation of cardiovascular morphology and associated anomalies on multidetector computed tomography angiography. J Card Surg 2022; 37:1145-1152. [PMID: 35137986 DOI: 10.1111/jocs.16301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 01/24/2022] [Accepted: 01/24/2022] [Indexed: 11/30/2022]
Abstract
AIM To evaluate the morphology and associated cardiovascular abnormalities in patients with juxtaposition of atrial appendages (JAA) on multidetector computed tomography (MDCT) angiography. MATERIALS AND METHODS We performed the retrospective study at a tertiary referral center to identify patients diagnosed with JAA on MDCT angiography using dual-source CT scanner between January 2014 and April 2021. The various imaging abnormalities evaluated included the type of JAA, morphological and positional classification of JAA, atrial situs, cardiac position, atrioventricular and ventriculoarterial connections, great vessel relationship, and other associated cardiovascular anomalies. RESULTS We identified 129 patients with JAA. Left-sided juxtaposition was seen in 124 (96.1%) patients while right-sided juxtaposition was seen in 5 (3.9%) patients. Among patients with left-sided juxtaposition, frequent cardiovascular associations included outflow tract malformations (100%), hypoplastic right ventricle (40.3%), tricuspid atresia (32.2%), and right-sided heart (19.4%). The most frequent outflow tract malformation was double outlet right ventricle (DORV; 60.5%) followed by transposition of great arteries (20.1%) and transposed aorta with pulmonary atresia (18.5%). In patients with right-sided juxtaposition, outflow tract malformation was seen in three (60%) patients with one (20%) patient each showing DORV, transposed aorta with pulmonary atresia, and tetralogy of Fallot, respectively. CONCLUSION The identification of JAA on MDCT angiography suggests coexistence of various complex congenital heart diseases, especially outflow tract malformations. A meticulous search is imperative to identify this anomaly before interventional or surgical procedures to avoid complications.
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Affiliation(s)
- Mansi Verma
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Niraj Nirmal Pandey
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Kumar
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | | | - Priya Jagia
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
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8
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Chowdhury UK, Anderson RH, Spicer DE, Sankhyan LK, Pandey NN, Goja S, Rajasekar P, Arvind B, Pradeep D. Surgical management of hearts with isomeric atrial appendages. J Card Surg 2022; 37:1340-1352. [PMID: 35122446 DOI: 10.1111/jocs.16268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/03/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIM On the basis of previously published accounts, coupled with our own experience, we have assessed the surgical approaches to patients with isomeric atrial appendages. METHODS We reviewed pertinent published studies on surgical treatment of individuals with isomeric atrial appendages, with the pertinent surgical details provided by most of the manuscripts. RESULTS Half of patients with right isomerism, and two-thirds of those with left isomerism have bilateral superior caval veins. Azygos extension of the inferior caval vein is reported in three-quarters of those with left isomerism. The coronary sinus is universally absent in right isomerism, along with totally anomalous pulmonary venous connection, and is absent in two-fifths of those with left isomerism. Univentricular atrioventricular connections are expected in up to three-quarters of those with right isomerism. Atrioventricular septal defect is reported in up to four-fifths, more frequently in right isomerism, with such patients typically having discordant ventriculoatrial connections or double outlet right ventricle. Reported mortalities extend to 85% for those with right, and 50% for those with left isomerism. In right isomerism, mortality is up to 54% for systemic-to-pulmonary arterial shunting, up to 75% for univentricular repair, and up to 95% for repair of totally anomalous pulmonary venous connection itself. No more than one-quarter had undergone Fontan completion, with reported mortalities of 21%. CONCLUSION Early surgical results are satisfactory in patients with left isomerism, but disappointing for those with right. Recent advances in cardiac and liver transplantation may offer improved survival.
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Affiliation(s)
- Ujjwal Kumar Chowdhury
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Robert H Anderson
- Institute of Biomedical Sciences, Newcastle University, Newcastle-upon-Tyne, UK
| | - Diane E Spicer
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Department of Pediatric Cardiology, University of Florida, Gainesville, Florida, USA
| | - Lakshmi K Sankhyan
- Department of Cardiothoracic Surgery, All India Institute of Medical Sciences, Bilaspur, India
| | - Niraj N Pandey
- Department of Cardiac Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Shikha Goja
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Palleti Rajasekar
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Balaji Arvind
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Doniparthi Pradeep
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
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9
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Van Praagh R. The Heterotaxy Syndromes. CONGENIT HEART DIS 2022. [DOI: 10.1016/b978-1-56053-368-9.00029-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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10
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Bansal N, Ghosh R, Sankhyan LK, Chatterjee S, Chatterjee S, Bose S. Left isomerism with bilateral superior vena cava, interrupted inferior vena cava and tetralogy of Fallot. Ann Pediatr Cardiol 2020; 13:364-367. [PMID: 33311931 PMCID: PMC7727908 DOI: 10.4103/apc.apc_117_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/09/2020] [Accepted: 07/28/2020] [Indexed: 11/05/2022] Open
Abstract
The association of left isomerism with tetralogy of Fallot (TOF) is rare and reported as scattered case reports. Complex congenital cardiac and noncardiac malformations are known to be associated with left isomerism, but right-sided obstructive lesions are rare. We present our experience with a case of left isomerism with bilateral superior vena cava, interrupted inferior vena cava, and TOF managed by atrial septation and intracardiac repair.
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Affiliation(s)
- Nikhil Bansal
- Department of Cardiothoracic Surgery, The Mission Hospital, Durgapur, West Bengal, India
| | - Rajarshi Ghosh
- Department of Cardiothoracic Surgery, The Mission Hospital, Durgapur, West Bengal, India
| | | | - Sujoy Chatterjee
- Department of Cardiothoracic Surgery, The Mission Hospital, Durgapur, West Bengal, India
| | - Srirup Chatterjee
- Department of Cardiothoracic Surgery, The Mission Hospital, Durgapur, West Bengal, India
| | - Satyajit Bose
- Department of Cardiothoracic Surgery, The Mission Hospital, Durgapur, West Bengal, India
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11
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Wang F, Zhu M, Wang X, Zhang W, Su Y, Lu Y, Pan X, Gao D, Zhang X, Chen W, Xu Y, Sun Y, Xu D. Predictive value of left atrial appendage lobes on left atrial thrombus or spontaneous echo contrast in patients with non-valvular atrial fibrillation. BMC Cardiovasc Disord 2018; 18:153. [PMID: 30064363 PMCID: PMC6069846 DOI: 10.1186/s12872-018-0889-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 07/16/2018] [Indexed: 01/26/2023] Open
Abstract
Background Left atrial appendage morphology has been proved to be an important predictor of left atrial thrombus (LAT) and left atrial spontaneous echo contrast (LASEC) and stroke in patients with non-valvular atrial fibrillation (NVAF). However, the relation between left atrial appendage (LAA) lobes and LAT or LASEC is still unknown. The aim of this study is to investigate the correlation between the number of left atrial appendage lobes and LAT/LASEC in patients with NVAF. Methods This monocentric cross-sectional study enrolled 472 consecutive patients with non-valvular atrial fibrillation, who had transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) prior to cardioversion or left atrial appendage closure (LAAC) from July 2009 to August 2015 in department of cardiology of Shanghai Tenth People’s Hospital. Patients who had significant mitral or aortic valve disease, previous cardiac valvular surgery and other complicated cardiac diseases were excluded. Individuals were divided into two groups:the LAT/LASEC group (16.95%), which comprised patients with LAT or LASEC, as confirmed by TEE; and a negative control group (83.05%).Baseline overall group characterization with demographic, clinical, laboratory data and echocardiographic parameters, alongside with information on medication was obtained for all patients. Subgroup analysis with line chart was applied for exploring the association between LAA lobes and LAT/LAESC. Receptor-operating curves (ROC) were used to test the value of LA anteroposterior diameter detected by different echocardiography methods predicting LAT or LASEC. Multivariable logistic regression analysis was used to investigate independent predictors of LAT/LASEC. Results Among 472 patients, 23 (4.87%) had LA/LAA thrombus and 57 (12.1%) had LA spontaneous echo contrast. Compared to the negative group, patients in LAT/LASEC group had higher CHA2DS2-VASc score (3.79 ± 1.75 vs 2.65 ± 1.76, p < 0.001), larger LAD (measured by TTE, 48.1 ± 7.7 vs 44.6 ± 6.5, P < 0.001; measured by TEE, 52.2 ± 6.2 vs 46.7 ± 7.1, P < 0.001), lower left upper pulmonary venous flow velocity (LUPVFV) (0.54 ± 0.17 m/s vs 0.67 ± 0.26 m/s, CI 95% 0.05–0.22, P = 0.003), more left atrial appendage lobes (1.67 ± 0.77 vs 1.25 ± 0.50, p < 0.001). There was a good discriminative capacity for LAD detected by TTE (area under the curve (AUC), 0.67, CI 95% 0.61–0.73, p < 0.001) and LAD detected by TEE (AUC, 0.73, CI 95% 0.67–0.79, p < 0.001). The subgroup analysis based on gender and different LAA lobes yielded similar results (male group: p < 0.001;female group: p = 0.004) that the number of LAA lobes were significantly associated with LA thrombus or SEC. In multivariable logistic regression analysis, both the number of LAA lobes (odds ratio: 2.37; CI 95% 1.37–4.09; p = 0.002) and the persistent AF (odds ratio: 3.57; CI 95% 1.68–7.57; p = 0.001) provided independent and incremental predictive value beyond CHA2DS2-VASc score. Conclusion The number of LAA lobes is an independent risk factor and has a moderate predictive value for LAT/LASEC among NVAF patients in China.
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Affiliation(s)
- Fan Wang
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, NO. 301 Middle Yanchang Road, Shanghai, 200072, China
| | - Mengyun Zhu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, NO. 301 Middle Yanchang Road, Shanghai, 200072, China
| | - Xiaoyu Wang
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, NO. 301 Middle Yanchang Road, Shanghai, 200072, China
| | - Wei Zhang
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, NO. 301 Middle Yanchang Road, Shanghai, 200072, China
| | - Yang Su
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, NO. 301 Middle Yanchang Road, Shanghai, 200072, China
| | - Yuyan Lu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, NO. 301 Middle Yanchang Road, Shanghai, 200072, China
| | - Xin Pan
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, NO. 301 Middle Yanchang Road, Shanghai, 200072, China
| | - Di Gao
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, NO. 301 Middle Yanchang Road, Shanghai, 200072, China
| | - Xianling Zhang
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, NO. 301 Middle Yanchang Road, Shanghai, 200072, China
| | - Wei Chen
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, NO. 301 Middle Yanchang Road, Shanghai, 200072, China
| | - Yawei Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, NO. 301 Middle Yanchang Road, Shanghai, 200072, China
| | - Yuxi Sun
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, NO. 301 Middle Yanchang Road, Shanghai, 200072, China.
| | - Dachun Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, NO. 301 Middle Yanchang Road, Shanghai, 200072, China.
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Caliskan E, Cox JL, Holmes DR, Meier B, Lakkireddy DR, Falk V, Salzberg SP, Emmert MY. Interventional and surgical occlusion of the left atrial appendage. Nat Rev Cardiol 2017; 14:727-743. [DOI: 10.1038/nrcardio.2017.107] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Spadotto V, Voges I, Kilner PJ, Yacoub MH, Ernst S, Ho SY, Babu-Narayan SV. Juxtaposition of the atrial appendages: A nidus for thrombus in atriopulmonary Fontan? Glob Cardiol Sci Pract 2016; 2016:e201619. [PMID: 29043267 PMCID: PMC5642832 DOI: 10.21542/gcsp.2016.19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 06/08/2016] [Indexed: 12/04/2022] Open
Abstract
Juxtaposition of atrial appendages is a rare cardiac congenital anomaly, usually associated with other cardiac malformations. Until now, it has not been linked to any significant clinical implications. We report cardiovascular magnetic resonance (CMR) findings of two adult patients who underwent atriopulmonary Fontan operation in the setting of left juxtaposition of the atrial appendages. The patients were in sinus rhythm at the time of the CMR study. Both patients had episodes of sustained atrial tachyarrhythmia requiring electrical cardioversion and were anticoagulated with warfarin with target INR 2-3. CMR images showed a thrombus located in the enlarged and juxtaposed right appendage in both patients. Blood flow frequently appears slow or sluggish in the dilated right atrium following atriopulmonary Fontan surgery. In addition, cine CMR suggested that blood flow reaches very low velocities in the massively dilated juxtaposed right atrial appendage cul-de-sac, thus potentially creating a substrate for clot formation. These findings propose that juxtaposed atrial appendages in atriopulmonary Fontan is an additional risk factor for clot formation, specifically in the dilated right atrial appendage on the left side juxtaposed with the left atrial appendage and that prophylactic anticoagulation is highly justified in these patients.
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Affiliation(s)
- Veronica Spadotto
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College, London, UK
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Inga Voges
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College, London, UK
- Justus-Liebig-University of Giessen, Pediatric Heart Center, Giessen, Germany
| | - Philip J. Kilner
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College, London, UK
| | - Magdi H. Yacoub
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College, London, UK
| | - Sabine Ernst
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College, London, UK
| | - Siew Yen Ho
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College, London, UK
- Department of Cardiac Morphology, Royal Brompton and Harefield NHS Foundation Trust
| | - Sonya V. Babu-Narayan
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College, London, UK
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Abstract
Atrial fibrillation (AF) remains the most common arrhythmia encountered in clinical practice. One of its more common deleterious effects is the development of thromboembolism leading to stroke. The left atrial appendage (LAA) has been shown to the site of the majority of thrombus formation leading to stroke. Anticoagulation with warfarin has been the treatment of choice for prevention of embolic events. Newer anticoagulants have been developed but they still have the potential side effect of causing major bleeding. Occlusion of the LAA has emerged as an alternative therapeutic approach to medical therapy. The aim of this article is to discuss in detail the role of the LAA in thromboembolism in AF, role of device and surgical therapies, and the current clinical data supporting their use. This is particularly timely in that there is now an approved LAA closure device approved in the US for stroke prevention in patients with nonvalvular AF.
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Sakr SA, El-Rasheedy WA, Ramadan MM, El-Menshawy I, Mahfouz E, Bayoumi M. Association between left atrial appendage morphology evaluated by trans-esophageal echocardiography and ischemic cerebral stroke in patients with atrial fibrillation. Int Heart J 2015; 56:329-34. [PMID: 25912903 DOI: 10.1536/ihj.14-374] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The left atrial appendage (LAA) represents one of the major sources of cardiac thrombi responsible for embolic stroke in patients with atrial fibrillation (AF). The aim of the present study was to evaluate LAA structure and functions by transesophageal echocardiography (TEE) in patients with AF to investigate the possible association between the different LAA morphologies and the patients' history of ischemic cerebral stroke. We included 50 patients with non-valvular AF (29 chronic, 21 paroxysmal), 24 patients (13 men) without stroke; and 26 patients (9 men) with a history of ischemic stroke. All patients underwent TEE evaluation of LAA morphology and functions. Compared to patients without stroke, patients with ischemic stroke had significantly higher CHADS2 scores (4.19 ± 0.89 versus 1.67 ± 1.13; P < 0.001) and C-reactive protein levels (8.3 ± 1.6 versus 7.6 ± 0.83 mg/L; P = 0.023), and lower peak filling (21.7 ± 11.3 versus 31.2 ± 9.5 cm/second; P = 0.033) and emptying (22.2 ± 9.7 versus 33.4 ± 13.4 cm/second, P = 0.030) velocities. Triangular LAA morphology had a higher prevalence in patients with stroke (36% versus 12% in non-stroke group); and in half of them an LAA thrombus was present. LAA thrombi were detected in 9 patients (18%) with stroke and in 5 patients (10%) without stroke. On multivariate logistic regression analysis, age (OR = 1.202 [1.042-1.585]; P = 0.041), LAA orifice diameter (OR = 1.275 [1.102-1.748]; P = 0.028), and triangular LAA morphology (OR = 4.53 [1.629-8.381]; P = 0.011) were significantly and independently associated with ischemic stroke in AF patients. LAA morphology evaluated by TEE may be useful for predicting ischemic cerebral stroke in patients with non-valvular AF, especially in those with a low CHADS2 score.
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Affiliation(s)
- Sherif A Sakr
- Department of Cardiology, Faculty of Medicine, Mansoura University
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Anderson RH, Brown NA, Meno C, Spicer DE. The importance of being isomeric. Clin Anat 2015; 28:477-86. [PMID: 25782978 DOI: 10.1002/ca.22517] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 01/18/2015] [Indexed: 11/07/2022]
Abstract
In the normal individual, the parietal components of the body are mirror-imaged and appropriately described as isomeric. The thoraco-abdominal organs, in contrast, are lateralized. However, in "visceral heterotaxy," the thoraco-abdominal organs also show some degree of isomerism, best seen in the arrangement of the bronchial tree. Whether isomerism can be found within the heart remains controversial. One of two recent publications in this journal emphasized the crucial features of bronchial isomerism; the other, in contrast, confused the situation of isomerism within the heart. In this review, we show how the topic of cardiac isomerism is clarified by concentrating on the anatomical features of the cardiac components and determining how best they can be described. Appropriate manipulation of developing mice produces unequivocal evidence of isomerism of the atrial appendages, but with no evidence of ventricular isomerism. In hearts from patients with so-called "heterotaxy," only the atrial appendages, distinguished on the basis of the pectinate muscles lining their walls, are uniformly isomeric, permitting the syndrome to be differentiated into the subsets of left as opposed to right atrial appendage isomerism. Thus, controversies are defused by simply describing the isomerism of the atrial appendages rather than "atrial isomerism," recognizing the frequency of abnormal venoatrial connections in these settings. Any suggestion of ambiguity is removed by the equally simple expedient of describing all the variable cardiac features, describing the arrangements of the thoracic and abdominal organs separately should there be discordances.
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Affiliation(s)
- Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
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Anderson RH, Sarwark A, Spicer DE, Backer CL. Exercises in anatomy: the normal heart. Multimed Man Cardiothorac Surg 2014; 2014:mmu023. [PMID: 25500767 DOI: 10.1093/mmcts/mmu023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
In this series of videoclips, we analyze the anatomy of the normal heart. We begin our overview by emphasizing the need, in the current era, to describe the heart in attitudinally appropriate fashion. Increasingly, clinicians are demonstrating the features of the heart as it is located within the body. It is no longer satisfactory, therefore, to describe these components in a ‘Valentine’ fashion, as continues to be the case in most textbooks of normal or cardiac anatomy.
We then emphasize the importance of the so-called morphological method, which states that structures within the heart should be defined on the basis of their own intrinsic morphology, and not according to other parts, which are themselves variable. We continue by using this concept to show how the appendages serve to distinguish between the atrial chambers, while the apical trabecular components provide the features to distinguish the ventricles. We then return to the cardiac chambers, emphasizing features of surgical significance, in particular the locations of the cardiac conduction tissues. We proceed by examining the cardiac valves, and conclude by providing a detailed analysis of the septal structures.
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Affiliation(s)
- Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK
| | - Anne Sarwark
- Division of Pediatric Cardiac Surgery, Lurie Children's Hospital, Chicago, IL, USA
| | - Diane E Spicer
- Division of Pediatric Cardiology, University of Florida, Gainesville, FL, USA Children's Heart Institute of Florida, All Children's Hospital, St Petersburg, FL, USA
| | - Carl L Backer
- Division of Pediatric Cardiac Surgery, Lurie Children's Hospital, Chicago, IL, USA
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Kar S, Hou D, Jones R, Werner D, Swanson L, Tischler B, Stein K, Huibregtse B, Ladich E, Kutys R, Virmani R. Impact of Watchman and Amplatzer Devices on Left Atrial Appendage Adjacent Structures and Healing Response in a Canine Model. JACC Cardiovasc Interv 2014; 7:801-9. [DOI: 10.1016/j.jcin.2014.03.003] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 02/27/2014] [Accepted: 03/13/2014] [Indexed: 11/29/2022]
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Genç B, Solak A, Kantarci M, Bayraktutan U, Ogul H, Yüceler Z, Oztürk A, Kizrak Y. Anatomical features and clinical importance of left atrial diverticula: MDCT findings. Clin Anat 2013; 27:738-47. [PMID: 24214737 DOI: 10.1002/ca.22320] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 08/07/2013] [Accepted: 08/15/2013] [Indexed: 11/09/2022]
Abstract
To assess the anatomical features and clinical importance of left atrial diverticula and atrial accessory appendages in patients undergoing cardiac computed tomography with multidetector computed tomography. A total of 1305 consecutive patients (385 female, 29.5%; 920 male, 70.5%) were assessed using electrocardiogram-gated computed tomography between May 2010 and June 2013. The anatomical features and the prevalences of left atrial diverticula and left atrial accessory appendages were retrospectively assessed by four radiologists. The relationships between the prevalence and size of the diverticula and the age and gender of the patients were assessed. Among the 1305 patients, 610 (46.7%) exhibited 708 left atrial diverticula, and 62 (4.8%) exhibited left atrial accessory appendages. The most common locations of the left atrial diverticula were the right anterior superior wall (n = 328, 46.3%) and the lateral superior wall (n = 96, 13.5%). In addition to classical cystic and tubular diverticula, 49 (3.7%) of the patients exhibited mixed (cystic-tubular), conical, or hook-shaped diverticula and diverticular forms containing mural calcifications. There was no significant relationship between the prevalence of diverticula and the age and gender of the patients (P > 0.05). In addition to tubular and cystic diverticula, the left atrial wall can host different diverticular forms (such as mixed, conical, calcific, and hook shaped). It could be beneficial to assess the left atrium using MDCT to determine the source of emboli in cryptogenic embolism and to reduce complications associated with interventional procedures performed for left atrial arrhythmias.
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Affiliation(s)
- Berhan Genç
- Şifa University, School of Medicine, Department of Radiology, İzmir, Turkey
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Leal S, Moreno R, de Sousa Almeida M, Silva JA, Lopez-Sendon JL. Evidence-based percutaneous closure of the left atrial appendage in patients with atrial fibrillation. Curr Cardiol Rev 2013; 8:37-42. [PMID: 22845814 PMCID: PMC3394106 DOI: 10.2174/157340312801215827] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2012] [Revised: 05/08/2012] [Accepted: 05/10/2012] [Indexed: 11/24/2022] Open
Abstract
Atrial fibrillation is the most common cardiac arrhythmia, and its prevalence is increasing. Cardioembolic stroke, most of the times secondary to thrombus formation in the left atrial appendage, is its most feared and life threatening consequence. Oral anticoagulation with vitamin-K-antagonists is currently the most used prophylaxis for stroke in patients with atrial fibrillation; unfortunately, its benefits are limited by a narrow therapeutic window and an increased risk for bleeding, making it often undesired. Percutaneous occlusion of the left atrial appendage is a novel alternative strategy for cardioembolic stroke prophylaxis in patients with atrial fibrillation at a high risk of stroke but with contraindication for long-term oral anticoagulation therapy. At present, several devices have been developed specifically for percutaneous occlusion of the left atrial appendage. Current results show good feasibility and efficacy for these devices, with a high rate of successful implantation, although also associated with the inherent potential periprocedural complications. This work reviews the current state of the art of percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation.
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Affiliation(s)
- Silvio Leal
- Cardiovascular Intervention Unit, Cardiology Service, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal.
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Shi AW, Chen ML, Yang B, Cao KJ, Kong XQ. A morphological study of the left atrial appendage in chinese patients with atrial fibrillation. J Int Med Res 2013; 40:1560-7. [PMID: 22971509 DOI: 10.1177/147323001204000436] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Using angiography, this study examined left atrial appendage (LAA) morphology in Chinese patients with atrial fibrillation (AF) or congenital atrial septal defects (ASD), to provide data that might aid the design of new LAA-occluding devices to prevent cardioembolism and stroke in patients with AF. METHODS Patients with AF or ASD were enrolled. The LAA was visualized angiographically; its dimensions were measured and the emptying fraction was calculated. RESULTS A total of 45 patients with AF and 30 patients with ASD were included in the study. LAA morphology was classified into eight categories. The majority of patients with AF had tube-shaped LAAs with a single lobe; the most common LAA morphologies in patients with ASD were irregular or sphere-like, with multiple lobes. Patients with AF had significantly larger LAAs with significantly lower emptying fractions compared with LAAs of patients with ASD. CONCLUSIONS The LAA demonstrated considerable morpho logical variability in terms of its size, shape and number of lobes. The design of new occluding devices must take into account the size and shape of the LAA in patients with AF.
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Affiliation(s)
- A-W Shi
- Department of Cardiology, Affiliated Nanjing Maternity and Child Health Care Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, China
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Saygi S. Atrial Fibrillation and the Role of LAA in Pathophysiology and Clinical Outcomes? J Atr Fibrillation 2012; 5:480. [PMID: 28496767 DOI: 10.4022/jafib.480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Revised: 03/10/2012] [Accepted: 05/21/2012] [Indexed: 11/10/2022]
Abstract
Left atrial appendage (LAA) is a source of thromboembolism especially in patients with non valvular atrial fibrillation (AF). It is reasonable to accept LAA as a distinct part of left atrium (LA) with unique anatomical and physiological properties. Advances in imaging modalities increased the knowledge about anatomical and physiological characteristics of LAA. It is important to prevent the AF patients from systemic thromboembolic events, and new pharmacological and non pharmacological management approaches demonstrate encouraging results. Also pulmonary vein isolation which has been accepted as a curative and useful treatment option for the treatment of drug resistant AF has been helpful in understanding the electrophysiological properties of LAA. Accumulating data revealed that LAA continues to be the one of the most important structure of heart during AF because of its distinctive anatomical, mechanical, and electrophysiological properties.
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Affiliation(s)
- Serkan Saygi
- Department of Cardiology, Canakkale Onsekiz Mart University, Turkey
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Koplay M, Erol C, Paksoy Y, Kivrak AS, Özbek S. An investigation of the anatomical variations of left atrial appendage by multidetector computed tomographic coronary angiography. Eur J Radiol 2012; 81:1575-80. [PMID: 21592706 DOI: 10.1016/j.ejrad.2011.04.060] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2011] [Accepted: 04/21/2011] [Indexed: 01/11/2023]
Affiliation(s)
- Mustafa Koplay
- Department of Radiology, Selcuklu Medical Faculty, Selcuk University, The Central Campus, 42075 Konya, Turkey.
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Abstract
A 7-year-old child was noted to have dextrojuxtaposition of the left atrial appendage at the time of surgical atrial septal defect repair. Given the favourable anatomic location and size of the atrial appendage, it was inverted and used to close the atrial defect. This is the first report of atrial septal defect repair using a juxtaposed atrial appendage. The cardiac anatomy and theoretical benefits of this repair are discussed.
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Analysis of left atrial appendix by dual-source CT coronary angiography: morphologic classification and imaging by volume rendered CT images. Eur J Radiol 2010; 80:e346-50. [PMID: 21126840 DOI: 10.1016/j.ejrad.2010.11.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Accepted: 11/03/2010] [Indexed: 11/22/2022]
Abstract
AIM We investigated the evaluability of left atrial appendix by dual source coronary CT angiography and analyzed morphologic features. MATERIALS AND METHODS We included 106 consecutive patients who underwent coronary CT angiography for various indications. Technical parameters were slice thickness 0.6 mm, reconstruction interval 0.3mm, gantry rotation time 165 ms. Images were reconstructed from 10% to 100% R-R intervals at 10% intervals to evaluate the left atrial appendix and 4-D inspace software was used for analysis. We recorded the R-R intervals when the left atrial appendix was at maximum and minimum volume. We also evaluated visibility of appendix at R-R intervals. Maximum appendix volume was calculated. Atrial appendices were classified morphologically based on number of chambers (types 1-3) seen on volume rendered images. RESULTS There were 60 male and 46 female patients in the study group and, mean age was 55±13. Mean heart rate was 72 (ranges 47-110). Left atrial was evaluable at maximum and minimum volume by coronary CT angiography in all patients. We noted types 1-3 appendix in 29 (27%), 73 (69%), and 4 (4%) patients, respectively. Mean R-R intervals at maximum and minimum volume were 40%±6 (95% CI; 28-52%) and 95%±5 (95% CI; 85-5%), respectively. Mean appendix maximum volume was 7±4 cm3. Appendix contours were mildly, moderately and severely irregular in 10 (9%), 58 (55%), 38 (36%) patients, respectively. CONCLUSION Left atrial appendix was visualized in all patients independent of heart rate at maximum and minimum volumes. Volume rendered CT images can allow excellent depiction of left atrial appendix morphology and classification. Presence of moderate and severe irregularity of appendix contour in most of the patients may be the cause of slow flow. This morphologic appearance may be the underlying reason for the propensity to atrial appendix thrombus formation.
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Leithäuser B, Park JW. Cardioembolic stroke in atrial fibrillation-rationale for preventive closure of the left atrial appendage. Korean Circ J 2009; 39:443-58. [PMID: 19997539 PMCID: PMC2790130 DOI: 10.4070/kcj.2009.39.11.443] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Atrial fibrillation is the most common cardiac arrhythmias, and a major cause of morbidity and mortality due to cardioembolic stroke. The left atrial appendage is the major site of thrombus formation in non-valvular atrial fibrillation. Loss of atrial systole in atrial fibrillation and increased relative risk of associated stroke point strongly toward a role for stasis of blood in left atrial thrombosis, although thrombus formation is multifactorial, and much more than blood flow irregularities are implicated. Oral anticoagulation with vitamin-K-antagonists is currently the most effective prophylaxis for stroke in atrial fibrillation. Unfortunately, this treatment is often contraindicated, particularly in the elderly, in whom risk of stroke is high. Moreover, given the risk of major bleeding, there is reason to be skeptical of the net benefit when warfarin is used in those patients. This work reviews the pathophysiology of cardioembolic stroke and critically spotlights the current status of preventive anticoagulation therapy. Various techniques to exclude the left atrial appendage from circulation were discussed as a considerable alternative for stroke prophylaxis.
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Affiliation(s)
- Boris Leithäuser
- Asklepios General Hospital Harburg, 1st Medical Department, Cardiology, Intensive Care Medicine, Hamburg, Germany
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Hara H, Virmani R, Holmes DR, Buchbinder M, Lesser JR, Van Tassel RA, Mooney MR, Schwartz RS. Is the left atrial appendage more than a simple appendage? Catheter Cardiovasc Interv 2009; 74:234-42. [PMID: 19360867 DOI: 10.1002/ccd.21983] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The left atrial appendage (LAA) is a cardiac structure with unique anatomic and functional features. It is significantly more than a simple chamber appended to the left atrium (LA), differing from the LA in structure, function, and hormonal activity. Unfortunately, it is the source of more than 90% of cardiac-based emboli, particularly in atrial fibrillation, mandating lifelong anticoagulation. Percutaneous LAA exclusion was developed to limit or eliminate cardioembolic events in patients with atrial fibrillation. Benign healing of the appendage occurs without adverse hemodynamic effects, and with no residual surface thrombus or tissue damage. The feasibility of this treatment is now established, suggesting that percutaneous therapy is safe, practical and possibly effective to eliminate the need for anticoagulation and significantly reduce cardioembolic events.
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Affiliation(s)
- Hidehiko Hara
- Minneapolis Heart Institute and Foundation, Minneapolis, Minnesota, USA.
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Killeen RP, Ryan R, MacErlane A, Martos R, Keane D, Dodd JD. Accessory left atrial diverticulae: contractile properties depicted with 64-slice cine-cardiac CT. Int J Cardiovasc Imaging 2009; 26:241-8. [PMID: 19768571 DOI: 10.1007/s10554-009-9511-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Accepted: 09/08/2009] [Indexed: 11/28/2022]
Abstract
To assess the contractility of accessory left atrial appendages (LAAs) using multiphasic cardiac CT. We retrospectively analyzed the presence, location, size and contractile properties of accessory LAAs using multiphasic cardiac 64-slice CT in 102 consecutive patients (63 males, 39 females, mean age 57). Multiplanar reformats were used to create image planes in axial oblique, sagittal oblique and coronal oblique planes. For all appendages with an orifice diameter >or= 10 mm, axial and sagittal diameters and appendage volumes were recorded in atrial diastole and systole. Regression analysis was performed to assess which imaging appearances best predicted accessory appendage contractility. Twenty-three (23%) patients demonstrated an accessory LAA, all identified along the anterior LA wall. Dimensions for axial oblique (AOD) and sagittal oblique (SOD) diameters and sagittal oblique length (SOL) were 6.3-19, 3.4-20 and 5-21 mm, respectively. All appendages (>or=10 mm) demonstrated significant contraction during atrial systole (greatest diameter reduction was AOD [3.8 mm, 27%]). Significant correlations were noted between AOD-contraction and AOD (R = 0.57, P < 0.05) and SOD-contraction and AOD, SOD and SOL (R = 0.6, P < 0.05). Mean diverticulum volume in atrial diastole was 468.4 +/- 493 mm(3) and in systole was 171.2 +/- 122 mm(3), indicating a mean change in volume of 297.2 +/- 390 mm(3), P < 0.0001. Stepwise multiple regression analysis revealed SOL to be the strongest independent predictor of appendage contractility (R(2) = 0.86, P < 0.0001) followed by SOD (R(2) = 0.91, P < 0.0001). Accessory LAAs show significant contractile properties on cardiac CT. Those accessory LAAs with a large sagittal height or depth should be evaluated for contractile properties, and if present should be examined for ectopic activity during electrophysiological studies.
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Affiliation(s)
- Ronan P Killeen
- Departments of Radiology, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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Yildirim SV, Tokel K, Varan B, Aslamaci S, Ekici E. Clinical investigations over 13 years to establish the nature of the cardiac defects in patients having abnormalities of lateralization. Cardiol Young 2007; 17:275-82. [PMID: 17615645 DOI: 10.1017/s1047951107000479] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION The first step in diagnosing congenital cardiac malformations is to assess the arrangement of the atrial appendages. In patients with abnormal lateralization of the organs of the body, the arrangement of atrial appendages is neither normal, nor a mirror image of normal. There are 2 categories of abnormal arrangement based on the morphology of the atrial appendices, namely right isomerism and left isomerism, and in almost all instances these are found in the setting of so-called heterotaxy syndromes. OBJECTIVE To evaluate the various congenital cardiac malformations those are associated with abnormalities of lateralization, and to discuss the diagnostic tools, therapeutic options, and outcome for these patients. PATIENTS AND METHODS We studied 134 patients, who had been admitted to our department of paediatric cardiology with known abnormalities of lateralization and congenital cardiac defects between 1990 and 2003. The data relating to each patient was evaluated retrospectively. The arrangement of the atrial appendages was established echocardiographically, and/or angiographically, and/or on the basis of morphologic investigations during the operation. These studies showed that 43 (32.1%) of the patients had right isomerism, and 88 (65.7%) had left isomerism. In 2 (1.5%), there was mirror-imaged arrangement, while in the final patient (0.07%), we were unable to determine sidedness with certainty. The median age at diagnosis was 0.66 years, and the females outnumbered the males in a ratio of 3 to 1. Patients in the 2 isomeric groups were compared with regard to age, cardiac defects, diagnostic tools and outcomes. RESULTS The difference in mean ages of the two groups of patients was statistically significant, those with right isomerism being 1.0 minus or plus 1.5 years, as opposed to those with left isomerism being 3.3 minus or plus 4.7 years (P is less than 0.005). Of the patients with right isomerism, 32 (74.4%) had left-sided, and 11 (25.6%) right-sided hearts, whereas in those with left isomerism, the hearts were left-sided in 65 (73.9%), and right-sided in 21 (23.9%), with 2 (2.2%) positioned in the midline. Extracardiac totally anomalous pulmonary venous connection was more common in those with right isomerism, being found in 13 patients (30.2%) as opposed to 5 patients (5.7%) with left isomerism. In only 8 of those with right isomerism did we find two perforate atrioventricular valves (18.6%), this arrangement being found in 34 (38.6%) of those with left isomerism. Pulmonary atresia and stenosis were present in 40 (93.0%) of those with right isomerism, but also in 41 (46.6%) of the patients with left isomerism. Angiographic and echocardiographic investigations were concordant in about three-quarters of patients with both right and left isomerism. All patients with extracardiac totally anomalous pulmonary venous connection died. Overall, 22 of the patients with right isomerism died (51.2%), as opposed to 20 (22.7%) of those with left isomerism. CONCLUSION Our experience confirms that patients with right isomerism have more complex cardiac defects than those with left isomerism. Overall, the presence of isomerism carries a poor prognosis, the more so for right isomerism, with this related to the complex cardiac abnormalities. In our cohort, extracardiac totally anomalous pulmonary venous connection with pulmonary arterial obstruction was always a fatal combination. The mapping of cardiac and abdominal morphologies is still essential for proper diagnosis of these syndromes, especially in fetal life.
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Affiliation(s)
- Selman Vefa Yildirim
- Division of Pediatric Cardiology, Baskent University Faculty of Medicine, Adana Teaching and Medical Research Center, Adana, Turkey.
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Kurio GH, Gulati R, Bichell DP, Perry JC. Malalignment of the septum primum with abnormally positioned left atrial appendage: unusual combination in a Shone's heart. Pediatr Cardiol 2006; 27:628-32. [PMID: 16944330 DOI: 10.1007/s00246-006-1364-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2006] [Accepted: 04/27/2006] [Indexed: 10/24/2022]
Abstract
This case discusses a Shone's variant with small left ventricle and mitral valve, bicuspid aortic valve, coarctation of the aorta, an unusual arrangement of atrial appendages, and partially anomalous pulmonary venous drainage due to a deviated atrial septum. The left atrial appendage could be directly entered from the right atrium at catheterization, but it was positioned behind the great arteries. The right atrial appendage was normal in origin and orientation. The implications of this anatomy in fetal cardiac development are reviewed.
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Affiliation(s)
- Gregory H Kurio
- Division of Pediatric Cardiology, Children's Hospital Los Angeles, 4650 Sunset Boulevard, No. 34, Los Angeles, CA 90027, USA.
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Tchervenkov CI, Jacobs ML, Del Duca D. Surgery for the functionally univentricular heart in patients with visceral heterotaxy. Cardiol Young 2006; 16 Suppl 1:72-9. [PMID: 16401367 DOI: 10.1017/s1047951105002362] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The heterotaxy syndromes are characterized by a high incidence of cardiac anomalies of extreme heterogeneity. Due to this, the surgical management is varied and challenging. Although a minority of patients can undergo biventricular repair, the complexity of the cardiac defects, and the high incidence of ventricular hypoplasia, mandate a surgical approach in the majority of patients depending on the creation of a functionally univentricular heart. Traditionally, the functionally univentricular approach was associated with a high mortality. More recently, the results have been improving as a result of better understanding of these malformations, and logical improvements in surgical technique. In this review, we will make brief comments on the nomenclature and classification of the heterotaxy syndromes, and the range of cardiac anomalies, before concentrating on the surgical treatment for those patients having functionally univentricular hearts in the setting of heterotaxy. More specifically, we will review initial palliation in early life, creation of the cavopulmonary anastomoses, including the Kawashima procedure and the Fontan circulation, and the role of transplantation.
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Affiliation(s)
- Christo I Tchervenkov
- Division of Cardiovascular Surgery, Montreal Children's Hospital of the McGill University Health Center, McGill University, Montréal, Québec, Canada.
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Friedberg MK, Ursell PC, Silverman NH. Isomerism of the left atrial appendage associated with ventricular noncompaction. Am J Cardiol 2005; 96:985-90. [PMID: 16188529 DOI: 10.1016/j.amjcard.2005.05.063] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2005] [Revised: 05/26/2005] [Accepted: 05/25/2005] [Indexed: 12/01/2022]
Abstract
This study investigated the rare association of ventricular noncompaction with isomerism of the left atrial appendage and heart block, demonstrating a dire prognosis for this condition. Prenatal recognition is possible by ultrasound, facilitating appropriate prenatal counseling.
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Affiliation(s)
- Mark K Friedberg
- Pediatric Echocardiography, Division of Pediatric Cardiology, Department of Pediatrics, Lucille Packard Children's Hospital and Stanford University, Stanford, California, USA
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Hong YK, Park YW, Ryu SJ, Won JW, Choi JY, Sul JH, Lee SK, Cho BK, Choe KO. Efficacy of MRI in complicated congenital heart disease with visceral heterotaxy syndrome. J Comput Assist Tomogr 2000; 24:671-82. [PMID: 11045684 DOI: 10.1097/00004728-200009000-00002] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE The authors' goal was to assess the diagnostic accuracy and clinical effect of MRI compared with echocardiography and catheterization in the evaluation of cardiac defects with situs ambiguous. METHOD Twenty-two patients with visceral heterotaxy syndrome were included. RESULTS Because situs determined by the relation between the pulmonary artery and bronchi showed most predominantly a tendency toward lateralization, this was regarded as the standard reference of situs determination. For the purpose of this study, patients were classified as having right isomerism (n = 13) or left isomerism groups (n = 9). MRI has several advantages compared with echocardiography or cardiac angiography for examining patients with situs ambiguous. (1) The bronchial, pulmonary arterial, and splenic situs can be readily determined, and discrepancies (n = 2) can be assessed easily. (2) Venoatrial connections are adequately imaged. In particular, all types of total and partial anomalous pulmonary venous return are delineated, regardless of whether restrictions of pulmonary blood flow or pulmonary venous obstructions are involved (n = 4). The courses of vertical veins were easily identified, and the prearterial position was revealed in only one of seven right isomerisms with total anomalous pulmonary venous return. The drain pattern of the hepatic vein can be visualized using three-dimensional spatial information and is useful for total cavopulmonary connection design. (3) Associated complicated cardiac anomalies, particularly the size or peripheral stenosis of the pulmonary arteries, may be evaluated, and this information is useful for palliative shunt operations. CONCLUSION Because of its wide field of view and imaging, which is not restricted by associated anomalies, a thorough understanding of the cardiovascular anatomy of the situs ambiguous can be achieved using MRI, which is of considerable value in the surgical correction of this complicated anomaly. MRI can obviate or facilitate catheterization in these critically ill patients.
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Affiliation(s)
- Y K Hong
- Department of Diagnostic Radiology, Yonsei University, College of Medicine, Seoul, Korea
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Gilljam T, McCrindle BW, Smallhorn JF, Williams WG, Freedom RM. Outcomes of left atrial isomerism over a 28-year period at a single institution. J Am Coll Cardiol 2000; 36:908-16. [PMID: 10987619 DOI: 10.1016/s0735-1097(00)00812-3] [Citation(s) in RCA: 147] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We determined long-term outcomes in a large cohort with left atrial isomerism (LAI). BACKGROUND Left atrial isomerism is associated with a complex spectrum of cardiac and noncardiac anomalies that may impact on outcomes. METHODS The records of all patients with LAI, born between 1970 and 1998, and treated at one center were reviewed. Kaplan-Meier survival was estimated, and independent factors associated with time-related death were identified. RESULTS There were 163 patients (63% women), and extracardiac anomalies were noted in 36%, including biliary atresia in 10%. Cardiac defects included interrupted inferior caval vein in 92%, anomalous pulmonary veins in 56%, atrioventricular septal defect in 49%, pulmonary atresia or stenosis in 28% and aortic coarctation in 16%, with congenital atrioventricular block in 7%. Of 22 patients with a normal heart, 18% died of extracardiac anomalies. Of 71 patients with hearts suitable for biventricular repair, 62 (87%) had surgery, with survival of 80% at one year, 71% at five years, 66% at 10 years and 63% after 15 years. Of 70 patients with unbalanced cardiac defects suitable for single-ventricle palliation, 47 (67%) had surgery, with survival of 73% at one year, 61% at five years, 53% at 10 years and 48% at 15 years (p < 0.001). Independent factors associated with time-related death included congenital atrioventricular block, aortic coarctation, single ventricle, biliary atresia and other gastrointestinal malformations. CONCLUSIONS Both cardiac and noncardiac anomalies contribute to a high mortality with LAI. Cardiac transplantation may need to be a considered a primary option for selected high-risk patients.
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Affiliation(s)
- T Gilljam
- Department of Pediatrics, Hospital for Sick Children and the University of Toronto Faculty of Medicine, Ontario, Canada
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Hashmi A, Abu-Sulaiman R, McCrindle BW, Smallhorn JF, Williams WG, Freedom RM. Management and outcomes of right atrial isomerism: a 26-year experience. J Am Coll Cardiol 1998; 31:1120-6. [PMID: 9562017 DOI: 10.1016/s0735-1097(98)00062-x] [Citation(s) in RCA: 143] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES We sought to determine, in a large series of patients with right atrial isomerism, factors associated with mortality. BACKGROUND Right atrial isomerism is associated with complex congenital heart disease and high morbidity and mortality. METHOD All data from patients diagnosed with right atrial isomerism between January 1970 and March 1996 were reviewed. RESULTS A total of 91 consecutive patients (54 male) were identified. Most patients (89%) presented within the first month of life, 62% at birth. Cardiac abnormalities included common atrioventricular (AV) valve (81%), ventricular hypoplasia or single ventricle (73%), abnormal ventriculoarterial connections (96%), pulmonary outflow tract obstruction (84%), anomalous pulmonary venous drainage (87%) and pulmonary vein obstruction (30%). The overall mortality rate was 69%. No interventions were planned or performed in 24%, 95% of whom died. The mortality rate for patients requiring their first cardiovascular operation in the neonatal period was 75% versus 51% for those with later first operations (p < 0.05). The surgical mortality rate for patients undergoing pulmonary vein repair was 95%. Overall survival estimates were 71% at 1 month, 49% at 1 year and 35% at 5 years. Independent risk factors for decreased time to death included the absence of pulmonary outflow obstruction (relative risk [RR] 2.23, p < 0.03), presence of major AV valve anomaly (RR 5.23, p < 0.03) and obstructed pulmonary veins (RR 5.43, p < 0.0001). CONCLUSIONS Right atrial isomerism continues to have an associated high mortality despite surgical innovations. Management of pulmonary vein obstruction remains a serious problem and is associated with high mortality.
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Affiliation(s)
- A Hashmi
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Veinot JP, Harrity PJ, Gentile F, Khandheria BK, Bailey KR, Eickholt JT, Seward JB, Tajik AJ, Edwards WD. Anatomy of the normal left atrial appendage: a quantitative study of age-related changes in 500 autopsy hearts: implications for echocardiographic examination. Circulation 1997; 96:3112-5. [PMID: 9386182 DOI: 10.1161/01.cir.96.9.3112] [Citation(s) in RCA: 257] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Transesophageal echocardiography (TEE) is the diagnostic modality of choice for visualizing the left atrial appendage (LAA). This study defined the morphology of the LAA in normal autopsy specimen hearts and considered the implications of these findings for TEE studies. METHODS AND RESULTS Five hundred normal autopsy hearts were reviewed (25 male and 25 female subjects from each decade for 10 decades). LAA length, width, orifice size, and number of lobes were recorded. Number of lobes was compared between sexes with the rank sum test and regressed against age. Mean length, width, and orifice size increased with age, up to age 20 years, in both sexes. Rates were significantly different between sexes for LAA size (P=.011) and width (P=.006). After age 20, statistically significant but clinically insignificant age-related changes were observed. Fifty-four percent of LAAs had two lobes (range, 1 to 4), with no age or sex differences. Lobes exist in different planes of the heart. Most pectinate muscles were > or = 1 mm in width. Pectinate muscles < 1 mm (2.6% of cases) were seen in only the first and last decades. CONCLUSIONS Age- and sex-related differences in LAA dimensions exist. These differences and the existence of multilobed appendages are important in the accurate TEE evaluation of LAA. Because lobes exist in different planes, imaging must be done in multiple planes to visualize the entire LAA.
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Affiliation(s)
- J P Veinot
- Division of Anatomic Pathology, Mayo Clinic and Mayo Foundation, Rochester, Minn 55905, USA
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Ho SY, Seo JW, Brown NA, Cook AC, Fagg NL, Anderson RH. Morphology of the sinus node in human and mouse hearts with isomerism of the atrial appendages. Heart 1995; 74:437-42. [PMID: 7488461 PMCID: PMC484053 DOI: 10.1136/hrt.74.4.437] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The location of the sinus node is known to be at best abnormal, or at worst unknown, in patients with isomerism of the morphologically left atrial appendage. In contrast, the sinus node is known to be an excellent histological marker of the morphologically right appendage, being duplicated in those with right isomerism. The aim of the study was to investigate this condition further in fetal human and mouse hearts. METHODS Serial histological sections of the area anticipated to contain the sinus node were studied in hearts with isomerism of the atrial appendages taken from 14 human fetuses and 13 iv/iv mice, using 12 mouse hearts with normally arranged or mirror imaged atrial chambers for controls. RESULTS All hearts with isomerism of the right appendages (two human and four mouse) had bilateral sinus nodes. The cases with isomerism of the left appendages (12 human and nine mouse) showed absence of a recognisable sinus node except in four cases (19%) in which a small remnant of the node was found. In three of these cases, it was related postero-inferiorly to the superior cavoatrial junction. CONCLUSIONS The concept of isomerism of the atrial appendages is endorsed by findings on the morphology of the sinus node, this being the most reliable histological criterion for existence of a morphologically right atrium. A small proportion of hearts with left isomerism had a structure resembling the sinus node, but it was hypoplastic and displaced postero-inferiorly, distant from its expected position had the hearts possessed an incompletely formed morphologically right appendage.
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Affiliation(s)
- S Y Ho
- Department of Paediatrics, National Heart and Lung Institute, London
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Uemura H, Ho SY, Devine WA, Kilpatrick LL, Anderson RH. Atrial appendages and venoatrial connections in hearts from patients with visceral heterotaxy. Ann Thorac Surg 1995; 60:561-9. [PMID: 7677481 DOI: 10.1016/0003-4975(95)00538-v] [Citation(s) in RCA: 178] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Venoatrial connections are important when choosing surgical options for patients with visceral heterotaxy. The precise morphology of the atriums, however, is often obfuscated by the term "visceral heterotaxy." This morphologic study aims to clarify the features of significance to the cardiac surgeon. METHODS We investigated 183 hearts from patients known from postmortem inspection to have so-called visceral heterotaxy. The connections of the systemic and pulmonary veins to the atriums, and the detailed morphology of the atriums, were examined in each case. RESULTS Pectinate muscles extended bilaterally to the crux in 125 hearts determined to have isomeric morphologically right appendages. The other 58 hearts all exhibited bilaterally smooth-walled vestibules, and were diagnosed as having isomeric left appendages. Bilateral superior caval veins were frequent in both groups. The inferior caval vein was right- or left-sided with equal frequency in both groups, but was interrupted only in hearts with isomeric left appendages. The pulmonary veins connected in extraatrial fashion in 48% of cases with isomeric right appendages, whereas, most commonly, pulmonary veins were connected bilaterally to the atriums in those with isomeric left appendages (60%). CONCLUSIONS Both the morphology of the atrial appendages and the venoatrial connections need to be distinguished to establish precise diagnoses in patients with so-called visceral heterotaxy ("splenic syndromes").
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Affiliation(s)
- H Uemura
- National Heart & Lung Institute, London, England
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Uemura H, Ho SY, Anderson RH, Devine WA, Smith A, Shinohara T, Yagihara T, Kawashima Y. The surgical anatomy of coronary venous return in hearts with isomeric atrial appendages. J Thorac Cardiovasc Surg 1995; 110:436-44. [PMID: 7637362 DOI: 10.1016/s0022-5223(95)70240-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Although absence of the coronary sinus is widely recognized in hearts with isomerism of the right atrial appendages, little attention has been paid to the fashion of the venous return from the heart itself. In this study, the arrangement of coronary venous return was investigated in 99 specimens with isomeric right and 49 with isomeric left appendages. In the normal heart, the coronary veins consist of a circumflex component within the atrioventricular groove and longitudinal components on the ventricular mass. The circumflex venous system was seen in 44 hearts with isomerism of left appendages (90%), but 23 of these hearts lacked the anatomic features of the coronary sinus. Circumflex veins were entirely lacking in the other 10% of hearts with isomeric left appendages and in all those with isomeric right appendages. In these hearts, longitudinal veins drained independently into the atria in three patterns. The first was a direct connection, with the venous orifice opening between the trabeculations of the atrial wall immediately having crossed the atrioventricular groove. The second was a crooked return, with the vein running an intramural course along the atrioventricular groove. The third was a distant connection, reaching superiorly to the smooth-walled atrial component after running an intramural course. Intramural courses were seen in 19% of the longitudinal veins, such veins being found in 62% of all hearts with no circumflex venous system. These findings, which to the best of our knowledge have never previously been recognized in detail, almost certainly have potential surgical significance.
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Affiliation(s)
- H Uemura
- National Heart and Lung Institute, London, United Kingdom
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Hirooka K, Yagihara T, Kishimoto H, Isobe F, Yamamoto F, Nishigaki K, Matsuki O, Uemura H, Kawashima Y. Biventricular repair in cardiac isomerism. Report of seventeen cases. J Thorac Cardiovasc Surg 1995; 109:530-5. [PMID: 7877315 DOI: 10.1016/s0022-5223(95)70285-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Ninety-three patients with cardiac isomerism were treated surgically from July 1985 to June 1991. Among them, three patients with right and 14 with left isomerism underwent biventricular repair. Ages ranged from 4 months to 41 years (mean 4.8 years). Anatomic repair was accomplished in 15 patients and functional repair with the right ventricle used as the systemic ventricle in two patients. Methods of atrial septation to separate pulmonary venous flow from systemic venous flow included atrial partition with a straight patch in seven patients, intraatrial rerouting with a tailored baffle in five, and a Mustard-type atrial switch in five. One hospital death (5.8%) and two late deaths (12%) occurred. Two patients required reoperation (12%), one reconstruction of a stenotic systemic venous connection and one mitral valve replacement because of incompetence. Surgically induced complete atrioventricular block was not observed in any of the patients. Optimal atrial septation offers the possibility of biventricular repair for patients with acceptable intraventricular structure.
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Affiliation(s)
- K Hirooka
- Division of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan
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Phoon CK, Neill CA. Reply. Am J Cardiol 1994. [DOI: 10.1016/0002-9149(94)90870-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Seo JW, Brown NA, Ho SY, Anderson RH. Abnormal laterality and congenital cardiac anomalies. Relations of visceral and cardiac morphologies in the iv/iv mouse. Circulation 1992; 86:642-50. [PMID: 1638728 DOI: 10.1161/01.cir.86.2.642] [Citation(s) in RCA: 60] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND In the management of hearts with deranged laterality, it is essential that the left and right atrial chambers are correctly identified. There are two major approaches, which are based on venous connections or on the morphology of the atrial appendages, and there is no consensus as to which is the most useful. We used the iv/iv mouse mutant, which is known to be pertinent to this problem, to evaluate the relations of cardiac defects with atrial, venous, and other visceral morphologies. METHODS AND RESULTS The morphology of the heart and other organs was examined in 275 iv/iv mice using criteria based on abnormal laterality in humans. The arrangement of the atrial appendages was determined by morphological examination of the junction between the appendage and the venous component of the atrium. On this basis, 45.1% of cases were shown to have usual atrial arrangement, 50.2% had mirror imagery, 1.5% had right isomerism, and 3.3% had left isomerism. Every case of atrial isomerism had a cardiac lesion; the morphological types were similar to those seen in human cases. Of cases with either usual or mirror-image arrangement of the appendages, 33.2% had abnormal spleens, but only 3.1% had cardiac defects. Similarly, venous abnormalities were much more common (30.1%) than cardiac defects. CONCLUSIONS Study results endorse the importance of the morphology of atrial appendages in predicting cardiac abnormalities and point to the marked inconsistency of the arrangement of other organs, including the spleen and the connections of the systemic veins.
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Affiliation(s)
- J W Seo
- Department of Paediatrics, National Heart and Lung Institute, London, UK
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Ho SY, Cook A, Anderson RH, Allan LD, Fagg N. Isomerism of the atrial appendages in the fetus. PEDIATRIC PATHOLOGY 1991; 11:589-608. [PMID: 1946078 DOI: 10.3109/15513819109064792] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Thirty hearts from fetuses with visceral heterotaxy were examined to determine the range of cardiac malformations. By examining the morphology of the atrial appendages, 20 hearts were identified as having left isomerism (67%) and 10 hearts right isomerism (33%). Fifteen of the hearts with left isomerism had biventricular atrioventricular connections and five had univentricular atrioventricular connections. All 10 hearts with right isomerism had biventricular atrioventricular connections. Flow to the pulmonary arteries was obstructed or occluded in 6 hearts with left isomerism (30%) and 7 hearts with right isomerism (70%). Obstruction to aortic flow was present in 4 hearts with left isomerism (20%). Anomalies of the systemic and pulmonary veins were common in both groups. The suprarenal portion of the inferior caval vein was interrupted in 11 hearts with left isomerism (55%) and 1 heart with right isomerism (10%). Atrioventricular septal defect was present in 13 hearts with left isomerism (65%) and 9 hearts with right isomerism (90%). The arrangement of the liver or stomach in each group was not consistent, nor was the status of the spleen. The constellations of cardiac malformations in both groups corresponded to those known in postnatal life and similar guidelines for their identification were applicable.
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Affiliation(s)
- S Y Ho
- Department of Paediatrics, National Heart and Lung Institute, London, England
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