Circulation, Vol 84, 223-231, Copyright © 1991 by American Heart Association
C Pollick and D Taylor
BACKGROUND. The predilection of the left atrial appendage (LAA) for
thrombus formation has long been known. METHODS AND RESULTS. We
prospectively studied the two-dimensional echocardiographic and Doppler
patterns of LAA function in 82 patients by transesophageal
echocardiography. In the 63 patients in sinus rhythm, LAA area was measured
during LAA diastole at the onset of the electrocardiographic (ECG) P wave
(LAAmax) and after LAA systole at the ECG R wave (LAAmin) and LAA ejection
fraction was calculated as (LAAmax-LAAmin)/LAAmax; peak Doppler velocity
was recorded from the LAA outlet. The 58 patients in sinus rhythm without
LAA thrombus were grouped according to left atrial size on transthoracic
echocardiography; 39 patients had a left atrial size of less than 40 mm
(group 1) and 19 had a left atrial size of 40 mm or greater (group 2). Five
patients in sinus rhythm had LAA thrombus. In the 19 patients with atrial
fibrillation or flutter LAAmax was measured independent of the ECG; three
of these patients had LAA spontaneous contrast, four had thrombus, and one
had both. Patients in sinus rhythm without LAA thrombus demonstrated a
characteristic pattern of a contractile LAA apex and a noncontractile base
with color flow and pulsed Doppler evidence of LAA emptying that coincided
with the P wave. Patients in sinus rhythm with LAA thrombus had a mean +/-
SD LAAmax (8.0 +/- 1.5 cm2) larger than that in group 1 (5.0 +/- 1.9 cm2)
(p less than 0.01) but not group 2 (6.7 +/- 3.1 cm2), LAAmin (6.5 +/- 1.0
cm2) larger than that in both group 1 (2.3 +/- 1.5 cm2) and group 2 (4.2
+/- 2.7 cm2) (p less than 0.01), and LAA ejection fraction (17 +/- 11%) and
LAA velocity (0.24 +/- 0.10 m/sec) less than those in both group 1 (55 +/-
21% and 0.48 +/- 0.24 m/sec, respectively) and group 2 (45 +/- 27% and 0.46
+/- 0.24 m/sec, respectively) (p less than 0.01). Patients with atrial
fibrillation or flutter with LAA spontaneous contrast and/or thrombus had
LAAmax (10.4 +/- 6.6 cm2) greater than that in patients with atrial
fibrillation or flutter without LAA contrast and/or thrombus (6.8 +/- 3.0
cm2) (p less than 0.05). The LAA appeared as a static pouch in seven of
eight of the former compared with in two of 11 of the latter. When
attempted, Doppler demonstrated a recognizable fibrillatory LAA outflow
velocity pattern in none of three in the former versus four of seven in the
latter group. CONCLUSIONS. We conclude that the LAA has a characteristic
pattern of emptying in sinus rhythm. LAA thrombus formation in sinus rhythm
and atrial fibrillation is associated with both poor LAA contraction and
LAA dilation.
ARTICLES
Assessment of left atrial appendage function by transesophageal echocardiography. Implications for the development of thrombus
Department of Medicine, Vancouver General Hospital, British Columbia, Canada.
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