Aneurysm of the left atrial appendage.

A 2-year old asymptomatic girl is presented in whom the chest x-ray film led to the discovery of a grossly distorted cardiac shadow. Angiocardiography showed a giant aneurysm originating from the left atrium. At operation an intrapericardial aneurysm of the left atrial appendage, measuring 12 X 4 X 4 cm, was found. It communicated with the left atrium through an orifice measuring 3 cm. The aneurysm was excised.     

Aneurysm of the left atrial appendage.

A 43-year-old woman underwent excision of an aneurysm of the left atrial appendage, which had been causing cerebrovascular embolic episodes. We attribute the aneurysm to congenital dysplasia of the musculi pectinati in the left atrial appendage and of the bands of atrial muscle from which they arise. In Appendix I, we draw attention to the morphologically similar arrangements of inner and outer bands that emanate from a common transverse interatrial band and yield morphologically similar medial, descending, and ascending palm-leaf arrangements of musculi pectinati. In addition, we observe that the strap-like arrangements of musculi in both atria connect the outer band with the para-annular segment of the inner band. In Appendix II, we briefly review the literature concerning musculi pectinati and related bands.     

Histopathological features of the resected left atrial appendage as predictors of recurrence after surgery for atrial fibrillation in valvular heart disease.

BACKGROUND: A histopathological assessment of left atrial appendages (LAA) resected during surgical treatment for atrial fibrillation (AF) was made, with the aim of improving the prediction of postoperative AF recurrence. METHODS AND RESULTS: This clinicopathological study involved 57 surgical cases of valvular AF and 34 age- and sex-matched control autopsy cases with a history of sinus rhythm. LAA from the cases with valvular AF showed greater hypertrophy of cardiomyocytes (p<0.0001), greater nuclear enlargement (p<0.0001), more bizarre nuclei (BN; p<0.0001), and more intercellular fibrosis (ICF; p<0.001). Partial disarray of cardiomyocytes and fatty infiltration were recognized in both the AF and control groups. Thirty-seven cases had maintained sinus rhythm after surgery from 7 months to 10 years. AF recurred within a month of surgery in 17 and after a month in 3; there was no significant difference in histopathological features between them. These 20 cases had more cellular hypertrophy (p<0.025), nuclear enlargement (p<0.025), BN (p<0.01), and ICF (p<0.025) than those who maintained sinus rhythm after surgery. CONCLUSIONS: The histopathological findings for LAA reflected the underlying valvular diseases; however, the most reliable predictors of postoperative AF recurrence were hypertrophy of cardiomyocytes, bizarre shaped nuclei, and extensive ICF.     

Congenital aneurysm of left atrial appendage.

Congenital aneurysm of the left atrial appendage is a rare anomaly, usually presenting in adult life. The case reported is that of a 55-year-old man who died of cerebral embolism originating from a thrombus in a congenital aneurysm of the left atrial appendage. The cardiac silhouette 11 years previously had suggested a cardiac tumour or a pericardial cyst. As judged frm 14 published cases, the major manifestations of these aneurysms are an abnormal cardiac silhouette in the x-ray, supraventricular tachycardia, and systemic embolism. Angiocardiography appears to be the method of choice in establishing the diagnosis. Resection of th aneurysm is the recommended form of treatment.     

Ethanol infusion in left atrial appendage vein for treating refractory left atrial appendage tachycardia

Introduction

We describe an unusual case of atrial tachycardia (AT) emanating from the left atrial appendage body (LAA), successfully treated by chemical ablation.

Methods

A 66-year-old patient with cardiac amyloidosis and history of persistent atrial fibrillation ablation presented poorly tolerated AT with 1:1 atrioventricular nodal conduction at 135/min, despite amiodarone therapy. Three-dimensional mapping suggested a reentrant AT from the anterior aspect of the left LAA.

Results

The tachycardia could not be terminated with radiofrequency ablation. The LAA vein was then selectively catheterized and infused with Ethanol, resulting in immediate termination of tachycardia, without LAA isolation. No recurrence occurred at 12 months.

Conclusion

Atrial tachycardias emanating from the LAA that are resistant to radiofrequency ablation may respond to chemical ablation of the LAA vein.     

Prediction of left atrial appendage thrombi in non-valvular atrial fibrillation.

AIMS: There is little knowledge about the predictors of left atrial appendage (LAA) thrombi in non-valvular atrial fibrillation (NVAF). We investigated the ability of D-dimer to predict LAA thrombi. METHODS AND RESULTS: In this study, 925 patients with NVAF were enrolled. At the time of transoesophageal echocardiography (TEE), D-dimer levels were measured simultaneously. Significant independent predictors of LAA thrombi were the presence of congestive heart failure [odds ratio (OR) 3.10, 95% confidence interval (CI) 1.77-5.50, P < 0.0001), a history of recent embolic events (OR 3.39, 95% CI 1.90-6.04, P < 0.0001), and D-dimer levels (OR 97.6, 95% CI 17.3-595.8, P < 0.0001). Receiver operating characteristic analysis yielded an optimal cutoff value of 1.15 microg/mL for D-dimer to detect LAA thrombi. LAA thrombi were detected in 21.8% of patients with higher D-dimer values, whereas it was detected in only 3.1% of patients with lower D-dimer values. D-dimer cutoff level of 1.15 microg/mL had a negative predictive value of 97% for identifying LAA thrombi. CONCLUSION: In patients with NVAF, D-dimer may be helpful for predicting the absence of LAA thrombi. D-dimer level was clinically useful to guide the management of patients with NVAF, especially for those complicated with congestive heart failure and/or recent embolic events.     

Echocardiogram of the month. Giant left atrial appendage

Aneurysmal left atrial appendage (LAA) is a rare congenital anomaly. It may result in supraventricular arrhythmias and embolic complications. We present a case of a 33 year-old female in whom echocardiography showed a giant LAA (6 x 3 cm), confirmed by computed tomography.     

Giant left atrial appendage aneurysm

A 67-year-old lady was referred to our hospital because of abnormalfindings on a simple chest radiograph. The chest radiographshowed a markedly prominent left cardiac border (Panel A). Becausea radiolucent cleft (Panel A, arrow heads)     

Intrapericardial giant left atrial appendage

Contrary to what the name implies, the left atrial appendage is increasingly becoming an organ of clinical importance. Its role in the pathogenesis of thromboembolism is now well established. Enlargement of the appendage due to haemodynamic disturbances or anatomic weakness increases this risk, along with the potential for arrhythmia. We report a rare case of gross enlargement of the left atrial appendage within the pericardial cavity.     

Percutaneous left atrial appendage closure

IntroductionAtrial fibrillation is a growing epidemic in the western world. Stroke as the most dreaded complication is effectively prevented by oral anticoagulation. Although effective in preventing stroke, oral anticoagulants come at a price of bleeding complications. Concerns about bleeding lead to a high rate of drug discontinuation and is the reason many patients are not put on oral anticoagulants at all. Percutaneous left atrial appendage (LAA) closure is an excellent option for patients who cannot or who do not want to be on oral anticoagulants, since the left atrial appendage is the origin of more than 90% of clots arising from the left atrium.MethodsUsing femoral venous access, a plug is placed in the left atrial appendage, thereby excluding this embryologic remnant from the circulation. The procedure can be performed on an outpatient basis. We report our own experience in 100 patients using the Amplatzer cardiac plug.ResultsOne hundred patients (72 ± 10 years) underwent LAA closure using only local anesthesia and without transesophageal guidance. Imaging and sizing of the LAA was performed by contrast injections through the 13 French TorqVue delivery sheath, followed by device implantation. Clopidogrel was prescribed for 1 month and acetylsalicylic acid for 3–6 months. The procedure was successful in 98% of patients and was often performed in conjunction with other interventional procedures. Periprocedural complication rate was 6% (2% pericardial effusion, 2% device embolization, 2% transient neurologic symptoms) with no long-term sequelae.ConclusionLAA closure is an attractive alternative to oral anticoagulation in patients suffering from atrial fibrillation.