Heart and Vessels

, Volume 33, Issue 7, pp 777–785 | Cite as

3D-computed tomography to compare the dimensions of the left atrial appendage in patients with normal sinus rhythm and those with paroxysmal atrial fibrillation

  • Maiko Hozawa
  • Yoshihiro MorinoEmail author
  • Yuki Matsumoto
  • Ryoichi Tanaka
  • Kyohei Nagata
  • Akiko Kumagai
  • Atsushi Tashiro
  • Akio Doi
  • Kunihiro Yoshioka
Original Article


Although paroxysmal atrial fibrillation (PAF) is an important cause of cardioembolic stroke, in contrast to chronic AF patients, the anatomical features of the left atrial appendage (LAA) in PAF patients remain unknown. Here, we investigated differences in LAA structures in patients with PAF and those with normal sinus rhythms (NSR) using 3D-computed tomography (3D-CT), which allows us to visualize complicated LAA structures at high spatial resolution. Study subjects were 30 consecutive PAF and 30 NSR patients with complete enhanced cardiac 3D-CT images available. After reconstruction of 3D LAA images, anatomical parameters of the LAA were measured and compared according to three proposed definitions of the LAA orifice plane determined by the following anatomical landmarks: DEF#1, center of warfarin ridge and centerline of proximal left circumflex artery; DEF#2, slope of warfarin ridge and mitral valve annulus; DEF#3, observers’ discretion by progressive rotation using the observers’ best estimate without the use of landmarks. The LAA volumes of the PAF groups were significantly greater than the NSR group according to all 3 definitions (DEF#1: 1.43 times, DEF#2: 1.44 times, and DEF#3: 1.36 times greater). The LAA orifice area was significantly larger in PAF than in NSR according to DEF#2, but was similar by DEF#1 and DEF#3. Intra-observer and inter-observer variations for any LAA measurements were very low. In conclusion, 3D-CT-based quantitative assessment of the LAA provides highly reproducible and detailed measurements, which can successfully discriminate differences of LAA volume between patients with NSR and those with PAF, suggesting significantly greater volumes in the latter.


Left atrial appendage Cardioembolic stroke Paroxysmal atrial fibrillation Orifice Computed tomography 



The authors would like to thank Tadashi Sasaki, Kota Takeda, Takuya Chiba, Yuta Ueyama, Akinobu Sasaki, Kei Kikuchi, Takanori Ueda (radiation technologists of Iwate Medical University), Toru Kato, Hiroki Takahashi (graduate students of Iwate Prefectural University) for collecting data and coaching of image-editing in this study.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical standards

This study is a retrospective study. For this type of study formal consent is not required.


  1. 1.
    Disertori M, Franzosi MG, Barlera S, Cosmi F, Quintarelli S, Favero C, Cappellini G, Fabbri G, Maggioni AP, Staszewsky L, Moroni LA, Latini R, Investigators G-A (2013) Thromboembolic event rate in paroxysmal and persistent atrial fibrillation: data from the GISSI-AF trial. BMC Cardiovasc Disord 13:28CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Agmon Y, Khandheria BK, Gentile F, Seward JB (1999) Echocardiographic assessment of the left atrial appendage. J Am Coll Cardiol 34:1867–1877CrossRefPubMedGoogle Scholar
  3. 3.
    Narumiya T, Sakamaki T, Sato Y, Kanmatsuse K (2003) Relationship between left atrial appendage function and left atrial thrombus in patients with nonvalvular chronic atrial fibrillation and atrial flutter. Circ J 67:68–72CrossRefPubMedGoogle Scholar
  4. 4.
    Burrell LD, Horne BD, Anderson JL, Muhlestein JB, Whisenant BK (2013) Usefulness of left atrial appendage volume as a predictor of embolic stroke in patients with atrial fibrillation. Am J Cardiol 112:1148–1152CrossRefPubMedGoogle Scholar
  5. 5.
    Nucifora G, Faletra FF, Regoli F, Pasotti E, Pedrazzini G, Moccetti T, Auricchio A (2011) Evaluation of the left atrial appendage with real-time 3-dimensional transesophageal echocardiography: implications for catheter-based left atrial appendage closure. Circ Cardiovasc Imaging 4:514–523CrossRefPubMedGoogle Scholar
  6. 6.
    Matsumoto Y, Morino Y, Kumagai A, Hozawa M, Nakamura M, Terayama Y, Tashiro A (2017) Characteristics of anatomy and function of the left atrial appendage and their relationships in patients with cardioembolic stroke: a 3-dimensional transesophageal echocardiography study. J Stroke Cerebrovasc Dis 26:470–479CrossRefPubMedGoogle Scholar
  7. 7.
    Doi A, Takahashi H, Syuto B, Katayama M, Nagashima H, Okumura M (2013) Tailor-made plate design and manufacturing system for treating bone fractures in small animals. J Adv Comput Intell Intell Inform 17:1–10CrossRefGoogle Scholar
  8. 8.
    Budge LP, Shaffer KM, Moorman JR, Lake DE, Ferguson JD, Mangrum JM (2008) Analysis of in vivo left atrial appendage morphology in patients with atrial fibrillation: a direct comparison of transesophageal echocardiography, planar cardiac CT, and segmented three-dimensional cardiac CT. J Interv Card Electrophysiol 23:87–93CrossRefPubMedGoogle Scholar
  9. 9.
    Yosefy C, Laish-Farkash A, Azhibekov Y, Khalameizer V, Brodkin B, Katz A (2016) A new method for direct three-dimensional measurement of left atrial appendage dimensions during transesophageal echocardiography. Echocardiography 33:69–76CrossRefPubMedGoogle Scholar
  10. 10.
    Mobius-Winkler S, Sandri M, Mangner N, Lurz P, Dahnert I, Schuler G (2012) The WATCHMAN left atrial appendage closure device for atrial fibrillation. J Vis Exp 60:3671Google Scholar
  11. 11.
    Masoudi FA, Calkins H, Kavinsky CJ, Drozda JP Jr, Gainsley P, Slotwiner DJ, Turi ZG (2015) 2015 ACC/HRS/SCAI left atrial appendage occlusion device societal overview. J Am Coll Cardiol 66:1497–1513CrossRefPubMedGoogle Scholar
  12. 12.
    Walker DT, Humphries JA, Phillips KP (2012) Anatomical analysis of the left atrial appendage using segmented, three-dimensional cardiac CT: a comparison of patients with paroxysmal and persistent forms of atrial fibrillation. J Interv Card Electrophysiol 34:173–179CrossRefPubMedGoogle Scholar
  13. 13.
    Imada M, Funabashi N, Asano M, Uehara M, Ueda M, Komuro I (2007) Anatomical remodeling of left atria in subjects with chronic and paroxysmal atrial fibrillation evaluated by multislice computed tomography. Int J Cardiol 119:384–388CrossRefPubMedGoogle Scholar
  14. 14.
    Lacomis JM, Goitein O, Deible C, Moran PL, Mamone G, Madan S, Schwartzman D (2007) Dynamic multidimensional imaging of the human left atrial appendage. Europace 9:1134–1140CrossRefPubMedGoogle Scholar
  15. 15.
    Ito T, Suwa M, Kobashi A, Yagi H, Hirota Y, Kawamura K (1998) Influence of altered loading conditions on left atrial appendage function in vivo. Am J Cardiol 81:1056–1059CrossRefPubMedGoogle Scholar
  16. 16.
    Tabata T, Oki T, Yamada H, Abe M, Onose Y, Thomas JD (2000) Relationship between left atrial appendage function and plasma concentration of atrial natriuretic peptide. Eur J Echocardiogr 1:130–137CrossRefPubMedGoogle Scholar
  17. 17.
    Di Biase L, Santangeli P, Anselmino M, Mohanty P, Salvetti I, Gili S, Horton R, Sanchez JE, Bai R, Mohanty S, Pump A, Cereceda Brantes M, Gallinghouse GJ, Burkhardt JD, Cesarani F, Scaglione M, Natale A, Gaita F (2012) Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation? Results from a multicenter study. J Am Coll Cardiol 60:531–538CrossRefPubMedGoogle Scholar
  18. 18.
    Beutler DS, Gerkin RD, Loli AI (2014) The morphology of left atrial appendage lobes: a novel characteristic naming scheme derived through three-dimensional cardiac computed tomography. World J Cardiovasc Surg 4:17–24CrossRefGoogle Scholar
  19. 19.
    Wang Y, Di Biase L, Horton RP, Nguyen T, Morhanty P, Natale A (2010) Left atrial appendage studied by computed tomography to help planning for appendage closure device placement. J Cardiovasc Electrophysiol 21:973–982CrossRefPubMedGoogle Scholar
  20. 20.
    Abdulla R, Blew GA, Holterman MJ (2004) Cardiovascular embryology. Pediatr Cardiol 25:191–200CrossRefPubMedGoogle Scholar
  21. 21.
    Taina M, Vanninen R, Hedman M, Jakala P, Karkkainen S, Tapiola T, Sipola P (2013) Left atrial appendage volume increased in more than half of patients with cryptogenic stroke. PLoS One 8:e79519CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Chung H, Jeon B, Chang HJ, Han D, Shim H, Cho IJ, Shim CY, Hong GR, Kim JS, Jang Y, Chung N (2015) Predicting peri-device leakage of left atrial appendage device closure using novel three-dimensional geometric CT analysis. J Cardiovasc Ultrasound 23:211–218CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, Mullin CM, Sick P, Investigators PA (2009) Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet 374:534–542CrossRefPubMedGoogle Scholar
  24. 24.
    Reddy VY, Doshi SK, Sievert H, Buchbinder M, Neuzil P, Huber K, Halperin JL, Holmes D, Investigators PA (2013) Percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation: 2.3-Year Follow-up of the PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) Trial. Circulation 127:720–729CrossRefPubMedGoogle Scholar
  25. 25.
    Otton JM, Spina R, Sulas R, Subbiah RN, Jacobs N, Muller DW, Gunalingam B (2015) Left atrial appendage closure guided by personalized 3D-printed cardiac reconstruction. JACC Cardiovasc Interv 8:1004–1006CrossRefPubMedGoogle Scholar
  26. 26.
    Pracon R, Grygoruk R, Dzielinska Z, Kepka C, Dabrowska A, Konka M, Jazwiec P, Reczuch K, Witkowski A, Demkow M (2016) Percutaneous occlusion of the left atrial appendage with complex anatomy facilitated with 3D-printed model of the heart. EuroIntervention 12:927CrossRefPubMedGoogle Scholar
  27. 27.
    Boucebci S, Pambrun T, Velasco S, Duboe PO, Ingrand P, Tasu JP (2016) Assessment of normal left atrial appendage anatomy and function over gender and ages by dynamic cardiac CT. Eur Radiol 26:1512–1520CrossRefPubMedGoogle Scholar
  28. 28.
    Veinot JP, Harrity PJ, Gentile F, Khandheria BK, Bailey KR, Eickholt JT, Seward JB, Tajik AJ, Edwards WD (1997) Anatomy of the normal left atrial appendage: a quantitative study of age-related changes in 500 autopsy hearts: implications for echocardiographic examination. Circulation 96:3112–3115CrossRefPubMedGoogle Scholar
  29. 29.
    Erol B, Karcaaltincaba M, Aytemir K, Cay N, Hazirolan T, Akata D (2011) Analysis of left atrial appendix by dual-source CT coronary angiography: morphologic classification and imaging by volume rendered CT images. Eur J Radiol 80:e346–e350CrossRefPubMedGoogle Scholar
  30. 30.
    Spencer RJ, DeJong P, Fahmy P, Lempereur M, Tsang MY, Gin KG, Lee PK, Nair P, Tsang TS, Jue J, Saw J (2015) Changes in left atrial appendage dimensions following volume loading during percutaneous left atrial appendage closure. JACC Cardiovasc Interv 8:1935–1941CrossRefPubMedGoogle Scholar
  31. 31.
    Fukushima K, Fukushima N, Kato K, Ejima K, Sato H, Fukushima K, Saito C, Hayashi K, Arai K, Manaka T, Ashihara K, Shoda M, Hagiwara N (2016) Correlation between left atrial appendage morphology and flow velocity in patients with paroxysmal atrial fibrillation. Eur Heart J Cardiovasc Imaging 17:59–66PubMedGoogle Scholar

Copyright information

© Springer Japan KK, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Cardiology, Department of Internal MedicineIwate Medical UniversityMoriokaJapan
  2. 2.Department of RadiologyIwate Medical UniversityMoriokaJapan
  3. 3.Division of Cardioangiology, Nephrology and Endocrinology, Department of Internal MedicineIwate Medical UniversityMoriokaJapan
  4. 4.Division of Cardioangiology, Nephrology and Endocrinology, Department of Laboratory MedicineIwate Medical UniversityMoriokaJapan
  5. 5.Faculty of Software and Information ScienceIwate Prefectural UniversityMoriokaJapan

Personalised recommendations