Three-dimensional assessment of left atrial appendage orifice geometry and potential implications for device closure

  • Julie O’BrienEmail author
  • Donya Al-hassan
  • Justin Ng
  • Madalsa Joshi
  • Cameron Hague
  • Santabhanu Chakrabarti
  • Jonathon Leipsic
Original Paper


Transcatheter placement of left atrial closure device is an attractive therapy for patients with atrial fibrillation (AF), to avoid anticoagulation and reduce cerebrovascular events; however peri-device leaks occur. The geometry of the left atrial appendage (LAA) is not well understood, largely owing to limitations of 2-dimensional imaging techniques. We sought to better define the LAA orifice geometry, by performing 3-dimensional multi-detector computed tomography measurements. We prospectively recruited 105 consecutive patients referred for pulmonary vein ablation (PVA) and age-matched controls. Area, short and long-axis measurements were performed. Eccentricity was calculated as 1-(short axis/long axis). Multiple clinical variables were tested for their ability to predict appendage orifice eccentricity using univariate linear regression models. The PVA cohort demographics included; 25 (24 %) females, mean age 59 years (SD = 10), median height (1.55–2.03), weight 89 (56–139) kg and body surface area 2.1 (1.61–2.58). In the PVA cohort, there was a significant difference between the long and short-axis; median short-axis dimension was 20.5 (12.9–35.4) mm, versus long-axis median 30.4 (17.7–43.8) (p < 0.001). Mean eccentricity score was 0.4. When compared with controls, there was a significant difference in the short and long-axis measurements (p < 0.001) as well as eccentricity (p = 0.04). All clinical variables tested showed limited ability to predict appendage eccentricity (p = NS). LAA ostium is an elliptical structure in the setting of AF with a high eccentricity index and uniformly significant differences between short and long-axis. There were significant differences between these parameters when compared with controls. A deeper appreciation of LAA geometry and eccentricity may allow for reduction in peri-closure leaks.


Left atrial appendage Multi-detector computed tomography Atrial fibrillation 



Atrial fibrillation


Multi-detector computed tomography


Pulmonary vein ablation


CT coronary angiography


Left atrial appendage


Percutaneous heart valve


Body surface area




Conflict of interest



  1. 1.
    Watson T, Shantsila E, Lip GYH (2009) Mechanisms of thrombogenesis in atrial fibrillation: Virchow’s triad revisited. Lancet 373:155–166PubMedCrossRefGoogle Scholar
  2. 2.
    Kerut E (2008) Anatomy of the left atrial appendage. Echocardiography 25(6):669–673PubMedCrossRefGoogle Scholar
  3. 3.
    Budoff MJ, Cohen MC, Garcia MJ et al (2009) American College of Cardiology Foundation; American Heart Association; American College of Physicians Task Force on Clinical Competence and Training; American Society of Echocardiography; American Society of Nuclear Cardiology; Society of Atherosclerosis Imaging; Society for Cardiovascular Angiography & Interventions. ACCF/AHA clinical competence statement on cardiac imaging with computed tomography and magnetic resonance: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training. J Am Coll Cardiol 2005; 46:383–402 [Errata in J Am Coll Cardiol 2007; 49:2378; and J Am Coll Cardiol 2009; 54:2463Google Scholar
  4. 4.
    Al-Saedy NM, Obel OA, Camm AJ (1999) Left atrial appendage: structure, function, and role in thromboembolism. Heart 82(5):547–554Google Scholar
  5. 5.
    Dittrich HC, Pearce LA, Asinger RW, McBride R, Webel R, Stroke Prevention in Atrial Fibrillation Investigators et al (1999) Left atrial diameter in nonvalvular atrial fibrillation: an echocardiographic study. Stroke Prevention in Atrial Fibrillation Investigators. Am Heart J 137(3):494–499Google Scholar
  6. 6.
    Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J et al (2009) Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 361(12):1139–1151PubMedCrossRefGoogle Scholar
  7. 7.
    Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM et al (2011) Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 365(11):981–992PubMedCrossRefGoogle Scholar
  8. 8.
    Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE et al (2011) Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 365(10):883–891PubMedCrossRefGoogle Scholar
  9. 9.
    Sievert H, Lesh MD, Trepels T, Omran H, Bartorelli A, Della Bella P, Nakai T, Reisman M, DiMario C, Block P, Kramer P, Fleschenberg D, Krumsdorf U, Scherer D (2002) Percutaneous left atrial appendage transcatheter occlusion to prevent stroke in high-risk patients with atrial fibrillation: early clinical experience. Circulation 105(16):1887–1889PubMedCrossRefGoogle Scholar
  10. 10.
    Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, Mullin CM, Sick P (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(9689):534–542PubMedCrossRefGoogle Scholar
  11. 11.
    Reddy VY, Holmes D, Doshi SK, Neuzil P, Kar S (2011) Safety of percutaneous left atrial appendage closure: results from the Watchman left atrial appendage system for embolic protection in patients with AF (PROTECT AF) clinical trial and the continued access registry. Circulation 123(4):417–424PubMedCrossRefGoogle Scholar
  12. 12.
    Viles-Gonzalez JF, Kar S, Douglas P, Dukkipati S, Feldman T, Horton R, Holmes D, Reddy VY (2012) The clinical impact of incomplete left atrial appendage closure with the Watchman device in patients with atrial fibrillation: a PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) substudy. J Am Coll Cardiol 59(10):923–929PubMedCrossRefGoogle Scholar
  13. 13.
    Nucifora G, Faletra F, 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 4:514–523PubMedCrossRefGoogle Scholar
  14. 14.
    Di Biase L, Santangeli P, Anselmino M, Mohanty P, Salvetti I et al (2012) Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation? JACC 60:531–538PubMedCrossRefGoogle Scholar
  15. 15.
    Willson AB, Webb JG, Labounty TM, Achenbach S, Moss R, Wheeler M, Thompson C, Min JK, Gurvitch R, Norgaard BL, Hague CJ, Toggweiler S, Binder R, Freeman M, Poulter R, Poulsen S, Wood DA, Leipsic J (2012) 3-dimensional aortic annular assessment by multidetector computed tomography predicts moderate or severe paravalvular regurgitation after transcatheter aortic valve replacement: a multicenter retrospective analysis. J Am Coll Cardiol 59(14):1287–1294PubMedCrossRefGoogle Scholar
  16. 16.
    Nakajima H, Seo Y, Ishizu T, Yamamoto M, Machino T et al (2010) Analysis of the left atrial appendage by three-dimensional transesophageal echocardiography. Am J Cardiol 106(6):885–892PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2014

Authors and Affiliations

  • Julie O’Brien
    • 1
    Email author
  • Donya Al-hassan
    • 1
  • Justin Ng
    • 2
  • Madalsa Joshi
    • 1
  • Cameron Hague
    • 1
  • Santabhanu Chakrabarti
    • 2
  • Jonathon Leipsic
    • 1
  1. 1.Cardiac Imaging Division, Department of RadiologySt. Paul’s HospitalVancouverCanada
  2. 2.Department of CardiologySt. Paul’s HospitalVancouverCanada

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