Left atrial appendage morphology and cardiac function in patients with sinus rhythm

  • Megumi ShimadaEmail author
  • Makoto Akaishi
  • Takayuki Kobayashi
Original Investigation



The left atrial appendage (LAA) is one of the major sources of cardiac thrombus formation. The morphology of the LAA correlates with stroke in patients with atrial fibrillation. In this study, we evaluated the correlation between LAA morphology and cardiac function by transthoracic echocardiography in patients with sinus rhythm.

Methods and Results

We studied 55 patients (36 men, 70 ± 11 years) who underwent cardiac computed tomography and transthoracic echocardiography. The following 4 different morphologies were used to categorize LAA by computed tomography: chicken wing (CW), windsock, cactus, and cauliflower. These morphologies were also classified into CW and non-CW (nonCW) types. There were no significant differences in the left ventricular ejection fraction (63% vs 62%), left atrial (LA) volume (22.2 vs 25.5 ml/m2), and LAA volume (4.3 vs 4.7 ml/m2) between nonCW and CW. Patients with nonCW showed a lower A′ velocity (8.0 vs 9.3 cm/s, p < 0.01), worse global longitudinal strain (− 17.2 vs − 20.2%, p < 0.01), lower tissue mitral annular displacement (9.7 vs 11.1 mm, p = 0.01), and lower LAS strain (22.6 vs 34.5%, p < 0.01) by speckle tracking echocardiography than did those with CW. Multiple logistic analysis showed that nonCW LAA morphology was closely associated with lower LAS strain. Furthermore, a change in volume of the LAA during the cardiac cycle was lower in nonCW than in CW.


These findings suggest that impaired LA and LAA functions are related to changes of the LAA in patients with sinus rhythm.


Left atrial appendage Sinus rhythm Computed tomography Echocardiography Left atrial function 



We thank Ellen Knapp, Ph.D., from Edanz Group ( for editing a draft of this manuscript.

Compliance with ethical standards

Conflict of interest

Megumi Shimada, Makoto Akaishi, and Takayuki Kobayashi declare that they have no conflicts of interest.

Human rights statements and informed consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later revisions. This study was approved by the clinical trial review committee of the Kitasato Institute Hospital (No. 17082). Opt-out consent was used because this was a retrospective study.


  1. 1.
    Al-Saady NM, Obel OA, Camm AJ. Left atrial appendage: structure, function, and role in thromboembolism. Heart. 1999;82:547–55.CrossRefGoogle Scholar
  2. 2.
    Kerut EK. Anatomy of the left atrial appendage. Echocardiography. 2008;25:669–73.CrossRefGoogle Scholar
  3. 3.
    Lee JM, Seo J, Uhm JS, et al. Why is left atrial appendage morphology related to strokes? An analysis of the flow velocity and orifice size of the left atrial appendage. J Cardiovasc Electrophysiol. 2015;1111:1–6.Google Scholar
  4. 4.
    Di Biase L, Santangeli P, Anselmino M, et al. Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation? J Am Coll Cardiol. 2012;60:531–8.CrossRefGoogle Scholar
  5. 5.
    Kimura T, Takatsuki S, Inagawa K, et al. Anatomical characteristics of the left atrial appendage in cardiogenic stroke with low CHADS2 scores. Heart Rhythm. 2013;10:921–5.CrossRefGoogle Scholar
  6. 6.
    Kishima H, Mine T, Ashida K, et al. Does left atrial appendage morphology influence left atrial appendage flow velocity? Circ J. 2015;79:1706–11.CrossRefGoogle Scholar
  7. 7.
    Fukushima K, Fukushima N, Kato K, et al. Correlation between left atrial appendage morphology and flow velocity in patients with paroxysmal atrial fibrillation. Eur Heart J Cardiovasc Imaging. 2016;17:59–66.PubMedGoogle Scholar
  8. 8.
    Lee JS, Shim CY, Wi J, et al. Left ventricular diastolic function is closely associated with mechanical function of the left atrium in patients with paroxysmal atrial fibrillation. Circ J. 2013;77:697–704.CrossRefGoogle Scholar
  9. 9.
    Ito T, Suwa M, Kobashi A, et al. Influence of altered loading conditions on left atrial appendage function in vivo. Am J Cardiol. 1998;81:1056–9.CrossRefGoogle Scholar
  10. 10.
    Yakar Tuluce S, Kayikcioglu M, Tuluce K, et al. Assessment of left atrial appendage function during sinus rhythm in patients with hypertrophic cardiomyopathy: transesophageal echocardiography and tissue doppler study. J Am Soc Echocardiogr. 2010;23:1207–16.CrossRefGoogle Scholar
  11. 11.
    Sasaki S, Watanabe T, Tamura H, et al. Left atrial strain as evaluated by two-dimensional speckle tracking predicts left atrial appendage dysfunction in patients with acute ischemic stroke. BBA Clin. 2014;2:40–7.CrossRefGoogle Scholar
  12. 12.
    Kim D, Shim CY, Hong GR, et al. Clinical implications and determinants of left atrial mechanical dysfunction in patients with stroke. Stroke. 2016;47:1444–51.CrossRefGoogle Scholar
  13. 13.
    Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28:1–39.CrossRefGoogle Scholar
  14. 14.
    Santos AB, Roca GQ, Claggett B, et al. Prognostic relevance of left atrial dysfunction in heart failure with preserved ejection fraction. Circ Heart Fail. 2016;9:e002763.CrossRefGoogle Scholar
  15. 15.
    Buss SJ, Mereles D, Emami M, et al. Rapid assessment of longitudinal systolic left ventricular function using speckle tracking of the mitral annulus. Clin Res Cardiol. 2012;101:273–80.CrossRefGoogle Scholar
  16. 16.
    Kurt M, Wang J, Torre-Amione G, et al. Left atrial function in diastolic heart failure. Circ Cardiovasc Imaging. 2009;2:10–5.CrossRefGoogle Scholar
  17. 17.
    Yasuda R, Murata M, Roberts R, et al. Left atrial strain is a powerful predictor of atrial fibrillation recurrence after catheter ablation: study of a heterogeneous population with sinus rhythm or atrial fibrillation. Eur Heart J Cardiovasc Imaging. 2015;16:1008–14.PubMedGoogle Scholar
  18. 18.
    Li CY, Gao BL, Liu XW, et al. Quantitative evaluation of the substantially variable morphology and function of the left atrial appendage and its relation with adjacent structures. PLoS ONE. 2015;10:e0126818.CrossRefGoogle Scholar
  19. 19.
    Kanda Y. Investigation of the freely available easy-to-use software ‘EZR’ for medical statistics. Bone Marrow Transplant. 2013;48:452–8.CrossRefGoogle Scholar
  20. 20.
    Karabay CY, Zehir R, Guler A, et al. Left atrial deformation parameters predict left atrial appendage function and thrombus in patients in sinus rhythm with suspected cardioembolic stroke: a speckle tracking and transesophageal echocardiography study. Echocardiography. 2013;30:572–81.CrossRefGoogle Scholar
  21. 21.
    Bakalli A, Georgievska-Ismail L, Musliu N, et al. Relationship of left ventricular size to left atrial and left atrial appendage size in sinus rhythm patients with dilated cardiomyopathy. Acta Inform Med. 2012;20:99–102.CrossRefGoogle Scholar
  22. 22.
    Vural MG, Çetin S, Gündüz H, et al. Assessment of left atrial appendage function during sinus rhythm in patients with obstructive sleep apnea. Anatol J Cardiol. 2016;16:34–41.PubMedGoogle Scholar
  23. 23.
    Kaneko K, Otaki Y, Kadowaki S, et al. Left atrial appendage dysfunction in acute cerebral embolism patients with sinus rhythm: correlation with pulse-wave tissue Doppler imaging. Int J Cardiovasc Imaging. 2014;30:1245–54.CrossRefGoogle Scholar
  24. 24.
    Donal E, Yamada H, Leclercq C, et al. The left atrial appendage, a small, blind-ended structure: a review of its echocardiographic evaluation and its clinical role. Chest. 2005;128:1853–62.CrossRefGoogle Scholar
  25. 25.
    Yamamoto M, Seo Y, Kawamatsu N, et al. Complex left atrial appendage morphology and left atrial appendage thrombus formation in patients with atrial fibrillation. Circ Cardiovasc Imaging. 2014;7:337–43.CrossRefGoogle Scholar
  26. 26.
    Asker M, Timucin OB, Asker S, et al. Effect of ramipril therapy on abnormal left atrial appendage function. J Int Med Res. 2011;39:2429–35.CrossRefGoogle Scholar
  27. 27.
    Koplay M, Erol C, Paksoy Y, et al. An investigation of the anatomical variations of left atrial appendage by multidetector computed tomographic coronary angiography. Eur J Radiol. 2012;81:1575–80.CrossRefGoogle Scholar

Copyright information

© Japanese Society of Echocardiography 2020

Authors and Affiliations

  1. 1.Department of General Internal MedicineTokai University Oiso HospitalNakagunJapan
  2. 2.Department of CardiologyTokai University Tokyo HospitalTokyoJapan
  3. 3.Department of RadiologyKitasato Institute Hospital, Kitasato UniversityTokyoJapan

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