Comparative assessment of left atrial appendage by transesophageal and combined two- and three-dimensional transthoracic echocardiography

Objective: Our objective was to compare the utility of combined two‐dimensional (2D) transthoracic echocardiography (TTE) and three‐dimensional (3D) TTE versus 2D transesophageal echocardiography (TEE) in evaluation of the left atrium (LA) and LA appendage (LAA) for clot. Background: 2DTEE, usually performed to visualize the LAA, is semi‐invasive and not without risks. With improved technology the LAA has been increasingly visualized by 2DTTE and 3DTTE in many patients. Methods: We compared combined 2DTTE and 3DTTE with 2DTEE in evaluating the LA/LAA for a thrombus. Ninety‐two patients underwent 2DTTE, 3DTTE, and 2DTEE. An additional 20 patients, in whom TEE could not be performed, underwent 2DTTE and 3DTTE. Results: LA and LAA could be visualized in all patients. Of 92 patients studied, 74 had no thrombus and 7 had thrombus in the LAA by all modalities. Eleven patients, 9 with atrial fibrillation (AF), had a suspected thrombus by 2DTEE, but 3DTTE cropping clearly showed these to be prominent pectinate muscles which were seen in short axis on 2DTEE as rounded echo dense masses and therefore mimicked thrombi. These 9 patients with AF underwent successful cardioversion without any complications. Of the 20 patients in whom TEE could not be performed, 19 had no thrombus in the LA/LAA and 1 had a clot in the LAA. These 19 patients underwent successful cardioversion without complications. Conclusions: Our preliminary study suggests that combined 2DTTE and 3DTTE has comparable accuracy to TEE in evaluating the LA and LAA for thrombus. In some patients TEE, but not 3DTTE, may misdiagnose pectinate musculature as thrombus.     

Comparison between transesophageal echocardiography and transthoracic echocardiography with harmonic tissue imaging for left atrial appendage assessment

BACKGROUND: Transesophageal echocardiography (TEE) is the method of choice for evaluating both anatomy and function of left atrial appendage (LAA). In contrast, conventional transthoracic echocardiography (TTE) does not result in images of sufficient quality to explore LAA. HYPOTHESIS: The aim of this study was to evaluate the potential role of TTE with harmonic frequency imaging (HFI) for assessing LAA normal anatomy and function. METHODS: The study group comprised 25 patients, (9 men, 16 women, mean age 51 years, range 20-82). The TTE as sessment of LAA both in fundamental frequency imaging (FFI) and HFI was performed using the apical two-chamber view, the longitudinal two-chamber view was used for TEE assessment of LAA. According to image quality, images were categorized into three classes: A: good quality, B: sufficient quality, C: poor quality. RESULTS: Transthoracic echocardiography conventional imaging allowed sufficient LAA visualization (class B) in only 5 of 25 patients (20%); the HFI resulted in adequate LAA visualization in 23 of 25 patients (92%). Images were of good quality (class A) in 18 of 23 patients and of sufficient quality (class B) in 5 of 23 patients. Transesophageal echocardiography achieved good quality images in 24 of 25 patients (96%). Average LAA maximum area determined by HFI and TEE was 3.46 +/-1.17 and 3.59 +/- 1.16 cm2, respectively; LAA minimum area was 1.81 +/- 0.98 and 1.77 +/- 0.97 cm2, respectively. Percent LAA area change was 51 +/- 16.5 and 50.9 +/- 16% with HFI and TEE, respectively. Statistical analysis showed no difference between the data obtained with the two methods. CONCLUSIONS: The results suggest that HFI TNE may be a useful tool for the exploration of LAA.     

Transesophageal investigation of surgically ligated left atrial appendage

Surgical ligation of the left atrial appendage is often performed during heart surgery for various diseases like mitral prosthesis implantation, mitral valve repair, and even coronary artery revascularization, mainly to prevent thrombus formation and systemic embolism in patients with atrial fibrillation. However surgical ligation is sometimes incomplete, thereby exposing the patient to residual embolic risk. We report two cases of surgical ligation of the left atrial appendage focusing on the transesophageal echographic aspects of complete or incomplete closure of the appendage.     

Transesophageal echocardiography in the diagnosis of acquired aneurysms of the left atrial appendage

We report a patient with what appeared to be a pericardial cyst by transthoracic echocardiography but was, in effect, an aneurysm of the left atrial appendage as documented by transesophageal echocardiography.     

Transesophageal echocardiographic diagnosis of thrombus in accessory lobes of the left atrial appendage

Fifty-four percent of left atrial appendages have two lobes. The number ranges from one to four lobes. We describe three patients with accessory lobes of the left atrial appendage studied with multiplanar transesophageal echocardiography (TEE). In one patient there was evidence of thrombi in the accessory lobe.     

Transesophageal echocardiographic finding of left atrial appendage lobe mimicking a mass lesion

We describe an elderly patient undergoing ablation for atrial fibrillation in whom, two-dimensional transesophageal echocardiography showed a mass-like lesion in or adjacent to left atrial appendage (LAA). This mass-like effect was produced by en face visualization of the top of a LAA lobe in the presence of a small effusion in the transverse sinus of the pericardium.     

Assessment of left atrial appendage by live three-dimensional echocardiography: early experience and comparison with transesophageal echocardiography

BACKGROUND: Live Three-Dimensional Echocardiography (L3D, Sonos 7500, Philips) has the potential to visualize all cardiac structures including left atrial appendage (LAA). We tested the feasibility of evaluating LAA by L3D and compared the findings to transthoracic echocardiography (2D) and in a subset of patients with transesophageal echocardiography (TEE). METHODS: L3D images were obtained in 204 consecutive patients referred for routine 2D or TEE. We performed wide-angled acquisitions from parasternal and apical views. TomTec system (4D Cardio-view, RT 1.2) was used to visualize LAA from multiple vantage points. RESULTS: LAA was adequately visualized by L3D in 139 of 204 (68.1%) patients. L3D visualization was dependent on image quality, suboptimal in 100 and diagnostic in 104 patients. Overall, LAA was visualized in 93 (45.5%) patients by 2D compared to 139 (68.1%) by L3D (P < 0.0001). In 100 patients with suboptimal image quality by L3D, LAA visualization was 16% by 2D and 35% by L3D, whereas in 104 patients with diagnostic images, LAA was visualized in 77 (74%) by 2D and in all 104 (100%) patients by L3D (P < 0.0001). In 37 patients referred for transesophageal echocardiography (TEE), live three-dimensional echocardiography (L3D) visualized left atrial appendage (LAA) in 34 patients with diagnostic image quality. Eight patients with LAA thrombi on TEE had thrombi detected by L3D as well. All patients with LAA thrombus had enlarged LA by both 2D and TEE. CONCLUSIONS: L3D is a promising technique in evaluation of LAA with and without thrombi. In patients with good quality transthoracic images L3D may be used as a screening tool in assessment of LAA.     

Membranes of left atrial appendage: real appearance or "pitfall"

The membranes of left atrial appendage (LAA) cavity are very rare entity. To date, only five cases of a membrane involving LAA have been described. In this report, we describe two different cases: in Case 1, we show image of a "real" nonobstructive membrane within the body of LAA, but in Case 2 we show a linear image, mimicking a membrane within the body of LAA. It really is a "pitfall" of transesophageal echocardiography (TEE).     

Strain and strain rate imaging in evaluating left atrial appendage function by transesophageal echocardiography

BACKGROUND: This study was planned to assess whether strain rate (Sr) and strain (S) echocardiography is a useful method for functional assessment of the left atrial appendage (LAA). MATERIAL AND METHODS: Fifty-seven consecutive patients underwent a clinically indicated study. LAA late empty velocity (LAAEV) was calculated as a gold standard for left atrial appendage function. Real-time 2-dimensional color Doppler myocardial imaging data were recorded from the LAA at a high frame rate. Analysis was performed for LAA longitudinal strain rate and strain from midsegment of lateral wall of LAA. LAA strain determines regional lengthening expressed as a positive value or shortening expressed as a negative value. Peak systolic values were calculated from the extracted curve. RESULTS: Spearman correlation test results showed a statistically significant positive correlation was between the S, Sr variables and LAAEV (LAAEV vs S; r = 0.886, P < 0.001; LAAEV vs Sr: r = 0.897, P < 0.001, respectively). Strain and strain rate values were also significantly lower in patients with spontaneous echocardiographic contrast when compared with those without (strain; 2.42 +/- 0.98 vs 13.1 +/- 5.9, P < 0.001 and strain rate: 0.97 +/- 0.54 vs 3.34 +/- 1.15, P < 0.001, respectively). In addition, LAA strain and strain rate values were significantly lower in the patients with LAA thrombus (strain; 2.15 +/- 0.96 vs 8.35 +/- 6.9, P < 0.001, strain rate; 0.79 +/- 0.46 vs 2.30 +/- 1.48, P < 0.001, respectively). CONCLUSION: S and Sr imaging can be considered a robust technique for the assessment of the LAA systolic deformation.     

Incremental value of live/real time three‐dimensional transesophageal echocardiography over the two‐dimensional technique in the assessment of a tuberculoma involving the left atrium and appendage

Intracardiac tuberculomas are extremely rare, and cardiac involvement in tuberculosis accounts for only 0.5% of extrapulmonary tuberculosis. We report for the first time incremental value of live/real time three‐dimensional transesophageal echocardiography over two‐dimensional transesophageal echocardiography in the assessment of a tuberculoma involving the left atrium and left atrial appendage.     

Utility of postural change in differentiating sludge from thrombus in the left atrial appendage: A case report

We detected symptomatic atrial fibrillation in a 64‐year‐old man who had undergone mitral valvuloplasty. While performing transesophageal echocardiography (TEE) in the left lateral decubitus position, we detected an isoechoic mass lesion at the bottom of the left atrial appendage (LAA). After changing the patient's position from left to right, the mass lesion dropped down from the bottom of the LAA, spread out into the left atrium, and appeared as a spontaneous echocardiographic contrast with mobility. We therefore diagnosed the mass lesion as not a thrombus but sludge. Changing the patient's position during TEE is useful for distinguishing sludge from thrombi.     

Prominent para-cardiac fat mimicking left atrial appendage thrombus on echocardiography: Utility of cardiac computed tomography

Transesophageal echocardiography is the most frequently used imaging modality for exclusion of left atrial appendage thrombus prior to cardioversion. Echocardiographers should be aware of rare conditions that may mimic left atrial appendage thrombus. Here, we describe a rare case of prominent para-cardiac fat mimicking left atrial appendage thrombus on transesophageal echocardiographic imaging. Multimodality imaging with cardiac computed tomography was instrumental in providing further anatomical delineation and characterization of the echodensity as prominent para-cardiac fat in this case.     

Assessment of left atrial appendage function by transesophageal echocardiography in patients two weeks after acute coronary syndromes

Background For many years in ischemic heart disease, ventricles rather than atria received attention so not much is known about left atrial function in left ventricular ischemia. Objective Our study aimed to evaluate left atrial appendage (LAA) function by means of biplane transesophageal echocardiography in patients ten days after acute coronary syndromes (ACS). Methods The study was performed on 16 adult patients (65.9±9.9 years old) in whom transesophageal echocardiography was done 10 days after ACS. The following left atrial appendage (LAA) planimetric parameters were analyzed: LAA transversal dimension, LAA longitudinal dimension,LAA maximal area, and LAA minimal area. LAA ejection fraction was calculated and analyzed. The following LAA Doppler parameters were analyzed: the peak LAA emptying and the peak LAA filling velocities. The control group consisted of 14 patients (43±14.6 years old) without cardiovascular diseases. Results Both LAA longitudinal dimension and LAA transversal dimension were significantly higher in patients with ACS than in control patients. The same was observed for LAA maximal area. Also LAA ejection fraction was higher in patients with ACS . LAA minimal area did not differ in the patients in either group. LAA peak emptying flow (LAAE) and LAA peak filling flow (LAAF) were significantly higher in patients of the study group than of the control group. Conclusion Our study shows that two weeks after acute coronary syndrome LAA as a reservoir as well as a pump works at a higher level than it does in the control group. (J Geriatr Cardiol 2005; 2(4):198-201)     

Intracardiac versus transesophageal echocardiography for left atrial appendage occlusion with watchman

Background: Left atrial appendage occlusion (LAAO) is mostly performed by transesophageal echocardiography (TEE) guidance. Intracardiac echocardiography (ICE) may be an alternative imaging modality for LAAO that precludes the need for general anesthesia or sedation. Methods and Results: All consecutive single center, single operator LAAO candidates were analyzed. Baseline clinical and procedural characteristics and in‐hospital outcomes were compared between patients in whom a Watchman was implanted with ICE vs. TEE guidance. In 76 consecutive patients the Watchman device was deployed under ICE in 32 patients (42%) and under TEE guidance in 44 patients (58%). Baseline characteristics were comparable between groups, except that patients in the TEE group were older (81 [75–85] years vs. 75 [68–80] years, P = 0.007). Total injected contrast media as well as fluoroscopy time were comparable between groups (90 ml [54–140] vs. 85 ml [80–110], P = 0.86 and 7.9 min [6.4–15.5] vs. 9.8 min [7.0–13.2], P = 0.51, for TEE vs. ICE, respectively). However, time from femoral venous puncture to transseptal puncture and to closure was longer in the ICE group (14 min [7.3–20] vs. 6 min [3.3–11], P = 0.007 and 48 min [40–60] vs. 34.5 min [27–44], P = 0.003, respectively). In the TEE group one patient suffered esophageal erosion with bleeding, which was managed conservatively and one non‐LAAO related in‐hospital mortality occurred in an 88‐year‐old patient. Device implantation success rate was 100% in both groups. No device embolization, no significant peri‐device leak, no tamponade, no stroke, and no access site bleeding occurred in any patient. Total hospital stay for stand‐alone LAAO was comparable between groups (2 days [2–2] vs. 2 days [2–3.3], P = 0.17, in ICE vs. TEE, respectively). Conclusions: ICE guidance for LAAO with the Watchman device is feasible and comparable to TEE and may become the preferred imaging modality for LAAO. © 2016 Wiley Periodicals, Inc.