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Do left atrial appendage morphology and function help predict thromboembolic risk in atrial fibrillation?

Anselmino, Matteo; Gili, Sebastiano; Castagno, Davide; Ferraris, Federico; Matta, Mario; Rovera, Chiara; Giustetto, Carla; Gaita, Fiorenzo

Journal of Cardiovascular Medicine: March 2016 - Volume 17 - Issue 3 - p 169–176
doi: 10.2459/JCM.0000000000000305
Atrial fibrillation Review

Clinical scores (i.e. CHA2DS2-VASc) are the mainstay of thromboembolic risk management in nonvalvular atrial fibrillation. Nonetheless, they bear some limitations to precisely define risk–benefit ratio of oral anticoagulation (OAC), both with vitamin K antagonists and with novel direct oral anticoagulants, especially in patients with low-intermediate scores. Cardiovascular imaging, allowing directly visualization of those pathophysiological alterations, which may lead to the formation of intracardiac thrombi, offers itself as a unique tool helping to refine thromboembolic risk stratification. Many parameters have been tested, focusing primarily on functional and morphological variables of the left atrium and left atrial appendage (LAA). Left atrium volume and LAA peak flow velocity have, for a longtime, been associated with increased thromboembolic risk, whereas some new parameters, such as left atrium fibrosis assessed by late-gadolinium enhanced (LGE) MRI, left atrium and LAA strain and LAA morphology have more recently shown some ability in predicting embolic events in atrial fibrillation patients. Overall, however, these parameters have seen, to date, scarce clinical implementation, especially because of the inconsistency of validated cutoffs and/or strong clinical evidence driven by technical limitations, such as expensiveness of the technologies (i.e. MRI or computed tomography), invasiveness (i.e. transesophageal echocardiography) or limited reproducibility (i.e. LGE MRI). In conclusion, to date, cardiovascular imaging plays a limited role; however, validation and diffusion of the new techniques hereby systematically presented hold the potential to refine thromboembolic risk stratification in nonvalvular atrial fibrillation.

Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy

Correspondence to Fiorenzo Gaita, MD, Professor, Cardiology Division, Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy Tel: +39 011 6709557; fax: +39 011 2369557; e-mail:

Received 8 April, 2015

Revised 17 May, 2015

Accepted 22 May, 2015

© 2016 Italian Federation of Cardiology. All rights reserved.