Altered left atrial appendage function associated with cardioembolic stroke in patients with rheumatic heart disease


  • Zeeshan H. Mansuri Department of Cardiology, SBKSMIRC, Waghodia, Vadodara, Gujarat, India
  • Jit H. Brahmbhatt Department of Cardiology, SBKSMIRC, Waghodia, Vadodara, Gujarat, India
  • Roopesh R. Singhal Department of Cardiology, SBKSMIRC, Waghodia, Vadodara, Gujarat, India
  • Karthik Natarajan Department of Cardiology, UNMICRC, BJMC, Ahmedabad, Gujarat, India



Left atrial appendage, Cardioembolic stroke, Atrial fibrillation, Rheumatic heart disease


Background: Left atrial appendage (LAA) is usually the first site for thrombus formation in rheumatic heart disease (RHD). LAA function is altered in RHD which may predispose it to thrombus formation. The aim of this study was to determine an association between function of LAA and cardioembolic stroke.

Methods:Total 132 patients with RHD were studied by means of transthoracic echocardiography and/or transesophageal echocardiography and left atrial (LA) size, LAA ejection fraction (EF) and peak flow velocities were measured. These patients were followed up for 18 months with reference to development of cardioembolic stroke.

Results: Seventy nine patients had atrial fibrillation (AF), of which 34 had thrombus in LAA. Out of 53 patients with sinus rhythm, 5 had LAA thrombus. Mean LAA EF was significantly lower in patients with thrombus in LAA, so was the peak flow velocity (both variables p<0.0001). Saw tooth LAA outflow velocity pattern was visible in 30 (80%) patients with LAA thrombus versus 20 (28%) patients without LAA thrombus. Total 14 patients experienced cardioembolic stroke. Patients with cardioembolic stroke had lower mean LAA EF and peak flow velocity as compared to patients without cardioembolic stroke.

Conclusions:Increased LAA size, reduced LAA EF and reduced peak flow velocity are associated with increased risk of cardioembolic stroke. LAA evaluation should be mandatory in deciding treatment strategies in patients with RHD and AF.


Author Biography

Zeeshan H. Mansuri, Department of Cardiology, SBKSMIRC, Waghodia, Vadodara, Gujarat, India

Assistant Professor in the Department of Cardiology


Salvo GD, Caso P, Piccolo RL, Fusco A, Martiniello AR, Russo MG, et al. Atrial myocardial deformation properties predict maintenance of sinus rhythm after external cardioversion of recent‑onset lone atrial fibrillation: a colour Doppler myocardial imaging and transthoracic and transoesophageal echocardiographic study. Circulation. 2005;112(3):387-95.

Cianciulli TF, Saccheri MC, Lax JA, Bermann AM, Ferreiro DE. Two‑dimensional speckle tracking echocardiography for the assessment of atrial function. World J Cardiol. 2010;2(7):163-70.

Thomas L, McKay T, Byth K, Marwick TH. Abnormalities of left atrial function after cardioversion: an atrial strain rate study. Heart. 2007;93(1):89-95.

Cameli M, Caputo M, Mondillo S, Ballo P, Palmerini E, Lisi M, et al. Feasibility and reference values of left atrial longitudinal strain imaging by two‑dimensional speckle tracking. Cardiovasc Ultrasound. 2009;7:6.

Quintana M, Lindell P, Saha SK, Furia FD, Lind B, Govind S, et al. Assessment of atrial regional and global electromechanical function by tissue velocity echocardiography: a feasibility study on healthy individuals. Cardiovasc Ultrasound. 2005;3:4.

Bansal M, Kasliwal RR. Echocardiography for left atrial appendage structure and function. Indian Heart J. 2012;64(5):469-75.

Doukky R, Garcia‑Sayan E, Gage H, Nagarajan V, Demopoulos A, Cena M, et al. The value of diastolic function parameters in the prediction of left atrial appendage thrombus in patients with nonvalvular atrial fibrillation. Cardiovasc Ultrasound. 2014;12:10.

Meissner I, Whisnant JP, Khandheria BK, Spittell PC, O'Fallon WM, Pascoe RD, et al. Prevalence of potential risk factors for stroke assessed by transesophageal echocardiography and carotid ultrasonography: the SPARC study. Stroke prevention: assessment of risk in a community. Mayo Clin Proc. 1999;74(9):862-9.

Lacomis JM, Goitein O, Deible C, Moran PL, Mamone G, Madan S, et al. Dynamic multidimensional imaging of the human left atrial appendage. Europace. 2007;9(12):1134-40.

Beigel R, Wunderlich NC, Ho SY, Arsanjani R, Siegel RJ. The left atrial appendage: Anatomy, function, and non-invasive evaluation. JACC Cardiovasc Imaging. 2014;7(12):1251-65.

Beutler DS, Gerkin RD, Loli AI. The morphology of left atrial appendage lobes: a novel characteristic naming scheme derived through three‑dimensional cardiac computed tomography. World J Card Surg. 2014;4(3):17‑24.

Kurzawski J, Janion‑Sadowska A, Sadowski M. Left atrial appendage function assessment and thrombus identification. Int J Cardiol Heart Vasc. 2016;14:33-40.

Tamura H, Watanabe T, Hirono O, Nishiyama S, Sasaki S, Shishido T, et al. Low wall velocity of left atrial appendage measured by trans‑thoracic echocardiography predicts thrombus formation caused by atrial appendage dysfunction. J Am Soc Echocardiogr. 2010;23(5):545-52.

Tamura H, Watanabe T, Nishiyama S, Sasaki S, Wanezaki M, Arimoto T, et al. Prognostic value of low left atrial appendage wall velocity in patients with ischemic stroke and atrial fibrillation. J Am Soc Echocardiogr. 2012;25(5):576-83.

Omran H, Jung W, Rabahieh R, Schimpf R, Wolpert C, Hagendorff A, et al. Left atrial chamber and appendage function after internal atrial defibrillation: a prospective and serial transesophageal echocardiographic study. J Am Coll Cardiol. 1997;29(1):131-8.

Uretsky S, Shah A, Bangalore S, Rosenberg L, Sarji R, Cantales DR, et al. Assessment of left atrial appendage function with transthoracic tissue Doppler echocardiography. Eur J Echocardiogr. 2009;10(3):363-71.

Gölbaşi Z, Ciçek D, Canbay A, Uçar O, Bayol H, Aydogdu S. Left atrial appendage function in patients with mitral stenosis in sinus rhythm. Eur J Echocardiogr. 2002;3(1):39-43.

Biase LD, Santangeli P, Anselmino M, Mohanty P, Salvetti I, Gili S, et al. 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. 2012;60(6):531-8.

Fatkin D, Kelly RP, Feneley MP. Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast and thromboembolic risk in vivo. J Am Coll Cardiol. 1994;23(4):961-9.

Reddy VG, Rajasekhar D, Vanajakshamma V. Effect of percutaneous mitral balloon valvuloplasty on left atrial appendage function: transesophageal echo study. Indian Heart J. 2012;64(5):462-8.






Original Research Articles