Morphological and functional assessment of the left atrial appendage in daily practice: a comprehensive approach using basic and advanced echocardiography with practical tips

Figures

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  Fig. 1. Normal left atrial appendage (LAA) anatomical structures as visualized by two dimensional (2D) transesophageal echocardiography (TEE). AThick pectinate muscle at the apex of the LAA (white arrows), prominent coumadin ridge (yellow arrow) between the LAA and left upper pulmonary vein (red star) as seen by (B) 2D-TEE and (C) 3D-TEE en face view. D, E Transverse pericardial sinus (white star) as visualized by 2D-TEE

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  Fig. 2. Upper panel shows two-dimensional transesophageal echocardiography examples of the left atrial appendage (LAA) lobe. A Single-lobed, (B) bi-lobed, an (C) tri-lobed LAA with color Doppler flow inside. Lower panel shows different LAA morphology of (D) chicken wing, (E) cactus, (F) windsock, and (G) cauliflower

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  Fig. 3. Pulsed wave Doppler of the left atrial appendage (LAA) flow velocity pattern. A In normal sinus rhythm (white thick arrow points toward the early diastolic emptying velocity, yellow thick arrow points toward the late diastolic emptying velocity, blue thick arrow points toward the LAA filling velocity, the three small arrows point toward the systolic reflection waves. B In patients with Atrial fibrillation. C In patients with atrial flutter, the lower panel shows (D) the tissue velocity pattern of the LAA as obtained by tissue-Doppler imaging and (E) longitudinal strain values and curves of the LAA measured by speckle tracking echocardiography

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  Fig. 4. Left atrial appendage (LAA) visualization by two-dimensional transesophageal echocardiography shows the sequel of blood stasis. A Severe spontaneous echo contrast (small white arrows). B X-plane view of LAA shows dense spontaneous echo contrast associated with sludge formation (yellow arrow). C Small rounded LAA thrombus (white arrow). D Large LAA thrombus protruding into the LA (white arrows) associated with sludge (yellow arrow)

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  Fig. 5. Visualization of the left atrial appendage (white arrow) using two-dimensional transthoracic echocardiography. A From the parasternal short-axis view at the aortic valve level. (B) Apical five-chamber view. C Apical two-chamber view. D Apical four-chamber view

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  Fig. 6. Visualization of the left atrial appendage (white arrow) using two-dimensional transesophageal echocardiography from the mid-esophageal level at different angles. A Between 0°–20°. B Between 45°–60°. C Between 80°–100°. D Between 120°–135°

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  Fig. 7. Scan of the left atrial appendage from 0°, 45°, 90°, and 135° views using two-dimensional transthoracic echocardiography to measure the maximum orifice diameter, landing zone, and maximum depth before device closure. Yellow circle indicates the circumflex artery

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  Fig. 8. F (A) Quad-screen acquisition using three-dimensional transthoracic echocardiography shows a Watchman (Boston Scientific) closure device of the left atrial appendage (white arrows). B, C Left atrial appendage closed surgically (star)