Refining the prognosis of patients with AF using 3D transesophageal echocardiography of the left atrial appendage

Abstract Background Left atrial (LA) volume is considered an echocardiographic marker of thrombosis risk and prognosis in atrial fibrillation (AF). Limited data is available on the prognostic value of left atrial appendage (LAA) volume in AF as evaluated with three-dimensional (3D) transoesophageal echocardiography (TEE). Purpose We hypothesized that 3D LAA volume is associated with prognosis in patients hospitalized with AF. Methods We prospectively evaluated 206 patients hospitalized for AF with two-dimensional transthoracic echocardiography (TTE) and 3D TEE of the LAA within 24 hours of admission. 3D parameters were analysed off-line using Tomtec software (4D Cardio-View, Generic Volume, Philips). The primary composite outcome was all-cause death during at 2 years follow up. Results The median age of the study group was 66.3 ± 11.5 years with 129 (62.6%) men. In the global population, at admission, the median 3D LAAV was 9.02 (6.96-12.15) ml. Patients were divided into two groups according to the median 3D LAAV: Group 1: LAAV < 9ml (103 patients) and Group 2: LAAV ≥ 9ml (103 patients). Patients with LAAV ≥ 9ml had more frequently a history of heart failure and chronic obstructive pulmonary disease. There were no significant intergroup differences in CHA2DS2-VASc score. Patients with LAAV ≥ 9ml had higher values of BNP and CRP and lower LVEF, higher LA volumes, higher E/e’, lower LAA emptying flow velocity, and higher 3D ES LAA ostium area. There were no statistical differences in LAA spontaneous echo contrast and LAA morphology between groups (Table 1). Kaplan–Meier curves demonstrated a significant difference in survival according to the 3D ES LAAV: 3 deaths occurred in the group with 3D ES LAA volume < 9mL and 11 in the group with 3D ES LAA Volume≥9mL (p=0.0315) (Figure 1). Conclusion Among LAA parameters, 3D LAA end-systolic volume is significantly associated with a worse outcome in patients with AF. Further investigations are needed to evaluate this unique parameter against usual geometric and functional LA/LAA parameters.