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. 2023 Oct 23;19(8):695-702.
doi: 10.4244/EIJ-D-23-00325.

Left atrial appendage angiography for stroke risk prediction in patients with atrial fibrillation

Lisheng Jiang  1 , Ziyong Hao  1 , Xiaoyi Xie  2 , Ke Xu  1 , Lan Shen  1 , Xin Pan  1 , Cheng Wang  1 , Lan Ma  2 , Linghong Shen  1 , Yiting Fan  1 , Ben He  1
Affiliations

Left atrial appendage angiography for stroke risk prediction in patients with atrial fibrillation

Lisheng Jiang et al. EuroIntervention. .

Abstract

Background: The current risk stratification schemes for stroke in patients with atrial fibrillation (AF) are insufficient for an accurate assessment of stroke risk.

Aims: This study evaluates the association between the mechanical function of the left atrial appendage (LAA), as assessed by angiography, and the risk of stroke.

Methods: We conducted a cross-sectional study to assess the mechanical function of the LAA by measuring the left atrial appendage ejection fraction (LAAEF) and grading the contrast retention (CR) using angiography.

Results: A total of 746 patients referred for a left atrial appendage occlusion (LAAO) procedure with (n=151; stroke group) or without (n=595; control group) a history of stroke were included in the analysis. LAAEF was significantly lower (14% [9-19] vs 20% [12-33]; p<0.001) and grade 3 CR was more common (66.9% vs 33.9%; p<0.001) in patients with a history of stroke. Multivariable analysis showed that CR was independently associated with stroke in patients with AF (grade 2 vs grade 1=7.29; 95% confidence interval [CI]: 2.84-21.65; p<0.001; grade 3 vs grade 1=16.45; 95% CI: 6.16-51.02; p<0.001). The receiver operating characteristics curve demonstrated that CR identified patients with stroke more accurately than the CHA2D-VASc score (C-statistic 0.712 vs 0.512; p<0.001), and the combination of CR and the CHA2DS2-VASc score provided the best performance (C-statistic 0.871 vs 0.829 [CHA2DS2-VASc score alone]; p=0.048) Conclusions: Impaired mechanical function of the LAA, indicated by a low LAAEF and CR, is associated with a history of stroke in patients with AF. Assessment of CR using LAA angiography helps improve the stratification scheme for stroke risk prediction.

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Conflict of interest statement

The authors have no conflicts of interest to declare.

Figures

Central illustration
Central illustration. Assessment of LAA contrast retention and the ROC curve.
Angiographic assessment of the mechanical function of the LAA by CR grading. A) Shows the end-diastolic image of contrast filling into the LAA; B) represents grade 1 CR (complete clearance of contrast agent); C) represents grade 2 CR (delayed clearance of contrast agent within 3 to 6 cardiac cycles), and D) represents grade 3 CR (the contrast agent stayed inside the LAA even at the end of the long LAA cine angiography). According to the ROC analysis on the right, the C-statistic for each parameter was as follows: CHA2D-VASc=0.512; LAAEF=0.652; CR=0.712; CHA2DS2-VASc=0.829; CHA2DS2-VASc+CR=0.871. CR identified patients with stroke more accurately than the CHA2D-VASc score (p<0.001) and LAAEF (p<0.001), and the combination of the CHA2DS2-VASc score and CR provided the best performance (p=0.048 compared to CHA2DS2-VASc alone). CR: contrast retention; LAA: left atrial appendage; LAAEF: left atrial appendage ejection fraction; ROC: receiver operating characteristics
Figure 1
Figure 1. Measurement of LAAEF based on LAA angiography.
A) The left atrial appendage end-diastolic area (LAAEDA), and B) the left atrial appendage end-systolic area (LAAESA). The LAAEF is calculated with the formula: LAAEF=(LAAEDA−LAAESA)/LAAEDA*100%. LAA: left atrial appendage; LAAEF: left atrial appendage ejection fraction
Figure 2
Figure 2. Patient distributions according to the grade of CR.
Patient distributions according to the grade of CR are significantly different between the stroke and control groups, and there are more patients with grade 2 and grade 3 CR in the stroke group. ***p<0.001. CR: contrast retention; LAA: left atrial appendage
Figure 3
Figure 3. Correlation between LAAEF and CR.
The boxplot shows the distribution of LAAEF in different CR grades. LAAEF became significantly lower as the degree of CR increased, which indicates a strong correlation between the two parameters. CR: contrast retention; LAA: left atrial appendage; LAAEF: left atrial appendage ejection fraction
See this image and copyright information in PMC

References

    1. Lippi G, Sanchis-Gomar F, Cervellin G. Global epidemiology of atrial fibrillation: An increasing epidemic and public health challenge. Int J Stroke. 2021;16:217–21. - PubMed
    1. Singer DE, Albers GW, Dalen JE, Fang MC, Go AS, Halperin JL, Lip GYH, Manning WJ. Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133:546S–92S. - PubMed
    1. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001;285:2864–70. - PubMed
    1. Lip GYH, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010;137:263–72. - PubMed
    1. Piccini JP, Stevens SR, Chang Y, Singer DE, Lokhnygina Y, Go AS, Patel MR, Mahaffey KW, Halperin JL, Breithardt G, Hankey GJ, Hacke W, Becker RC, Nessel CC, Fox KAA, Califf RM ROCKET AF Steering Committee and Investigators. Renal dysfunction as a predictor of stroke and systemic embolism in patients with nonvalvular atrial fibrillation: validation of the R(2)CHADS(2) index in the ROCKET AF (Rivaroxaban Once-daily, oral, direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation) and ATRIA (AnTicoagulation and Risk factors In Atrial fibrillation) study cohorts. Circulation. 2013;127:224–32. - PubMed