The Last View: A Critical Finding Revealed by Systematic Multi-Angle Imaging

The Last View: A Critical Finding Revealed by Systematic Multi-Angle Imaging | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 30 August 2025 V1 Latest version Share on The Last View: A Critical Finding Revealed by Systematic Multi-Angle Imaging Authors : Charles Pollick 0000-0002-6855-7353 and Alexander Kukuev [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.175654804.43828585/v1 129 views 99 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Left atrial appendage (LAA) thrombus formation is a well-known finding in patients with atrial fibrillation and in other conditions associated with loss of LAA mechanical function. Comprehensive, multi-angle transesophageal echocardiography is essential for accurate LAA assessment. Clinically significant findings, such as thrombus, may only be visualized at specific angles, underscoring the importance of systematic multi-angle imaging to avoid missed diagnoses. The Last View: A Critical Finding Revealed by Systematic Multi-Angle Imaging Charles Pollick | Alexander Kukuev Smidt Heart Institute, Cedars-Sinai, LA, USA correspondence: Charles Pollick ( [email protected] ) | Alexander Kukuev ( [email protected] ) Keywords: left atrial appendage | thromboembolism | trans-esophageal Echocardiography | Left atrial appendage isolation ABSTRACT Left atrial appendage (LAA) thrombus formation is a well-known finding in patients with atrial fibrillation and in other conditions associated with loss of LAA mechanical function. Comprehensive, multi-angle transesophageal echocardiography is essential for accurate LAA assessment. Clinically significant findings, such as thrombus, may only be visualized at specific angles, underscoring the importance of systematic multi-angle imaging to avoid missed diagnoses. Background The left atrial appendage (LAA) is an important potential source of systemic embolism in patients with atrial fibrillation. Loss of LAA mechanical function may occur in various pathologies and can also result from ablation procedures for atrial fibrillation, as will be further discussed(1,2). Transesophageal echocardiography (TEE) is the recommended modality for LAA assessment when systemic embolism is suspected. Given the complex anatomy of the LAA, a meticulous and comprehensive TEE evaluation is essential to avoid overlooking clinically significant findings(3,4). Case report A 75-year-old man with a history of ischemic heart disease with multiple coronary interventions, hypertension, dyslipidemia and chronic kidney disease. The patient was diagnosed with atrial fibrillation in 2009. He subsequently underwent multiple cardioversion attempts, received antiarrhythmic therapy, but these interventions failed, and atrial fibrillation recurred. Subsequently, he underwent his first atrial fibrillation ablation procedure. In 2013, he experienced his first post ablation recurrence of AF, prompting another ablation, which included left atrial appendage electrical isolation (LAAEI). Although the patient was prescribed anticoagulation, he was non-compliant with therapy. Previous transesophageal echocardiography (TEE) studies had demonstrated low LAA velocities, and the potential clinical significance was discussed with him. In 2018, he developed an episode of atrial flutter and underwent another electrophysiological study and ablation. During the procedure, a single segment of the LAA had reconnected and was re-isolated. The patient was discharged on anticoagulation, and the option of LAA occlusion was discussed; however, he did not return for follow-up. On March 2024, he presented to the emergency department with sudden onset of severe left-sided abdominal pain radiating to the flank, which began shortly after eating lunch. He denied nausea, vomiting, diarrhea, constipation, hematochezia, chest pain, dyspnea, or diaphoresis. The patient admitted to non-compliance with his chronic medications. On admission, vital signs revealed markedly elevated blood pressure (215/105 mmHg), heart rate of 73 bpm, and oxygen saturation of 97% on room air. Physical examination revealed a soft, non-distended abdomen with significant tenderness in the left upper quadrant (LUQ) on palpation; no other abnormalities were noted. Electrocardiography demonstrated regular sinus rhythm with complete right bundle branch block. Laboratory evaluation revealed leukocytosis (14.5 × 10^9/µL) and modest troponin elevation, without significant abnormalities in the remainder of the complete blood count or metabolic panel. Abdominal computed tomography (CT) demonstrated a large area of diminished enhancement involving approximately two-thirds of the spleen, consistent with infarction (Image 1). Surgical consultation determined that urgent intervention was not required. Given the patient’s history and imaging findings, a cardiogenic embolic source was suspected, and the patient was admitted to the Internal Medicine department. He was started on intravenous heparin for anticoagulation. Transesophageal echocardiography (TEE) was performed to identify a potential source of embolism, with particular attention to the left atrial appendage (LAA). Initial imaging confirmed persistently low LAA emptying velocities and absence of mechanical function, despite the patient being in sinus rhythm at the time of examination (Figure 2, Video 1). The LAA was systematically evaluated at the standard recommended angles. Notably, only at the final acquisition, around 130–135°, was a large, finger-like, mobile mass identified, consistent with thrombus formation (Figure 3, Video 2-4). These findings confirmed systemic embolism originating from the LAA in the setting of mechanical dysfunction following electrical isolation and anticoagulation non-compliance. Following multidisciplinary discussion, the patient was transitioned to oral anticoagulation with a direct oral anticoagulant (DOAC). At one-month follow-up, CT angiography demonstrated a 25 × 5 mm filling defect in the distal LAA, consistent with thrombus. After discussing options including percutaneous LAA occlusion or thrombectomy, a decision was made to continue medical therapy. Subsequent TEE demonstrated a smaller thrombus measuring 0.5 × 1.5 cm. After consultation with an interventional cardiologist, the patient continued medical therapy. Discussion As pulmonary vein isolation (PVI) emerged as the cornerstone of atrial fibrillation treatment, new technologies and techniques were developed to further enhance success rates, particularly for patients who did not initially respond to standard therapies. In addition to conventional PVI, left atrial appendage is believed to play an important role in triggering AF(5), so left atrial appendage electrical isolation (LAAEI) attracted increasing attention and has become a more commonly adopted strategy in the management of atrial fibrillation, including patients with longstanding persistent AF as was demonstrated in the BEILIEF trial(6). A major concern after LAAEI is the need for long-term anticoagulation, given that the mechanical function of the left atrial appendage (LAA) is lost. In some cases, thrombus formation occurs at unexpectedly high rates—reported up to 21.3%—even despite adequate anticoagulation therapy(7). Previous studies have shown that patients with a left atrial appendage (LAA) emptying velocity of <0.4 m/s and abnormal LAA function are at increased risk of embolic events, irrespective of the CHA₂DS₂-VASc score(2,6) . Subsequent studies have demonstrated that left atrial appendage (LAA) ligation or closure significantly reduces the incidence of intracardiac thrombus formation, even after discontinuation of anticoagulation therapy, including in patients with a prior history of left atrial thrombus(1,8) . Therefore, LAA closure is routinely incorporated into LAA electrical isolation (LAAEI) procedures to significantly reduce the risk of thromboembolic events. The anatomic differences in the LAA structure among population was previously shown in autopsies. By definition LAA must have at least one lobe. The shape and the measurements of the orifice were assessed and a lobe was defined as an outpouching from the main tubular body of the LAA, usually demarcated by external crease, with a depth of 2 mm and occasionally associated with a change in direction of the main tubular body(4) Another study evaluated left atrial appendage (LAA) morphology using CT and MRI, identifying four distinct morphologies: cactus, chicken wing, windsock, and cauliflower. The authors also assessed the relationship between LAA morphology and the risk of stroke or transient ischemic attack (TIA). They found that the chicken wing morphology was associated with a statistically significant lower risk of stroke or TIA compared with the other LAA morphologies(9) The variability of left atrial appendage (LAA) anatomy and its frequent multi-lobular structure underscore the importance of carefully assessing individual patient morphology. According to the ASE guidelines, comprehensive evaluation of the LAA should include imaging at four standard angles (0°, 45°, 90°, and 135°). In addition, the use of biplane imaging, three-dimensional echocardiography, and specific maneuvers is recommended, particularly for device sizing and pre-procedural planning of intracardiac interventions(10). Conclusion This case underscores the long-term thromboembolic risk associated with left atrial appendage electrical isolation, particularly in patients with reduced LAA mechanical function and suboptimal anticoagulation adherence. Comprehensive assessment of LAA anatomy and function using multimodal imaging, including TEE at multiple standard angles, is critical to identify thrombus formation and guide management. In this patient only the 135̊ view showed the thrombus. Consideration of concomitant LAA closure should be strongly weighed in patients undergoing LAAEI to minimize systemic embolic complications. Figures and Video Figure 1- Abdominal CTA demonstrating - a large area of diminished enhancement involving approximately two-thirds of the spleen, consistent with infarction Figure 2 – TEE – Reduced LAA velocities seen by a PW doppler at the level of the LAA. Figure 3 – Tee at 130̊ demonstrates a finger-like mass, consistent with a thrombus in an outpouching lobe of the LAA. Video 1 – TEE demonstrate the absence of mechanical function. No evidence of a thrombus at 50̊ . Video 2 – TEE – LAA at 95̊, no evidence of a thrombus. Video 3 – TEE – LAA at 111̊, no evidence of a thrombus. Video 4 – TEE - LAA finger-like clot seen only on 135°. References 1. Fink T, Schlüter M, Heeger CH, Lemeš C, Maurer T, Reissmann B, et al. Combination of Left Atrial Appendage Isolation and Ligation to Treat Nonresponders of Pulmonary Vein Isolation. JACC Clin Electrophysiol. 2018 Dec 1;4(12):1569–79. 2. Fink T, Vogler J, Heeger CH, Sano M, Sciacca V, Reissmann B, et al. Impact of Left Atrial Appendage Closure on LAA Thrombus Formation and Thromboembolism After LAA Isolation. Focus Atr Fibrillation. 2020 Dec 14;6(13):1687–97. 3. Saric M, Armour AC, Arnaout MS, Chaudhry FA, Grimm RA, Kronzon I, et al. Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism. J Am Soc Echocardiogr. 2016 Jan;29(1):1–42. 4. Veinot JP, Harrity PJ, Gentile F, Khandheria BK, Bailey KR, Eickholt JT, et al. Anatomy of the Normal Left Atrial Appendage. Circulation. 1997 Nov 4;96(9):3112–5. 5. Di Biase L, Burkhardt JD, Mohanty P, Sanchez J, Mohanty S, Horton R, et al. Left Atrial Appendage. Circulation. 2010 July 13;122(2):109–18. 6. Di Biase L, Burkhardt JD, Mohanty P, Mohanty S, Sanchez JE, Trivedi C, et al. Left Atrial Appendage Isolation in Patients With Longstanding Persistent AF Undergoing Catheter Ablation: BELIEF Trial. J Am Coll Cardiol. 2016 Nov 1;68(18):1929–40. 7. Rillig A, Tilz RR, Lin T, Fink T, Heeger CH, Arya A, et al. Unexpectedly High Incidence of Stroke and Left Atrial Appendage Thrombus Formation After Electrical Isolation of the Left Atrial Appendage for the Treatment of Atrial Tachyarrhythmias. Circ Arrhythm Electrophysiol. 2016 May 1;9(5):e003461. 8. Heeger CH, Rillig A, Geisler D, Wohlmuth P, Fink T, Mathew S, et al. Left Atrial Appendage Isolation in Patients Not Responding to Pulmonary Vein Isolation. Circulation. 2019 Jan 29;139(5):712–5. 9. Di Biase L, 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 Aug 7;60(6):531–8. 10. Hahn RT, Saric M, Faletra FF, Garg R, Gillam LD, Horton K, et al. Recommended Standards for the Performance of Transesophageal Echocardiographic Screening for Structural Heart Intervention: From the American Society of Echocardiography. J Am Soc Echocardiogr. 2022 Jan;35(1):1–76. Information & Authors Information Version history V1 Version 1 30 August 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords left atrial appendage left atrial appendage isolation thromboembolism trans-esophageal echocardiography Authors Affiliations Charles Pollick 0000-0002-6855-7353 Cedars-Sinai Medical Center Smidt Heart Institute View all articles by this author Alexander Kukuev [email protected] Cedars-Sinai Medical Center Smidt Heart Institute View all articles by this author Metrics & Citations Metrics Article Usage 129 views 99 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Charles Pollick, Alexander Kukuev. The Last View: A Critical Finding Revealed by Systematic Multi-Angle Imaging. Authorea . 30 August 2025. DOI: https://doi.org/10.22541/au.175654804.43828585/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. 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