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Objectives This study investigated the left atrial appendage (LAA) by computed tomography (CT) and magnetic resonance imaging (MRI) to categorize different LAA morphologies and to correlate the morphology with the history of stroke/transient ischemic attack (TIA). Background LAA represents one of the major sources of cardiac thrombus formation responsible for TIA/stroke in patients with atrial fibrillation (AF). Methods We studied 932 patients with drug-refractory AF who were planning to undergo catheter ablation. All patients underwent cardiac CT or MRI of the LAA and were screened for history of TIA/stroke. Four different morphologies were used to categorize LAA: Cactus, Chicken Wing, Windsock, and Cauliflower. Results CT scans of 499 patients and MRI scans of 433 patients were analyzed (age 59 ± 10 years, 79% were male, and 14% had CHADS2 [Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack] score ≥2). The distribution of different LAA morphologies was Cactus (278 [30%]), Chicken Wing (451 [48%]), Windsock (179 [19%]), and Cauliflower (24 [3%]). Of the 932 patients, 78 (8%) had a history of ischemic stroke or TIA. The prevalence of pre-procedure stroke/TIA in Cactus, Chicken Wing, Windsock, and Cauliflower morphologies was 12%, 4%, 10%, and 18%, respectively (p = 0.003). After controlling for CHADS2 score, gender, and AF types in a multivariable logistic model, Chicken Wing morphology was found to be 79% less likely to have a stroke/TIA history (odd ratio: 0.21, 95% confidence interval: 0.05 to 0.91, p = 0.036). In a separate multivariate model, we entered Chicken Wing as the reference group and assessed the likelihood of stroke in other groups in relation to reference. Compared with Chicken Wing, Cactus was 4.08 times (p = 0.046), Windsock was 4.5 times (p = 0.038), and Cauliflower was 8.0 times (p = 0.056) more likely to have had a stroke/TIA. Conclusions Patients with Chicken Wing LAA morphology are less likely to have an embolic event even after controlling for comorbidities and CHADS2 score. If confirmed, these results could have a relevant impact on the anticoagulation management of patients with a low-intermediate risk for stroke/TIA.

Incomplete LAA Occlusion by WATCHMAN Device. Introduction: Transcatheter left atrial appendage (LAA) closure with the WATCHMAN device has become one of the therapeutic options in atrial fibrillation (AF) patients who are at high risk for ischemic stroke. However, the incidence and evolution of incomplete occlusion of the LAA during and after placement of the WATCHMAN device has not been reported. Methods and Results: Fifty-eight consecutive patients who had undergone WATCHMAN device implant were included in the study. Intraprocedural, 45-day and 12-month transesophageal echocardiogram images were reviewed and analyzed. Peridevice gap was noted in 16 (27.6%), 17 (29.3%), and 20 (34.5%) patients across the 3 time points. Intraprocedural gaps are more likely to be persistent until 12 months and become larger in size over time. New gap also occurs during follow-up even if the LAA was completely sealed at implantation. One patient had an ischemic stroke 4.7 months after implant; another patient developed a left atrial thrombus over the device 21.6 months after implant. Both patients had intraprocedural gap and discontinued warfarin therapy after the 45-day evaluation. Conclusion: Incomplete LAA occlusion with a gap between the WATCHMAN device surface and the LAA wall is relatively common. Intraprocedural gaps are more likely to become bigger over time and persist, while new gaps also occur during follow-up. Further studies are warranted to verify whether the presence and persistence of a peridevice gap is associated with increased risk of thromboembolic event in AF patients implanted with a WATCHMAN device. (J Cardiovasc Electrophysiol, Vol. 23, pp. 455-461, May 2012)

Background The risk of cerebrovascular embolic events with atrial fibrillation (AF) is potentially linked to an increased risk of cognitive decline and dementia. However, epidemiologic studies exploring the association between AF and incident dementia have reported conflicting results. Objective The purpose of this study was to perform a meta-analysis of observational studies specifically designed to evaluate the prospective relationship between AF and incident dementia. Methods We searched PubMed, CENTRAL, BioMedCentral, Embase, Cardiosource, clinicaltrials.gov, and ISI Web of Science (January 1980 to May 2012). No language restriction was applied. Two independent reviewers screened titles and abstracts to identify population-based studies that prospectively evaluated the association between AF and the incidence of dementia in patients not suffering an acute stroke and with normal cognitive function at baseline, providing the hazard ratio (HR) obtained in multiple Cox regression analyses, and adjusted for all confounding variables. Two independent reviewers assessed risk of bias according to the Cochrane Collaboration, and extracted patient and study characteristics and the adjusted HR of incident dementia with its 95% confidence interval (CI) of patients with AF vs those without AF. Results Eight studies with 77,668 patients were included in the analysis. All studies had a prospective observational design and included elderly patients (mean age range 61–84 years) with normal cognitive function at baseline, of whom 11,700 (15%) had AF. After a mean follow-up of 7.7 ± 9.1 years (range 1.8–30 years), 4773 of 73,321 (6.5%) patients developed dementia. Two studies did not report the rates of dementia at follow-up but reported the adjusted HR and were included in the pooled analysis. At pooled analysis adjusted for baseline confounders and covariates, AF was independently associated with increased risk of incident dementia (HR = 1.42 [95% CI 1.17–1.72], P Conclusion AF is independently associated with increased risk of dementia. Patients with AF should be periodically screened for dementia, which should be included among the outcomes assessed in AF treatment trials.