Structural Remodeling of the Left Atrial Appendage in Patients with Chronic Non-Valvular Atrial Fibrillation: Implications for Thrombus Formation, Systemic Embolism, and Assessment by Transesophageal Echocardiography

Left atrial appendage (LAA) is frequently the site of thrombus formation in patients with chronic atrial fibrillation (AF). Transesophageal echocardiography and hematologic studies have identified blood flow stasis (spontaneous echogenic contrast) and abnormal coagulation (increased serum fibrinogen) as important predisposing factors to formation of LAA thrombi. However, the third component of the Virchowʹs triad, i.e., endothelial abnormalities, has not been adequately studied. Accordingly, we studied, at necropsy, the LAA morphology in 46 hearts of patients with (n = 22) and without (n = 24) chronic AF. Compared to patients without AF, those with AF had significantly larger LAA volumes (1.7% 1.1 vs. 5.4% 3.7 mL, p = 0.0002), and larger luminal surface area of the bisected LAA (4.4% 1.8 vs. 7.1% 4.5 cm2, p = 0.01). However, both the absolute and relative surface area of the transected pectinate muscles were reduced in patients with AF (2.6% 1.1 vs. 1.8% 1.0 cm2, p = 0.02 and 38% 15 vs. 21% 14%, p = 0.0003). In addition, in most patients (73%) with chronic AF, the LAA showed significant endocardial thickening with fibrous and elastic tissue (endocardial fibroelastosis) compared to those without AF (13%, p < 0.0001). Endocardial fibroelastosis resulted in a smooth LAA luminal surface and encased the pectinate muscles. These findings suggest that LAA remodeling (dilation, stretching, and reduction in pectinate muscle volume, as well as endocardial fibroelastosis) occurs frequently in chronic AF and may contribute to the increased risk of thrombus formation and systemic embolism. Additionally, the information may have relevance in interpreting transesophageal echocardiographic images of the LAA in patients with chronic AF.