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The Story of Heart Ears: Understanding Left Atrial Appendage Anatomy and Risk

Date: 18th November 2024

 
Heart Ears

During a recent teaching course in the Netherlands, I found myself intrigued by a simple yet fascinating observation. My Dutch colleagues referred to the left atrial appendage as 'hartoor' - meaning 'heart ear'. Despite practicing echocardiography for many years and being familiar with the Latin term 'auricle', this straightforward translation made me pause and smile. Sometimes the simplest descriptions carry the most clarity.


This observation led me to explore the growing body of evidence surrounding left atrial appendage morphology. What emerged was far more significant than etymology - the shape of this small cardiac structure holds remarkable implications for stroke risk. Just as our external ears vary in shape and size, the left atrial appendage presents in distinct patterns, each carrying its own clinical significance.


Through my experience in practicing and teaching echocardiography, I've observed how our understanding of these structures continues to evolve. Recent research has transformed our approach to risk assessment and patient care, particularly in the context of stroke prevention. This guide aims to share these insights, exploring both the fundamental anatomy and its crucial clinical implications.


Getting to Know the Left Atrium


The left atrium often reminds me of a central railway station - all tracks lead here. Positioned superior to the left ventricle, it receives oxygenated blood from four pulmonary veins and manages this flow with remarkable efficiency. In my daily practice, I've found that understanding its position helps immensely with image acquisition - the posterior wall nestles against the oesophagus and descending aorta, while the upper portion sits beneath the right pulmonary artery.


Size matters in cardiac imaging, but context is everything. A typical left atrium measures between 30-40mm front to back, though these measurements can vary significantly depending on what's happening in the heart. Recent data has shown us that volumes typically range from 78mL in those with normal rhythm to 109mL in patients with atrial fibrillation - a difference that tells its own story about cardiac adaptation.


The Intriguing World of the Left Atrial Appendage


If the left atrium is a railway station, then the left atrial appendage is rather like the station coffee shop with significant functional importance. Recent research has helped us understand that this structure comes in four distinct forms, each with its own implications for patient care:


  1. Chicken Wing Pattern: This variant, seen in about 11% of cases, features a distinctive bend that reminds me of a folded wing. Interestingly, it becomes more common as our patients age, and research suggests it generally carries a lower stroke risk.

  2. Swan Pattern: Previously known as Cactus, this form appears in roughly 4% of cases. It's particularly interesting because recent studies, especially the work by Smit and colleagues, have shown it carries the highest stroke risk - about 3-4 times higher than other patterns.

  3. Cauliflower Pattern: The most common variant, appearing in around 53% of cases, shows a compact form with a wider tip than base. Think of it as nature's compromise between form and function.

  4. Windsock Pattern: Making up about 32% of cases, this pattern shows a single, elongated lobe. It's more commonly found in younger patients, perhaps reflecting how these structures change over time.


Modern Imaging Approaches


In my practice, I've found that understanding these structures requires a thoughtful approach to imaging. While standard transthoracic echo gives us our first look, transoesophageal imaging really opens the window to detailed assessment. It's rather like switching from a standard camera to a macro lens - suddenly, the fine details come into focus.


The advent of 3D imaging has been particularly revolutionary. It allows us to rotate and examine these structures from angles we could only imagine a decade ago. This technology has proven especially valuable when we're planning interventional procedures or trying to understand complex anatomical relationships.


Clinical Impact and Risk Assessment


One of the most fascinating aspects of recent research has been understanding how anatomy influences risk. The finding that swan morphology carries a higher stroke risk, regardless of whether a patient has atrial fibrillation, has changed how we think about risk assessment. It's not just about rhythm anymore - structure plays a crucial role.


Volume measurements tell an important story too. An LAA volume of 6.6mL in someone without AF versus 8.8mL in someone with AF might seem like a small difference, but it reflects significant cardiac remodelling. These measurements help us track disease progression and guide treatment decisions.


Looking to the Future


The field of cardiac imaging continues to evolve at a remarkable pace. Artificial intelligence is beginning to help with automated classification of LAA morphology, and new imaging techniques are emerging regularly. I'm particularly excited about the potential of fusion imaging and real-time flow assessment to enhance our understanding further.


Conclusion


Understanding left atrial and LAA anatomy has never been more important than it is today. What started as a simple observation about anatomical naming has led us through a fascinating journey of structure, function, and clinical significance. As echocardiographers, our role in identifying and characterising these structures continues to grow in importance, directly impacting patient care.


From simple 'heart ears' to sophisticated risk predictors, these cardiac structures remind us that in medicine, careful observation and continuous learning remain at the heart of progress. As we continue to refine our understanding and techniques, the future of cardiac imaging looks brighter than ever.


 

About the writer

Intensivist

Hannah Conway, a clinical-academic and National FUSIC Heart Lead for the UK.


Interests lie in PoCUS education, Echocardiography, RV injury and telemedicine 


Follow me on Twitter/X for more PoCUS related educational content https://x.com/cardiacaccp


 

References


1. Smit et al. Anatomical Characteristics of the Left Atrium and Left Atrial Appendage in Relation to the Risk of Stroke in Patients With Versus Without Atrial Fibrillation. Circulation. 2021

 

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