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Number 09-09 Left Atrial Appendage Clot and Atrial Fibrillation
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Number 09-09 Left Atrial Appendage Clot and Atrial Fibrillation

Case from: Raju Ailiani, Kevin Jaeger, Umang Patel, Tim Tisue, Marv Shear. Gundersen Lutheran Heart Institute, La Crosse, WI, United States.

Clinical history: A 62 year old male with DCM, chronic atrial fibrillation and multiple failed DC cardioversions and failed ablation, underwent video assisted thoracoscopic left atrial appendage amputation. CMR was requested to document the adequacy of the amputation.

 

 


2-Chamber Cine View

 

 

         

Cine Aortic Valve View                         CMR Angiography

 

Cine and Angio CMR: The CMR was successfully performed despite atrial fibrillation. TrueFISP cines (2-chamber and aortic valve view) identified the presence of a thrombus in the LAA. 2D angio image confirmed the persistence of a sizeable LAA despite previous video assisted thoracoscopic amputation with thrombus. Imaging of the LAA was also achievable owing to the fact that the motion of the LAA remains quite modest despite AF or tachycardia.  

Repeat Cine and Angio CMR following 6 months of oral anticoagulation showed thrombus resolution.

 

    

2-Chamber cine with visible LAA Clot             2-Chamber cine 6 months post anticoagulation

 

   

CMR Angiography with visible LAA Clot         CMR Angiography 6 months post anticoagulatio

 

Perspective: This is a nice example of how satisfactory imaging of the LAA was achievable without the need for semi-invasive TEE and also how high quality images are possible in patients in atrial fibrillation.

References: 
1. Rustemli et al. Evaluating cardiac sources of embolic stroke with MRI. Echocardiography 2007;24:301-308.
An interesting paper evaluating the contribution of CMR to the search for cardiac sources of thomboembolism.

2. Heist EK et al. Analysis of the left atrial appendage by magnetic resonance angiography in patients with atrial fibrillation. Heart Rhythm 2006;11:1313-1318.
A prospective study of CMR imaging of the LAA in patients with atrial fibrillation.

3. Kramer CM et al. Standardised cardiovascular magnetic resonance imaging (CMR) protocols, society for cardiovascular magnetic resonance: board of trustees task force on standardised protocols. J Cardiovasc Magn Reson 2008;10:35
Useful resource providing standardised imaging protocols for CMR including MR Angiography.

Editors Comment: Acheiving high quality images in patients with arrhythmia can be challenging. A number of approaches can be used to optimise image acquisition including arrhythmia suppresion (timing to ignore "extra" beats within a set number of milliseconds from the  preceeding QRS), triggered acquisition as opposed to retropective gating (with the advise to change the number of segments to increase the total number of phases to avoid abrupt ending of cine before end-diastole), and finally real time cine as a last resort. A more detailed "How I Image in Arrhythmia" will be available soon.

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COTW handling editor: Rory O' Hanlon

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