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<meta name="robots" content="INDEX,FOLLOW,NOARCHIVE" /><meta name="citation_inbook_title" content="StatPearls [Internet]" /><meta name="citation_title" content="Anatomy, Thorax, Heart Left Atrial Appendage" /><meta name="citation_publisher" content="StatPearls Publishing" /><meta name="citation_date" content="2023/09/04" /><meta name="citation_author" content="Yingyot Arora" /><meta name="citation_author" content="Felix Jozsa" /><meta name="citation_author" content="Michael P. Soos" /><meta name="citation_pmid" content="31985999" /><meta name="citation_fulltext_html_url" content="https://www.ncbi.nlm.nih.gov/books/NBK553218/" /><link rel="schema.DC" href="http://purl.org/DC/elements/1.0/" /><meta name="DC.Title" content="Anatomy, Thorax, Heart Left Atrial Appendage" /><meta name="DC.Type" content="Text" /><meta name="DC.Publisher" content="StatPearls Publishing" /><meta name="DC.Contributor" content="Yingyot Arora" /><meta name="DC.Contributor" content="Felix Jozsa" /><meta name="DC.Contributor" content="Michael P. Soos" /><meta name="DC.Date" content="2023/09/04" /><meta name="DC.Identifier" content="https://www.ncbi.nlm.nih.gov/books/NBK553218/" /><meta name="description" content="The left atrial appendage (LAA) is a unique structure within the pericardium, close to the free wall of the left ventricle. It has unique developmental, structural, and physiological characteristics that separate it from the left atrium proper.[1] In normal cardiac physiology, the LAA plays an essential role in regulating intravascular volume by releasing natriuretic peptides in response to hemodynamic changes. The LAA also plays a vital role in the pathogenesis of transient ischemic attack (TIA) and stroke in patients with atrial fibrillation (AF).[2] " /><meta name="og:title" content="Anatomy, Thorax, Heart Left Atrial Appendage" /><meta name="og:type" content="book" /><meta name="og:description" content="The left atrial appendage (LAA) is a unique structure within the pericardium, close to the free wall of the left ventricle. It has unique developmental, structural, and physiological characteristics that separate it from the left atrium proper.[1] In normal cardiac physiology, the LAA plays an essential role in regulating intravascular volume by releasing natriuretic peptides in response to hemodynamic changes. The LAA also plays a vital role in the pathogenesis of transient ischemic attack (TIA) and stroke in patients with atrial fibrillation (AF).[2] " /><meta name="og:url" content="https://www.ncbi.nlm.nih.gov/books/NBK553218/" /><meta name="og:site_name" content="NCBI Bookshelf" /><meta name="og:image" content="https://www.ncbi.nlm.nih.gov/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-statpearls-lrg.png" /><meta name="twitter:card" content="summary" /><meta name="twitter:site" content="@ncbibooks" /><meta name="bk-non-canon-loc" content="/books/n/statpearls/article-76855/" /><link rel="canonical" href="https://www.ncbi.nlm.nih.gov/books/NBK553218/" /><link rel="stylesheet" href="/corehtml/pmc/css/figpopup.css" type="text/css" media="screen" /><link rel="stylesheet" href="/corehtml/pmc/css/bookshelf/2.26/css/books.min.css" type="text/css" /><link rel="stylesheet" href="/corehtml/pmc/css/bookshelf/2.26/css/books_print.min.css" type="text/css" /><style type="text/css">p a.figpopup{display:inline !important} .bk_tt {font-family: monospace} .first-line-outdent .bk_ref {display: inline} </style><script type="text/javascript" src="/corehtml/pmc/js/jquery.hoverIntent.min.js"> </script><script type="text/javascript" src="/corehtml/pmc/js/common.min.js?_=3.18"> </script><script type="text/javascript">window.name="mainwindow";</script><script type="text/javascript" src="/corehtml/pmc/js/bookshelf/2.26/book-toc.min.js"> </script><script type="text/javascript" src="/corehtml/pmc/js/bookshelf/2.26/books.min.js"> </script>
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<div class="pre-content"><div><div class="bk_prnt"><p class="small">NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.</p><p>StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. </p></div></div></div>
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<div class="main-content lit-style" itemscope="itemscope" itemtype="http://schema.org/CreativeWork"><div class="meta-content fm-sec"><h1 id="_NBK553218_"><span class="title" itemprop="name">Anatomy, Thorax, Heart Left Atrial Appendage</span></h1><p class="contrib-group"><h4>Authors</h4><span itemprop="author">Yingyot Arora</span><sup>1</sup>; <span itemprop="author">Felix Jozsa</span><sup>2</sup>; <span itemprop="author">Michael P. Soos</span><sup>3</sup>.</p><h4>Affiliations</h4><div class="affiliation"><sup>1</sup> University of Miami / Miller School</div><div class="affiliation"><sup>2</sup> University College London</div><div class="affiliation"><sup>3</sup> McLaren Greater Lansing</div><p class="small">Last Update: <span itemprop="dateModified">September 4, 2023</span>.</p></div><div class="body-content whole_rhythm" itemprop="text"><div id="article-76855.s1"><h2 id="_article-76855_s1_">Introduction</h2><p>The left atrial appendage (LAA) is a unique structure within the pericardium, close to the free wall of the left ventricle. It has unique developmental, structural, and physiological characteristics that separate it from the left atrium proper.<a class="bk_pop" href="#article-76855.r1">[1]</a> In normal cardiac physiology, the LAA plays an essential role in regulating intravascular volume by releasing natriuretic peptides in response to hemodynamic changes. The LAA also plays a vital role in the pathogenesis of transient ischemic attack (TIA) and stroke in patients with atrial fibrillation (AF).<a class="bk_pop" href="#article-76855.r2">[2]</a> </p></div><div id="article-76855.s2"><h2 id="_article-76855_s2_">Structure and Function</h2><p>The left atrial appendage is often described as a small ear-shaped outpouching of the muscular wall of the left atrium. It lies anteriorly in the atrioventricular sulcus, close to the left circumflex artery, phrenic nerve, and pulmonary veins.<a class="bk_pop" href="#article-76855.r3">[3]</a><a class="bk_pop" href="#article-76855.r4">[4]</a> It is adjacent to the free wall of the left ventricle and, thus, is closely associated with left ventricular function. Although several physiological variants exist, in most individuals, the LAA is a unilobar structure lying parallel to the left superior pulmonary vein. A structural analysis of the LAA using computerized tomography (CT) in 612 individuals suggested that, on average, the appendage is 46 mm long and has a volume of approximately 9 mL.<a class="bk_pop" href="#article-76855.r2">[2]</a> The most common general topology of the LAA is for it to project anterosuperiorly to lie over the superior-most part of the left ventricle or the pulmonary trunk. In a small number of cases, it may be pointed behind the pulmonary trunk directly in the transverse cardiac sinus.<a class="bk_pop" href="#article-76855.r5">[5]</a> The interior surface of the LAA is muscular and marked with muscular ridges, in contrast to the rest of the left atrial interior surface, which is smooth, a difference that can be explained by their embryological origins, as described later.</p><p>In normal cardiac physiology, the LAA is an essential modulator of intravascular volume. In response to increased myocyte stretch, the LAA releases atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) into the coronary sinus. From here, these peptides enter the general circulation and regulate blood pressure and volume via their diuretic, natriuretic, and vasodilatory effects.<a class="bk_pop" href="#article-76855.r6">[6]</a> The action of ANP in response to increased myocyte stretch includes changes in both renal and systemic vasculature function. ANP promotes acute increased glomerular filtration and thus renal excretion of sodium and water.<a class="bk_pop" href="#article-76855.r7">[7]</a> Furthermore, its effect on the vasculature includes vascular smooth muscle relaxation and increased microvasculature permeability, which promotes protein movement into the interstitial space, effectively decreasing circulating intravascular volume. BNP is stored in a significantly lower concentration in the LAA compared to ANP and is found in greater concentration in the cardiac ventricles.<a class="bk_pop" href="#article-76855.r8">[8]</a><a class="bk_pop" href="#article-76855.r9">[9]</a> Nevertheless, it is also released from the LAA in response to cardiac overload. It is a sensitive biomarker for heart failure, as its levels rise markedly in response to congestive heart failure. BNP's half-life is around 20 minutes, significantly longer than that of ANP, which is approximately only 2 minutes.<a class="bk_pop" href="#article-76855.r10">[10]</a></p></div><div id="article-76855.s3"><h2 id="_article-76855_s3_">Embryology</h2><p>The left atrial appendage develops during the fourth week of embryonic development as a remnant of the embryonic left atrium (LA), which forms during the third week of gestation.<a class="bk_pop" href="#article-76855.r1">[1]</a><a class="bk_pop" href="#article-76855.r11">[11]</a> This development contrasts with the rest of the LA cavity, which develops as an outgrowth of the pulmonary veins.<a class="bk_pop" href="#article-76855.r12">[12]</a> For this reason, the LAA is marked with muscular ridges in contrast to the rest of the left atrium, which is smooth-walled.</p></div><div id="article-76855.s4"><h2 id="_article-76855_s4_">Nerves</h2><p>The left atrial appendage does not have significant nervous innervation.</p></div><div id="article-76855.s5"><h2 id="_article-76855_s5_">Muscles</h2><p>The left atrial appendage does not perfuse any muscles.</p></div><div id="article-76855.s6"><h2 id="_article-76855_s6_">Physiologic Variants</h2><p>There are several well-described left atrial appendage morphologies. The LAA classification system has its basis on the shape, the relationship of the LAA to the left superior pulmonary vein, length from the ostium to apex, number of lobes, angle of the fist bend formed by the primary lobe, and the distance from the first bend to the LAA orifice. Based on these features, Wang et. described four classical structural morphologies accounting for the majority of anatomical variants seen.<a class="bk_pop" href="#article-76855.r2">[2]</a></p><p>The “chicken wing” morphology describes an LAA with an obvious bend in the proximal or middle part of the dominant lobe and is the most common variant found in one study of 932 patients to be present in 40%.<a class="bk_pop" href="#article-76855.r3">[3]</a> The “cactus” LAA has a dominant central lobe with secondary lobes extending from the central lobe in both superior and inferior directions and was found in 30% of patients. The “windsock” morphology describes an LAA in which one dominant lobe of sufficient length is the primary structure, found in 19% of patients. Finally, the “cauliflower” LAA’s main characteristic is an LAA that has limited overall length with complex internal features, present in just 3% of patients.</p></div><div id="article-76855.s7"><h2 id="_article-76855_s7_">Surgical Considerations</h2><p>In open cardiac procedures, such as coronary artery bypass grafts (CABG), the left atrial appendage is often isolated or ligated. This process is especially important in patients with a history of AF, as isolation and catheter ablation correlates with a decrease in AF recurrence and a reduction in stroke risk.<a class="bk_pop" href="#article-76855.r13">[13]</a> The 2021 Left Atrial Appendage Occlusion Study (LAAOS III) was a randomized control trial treating patients undergoing cardiac surgery who had atrial fibrillation and a stroke risk score (CHA2DS2-VASC) of two or more with either standard of care or LAA occlusion at the time of their cardiac surgery.<a class="bk_pop" href="#article-76855.r14">[14]</a><a class="bk_pop" href="#article-76855.r15">[15]</a><a class="bk_pop" href="#article-76855.r14">[14]</a> The rationale behind this was that these patients are at increased risk of ischemic stroke as implied by their CHA2DS2-VASc score, and given the significant morbidity and mortality from ischaemic stroke, the known pathogenic site of LAA, and the relatively simple procedure for occlusion during concomitant cardiac surgery for other pathology, this may provide a good opportunity to administer prophylactic intervention in this patient group. The results of this trial, which included 4811 patients, demonstrated that in the intervention group undergoing concomitant LAA occlusion at the time of cardiac surgery, there was a 33% reduced risk of ischaemic stroke compared to the group undergoing cardiac surgery only.<a class="bk_pop" href="#article-76855.r16">[16]</a> </p><p>Furthermore, the addition of LAA occlusion added no significant extra time to heart bypass during the concomitant procedure being performed. Despite removing the proposed source of embolic stroke from circulation, the authors did not recommend ceasing therapeutic anticoagulation following LAA occlusion, given the lack of evidence comparing LAA occlusion alone versus anticoagulation for stroke prevention. Interestingly, despite a hypothesized increase in heart failure one might observe in patients following LAA occlusion owing to the physiologically impaired ability to excrete sodium and water in volume overload from reduced atrial natriuretic peptide production, there was no statistical difference in the incidence of heart failure between the groups in LAAOS III, either immediately post-operatively or at long-term follow-up.<a class="bk_pop" href="#article-76855.r17">[17]</a><a class="bk_pop" href="#article-76855.r14">[14]</a></p><p>Although providing solid evidence for the use of LAA in the cardiac surgery setting for patients with atrial fibrillation, there remains a question as to the best way to manage ischaemic stroke risk in patients with atrial fibrillation who do not have cardiac surgery planned. Any surgical intervention carries risk, and randomized control trials are needed to interrogate the relative benefit of continuing anticoagulation alone or undertaking LAA occlusion in patients with atrial fibrillation with no cardiac surgery planned.<a class="bk_pop" href="#article-76855.r16">[16]</a> Of note, although studies such as the PROTECT-AF and PREVAIL clinical trials have compared the use of the Watchman LAA closure device with anticoagulation with warfarin only, the recent ascent of the use of direct-acting oral anticoagulants (DOACs) for a broad range of indications including atrial fibrillation means that these trials need to be updated with a direct comparison of these new drugs (e.g., apixaban, rivaroxaban, dabigatran) in order to be relevant to the current population.<a class="bk_pop" href="#article-76855.r18">[18]</a><a class="bk_pop" href="#article-76855.r19">[19]</a><a class="bk_pop" href="#article-76855.r18">[18]</a><a class="bk_pop" href="#article-76855.r20">[20]</a> However, existing evidence regarding the risk of left atrial appendage occlusion devices shows there are several known associated complications, including hematoma associated with vascular access, air embolism related to device-delivery sheaths, and pericardial effusion associated with the transseptal puncture approach for device implantation, and the relative risk of these must be examined in the context of the anticoagulated atrial fibrillation patient group.<a class="bk_pop" href="#article-76855.r21">[21]</a></p></div><div id="article-76855.s8"><h2 id="_article-76855_s8_">Clinical Significance</h2><p>The LAA is implicated in the pathogenesis of several conditions, including AF and hypertension.</p><p>It is well established that the LAA is the primary site of thrombi formation in patients with nonvalvular AF.<a class="bk_pop" href="#article-76855.r2">[2]</a> Researchers postulate that the LAA is the source of thromboembolism in up to 90% of these patients<a class="bk_pop" href="#article-76855.r22">[22]</a>. In normal sinus rhythm, there is good blood flow within the LAA and thus no thrombus formation in normal cardiac function. However, in atrial fibrillation there is reduced contractility, flow stasis, and this consequently causes the LAA to act more as a static pouch in which thombi can easily form<a class="bk_pop" href="#article-76855.r5">[5]</a>. Therefore, anticoagulation therapy and/or LAA occlusion systems are often used prophylactically to reduce stroke risk in these patients. Until recently, there has been little published data on the impact that LAA isolation has on the release of ANP. Several animal models demonstrated an immediate reduction in the immediate levels of ANP secretion following an atrial appendectomy.<a class="bk_pop" href="#article-76855.r6">[6]</a> However, these studies did not explore the long-term effects on ANP levels associated with the isolation of the LAA.</p><p>The 2018 LAA HOMEOSTASIS study was one of the first studies which examined the impact of epicardial and endocardial LAA occlusion techniques on neurohormonal modulation in humans. This study, consisting of 77 patients, found that after epicardial LAA closure, ANP and BNP levels decrease significantly immediately post-procedure, began to rise at 24 hours, and normalized at three months. In patients undergoing endocardial LAA device implantations, the ANP/BNP levels significantly increased post-procedure and normalized by three months. Of note, epicardial LAA devices were associated with a down-regulation of the adrenergic system and RAAS, resulting in a significant decrease in systolic blood pressure. No such effect was noted in endocardial device implantations.<a class="bk_pop" href="#article-76855.r23">[23]</a> Further studies are required to determine what effect, if any, these changes in neurohormonal regulation may have on outcomes or patient management.</p><p>LAA morphology has demonstrated a correlation with the risk of stroke in patients with atrial fibrillation. Following large imaging cohorts of patients, four main LAA morphologies have been classified: chicken wing, cactus, windsock, and califlower - the former of these four being the most prevelant found in 48% of patients and the other found in 30%, 19%, and 3%, respectively<a class="bk_pop" href="#article-76855.r24">[24]</a>. A multicenter study found that in patients with AF, the cauliflower morphology was associated with the highest risk of stroke, while those with the chicken wing morphology had the lowest risk of stroke.<a class="bk_pop" href="#article-76855.r3">[3]</a> This consideration may be a valuable consideration when developing a more sophisticated risk assessment for the chronic management of individuals with AF.</p><p>There have also been reports of tears in the LAA associated with blunt chest wall trauma from motor vehicle accidents. Despite being a rare complication, these injuries correlate with high morbidity and mortality. Approximately 10% of blunt trauma to the chest involves the LAA, and mortality estimates range between 50% to 80%.<a class="bk_pop" href="#article-76855.r25">[25]</a> There are multiple causes for cardiac rupture, ranging from simple blows to severe directional forces. The heart is particularly vulnerable as it hangs freely in the mediastinum, suspended by the great vessels between the sternum and thoracic vertebrae.<a class="bk_pop" href="#article-76855.r26">[26]</a> All chambers of the heart are susceptible to injury, but the LAA is particularly vulnerable due to its relative thinness. The presence of an intact pericardium is a protective factor in these injuries—restricting the effects of tamponade, thereby preventing fatal exsanguination and allowing for patients to survive the journey to the hospital.<a class="bk_pop" href="#article-76855.r25">[25]</a></p></div><div id="article-76855.s9"><h2 id="_article-76855_s9_">Review Questions</h2><ul><li class="half_rhythm"><div>
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</div></li></ul></div><div class="floats-group" id="article-76855.s10"></div><div class="floats-group" id="article-76855.s11"></div><div class="floats-group" id="article-76855.s12"></div><div class="floats-group" id="article-76855.s13"></div><div id="article-76855.s14"><h2 id="_article-76855_s14_">References</h2><dl class="temp-labeled-list"><dt>1.</dt><dd><div class="bk_ref" id="article-76855.r1">Al-Saady NM, Obel OA, Camm AJ. Left atrial appendage: structure, function, and role in thromboembolism. <span><span class="ref-journal">Heart. </span>1999 Nov;<span class="ref-vol">82</span>(5):547-54.</span> [<a href="/pmc/articles/PMC1760793/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC1760793</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/10525506" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 10525506</span></a>]</div></dd><dt>2.</dt><dd><div class="bk_ref" id="article-76855.r2">Di Biase L, Natale A, Romero J. Thrombogenic and Arrhythmogenic Roles of the Left Atrial Appendage in Atrial Fibrillation. <span><span class="ref-journal">Circulation. </span>2018 Oct 30;<span class="ref-vol">138</span>(18):2036-2050.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/30372144" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30372144</span></a>]</div></dd><dt>3.</dt><dd><div class="bk_ref" id="article-76855.r3">Di Biase L, Santangeli P, Anselmino M, Mohanty P, Salvetti I, Gili S, Horton R, Sanchez JE, Bai R, Mohanty S, Pump A, Cereceda Brantes M, Gallinghouse GJ, Burkhardt JD, Cesarani F, Scaglione M, Natale A, Gaita F. Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation? Results from a multicenter study. <span><span class="ref-journal">J Am Coll Cardiol. </span>2012 Aug 07;<span class="ref-vol">60</span>(6):531-8.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/22858289" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22858289</span></a>]</div></dd><dt>4.</dt><dd><div class="bk_ref" id="article-76855.r4">Wang Y, Di Biase L, Horton RP, Nguyen T, Morhanty P, Natale A. Left atrial appendage studied by computed tomography to help planning for appendage closure device placement. <span><span class="ref-journal">J Cardiovasc Electrophysiol. </span>2010 Sep;<span class="ref-vol">21</span>(9):973-82.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/20550614" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 20550614</span></a>]</div></dd><dt>5.</dt><dd><div class="bk_ref" id="article-76855.r5">Beigel R, Wunderlich NC, Ho SY, Arsanjani R, Siegel RJ. The left atrial appendage: anatomy, function, and noninvasive evaluation. <span><span class="ref-journal">JACC Cardiovasc Imaging. </span>2014 Dec;<span class="ref-vol">7</span>(12):1251-65.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/25496544" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 25496544</span></a>]</div></dd><dt>6.</dt><dd><div class="bk_ref" id="article-76855.r6">Majunke N, Sandri M, Adams V, Daehnert I, Mangner N, Schuler G, Moebius-Winkler S. Atrial and Brain Natriuretic Peptide Secretion After Percutaneous Closure of the Left Atrial Appendage With the Watchman Device. <span><span class="ref-journal">J Invasive Cardiol. </span>2015 Oct;<span class="ref-vol">27</span>(10):448-52.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/25999139" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 25999139</span></a>]</div></dd><dt>7.</dt><dd><div class="bk_ref" id="article-76855.r7">Baxter GF. The natriuretic peptides. <span><span class="ref-journal">Basic Res Cardiol. </span>2004 Mar;<span class="ref-vol">99</span>(2):71-5.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/14963664" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 14963664</span></a>]</div></dd><dt>8.</dt><dd><div class="bk_ref" id="article-76855.r8">Curry FR. Atrial natriuretic peptide: an essential physiological regulator of transvascular fluid, protein transport, and plasma volume. <span><span class="ref-journal">J Clin Invest. </span>2005 Jun;<span class="ref-vol">115</span>(6):1458-61.</span> [<a href="/pmc/articles/PMC1137012/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC1137012</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/15931381" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 15931381</span></a>]</div></dd><dt>9.</dt><dd><div class="bk_ref" id="article-76855.r9">Potter LR, Yoder AR, Flora DR, Antos LK, Dickey DM. Natriuretic peptides: their structures, receptors, physiologic functions and therapeutic applications. <span><span class="ref-journal">Handb Exp Pharmacol. </span>2009;(191):341-66.</span> [<a href="/pmc/articles/PMC4855512/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4855512</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/19089336" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19089336</span></a>]</div></dd><dt>10.</dt><dd><div class="bk_ref" id="article-76855.r10">Mukoyama M, Nakao K, Hosoda K, Suga S, Saito Y, Ogawa Y, Shirakami G, Jougasaki M, Obata K, Yasue H. Brain natriuretic peptide as a novel cardiac hormone in humans. Evidence for an exquisite dual natriuretic peptide system, atrial natriuretic peptide and brain natriuretic peptide. <span><span class="ref-journal">J Clin Invest. </span>1991 Apr;<span class="ref-vol">87</span>(4):1402-12.</span> [<a href="/pmc/articles/PMC295184/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC295184</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/1849149" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 1849149</span></a>]</div></dd><dt>11.</dt><dd><div class="bk_ref" id="article-76855.r11">Sherif HM. The developing pulmonary veins and left atrium: implications for ablation strategy for atrial fibrillation. <span><span class="ref-journal">Eur J Cardiothorac Surg. </span>2013 Nov;<span class="ref-vol">44</span>(5):792-9.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/23447471" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23447471</span></a>]</div></dd><dt>12.</dt><dd><div class="bk_ref" id="article-76855.r12">Regazzoli D, Ancona F, Trevisi N, Guarracini F, Radinovic A, Oppizzi M, Agricola E, Marzi A, Sora NC, Della Bella P, Mazzone P. Left Atrial Appendage: Physiology, Pathology, and Role as a Therapeutic Target. <span><span class="ref-journal">Biomed Res Int. </span>2015;<span class="ref-vol">2015</span>:205013.</span> [<a href="/pmc/articles/PMC4508372/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4508372</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/26236716" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26236716</span></a>]</div></dd><dt>13.</dt><dd><div class="bk_ref" id="article-76855.r13">AlTurki A, Huynh T, Dawas A, AlTurki H, Joza J, Healey JS, Essebag V. Left atrial appendage isolation in atrial fibrillation catheter ablation: A meta-analysis. <span><span class="ref-journal">J Arrhythm. </span>2018 Oct;<span class="ref-vol">34</span>(5):478-484.</span> [<a href="/pmc/articles/PMC6174377/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6174377</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/30327692" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30327692</span></a>]</div></dd><dt>14.</dt><dd><div class="bk_ref" id="article-76855.r14">Whitlock RP, Belley-Cote EP, Paparella D, Healey JS, Brady K, Sharma M, Reents W, Budera P, Baddour AJ, Fila P, Devereaux PJ, Bogachev-Prokophiev A, Boening A, Teoh KHT, Tagarakis GI, Slaughter MS, Royse AG, McGuinness S, Alings M, Punjabi PP, Mazer CD, Folkeringa RJ, Colli A, Avezum Á, Nakamya J, Balasubramanian K, Vincent J, Voisine P, Lamy A, Yusuf S, Connolly SJ., LAAOS III Investigators. Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke. <span><span class="ref-journal">N Engl J Med. </span>2021 Jun 03;<span class="ref-vol">384</span>(22):2081-2091.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/33999547" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 33999547</span></a>]</div></dd><dt>15.</dt><dd><div class="bk_ref" id="article-76855.r15">Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. <span><span class="ref-journal">Chest. </span>2010 Feb;<span class="ref-vol">137</span>(2):263-72.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/19762550" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19762550</span></a>]</div></dd><dt>16.</dt><dd><div class="bk_ref" id="article-76855.r16">Page RL. The Closing Argument for Surgical Left Atrial Appendage Occlusion. <span><span class="ref-journal">N Engl J Med. </span>2021 Jun 03;<span class="ref-vol">384</span>(22):2154-2155.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/33999543" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 33999543</span></a>]</div></dd><dt>17.</dt><dd><div class="bk_ref" id="article-76855.r17">Mahmood E, Matyal R, Mahmood F, Xu X, Sharkey A, Chaudhary O, Karani S, Khabbaz K. Impact of Left Atrial Appendage Exclusion on Short-Term Outcomes in Isolated Coronary Artery Bypass Graft Surgery. <span><span class="ref-journal">Circulation. </span>2020 Jul 07;<span class="ref-vol">142</span>(1):20-28.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/32489114" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32489114</span></a>]</div></dd><dt>18.</dt><dd><div class="bk_ref" id="article-76855.r18">Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, Mullin CM, Sick P., PROTECT AF Investigators. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. <span><span class="ref-journal">Lancet. </span>2009 Aug 15;<span class="ref-vol">374</span>(9689):534-42.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/19683639" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19683639</span></a>]</div></dd><dt>19.</dt><dd><div class="bk_ref" id="article-76855.r19">Holmes DR, Kar S, Price MJ, Whisenant B, Sievert H, Doshi SK, Huber K, Reddy VY. Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. <span><span class="ref-journal">J Am Coll Cardiol. </span>2014 Jul 08;<span class="ref-vol">64</span>(1):1-12.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/24998121" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24998121</span></a>]</div></dd><dt>20.</dt><dd><div class="bk_ref" id="article-76855.r20">López-López JA, Sterne JAC, Thom HHZ, Higgins JPT, Hingorani AD, Okoli GN, Davies PA, Bodalia PN, Bryden PA, Welton NJ, Hollingworth W, Caldwell DM, Savović J, Dias S, Salisbury C, Eaton D, Stephens-Boal A, Sofat R. Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis, and cost effectiveness analysis. <span><span class="ref-journal">BMJ. </span>2017 Nov 28;<span class="ref-vol">359</span>:j5058.</span> [<a href="/pmc/articles/PMC5704695/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC5704695</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/29183961" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29183961</span></a>]</div></dd><dt>21.</dt><dd><div class="bk_ref" id="article-76855.r21">Perrotta L, Bordignon S, Dugo D, Fürnkranz A, Konstantinou A, Ricciardi G, Pieragnoli P, Schmidt B, Chun KJ. Complications From Left Atrial Appendage Exclusion Devices. <span><span class="ref-journal">J Atr Fibrillation. </span>2014 Jun-Jul;<span class="ref-vol">7</span>(1):1034.</span> [<a href="/pmc/articles/PMC5135147/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC5135147</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/27957078" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27957078</span></a>]</div></dd><dt>22.</dt><dd><div class="bk_ref" id="article-76855.r22">Sakellaridis T, Argiriou M, Charitos C, Tsakiridis K, Zarogoulidis P, Katsikogiannis N, Kougioumtzi I, Machairiotis N, Tsiouda T, Arikas S, Mpakas A, Beleveslis T, Koletas A, Zarogoulidis K. Left atrial appendage exclusion-Where do we stand? <span><span class="ref-journal">J Thorac Dis. </span>2014 Mar;<span class="ref-vol">6 Suppl 1</span>(Suppl 1):S70-7.</span> [<a href="/pmc/articles/PMC3966155/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3966155</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/24672702" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24672702</span></a>]</div></dd><dt>23.</dt><dd><div class="bk_ref" id="article-76855.r23">Lakkireddy D, Turagam M, Afzal MR, Rajasingh J, Atkins D, Dawn B, Di Biase L, Bartus K, Kar S, Natale A, Holmes DJ. Left Atrial Appendage Closure and Systemic Homeostasis: The LAA HOMEOSTASIS Study. <span><span class="ref-journal">J Am Coll Cardiol. </span>2018 Jan 16;<span class="ref-vol">71</span>(2):135-144.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/29325636" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29325636</span></a>]</div></dd><dt>24.</dt><dd><div class="bk_ref" id="article-76855.r24">Yaghi S, Song C, Gray WA, Furie KL, Elkind MS, Kamel H. Left Atrial Appendage Function and Stroke Risk. <span><span class="ref-journal">Stroke. </span>2015 Dec;<span class="ref-vol">46</span>(12):3554-9.</span> [<a href="/pmc/articles/PMC4659748/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4659748</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/26508750" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26508750</span></a>]</div></dd><dt>25.</dt><dd><div class="bk_ref" id="article-76855.r25">Salooja MS, Singla M, Srivastava A, Mukherjee KC. Isolated tear in left atrial appendage due to blunt trauma chest: A rare case report. <span><span class="ref-journal">J Saudi Heart Assoc. </span>2013 Apr;<span class="ref-vol">25</span>(2):95-7.</span> [<a href="/pmc/articles/PMC3809503/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3809503</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/24174854" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24174854</span></a>]</div></dd><dt>26.</dt><dd><div class="bk_ref" id="article-76855.r26">Scorpio RJ, Wesson DE, Smith CR, Hu X, Spence LJ. Blunt cardiac injuries in children: a postmortem study. <span><span class="ref-journal">J Trauma. </span>1996 Aug;<span class="ref-vol">41</span>(2):306-9.</span> [<a href="https://pubmed.ncbi.nlm.nih.gov/8760541" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 8760541</span></a>]</div></dd></dl></div><div><dl class="temp-labeled-list small"><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Yingyot Arora declares no relevant financial relationships with ineligible companies.</p></div></dd><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Felix Jozsa declares no relevant financial relationships with ineligible companies.</p></div></dd><dt></dt><dd><div><p class="no_top_margin">
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<b>Disclosure: </b>Michael Soos declares no relevant financial relationships with ineligible companies.</p></div></dd></dl></div><div class="bk_prnt_sctn"><h2>Figures</h2><div class="whole_rhythm bk_prnt_obj bk_first_prnt_obj"><div id="article-76855.image.f1" class="figure bk_fig"><div class="graphic"><img src="/books/NBK553218/bin/p-4.jpg" alt="Image p-4" /></div><div class="caption"><p>Left atrial appendage, heart Illustration by Emma Gregory</p></div></div></div><div class="whole_rhythm bk_prnt_obj"><div id="article-76855.image.f2" class="figure bk_fig"><div class="graphic"><img src="/books/NBK553218/bin/Atria_1.jpg" alt="Cadaveric dissection of human heart showing left atrial appendage (left auricle) Anatomist90, CC BY-SA 3" /></div><div class="caption"><p>Cadaveric dissection of human heart showing left atrial appendage (left auricle) Anatomist90, <a href="https://creativecommons.org/licenses/by-sa/3.0" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">CC BY-SA 3.0</a> , via Wikimedia Commons</p></div></div></div><div class="whole_rhythm bk_prnt_obj"><div id="article-76855.image.f3" class="figure bk_fig"><div class="graphic"><img src="/books/NBK553218/bin/3D_Medical_Animation_of_Left_Atrial_Appendage_Occlusion.jpg" alt="Illustration of left atrial appendage occlusion device used for stroke prevention in patients with atrial fibrillation Scientific Animations, CC BY-SA 4" /></div><div class="caption"><p>Illustration of left atrial appendage occlusion device used for stroke prevention in patients with atrial fibrillation <a href="https://www.scientificanimations.com" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Scientific Animations</a>, <a href="https://creativecommons.org/licenses/by-sa/4.0" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">CC BY-SA 4.0</a> , via Wikimedia Commons</p></div></div></div><div class="whole_rhythm bk_prnt_obj"><div id="article-76855.image.f4" class="figure bk_fig"><div class="graphic"><img src="/books/NBK553218/bin/Gray505.jpg" alt="Image Gray505" /></div><div class="caption"><p>Anatomy drawing of heart and related structures Henry Vandyke Carter, Public Domain, via Wikimedia Commons</p></div></div></div></div></div></div>
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