When Virchow Meets Da Vinci
Correlating Thrombogenesis With Intracardiac Flow Dynamics
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- atrial appendage
- atrial fibrillation
- flow imaging
- magnetic resonance imaging
Atrial fibrillation (AF) is the most common sustained arrhythmia, afflicting >5 million people in the United States alone1 and associated with considerable morbidity because of migration of left atrial (LA) and specifically left atrial appendage (LAA) thrombi. A combination of LA anatomic, inflammatory, and metabolic changes results in abnormalities in both flow characteristics, endothelial function, and blood constituents. Thus, AF creates an hypercoagulable state in the LA by virtue of fulfilling Virchow’s triad of thrombogenesis.2 Although the CHADS2 and CHA2DS2-VASc risk scores are clinically useful for identifying AF patients who are at high risk for thromboembolism,3 they are imperfect (C statistics 0.60–0.69).4,5 They concentrate on the clinical substrate and do not consider local physiological factors such as LA/LAA flow, which are likely to offer higher fidelity discrimination of those at highest risk for thrombus formation.
See Article by Markl et al
The essence of cardiology is blood flow, but noninvasive tools to comprehensively characterize intracavitary blood flow dynamics have been lacking. Cardiovascular magnetic resonance (CMR) is already recognized as the noninvasive clinical gold standard for the assessment of cardiac volumes, regional/global systolic function, fibrosis, and inflammation.6,7 More recently, 2D phase-contrast CMR has been shown to be clinically important for assessment of mitral regurgitation.8 Advancement in flow visualization have now provided us with more powerful tools for in vivo multidirectional blood flow assessment using either phase-contrast CMR, echocardiography particle imaging velocimetry, and echocardiography vector flow mapping.9 These novel tools enable us to verify and continue Leonardo Da Vinci’s quest to study intracavitary flow dynamics10 and provide new insights regarding intracardiac flow—revealing asymmetrical spiral flow in the heart chambers and great arteries that have pivotal importance in physiological and pathological conditions.11
The use of …