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Diagnostic value of transesophageal echocardiography on morphology and function of left atrial appendage in patients with unclosed foramen ovale complicated with atrial fibrillation

BMC Cardiovascular Disorders volume 25, Article number: 300 (2025) Cite this article

Abstract

Background

This study investigates the diagnostic value of transesophageal echocardiography (TEE) for assessing the left atrial appendage (LAA) in patients with patent foramen ovale (PFO) and atrial fibrillation (AF). TEE provides detailed images that help evaluate the morphology and function of the LAA, which are crucial in diagnosing and managing these conditions.

Methods

The study included 104 PFO patients admitted between December 2021 and January 2024, divided into AF (n = 53) and non-AF groups (n = 51). Additionally, 30 healthy individuals served as controls. All participants underwent TEE to compare ultrasound indices, LAA morphology, and function. The diagnostic values of these measurements were analyzed and compared across the three groups.

Results

The AF group had a larger left atrial diameter (LAD) compared to the non-AF and control groups (P < 0.001). Both PFO groups had lower left ventricular ejection fractions (LVEF) than controls (P < 0.001), with the AF group showing lower LVEF than the non-AF group (P < 0.001). The AF group’s LAA long diameter was greater (P < 0.05). LAA ejection fraction (LAAEF) and maximal emptying velocity (LAAPEV) were lower in PFO groups compared to controls, with the AF group also lower than the non-AF group (P < 0.01). Combined diagnostic measurements of LAA parameters showed higher accuracy (AUC = 0.979) than single measurements.

Conclusions

TEE evaluates LAA morphology and function effectively, providing significant diagnostic value for PFO with AF. Combined diagnostic parameters yield high specificity and sensitivity, enhancing diagnostic accuracy.

Peer Review reports

Introduction

Atrial fibrillation (AF) is the loss of regular and orderly atrial electrical activity, replaced by rapid and disordered fibrillation waves, which is a severe disorder of atrial electrical activity and a common clinical persistent arrhythmia [1]. The overall prevalence of AF in the population is 0.77 per cent, which increases with age [2]. Recently, the aging population in China has increased, and the prevalence of AF has increased by nearly 20 times [3]. Patients usually present with palpitations, fatigue, chest tightness, and in severe cases, it can result in thromboembolism, heart failure, and stroke complications, which are life-threatening [4].

The foramen ovale is a physiological passageway of the atrial septum of the heart during the embryonic period and usually fuses around 2 months after birth. Failure to fuse after 1 year of age results in patent foramen ovale (PFO) [5]. During embryonic development, primary septum, primary foramen, secondary foramen, secondary septum and foramen ovale are formed successively [6]. From the fifth week of embryonic life, the primary septum grows downward from the top of the atrium to the atrioventricular cushion, leaving a hole, the primary foramen [7]. Subsequently, the upper part of the primary septum is absorbed to form the secondary foramen, while the primary septum grows downward and the endocardial cushion grows upward, and the primary foramen is closed [8]. After the formation of the secondary foramen, on the right atrial side of the primary septum, the secondary septum grows down from the top of the atrium and leaves a hole at the lower margin, the foramen ovale [9]. The secondary foramen is above, the ovale is below, the secondary septum covers the secondary foramen from the right atrium, and the primary septum covers the ovale from the left atrium [10]. The primary septum that covers the foramen ovale acts as a valve, facilitating the entry of inferior venous blood directly into the left atrium through the foramen ovale before birth [11]. Pulmonary circulation is established immediately after birth, the resistance of pulmonary circulation is reduced, the pressure of the left atrium is increased, the primary and secondary septum of the atrial septum are close to each other, fuse together, and form a permanent anatomical closure after birth, that is, the patent foramen ovale [12]. PFO is more common in the general population and is comorbid in about 25% of adults [6]. PFO is one of the most common congenital structural anomalies of the heart in adults, most of which are asymptomatic and some of which cause symptoms such as weakness and dyspnoea due to right-to-left shunting of blood in the heart. Studies have confirmed that both patent foramen ovale and atrial fibrillation are risk factors for adverse cardiovascular events [13, 14]. Therefore, rapid and accurate diagnosis of patients with patent foramen ovale and atrial fibrillation and timely and effective treatment according to the changes in the condition are of great value.

Transesophageal echocardiography (TEE) allows for a close examination of the patient’s heart structure [15]. Compared with conventional transthoracic cardiac ultrasound, it can effectively avoid the interference of various factors such as obesity, interference from thoracic and abdominal gases, and inability to tolerate pressure on the ultrasound image [16]. TEE can more clearly and intuitively visualize the anatomical structure of the interatrial septum, which can be used to observe the structure, morphology, and size of the PFO, with a sensitivity and specificity higher than that of transthoracic ultrasound, and it is regarded as the gold standard for clinical diagnosis of PFO [17]. Echocardiography is often used to diagnose PFO. TEE places the probe into the esophagus to maximize proximity to the heart to fully examine the structure and function of the patient’s left atrial (LA) and left atrial appendage (LAA). Sonaglioni’s study showed that TEE can comprehensively examine LAA indicators in patients with AF and is of high clinical value [18]. Although LAA dysfunction is more common in patients with AF, it is more pronounced in patients with PFO combined with AF and is strongly associated with thromboembolic risk. The present study provides a more detailed assessment of LAA morphology and function by means of TEE techniques, aiming to explore the potential value of these parameters in diagnosis and prognosis.

Materials and methods

General information about patients

104 patients with PFO admitted to the hospital from December 2021 to January 2024 were chosen as the case group, and were divided into the PFO combined with AF group (n = 53, AF group) and the PFO not combined with AF group (n = 51, non-AF group) according to whether or not they were combined with AF, and 30 cases of people who had a physical examination during the same period of time were chosen as the healthy control group (HC group).

Inclusion and exclusion criteria

Inclusion criteria: (1) The patients were diagnosed with patent foramen ovale by ultrasonography; (2) The patients with AF met the diagnostic criteria for AF in the 2020ECS/EACTS Guidelines for the Diagnosis and Management of AF, and the electrocardiograms showed irregular waveforms with irregular intervals, disappearance of the P-wave, appearance of the f-wave, a frequency of 350–600 beats/min, irregular RR intervals, and the patients had symptoms of palpitations, chest tightness, and panic attacks; (3) The patient was < 75 years old and underwent TEE examination.

Exclusion criteria: (1) Patients with severe arrhythmias and severe heart failure except AF; (2) The patient is extremely weak, accompanied by persistent high fever; (3) Patients with esophageal varices, esophageal stenosis, inflammatory response, diverticulum or esophageal tumors who could not perform TEE examination; (4) Patients with severe chest pain, chest tightness or severe cough symptoms cannot be relieved; (5) Abnormal blood pressure, in the acute stage of myocardial infarction; (6) Active upper gastrointestinal bleeding and coagulation disorders.

Atrial fibrillation diagnosis: Patients with atrial fibrillation should meet the diagnostic criteria in the 2020 ESC/EACTS Guidelines for the Diagnosis and Management of Atrial Fibrillation. Specific diagnostic methods include electrocardiography (ECG), which requires at least 12-lead ECG recordings of at least 10 s duration to ensure that typical features of AF, such as loss of P-wave, appearance of f-wave, and irregular RR intervals, are captured. For patients with paroxysmal AF, ECG evidence from at least one episode was required; for patients with persistent and permanent AF, continuous ECGs were recorded to confirm the persistence of AF. This study included patients with all types of AF, including paroxysmal, persistent, and permanent AF, in order to comprehensively assess the changes in LAA morphology and function in different types of AF.

Observation indicators and methods

  1. (1)

    Left heart function and morphology index: PHILIPS 7c color Doppler ultrasound diagnostic apparatus (General Electric Company, USA) equipped with S5-1 cardiac probe for routine transthoracic examination was used for the examination. Before the examination, the patient had to be fasted for 6–8 h, lying on the left side, connected to the three-lead electrocardiogram, and the long-axis section of the left ventricle was collected through the two-dimensional ultrasound probe. The left at-rial diameter (LAD), left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVED) and left ventricular end-systolic volume (LVESV) were measured using the Simpson method.

  2. (2)

    PHILIPS 7c color Doppler ultrasonic diagnostic instrument with X7 full-volume RT-3D TEE probe was used for examination. After local oropharyngeal anesthesia with 2% lidocaine glue, the probe was sent into the esophagus for TTE examination. The depth of the probe was 30–40 cm away from the incisor, and the section Angle was adjusted to 0–180°. The LAA structure was observed by counterclockwise rotation, and the LA and LAA were observed by multi-section two-dimensional TEE for spontaneous development. 3DZOOM was activated to make the two vertical two-dimensional images completely include the target region of the left atrial appendage, and then 3DZOOM was activated again to obtain three-dimensional LAA images and access real-time three-dimensional dynamic images. Image analysis was performed and evaluated using 3D ZOOM analysis software. The morphology of LAA was measured, including LAA long diameter, LAA opening long diameter, LAA opening short diameter and LAA hole area.

  3. (3)

    LAA functional indicators: Using QLab9.1 software of PHILIPS 7c color doppler ultrasonic diagnostic instrument check LAA function, including the LAA ejection fraction (LAAEF), left atrial appendage end-diastolic volume (LAAEDV), LAA appendage emptying maximum velocity (LAAPEV), LAA end-systolic volume (LAAESV).

Statistical methods

SPSS 27.0 statistical analysis software was used to process the data. The measurement data conforming to normal distribution were expressed as \(\:\stackrel{-}{x}\)±s, t test and F test were used for comparison. The statistical data were expressed as frequency, and χ2 test was used for comparison. Receiver operating characteristic (ROC) curve was drawn to analyze the diagnostic value of LAA long diameter, LAAEF and LAAPEV in atrial fibrillation with unclosed foramen ovale. P < 0.05 was considered statistically significant.

Results

Comparison of baseline data

There were no obvious differences in baseline data including age, sex, BMI, comorbid diabetes mellitus, comorbid coronary artery disease, smoking, and alcohol consumption among the 3 groups (Table 1).

Comparison of cardiac function indexes detected by ultrasound

LAD in AF group was higher than that in non-AF group and HC group (t = 14.642, 11.450, all P < 0.001). LVEF in AF group and non-AF group was lower than that in HC group (t = 30.399, 19.989, all P < 0.001), and it was lower in the AF group than in the non-AF group (t = 8.094, P < 0.001). There was no significant difference in LVESV and LVEDD among the three groups (P > 0.05, Table 1). The AF group exhibited a larger LAD compared to the non-AF and HC groups (Fig. 1).

Table 1 Results of cardiac function indexes
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Fig. 1
figure 1

TEE image showing LAD measurement. Note: (A) AF group; (B) Non-AF group; (C) HC group

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Comparison of LAA morphology

LAA long diameter in AF group was larger than that in non-AF group and HC group (t = 6.399, 5.499, all P < 0.05). There was no obvious difference in LAA long diameter between the non-AF group and the HC group (P > 0.05). There were no significant differences in the long diameter, short diameter, and area of LAA opening among the three groups (P > 0.05, Table 2). The AF group demonstrated a greater LAA long diameter (Fig. 2).

Table 2 Results of LAA morphology
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Fig. 2
figure 2

TEE image showing the morphology of the LAA. Note: (A) AF group; (B) Non-AF group; (C) HC group

Full size image

Comparison of LAA function

LAAEF and LAAPEV in AF group and non-AF group were lower than those in HC group, LAAEDV was higher than that in HC group. And LAAEF and LAAPEV in AF group were lower than those in non-AF group (P < 0.01, Table 3). The AF group had lower LAA ejection fraction (LAAEF) and maximal emptying velocity (LAAPEV) compared to the non-AF group and HC group (Fig. 3).

Table 3 Results of LAA function
Full size table
Fig. 3
figure 3

TEE image with color Doppler showing the functional assessment of the LAA. Note: (A) AF group; (B) Non-AF group; (C) HC group

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Analysis of the diagnostic value of LAA morphology and function in PFO combined with AF

LAAEDV has no statistical significance in the diagnosis of PFO with AF (P = 0.714). The area under the curve (AUC) of AFLAA long diameter, LAAEF, LAAPEV alone and in combination for the diagnosis of patent foramen ovale complicated with AF were 0.820, 0.942, 0.895, 0.979, respectively. The AUC of combined diagnosis was significantly higher than that of single diagnosis (P = 0.007, < 0.001, < 0.001). The combined diagnostic measurements of LAA parameters showed higher accuracy (Table 4; Fig. 4).

Table 4 Analysis of the diagnostic value of LAA morphology and function in PFO combined with AF
Full size table
Fig. 4
figure 4

ROC map of LAA long diameter, LAAEF, LAAEDV and LAAPEV in diagnosing PFO with AF

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Discussion

AF is a risk reason for thrombosis, stroke, and heart failure, and is classified as paroxysmal, persistent, or permanent AF [19]. PFO is an anatomical variant and a common form of structural heart disease, which usually does not cause interatrial blood shunting because the LA pressure is slightly higher than the right atrial pressure and the foramen ovale is closed [20]. In patent foramen ovale, there is a small defect at the foramen ovale, which can cause left-to-right shunting, which in combination with atrial fibrillation can affect the quality of life of the patient and endanger the patient’s life [21]. Studies have shown that AF mostly originates from the LAA, and spontaneous acoustic visualization of blood at the LAA during the onset of AF can be clearly demonstrated [22, 23]. The shortening of the LAA and left atrial emptying and filling time increases the LAA end-systolic volume, leading to a decrease in LAAEF [24]. Currently, studies have confirmed the existence of LAA morphological and functional abnormalities in AF by TEE [25, 26]. TEE has good diagnostic effect in PFO, and its application value is high. In this study, we assessed the morphology and function of the left atrial appendage (LAA) by transesophageal echocardiography (TEE) in patients with patent foramen ovale not closure (PFO) complicated by atrial fibrillation (AF), and the results showed that the LAA length diameter, LAA ejection fraction (LAAEF), and maximal emptying velocity (LAAPEV) in the AF group differed significantly from that of the non-AF group and the healthy control group. These findings not only help to diagnose PFO combined with AF, but also have important implications for clinical management.

PFO triggers hemodynamic changes, increasing the volume of blood in the pulmonary artery and atria of the right heart system [27]. Volume overload increases the pressure and stretching force of atrial wall, interstitial fibrosis of atrial wall, and anatomical reconstruction of atrial electrocardiography, leading to AF [28]. TEE is a new cardiovascular ultrasound technique that opens a new window in cardiac macrovascular imaging by using a special probe position and high-quality image display [29]. TEE mainly places the ultrasound probe into the esophagus to examine the shape and function of the LAA from the back of the heart to the front, avoiding the interference of the chest wall and gas in the lungs. Therefore, it can display clear images and improve the sensitivity and reliability of cardiovascular disease diagnosis. In this study, TEE was performed in patients with PFO combined with AF, and the results showed that LAD was higher and LVEF was lower in patients with PFO combined with AF by 2D ultrasound probe. When AF occurs, the contractile function of the left atrium is weakened, the blood flow in the left atrium is stagnant, and the pressure increases. The LAA relieves the pressure in the left atrium by increasing the inner diameter to ensure that the left ventricle can receive sufficient blood volume. Rigatelli’s study showed that not all PFOs lead to left atrial enlargement, but left atrial enlargement predicts an increased incidence of combined AF [30]. Therefore, our results indicate that the LAD in PFO and healthy individuals is not different. LAA opening size increased with age, but little effect was observed after the age of 20. In this study, the patients were all over 20 years old, so there was no significant difference in LAA opening size among patients.

The loss of regular and orderly electrical activity in the atria in PFO combined with AF results in decreased cardiac function and reduced LVEF. TEE uses 3D ZOOM to obtain clearer three-dimensional images of the LAA. 3DZOOM acquires images with a lower frame rate, which may be affected by the faster heart rate of patients with AF, resulting in lower image quality. However, the quality of LAA images obtained in this study is better, and 3D TEE can more accurately assess the LAA size than 2D TEE. LAA length diameter was higher in patients with PFO combined with AF than in patients with PFO combined with non-AF and healthy subjects, suggesting that PFO combined with AF has an effect on LAA morphology, which can be assessed by TEE examination. Studies have reported that LAA emptying velocity can reflect the left atrial function and the severity of left atrial remodeling [31]. Several studies have found that LAA volume is enlarged and function is significantly reduced in patients with AF [32]. Our results also showed that LAAEF and LAAPEV were reduced in patients with PFO combined with AF, suggesting that PFO combined with AF has a certain effect on LAA function. In patients with PFO combined with AF, LAA function is structurally impaired and there is structural remodeling phenomenon, LAA is enlarged, and LAA loses effective regular contraction, which is replaced by fibrillation of LAA, and thus systolic and diastolic functions are reduced, and it is difficult for LAA inward movement to cause sufficient filling and emptying, so LAAEF, LAAPEV, and LAAEDV are reduced.

Potential confounding factors that may affect LAA morphology and function were not adequately considered in this study. For example, the use of anticoagulants and antiarrhythmic drugs may have an impact on LAA function. Anticoagulants may indirectly affect hemodynamics within the LAA by altering the rheological properties of the blood, thereby affecting measurements of LAAEF and LAAPEV. In addition, antiarrhythmic drugs may affect LAA emptying function by altering myocardial contractility or rhythm. Future studies should consider documenting and analyzing the use of these medications in detail to rule out their interference with study results. Also, comorbidities such as hypertension and diabetes mellitus may have an impact on LAA morphology and function. Hypertension may lead to increased left atrial pressure, which in turn affects LAA morphology; diabetes may indirectly affect LAA function by affecting microvascular circulation. These comorbidities were not analyzed in detail in this study, and future studies should further investigate the effects of these potential confounding factors on LAA morphology and function to improve the accuracy and reliability of the results.

A study suggests that LAA physiology can be assessed in patients with AF by observing the changes in LAA function and volume by TEE [33]. Li’s study showed that TEE examination of LAA function has a predictive value for recurrence in patients with AF [24]. Our results revealed that the AUC of LAA length, LAAEF and LAAPEV in the joint diagnosis of AF with PFO was 0.979, and the sensitivity and specificity of the joint diagnosis were higher, suggesting that the combination of LAA morphology and function has a high diagnostic value for AF with PFO. In addition, a decrease in LAAEF and LAAPEV not only suggests impaired contractile and emptying functions of the LAA, which may lead to blood retention within the LAA and increase the risk of thrombosis, but may also predict a higher risk of thromboembolism, such as stroke, whose mechanism is closely related to the stagnation of blood flow within the LAA [24, 33]. Therefore, clinicians can utilize these parameters to assess a patient’s thromboembolic risk and adjust anticoagulation strategies accordingly. Meanwhile, reduced LAA function may also affect the progression of AF by elevating left atrial pressure, further exacerbating atrial fibrosis and remodeling, and thus promoting the persistence and progression of AF [24]. Therefore, abnormalities in LAA morphology and function may be associated not only with thromboembolic risk but also with the disease process of AF. Future studies could further explore the role of these parameters in predicting the therapeutic response and prognosis of AF and provide more comprehensive guidance for clinical management. However, the sample size of this study was small, and the type and prognosis of PFO were not analyzed by TEE, so a larger sample size and a more comprehensive in-depth study are needed.

Conclusion

In conclusion, TEE is a common and effective method for the examination and diagnosis of PFO combined with AF. PFO combined with AF has abnormal LAA morphology and function. At the same time, LAA morphology and function can help the diagnosis of PFO combined with AF, in which the combined diagnosis of LAA long diameter, LAAEF, and LAAPEV can improve the sensitivity and specificity.

Data availability

The datasets used or analyzed during the current study are available from the corresponding author on reasonable request.

References

  1. Elliott AD, Middeldorp ME, Van Gelder IC, Albert CM, Sanders P. Epidemiology and modifiable risk factors for atrial fibrillation. Nat Reviews Cardiol. 2023;20(6):404–17.

    Article  Google Scholar 

  2. Bizhanov KA, Аbzaliyev KB, Baimbetov AK, Sarsenbayeva AB, Lyan E. Atrial fibrillation: epidemiology, pathophysiology, and clinical complications (literature review). J Cardiovasc Electrophys. 2023;34(1):153–65.

    Article  Google Scholar 

  3. Shi S et al. Prevalence and risk of atrial fibrillation in China: a National cross-sectional epidemiological study. Lancet Reg Health–Western Pac, 23,2022.

  4. Davidson KW et al. Screening for atrial fibrillation: US preventive services task force recommendation statement, Jama, 2022;327(4):360–367.

  5. Kavinsky CJ, et al. SCAI guidelines for the management of patent foramen ovale. J Soc Cardiovasc Angiography Interventions. 2022;1(4):100039.

    Article  Google Scholar 

  6. Devos P, Guedeney P, Montalescot G. Patent foramen ovale percutaneous closure: evolution and ongoing challenges. J Clin Med. 2023;13(1):54.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Meier B. A cardiologist’s perspective on patent foramen Ovale-Associated conditions. Cardiol Clin, 2024; 42(4):547-557.

  8. Nakayama R et al. Relationship between patent foramen ovale anatomical features and residual shunt after patent foramen ovale closure. Cardiovasc Intervention Ther. 2024;39(2):200–6.

  9. Aoun J, Hatab T, Volpi J, Lin CH. Patent foramen ovale and atrial septal defect. Cardiol Clin. 2024;42(3):417–31.

  10. Lovering AT, Kelly TS, DiMarco KG, Bradbury KE, Charkoudian N. Implications of a patent foramen ovale for environmental physiology and pathophysiology: do we know the ‘hole’story? J Physiol. 2022;600(7):1541–53.

    Article  CAS  PubMed  Google Scholar 

  11. Gonnah AR, Bharadwaj MS, Nassar H, Abdelaziz HK, Roberts DH. Patent foramen ovale: diagnostic evaluation and the role of device closure. Clin Med. 2022;22(5):441.

    Article  Google Scholar 

  12. Apostolos A, et al. The management of patent foramen ovale in divers: where do we stand? Ther Adv Neurol Disord. 2022;15:17562864221103459.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Andersen A, et al. Atrial fibrillation after closure of patent foramen ovale in the REDUCE clinical study. Catheter Cardiovasc Interv. 2022;99(5):1551–7.

    Article  PubMed  Google Scholar 

  14. Farjat-Pasos JI, et al. Cerebrovascular events in older patients with patent foramen ovale: current status and future perspectives. J Stroke. 2023;25(3):338.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Efrimescu CI, Moorthy A, Griffin M. Rescue transesophageal echocardiography: a narrative review of current knowledge and practice. J Cardiothorac Vasc Anesth. 2023;37(4):584–600.

    Article  PubMed  Google Scholar 

  16. Reardon RF, et al. Feasibility, utility, and safety of fully incorporating transesophageal echocardiography into emergency medicine practice. Acad Emerg Med. 2022;29(3):334–43.

    Article  PubMed  Google Scholar 

  17. Huang GS, Sheehan FH, Gill EA. Transesophageal echocardiography simulation: A review of current technology, Echocardiography, 2022;39(1):89–100.

  18. Sonaglioni A, Lombardo M, Nicolosi GL, Gensini GF, Ambrosio G. Mechanical concordance between left atrium and left atrial appendage in nonvalvular atrial fibrillation: can it be exploited to avoid transesophageal echocardiography prior to electrical cardioversion during Covid-19 pandemic? Int J Cardiovasc Imaging. 2022;38(2):351–62.

    Article  PubMed  Google Scholar 

  19. Hu D, et al. Advances in basic and translational research in atrial fibrillation. Philosophical Trans Royal Soc B. 2023;378(1879):20220174.

    Article  CAS  Google Scholar 

  20. Song J-K. Pearls and pitfalls in the transesophageal echocardiographic diagnosis of patent foramen ovale. J Am Soc Echocardiogr. 2023;36(9):895–905.e3.

  21. Goldsweig AM, et al. Approval, evidence, and off-label device utilization: the patent foramen ovale closure story. Circulation: Cardiovasc Qual Outcomes. 2024;17(1):e010200.

    Google Scholar 

  22. Chen JZ, Thijs VN. Atrial fibrillation following patent foramen ovale closure: systematic review and meta-analysis of observational studies and clinical trials. Stroke. 2021;52(5):1653–61.

  23. Krishnamurthy Y, Ben-Ami J, Robbins BT, Sommer RJ. Incidence and time course of atrial fibrillation following patent foramen ovale closure. Catheter Cardiovasc Interv. 2022;100(2):219–24.

    Article  PubMed  Google Scholar 

  24. Li J, et al. Evaluating the novel parameters for assessing the LAA function and thrombus formation with nonvalvular atrial fibrillation. Saudi J Biol Sci. 2021;28(1):560–5.

    Article  PubMed  Google Scholar 

  25. He Y, Zhang B, Zhu F, Hu Z, Zhong J, Zhu W. Transesophageal echocardiography measures left atrial appendage volume and function and predicts recurrence of paroxysmal atrial fibrillation after radiofrequency catheter ablation, Echocardiography, 2018;35(7):985–990.

  26. Kim J, et al. Left atrial strain predicts fibrosis of left atrial appendage in patients with atrial fibrillation undergoing totally thoracoscopic ablation. Front Cardiovasc Med. 2023;10:1130372.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Crispino SP et al. A sudden right-to-left shunt: the importance of evaluating patent foramen ovale during exercise. Monaldi Arch Chest Dis, 2024;94(1).

  28. Skibsted CV, Korsholm K, Pedersen L, Bonnesen K, Nielsen-Kudsk JE, Schmidt M. Long-term risk of atrial fibrillation or flutter after transcatheter patent foramen ovale closure: a nationwide Danish study. Eur Heart J. 2023;44(36):3469–77.

    Article  PubMed  Google Scholar 

  29. Steffner KR, et al. Deep learning for transesophageal echocardiography view classification. Sci Rep. 2024;14(1):11.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Rigatelli G, et al. Left atrial enlargement as a maker of significant high-risk patent foramen ovale. Int J Cardiovasc Imaging. 2019;35:2049–56.

    Article  PubMed  Google Scholar 

  31. Raxwal B, Patel S, Tongar Y, parekh dM, Samir A. Left Atrial Appendage Emptying Velocity as a Predictor of Energy Required for Successful DC Cardioversion in Patients With Atrial Fibrillation, Circulation, 2023;148(Suppl_1):A14165-A14165.

  32. Park J-H, Yang D-H, Kim J-H, Kim Y-R. Left atrium volume measured with multislice computed tomography as a prognostic predictor for atrial fibrillation catheter ablation outcomes. J Clin Med. 2024;13(7):1859.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Uziębło-Życzkowska B, et al. Predicting reduced left atrial appendage velocity from echocardiographic left atrial function parameters in patients with atrial fibrillation undergoing catheter ablation. Sci Rep. 2024;14(1):7282.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

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Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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Author notes

  1. Zhaojun Zhang and Yu Zhu contributed equally to this work and should be considered co-first authors.

Authors and Affiliations

  1. Department of Ultrasound, Renmin Hospital, Hubei University of Medicine, No. 39 Chaoyang Middle Road, Maojian District, Shiyan, 442000, China

    Zhaojun Zhang, Yu Zhu, Guangmei Zheng, Hongxia Jing, Bin Xiao & Lin Xiong

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Contributions

Z.Z. and Y.Z. contributed equally to this work and should be considered co-first authors. Z.Z. was responsible for designing the experiments, analyzing the data, and drafting the main manuscript text. Y.Z. assisted in conducting the experiments, collecting data, and revising the manuscript. G.Z. provided valuable guidance throughout the research process and contributed to the interpretation of the results. H.J. helped with the statistical analysis and reviewed the methodology section. B.X. prepared Figs. 1 and 2, ensuring their accuracy and clarity. L.X. contributed to the preparation of Fig. 3 and was in charge of ensuring all figures adhered to the journal’s guidelines. All authors (Z.Z., Y.Z., G.Z., H.J., B.X., L.X.) reviewed the manuscript critically for important intellectual content and approved the final version for submission.

Corresponding authors

Correspondence to Bin Xiao or Lin Xiong.

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Ethics approval and consent to participate

Approval for the study was obtained from ethics committee of Renmin Hospital, Hubei University of Medicine. All of the patients had consented to research authorization for record review, and the study was approved by the institutional review board.

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Written informed consent was obtained from the patient for publication of this case report and any accompanying images. (A copy of the written consent is available for review by the Editor-in-Chief of this journal.

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Zhang, Z., Zhu, Y., Zheng, G. et al. Diagnostic value of transesophageal echocardiography on morphology and function of left atrial appendage in patients with unclosed foramen ovale complicated with atrial fibrillation. BMC Cardiovasc Disord 25, 300 (2025). https://doi.org/10.1186/s12872-025-04651-6

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BMC Cardiovascular Disorders

ISSN: 1471-2261

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