IJCS | Volume 32, Nº5, September/October 2019

472 hand, the appendage flow velocity can be obtained with pulsed Doppler interrogation and < 55 cm/s velocity appears to be related to thrombus formation. In these conditions, slow-swirling echoes resembling smoky haze and “spontaneous echo-contrast” (SEC) are findings that physiologically represent the conditions for LAA thrombogenesis. Flow velocities in patients with “chicken-wing LAA” are higher than other LAA morphologies, potentially reducing stasis, thrombus formation and stroke risk. It is possible that the “acute angle” in these cases may be protective against stroke by providing a milieu in which thrombi are less likely to form. TEE iswidely utilized in patients prior to cardioversion or AF ablation to rule out the presence of LAA thrombus, providing imageswith important anatomic and functional information that has not been incorporated into clinical risk scores. This additional information regarding LAA morphology and functionmay be important in situations where AF is “eliminated”, helping to decide over controversies such as withheld anticoagulation therapy in selected patients after successful catheter ablation and no recurrences of AF. This simple echocardiographic classification of LAA anatomymay help to identify patientswith cardioembolic risk of stroke subtypes in patients with AF and clinical conditions, where TEE was indicated. Larger studies are needed to validate these findings. Patients with “malignant LAAmorphologies” deserve special attention especially for difficult and critical clinical decisions in the anticoagulation scenario for stroke prevention of patients with AF. It is time to have a different approach for patients where the risk/benefit decision for anticoagulation is provocative, such as post-ablation AF patients. Designing studies with risk scores including LA/LAA morphology and function may provide important information and, hopefully, allow to put these parameters into clinical practice! 1. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al; 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37(38)2893–962. 2. Di Biase L, Santangeli P, Anselmino M, Mohanty P, Salvetti I, Gili S, et al . Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation? Results from a multicenter study. J Am Coll Cardiol. 2012; 60(6):531-8. 3. Lee JM, Seo J, Uhm JS, Kim YJ, Lee HJ, Kim JY, et al. Why is left atrial appendage morphology related to strokes? An analysis of the flow velocity and orifice size of theleft atrial appendage. J Cardiovasc Electrophysiol. 2015;26(9):922-7 4. Lee Y, Park HC, Lee Y, Kim SG. Comparison of morphologic features and flow velocity of the left atrial appendage among patients with atrial fibrillation alone, transient ischemic attack, and cardioembolic stroke. Am J Cardiol. 2017;119(10):1596-604 5. Kimura T, Takatsuki S, Inagawa K, Katsumata Y, Nishiyama T, Nishiyama N, et al. Anatomical characteristics of the left atrial appendage in cardiogenic stroke with low chads2 scores. Heart Rhythm. 2013;10(6):921-5. 6. Anselmino M, Scaglione M, Di Biase L, Gili S, Santangeli P, Corsinovi L, et al. Left atrial appendage morphology and silent cerebral ischemia in patients with atrial fibrillation. Heart Rhythm. 2014;11(1):2-7. 7. Korhonen M, Muuronen A, Arponen O, Mustonen P, Hedman M, Jakala P, et al. Left atrial appendage morphology in patients with suspected cardiogenic stroke without known atrial fibrillation. PloS One. 2015;10(3):e0118822. 8. Nedios S, Kornej J, Koutalas E, Bertagnolli L, Kosiuk J, Rolf S, et al. Left atrial appendage morphology and thromboembolic risk after catheter ablation for atrial fibrillation. Heart Rhythm. 2014;11(12):2239-46. 9. Petersen M, Roehrich A, Balzer J, Shin DI, Meyer C, Kelm M, et al. Left atrial appendage morphology is closely associated with specific echocardiographic flow pattern in patients with atrial fibrillation. Europace . 2015;17(4):539-45. 10. Khurram IM, Dewire J, Mager M, Maqbool F, Zimmerman SL, Zipunnikov V, et al. Relationship between left atrial appendage morphology and stroke in patients with atrial fibrillation. Heart Rhythm. 2013;10(12):1843-9. 11. Linhares RJ, Moreira DA, Peixoto LB, Da Cruz AP, Barretto RB, Le Bihan DC,et al. Association between morphodynamic variables by transesophageal echocardiography and CHA2DS2-Vasc values. Int J Cardiovasc Sci. 2019;32(5):460-470. References Angelo A.V. de Paola Risk scores for stroke prevention Int J Cardiovasc Sci. 2019;32(5):471-472 Editorial This is an open-access article distributed under the terms of the Creative Commons Attribution License