ReviewFrontiers in cardiovascular medicine2026
Left atrial appendage morphology and hemodynamics: potential new markers for individualized thromboembolic risk assessment in atrial fibrillation.
Review in Frontiers in cardiovascular medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: Traditional CHA₂DS₂-VASc scoring has well-recognized limitations in thromboembolic risk assessment for atrial fibrillation (AF), particularly in low-score patients who nevertheless thrombose, high-score event-free individuals, cancer patients, and post-ablation cohorts. The left atrial appendage (LAA) is the source of 98% of thrombi in non-valvular AF and exhibits marked inter-individual morphological and hemodynamic variability that traditional scores completely ignore. Aims: This narrative review critically evaluates current evidence on LAA morphology, hemodynamics, computational fluid dynamics/fluid-structure interaction (CFD/FSI) studies, and digital twin technology, and proposes a mechanism-driven, individualized risk assessment framework for AF-related thromboembolism. Methods: A literature search was conducted in PubMed/MEDLINE and Web of Science (1990-May 2026) using combinations of keywords related to LAA morphology, hemodynamics, AF, and thromboembolism. Priority was given to landmark original studies, high-quality observational studies with multivariable adjustment, meta-analyses, and contemporary CFD/digital twin studies. A narrative synthesis was adopted owing to heterogeneity in study designs and outcomes. Results: LAA morphological subtypes are associated with long-term stroke risk, with chicken-wing being protective (OR 0.21, 95% CI 0.05-0.91) and cauliflower carrying the highest risk (OR 8.02, 95% CI 0.92-27.86). However, risk is highly context-dependent, with chicken-wing unexpectedly increasing peri-ablation thromboembolic risk (OR 7.2, 95% CI 1.35-38.33) and windsock morphology independently predicting post-ablation AF recurrence (OR 2.72, 95% CI 1.21-6.12). Importantly, traditional morphological classification does not correlate directly with blood stasis ( Conclusion: Based on these findings, we propose a practical two-tier assessment framework combining basic morphological classification with multimodal refined evaluation (digital twin) for intermediate-/high-risk or clinically challenging cases. This framework represents a paradigm shift from static clinical scores toward mechanism-driven, individualized risk management. Prospective validation of this approach is now warranted.
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