WSC 2026 | Could the left atrial appendage be a source of embolic stroke without atrial fibrillation?

This is not an easy question because when I was asked to do this talk about left appendage in patients without atrial fibrillation, I thought, what shall I look for and what is behind this reasoning? And I started to go through the literature and I realized that first of all, atrial fibrillation in patients, in so-called ESUS, which are patients, they have a stroke, but we don’t have an embolic source without finding an atrial fibrillation. Sometimes you have to wait until you find this atrial fibrillation. It’s how long you measure. So it’s not so straightforward. So first of all, let’s be sure that there is really no atrial fibrillation. Second, left appendage is a part of the atrium, very important in the regulation of the production of hormones, but sometimes it can be a cause of thrombosis and there are different features of left appendage which are more thrombogenic than others. So still we do not have really clear data if there is a thrombogenicity among the different features or if there is, as we have the remodelling of the heart, there can be also some of what was before positive as production of hormones can be then a cause of thrombogenicity. And this is something that we need to detect. And when we have an embolic stroke, we exclude it, there is no atrial fibrillation. Then we have to study the heart. And my main message was, look at the heart. If you find something, maybe also a microthrombus or something like this, then there is probably something else that we need to consider. In this case, left appendage is important and we do not know if there are data to close this, but at least we have to consider, we have to study better the heart in order to prevent more strokes.

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