Computer Methods and Programs in Biomedicine 213 (2022) 106506

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Computer Methods and Programs in Biomedicine

journal homepage: www.elsevier.com/locate/cmpb

Left atrial appendage shape impacts on the left atrial flow

hemodynamics: A numerical hypothesis generating study on two cases
Lida Alinezhad a, Farzan Ghalichi a, Majid Ahmadlouydarab b,∗, Maryam Chenaghlou c
a
Department of Biomedical Engineering, Division of Biomechanics, Sahand University of Technology, Tabriz, Iran
b
Faculty of Chemical & Petroleum Engineering, University of Tabriz, Tabriz, Iran
c
Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran

a r t i c l e i n f o a b s t r a c t

Article history: Background and objectives: The left atrial appendage (LAA) is the most common region for thrombus
Received 31 October 2020 formation in atrial fibrillation (AF). Morphological parameters such as shape, size, and LAA volume can
Accepted 25 October 2021
cause insufficient effectiveness of available therapeutic options. This study aimed to examine blood flow
inside LAA and its removal effects. Computational fluid dynamic (CFD) simulations were carried out on
Keywords: two patients with different morphologies.
Left atrial appendage Methods: Two patients’ CT was used to reconstruct the 3D geometries of the left atrium (LA) and left
Shape and volume atrial appendage (LAA). Then, the geometries were refined in the mentioned software, and the LAA in
Atrial fibrillation some models was removed. Next, in generated 3D volume mesh, sinus rhythm (SR) and atrial fibrillation
CFD simulation
(AF) outflow velocity were imposed at the mitral valve as boundary conditions. Finally, CFD simulation
Thrombus formation
was conducted to analyzing blood flow within LA with/without LA.
Results: The results confirmed that velocity and vorticity decreased under AF conditions inside the LA
domain for both patients. However, removing LAA may cause unpredictable consequences, due to dif-
ferent shape and volume of LAA. LAA removal had insignificant effects on velocity and vorticity within
LA in SR-mitral outflow. However, removing LAA increased the blood flow rate by 9.15% and vorticity by
7.27% for patient one under AF rhythm (SR)-outflow. In contrast, for patient two, LAA removal in both
AF and SR decreased velocity and vorticity within the LA domain. In SR-mitral outflow, velocity dropped
by 18.8 %, and vorticity by 13.2%. Also, under AF velocity and vorticity decreased by 23.33% and 18.6%
respectively. Meanwhile, the results indicated that the vorticity magnitude increased inside the LAA un-
der AF associated with the risk of thrombus formation, particularly for patient one under AF. The distal
part of LAA in both patients was the most common region for blood stasis because of the lowest velocity
magnitude.
Conclusion: Overall, the morphology of LAA could be the critical parameter to determine the possibility
of thrombosis formation, particularly under AF conditions. High volume, low blood flow velocity and
two-lobe-appendage are more likely to have blood stasis. Furthermore, the morphology difference can
affect the LAA removal result and make it more complicated. So, it could be challenging to generalize
LAA removal as a therapeutic option for different patients. The implication of this CFD observation needs
more investigation.
© 2021 Elsevier B.V. All rights reserved.

1. Introduction
The left atrial appendage (LAA) originates from the left atrium
and develops during fetal growth [1]. Anatomical and morpho-
logical studies illustrate the LAA as a long, tubular, and hooked
structure with variations in size, shape, and volume. Recent stud-
ies based on computed tomography (CT) categorized the LAA into
∗
Corresponding author.
E-mail address: mahmadlouydarab@tabrizu.ac.ir (M. Ahmadlouydarab).
four main types: Chicken Wing is the most prevalent (48%), fol-
lowed by Cactus shape (30%), with a dominant central lobe and
secondary lobes extending from the main lobe in both superior
and inferior directions; Wind Sock (19%) has one dominant lobe;
and Cauliflower (3%) with a complex internal shape [2]. LAA mor-
phology, size, and volume make it hard to estimate its effect on
left atrial flow. Recent studies reveal that LAA is the most preva-
lent region for thrombosis, also increases the risk of stroke in pa-
tients with atrial fibrillation (AF) [3–5]. Atrial fibrillation (AF) is
an electrophysiological pathology with irregular atrial beats and
is known as the most common cardiac arrhythmia that augments

https://doi.org/10.1016/j.cmpb.2021.106506
0169-2607/© 2021 Elsevier B.V. All rights reserved.
L. Alinezhad, F. Ghalichi, M. Ahmadlouydarab et al.
the rate of mortality and morbidity [6,7]. Atrial fibrillation is as-
sociated with valvular heart diseases such as aortic stenosis and
mitral stenosis, especially mitral regurgitation [8,9]. Undergoing AF
can cause electrical, structural, and contractile remodeling [10–13].
Atrial enlargement, LA malfunction, and insufficient atrial contrac-
tion lead to thrombus formation, predominantly in the LAA [3,14].
Although the location of atrial thrombus in subjects with AF can
differ, the LAA cavity is the most common region for thrombus
in patients with non-valvular AF [15]. Blood stagnation commonly
occurs in the LAA, where blood flow velocity drops dramatically
[1,5,13]. So, LAA has recently gained attention as a therapeutic tar-
get in predicting thrombosis, especially in AF patients. There are
several ways to prevent thrombus, including oral anticoagulants,
LAA occlusion, or LAA removal during valve surgery [1,13]. Al-
though drug therapy can prevent blood stasis, it has a high risk
of bleeding complications. Also, Surgical closure of the LAA can
fail in some patients [16,17]. Though several clinical treatments
have been proposed to decrease the risk of thrombus formation
in the LAA, studies have shown that there is still ongoing risk in
some patients [1,13,16,18]. These methods could fail due to the
different morphological parameters like shape, size, and LAA vol-
ume. Researchers have identified hemodynamic parameters, such
as velocity, vorticity, and shear stress, as indicators of thrombo-
sis [19,20]. So far, different techniques have been used to assess
blood flow within the left atrium. A transesophageal echocardio-
gram (TEE) is frequently used in clinical practice to assess flow ve-
locity and assess blood stasis in the LAA and LA. However, TEE can-
not accurately monitor hemodynamic parameters within the small
region [21,22]. Indeed, TEE is an invasive procedure. 4D MRI is a
cutting-edge technology in clinical research to provide more de-
tailed information about the 3D blood flow during the cardiac cy-
cle. However, resolution limitations make it challenging to capture
blood flow parameters accurately. Additionally, the scan time is rel-
atively long [23,24]. Today, computational modeling can provide a
comprehensive understanding of the AF mechanisms and conse-
quences [25,26]. Personalized computational models can provide
fibrosis modeling, atrial fiber orientation, wall thickness hetero-
geneity impacts on AF within realistic geometry and tissue prop-
erties [27,28]. Computational fluid dynamics (CFD) can give more
quantitative information about blood flow and assess thrombosis
risk [29]. It also allows evaluating blood flow in small regions con-
taining the lobes of LAA. Some CFD simulations have been done in
different LAA morphologies to analyze hemodynamic parameters
and thrombus formation risk. Otani et al. (2016) developed a CFD
framework to perform blood flow analysis, considering patient-
specific LA wall motion [30]. Their studies showed that computa-
tional methodology could help understand intracardiac thrombo-
sis and stroke in individual patients with LA structural remodeling.
Also, despite lower kinetic energy, the subject with relatively sim-
ple LAA morphology may be less prone to stroke than the other
with a more complex morphology [30]. Next, Bosi et al. (2018)
established a CFD simulation in different morphology with rigid
wall assumption for the LA movement [31]. They showed the risk
of thromboembolism in LAA with cauliflower shape is higher than
that of others. Jia et al. (2019) proposed a CFD framework to pre-
dict the LAA closure impacts in one particular patient, considering
a rigid LA wall [32]. Their results confirmed that the velocity mag-
nitudes dropped dramatically to almost zero in the distal part of
the LAA. Additionally, after LAA occlusion, vortices are reduced in
size, strength, and number. Masci et al. (2019, 2020) used the CFD
simulation approach on two cases under AF and SR to estimate
thrombus formation risk [33]. Also, they developed a workflow to
investigate LAA morphology’s impacts on LA blood flow by con-
sidering the wall motion in another study [34]. Under AF, loss of
LAA contractility may contribute to blood stasis. Furthermore, the
mean blood flow velocity in the LAA during the cardiac cycle was
2
Computer Methods and Programs in Biomedicine 213 (2022) 106506
higher in SR than in AF. Fluid particles observation after three car-
diac cycles revealed that AF could increase the risk. Their studies
demonstrated that low quantities of vorticity and velocity carry a
higher risk of thrombosis. Simple morphologies showed an equal
or even higher risk of thrombus formation than complex ones.
More recently, Wang et al. (2020) performed a patient-specific CFD
simulation based on the same boundary conditions as Bosi et al.
used (the same mitral outflow and the rigid LA wall). Their study
showed that thrombosis begins to form on the LAA wall and then
expands toward the internal domain of LAA [35]. Also, Fanni et al.
(2020) conducted CFD simulation on different LAA shapes with a
rigid wall assumption. Their results showed that LAA orifice area
and low velocity in the Cauliflower and Cactus shapes were associ-
ated with thrombogenicity [36]. Then, Villalba et al. (2021) con-
sidered six patients with different atrial functions, three with a
history of LAA thrombus or transient ischemic attacks, and three
without thrombus [37]. They compared the rigid wall and moving
wall results and showed LA wall motion could affect hemodynamic
parameters, particularly patients with intermediate residence time.
Also, they found that LA wall function had an impact on LAA’s clot.
Unfortunately, despite all the studies mentioned earlier, there is
a lack of knowledge about LAA shape impacts on blood flow pa-
rameters inside LA and LAA; and how LAA removing affects the
blood flow. So, in the current numerical study, first and foremost,
we aim to assess the removal of LAA effects on the blood flow in
LA in patients with different geometries and two mitral outflow
profiles. Second, we will analyze hemodynamic parameters in dif-
ferent LAA morphologies that contribute to blood stasis.
2. Methods
These studies included eight models under different conditions.
In some models, the left atrial appendage was removed to show its
effects on the left atrial blood flow. The CFD simulations were con-
ducted for two different outflows on the mitral valve; sinus rhythm
(SR) and atrial fibrillation (AF). Table 1 shows information for each
prepared model. It is worth mentioning that models 1 to 4 con-
tribute to patient 1 (Male, 58-year-old), and Models 5 to 8 are re-
lated to patient 2 (Male, 50-year-old).
2.1. Image processing
Fig. 1 shows 3D patient-specific models with different LAA mor-
phologies based on CT images. Data characteristics include the fol-
lowing:
Patient 1; The image resolution is 512∗ 512∗ 239; the in-plane
pixel size is 0.369 mm ∗ 0.369 mm; the slice thickness is 0.6 mm,
and the slice gap is 0.6 mm.
Patient 2; The image resolution is 512∗ 512∗ 295, The in-plan
pixel dimensions size 0.349 mm ∗ 0.349 mm, the slice thickness
0.75 mm, and the slice gap 0.5 mm.
The 3D geometry of the patients was reconstructed using the
CT Heart Segmentation and Seed Point Detection method (Mimics
Medical 21.0 Software). Then, pulmonary vein bifurcations were re-
moved, and the geometries improved by using 3-Matic 11 Research
software. Also, LAA was removed in some models (Table 1). The
surfaces were made on LA in Geomagic Design X. Software. Next,
the geometries were transferred to SOLIDWORKS software to cor-
rect the broken faces and merge the surfaces. Also, the inlets and
outlet surfaces were defined in SOLIDWORKS software. Eventually,
the geometries were imported into ANSYS WORKBENCH. To reduce
the entrance effects, the entrance lengths were extended in ANSYS
GEOMETRY. To set up the simulation, 3D patient-specific models
were meshed by using ANSYS Meshing. Different mesh sizes were
constructed for meshing convergence examination, and the final
meshes described here are the optimal meshes with high without
L. Alinezhad, F. Ghalichi, M. Ahmadlouydarab et al. Computer Methods and Programs in Biomedicine 213 (2022) 106506

Table 1
Properties of the models.

Model number LA Volume (ml) LAA Volume (ml) LAA Orifice Area (mm2 ) LAA lobe Total Element Number

Model 1 (SR) 118 9.08 305.5 2 761750

Model 2 (SR) 113.47 Removed - - 734245
Model 3 (AF) 118 9.08 305.5 2 761750
Model 4 (AF) 113.47 Removed - - 734245
Model 5 (SR) 70.635 4.74 296.1 1 531401
Model 6 (SR) 68.22 Removed - - 503758
Model 7 (AF) 70.635 4.74 296.1 1 531401
Model 8 (AF) 68.22 Removed - - 503758

Fig. 1. Shape of LAA in two selected patients.

compromising solution accuracy. Fig. 2 illustrates the reconstruc-
tion of geometry for one of the patients. Each model was subjected
to this procedure.
2.2. Flow Simulation
In the present study, flow simulations were conducted us-
ing ANSYS CFX on 3D patient-specific models. The simulations were
performed for three cardiac cycles to reach periodicity. Each car-
diac cycle was assumed 0.8 s or 75 beats per minute, and the cal-
culations were run with 100 iterations per time step to ensure
solution convergence. The residuals for continuity and momen-
tum equations were converged to in each time step. The blood in
LA/LAA was considered Newtonian, homogenous and incompress-
ible fluid with a density of ρ = 1060 kg/m^3 and a dynamic viscos-
ity of μ = 0.0035 kg/m-s. The non-Newtonian effect of the blood
flow in the large cavity like the left atrium can be negligible. In
these simulation models, the left atrium had four pulmonary veins
as inlets. The blood flow was also assumed as laminar. The gov-
erning equations, including incompressible continuity and Navier-
Stokes equations, have been listed in Eq. 1 and Eq. 2.
left atrium and the left ventricle (LV). A-wave happens at the end-
diastolic phase and associates with LA contraction. As shown in
Fig. 3(a), in sinus rhythm, both E- and A- waves occur during the
cardiac cycle’s systolic phase. However, in Fig. 3(b) with atrial fib-
rillation, the A-wave was disappeared due to insufficient atrial con-
traction. The transmitral velocity profiles and the E/A peak veloc-
ity show diastolic function and pathological conditions [39,40]. In
AF management and AF progression, the mitral flow velocity is an
important feature [41,42]. Note that, in the current study, the si-
nus rhythm does not indicate normal LA contraction, and there
is only an association with mitral outflow profile. Sinus rhythm
(SR) and atrial fibrillation (AF) are related to the same boundary
conditions were used by Bosi and Wang et al. to investigate LAA
shape effects [31,35]. Two mitral outflows help to evaluate affected
hemodynamic parameters due to shape differences under the same
conditions. It worth mentioning, our study aims to investigate the
LAA removal and LAA shape effects considering different geome-
tries, not to model LA function. So, we assume that LA function is
severely impaired, and the LA wall is rigid [31,32,35,36].
3. Results

∇ · v = 0 (1) In this section, the hemodynamic characteristics of the blood

−  flow for each model are discussed. Besides, the consequences of
→
ρ vt + v · ∇v = −∇ P + μ∇ 2v
Where v is velocity vector, vt is velocity time derivative, P is pres-
sure, ρ is density, and μ dynamic viscosity.
2.3. Boundary conditions
The opening boundary condition with zero constant pres-
sure was considered for inlets (four pulmonary veins) [31]. At
the outlet (mitral valve), transient velocity profiles were used in
both sinus rhythm (SR) and atrial fibrillation (AF). By considering
each patient’s mitral orifice area and flow rate across the mitral
valve based on Gautam et al. s’ study, transmitral velocities were
achieved [31,35,38]. The transmitral flow curve has two waves, E-
wave and A-wave at the diastolic phase. E-wave corresponds to
the rapid filling of LV due to the pressure difference between the
(2) LAA removal in specific models are examined. The cardiac cycle
begins with the systolic phase when the mitral valve is closed. The
blood flow enters the left atrium chamber through the four pul-
monary entrances. Then, the diastolic phase begins, and the mitral
valve opens, and blood flow passes through the mitral valve.
As already mentioned, the conducted CFD simulation is for
three complete cardiac cycles for each model. After the second cy-
cle, the flow got fully periodic, and no considerable differences are
observed. All the reported results, hereafter, are from the third car-
diac cycle.
3.1. Hemodynamics characteristics in the left atrium
A box and whisker plots are used to compare the blood flow
parameters in different geometries with defined mitral outflows.
Like, Jia et al., used these plots to compare velocities in different

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L. Alinezhad, F. Ghalichi, M. Ahmadlouydarab et al. Computer Methods and Programs in Biomedicine 213 (2022) 106506

Fig. 2. The schematic of the geometry reconstruction from CT images: (a) LA mask in Mimics software, (b) Developed geometry volumes and surfaces, (c) quality of the
created meshes. Extended length of the inputs and output also have been shown.

locations inside the LA domain [32]. Generally, comparing the ve- Table 2
locity range between patients (with different conditions) reveals The range of velocity magnitudes for patient 1.
that in models with atrial fibrillation (models 3, 4, 7, and 8), the Model 1 Model 2 Model 3 Model 4
velocity magnitude reduces dramatically. In AF, the velocity drops Velocity (m. s−1 ) Velocity (m. s−1 ) Velocity (m. s−1 ) Velocity (m. s−1 )
inside the LA domain. Because, disappearing A-wave in AF effects Max: 0.185 Max: 0.188 Max: 0.183 Max: 0.187
the blood flow inside LA, in agreement with the literature [14]. Min: 0.0485 Min: 0.04603 Min: 0.0352 Min: 0.0367
The LAA morphology also impacts the magnitude of the velocity, in Q1: 0.06125 Q1: 0.0598 Q1: 0.0456 Q1: 0.0477
good agreement with the literature [43–45]. Figs. 4 and 5 show the Median: 0.089 Median: 0.0905 Median: 0.0634 Median: 0.0692
Q3: 0.133 Q3: 0.1350 Q3: 0.09405 Q3: 0.0994
average velocity distribution inside the left atrium for patient one
and patient two, respectively. Also, Tables 2 and 3 give information
about the interquartile range of velocity for both patients. Models Table 3
for patient two with one lobe appendage have considerable veloc- The range of velocity magnitude for patient 2.

ity differences, and the velocity increases under the same condi- Model 5 Model 6 Model 7 Model 8
tion (SR or AF), compared with two lobes appendage. For instance, Velocity (m. s−1 ) Velocity (m. s−1 ) Velocity (m. s−1 ) Velocity (m. s−1 )
in model 5 the maximum average velocity is 0.249 m/s (median Max: 0.249 Max: 0.243 Max: 0.241 Max: 0.2403
velocity 0.133 m/s, interquartile range: 0.09 to 0.17 m/s for one Min: 0.0675 Min: 0.0519 Min: 0.0486 Min: 0.03587
lobe appendage in sinus rhythm), but the highest velocity for pa- Q1: 0.0915 Q1: 0.0686 Q1: 0.06295 Q1: 0.0476
Median: 0.133 Median: 0.108 Median: 0.093 Median: 0.0713
tient 1 with two lobes is almost 0.19 m/s.
Q3: 0.178 Q3: 0.17 Q3: 0.134 Q3: 0.11

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L. Alinezhad, F. Ghalichi, M. Ahmadlouydarab et al.
Fig. 3. The transmitral velocity profile. (a) Mitral flow velocity in sinus rhythm (SR), (b) Mitral flow velocity in atrial fibrillation (AF).
Fig. 4. The average velocity distribution inside left atrium for patient 1. Model 1:
Appendage with two lobes in sinus rhythm (SR), Model 2: Removed two lobes ap-
pendage in SR, Model 3: Appendage with two lobes in atrial fibrillation (AF), Model
4: Removed two lobes appendage in AF.
Furthermore, simulation results demonstrate that the LAA re-
moval affects velocity magnitude for models 2, 4, 6, and 8. Re-
5
Computer Methods and Programs in Biomedicine 213 (2022) 106506
moving two lobes appendage (models 2 and 4) causes a slight in-
crease in blood flow velocity in both sinus rhythm (SR) and atrial
fibrillation (AF). By comparing models with LAA (models 1 and 3)
in Table 2, the median velocity in model 1(SR), from 0.089 m/s
(interquartile range: 0.0612 to 0.133 m/s) rises to 0.0905 m/s (in-
terquartile range: 0.0598 to 0.135 m/s) in model 2 (SR) with 1.7 %
increase. In models 3 and 4 (AF), median velocity increases by 9.15
% from 0.0634 m/s to 0.0692 m/s. However, models 5 and 6 (SR)
for patient 2 show 18.8% reduction in median velocity from 0.133
m/s to 0.17 m/s indicated in Table 3. Under AF condition, models 7
and 8, the median velocity decreases by 23.33% from 0.093 m/s to
0.0713 m/s.
The volume integral of vorticity shows the total reduction of
vorticity strength [32]. Figs. 6 and 7 show vorticity strength for
patients 1 and 2, respectively. In general, the magnitude of volume
integral vorticity drops under AF in the whole left atrial domain.
Moreover, the LAA removal can affect the vorticity magnitude in
the left atrial domain in two opposite directions.
Fig. 6 and Table 4 show the interquartile range and the me-
dian value of vorticity for patient 1. Under SR condition, mod-
els 1 and 2, the vorticity strength decreases 1.1% by removing
LAA. On the other hand, models 3 and 4 have a slight increase
in vorticity magnitude (by 7.27% rise shown in Table 4). Results
for patient two shown in Fig. 7 and Table 5 depict a reduction
L. Alinezhad, F. Ghalichi, M. Ahmadlouydarab et al. Computer Methods and Programs in Biomedicine 213 (2022) 106506

Table. 4
The range of volume integral vorticity for patient 1.

Model 1 Model 2 Model 3 Model 4

Volume integral of vorticity (m3 .s−1 ) Volume integral of vorticity (m3 .s−1 ) Volume integral of vorticity (m3 .s−1 ) Volume integral of vorticity (m3 .s−1 )

Max: 7.57 × 10−3 Max: 7.42 × 10−3 Max: 7.19 × 10−3 Max: 7.14 × 10−3
Min: 2.97 × 10−3 Min: 2.81 × 10−3 Min: 2.22 × 10−3 Min: 2.21 × 10−3
Q1: 3.765 × 10−3 Q1: 3.85 × 10−3 Q1: 2.81 × 10−3 Q1: 2.9 × 10−3
Median: 5.61 × 10−3 Median: 5.55 × 10−3 Median: 3.85 × 10−3 Median: 4.13 × 10−3
Q3: 6.47 × 10−3 Q3: 6.38 × 10−3 Q3: 5.37 × 10−3 Q3: 5.48 × 10−3

Table .5
The range of volume integral vorticity for patient 1.

Model 5 Model 6 Model 7 Model 8

Volume integral of vorticity (m3 .s−1 ) Volume integral of vorticity (m3 .s−1 ) Volume integral of vorticity (m3 .s−1 ) Volume integral of vorticity (m3 .s−1 )

Max: 7.98 × 10−3 Max: 7.039 × 10−3 Max: 7.448 × 10−3 Max: 6.772 × 10−3
Min: 3.12 × 10−3 Min: 2.30 × 10−3 Min: 2.131 × 10−3 Min: 1.619 × 10−3
Q1: 4.085 × 10−3 Q1: 3.18 × 10−3 Q1: 2.84 × 10−3 Q1: 2.20 × 10−3
Median: 5.6 × 10−3 Median: 4.86 × 10−3 Median: 3.98 × 10−3 Median: 3.249 × 10−3
Q3: 6.59 × 10−3 Q3: 5.78 × 10−3 Q3: 5.54 × 10−3 Q3: 4.851 × 10−3

Fig. 5. The average velocity distribution inside the left atrium domain for patient Fig. 7. The volume integral of vorticity distribution for patient 1.
2. Model 5: Appendage with one lobe in sinus rhythm (SR), Model 6: Removed ap-
pendage in SR, Model 7: Appendage with one lobe in atrial fibrillation (AF), Model
8: Removed appendage in AF.
3.2. The left atrial appendage flow characteristics

Fig. 6. The Volume integral of vorticity distribution for patient 1.
in vorticity under LAA removal conditions, i.e., 13.2% and 18.36%
for models 6 and 8, respectively. Our results for patient 2 with
one lobe appendage are comparable with reported data by Jia
et al [32].
The velocity along the LAA, at the ostium, and the vorticity in-
side LAA are the main parameters to describe LAA hemodynam-
ics [2,31,33,34]. Fig. 8 and Fig. 10 shows the blood flow magnitude
and direction at the LAA ostium for patient one and two, respec-
tively. At the beginning of the diastolic phase (40% tc ), the velocity
magnitude is considerably low for patient one (Fig. 8) compared
to patient two (Fig. 9). At 55% tc (Peak E), The blood flow veloc-
ity increases in both patients, and the blood enters the LAA cav-
ity. Then, at 75% tc , the velocity magnitude drops and the blood
is emptying from the LAA. However, the differences in velocities
become noticeable at 100%. The low-velocity magnitude at ostium
can be observed in models with AF, associating with increasing the
possibility of thrombus. Fig. 9 (a) shows the velocity magnitude at
LAA ostium for patient one. At the beginning of the cardiac cy-
cle, the velocity is low in the AF condition (model 3), but at 55%
tc , the velocity precedes the SR condition. However, at the end of
the cardiac cycle, the blood flow velocity drops considerably in AF
(model 3). The velocity magnitude increases at the end of the car-
diac cycle, comparing to model 1. In Fig. 10, The velocity vectors for
patient two have a similar trend like the patient one, but the ve-
locity magnitudes changes. Comparing the velocity magnitudes in
Fig. 9 and Fig. 11 shows that the one lobe appendage has a higher
average velocity at LAA ostium. However, the average area velocity
magnitude drops for two lobes appendage. Consequently, the pos-

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L. Alinezhad, F. Ghalichi, M. Ahmadlouydarab et al. Computer Methods and Programs in Biomedicine 213 (2022) 106506

Fig. 8. The velocity vectors at the LAA ostium (Patient one; Model 1 and Model 3).

Fig. 9. The velocity magnitude profile patient one (Model 1 and 3). (a) The velocity profile at the LAA ostium plane. (b) The velocity profile inside LAA along the AB line.

sibility of the thrombogenicity increases in two lobes appendage
[2,45].
The velocity profiles at the end of the cardiac cycle have been
presented in Fig. 9(b) and Fig. 11 (b). In SR, the blood flow veloc-
ity in the left atrial appendage drops along the AB line steadily
for models 1 and 5. Note that velocity reduction inside the LAA is
more dominant for models 3 and 7, under AF. Furthermore, com-
paring velocity profiles in Fig .9 (b) and Fig. 11 (b) together reveals
that the velocity value for model 5 is higher than that of model 1,
and model 7 is higher than that of model 3. Also, by comparing
the velocity profiles in Fig. 9 (a and b) and Fig. 11 (a and b), it is
concluded that LAA shape differences may affect the velocity pro-
file. As shown in Fig .9 (b) and Fig. 11 (b), the velocity magnitude
drops considerably at the tip of LAA in both patients. So, the dis-
tal part of LAA is the possible region for having thrombus due to
almost zero blood flow velocity [31,32,35,43].
Fig. 12 shows the vorticity magnitude within the left atrial ap-
pendage. In general, atrial fibrillation increases the strength of vor-

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L. Alinezhad, F. Ghalichi, M. Ahmadlouydarab et al. Computer Methods and Programs in Biomedicine 213 (2022) 106506

Fig 10. The velocity vectors and contours at the LAA ostium plane (Patient two; Model 5 and 7).

Table 6
The rang of volume integral vorticity inside LAA for models.

Model 1 Model 3 Model 5 Model 7

Volume integral of vorticity (m3 .s−1 ) Volume integral of vorticity (m3 .s−1 ) Volume integral of vorticity (m3 .s−1 ) Volume integral of vorticity (m3 .s−1 )

Max: 6.28 × 10−5 Max: 9.10 × 10−5 Max: 3.02 × 10−5 Max: 5.69 × 10−5
Min: 3.74 × 10−5 Min: 2.44 × 10−5 Min: 1.46 × 10−5 Min: 2.99 × 10−5
Q1: 4.27 × 10−5 Q1: 3.13 × 10−5 Q1: 1.78 × 10−5 Q1: 4.09 × 10−5
Median: 4.57 × 10−5 Median: 4.52 × 10−5 Median: 2.19 × 10−5 Median: 4.44 × 10−5
Q3: 5.46 × 10−5 Q3: 6.68 × 10−5 Q3: 2.63 × 10−5 Q3: 4.65 × 10−5

ticity inside the LAA domain. Especially Model 3 has a wide vortic-
ity range and magnitude. The median value is almost the same in
models 1 and 3, but the interquartile range increases by 78.4% in
model 3. Besides, by comparing models 5 and 7 together, a consid-
erable rise in AF condition can be observed in both median values
and interquartile ranges according to Table 6.
4. Discussion
This numerical study explored LAA’s shape effects on hemo-
dynamic properties in two cases. Furthermore, this work investi-
gated whether LAA removal can reduce thrombosis. Patient 1 had a
two-lobe appendage, and patient 2 had one lobe. The results illus-
trated that AF and LAA morphology had significant roles in throm-
bus formation. Anatomical, morphological, and hemodynamic ab-
normalities happen in LAA under AF conditions. In patients with
AF, increased blood stasis, endothelial dysfunction or damage, and
atrial tissue injury caused thrombus formation and subsequent
stroke [46,47]. It is also possible to correlate LAA morphology with
platelet activity, fibrinolysis function, endothelial dysfunction, and
inflammation [48]. Consequently, the study of LAA morphology can
stratify the risk for thrombosis and stroke in AF patients. Accord-
ing to the statistical analysis, the shapes of LAA lead to different
stroke risk rates in patients with AF. Several studies show LAA ori-
fice area, LAA depth, LAA volume, and LAA flow velocity impact
thrombotic events. A larger LAA orifice size or an increased LAA
volume, along with a decreased LAA velocity, are strongly associ-
ated with higher stroke risk in AF [44,49-53].
It is evident that under AF, the velocity and vorticity decreased
inside the LA domain. Due to the absence of A- wave in AF, the
blood flow in the LA domain cannot wash out properly from the
domain at the end of the diastolic phase. Besides, velocity dropped
considerably inside LAA associated with increasing the thrombo-
genicity in this region [31–35]. The LAA tip had the lowest velocity
value in both patients, and the blood flow is almost zero [32–36].
Furthermore, the well-known factors to estimate thromboses in-

8
L. Alinezhad, F. Ghalichi, M. Ahmadlouydarab et al.
Fig. 11. The velocity magnitude profile patient one (Model 1 and 3). (a) The velocity profile at the LAA ostium plane. (b) The velocity profile inside LAA along the AB line.
Fig. 12. The volume integral vorticity inside the LAA.
side LAA are lobes number [54]. Thrombosis risk is relatively high
in LAA with two lobes and large volume due to the wide vorticity
range or/and low-velocity values [2,30,45].
In the case of LAA removal in patient 1 (two-lobe appendage),
there was no significant change in velocity and vorticity under
SR. While, the magnitudes were slightly high under AF, 9.15% and
7.27% rise in velocity and vorticity, respectively. The changes in
blood flow velocity and vorticity in patient 2 (one-lobe appendage)
were more dominant than the other one. The velocity and vorticity
decreased due to LAA removal under SR (18.8 % and 13.2%, respec-
tively) and AF (23.33% and 18.6%, respectively). Under the same
conditions, LAA morphology may influence LAA removal impacts
and cause unexpected results depending on the morphology. In
one lobe appendage, the LAA removal effects were more dominant,
especially under AF, resulting in unforeseen consequences. The LAA
morphological characteristics make it hard to estimate LAA isola-
tion impacts in patients with persistent AF.
This study had both strengths and limitations by considering
two patients. It is necessary to consider more patients to deter-
mine whether the results are reliable and applicable clinically. It is
recommended for future studies to include patients with paroxys-
mal AF, patients with persisting AF, and patients without AF. Fur-
thermore, since LAA has a wide range of shapes, more computa-
tional studies are needed to understand the shape impacts in dif-
ferent subjects. In the current study, it aimed to show that the
9
Computer Methods and Programs in Biomedicine 213 (2022) 106506
morphology of the LAA can influence blood flow parameters, even
after the LAA removal. For this purpose, two patients with different
shapes and volumes of LAA were considered.
Also, in this research, the sinus rhythm was not associated with
normal LA contraction, and this assumption was for investigating
the mitral outflow impacts. The LA wall was rigid, with severely
impaired LA function. Based on the LA impairment, the wall mo-
tion could be reduced [55]. So, only the LAA morphology and its
effects on the blood flow were investigated. However, considering
left atrial wall motion with immersed-boundary CFD analyses of
LA blood flow is essential in future studies to reach patient-specific
data for predicting LAA thrombosis.
Our results with other literature data indicated that LAA mor-
phology parameters (volume, lobe, and complexity) affected hemo-
dynamics inside the LA and LAA [30,31,37,43]. Otani et al. showed
that the relatively simple LAA morphology with low kinetic energy
was less related to stroke risk than a more complex LAA morphol-
ogy with high kinetic energy [30]. Other than LA wall motion, LAA
morphology can play a critical role in blood flow and thrombo-
sis [30,37]. Also, there are clinical studies that support our results
[49–55].
5. Conclusion
This study confirmed that a relatively complex LAA geometry
could affect the hemodynamics in the domain and increase the
thrombus formation. LAA with two lobes and higher volume was
more likely to have a thrombosis. The number of lobes influenced
fluid dynamics. Also, in the same condition, morphological differ-
ences can affect LAA removal consequences. Despite the limitation
in the LA movement and subject number, the current study cov-
ered fluid dynamic simulation evaluating LAA removal effective-
ness in patient-specific geometries, under different simulation con-
ditions.
Conflict of Interest
None
Acknowledgements
The authors would like to greatly thank Rajaie Cardiovascular,
Medical, and Research Center for providing CT images.
L. Alinezhad, F. Ghalichi, M. Ahmadlouydarab et al.
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