Aim <p>Non-valvular atrial fibrillation (NVAF) serves as the primary cause of cardiogenic embolic stroke (CES), and the recurrence rate and mortality of CES are on an annual upward trend. The objective is to explore the structural and functional changes of the left atrial (LA) and left atrial appendage (LAA) in patients with NVAF by means of real-time three-dimensional transesophageal echocardiography (RT-3D TEE) in combination with two-dimensional speckle tracking imaging (2D-STI), and to identify the risk factors for CES.</p> Methods <p>A total of 125 patients with NVAF were recruited from our hospital, among whom 55 had CES and 70 did not. Additionally, 96 controls with sinus rhythm were included. General clinical data, as well as transthoracic and transesophageal echocardiographic data, were collected. RT-3D TEE and 2D-STI were employed to assess the structural and functional characteristics of the LA and LAA. Multivariate logistic regression and receiver operating characteristic (ROC) curve analyses were conducted to evaluate the independent risk factors and their predictive value for CES.</p> Result <p>In comparison with the control group, both NVAF groups exhibited elevated LA and LAA volumes as well as impaired functional parameters, with more pronounced alterations observed in the CES subgroup. Multivariate logistic regression analysis determined that CHA₂DS₂-VASc ≥ 2, impaired LA reservoir strain (LASr), and an increased LAA maximum volume index (LAAVImax) were independent risk factors for CES. ROC curve analysis indicated that LAAVImax (AUC = 0.803) and LASr (AUC = 0.720) had greater predictive value than CHA₂DS₂-VASc ≥ 2 alone (AUC = 0.685). The combination of all three factors resulted in the highest predictive accuracy (AUC = 0.854).</p> Conclusion <p>NVAF patients with CES showed greater impairment of LA and LAA structure and function. LASr and LAAVImax were independently associated with CES and may improve risk stratification when combined with clinical risk scores.</p>