Abstract 17496: Exploring the Benefits: Role of Repeat Transesophageal Echocardiography (TEE) in Patients Anticoagulated for Four Weeks

Abstract

Background: A left atrial appendage (LAA) thrombus is a well-known complication of atrial fibrillation (AF). Vitamin K antagonists (VKAs) have been well studied been considered the gold standard for thromboembolic prophylaxis. We present a case of LAA thrombus despite compliance with VKAs. Clinical presentation: A 70-year-old female with atrial fibrillation and diabetes presented with left-sided weakness and left facial droop, CT head showed right middle cerebral artery infarct. Vitals were unremarkable. Electrocardiogram showed AF with a rapid ventricular response. She was on warfarin with the most recent international normalized ratio level of 2.3. Transthoracic echocardiography revealed an ejection fraction of 55%, severe left ventricular hypertrophy, and severely dilated left atrium (LA) with LA diameter of 5.3 cm (>= 4.7 cm in women indicates severe dilatation). Transesophageal echocardiography (TEE) with bubble study demonstrated a large thrombus in the LAA with evidence of patent foramen ovale. The pulse wave Doppler (PWD) of the LAA on TEE also showed an LAA velocity of <20 cm/sec, which indicated that there was the highest probability that the thrombus was forming within LAA. Hypercoagulability work-up for thrombosis while on Coumadin such as anti-B2 glycoprotein, anticardiolipin, and factor V Leiden mutation were negative. The patient was started on enoxaparin with appropriate follow-up upon discharge. Discussion: The prevalence of LAA thrombus in patients with AF receiving a minimum of 3 weeks of anticoagulation, was approximately 3%. The presence of a LAA thrombus is a known contraindication to cardioversion and catheter ablation in patients with AF as it can result in cardioembolic stroke. However, current guidelines for cardioversion do not recommend pre-procedural TEE in patients undergoing cardioversion for AF if they have been on therapeutic oral anticoagulation for at least 3 weeks while TEE use remains variable before catheter ablation.