Abstract
Guidelines recommend transesophageal echocardiography (TEE) before cardioversion in thrombogenic arrhythmias when the requirement of ≥ 3 weeks of anticoagulation is not met. Current data to support this approach, especially with direct oral anticoagulants (DOAC), are scarce. We analyzed consecutive elective pre-cardioversion TEE in a high-volume electrophysiology center for the occurrence of left atrial appendage (LAA) thrombi or reduced LAA flow velocity. Possible predictors were recorded and compared in a multivariate logistic regression analysis. Consecutive pre-cardioversion TEE in 512 patients (148 female, median age 69 years) were included. In all patients, indication for TEE was either intake of anticoagulation < 3 weeks before cardioversion or uncertain adherence to the prescribed anticoagulation regimen. Of the 512 TEE, 19 (3.7%) depicted a LAA thrombus. An additional 41 patients (8.0%) showed either a reduced LAA flow velocity (≤ 20 cm/s), LAA sludge, or both. In a multivariate logistic regression analysis, QRS width on admission 12-lead ECG emerged as a possible predictor of LAA thrombus and reduced LAA flow (p = 0.008). Noteworthy, a high CHA2DS2-VASc score was not associated with an increased risk of reduced LAA emptying velocity and LAA thrombi were even found in patients with a CHA2DS2-VASc score of 0 (n = 1) and 1 (n = 1). The presence of LAA thrombus before an elective cardioversion is a rare event in the age of direct oral anticoagulants. However, LAA thrombi occurred even in supposed low-risk individuals according to the CHA2DS2-VASc score. QRS width may aid in identifying patients at risk of reduced LAA flow velocity.
Highlights
Guidelines recommend transesophageal echocardiography (TEE) before cardioversion in thrombogenic arrhythmias when the requirement of ≥ 3 weeks of anticoagulation is not met
All included patients underwent transesophageal echocardiography after giving informed consent. 292 (57%) of all patients were on a direct oral anticoagulant (DOAC) while 138 (27%) were anticoagulated with an oral vitamin K antagonist (VKA)
The present study provides an update on the available evidence for left atrial appendage (LAA) thrombus detection on transesophageal echocardiography before an elective cardioversion in a large cohort
Summary
Guidelines recommend transesophageal echocardiography (TEE) before cardioversion in thrombogenic arrhythmias when the requirement of ≥ 3 weeks of anticoagulation is not met. We analyzed consecutive elective pre-cardioversion TEE in a high-volume electrophysiology center for the occurrence of left atrial appendage (LAA) thrombi or reduced LAA flow velocity. In a multivariate logistic regression analysis, QRS width on admission 12-lead ECG emerged as a possible predictor of LAA thrombus and reduced LAA flow (p = 0.008). For more than twenty years, guidelines on the management of atrial fibrillation (AF) have recommended transesophageal echocardiography (TEE) before an elective cardioversion (ECV) in patients who do not meet the requirement of uninterrupted effective oral anticoagulation for ≥ 3 weeks. In the time since these recommendations were first given, the management of thromboembolic complications of atrial fibrillation has seen numerous changes including the establishment of the International Normalized Ratio, the advent of the CHADS- and later the CHA2DS2-VASc scoring systems, and the routine use of direct oral anticoagulants (DOAC). The present study was designed to analyze the incidence of LAA thrombi in a contemporary cohort and elicit predictive factors of low-flow situations of the LAA, possibly identifying patient groups at such a low risk of LAA thrombus that the risks of TEE might outweigh the benefits
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