Abstract
Thrombus in the left atrial appendage is a contraindication for cardioversion. Sludge is considered similarly as threatening as thrombus; however, the risk of death and ischemic stroke in patients with atrial arrhythmia and thrombus or sludge is not well-known. This study focused on assessing the risk of death and ischemic stroke at one-year follow-up in patients with atrial arrhythmia and thrombus or sludge, as well as the effectiveness of anticoagulation in thrombus resolution. 77 out of 267 (29%) of patients who were scheduled for cardioversion were diagnosed with thrombus or sludge. The annual mortality in patients with thrombus or sludge was 23%. In the group without thrombus, the annual mortality was 1.6%. Overall, 17% of patients with thrombus or sludge experienced ischemic stroke. In patients without thrombus, the risk of stroke was 1%. Sludge increased risk of stroke compared to those without thrombus or sludge by 11% vs. 1%, respectively. No differences in mortality or stroke prevalence were observed between sludge and thrombus. Thrombus or sludge in the LAA have a poor prognosis. A diagnosis of sludge has a similar impact on risk of ischemic strokes as does a diagnosis of thrombus.
Highlights
Atrial fibrillation (AF) and atrial flutter (AFL) are the most frequent sustained cardiac arrhythmias, with a prevalence of about 2–4% in the general population; they have a 10% annual risk of death [1,2,3]
AF and AFL are associated with the development of left atrial appendage (LAA) thrombus, which is the main cause of stroke and systemic embolism [4,5,6,7]
There are no recommendations to perform routine transesophageal echocardiography (TOE) control for assessing thrombus resolution, and the decision to perform TOE control is usually made by the physician and the patient when the AF/AFL is persistent before planned cardioversion [20]
Summary
Atrial fibrillation (AF) and atrial flutter (AFL) are the most frequent sustained cardiac arrhythmias, with a prevalence of about 2–4% in the general population; they have a 10% annual risk of death [1,2,3]. In subjects with atrial fibrillation, it is still unclear if dense spontaneous echo contrast (sludge) in the LAA is a robust independent risk factor for stroke, similar to thrombus formation [11,12,13]. Another recognized neurological complication is cognitive disorders: patients with thrombus or sludge in the LAA scored significantly lower on the Mini Mental State Examination (MMSE) than patients free from thrombus or sludge [14]. Many patients are still diagnosed with thrombus or dense spontaneous echocontrast in the LAA despite proper anticoagulation [14,17,18,19]. There are no recommendations to perform routine TOE control for assessing thrombus resolution, and the decision to perform TOE control is usually made by the physician and the patient when the AF/AFL is persistent before planned cardioversion [20]
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