Atrial Thrombus In Patients Research Articles

Multivariate analysis in the prediction of left atrial thrombi in patients with mitral stenosis

The prediction of left atrial thrombi based on clinical and investigative data was evaluated prospectively in 100 consecutive patients with significant mitral stenosis. Nineteen patients had left atrial thrombi by surgical findings. Age, atrial fibrillation, and mitral valve area were the variables that predicted the presence of left atrial thrombus, whereas sex, dimension of left atrium, history of systemic embolism, history of previous mitral valvuloplasty, and associated significant mitral regurgitation were not. Patients with atrial fibrillation have a sixfold increase in risk of atrial thrombi compared with patients in sinus rhythm. Transthoracic echocardiography detected 11 (58%) of 19 and transesophageal echocardiography detected 17 (89%) of 19 thrombi found by surgical inspection. Multivariate analysis showed that age and atrial fibrillation were the best predictors of left atrial thrombus. In general clinical practice, these variables could be used to predict left atrial thrombi in patients with mitral stenosis. However, in certain situations such as prior percutaneous balloon mitral valvuloplasty or prior electrical cardioversion, transesophageal echocardiographic examination should be used for high accuracy in the detection of extent and location of left atrial thrombi.

Role of transesophageal echocardiography in the detection of left atrial thrombus in patients with chronic nonrheumatic atrial fibrillation

Transesophageal echocardiography was used to assess cardiac abnormalities associated with embolization in patients who had completed the Department of Veterans Affairs Cooperative Study of Stroke Prevention in Nonrheumatic Atrial Fibrillation at the Minneapolis and West Haven Department of Veterans Affairs Medical Centers without an embolic event. Patients were men, 71 ± 7 years old, with atrial fibrillation of 6.2 ± 4.3 years' duration who had received warfarin ( n = 32) or placebo ( n = 23) for 2 years. Thrombi were found in 5 of 55 patients (warfarin 4 and placebo 1; p = 0.39); spontaneous echo contrast was seen in 4 of 5 patients. Other abnormalities identified included spontaneous echo contrast (47%), patent foramen ovale (54%), atrial septal aneurysm (7.3%), and left ventricular thrombus (3.6%). During 34 months of posttreatment follow-up, 5 patients had a stroke (1 fatal), and 10 died. Potential sources of emboli did not predict subsequent outcome. Thus warfarin therapy did not preclude the presence of thrombi. Stroke reduction likely involves the prevention of emboli from sources in addition to the atrial appendage.

Left atrial appendage thrombus is not uncommon in patients with acute atrial fibrillation and a recent embolic event: A transesophageal echocardiographics tudy

Objectives. The objective of this study was to determine the frequency of left atrial thrombus in patients with acute atrial fibrillation.Background. It is commonly assumed but unproved that left atrial thrombus in patients with atrial fibrillation begins to form after the onset of atrial fibrillation and that it requires ≥3 days to form. Thus, patients with acute atrial fibrillation (i.e., <3 days) frequently undergo cardioversion without anticoagulation prophylaxis.Methods. Three hundred seventeen patients (250 men, 67 women; mean [±SD] age 64 ± 12 years) with acute (n = 143) or chronic (n = 174) atrial fibrillation were studied by two-dimensional transesophageal echocardiography.Results. Left atrial appendage thrombus was present in 20 patients (14%) with acute and 47 patients (27%, p < 0.01) with chronic atrial fibrillation. In patients with a recent embolic event, the frequency of left atrial appendage thrombus did not differ between those with acute (5 [21%] of 24) and those with chronic (12 [23%] of 52, p = NS) atrial fibrillation. Patients with acute versus chronic atrial fibrillation, respectively, did not differ (p = NS) in mean age (64 ± 13 vs. 65 ± 11 years), frequency of concentric left ventricular hypertrophy (32% vs. 26%), hypertension (32% vs. 41%), coronary artery disease (35% vs. 39%), congestive heart failure (43% vs. 48%), mitral stenosis (4% vs. 7%) or mitral valve replacement (1.4% vs. 6%). The minimally detectable difference in proportions between patients with acute and chronic atrial fibrillation based on a power of 0.80 and base proportion of 0.20 was 14%.Conclusions. Left atrial thrombus does occur in patients with acute atrial fibrillation <3 days in duration. The frequency of left atrial thrombus in patients with recent emboli is comparable between those with acute and chronic atrial fibrillation. These data suggest that patients with acute atrial fibrillation for <3 days require anticoagulation prophylaxis or evaluation by transesophageal echocardiography before cardioversion and should not be assumed to be free of left atrial thrombus.

Transesophageal echocardiographic detection of atrial thrombi in patients with nonfibrillation atrial tachyarrhythmias and congenital heart disease

Objectives. We hypothesized an association between atrial thrombi and nonfibrillation atrial tachyarrhythmias in patients with congenital heart disease.Background. We observed a fatal thromboembolus after direct current cardioversion in an adolescent with atrial flutter and repaired tetralogy of Fallot.Methods. Using transesophageal echocardiography, we prospectively studied 19 consecutive patients with congenital heart disease with nonfibrillation atrial tachyarrhythmia (atrial flutter in 18, primary atrial tachycardia in 1) undergoing electrophysiologic procedures (median age 19.6 years, range 7.0 to 53.8; 11 male, 8 female). Transthoracic echocardiograms were available for 17 patients.Results. All transesophageal examinations were performed without incident. No atrial thrombi were detected in 11 patients who subsequently had uncomplicated direct current cardioversion. Eight solitary atrial thrombi were detected (incidence 42%). Six thrombi were located in the right atrium (Fontan repair in four patients, Ebstein's malformation repair in two), and two were noted in the left atrium (congenital hypertrophic cardiomyopathy and atrial septal defect repair in one patient each). Transthoracic echocardiograms were available in seven of eight patients with thrombus detected by transesophageal echocardiography, with only one study conclusive for an atrial thrombus. Cardioversion was deferred in six of eight patients with thrombus, and anticoagulation therapy was initiated. Uncomplicated electrophysiologic procedures were conducted in two patients at the time of detection of right atrial thrombus (atrioventricular node ablation in one patient, direct current cardioversion in the other).Conclusions. Prothrombic conditions exist in patients with congenital heart disease with nonfibrillation atrial tachyarrhythmias, as indicated by a significant incidence of transesophageally detected atrial thrombi. The need for prophylactic anticoagulation and the safety of pharmacologic or direct current cardioversion are issues that remain unresolved.

Diagnostic accuracy of transesophageal echocardiography for detecting left atrial thrombi in patients with rheumatic heart disease having undergone mitral valve operations

Transesophageal echocardiography (TEE) has emerged as an efficient method for detecting left atrial (LA) thrombi in recent years, but its accuracy has not been fully evaluated. A prospective clinicopathologic study in 213 consecutive patients with chronic rheumatic mitral valve disease over a period of 39 months was undertaken. All patients underwent open heart surgery within 3 days after the TEE study. The presence or absence of LA thrombi was confirmed at surgery by direct inspection of the left atrium and proven by histopathologic examination. Of the 213 patients, 147 had predominant mitral stenosis, and the remaining 66 patients had significant mitral regurgitation. Twenty-eight patients had LA thrombi by TEE criteria. These findings were all confirmed at surgicopathologic studies (specificity 100%). However, in 2 patients, LA thrombi were present but could not be detected by TEE (sensitivity 93.3%). Therefore, the positive predictive value was 100%, the negative predictive value was 98.9% and the diagnostic accuracy was 99.1%. No thrombi were found in patients with significant mitral regurgitation. The frequency of LA thrombi in patients with predominant mitral stenosis was 20% (30 of 147), and most of these patients had chronic atrial fibrillation (28 of 30, 93%). Only 16 patients (16 of 30, 53%) were found to have LA thrombi by transthoracic echocardiography. Furthermore, our data showed poor correlation between the echogenicity of LA thrombi and the degree of thrombus organization. Thus, TEE is excellent for detecting LA thrombi in patients with rheumatic heart disease severe enough to warrant mitral valve operations.

Use of transoesophageal echocardiography to detect left atrial thrombi before percutaneous balloon dilatation of the mitral valve: a prospective study.

Systemic emboli related to atrial thrombi are a well known complication of percutaneous balloon dilatation of the mitral valve. The presence of left atrial thrombi therefore, is believed to be a contraindication to balloon dilatation. The purpose of this study was to determine the frequency of left atrial thrombi in patients referred for balloon dilatation of the mitral valve, the added benefit of pre-procedural transoesophageal echocardiography, and to identify factors that predicted left atrial thrombi. Prospective study over a 14 month period of 20 consecutive patients by cross sectional transthoracic echocardiography 24-48 hours before balloon dilatation of the mitral valve and by transoesophageal echocardiography immediately before the procedure. One patient had a left atrial thrombus detected by transthoracic study. Two patients (10%) had left atrial thrombi identified by transoesophageal echocardiography. In both valve dilatation was not attempted and the thrombi were confirmed at surgery. The remaining 18 patients all underwent successful balloon dilatation of the mitral valve without clinical evidence of an embolic event. No association was found between patient age, mitral valve area, transmitral gradient, left atrial size, presence of atrial fibrillation, severity of mitral regurgitation, cardiac output, or the presence of left atrial swirling and an increased prevalence of atrial thrombi. Left atrial thrombi are often seen despite long term systemic anticoagulation in patients referred for balloon dilatation of the mitral valve. The frequency of unsuspected left atrial thrombi detected by transoesophageal echocardiography was similar to the reported frequency of embolic events after balloon dilatation of the mitral valve. Transoesophageal echocardiography for the identification of left atrial thrombi is strongly recommended in all patients before balloon dilatation of the mitral valve including those treated with systemic anticoagulation and those who have had a normal transthoracic echocardiographic study.

Value and Limitations of Two-Dimensional Echocardiography in the Diagnosis of Cardiac Masses

Thirty-one patients are described, in whom two-dimensional echocardiography (2D-Echo) identified the presence of cardiac masses: 13 extracavitary, 18 intracavitary. Among the former, 4 were pericardial cysts: 1 echinococcal cyst which was surgically removed and 3 clear-edged discrete cysts which were considered benign. In 5 patients affected by malignant neoplasms, 2D-Echo revealed conspicuous pericardial effusion: in 4 of them a mass of metastatic origin could be seen and in 1 the mediastinal invasion of a lymphoma. Two patients had a mass compressing the main pulmonary artery: 1 was a malign lymphogranuloma and the other pulmonary cancer. Finally, in 2 patients with AIDS, an epicardial Kaposi’s sarcoma was found. Of the 18 patients with intracardiac masses, 8 were affected by left and 2 by right atrial myxoma, 1 had an echinococcal cyst originating in the left atrium and, in a further 7 patients with mitral valve disease, 6 were affected by left atrial thrombus and 1 by a mass localized in the right ventricle which at surgery resulted to be a hemoangioendothelioma. With the exception of the 3 benign cysts, all diagnoses were confirmed by surgery. 2D-Echo proved determinant in establishing the therapy for the patients with pericardial cysts, atrial myxomas and the patient with hemoangioendothelioma. In the other cases, diagnoses were confirmed by other techniques (computer axial tomography, magnetic resonance imaging). In the cases of atrial thrombi in patients with mitral valve disease, echocardiography gave additional information useful to the surgeon. 2D-Echo has proved to be very useful in identifying the presence of cardiac masses. It represents an important step in the diagnosis of such conditions, providing certain limitations in its use are taken into account.

Diagnostic accuracy of two-dimensional echocardiography for detection of left atrial thrombus in patients with mitral stenosis.

Two-dimensional echocardiograms of 56 patients with mitral stenosis, who subsequently underwent operation, were analyzed to evaluate the accuracy for the detection of left atrial thrombi. From left parasternal, apical, and subcostal cardiac windows, multiple planes (including standard planes and their derived scanning planes) were assessed for the presence or absence of mass echoes in the left atrium. The results showed 63% sensitivity, 95% specificity, 87% positive predictive value, 84% negative predictive value, and 83% overall diagnostic accuracy. Most of the false-negative cases had their thrombi confined to the left atrial appendage. We conclude that in patients with mitral stenosis, two-dimensional echocardiography is promising for the diagnosis of left atrial thrombi, particularly when they locate or extend to the main left atrial cavity (not confined to atrial appendage).