Predictors Of Left Atrial Appendage Thrombus Research Articles

A novel score to predict left atrial appendage thrombus and sludge in patients with persistent atrial fibrillation on chronic anticoagulants

Abstract Introduction Left atrium (LA) and left atrial appendage (LAA) thrombus may occur during atrial fibrillation (AF) and atrial flutter (AFl), and potentially cause main embolic events. Sludge is a pre-thrombotic condition, associated with long term adverse outcomes. Current guidelines do not recommend to perform transesophageal echocardiography (TEE) before cardioversion (CV) of patients with persistent AF/AFl when at least 3 weeks of anticoagulation are administered with appropriate compliance. Instead, they suggest TEE before atrial ablations (Abl), even in anticoagulated patients. Evidence to support these approaches are weak and conflicting, due to not infrequent occurrence of peri-procedural stroke and several reports of not negligible prevalence of LAA thrombus finding. Purpose Aim of the study was to evaluate the real prevalence of LAA thrombus and sludge in a retrospective cohort of consecutive anticoagulated patients with persistent AF and AFl, who underwent TEE before a scheduled cardioversion or catheter ablation. Moreover, clinical and echocardiographic characteristics were analyzed to develop a score that could predict the individual risk of combined thrombus/sludge. Methods We conducted a retrospective, monocentric, observational study, recruiting 1037 consecutive patients with persistent AF/AFl referred to our center for CV or Abl. TEE had been always performed to rule out thrombus and sludge before procedures. We collected data about patients characteristics, medication and compliance, electrographic and echocardiographic findings and type of scheduled procedure. Data was compared in univariate and multivariate analysis to identify possible predictors of LAA thrombus and sludge, and we used the last significant results to create a predictive score with logistic regression analysis. We identified best cutoff value with ROC curve. Results 767 patients were included in final dataset. Mean CHA2DS2-VASc was 3.2. LA/LAA thrombus and sludge were identified in 63 subjects (8.21%), 17 thrombi (2.21%) and 45 sludge (5.86%). Presence of valvular AF (+1), previous stroke or TIA (+1.5), heart failure history (+1), ventricular systolic (LVEF < 45%)(+0.5) and diastolic (Lateral E/e’ > 9) dysfunctions (+1) were significantly associated to higher risk of thrombus/sludge occurrence, meanwhile AFl (-1) was associated to lower risk. A novel score, called HEELP score, was developed based on these variables, and a threshold of 1 point showed high sensitivity (89%) and remarkable negative predictive value (98%). Conclusion Thrombus and sludge prevalence is not infrequent in anticoagulated patients with persistent AF/AFl. A strategy to perform TEE before procedures in patients with high risk features according to our score could be effective in preventing main embolic events, but it has to be validated in further studies.LAA empty (1), sludge (2), thrombus (3)HEELP score

The predictive value of the systemic immune-inflammatory index for left atrial appendage thrombus in non-valvular atrial fibrillation.

The systemic immune inflammatory index (SII) has prognostic value in cardiovascular diseases. The aim of current study was to investigate whether or not left atrial appendage (LAA) thrombus could be predicted by SII in patients with non-valvular atrial fibrillation. The study included 525 patients newly diagnosed with non-valvular atrial fibrillation, who had not previously had anticoagulant treatment (50.7% male, mean age 62.94±10.79 years). All patients underwent transoesophageal echocardiography. LAA thrombus was observed in 86 patients (16.4%). In the ROC curve SII had a good diagnostic power in predicting LAA thrombus (AUC: 0.760, 95% CI: 0.703-0.818, P<0.001). In the multivariate regression analysis, diabetes (Hazard ratio: 2.264, 95% CI: 1.169-4.389, P=0.015), LAA emptying rate of <20 cm/s (Hazard ratio: 59.347, 95% CI: 25.397-138.680, P<0.001), and SII value of >750 (Hazard ratio: 4.291, 95% CI: 2.144-8.586 P<0.001) were determined as independent predictors for LAA thrombus. A poor correlation was found between SII and the CHADS2 VASc score (r=0.239, P<0.001) Conclusion. The SII, a practical and easily obtained test, can be used as a predictor of LAA thrombus in patients with non-valvular atrial fibrillation, and to decide on the anticoagulant treatment.

Risk of left atrial appendage thrombus in patients with atrial fibrillation and chronic kidney disease.

BackgroundAtrial fibrillation (AF) and chronic kidney disease (CKD) are associated with an increased risk of ischemic stroke. The aim of this study was to compare the clinical characteristics, the incidence of left atrial appendage (LAA) thrombus and its predictors, and spontaneous echo contrast (SEC) in a population of patients with AF depending on estimated glomerular filtration rate (eGFR) values.MethodsThis study included 1962 patients who underwent transesophageal echocardiographic examination prior to cardioversion or ablation in the years 2014–2018 in three cardiac centers.ResultsMore than a quarter of AF patients had decreased eGFR (< 60 mL/min/1.73 m2) and were characterized as a high-risk population, with more comorbidities, higher thromboembolic and bleeding risk compared to those with normal renal function. Oral anticoagulation (OAC) was prescribed in 97% and 93% of patients with decreased and normal eGFR, respectively, with a higher prevalence of prescribed non-vitamin K antagonist oral anticoagulants (NOACs). The incidence of LAA thrombus (24%, 9% and 4%) and SEC (25%, 25% and 19%) increases simultaneously with a decrease in eGFR (< 30, 30–59 and ≥ 60 mL/min/1.73 m2, respectively). Among patients prescribed reduced doses of NOAC, those with decreased eGFR were more often observed with LAA thrombus (10% vs. 2.5%). Non-paroxysmal AF, heart failure and previous bleeding were predictors of LAA thrombus, irrespective of eGFR value. CKD was the predictor of LAA thrombus in all patients including those with non-paroxysmal AF, males, without diabetes, without hypertension and with CHA2DS2-VASc < 2.ConclusionsDespite OAC, patients with concomitant AF and CKD remain at high risk for LAA thrombus formation.

Incidence and predictors of left atrial appendage thrombus on transesophageal echocardiography before elective cardioversion

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.

Prevalence of left atrial appendage thrombus in patients with acute ischaemic stroke and sinus rhythm: a cross-sectional study

ObjectiveThrombi originating in the left atrial appendage (LAA) mainly form because of atrial fibrillation (AF) and are a known cause of cardioembolic stroke. We aimed to investigate the prevalence of...

Risk of left atrial appendage thrombus in older patients with atrial fibrillation.

We aimed to compare the prevalence of left atrial appendage (LAA) thrombus and its predictors between old and young patients with atrial fibrillation (AF). The study included 1970 patients aged ≥ 65 (n = 822 (41.7%)) and < 65 (n = 1148 (58.3%)) referred for AF cardioversion or ablation preceded by transoesophageal echocardiography (TEE). Oral anticoagulation (OAC) was prescribed in 799 (97.2%) patients aged ≥ 65 years and in 1054 (91.8%) of those aged < 65 years (p < 0.001). In patients treated with OAC, those aged ≥ 65 years less often received vitamin K antagonist (VKA) (267 (33.4%) vs. 416 (39.5%)) and more often non-VKA-OAC (NOAC) (532 (66.6%) vs. 638 (60.5%), p = 0.008, p = 0.008) compared to patients < 65 years. On TEE, LAA thrombus was more often observed in patients aged ≥ 65 years than those aged < 65 years (63 (7.7%) vs. 46 (4.0%), p < 0.001), with an absolute but not statistically significant difference between patients aged 65-74 and ≥ 75 years (47 (7.3%) vs. 16 (8.8%), p = 0.528). In patients aged ≥ 65 years, there was no difference in the prevalence of LAA thrombus between patients treated with VKA and NOAC, in contrast to patients aged < 65 years, in whom such a difference was observed (27 (6.5%) vs. 16 (2.5%), p = 0.002). In multivariate logistic regression, predictors of LAA thrombus in both age groups were older age, non-paroxysmal AF, and heart failure, whereas only in patients aged < 65 years - VKA use, and in those aged ≥ 65 years - lower glomerular filtration rate and platelet count. Despite OAC use, older patients with AF remain at high risk of LAA thrombus formation. Older age, non-paroxysmal AF, and heart failure are predictors of LAA thrombus, irrespective of age.

Consideration of non-valvular atrial fibrillation with left atrial appendage thrombus formation despite under appropriate oral anticoagulation therapy

Abstract Background Atrial fibrillation (AF) is the most frequently sustained cardiac arrhythmia, with a prevalence of about 2–3% in the general population. In accordance with CHADS2 or CHA2DS2-VASc score, appropriate oral anticoagulation therapy such as warfarin or direct oral anticoagulants (DOAC) significantly reduced the risk of thromboembolic events. However, left atrial (LA) thrombus can be detected in the LA appendage (LAA) in AF patients despite appropriate oral anticoagulation therapy. Purpose Our purpose was to investigate the associated factors of LAA thrombus formation in non-valvular atrial fibrillation (NVAF) patients despite under appropriate oral anticoagulation therapy. Methods We retrospectively studied consecutive 286 NVAF patients for scheduled catheter ablation or electrical cardioversion for AF in our institution between February 2017 and September 2019. Mean age was 67.1±9.4 years, 79 patients (29.5%) were female, and 140 (52.2%) were paroxysmal AF. All patients underwent transthoracic and transesophageal echocardiography before catheter ablation or electrical cardioversion. All patients received appropriate oral anticoagulation therapy including warfarin or DOAC for at least 3 weeks prior to transesophageal echocardiography based on the current guidelines. LAA thrombus was defined as an echodense intracavitary mass distinct from the underlying endocardium and not caused by pectinate muscles by at least three senior echocardiologists. Results Of 286 NVAF patients with under appropriate oral anticoagulation therapy, LAA thrombus was observed in 9 patients (3.3%). Univariate logistic regression analysis showed that age, paroxysmal AF, CHADS2 score ≥3, left ventricular end-diastolic volume index (LVEDVI), left ventricular ejection fraction (LVEF), left ventricular mass index (LVMI), LA volume index (LAVI), mitral inflow E and mitral e' annular velocities ratio (E/e'), and LAA flow were associated with LAA thrombus formation. It was noteworthy that multivariate logistic regression analysis showed that LAA flow was independent predictor of LAA thrombus (OR: 0.72, 95% CI: 0.59–0.89, p&amp;lt;0.005) as well as LVEF. Furthermore, receiver operating characteristic (ROC) curve analysis identified the optimal cutoff value of LAA flow for predicting LAA thrombus as ≤15cm/s, with a sensitivity of 88%, specificity of 93%, and area under the curve (AUC) of 0.95. Conclusions LAA flow was strongly associated with LAA thrombus formation even in NVAF patients with appropriate oral anticoagulation therapy. According to our findings, further strengthen of oral anticoagulation therapy or percutaneous transcatheter closure of the LAA may be considered in NVAF patients with appropriate oral anticoagulation therapy but low LAA flow, especially &amp;lt;15cm/s. Funding Acknowledgement Type of funding source: None

Left Atrial Appendage Thrombus Formation Despite Continuous Non-Vitamin K Antagonist Oral Anticoagulant Therapy in Atrial Fibrillation Patients Undergoing Electrical Cardioversion or Catheter Ablation: A Comparison of Dabigatran and Rivaroxaban.

Left atrial appendage thrombus (LAAT) may be detected by transesophageal echocardiography (TOE) in patients with atrial fibrillation (AF) despite continuous anticoagulation therapy. We examined the factors predisposing to LAAT in patients treated with the anticoagulants dabigatran and rivaroxaban. We retrospectively evaluated 1,256 AF patients from three centres who underwent TOE before electrical cardioversion (n = 611, 51.4%) or catheter ablation (n = 645, 48.6%) from January 2013 to December 2019 and had been on at least three weeks of continuous dabigatran (n = 603, 48%) or rivaroxaban (n = 653, 52%) therapy. Preprocedural TOE diagnosed LAAT in 51 patients (4.1%), including 30 patients (5%) treated with dabigatran and 21 patients (3.2%) treated with rivaroxaban (p=0.1145). In multivariate logistic regression, predictors of LAAT in patients treated with dabigatran were non-paroxysmal AF (vs. paroxysmal AF) (OR = 6.2, p=0.015), heart failure (OR = 3.22, p=0.003), and a eGFR <60 ml/min/1.73 m2 (OR = 2.65, p=0.012); the predictors in patients treated with rivaroxaban were non-paroxysmal AF (vs. paroxysmal AF) (OR = 5.73, p=0.0221) and heart failure (OR = 3.19, p=0.116). In ROC analysis of the dabigatran group, the area under the curve (AUC) for the CHA2DS2-VASc-RAF score was significantly higher (0.78) than those for the CHADS2, CHA2DS2-VASc, and R2CHADS2 scores (0.67, 0.70, and 0.72, respectively). In the rivaroxaban group, the CHA2DS2-VASc-RAF score also performed significantly better (AUC of 0.77) than the CHADS2, CHA2DS2-VASc, and R2CHADS2 scores (AUC of 0.66, 0.64, and 0.67, respectively). The risk of LAAT was the same for patients in both treatment groups. In all patients, non-paroxysmal AF or heart failure, and in patients treated with dabigatran an eGFR <60 ml/min/1.73 m2, were independent predictors of LAAT. The new CHA2DS2-VASc-RAF scale had the highest predictive value for LAAT in the entire study population.

Safety of transesophageal echocardiography‑guided electrical cardioversion in patients with atrial fibrillation and inadequate anticoagulation.

INTRODUCTION Restoring sinus rhythm in patients with atrial fibrillation (AF)/atrial flutter (AFl) requires adequate oral anticoagulation prior to direct current cardioversion (DCC). Some patients eligible for DCC are not properly anticoagulated. OBJECTIVES The aim of the study was to assess risk factors for thrombus and spontaneous echo contrast (SEC) in the left atrium (LA) as well as the safety profile of transesophageal echocardiography (TEE)-guided DCC in patients with inadequate anticoagulation. PATIENTS AND METHODS From the cohort of 316 patients admitted for DCC, 139 patients (mean [SD] age, 63.4 [11.5] years) had inadequate anticoagulation; 91 patients were admitted urgently for acute coronary syndrome, heart failure (HF), or poor tolerance of arrhythmia. The mean (SD) CHA2DS2‑VASc score was 3.0 (1.7). RESULTS TEE revealed a left atrial appendage (LAA) thrombus in 16 patients (11.5%), and SEC in the LA in 63 patients (45.3%). In a univariate analysis, LAA thrombus was more common in patients after myocardial infarction (odds ratio [OR], 3.92; 95% CI, 1.34-11.48; P = 0.009), while SEC in the LA was more common in patients with HF (OR, 2.23; 95% CI, 1.1-4.53; P = 0.02) and left ventricular ejection fraction of less than 40% (OR, 3.65; 95% CI, 1.66-8.06; P = 0.001). In a multivariate model, the most powerful SEC‑predicting factor was the LA size exceeding 45 mm (OR, 3.08; 95% CI, 1.3-7.29). DCC was performed in 105 patients. No complications of TEE or DCC were observed. CONCLUSIONS AF/AFl inadequately treated with oral anticoagulation predisposes to thrombus formation and SEC in the LA. Once thrombus is excluded, DCC is a safe procedure. There were no predictors of LAA thrombus; therefore, TEE before DCC should be performed in all patients with AF/AFl in accordance with the guidelines.

Decreased left atrial peak systolic strain evaluated by two-dimensional speckle tracking reflects left atrial appendage dysfunction in sinus rhythm patients with acute ischemic stroke

It is well known that transesophageal echocardiography (TEE) is useful for evaluating left atrial appendage (LAA) function, but TEE is a semi-invasive procedure. Many clinical studies have shown a close relationship between LAA thrombus formation and left atrial (LA) mechanical remodeling. Left atrial (LA) strain assessed by two-dimensional speckle tracking echocardiography is a new tool to evaluate LA function. However, the association of LA strain and LAA function remains to be fully determined. We performed transthoracic and transesophageal echocardiography in 58 consecutive patients with acute ischemic stroke within 7 days of onset and sinus rhythm at TEE performed (40 males, mean age 71±11 years). Longitudinal LA strain was obtained using two-dimensional speckle tracking imaging at each LA segment, and peak systolic strain (S-LAs) was calculated by averaging the results for each segment. Eight patients had LAA thrombus and/or severe LAA spontaneous echo contrast (LAA-SEC). S-LAs was significantly lower in patients with LAA dysfunction than in those without (34.5±12.5 vs. 15.9±7.2%, P<0.01). S-LAs was significantly correlated with LAA eV (r=0.466, p<0.01). The optimal cut off value of S-LAs for predicting LAA dysfunction was determined for 21% (Figure). In patients with LAA dysfunction, 7 patients had low S-LAs. In those 6 patients (86%) had history of paroxysmal atrial fibrillation before stroke onset. Multivariate logistic regression analysis showed that S-LAs was an independent predictor of LAA thrombus and/or LAA-SEC (odds ratio 1.758, p<0.01). In conclusion, decreased S-LAs was independently associated with LAA dysfunction and thrombus formation in patients with acute ischemic stroke and sinus rhythm at echocardiography ![Figure][1] Figure 1. Receiver operating characteristics (ROC) curve analysis of LA peak systolic strain for predicting LAA dysfunction. [1]: pending:yes

Predictors of left atrial appendage thrombus in heart failure patients at sinus rhythm

Purpose: It is a well recognized fact that thromboembolic events are frequent in patients with congestive heart failure. Left atrial appendage (LAA) may be a crucial source of thromboembolism in patients with dilated cardiomyopathy. The purpose of this study was to identify clinical and echocardiographic predictors of LAA thrombus in sinus rhythm (SR) patients with dilated cardiomyopathy of mild to moderate systolic dysfunction. Methods: This was a prospective, cross-sectional study conducted on 101 SR patients with dilated cardiomyopathy of ischemic and non-ischemic etiology at mild to moderate systolic dysfunction, which were not under anticoagulation therapy. Demographics, history data, ECG, chest X-ray, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were completed for every patient. Results: Mean patient age was 58.1±12.7 years, 69% were men and 75% were taking Aspirin prior to entering the study. Mean partial thromboplastin time (PTT), LV end-diastolic diameter, LV ejection fraction, LV length in diastole, LA diameter, LAA maximal area were: 25.5±4.2 s, 66.6±6.1 mm, 39±6.4%, 7.7±0.9 cm, 45.9±4.9 mm and 4.7±1.6 cm2, respectively. LAA thrombus was detected in 46 (45.5%) patients, with 87% of them being small and 13% moderate size thrombi. The overall prediction model performed with logistic regression analysis revealed PTT, more prominent LV length in diastole and larger LAA maximal area as significant independent factors of LAA thrombus presence (Table 1). We established the value 8.0 cm as cut-off value for LV length in diastole associated with high frequency of LAA thrombi. View this table: Prediction model for LAA thrombus Conclusions: The high frequency of LAA thrombi detected in our patients with dilated cardiomyopathy demonstrates the necessity for more extensive use of TEE and potential broader use of anticoagulation therapy. We suggest that SR patients with dilated cardiomyopathy whose LV length in diastole measured by TTE is above 8.0 cm should be considered for TEE.

PREDICTING VALUE OF LEFT ATRIAL APPENDAGE THROMBUS IN NONVALVULAR ATRIAL FIBRILLATION PATIENTS BY CHADS2 AND CHADS2-VAS’SCORE AND BY TRANSTHORACIC ECHOCARDIOGRAPHIC PARAMETERS

Objectives: To evaluate size and function of left atrium and left atrial appendage (LAA) by using transthoracic and transesophageal echocardiography in nonvalvular atrial fibrillation (NVAF) patients. Method: 127 NVAF patients (mean age 65,8 ± 10,0 years) were assessed by using CHADS2 and CHADS2-VAS score, transthoracic and transesophageal echocardiographic parameters. Results: CHADS2 ≥3, CHADS2-VAS ≥ 4 and LAVI ≥ 38ml/m2, diagnosis of LAA thrombus has been expected in turn with Se=67% and Sp=70%, Se=67% and Sp=71% and Se=80% and Sp=60%; With LEVF/LAVI ≤1,5, risk of LAA thrombus was OR=13,3; 95% CI (1,8 – 98,5) with p=0,001. Conclusion: CHADS2, CHADS2-VAS, LAVI and ratio LVEF/LAVI are predictors of LAA thrombus in NVAF patients. Key words: CHADS 2, CHADS 2 -VAS, left atrial appendage thrombus, thromboembolism, nonvalvular atrial fibrillation

Cardioversion safety in patients with nonvalvular atrial fibrillation

The objective of this study was to derive and test a score that can accurately predict the presence of left atrial or left atrial appendage thrombus (LAAT) in order to identify patients with nonvalvular atrial fibrillation who can be spared transesophageal echocardiogram (TEE) and safely cardioverted. This cross-sectional observational study including 180 individuals (37.2% women) undergoing clinical, echocardiographic and laboratory evaluation (including cardiac troponin I and C reactive protein; CRP) during an atrial fibrillation episode. LAAT was sought on TEE and predictors of this transesophageal echocardiographic finding were assessed. Based on predictors of LAAT (CRP, atrial volume, troponin, episode duration and stroke or embolism) we derived the CATES score and tested its accuracy through receiver operating curve analysis. LAAT was found in 9.4%. CHADS2 and CHA2DS2-VASc had a modest performance in predicting these changes displaying a 0.620 (c-statistic) in average. Using CATES score displayed a higher area under the curve value 0.816 for LAAT. No patients with LAAT were observed in patients with CATES scores ranging from '0' to '2', which corresponded to 49.4% (n = 89) of the sample. We developed a score that presented a very good accuracy for the detection of LAAT in our sample. Further studies in other populations, such as with bigger dimensions, are needed to validate this score and confirm its capability of selecting a very low risk group of patients that can be spared transesophageal echocardiography.