Spontaneous Echocardiographic Contrast Research Articles

Risk factors for thrombus and spontaneous echocardiographic contrast with sludge among atrial fibrillation patients treated with oral anticoagulants before electrical cardioversion.

Risk factors for thrombus and spontaneous echocardiographic contrast with sludge among atrial fibrillation patients treated with oral anticoagulants before electrical cardioversion.

Rivaroxaban versus enoxaparin plus clopidogrel therapy for hypertrophic cardiomyopathy-associated thromboembolism in cats

Background and Aim: Cardiogenic embolism (CE) is a common complication of feline hypertrophic cardiomyopathy (HCM), leading to severe clinical symptoms. This study compared the effects of rivaroxaban and enoxaparin combined with clopidogrel on cats. Materials and Methods: This was a single-center, prospective, randomized controlled trial. In this study, rivaroxaban or enoxaparin plus clopidogrel was prescribed to 23 cats for at least one of the following events: Abnormal movement of the anterior mitral leaflet during systole, enlargement of the left atrium, spontaneous echocardiographic contrast, or presence of arterial thromboembolism. Oral rivaroxaban (2.5 mg, q24 h) was prescribed to six cats. Subcutaneous injections of enoxaparin (1 mg/kg, q24 h) plus oral clopidogrel (3 mg/kg, PO q24 h) for 60 days were administered to 17 cats. Renal insufficiency and bleeding complications were observed. Plasma concentrations of D-dimer, prothrombin time (PT), partial thromboplastin time, and international normalized ratio (INR) were evaluated. We analyzed the relationship between echocardiography parameters and the effects of coagulation. Blood samples were collected from all cats at baseline and at 1 and 2 months post-treatment. Results: Rivaroxaban alone and in combination with enoxaparin and clopidogrel significantly affected PT and INR. In cats treated with 2.5 mg/kg rivaroxaban for 60 days, no bleeding or recurrence of thrombus formation was observed. These data support the use of rivaroxaban for the treatment of HCM-associated thromboembolism in cats. Conclusion: Treatment of HCM-associated thromboembolism with rivaroxaban alone demonstrated clinical effectiveness with no clinical complications in cats. Keywords: cardiomyopathy, D-dimer, echocardiography, prothrombin time.

Prediction of spontaneous echocardiographic contrast within the left atrial appendage in cardiac computed tomography of patients with atrial fibrillation.

This study aimed to assess the predictors of spontaneous echocardiographic contrast (SEC) using left atrial appendage (LAA) findings in cardiac computed tomography (CT) of patients with atrial fibrillation (AF). We retrospectively analyzed cardiac CT findings of the LAA, including morphology, volume, and filling defects, of 641 patients who underwent transesophageal echocardiography (TEE) prior to pulmonary vein isolation (PVI) from January 6, 2013 through December 16, 2019 at our institution. We investigated potential associated factors that might be predictors of SEC using cardiac CT findings and computed a receiver operator characteristic, choosing a threshold value at which the likelihood of SEC could be predicted based on the LAA volume indexed for body size. SEC correlated significantly with indexed LAA volume (P < 0.001; odds ratio [OR], 1.31; 95% confidence interval [CI], 1.17-1.48) of 7.75 cm3/m2 or greater (sensitivity, 76.0%; specificity, 57.7%), LAA early filling defect (P = 0.005; OR, 2.72; 95% CI, 1.35-5.48), a history of persistent AF (P < 0.001; OR, 3.81; 95% CI, 1.86-7.80), and LAA flow velocity (P < 0.001; OR, 0.97; 95% CI, 0.96-0.99). Findings of LAA in cardiac CT can allow for the noninvasive estimation of SEC to determine the need for additional TEE investigation and the need to obtain additional information for risk stratification and management of thromboembolic events in patients with AF.

Study on the correlation between false-positive filling defect in LAA CT and LAA structure in patients with atrial fibrillation based on TEE.

This study aims to explore the actual meaning of "false positive filling defect" in left atrial appendage (LAA) computed tomography (CT) in patients with atrial fibrillation (AF), with transesophageal echocardiography (TEE) as the gold standard. Patients with AF undergoing cardiac CT angiography and TEE examinations for proposed radiofrequency catheter ablation between October 2020 and October 2021 were selected as the study subjects. Transesophageal echocardiography was taken as the "gold standard," and spontaneous echocardiographic contrast (SEC) and thrombus events were defined as positive events. The CT manifestations were classified into three groups (true positive, false positive, and true negative) to evaluate the differences in left atrium (LA) anterior-posterior diameter (LAAP), LA anterior wall thickness, and LAA orifice long diameter and short diameter, area, and depth between the three groups. (1) There was no statistical difference in LA anterior wall thickness between the three groups (p > .05); there was a statistical difference in LAAP (only) between the true-positive group and the true-negative group (p < .05). (2) There was a statistical difference in LAA orifice long diameter, short diameter, and area between the true-positive group and the true-negative group as well as between the false-positive group and the true-negative group (p < .05). (3) There was a statistical difference in LAA depth between the true-positive group and the false-positive group as well as between the true-positive group and the true-negative group (p < .05). (4) The area under the receiver operator characteristic curve (AUC) of LAA depth affecting the LAA thrombus and SEC was 0.863 (confidence interval=0.718-1.000), the sensitivity was 77.8%, and the specificity was 90.6% for predicting the occurrence of LAA thrombus and SEC in patients with nonvalvular AF (NVAF) and an LAA depth of ≥50.84 mm. There was a difference in LAA diameter between the TEE-based CT false-positive group and the other groups. A "CT false positive" is an objectively existing state, and CT might be able to identify the LAA hemodynamic disorder earlier than TEE. Furthermore, a CT + TEE combined application could more accurately evaluate LAA hemodynamics in patients with AF.

NO CLOT, NO PROBLEM? NOT EXACTLY

SESSION TITLE: Imaging in Cardiovascular CasesSESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/18/2022 12:25 pm - 01:25 pmINTRODUCTION: Atrial stunning is a transient mechanical dysfunction of the left atrium (LA) and left atrial appendage (LAA) related to cardioversion. Left atrial stunning is associated with up to 53% reduction in LAA blood flow velocities and appearance of spontaneous echo contrast (SEC) in 80% of the patients with conversion to sinus rhythm post-cardioversion [1].CASE PRESENTATION: A 92-year-old woman (weight 58.1 kg) with a history of chronic kidney disease Stage IIIb (creatinine 1.5 mg/dL) and symptomatic paroxysmal atrial fibrillation (CHA₂DS₂-VASc score 3) on dose reduced apixaban presented for an elective transesophageal echocardiogram (TEE) and external direct current cardioversion (DCCV). TEE showed preserved LV systolic function without valvular disease. The LA was dilated without findings of left atrial thrombus. The LAA was dilated, SEC was present with diminished exit velocity < 20 cm/s, and no thrombus was noted. The patient underwent successful cardioversion of atrial fibrillation to sinus rhythm. Unfortunately, hours later the patient developed severe right-sided extremity and left-sided facial weakness. CT angiography of head and neck showed a completely occluded left internal carotid artery (LICA). MRI of head and neck showed a large infarct of the left middle cerebral artery. The patient underwent emergent aspiration thrombectomy with extraction of a thrombus measuring 1.2 cm and total vessel recanalization. The patient had partial neurological recovery requiring extensive rehabilitation care.DISCUSSION: Atrial fibrillation has a strong association with larger LA and LAA sizes as well as reduced LAA blood flow velocities. All methods of cardioversion (transthoracic electrical, internal electrical, pharmacological and spontaneous) results in some degree of left atrial stunning and LAA dysfunction. The prevalence of LAA thrombus and relative risk of ischemic stroke is 2.6 times higher when peak LAA velocity is < 20 cm/s [2]. Appearance of SEC also has a strong association with reduced peak LAA velocities per Fatkin et al [3]. It is important to recognize the importance of echocardiographic parameters such as peak LAA blood flow velocities and appearance of SEC in the absence of thrombus even in an anticoagulated patient prior to cardioversion to minimize the risk of thromboembolic events post-cardioversion.CONCLUSIONS: This case highlights the significance of atrial stunning and the potential consequences. Paradoxical reduction of the blood flow in the LA and LAA is directly correlated with increased risk of thromboembolic events for hours to weeks post-cardioversion.Reference #1: Khan IA. Atrial stunning: basics and clinical considerations. Int J Cardiol. 2003;92(2-3):113-128. doi:10.1016/s0167-5273(03)00107-4Reference #2: Stroke Prevention In Atrial Fibrillation Investigators. The stroke prevention in atrial fibrillation III study: rationale, design, and patient features. J Stroke Cerebrovasc Dis. 1997;6(5):341-353Reference #3: Fatkin D, Kelly RP, Feneley MP. Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast and thromboembolic risk in vivo. J Am Coll Cardiol. 1994;23(4):961-969. doi:10.1016/0735-1097(94)90644-0DISCLOSURES: Consultant relationship with Siemens Medical Please note: 03/01/2021-Current Added 03/30/2022 by Nathaniel Dittoe, value=Grant/Research SupportNo relevant relationships by Akruti PrabhakarNo relevant relationships by EricsonJohn TorralbaNo relevant relationships by Damian Valencia SESSION TITLE: Imaging in Cardiovascular Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Atrial stunning is a transient mechanical dysfunction of the left atrium (LA) and left atrial appendage (LAA) related to cardioversion. Left atrial stunning is associated with up to 53% reduction in LAA blood flow velocities and appearance of spontaneous echo contrast (SEC) in 80% of the patients with conversion to sinus rhythm post-cardioversion [1]. CASE PRESENTATION: A 92-year-old woman (weight 58.1 kg) with a history of chronic kidney disease Stage IIIb (creatinine 1.5 mg/dL) and symptomatic paroxysmal atrial fibrillation (CHA₂DS₂-VASc score 3) on dose reduced apixaban presented for an elective transesophageal echocardiogram (TEE) and external direct current cardioversion (DCCV). TEE showed preserved LV systolic function without valvular disease. The LA was dilated without findings of left atrial thrombus. The LAA was dilated, SEC was present with diminished exit velocity < 20 cm/s, and no thrombus was noted. The patient underwent successful cardioversion of atrial fibrillation to sinus rhythm. Unfortunately, hours later the patient developed severe right-sided extremity and left-sided facial weakness. CT angiography of head and neck showed a completely occluded left internal carotid artery (LICA). MRI of head and neck showed a large infarct of the left middle cerebral artery. The patient underwent emergent aspiration thrombectomy with extraction of a thrombus measuring 1.2 cm and total vessel recanalization. The patient had partial neurological recovery requiring extensive rehabilitation care. DISCUSSION: Atrial fibrillation has a strong association with larger LA and LAA sizes as well as reduced LAA blood flow velocities. All methods of cardioversion (transthoracic electrical, internal electrical, pharmacological and spontaneous) results in some degree of left atrial stunning and LAA dysfunction. The prevalence of LAA thrombus and relative risk of ischemic stroke is 2.6 times higher when peak LAA velocity is < 20 cm/s [2]. Appearance of SEC also has a strong association with reduced peak LAA velocities per Fatkin et al [3]. It is important to recognize the importance of echocardiographic parameters such as peak LAA blood flow velocities and appearance of SEC in the absence of thrombus even in an anticoagulated patient prior to cardioversion to minimize the risk of thromboembolic events post-cardioversion. CONCLUSIONS: This case highlights the significance of atrial stunning and the potential consequences. Paradoxical reduction of the blood flow in the LA and LAA is directly correlated with increased risk of thromboembolic events for hours to weeks post-cardioversion. Reference #1: Khan IA. Atrial stunning: basics and clinical considerations. Int J Cardiol. 2003;92(2-3):113-128. doi:10.1016/s0167-5273(03)00107-4 Reference #2: Stroke Prevention In Atrial Fibrillation Investigators. The stroke prevention in atrial fibrillation III study: rationale, design, and patient features. J Stroke Cerebrovasc Dis. 1997;6(5):341-353 Reference #3: Fatkin D, Kelly RP, Feneley MP. Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast and thromboembolic risk in vivo. J Am Coll Cardiol. 1994;23(4):961-969. doi:10.1016/0735-1097(94)90644-0 DISCLOSURES: Consultant relationship with Siemens Medical Please note: 03/01/2021-Current Added 03/30/2022 by Nathaniel Dittoe, value=Grant/Research Support No relevant relationships by Akruti Prabhakar No relevant relationships by EricsonJohn Torralba No relevant relationships by Damian Valencia

Significance of Spontaneous Echocardiographic Contrast in Transcatheter Edge-to-Edge Repair for Mitral Regurgitation

Spontaneous echocardiographic contrast (SEC) in the left atrium can occur with transcatheter edge-to-edge repair (TEER), but the clinical significance is unknown. The authors examined the clinical association of the procedural appearance of SEC in 316 patients (median age, 82years; interquartile range, 76-86years; 43.4% women) undergoing TEER with the MitraClip for mitral regurgitation. Acute, 30-day, and 2-year clinical outcomes were analyzed. SEC was common, occurring following device implantation in 106 patients (34%). Although the occurrence of SEC was not related to clinical characteristics, such as atrial fibrillation, anticoagulant use, or left ventricular function, there was a strong relation to beneficial outcomes with TEER. The frequency of optimal reduction in mitral regurgitation was higher in patients who had SEC (99.1% vs 72.9%, P<.001). Survival was greater, with a 2-year estimate for freedom from all-cause mortality of 88.4% versus 71.5% (log-rank P=.004). Importantly, the higher survival observed in patients with SEC was present without increased rates of procedural complications or stroke and remained significant in multivariate analyses that adjusted for baseline clinical and echocardiographic variables (P=.01). The occurrence of SEC in patients with TEER is associated with beneficial acute and intermediate-term outcomes.

Platelet Priming and Activation in Naturally Occurring Thermal Burn Injuries and Wildfire Smoke Exposure Is Associated With Intracardiac Thrombosis and Spontaneous Echocardiographic Contrast in Feline Survivors.

Wildfires pose a major health risk for humans, wildlife, and domestic animals. We previously discovered pathophysiologic parallels between domestic cats with naturally occurring smoke inhalation and thermal burn injuries and human beings with similar injuries; these were characterized by transient myocardial thickening, cardiac troponin I elevation and formation of intracardiac thrombosis. While the underlying mechanisms remain unclear, results from murine models suggest that platelet priming and activation may contribute to a global hypercoagulable state and thrombosis. Herein, we evaluated and compared the degree of platelet activation, platelet response to physiologic agonists and levels of platelet-derived microvesicles (PDMV) in 29 cats with naturally occurring wildfire thermal injuries (WF), 21 clinically healthy cats with subclinical hypertrophic cardiomyopathy (HCM) and 11 healthy cats without HCM (CC). We also quantified and compared circulating PDMVs in WF cats to CC cats. In addition, we examined the association between thrombotic events, severity of burn injuries, myocardial changes, and the degree of platelet activation in cats exposed to wildfires. Flow cytometric detection of platelet surface P-selectin expression showed that WF cats had increased platelet response to adenosine diphosphate (ADP) and thrombin compared to the two control groups indicating the presence of primed platelets in circulation. In addition, cats in the WF group had increased circulating levels of PDMV, characterized by increased phosphatidylserine on the external leaflet. Cats in the WF group with documented intracardiac thrombosis had elevated platelet activation and platelet priming in the presence of ADP. While high dose arachidonic acid (AA) mostly resulted in platelet inhibition, persistent response to AA was noted among cats in the WF group with intracardiac thrombosis. Univariate and multiple logistic regression analyses demonstrated that increased platelet response to AA was independently associated with thrombotic events. This is the first study reporting the significant association between platelet priming and intracardiac thrombosis in domestic cats with naturally occurring wildfire-related injuries and smoke inhalation. Further studies are required to delineate additional mechanisms between inflammation and thrombosis, especially regarding platelet primers and the cyclooxygenase pathway.One Sentence SummaryPlatelet activation and shedding of platelet-derived microvesicles due to platelet priming is present following naturally occurring wildfire smoke exposure and thermal burn injuries in a population of domestic cats.

The Impact of Spontaneous Echocardiographic Contrast Occurring After Clip Deployment in Transcatheter Edge-to-Edge Repair for Mitral Regurgitation

The Impact of Spontaneous Echocardiographic Contrast Occurring After Clip Deployment in Transcatheter Edge-to-Edge Repair for Mitral Regurgitation

Causes, predisposing factors and clinical implications of spontaneous echocardiographic contrast

Spontaneous echocardiographic contrast is a manifestation of SLUDGE syndrome in the cavities of the heart. The factors that contribute to the emergence of this phenomenon are atrial fibrillation, mitral stenosis, mitral valve prosthesis, left atrial dilatation, decreased left ventricular ejection fraction, hypercoagulable blood conditions, inflammatory diseases, dyslipidemia. Spontaneous echo contrast is a prothrombogenic condition and increases the risk of thromboembolic events, including cerebrovascular complications. This article presents an analytical review of literary sources on this phenomenon for the purpose of its study and determination of treatment tactics in each clinical case.

Newly developed spontaneous echocardiographic contrast as a potential marker of intracardiac thrombus formation after a transcatheter edge-to-edge mitral valve repair

Newly developed spontaneous echocardiographic contrast as a potential marker of intracardiac thrombus formation after a transcatheter edge-to-edge mitral valve repair

CRT-700.59 The Impact of Spontaneous Echocardiographic Contrast Occurring After Clip Deployment in Transcatheter Edge-to-Edge Repair for Mitral Regurgitation

CRT-700.59 The Impact of Spontaneous Echocardiographic Contrast Occurring After Clip Deployment in Transcatheter Edge-to-Edge Repair for Mitral Regurgitation

Incidence of Left Atrial Thrombus Development and Imaging Approach in Patients Scheduled for Repeat Catheter Ablation for Atrial Fibrillation

The risk for developing left atrial (LA) thrombi after initial catheter ablation for atrial fibrillation (AF) and requirements for imaging evaluation for thrombi screening at repeat ablation is unclear. This study aimed to assess the occurrence of thrombus development and frequency of any imaging study evaluating thrombus formation during repeat ablation for AF. Of 2,066 patients undergoing initial catheter ablation for AF with uninterrupted oral anticoagulation, 615 patients underwent repeat ablation after 258.0 (105.0-882.0) days. We investigated the factors associated with safety outcomes and requirements for thrombus screening. All patients underwent at least one imaging examination to screen for thrombi in the initial session; however, the examination rate decreased to 476 patients (77%) before the repeat session. The frequency of imaging evaluations was 5.0%, 11%, 21%, 84%, and 91% for transesophageal echocardiography and 18%, 33%, 49%, 98%, and 99% for any imaging modality at repeat ablation performed ≤60 days, ≤90 days, ≤180 days, >180 days, and >1 year after the initial session, respectively. Three patients (0.5%) developed LA thrombi at repeat ablation due to identifiable causes, and no patients experienced thromboembolic events when no imaging evaluation was performed. Multivariate analysis revealed that repeat ablation performed after >180 days, non-paroxysmal atrial arrhythmias, and lower left ventricular ejection fraction were predictors of thrombus development and severe spontaneous echocardiography contrast. In conclusion, the risk for thrombus development at repeat ablation for AF was low. There needs to be a risk stratification of the imaging screening for thrombi at repeat ablation.

Is transesophageal echocardiogram mandatory for patients undergoing ablation for right atrial flutter with uninterrupted anticoagulants? A prospective single registry

Abstract Funding Acknowledgements Type of funding sources: None. Background. Limited data exist regarding the prevalence of left atrial appendage (LAA) thrombi and spontaneous echocardiographic contrast (SEC) in patients with atrial flutter (AFL). Objectives. Our prospective single-center observational study sought to evaluate the prevalence of LAA thrombi in patients referred for AFL ablation, compared to those requiring atrial fibrillation (AFib) ablation during the same time period, as well as to determine the predictive factors of LAA thrombi in terms of arrhythmia etiology. Methods and Results. From July 2019 to August 2020, 321 consecutive patients who were referred for either AFib ablation (n = 229) or AFL ablation (n = 92) were included in the study, with a thrombus detected by transesophageal echocardiography (TEE) in 3.22% (12/321). Prior to ablation under anticoagulants, the percentage of thrombi was similar between patients referred for AFL ablation and those referred for AFib ablation (5.4% [n = 5/92] vs. 3.1% [n = 7/229]; p = 0.3). In the overall population, patients with LAA thrombi had a higher CHA²DS²-VASc score (3 ± 2 vs. 2 ± 1.5; p = 0.048) and a higher presence of valvular prothesis (25% vs. 4.9%; p = 0.003), with relevant left atrial remodeling  more often observed, such as demonstrated by a higher left atrium (LA) volume (57 ± 19 vs. 46 ± 17 ml/m²; p = 0.04), a lower LAA velocity (0.41 ± 0.3 vs. 0.55 ± 0.2; p = 0.04) and a more severe LAA echo contrast (83.3% vs. 3.2%; p &amp;lt;0.0001). In the subset of patients with right AFL, patients with LAA thrombi had a higher CHA²DS²-VASc score (4.4 ± 1 vs. 2.5 ± 1.5; p = 0.008), had more often hypertension (100% vs. 53%; p = 0.04) and more often diabetes mellitus (60% vs. 18.4%; p = 0.03), and a more severe LAA echo contrast (80% vs. 5.7%; p &amp;lt;0.0001). Predictive factors of atrial thrombi evaluated by crude odds ratios were the presence of valvular prosthesis (OR = 6.53; [1.60, 26.65] ; p = 0.009), the CHA²DS²-VASc score (OR = 1.41 [0.99, 2.01] ; p = 0.05), the LAA velocity (cm/s) (OR = 0.03; [0.001, 0.79]; p = 0.04) and presence of severe LAA contrast (OR = 188 ; [35.32, 1002.02] ; &amp;lt;0.0001) rather than the atrial arrhythmia itself. Conclusions. Patients referred for ablation with right AFL have a similar risk of LAA thrombi, compared to those with AFib. The risk of LAA thrombi is better related to the presence of valvular prosthesis, CHA²DS²-VASc score and LA remodelling than the atrial arrhythmia itself. Accordingly, TEE should be recommended before right AFL ablation, especially in case of a valvular prosthesis, high CHA²DS²-VASc score or LA alteration.

Dual therapy with clopidogrel and rivaroxaban in cats with thromboembolic disease.

Feline arterial thromboembolism (ATE), an often devastating outcome, was recently shown to affect 11.3% of cats with hypertrophic cardiomyopathy over 10 years. Current American College of Veterinary Internal Medicine guidelines recommend the use of clopidogrel in cats at risk for ATE, with addition of a factor Xa inhibitor in very high risk or post-ATE cases. To date, no studies have examined the safety or efficacy of this combined antithrombotic therapy. This retrospective case series aimed to assess the frequency and type of adverse events that occurred in cats prescribed dual clopidogrel and rivaroxaban therapy. Secondary aims were to evaluate indications for dual therapy and clinical outcome. The study included 32 cats prescribed clopidogrel (18.75 mg PO q24h) and rivaroxaban (2.5 mg PO q24h) on an outpatient basis over a 5-year period. Cats were prescribed dual therapy for at least one of the following: ATE event (n = 18), presence of an intracardiac thrombi (n = 17) or presence of spontaneous echocardiographic contrast (SEC) (n = 16). Five cats experienced adverse effects that could be attributed to medications, a median of 13 days from initiation (epistaxis, hematemesis, hematochezia or hematuria). No cat required hospitalization as a result of these events. Median survival time from onset of therapy was 257 days (interquartile range [IQR] = 38-497) for all cats, 502 days (IQR = 171-663) for ATE cats, 725 days (IQR = 133-856) for cats with an ATE to two or more limbs and 301 days (IQR = 221-431) for cats with only one limb affected. Recurrence rate of ATE while on dual therapy was 16.7%; no cat newly developed an ATE while on dual therapy. Dual antithrombotic therapy with clopidogrel and rivaroxaban resulted in a low reported incidence of adverse events. Cats placed on dual therapy for an ATE event experienced a low rate of recurrence and effective thromboprophylaxis was achieved in cats with intracardiac thrombi or SEC.

[Safety and efficacy of percutaneous left atrial appendage closure in nonvalvular atrial fibrillation patients with left atrial spontaneous echocardiographic contrast].

Objective: To investigate the safety and efficacy of percutaneous left atrial appendage closure (LAAC) in nonvalvular atrial fibrillation patients (NVAF) with left atrial spontaneous echocardiographic contrast (LA SEC). Methods: A total of 95 NVAF patients treated in the Department of Cardiology of Ningbo First Hospital from July 2018 to June 2019 were enrolled in this study. The study population was divided into two group according to the presence or absence of LA SEC detected by transesophageal echocardiography (TEE). TEE was scheduled 45 days post-procedure to detect device-related thrombus (DRT). Stroke and bleeding events were recorded during follow-up. Periprocedural complications and follow-up results were compared between the two groups. Results: LA diameters were smaller in non-LA SEC group than LA SEC group ((44.0±7.4)mm vs (47.3±6.6)mm, P=0.033). Watchman device was successfully implanted into all the enrolled patients. No death, transient ischemic attack (TIA)/stroke, device embolization and major bleeding events occurred. Fifty patients (90.2%) in LA SEC group and 31 patients (91.2%) in non-LA SEC group finished TEE follow-up 45 days post-procedure. No device-related thrombus was detected in non-LA SEC group, while 2 cases (6.5%) were detected in LA SEC group, but there was no significant differences in the incidence between the two groups (P=0.127). The LA SEC group and non-LA SEC group were followed-up for (12.3±3.8) months and (12.9±3.3) months, respectively; and there was no significant differences in the incidence of death, TIA/stroke, major and minor bleeding events between two groups during the follow-up (all P>0.05). Conclusion: LAAC in NVAF patients with LA SEC was safe and effective. However, the incidence of DRT was slightly higher.

Estimation of left atrial appendage wall motion velocity in patients with persistent nonvalvular atrial fibrillation and its effect on thrombotic risk

Background and aim Atrial fibrillation (AF) is the most common arrhythmia and accounts for one-third of hospitalizations for rhythm disorders in the United States. This increasing burden of AF leads to a higher incidence of stroke.Aim The aim of the study is to assess the risk of thrombogenesis in patients with persistent nonvalvular AF by using transthoracic echocardiogram, transesophageal echocardiogram, and tissue Doppler imaging in relation to the risk of thromboembolism (CHA2DS2-VAS score).Patients and methods Selected 50 patients with persistent AF were included. All patients underwent echocardiography assessment at the echocardiography unit.Results Regarding spontaneous echocardiography contrast, there was a statistically significant difference among the three groups. Regarding left atrial appendage (LAA) thrombus, there was a statistically significant difference among the three groups. Regarding left atial appendage flow velosity (LAAFV), there was an extremely statistically significant difference among the three groups. Regarding left atrial appendage wall velosity (LAAWV) by transthoracic echocardiogram, there was an extremely statistically significant difference among the three groups. Regarding LAAWV by transesophageal echocardiogram, there was an extremely statistically significant difference among the three groups.Conclusion Patients with clinical predictors of high risk included in the CHA2DS2-VASc score were associated with increased incidence of thrombus in the LAA. In patients with nonvalvular AF, the CHA2DS2-VASc score is recommended for assessment of stroke risk. There was a correlation between the development of thromboembolic events and high-risk CHA2DS2-VASc score, as high scores indicate increased thrombogenicity.

A novel risk model to predict first-ever ischemic stroke in heart failure with reduced ejection fraction

Patients with heart failure are at increased risk for ischemic stroke. We aim to develop a more accurate stroke risk prediction tools identify high-risk patients with heart failure with reduced ejection fraction (HFrEF). Patient data were extracted retrospectively from the electronic medical database between January 2009 and February 2019. Univariate and multivariate Cox regression analysis were performed to identify independent predictors, which were utilized to construct a nomogram for predicting ischemic stroke. AUROC analysis was used to compare the prognostic value between the new risk score and CHADS2/CHA2DS2-VASc scores. In 6087 patients with HFrEF, the risk of first-ever ischemic stroke was 5.8% events/pts-years (n=468) during 8007.2 person-years follow-up. A nomogram constructed by integrating 6 variables, including age, atrial fibrillation (AF), deep vein thrombosis (DVT), d-dimer, anticoagulant use and spontaneous echocardiographic contrast (SEC)/left ventricular thrombus (LVT), exhibited a greater area under the curve of 0.727, 0.728 and 0.714 than that by CHADS2 score (0.515, 0.522 and 0.540), and by CHA2DS2-VASc score (0.547, 0.553 and 0.562) for predicting first-ever ischemic stroke at hospitalization, 30-day and 6-month follow-up (all p<0.001). This novel stroke risk score performed better than existing CHADS2/ CHA2DS2-VASc scores and showed improvement in predicting first-ever ischemic stroke in HFrEF patients.

The prevalence, predictors, and outcomes of spontaneous echocardiographic contrast or left ventricular thrombus in patients with HFrEF.

AimsThis study aimed to determine prevalence, predictors, and association with ischaemic stroke risk of spontaneous echocardiographic contrast (SEC) or left ventricular thrombus (LVT) in patients with heart failure with reduced ejection fraction (HFrEF).Methods and resultsClinical, echocardiographic, and follow‐up data from January 2009 through February 2019 were retrospectively extracted from electronic medical records of patients with heart failure with left ventricular ejection fraction < 40% by echocardiography on admission, with follow‐up to February 2020. Of 9485 consecutive patients with HFrEF, 123 (1.3%) presented LVT and 331 (3.5%) presented SEC. Patients with vs. those without SEC/LVT had larger left ventricular end‐diastolic volume (199.5 ± 77.7 vs. 165.8 ± 61.3 mL, P < 0.001), lower left ventricular ejection fractions (29.5 ± 7.0% vs. 33.7 ± 5.5%, P < 0.001), and more often ischaemic cardiomyopathy, apical aneurysm, chronic kidney diseases, and smoking habit. In Cox regression analysis, SEC and LVT were independent predictors for ischaemic stroke occurrence [hazard ratio (HR) = 2.40, 95% confidence interval (CI): 1.74–3.31; HR = 4.52, 95% CI: 2.77–7.40, both P < 0.001]. In patients with those without SEC or LVT, stroke risk was higher among those not on anticoagulants (HR = 2.55, 95% CI: 1.85–3.53; HR = 4.71, 95% CI: 2.84–7.81, both P < 0.001), but similar among those on anticoagulants (P > 0.05). In patients with sinus rhythm, the associations between SEC/LVT and ischaemic stroke persist with HRs of 2.57 (95% CI: 1.69–3.92) and 5.74 (95% CI: 3.38–9.75).ConclusionsIn patients with HFrEF, SEC was not uncommon and increased risk of ischaemic stroke as well as LVT. Anticoagulants could play a role in the reduction of stroke risk, suggesting that patients with SEC/LVT, even those in sinus rhythm, would benefit from systemic anticoagulation treatment.

Evaluating the novel parameters for assessing the LAA function and thrombus formation with nonvalvular atrial fibrillation.

The dysfunction of left atrial appendage (LAA) is prone to form thrombus when atrial fibrillation (AF) sustained more than 48 h. Traditional 2D-TEE (transesophageal echocardiography) can not accurate evaluate the function of LAA. The purpose of this study is to analyze the relationship of LAA function parameters and thrombus formation in patients with non-valvular atrial fibrillation (NVAF) by real-time three-dimensional transesophageal echocardiography (RT-3D-TEE). High risk patients can be identified according to the characteristics of ultrasonic index in patients with left atrial appendage thrombosis, which has important clinical value and significance in the risk assessment, guiding treatment and judging prognosis. We examined the relationship between the echocardiographic parameters of LAA function and the incidence of thrombus in 102 NVAF patients. They underwent RT-3D-TEE and left atrial appendage thrombus (LAAT)/severe spontaneous echocardiographic contrast (SSEC) was found in 67 patients (thrombus group) but absent in the remaining 35 patients (non-thrombus group). After measured by QLAB software, the LAA functional parameters were significantly associated with LAAT/SEC formation. Univariate analysis indicated that AF time, LAD, LVEF, LAA-OAmax, LAAVmax, LAAVI and LAAEF demonstrated a positive association (P < 0.05). However, logistic regression analysis identified that AF time (OR:1.73, P < 0.05)、LAAEF (OR:4.09, P < 0.01)and LAAVI (OR:3.28, P < 0.01) were independent predictors of LAAT/SSEC. In patients with nonvalvular atrial fibrillation, echocardiographic parameters of LAA function are significantly associated with LAAT/SSEC.

TCT CONNECT-441 The Prevalence, Predictors, and Clinical Outcomes of Spontaneous Echocardiographic Contrast or Left Ventricular Thrombus in Patients With HFrEF

Spontaneous echocardiographic contrast (SEC) predisposes to intracardiac thrombus; the clinical outcomes of SEC have rarely been addressed. The aim of this study was to identify ischemic stroke risk associated with the presence of SEC or left ventricular thrombus (LVT) in patients with heart failure