Thrombus In Left Atrium Research Articles

Resolution of silent left atrial thrombi and clinical outcomes in patients with atrial fibrillation: insight from the LAT trial

Abstract Background Silent thrombi in the left atrium (LA), which are thrombi that have not yet caused thromboembolism, are occasionally observed in patients undergoing transesophageal echocardiography (TEE) for atrial fibrillation (AF). However, there is limited data regarding the impact of resolving these silent LA thrombi (LAT) on patient outcomes. Methods We conducted a retrospective review of clinical records from 2010 to 2018 at six hospitals, involving 17,436 TEE procedures for patients with AF. Among these, 297 patients (1.7%) were identified with silent LAT. Of these, 169 patients with follow-up TEE or cardiac computed tomography data for assessing the resolution of LAT were included in this study. The study population were categorized into two groups: the successful resolution group, defined as those with complete LAT resolution without any related events (N=130), and the failed resolution group (N=39). The latter included patients with residual LAT at the last follow-up (N=26), individuals with thromboembolic events (N=8), or those who required surgical intervention for LAT (N=5). Results During the median follow-up period of 394 days (interquartile range, 373-421 days) following thrombi detection, ischemic stroke and systemic thromboembolism (IS/SE) were observed in 10 cases, major bleeding in 23 cases, and all-cause death in 8 cases. In comparison to the successful resolution group, the failed resolution group not only exhibited a higher incidence of IS/SE (1.5% in the successful vs. 20.5% in the failed resolution group, Log-rank p < 0.001) but also showed trends toward increased major bleeding (10% vs. 23.1%, p = 0.033) and higher total mortality rates (3.1% vs. 10.3%, p = 0.05). These differences in composite endpoints were also statistically significant (13.9% vs. 35.9%, p = 0.001). Conclusion In patients with silent LATs were identified, non-resolution of these LATs was associated with not only a higher incidence of IS/SE but also increased rates of major bleeding and all-cause mortality. Conversely, patients who experienced LAT resolution exhibited more preferable prognoses. The status of LAT resolution is closely associated with patient outcomes, underscoring the importance of monitoring LAT resolution in stratifying patient prognoses.

Assessment of Coagulation Factors in Patients with Severe Rheumatic Mitral Stenosis in Sinus Rhythm with Left Atrial Appendage Inactivity

BackgroundPatients with severe mitral stenosis (MS) in normal sinus rhythm (NSR), presenting with left atrial appendage (LAA) inactivity and associated left atrial spontaneous echo contrast (LASEC) are prone to left atrium (LA) or LAA thrombus formation. But unlike for atrial fibrillation, oral anticoagulants are not commonly prescribed for this patient subset. This study aimed to compare the levels of procoagulants and fibrinogen in both local (LA) and systemic contexts between patients with severe MS in NSR vs those in healthy control subjects. MethodsThe study involved 35 patients with severe MS in NSR with LAA inactivity and LASEC who were eligible for balloon mitral valvuloplasty vs 35 healthy controls. All patients underwent transthoracic and transesophageal echocardiography to assess MS severity, LAA activity, and LASEC grade, and had blood samples analyzed for procoagulant levels. ResultsResults showed comparable baseline characteristics between groups, with most patients in the New York Heart Association II or III functional classes, and with varying LASEC grades. Patients exhibited significantly higher levels of prothrombin fragment 1 + 2 [patient vs control, 9017 pg/mL (6228.0-10,963.5) vs 1790 pg/mL (842.3-2712), P < 0.0001], thrombin-antithrombin III [patient vs control, 39 ng/mL (5.45-74.85) vs 2.80 ng/mL (1.6-6.5), P < 0.0001], plasminogen activator inhibitor-1 (patients vs controls, 26.09 ± 8.18 ng/mL vs 8.05 ± 3.53 ng/mL, P < 0.0001), and fibrinogen (3.48 ± 0.89 g/L vs 3.01 ± 0.53 g/L, P = 0.029) in the LA of patients, compared to those in control subjects. Systemic procoagulant levels also were elevated in patients, but D-dimer levels were similar between the 2 groups. ConclusionsThe findings suggest a hypercoagulable state in patients, similar to that in patients with atrial fibrillation. The study advocates for consideration of use of oral anticoagulants in these patients until LA and LAA function improves, to mitigate thrombus formation.

Giant mobile thrombus in left atrium

Giant mobile left atrial thrombus has a rare occurrence. Rheumatic mitral valve stenosis (RMVS), which is frequently seen in developing countries, atrial fibrillation, and left atrial dilatation contribute to faster and higher volume thrombus formation. A 46-year-old female suffering from dyspnea was admitted to the cardiology outpatient. Transthoracic and transesophagial echocardiography confirmed rheumatic mitral stenosis with 3.5x 2.5 cm mobile circulating thrombus in left atrium. The patient underwent successful surgical thrombus removal, prostetic mitral valve replacement, and surgical ligation of the left appendage.

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 &amp;lt; 45%)(+0.5) and diastolic (Lateral E/e’ &amp;gt; 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

Percutaneous left atrial appendage occlusion in mitral valve disease: A Nationwide Readmission Database analysis

BackgroundPercutaneous left atrial appendage occlusion (LAAO) has emerged as a non-pharmacologic alternative to oral anticoagulation in reducing stroke risk in AF patients. However, patients with mitral valve disease (MVD), who are expected to have a significantly greater risk of left atrium (LA) thrombus formation and embolic stroke were excluded from randomized trials examining percutaneous LAAO. To address this gap, we present a national registry analysis of the use of LAAO among patients with MVD. MethodsUsing the National Readmissions Database, we performed a retrospective review of all hospitalizations for LAAO identified between September 2015 and November 2019. Of these, patients with ICD-10 codes for MVD were identified. Propensity matched (PSM) analysis was used to compare patients with MVD with a matched sample of patients undergoing LAAO with non-valvular AF. Outcomes examined included all-cause mortality, stroke, major bleeding, pericardial effusion (PE), and tamponade. Results51,540 patients who underwent LAAO without a history of MVD and 3777 with a history of MVD were identified. Crude analysis demonstrated the odds of mortality, PE, and cardiac tamponade during index hospitalization to be higher in the MVD group. The length of stay and cost of index hospitalization were also slightly greater for the MVD group. A sample of 7649 patients (MVD: 3777 MVD and no MVD: 3872) were selected for PSM analysis with similar comorbidities across the two groups. In the PSM comparison, MVD was associated with higher risk of PE. The MVD group had a slightly higher rate of readmissions the association with PE remained at 30-day readmission (OR: 2.099 [1.360–3.238], p-value: <0.001). ConclusionTo our knowledge, this is the first study examining the use of LAAO among MVD patients. Our findings suggest that patients with MVD who underwent LAAO had a higher risk of post-procedural PE without an increase in mortality, stroke, or major bleeding. These results provide a rationale for considering LAAO as part of the stroke prevention strategy among patients with valvular AF.

Cardiac thrombus dissolution in acute ischemic stroke: A substudy of Mind the Heart

BackgroundCardiac thrombi are an important cause of ischemic stroke but are infrequently detected on cardiac imaging. We hypothesized that this might be explained by early dissolution of these cardiac thrombi after stroke occurrence. MethodsWe performed a single-center observational pilot study between November 2019 and November 2020, embedded in the larger “Mind-the-Heart” study. We included patients with AIS and a cardiac thrombus in the left atrium or ventricle (filling defect <100 Hounsfield Units) diagnosed on cardiac CT that was acquired during the initial stroke imaging protocol. We repeated cardiac CT within one week to determine if the thrombus had dissolved. ResultsFive patients (four men, median age 52 years, three with atrial fibrillation and one with anticoagulation therapy at baseline) were included. Median time from symptom onset to first cardiac CT was 383 (range 42–852) minutes and median time from first to second cardiac CT was three days (range 1–7). Two patients received intravenous thrombolysis (IVT). In total, six thrombi were seen on initial CT imaging (one in the left ventricle, four in the left atrial appendage, one in the left atrium). The left atrium thrombus and one left atrial appendage thrombus had dissolved on follow-up cardiac CT, one of which was in a patient with IVT treatment. ConclusionThis pilot study illustrates that cardiac thrombi can dissolve within days of stroke occurrence both with and without IVT treatment.

Aetiology and Clinical Profile of Giant Left Atrium – An Observational Study

Background: The predominant cause of giant left atrium (GLA) is rheumatic mitral valvular disease. GLA is commonly defined echocardiographically by measuring the left atrial diameter (LAD). In the context of changing epidemiology of rheumatic heart disease (RHD) globally, and introduction of left atrial volume index (LAVI), the aetiology of GLA and utility of LAVI for defining GLA may be necessary. Methods: The prospective observational study was carried out at a dedicated tertiary care cardiac centre of a developing country to know the aetiology and clinical pattern of GLA over 8 years. GLA was defined echocardiographically as a left atrium (LA) having a diameter ≥80 mm in the left parasternal long-axis view. Follow-up was made over the telephone. Results: Thirty cases of GLA were diagnosed over 8 years from 2013 to 2021. Twenty two were due to rheumatic heart disease (RHD), 7 due to MVP, and 1 due to flail anterior mitral leaflet. Mean LAD was 92.13 ± 16.72 mm, and the mean LAVI was 288.77 ± 134.40 ml/m2. LA thrombus was present in 5 patients, 6 had spontaneous echo contrast (SEC) in LA, 2 had both LA thrombus and SEC. Mean follow-up was 0.99 ± 1.06 years. Out of 15 patients, 5 died, while 10 were alive. Mean survival was 1.8 ± 1.17 years, ranging from less than 1 year to 4 years. Conclusion: RHD continues to be the predominant cause of GLA; however, MVP is also important. The cut-off value of LAVI for defining GLA needs further study. Cardiovasc j 2023; 15(2): 151-158

The pathogenesis of aging-induced left atrial appendage thrombus formation and cardioembolic stroke in mice is influenced by inflammation-derived matrix metalloproteinases

Elderly people without atrial fibrillation (AF) still have a high incidence of cardioembolic stroke, suggesting that thrombus formation within the left atrial appendage (LAA) may also occur in an AF-independent manner. In the present study, we explored the potential mechanisms for aging-induced LAA thrombus formation and stroke in mice. We monitored stroke events in 180 aging male mice (14–24 months) and assessed left atrium (LA) remodeling by echocardiography at different ages. Mice that had stroke were implanted with telemeters to confirm AF. Histological features of LA and LAA thrombi were examined, as well as collagen content, expression of matrix metalloproteinases (MMPs), and leukocyte density in the atria at different ages, in mice with or without stroke. Also, the effects of MMP inhibition on stroke incidence and atrial inflammation were tested. We detected 20 mice (11 %) with stroke, 60 % of which were within 18–19 months of age. Although we did not detect AF in mice with stroke, we detected the presence of LAA thrombi, suggesting that stroke originated from the hearts of these mice. Compared with 18-month-old mice without stroke, 18-month-old stroke mice had enlarged LA with a very thin endocardium, that was associated with less collagen and heightened MMP expression in the atria. During aging, we found that the expression of mRNAs for atrial MMP7, MMP8, and MMP9 peaked at 18 months, which closely correlated with reductions in collagen content and the time-window for cardioembolic stroke in these mice. Treatment of mice with an MMP inhibitor at 17–18 months of age reduced atrial inflammation and remodeling, and stroke incidence. Taken together, our study demonstrates that aging-induced LAA thrombus formation occurs through a mechanism involving upregulation of MMPs and breakdown of collagen, and that treatment with an MMP inhibitor may be effective as a treatment strategy for this heart condition.

Abstract 14050: A Giant Free-Floating Ball Thrombus or a Tiny Fibroelastoma: Which Causes Multiple Strokes?

Background: Left atrial (LA) thrombus is not rare in patients with mitral valve stenosis, but in patients with nonvalvular atrial fibrillation on anticoagulation, the formation of a "ball thrombus" in the LA is uncommon. Case: A 73-year-old man with nonvalvular atrial fibrillation on eliquis presented with frequent syncope and slurred speech. .The appearance of the infarcts on brain MRI and involvement of different vascular territories suggests embolic phenomena as the cause. On transthoracic echo a large, highly mobile echo density in the left atrium was noted. Transesophageal echo revealed smoke in the left atrium and the left atrial appendage. A large round mobile echo density mass measuring 4.7 cm X 3.6 cm was seen in left atrium with no attachment to left atrium. A mobile round density measuring 0.7x0.7 cm was seen on the right coronary cusp. Absence of perfusion, no enhancement, and high signal intensity on T1 and T2 weighted images on cardiac MRI was suggestive organized clot in left atrium. Decision-making: Both masses were removed successfully. Pathology confirmed a large intact spherical organized clot from the LA and a small fibroelastoma attached to the aortic leaflet. Conclusion: This was a rare case of giant round-shaped left atrium thrombus, which occurred in a patient with nonvalvular atrial fibrillation on anticoagulation. An aortic fibroelastoma was also discovered by transesophegeal echo as another potential cause of stroke. The left atrial thrombus is thought to have developed from a small mural thrombus caused by prolonged blood stagnation, which gets rounded by the sculpting impact of multiple complex encounters with the atrial wall. This may then detach from the LAA and form a floating "ball thrombus.

Predicting the presence of left atrial appendage thrombus with clinical features and transthoracic measurements using machine learning

Abstract Background Atrial fibrillation and flutter (AF/AFl) increase the risk of thromboembolic events by promoting clot formation in the left atrium (LA), which can be visualised using transoesophageal echocardiography (TEE). Current guidelines recommend initiation of oral anticoagulation (OAC) in patients with AF/AFl based solely on CHA2DS2VASc score (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, history of stroke or thromboembolism, vascular disease, age 65 to 74 years, female sex). Yet, some patients develop left LA thrombus (LAT) and experience thromboembolic events despite OAC. Purpose We sought to develop and externally validate a machine learning model for prediction of presence of LAT based on clinical, laboratory and transthoracic echocardiography (TTE) features. Methods We analyzed data from the multicenter, prospective LATTEE registry (Left Atrial Thrombus on Transesophageal Echocardiography) that included patients from 13 sites who underwent TEE before cardioversion or ablation between November 2018 and March 2021. We used XgBoost model to predict presence of LAT in TEE based on 29 clinical features, 10 biomarkers and 5 TTE measurements. We trained and tested the model internally using 10-fold hold-out cross validation and data from 12 sites (N=2489). We then tested the final model externally using data from the 13th site (that had recruited most patients, N=400). We compared the predictive performance with that of CHA2DS2VASc score using areas under receiver operating curve (AUC) and DeLong test. Results In the training and internal testing cohort the median age was 67 (Inter Quartile Range [IQR] 59, 74), 63% were male, 85% received OAC and LAT was found in 8.4%. Ablation was the indication for TEE in 43%, cardioversion in 57%. In internal, 10-fold hold-out cross validation, the model achieved AUC of 0.755 (95% confidence interval [CI]: 0.722, 0.788) while CHA2DS2VASc performed significantly worse with AUC of 0.638 (95% CI: 0.604, 0.673), P&amp;lt;0.0001 (Figure 1). Left ventricular ejection fraction, rhythm at the time of study (AF/AFl or sinus rhythm) and age received the highest feature importance ranking (Figure 2). In the external testing cohort the median age was 67 (IQR 59, 74), 66% were male, 88% received OAC, ablation was the indication for TEE in 49% of cases and LAT was found in 6.8%. In this external cohort, our model achieved AUC of 0.815 (95% CI: 0.741, 0.889) while CHA2DS2VASc performed significantly worse with AUC of 0.684 (95% CI: 0.583, 0.785), P=0.028. Conclusion Machine learning based on readily available clinical data allows accurate prediction of the presence of LAT in patients with AF/AFl irrespective of OAC treatment. Such score could be used to identify patients who should undergo TEE before ablation or cardioversion. Subsequent studies to clinically evaluate such application of our model as well as how the model can predict future thromboembolic events are warranted. Funding Acknowledgement Type of funding sources: None.

Giant Left Atrial Thrombus in a Heart Transplant Recipient - Risk Factors and Diagnostic Approach

<h3>Introduction</h3> The left atrium (LA) in heart transplant (HT) recipients is a surgically created chamber from different portions of donor and recipient atria and is thus frequently enlarged. It was hypothesized that remaining sutures and LA enlargement may precipitate LA thrombus (LAT) formation, but LAT following bi-caval anastomosis has seldom been described. We report a case of a giant LAT diagnosed upon routine transthoracic echocardiography in an asymptomatic HT recipient. <h3>Case Report</h3> A 58 y/o man with non-ischemic cardiomyopathy underwent orthotopic HT (bi-caval technique) from a 30 y/o donor with head trauma. Perioperative course and long-term follow up were uneventful, except for an early single self-resolving episode of atrial fibrillation (AF). Chronic aspirin therapy was administered per institutional protocol. The immunosuppression protocol included tacrolimus, mTORi and prednisone. Five years after HT, routine follow up TTE revealed, within a known enlarged LA (AP diameter 56mm, area 30mm²), a new large fixed mass (29*39mm) that had not been evident on previous TTEs done every 3 months. Blood count, electrolytes, and CRP were unremarkable; no arrhythmia was documented. Transesophageal echocardiography revealed a large immobile echogenic mass attached to the interatrial septum (Fig. 1A), and ECG-gated CT revealed a non-contrast enhancing filling defect (36*31*39mm) adjacent to the interatrial septum (Fig. 1B). Cardiac MRI showed a homogenous non-gadolinium enhancing mass adherent to the interatrial septum at the upper pole of the LA. Collectively, these findings were consistent with a diagnosis of LAT. Anticoagulation therapy was initiated, and mTORi was withdrawn; no further embolic events were recorded. <h3>Summary</h3> Remaining sutures, enlarged LA, history of AF and immunosuppressive therapies may play a role in thrombus formation. Systematic echocardiographic surveillance post-HT should be considered for early diagnosis and treatment of this potentially devastating complication.

Abstract 10358: Incidence of Transesophageal Echocardiography-Related Esophageal Mucosal Injury in Patients with Pulmonary Vein Isolation as a Treatment for Atrial Fibrillation

Introduction: Transesophageal echocardiography (TEE) is the gold standard modality for detecting a thrombus in the left atrium (LA) and the left atrial appendage (LAA) prior to pulmonary vein isolation (PVI) for the treatment of atrial fibrillation. Although TEE is has a good safety profile, it was recently reported that TEE preceding PVI can cause esophageal mucosal injury (EMI). However, the detailed data and mechanism of EMI by TEE remain to be elucidated. Herein, we investigated the incidence and risk factors of TEE-related EMI in patients who underwent PVI for AF. Methods: This study included 262 consecutive patients who underwent PVI with preoperative TEE using a 3D TEE probe and postoperative esophagogastroduodenoscopy. The cause of EMI was classified by an experienced gastroenterologist. Results: TEE-related EMI was found in 16 (6.1%) patients, whereas PVI-related EMI was found in 5 (1.9%) patients. Only one patient with TEE-related EMI experienced mild chest discomfort. In the multivariate analysis, advanced age was an independent risk factor for TEE-related EMI (odds ratio, 1.08 per 1-year increment; 95% confidence interval, 1.01-1.16; p = 0.0274). Conclusions: The incidence of TEE-related EMI, for which advanced age could be a significant risk factor, using a 3D TEE probe was relatively high in patients who underwent PVI. This study suggests that attention should be paid to the indications of TEE before performing PVI, especially in elderly patients, and other modalities for ruling out LA and LAA thrombus should also be considered.

A Mass in the Left Ventricular Outflow Tract After Mitral Valve Replacement

A 34-year-old woman presented with a four-year history of shortness of breath and dyspnea on exertion that had worsened over the preceding six months. The patient had a stroke two years before her current presentation but had no residual neurologic deficits. Transthoracic 2 two-dimensional echocardiography revealed severe mitral stenosis (peak/mean gradients = 21/14 mmHg), with a mitral valve area of 0.7 cm2 by the pressure-half time method, and calcific thickened mitral valve leaflets with commissural fusion and subvalvular thickening. Pulmonary hypertension was present (right ventricular systolic pressure of 45 mmHg). Left ventricular (LV) ejection fraction was normal (62%). The left atrium (LA) was dilated (60 mm) but LA thrombus was absent. Normal sinus rhythm was present. During surgery, the native mitral valve was replaced with a 25-mm bileaflet mechanical prosthesis. Preservation of both the mitral leaflets and the subvalvular apparatus was carried out. Repeat transesophageal echocardiography (TEE) showed the mechanical prosthesis to be functioning well. In the midesophageal aortic valve (AV) long-and short-axis views, a new mass measuring 8 × 7 mm was seen moving into the aortic root in systole and the left ventricular outflow (LVOT) tract in diastole (Fig. 1, A-C and Video loop 1). Color-flow Doppler did not reveal any systolic flow turbulence (Fig 1, D and Video loop 1). What is the diagnosis?

Different clinical features between left atrial and left atrial appendage thrombus: an insight into more than 16,000 transesophageal echography database

Abstract Background Thrombosis localization inside the left atrium (LA) is very frequently in the left atrial appendage (LAA). Some cases show atrial thrombus outside LAA, whose characteristics have not well elucidated. Purpose To reveal the different clinical background between thrombus inside LAA and outside LAA in a large transesophageal echo (TEE) database. Methods We searched the TEE database over 8 years of our center to identify patients in whom LA thrombus was pointed out. After initial TEE imaging, LA thrombus was confirmed with repeated TEE by echocardiography specialist or other modality, such as CT images. Results In a consecutive 16,142 TEE cases, LA thrombus was suspected in 162 cases (1%), finally 38 cases were identified as LA thrombus. They were divided into two groups; LAA only group and outside LAA group. Atrial fibrillation was concomitant in 34 patients (89%). History of stroke was significantly higher in LAA group (46.2% vs 8.3%, p=0.03) and malignant tumor was significantly higher in outside LAA group (23.1% vs 58.3%, p=0.035). LA thrombus was the first symptom in 3 cases of outside LAA group, following by malignant tumor was newly detected. Oral anticoagulation was prescribed in 23 cases (61%) at TEE study, mostly treated with warfarin, and median 123 days later thrombus dissolution was confirmed in 21 cases (55%). During mean follow up of 893 days, 4 patients experienced ischemic stroke, but two of them were due to self-interruption. Conclusion Outside LAA thrombus is minor but more concomitant with malignant tumor. Physician must be aware that screening of cancer is important if outside LAA thrombus is detected. Funding Acknowledgement Type of funding source: None

The Predictive Value of PRECISE-DAPT Score for the Thrombogenic Milieu in Left Atrium and Left Atrial Appendix in the Patients with Atrial Fibrillation Planned AF Ablation

Abstract Introduction and aim Atrial fibrillation (AF) is the most common arrhythmia in the clinical practice. In AF patients, the assessment of thromboembolic risk and the initiation of anticoagulant therapy to appropriate patients play critical role in management of these patients. Current guidelines recommend to use CHA2DS2VASC score in evaluation of thromboembolic risk. However, the effectiveness of this score has been questioned recently. This situation requires new risk indicators. Although PRECISE-DAPT score was initially constituted to determine the duration of dual antiplatelet therapy in patients with PCI, current studies have reported that this score may also predict thrombotic events. In this study, we aimed to evaluate the effectiveness of PRECISE-DAPT score to predict thrombogenic milieu by comparing with CHA2DS2VASC score in non valvular AF patients whom referred TEE before AF ablation procedure. Method 428 patients were included in the study. The presence of grade 2–3 SEC and thrombus in left atrium and/or left atrial appendage were accepted as thrombogenic milieu. The patients were divided into two groups according to the presence of thrombogenic milieu. In addition, we constituted three groups as grade 0–1 SEC group, grade 2–3 SEC group and thrombus group to evaluate the parameters in detail. Results Grade 2–3 SEC was found in 36 patients and thrombus was detected in 24 patients. 60 patients was included to the thrombogenic positive (artı) group while 368 patients was included to thrombogenic milieu (−) group. PRECISE-DAPT and CHA2DS2VASC scores were higher in thrombogenic positive (artı) group In multivariate logistic regression analysis, PRECISE-DAPT score was found to be an independent predictor of thrombogenic milieu (OR: 1.145, CI:1.083–1.211, p&amp;lt;0,001). The comparison of ROC curves was shown that PRECISE DAPT score was higher area under curve than CHA2DS2VASC score, 0,753 and 0,649 respectively. Conclusion In our study, in patients performed TEE before AF ablation, PRECISE-DAPT score was found to be an independent predictor for thrombogenic milieu presented as high grade SEC and thrombus, there by thromboembolic risk. PRECISE-DAPT score seems to be more effective than CHA2DS2VASC score. In AF patients, PRECISE-DAPT score may provide additional benefit in assessment of thromboembolic risk, thus enabling a more individual and accurate anticoagulation decision in these patients. Funding Acknowledgement Type of funding source: None

Incidence and predictors of left atrium thrombus in acute ischemic stroke patients without atrial fibrillation: a single center cohort study

Abstract Introduction The present study aimed to determine independent predictors of left atrial thrombus (LAT) in acute ischemic stroke patients without atrial fibrillation (AF) using transesophageal echocardiography (TEE). Material and methods In this single center, retrospective cohort study, we enrolled 149 consecutive acute ischemic stroke patients. All of the patients underwent TEE examination to detect LAT within 10 days following admission. Multivariate logistic regression analysis was performed to assess independent predictors of LAT. Results Among all cases, 14 patients (9.3%) had a diagnosis of LAT on TEE examination. In a multivariate analysis; a previous diagnosis of cerebrovascular accident, elevated mean platelet volume (MPV), low left ventricle ejection fraction (EF) and a reduced left atrium appendix (LAA) peak emptying velocity were independent predictors of LAT. The area of MPV under the receiver operating characteristic curve analysis was 0.70 (95% CI: 0.57–0.83; p=0.011). With the optimal cut-off value of 9.45, MPV had a sensitivity of 71.4% and a specificity of 63% to predict LAT. Conclusion Patients with low ventricle EF and elevated MPV should undergo further TEE examination for the possibility of cardio-embolic source. In addition, this research may provide novel information with respect to the applicability of MPV to predict LAT in acute ischemic stroke patients without AF. Figure 1 Funding Acknowledgement Type of funding source: None

Thrombus of left atrium and/or its appendage in nonvalvular atrial fibrillation: echocardiographic and laboratory risk factors, capabilities for prediction and correction

The review presents data on the feasibility of using laboratory findings to predict the presence of left atrium (LA) and/or left atrial appendage (LAA) thrombus in non-valvular atrial fibrillation (NvAF). It describes the relationship between the presence of a blood clot in the LA/LAA and a blood group, certain parameters of peripheral blood, blood brain natriuretic peptide levels, homocysteine, asymmetric D-methylarginine, uric acid and D-dimer. The authors presented data of studies to show a relationship between the presence of LA/LAA trombus and individual parameters obtained during transthoracic echocardiography: left ventricular mass index, left atrial volume index, LvEF/left atrial volume index ratio, E/e' ratio, peak systolic deformity of the left atrium. The capabilities of different scales in assessing the likelihood of the presence of LA/LAA thrombus in NvAF are evaluated. insufficient information capacity of the CHADS 2 and CHA 2 DS 2 -vASc scales is demonstrated. The article described attempts to improve the scales by adding other risk factors (CHA 2 DS 2 -VASc-MS, CHA 2 DS 2 VASc-AFR, CHA 2 DS 2 VASc-RAF scales, as well as the possible role of additional consideration of blood brain natriuretic peptide levels). It is shown that it is feasible to add information on the duration of NvAF paroxysm and glomerular filtration rate to the CHA 2 DS 2 -VASc scale. in addition, consideration of the presence of metabolic syndrome may be beneficial. Overall, approaches with addition of information on the duration of NvAF paroxysm and glomerular filtration rate to the CHA 2 DS 2 -VASc scale proved to be most successful. The authors presented the shortcomings of accumulated evidence base regarding the relationship between the studied parameters and the presence of LA/LAA thrombus, including a small number of examined patients, usually a retrospective character of the study, a search of LA/LAA thrombus before the planned catheter ablation or electropulse therapy. As a result, it is not known to what extent the studied predictors and scales may be applied to a wider contingent of patients with NvAF. In addition, most studies have been performed on the Asian population and it is unclear whether their results can be extrapolated to other ethnic groups. It was shown that thrombi do not disappear under pressure of anticoagulant therapy in at least one-third of patients.

P1086Prevalence and predictors of left atrial thrombi in patients scheduled for electrical cardioversion of nonvalvular atrial fibrillation

Abstract Background Transesophageal echocardiography (TEE) showed the presence of thrombi in 12 to 26% of patients with atrial fibrillation (AF). Purpose To assess clinical and echocardiographic variables associated with thrombi in the left atrium (LA) prior to electrical cardioversion in patients with nonvalvular atrial fibrillation (AF). Methods Cross-sectional study including 188 patients. Clinical and echocardiographic variables were analyzed. Qualitative variables are expressed in percentages and quantitative variables in mean and standard deviations. Qualitative variables were analyzed by the Chi square method. A value of p &amp;lt;0.05 was considered statistically significant. Results Mean age was 60.7 ± 12.3 and 75.5% males. The mean CHA2DS2-VASc and HAS-BLED scores were 2.43 ± 1.6 and 1.06 ± 1. The percentage of paroxysmal AF was 49.7%, nonparoxysmal 23.2% and atrial flutter 27%. Mean ejection fraction (EF) was 52.2 ± 13%. The prevalence of thrombus was 12.3%. Female gender (p = 0.0275), heart failure (p = 0.0006), CHA2DS2-VASc score ≥2 (p = 0.0015), EF &amp;lt;50% (p = 0.0089), moderate/severe spontaneous echocardiographic contrast (p = 0.000042) and LA appendage emptying velocity ≤20 cm/sec (p = 0.0000001) are associated to the presence of thrombi in the LA. No thrombi were detected in patients with CHA2DS2-VASc score of 0. History of previous anticoagulation for over thirty days or creatinine clearance &amp;lt;56 ml/min were not predictors of LA thrombi. Conclusion Female gender, heart failure, EF &amp;lt;50% and CHA2DS2-VASc score ≥2, emptying velocity of less than 20 cm/sec and spontaneous echocardiographic contrast were univariate predictors of thrombi in the LA. CHA2DS2-VASc score of 0 is a strong predictor of absence of thrombi.

Reccurent thrombus in the gigantic left atrium during effective anticoagulant therapy: case report

BackgroundGigantic left atrium is defined in the current literature as an excessive dilatation of the left atrium above 65mm. Chronic mitral valve disease is associated with the development of thrombus in the left atrium in up to 19% of all cases of mitral insufficiency and appropriate treatment must be initiated to prevent thromboembolic events. In order to diagnose thrombi in the left atrium or left atrial appendage, various imaging methods may be used, including cardiac magnetic resonance.Case presentationThe case report describes a 73-year-old male who developed recurrent sessile thrombus on the posterior wall of the gigantic left atrium. A large thrombus was first detected following mitral valve surgery despite effective vitamin K antagonist anticoagulation therapy. Echocardiography and cardiac magnetic resonance were used within the diagnostic procedure and to monitor the treatment outcomes. Cardiac magnetic resonance was shown to be beneficial as it provided a more precise description of the intra-atrial masses located on the posterior left atrial wall, and in such situations, is of greater benefit than standard echocardiography. This led to the surgical removal of the intra-atrial mass; nevertheless, it was quickly followed by the recurrence of the thrombus. The anticoagulant therapy was adjusted and fortified by the introduction of acetylsalicylic acid and sequentially clopidogrel, but this also did not resolve the thrombus formation. Finally, employing a combination of rivaroxaban and clopidogrel resulted in partial thrombus regression. Therefore, various pathophysiological aspects of thrombus formation and used anticoagulation strategies are discussed.ConclusionsWe describe a unique case of a recurrent thrombus located on the posterior wall of the gigantic left atrium. Cardiac magnetic resonance was shown to be beneficial in providing a more precise description of the intra-atrial masses located on the posterior left atrial wall as compared to standard echocardiographic examination. Development of a thrombus after mitral valve surgery despite effective anticoagulant therapy and its final resolution by introducing a combination of rivaroxaban and clopidogrel highlights the complex etiopathogenesis of thrombus formation. This supports the potential use of this combination in tailoring an individual personalized therapy for patients with recurrent atrial thrombi.

The impact of age on the characteristics of mitral stenosis: A retrospective study

The main etiology of mitral stenosis is rheumatic fever. There remains a significant problem in developing countries and persists also in developed countries despite a marked decline in prevalence in recent decades. It mainly affects young adults, however it changes clinical presentation in older patients with more altered valvular anatomy. The objective of this work is to analyse the particularity of the mitral stenosis in Moroccan elderly over 45 years. This is a descriptive and analytical study, conducted in Ibn-Rochd Center of Cardiology from January 2014 to November 2018, which included 116 patients with a sever mitral stenosis, divided into 2 groups: Group I 132 patients < 45 years, group II 124 patients > 45 years. In our series, there was a female predominance in the 2 groups (68% group I vs. 71% group II). In patients over 45 years, the atrial fibrillation was more common (83%), left atrium was more dilated, the valves were more calcified (84% vs. 73,33%), and the average gradient was higher (44,64% vs. 30%). The history percutaneous mitral dilatation was more frequent in group II (33%). 3% of the patients in the second group had a thrombus of left atrium. The mitral stenosis in elderly subjects has more impact on the cardiac arrhythmia, the size of the LA, thrombo-embolisme complications, the severity of the gradient, and on valvular anatomy that is more calcified.