Fate of left atrial thrombi in patients with atrial fibrillation determined by transesophageal echocardiography and cerebral magnetic resonance imaging

An Observational Study: Clinical Manifestations and Prognosis of Left Atrial Thrombosis in Atrial Fibrillation

We did this study to find out the clinical manifestations and prognosis of left atrial thrombosis in different types of atrial fibrillation and the relationship with systemic thromboembolism, hoping to find a better therapy strategy. A single-center retrospective study enrolled patients with definite diagnosis of atrial fibrillation complicated with left atrial thrombosis. Data of general clinical information, anticoagulation medications, thromboembolism events, and thrombosis prognosis were recorded and analyzed. A total of 103 patients were enrolled. Compared with non-valvular atrial fibrillation (NVAF), thrombosis outside the left atrial appendage (LAA) was much more common in valvular atrial fibrillation (VAF) with p=0.003. Total prevalence of systemic thromboembolism was 33.0%. Thrombi disappeared in 78 cases (75.7%) under anticoagulation treatment within 2 years. There was no significant difference between warfarin, dabigatran, and rivaroxaban on thromboembolism events and thrombosis prognosis in NVAF, with p=0.740 and 0.493, respectively. Atrial fibrillation patients with LA thrombosis have a high risk of systemic thromboembolism events. Compared with NVAF, patients with VAF had higher incidence of thrombosis outside the LAA. Standard stroke-preventing doses of anticoagulants might not be sufficient to deplete all LA thrombi. There was no statistically difference between warfarin, dabigatran, and rivaroxaban for depleting LA thrombi in NVAF patients.

Predictors of thrombosis of left atrium and its appendage before catheter ablation or cardioversion in patients with non-valvular atrial fibrillation or atrial flutter

Aim. To determine the incidence of left atrial (LA) and/or LA appendage (LAA) thrombosis in patients with non-valvular atrial fibrillation (AF) (NAF) or atrial flutter (AFL) on transesophageal echocardiography (TEE) before elective catheter ablation (CA) or cardioversion (CV) and characterize the predictors of LA/LAA thrombosis among the indicators available in the routine practice of cardiologists and general practitioners.

Material and methods. In this retrospective, single-center, casecontrol study, the medical records of 1994 patients with NAF or AFL for the period 2014-2019, who underwent TEE before CA or elective CV, were analyzed. A thrombus in the LA/LAA was detected in 33 (1,6%) of them. For the comparison group, 167 patients were randomly selected without LA/LAA thrombosis. Demographic, anamnestic and clinical parameters, transthoracic echocardiography data, and laboratory results were analyzed as potential predictors of LA/LAA thrombosis.

Results. Patients with LA/LAA thrombosis were older (mean age, 64,8±1,6 vs 59,4±10,8 (p=0,01), more often had persistent or longstanding persistent AF, hypertension, heart failure, enlarged LA, lower left ventricular ejection fraction (LVEF) and estimated glomerular filtration rate, as well as more severe symptoms according to the modified European Heart Rhythm Association (EHRA) score and a higher CHA2DS2-VASc score (median, 4,0 vs 2,0; p=0,0001). Oral anticoagulants were taken by 88% of patients; there were no significant differences in the presence and composition of anticoagulant therapy between the groups. Functional class (FC) according to the modified EHRA score (odds ratio (OR), 5,4; 95% confidence interval (CI): 1,9814,96; p=0,001) and LVEF were independent predictors of LA/LAA thrombosis (OR, 0,87; 95% CI: 0,80-0,95; p=0,002). For EHRA class 3-4, the OR was 5,1; 95% CI: 2,3-11,4 (p<0,0001), for LVEF <48% — 7,4; 95% CI: 1,2-46,7 (p=0,03). For EHRA class 3-4, the sensitivity for LA/LAA thrombosis was 93,7%, specificity — 71,9%, positive predictive value — 50,0%, negative predictive value — 87,6%; for LVEF <48% — 66,7, 32,3, 31,9 and 91,6%, respectively.

Conclusion. In the studied group of patients with NAF or AFL, without severe structural heart disease and severe concomitant diseases, most of whom received oral anticoagulants, LA/LAA thrombosis at TEE before elective CA or CV was detected in 1,6% of cases. Among the indicators available in routine medical practice, the severity of arrhythmia symptoms, assessed by the modified EHRA score, and lower LVEF were independent predictors of LA/LAA thrombosis.

Efficacy and Safety Profile of Novel Oral Anticoagulants in the Treatment of Left Atrial Thrombosis: A Systematic Review and Meta-Analysis

Background

The presence of left atrial/left atrial appendage thrombosis is associated with a higher risk of thromboembolic events in patients with atrial fibrillation. The optimal antithrombotic strategy is not established to date.

Objective

Our aim was to compare the efficacy and safety profile of novel oral anticoagulants with warfarin in the treatment of left atrial/left atrial appendage thrombosis.

Methods

We conducted a systematic search in PubMed, Embase, Cochrane Library, ClinicalTrials.gov, and 3 Chinese databases for all randomized controlled trials and cohort studies (PROSPERO, CRD42021238952) from inception to 7 May 2021. Two authors independently performed the articles selection, data extraction, and quality assessment. The efficacy outcome was the resolution of left atrial/left atrial appendage thrombosis, and the safety outcomes were bleeding and stroke/transient ischemic attack.

Results

One randomized controlled trial and 5 cohort studies were included, with a total of 353 patients. Compared with warfarin, novel oral anticoagulants were associated with increased probability of left atrial/left atrial appendage thrombosis resolution (OR = 2.20; 95% CI, 1.35–3.60; I² = 0%). Compared with warfarin, novel oral anticoagulants had a similar risk of bleeding (OR = 0.91; 95% CI, 0.39–2.13; I² = 0%). There was no evidence of increased risk of stroke/transient ischemic attack (OR = 0.42; 95% CI, 0.12–1.45; I² = 0%).

Conclusions

Novel oral anticoagulants were more effective than warfarin in promoting the resolution of left atrial/left atrial appendage thrombosis, without increased risks of bleeding and stroke/transient ischemic attack. Our study provides valuable insight into clinical practice. Further well-designed randomized controlled trials are needed to fully evaluate the benefits and risks in these patients. PROSPERO Registration No.: CRD42021238952.

A Prospective Study to Evaluate the Effectiveness of Edoxaban for the Resolution of Left Atrial Thrombosis in Patients with Atrial Fibrillation

Available evidence on left atrial (LA) thrombus dissolution in patients with atrial fibrillation (AF) largely refers to the use of vitamin K antagonist oral anticoagulants (VKAs), showing >50% thrombus resolution over a 4-week to 12-month treatment period. Available data on non-vitamin K antagonist anticoagulants (NOACs) in this setting are limited and derive from isolated case reports or observational small-sized investigations with dabigatran, rivaroxaban or apixaban. The aim of this study was to investigate the extent of thrombus resolution with edoxaban therapy in patients with AF and LA thrombosis. We conducted a prospective, observational, open-label pilot study in seven Italian institutions. We included a total of 25 patients with non-valvular AF and LA (or left atrial appendage (LAA)) thrombosis, documented by transesophageal echocardiography (TEE). All patients received edoxaban OD treatment (n = 23 on 60 mg daily; n = 2 on 30 mg daily) and underwent TEE examination after 4 weeks. The primary endpoint was the percentage of patients with complete thrombus resolution by TEE imaging at 4 weeks. The mean age of the study population was 68.3 ± 10.8 years with a female population of 16%. AF was permanent in all cases, with a mean arrhythmia duration of 4.3 ± 1.7 years. CHA2DS2-VASc and HAS-BLED scores were 3.2 ± 1.5 and 1.9 ± 1.1, respectively. We were able to demonstrate a complete thrombus resolution in 14 patients (56%) at 4 weeks. In patients with residual atrial thrombosis (n = 11), we observed a 15.4 ± 14.9% reduction in the thrombus area from baseline. As compared with patients without thrombus dissolution, those with thrombus resolution had a numerically lower-indexed LA diameter (27.9 ± 9.3 vs 34.8 ± 16.1 mm/m2), a smaller maximum thrombus area at baseline (45.5 ± 44.6 vs 63.9 ± 43.5 mm2), a higher left ventricular ejection fraction (47.4 ± 21.0% vs 38.4 ± 20.6%) and higher maximum LAA flow velocities (26.3 ± 15.2 vs 19.3 ± 10.0 cm/s). Figures on the percentage of thrombus resolution in this study are comparable to those reported in the literature for the other OACs. We conclude that, in patients with AF, the use of edoxaban is associated with a >50% resolution of atrial thrombus at 4 weeks, similar to studies using VKAs and the other NOACs (ClinicalTrials.gov identifier number: NCT034899395).

Large left atrial thrombus resection in a patient in sinus rhythm without mitral valve disease: A case report

Introduction

Left atrial (LA) ball thrombi are often associated with atrial fibrillation (AF) and mitral valve disease (MVD). Differentiating between thrombi and LA tumors can be challenging.

Presentation of a case

A 63-year-old man with a prior mesh insertion for abdominal incisional hernia was admitted with fever. He was diagnosed with an abdominal mesh-related infection requiring surgical debridement. Preoperative transthoracic echocardiography revealed a 39-mm smooth mass in the LA adherent to the atrial septum. The mass was suspected to be a cardiac tumor based on the morphology. The patient underwent mass resection. Pathophysiology revealed that the mass was a thrombus, necessitating anticoagulation therapy. No recurrence of thrombus formation was reported.

Discussion

In this case, a plausible factor causing the thrombus formation is the chronic mesh. Since LA thrombi can become free-floating or grow rapidly, early surgical intervention is essential to prevent thrombotic events or sudden death.

Conclusion

An LA thrombus should be included in the differential diagnosis when an LA mass is detected. Prompt surgical resection prevents thrombotic events and improves patient outcomes.

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Causes of left atrial thrombus include mitral valve disease and atrial fibrillation.

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Left atrial thrombi can be difficult to differentiate from left atrial tumors.

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Large left atrial thrombi can become free-floating or grow rapidly.

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For large left atrial thrombi, prompt surgery is required.

Non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation and atrial thrombosis: An appraisal of current evidence

Major thromboembolic complications in patients with atrial fibrillation, secondary to thromboembolism from the left atrium or the left atrial appendage, are a major concern because of their burden of disabling stroke and mortality. To date, non-vitamin K antagonist oral anticoagulants (NOACs) are considered the first-line strategy in most patients with atrial fibrillation receiving chronic anticoagulation, as they have major advantages compared with vitamin K antagonists, including minimization of intracranial bleeding risk. Although several studies and post-hoc analyses have provided initial data on the use of NOACs in patients with documented atrial and/or left atrial appendage thrombosis, the benefit of NOACs in these patients has not been fully elucidated. In this review, we reappraise current evidence supporting the use of NOACs in patients with established atrial and/or left atrial appendage thrombosis, discussing potential mechanisms favouring the use of a NOAC-based strategy in this special setting.

[Surgical considerations for two patients with cardioembolic stroke and mobile thrombus in the left atrium appendage]

Two men (Case 1, 74 years old; Case 2, 65 years old) developed cardioembolic stroke due to self-interruption of anticoagulants for treating atrial fibrillation. They both had mobile thrombus in the left atrial appendage. In Case 1, a left atrial thrombectomy was scheduled on day 8, but infarction re-occurred on the morning of the the surgery, producing neurological sequelae. In Case 2, left atrial thrombectomy and left atrial appendage closure were performed successfully on day 8. The indication and timing of cardiac thrombectomy after the onset of cerebral infarction have not been standardized, and they seem to differ among individuals. Therefore, in the future, the optimal timing of left atrial thrombectomy should be decided based on the size and morphology of the left atrial thrombus, the size of the cerebral infarction and the presence or absence of hemorrhagic infarction.

Rivaroxaban in atrial fibrillation cardioversion: an update

Currently, atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with a prevalence of about 2-3% in the general population, representing a powerful risk factor for stroke and systemic thromboembolism and increased mortality and morbidity. Restoration of sinus rhythm is an important treatment option in AF and has a high success rate, but there is the need for an effective anticoagulation strategy to reduce the risk of embolic events. Anticoagulation with vitamin K antagonists is often associated with failure to achieving effective international normalized ratio. In this setting, recent data have led to extended approval for rivaroxaban in clinical practice, because it is effective and safe in patients with AF undergoing cardioversion, avoiding additional health costs and related time loss, while improving patient satisfaction. The present report provides an overview of the main randomized controlled trial and the main real-life studies, documenting the use of rivaroxaban in patients with non-valvular AF who underwent the cardioversion procedure. Considering that novel non-vitamin K antagonist oral anticoagulants in left atrial appendage thrombi resolution is still unknown in the real-world practice, the main findings on the use of rivaroxaban in this setting are also discussed.

Frequency of atrial thrombus formation in patients with atrial fibrillation under treatment with non-vitamin K oral anticoagulants in comparison to vitamin K antagonists: a systematic review and meta-analysis

BACKGROUND

To assess the frequency of left atrium/left atrial appendage (LA/LAA) thrombus under treatment with non-vitamin K oral anticoagulants (NOACs) in comparison with vitamin K antagonists (VKAs) in patients with non-valvular atrial fibrillation (AF).

METHODS

PubMed, Web of Science™, EMBASE and the Cochrane Library databases were searched for studies comparing NOACs with VKAs in AF patients who underwent diagnostic transoesophageal echocardiography (TEE).

RESULTS

A total of four trials were considered eligible and were included in the meta-analysis. Four RCTs comprising n = 2397 AF patients (NOACs: n = 1412, VKAs: n = 985) were included in the meta-analysis. The frequency of LA/LAA thrombus formation under treatment with NOACs was similar to VKAs [odds ratio (OR) 1.14, 95% confidence intervals (95% CIs) 0.97-1.65, p = 0.48]. Both treatment groups revealed an approximately 5% frequency of thrombus formation, although a precise calculation is not possible due to Simpson paradox. Indications of heterogeneity between the included trials were not found (χ2 test p = 0.99, I2 = 0%).

CONCLUSIONS

The findings of this meta-analysis suggest that NOACs are similar to VKAs regarding the frequency of LA/LAA thrombus in patients with AF. An unknown number of patients in the original studies did not receive sufficient anticoagulation for at least 3 weeks prior to TEE examination, and therefore the present results should be interpreted with caution. Systematic review registration- http://www.crd.york.ac.uk/PROSPERO . Unique identifier: PROSPERO CRD42017059293.

Left atrial thrombus despite continuous direct oral anticoagulant or warfarin therapy in patients with atrial fibrillation: insights into rates and timing of thrombus resolution

PURPOSE

Left atrial thrombus (LAT) may be detected by transesophageal echocardiography (TEE) in patients with atrial fibrillation (AF) or flutter (AFL) despite continuous anticoagulation therapy. We sought to examine the rates and timing of LAT resolution in response to changes in anticoagulation regimen.

METHODS

A retrospective study of 1517 consecutive patients on ≥ 4 weeks continuous oral anticoagulation (OAC) undergoing TEE prior to either direct current cardioversion or catheter ablation for AF or AFL was performed. Patients who had LAT on index TEE imaging and had follow-up TEEs were analyzed.

RESULTS

Despite ≥ 4 weeks of continuous anticoagulation therapy, 63 (4.2%) patients had LAT. Forty-four patients (median age 67 [IQR 58, 74]; 33 [75%] male; 25 [57%] on direct oral anticoagulant [DOAC]) had follow-up TEEs performed. Upon detection of LAT on index TEE, 8 patients switched from warfarin to a DOAC, 21 patients switched from a DOAC to warfarin or another DOAC, and 15 patients remained on the same OAC. Over median 4.2 months (IQR 2.9, 6.6), LAT resolution was seen in 25 (57%) patients. Of the 25 patients who had LAT resolution, 7 (28%) required TEE imaging > 6 months after index TEE to show clearance of thrombus. Rates of LAT resolution were similar between patients who had alterations in OAC and those who did not (52 vs. 60%; P = 0.601).

CONCLUSIONS

After initial detection of left atrial thrombus despite uninterrupted anticoagulation for atrial fibrillation or flutter, > 40% patients have persistent clot despite additional extended anticoagulation.

THROMBOSIS OF LEFT ATRIAL APPENDAGE DURING THERAPY WITH DIRECT ORAL ANTICOAGULANT. CLINICAL CASE

The article presents a clinical observation of the left atrial appendage thrombosis in a 51-year-old female patient with a paroxysmal form of nonvalvular atrial fibrillation which occurred despite long-term anticoagulant therapy with apixaban in a full dose (5 mg b.i.d.), and the patient’s management. The patient was admitted with recurrent symptomatic paroxysm for more than 48 hours, because of which, in accordance with the recommendations, transesophageal echocardiography was performed before an emergency rhythm restoration. Thrombus in the left atrial appendage 0.5×1.03 cm in size was detected. It was decided to refrain from the immediate restoration of the rhythm due to the very high risk of thromboembolic complications. In connection with the categorical refusal of the patient from warfarin, it was decided to replace apixaban with another direct oral anticoagulant – dabigatran 150 mg bid for a period of 4 weeks followed by performing a control transesophageal echocardiographic study. As a result, no thrombus was found on control echocardiography. The particularity of this observation is concomitant hypertrophic cardiomyopathy and diabetes mellitus type 1 in this patient.

Feasibility of Left Atrial Appendage Occlusion for Left Atrial Appendage Thrombus in Patients With Persistent Atrial Fibrillation

This study sought to investigate the safety of percutaneous left atrial appendage (LAA) occlusion for stroke prevention in patients with nonvalvular atrial fibrillation who have LAA thrombus. From October 2010 to October 2016, LAA occlusions were performed in facilities within a Korean multicenter registry in patients without (n = 132) or with (n = 10) LAA thrombus (detected during preprocedural assessments). The incidences of periprocedural complications, including stroke, pericardial tamponade, major bleeding, and device embolization, were assessed and compared between the groups. The incidence of periprocedural complications was not significantly different between patients with and without LAA thrombus (0% vs 5% [6 of 132]; p = 0.49). During the mean 23.2 ± 17.5-month follow-up duration, 7 major adverse cardiac events occurred (1 cardiovascular death, 6 ischemic strokes), but overall event rates were not significantly different between the groups (14% vs 9%; p = 0.47). In conclusion, percutaneous LAA occlusion in nonvalvular atrial fibrillation patients with LAA thrombus may be a safe and feasible alternative to anticoagulation in select patients at a high risk of bleeding or contraindication to anticoagulation, or in whom anticoagulation failed to prevent stroke.

Submassive Pulmonary Embolism and Left Atrial Thrombus

•LA thrombus was seen in the setting of acute PE. •Surgical and medical management strategies are discussed. •Factors that predict thrombus resolution and systemic embolism are discussed.

A left atrial appendage thrombus that developed during prophylactic low-dose dabigatran treatment resolved after switching to apixaban

We describe a case of atrial fibrillation in which an intracardiac thrombus that could not be prevented with “low‐dose” dabigatran treatment was resolved by switching to apixaban treatment. Thrombolysis using direct oral anticoagulants (DOACs) could be a therapeutic option for patients with intracardiac thrombi, although the efficacies of different DOACs seem to differ and need further examination.

Left atrial thrombus resolution in atrial fibrillation or flutter: Results of a prospective study with rivaroxaban (X-TRA) and a retrospective observational registry providing baseline data (CLOT-AF)

BACKGROUND

Data on left atrial/left atrial appendage (LA/LAA) thrombus resolution after non-vitamin K antagonist (VKA) oral anticoagulant treatment are scarce. The primary objective of X-TRA was to explore the use of rivaroxaban for the resolution of LA/LAA thrombi in patients with nonvalvular atrial fibrillation (AF) or atrial flutter, with the CLOT-AF registry providing retrospective data after standard-of-care therapy in this setting.

METHODS

X-TRA was a prospective, single-arm, open-label, multicenter study that investigated rivaroxaban treatment for 6 weeks for LA/LAA thrombus resolution in patients with nonvalvular AF or atrial flutter and LA/LAA thrombus confirmed at baseline on a transesophageal echocardiogram (TEE). CLOT-AF retrospectively collected thrombus-related patient outcome data after standard-of-care anticoagulant treatment for 3 to 12 weeks in patients with nonvalvular AF or atrial flutter who had LA/LAA thrombi on TEE recorded in their medical file.

RESULTS

In X-TRA, patients were predominantly (95.0%) from Eastern European countries. The adjudicated thrombus resolution rate was 41.5% (22/53 modified intention-to-treat [mITT] patients, 95% CI 28.1%-55.9%) based on central TEE assessments. Resolved or reduced thrombus was evident in 60.4% (32/53 mITT patients, 95% CI 46.0%-73.6%) of patients. In CLOT-AF, the reported thrombus resolution rate was 62.5% (60/96 mITT patients, 95% CI 52.0%-72.2%) and appeared better in Western European countries (34/50; 68.0%) than in Eastern European countries (26/46; 56.5%).

CONCLUSION

X-TRA is the first prospective, multicenter study examining LA/LAA thrombus resolution with a non-VKA oral anticoagulant in VKA-naïve patients or in patients with suboptimal VKA therapy. Rivaroxaban could be a potential option for the treatment of LA/LAA thrombi.

Treatment of patients with acute deep vein thrombosis and/or pulmonary embolism: efficacy and safety of non-VKA oral anticoagulants in selected populations

Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), presents a large clinical burden. Prompt, effective and sustained anticoagulation is vital because of the risk of recurrent events, including life-threatening PE, and complications such as post-thrombotic syndrome and chronic thromboembolic pulmonary hypertension. Dual-drug standard therapy is effective; however, parenteral low molecular weight heparin, coupled with routine coagulation monitoring and dose adjustment of vitamin K antagonists (VKAs), presents challenges for patients and healthcare providers. Non-VKA oral anticoagulants provide a simplified option for VTE treatment. Phase III studies have investigated rivaroxaban and apixaban as single-drug approaches, and edoxaban and dabigatran in conjunction with initial heparin therapy. These agents demonstrated non-inferiority to standard therapy, and most showed significant reductions in major bleeding. However, clinical information is limited in patient subgroups, e.g. fragile patients or patients with renal impairment or cancer, who may be at higher risk of bleeding and/or VTE. A prespecified pooled analysis of the EINSTEIN DVT and EINSTEIN PE studies (8281 patients), undertaken to evaluate clinical outcomes with rivaroxaban versus standard therapy, confirmed the non-inferiority of rivaroxaban, with significant reductions in major bleeding and fewer intracranial and retroperitoneal bleeding events. Consistent efficacy and safety were observed with rivaroxaban, irrespective of fragility, cancer or clot severity. The introduction of the non-VKA oral anticoagulants and approval of rivaroxaban in the EU, US and Canada for the treatment and secondary prevention of DVT and PE offer the potential for improvements in effective care across a broad spectrum of patients with VTE.

Inherited thrombophilia-related complications in the treatment of a biatrial thrombus

The study emphasizes the importance of the high risk of thromboembolism with inherited thrombophilic factors. Transesophageal echocardiography revealed large biatrial masses in an 87-year-old woman with history of nonvalvular atrial fibrillation, pulmonary embolism, and prescribed oral anticoagulation for prophylaxis of embolic events. The surgical removal of the presumed thrombus was declined by the patient and intravenous anticoagulation with unfractionated heparin was initiated. Treatment was complicated by additional embolic events and the patient succumbed after 14 days due to multiple organ failure. Testing revealed heterozygosity for both the factor V Leiden and the methylenetetrahydrofolate reductase C677T mutations inducing resistance to activated protein C. The combination of these thrombophilic factors can probably explain the poor anticoagulant response, embolic events, and the failure of resolution of the biatrial masses.

Presence Of Left Atrial Appendage Thrombus In Patients Presenting For Left Atrial Ablation Of Atrial Fibrillation Despite Pre-Operative Anticoagulation

Background: One of the recognised complications of left atrial ablation for atrial fibrillation (AF) is stroke. Left atrial (LA) thrombus, which may be dislodged by catheter manipulation, is an absolute contraindication to ablation. It is unclear whether imaging of the left atrial appendage (LAA) by transesophageal echo (TEE) is mandatory to exclude LA clot prior to ablation, particularly in "low-risk" patients with paroxysmal AF and normal left ventricular (LV) function. Methods and Results: We carried out a retrospective analysis of pre-ablation TEE in patients presenting for ablation of AF. Images from 244 ablation procedures carried out in 148 patients were examined, including 106 patients with paroxysmal AF and normal LV function. Despite at least 4 weeks of pre-operative therapeutic anticoagulation with Warfarin (INR>2.0), LAA thrombus was identified in 4 patients (2.7% (0.1-5.3%)). These included 2 patients with paroxysmal AF and normal LV function, although both had a high arrhythmia burden. The thrombi regressed with intensification of anticoagulation. Conclusions: Pre-operative imaging of the LAA remains advisable to exclude thrombus prior to ablation for AF even in patients with paroxysmal AF and normal LV function, especially if there is a high AF burden.

Giant Left Atrial Thrombus Successfully Treated with Anticoagulation

A giant left atrial mass (6 cm x 4 cm) was visualised on a transoesophageal echocardiogram in an elderly woman who had a history of nonvalvular atrial fibrillation. The surgical removal of the mass, presumed to be a thrombus, was declined by the patient, and oral anticoagulation with warfarin was initiated. After eight weeks of anticoagulation, a repeat echocardiogram demonstrated complete resolution of the mass, without systemic embolisation.

Atrial fibrillation - patients at high risk for cerebral embolism

OBJECTIVE

Patients with atrial fibrillation (AF) have a risk of cerebral embolism. Echocardiographic parameters elevate this risk significantly. However, there is little knowledge about the long-term fate and the rate of clinically silent cerebral embolism under continued oral anticoagulation. The aims of our study were to assess prognosis of patients with AF and determine a high risk group with an increased risk of cerebral embolism under oral anticoagulation.

METHODS

Consecutive patients with persistent or permanent AF and left atrial (LA) thrombi, dense spontaneous echo contrast (SEC) and/or reduced LA appendage peak emptying velocities (LAAv) were included in the study (N = 128). Patients with AF and without echocardiographic risk factors (N = 114) served as controls. All patients were examined with transesophageal echocardiography, cranial magnetic resonance imaging and clinically during a period of three years.

RESULTS

During the three-year follow-up period 6 (5%) of the high risk patients had cerebral embolism with neurological deficits. 4 (3%) patients died due to embolic events and 17 (13%) patients had silent embolism as documented on MRI. In the control group 8 (7%) patients had embolic events (n = 1 clinically apparent and n = 7 silent embolism) documented on MRI, one was clinically apparent. Study patients with an event had more commonly previous thromboembolism (p < 0.0001).

CONCLUSIONS

Patients with peristent or permanent AF and LA thrombi, dense SEC or reduced LAAv have an explicitly increased risk of cerebral embolism (21%) despite oral anticoagulation. Previous thromboembolic event is another important predictor for an event.

Patients at High Risk with Atrial Fibrillation: A Prospective and Serial Follow-up During 12 Months with Transesophageal Echocardiography and Cerebral Magnetic Resonance Imaging

OBJECTIVE

Patients with atrial fibrillation and echocardiographic risk factors have a relevant risk of cerebral embolism. However, there is little knowledge about the long-term fate and the rate of clinical silent cerebral embolism under continued oral anticoagulation. Our aims were to assess the prognosis of patients with atrial fibrillation and determine a high-risk group with an increased risk of cerebral embolism under oral anticoagulation.

METHODS

A total of 173 consecutive patients with persistent or permanent atrial fibrillation and left atrial (LA) thrombi, dense spontaneous echocontrast, reduced LA appendage peak emptying velocities, or a combination of these were included in the study. In all, 169 patients with atrial fibrillation and without echocardiographic risk factors served as control patients. We performed serial and prospective transesophageal echocardiography, cranial magnetic resonance imaging, and clinical examinations during a period of 12 months.

RESULTS

During the follow-up period 7 (4%) of the patients at high risk had cerebral embolism with neurologic deficits. A total of 4 (2%) patients died because of embolic events and 19 (11%) patients had silent embolism as documented on magnetic resonance imaging. In the control group, 10 (6%) patients had embolic events documented on magnetic resonance imaging; one was clinically apparent. Study patients with an event had more often previous thromboembolism (P < .0001).

CONCLUSIONS

Patients with persistent or permanent atrial fibrillation and LA thrombi, dense spontaneous echocontrast, or reduced LA appendage peak emptying velocities have an explicitly increased risk of cerebral embolism (17%) despite oral anticoagulation. Previous thromboembolic event is another important predictor for an event.