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Qiao Y, Zhao Z, Cai X, Guo Y, Liu K, Guo J, Guo T, Niu G. Prevalence, predictors and management of left atrial appendage thrombogenic milieu in atrial fibrillation with low thromboembolic risk. Thromb J 2023; 21:34. [PMID: 36998006 PMCID: PMC10064768 DOI: 10.1186/s12959-023-00478-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/22/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND The present study aimed to investigate the prevalence, predictors, and management of left atrial appendage (LAA) thrombogenic milieu (TM) identified with transesophageal echocardiography (TEE) in non-valvular atrial fibrillation (NVAF) patients with low to moderate thromboembolic (TE) risk. METHODS We retrospectively analyzed the baseline clinical data and TEE findings in 391 NVAF patients (54.7 ± 8.9 years, 69.1% male) with low to moderate TE risk according to the CHA2DS2-VASc score. LAA TM was defined as LAA thrombus (LAAT), sludge or spontaneous echo contrast (SEC). Management of LAA TM was at the discretion of the treating physician. RESULTS A total of 43 patients (11.0%) were detected with LAA TM, including 5 with LAAT (11.6%), 4 with LAAT + Sect. (9.3%), 3 with sludge (7.0%), and 31 with Sect. (72.1%). In multivariate model, non-paroxysmal AF (OR 3.121; 95% CI 1.205-8.083, p = 0.019), and a larger left atrial diameter (LAD) (OR 1.134; 95% CI 1.060-1.213, p < 0.001) were significantly associated with the presence of LAA TM. All LAATs or sludges effectively resolved after mean duration of 117.5 ± 20.0 days for oral anticoagulant (OAC) medication. TE events occurred in 3 patients (18.8%) among those discontinuing OAC over a mean follow-up of 26.2 ± 8.8 months, while no TE events occurred in patients with continuous OAC. CONCLUSIONS LAA TM could be identified in 11.0% in NVAF patients with low to moderate TE risk, especially in those with non-paroxysmal AF and enlarged LAD. Short-term OAC medication could effectively resolve the LAAT or sludge.
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Affiliation(s)
- Yu Qiao
- Department of Cardiac Arrhythmia, Fuwai Yunnan Cardiovascular Hospital, Kunming Medical University, Kunming, Yunnan, 650032, People's Republic of China
| | - Zhen Zhao
- Department of Cardiac Arrhythmia, Fuwai Yunnan Cardiovascular Hospital, Kunming Medical University, Kunming, Yunnan, 650032, People's Republic of China
| | - Xiang Cai
- Department of Cardiac Arrhythmia, Fuwai Yunnan Cardiovascular Hospital, Kunming Medical University, Kunming, Yunnan, 650032, People's Republic of China
| | - Yulong Guo
- Department of Cardiac Arrhythmia, Fuwai Yunnan Cardiovascular Hospital, Kunming Medical University, Kunming, Yunnan, 650032, People's Republic of China
| | - Ke Liu
- Department of Cardiac Arrhythmia, Fuwai Yunnan Cardiovascular Hospital, Kunming Medical University, Kunming, Yunnan, 650032, People's Republic of China
| | - Jinrui Guo
- Department of Cardiac Arrhythmia, Fuwai Yunnan Cardiovascular Hospital, Kunming Medical University, Kunming, Yunnan, 650032, People's Republic of China
| | - Tao Guo
- Department of Cardiac Arrhythmia, Fuwai Yunnan Cardiovascular Hospital, Kunming Medical University, Kunming, Yunnan, 650032, People's Republic of China
| | - Guodong Niu
- Department of Cardiac Arrhythmia, Fuwai Yunnan Cardiovascular Hospital, Kunming Medical University, Kunming, Yunnan, 650032, People's Republic of China.
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, People's Republic of China.
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Wybraniec MT, Mizia‐Szubryt M, Cichoń M, Wrona‐Kolasa K, Kapłon‐Cieślicka A, Gawałko M, Budnik M, Uziębło‐Życzkowska B, Krzesiński P, Starzyk K, Gorczyca‐Głowacka I, Daniłowicz‐Szymanowicz L, Kaufmann D, Wójcik M, Błaszczyk R, Hiczkiewicz J, Łojewska K, Kosmalska K, Fijałkowski M, Szymańska A, Wiktorska A, Haberka M, Kucio M, Michalski B, Kupczyńska K, Tomaszuk‐Kazberuk A, Wilk‐Śledziewska K, Wachnicka‐Truty R, Koziński M, Burchardt P, Mizia‐Stec K. Heart failure and the risk of left atrial thrombus formation in patients with atrial fibrillation or atrial flutter. ESC Heart Fail 2022; 9:4064-4076. [PMID: 36039813 PMCID: PMC9773653 DOI: 10.1002/ehf2.14105] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/19/2022] [Accepted: 07/28/2022] [Indexed: 01/19/2023] Open
Abstract
AIMS The aim of the study was to evaluate the prevalence of left atrial thrombus (LAT) on transoesophageal echocardiography (TOE) in patients with atrial fibrillation or atrial flutter (AF/AFl) with reference to the presence of heart failure (HF) and its subtypes. METHODS AND RESULTS The research is a sub-study of the multicentre, prospective, observational Left Atrial Thrombus on Transoesophageal Echocardiography (LATTEE) registry, which comprised 3109 consecutive patients with AF/AFl undergoing TOE prior to direct current cardioversion or catheter ablation. TOE parameters, including presence of LAT, were compared between patients with and without HF and across different subtypes of HF, including HF with preserved (HFpEF), mid-range (HFmrEF), and reduced ejection fraction (HFrEF). HF was diagnosed in 1336 patients (43%). HF patients had higher prevalence of LAT than non-HF patients (12.8% vs. 4.4%; P < 0.001). LAT presence increased with more advanced type of systolic dysfunction (HFpEF vs. HFmrEF vs. HFrEF: 7.4% vs. 10.5% vs. 20.3%; P < 0.001). Univariate analysis revealed that HFrEF (odds ratio [OR] 4.13; 95% confidence interval [95% CI]: 3.13-5.46), but not HFmrEF or HFpEF, was associated with the presence of LAT. Multivariable logistic regression indicated that lower left ventricular ejection fraction (OR per 1%: 0.94; 95% CI 0.93-0.95) was an independent predictor of LAT formation. Receiver operator characteristic analysis showed LVEF ≤48% adequately predicted increased risk of LAT presence (area under the curve [AUC] 0.74; P < 0.0001). CONCLUSION The diagnosis of HFrEF, but neither HFmrEF nor HFpEF, confers a considerable risk of LAT presence despite widespread utilization of adequate anticoagulation.
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Affiliation(s)
- Maciej T. Wybraniec
- ‘Club 30’Polish Cardiac SocietyWarsawPoland,First Department of Cardiology, School of Medicine in KatowiceMedical University of SilesiaKatowicePoland,Members of the European Reference Network on Heart diseases ‐ ERN GUARD‐HEARTAmsterdamNetherlands
| | - Magdalena Mizia‐Szubryt
- First Department of Cardiology, School of Medicine in KatowiceMedical University of SilesiaKatowicePoland
| | - Małgorzata Cichoń
- ‘Club 30’Polish Cardiac SocietyWarsawPoland,First Department of Cardiology, School of Medicine in KatowiceMedical University of SilesiaKatowicePoland
| | - Karolina Wrona‐Kolasa
- First Department of Cardiology, School of Medicine in KatowiceMedical University of SilesiaKatowicePoland
| | - Agnieszka Kapłon‐Cieślicka
- ‘Club 30’Polish Cardiac SocietyWarsawPoland,1st Chair and Department of CardiologyMedical University of WarsawWarsawPoland
| | - Monika Gawałko
- ‘Club 30’Polish Cardiac SocietyWarsawPoland,1st Chair and Department of CardiologyMedical University of WarsawWarsawPoland,Department of CardiologyMaastricht University Medical Centre and Cardiovascular Research Institute MaastrichtMaastrichtThe Netherlands,Institute of Pharmacology, West German Heart and Vascular CentreUniversity of Duisburg‐EssenDuisburgGermany
| | - Monika Budnik
- ‘Club 30’Polish Cardiac SocietyWarsawPoland,1st Chair and Department of CardiologyMedical University of WarsawWarsawPoland
| | | | - Paweł Krzesiński
- ‘Club 30’Polish Cardiac SocietyWarsawPoland,Department of Cardiology and Internal DiseasesMilitary Institute of MedicineWarsawPoland
| | - Katarzyna Starzyk
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre; Collegium MedicumThe Jan Kochanowski UniversityKielcePoland
| | - Iwona Gorczyca‐Głowacka
- ‘Club 30’Polish Cardiac SocietyWarsawPoland,1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre; Collegium MedicumThe Jan Kochanowski UniversityKielcePoland
| | | | - Damian Kaufmann
- Department of Cardiology and ElectrotherapyMedical University of GdańskGdańskPoland
| | - Maciej Wójcik
- ‘Club 30’Polish Cardiac SocietyWarsawPoland,Department of CardiologyMedical University of LublinLublinPoland
| | - Robert Błaszczyk
- Department of CardiologyMedical University of LublinLublinPoland
| | - Jarosław Hiczkiewicz
- Clinical Department of CardiologyNowa Sól Multidisciplinary HospitalNowa SólPoland,University of Zielona GóraZielona GóraPoland
| | - Katarzyna Łojewska
- Clinical Department of CardiologyNowa Sól Multidisciplinary HospitalNowa SólPoland
| | | | - Marcin Fijałkowski
- ‘Club 30’Polish Cardiac SocietyWarsawPoland,1st Department of CardiologyMedical University of GdanskGdańskPoland
| | - Anna Szymańska
- ‘Club 30’Polish Cardiac SocietyWarsawPoland,Department of Heart DiseasesPostgraduate Medical SchoolWarsawPoland
| | - Anna Wiktorska
- Department of Heart DiseasesPostgraduate Medical SchoolWarsawPoland
| | - Maciej Haberka
- ‘Club 30’Polish Cardiac SocietyWarsawPoland,Department of Cardiology, School of Health SciencesMedical University of SilesiaKatowicePoland
| | - Michał Kucio
- Department of Cardiology, School of Health SciencesMedical University of SilesiaKatowicePoland
| | - Błażej Michalski
- ‘Club 30’Polish Cardiac SocietyWarsawPoland,Department of CardiologyMedical University of LódżŁódźPoland
| | - Karolina Kupczyńska
- ‘Club 30’Polish Cardiac SocietyWarsawPoland,Department of CardiologyMedical University of LódżŁódźPoland
| | - Anna Tomaszuk‐Kazberuk
- ‘Club 30’Polish Cardiac SocietyWarsawPoland,Department of CardiologyMedical University of BiałystokBiałystokPoland
| | | | - Renata Wachnicka‐Truty
- ‘Club 30’Polish Cardiac SocietyWarsawPoland,Department of Cardiology and Internal MedicineMedical University of GdańskGdyniaPoland
| | - Marek Koziński
- ‘Club 30’Polish Cardiac SocietyWarsawPoland,Department of Cardiology and Internal MedicineMedical University of GdańskGdyniaPoland
| | - Paweł Burchardt
- ‘Club 30’Polish Cardiac SocietyWarsawPoland,Department of Biology and Lipid DisordersPoznań University of Medical SciencesPoznańPoland
| | - Katarzyna Mizia‐Stec
- ‘Club 30’Polish Cardiac SocietyWarsawPoland,First Department of Cardiology, School of Medicine in KatowiceMedical University of SilesiaKatowicePoland,Members of the European Reference Network on Heart diseases ‐ ERN GUARD‐HEARTAmsterdamNetherlands
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Yilmaz MF, Acar E, Inanir M, Karabay CY, Izgi IA. Serum heparanase levels and left atrial/left atrial appendage thrombus in patients with nonvalvular atrial fibrillation. Herz 2021; 47:251-257. [PMID: 34351431 DOI: 10.1007/s00059-021-05052-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 05/05/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Data regarding the possible role of heparanase (HPA) in the occurrence of left atrial/left atrial appendage (LA/LAA) thrombus in patients with atrial fibrillation (AF) is lacking. The goal of the present study was to assess the association between plasma levels of HPA and LA/LAA thrombus in AF. METHODS A total of 687 patients with nonvalvular AF (NVAF) without anticoagulation therapy were included from January 2016 to June 2019. Serum HPA analysis was performed with a commercially available human ELISA kit. Logistic regression models were used to test for association. RESULTS Serum HPA levels were significantly higher in patients with LA/LAA thrombus than in those without LA/LAA thrombus (270.8 [193.4 ± 353.2] pg/mL vs 150.3 [125.2 ± 208.4] pg/mL; P < 0.001). In multivariate analysis, serum HPA remained a significantly independent predictor of LA/LAA thrombus (odds ratio 1.674, 95% confidence interval [CI] 1.339-2.289, P < 0.001). In the receiver operating characteristic (ROC) curve analysis, HPA showed a predictive value with an area under the curve (AUC) of 0.757 (95% CI 0.652-0.810, P < 0.001). The optimal cutoff level for HPA predicting LA/LAA thrombus was 210.7 pg/mL, with a sensitivity of 74.3% and a specificity of 64.8%. CONCLUSION An elevated HPA level was associated with the presence of LA/LAA thrombus in patients with AF. HPA might portend the risk for the prothrombotic state in AF patients.
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Affiliation(s)
- Mehmet Fatih Yilmaz
- Siyami Ersek High Specialization Health Application and Research Center, Department of Cardiology, University of Health Sciences, Istanbul, Turkey.
| | - Emrah Acar
- Department of Cardiology, Gumushane State Hospital, Gumushane, Turkey
| | - Mehmet Inanir
- Department of Cardiology, Bolu Abant Izzet Baysal University, Bolu, Turkey
| | - Can Yücel Karabay
- Siyami Ersek High Specialization Health Application and Research Center, Department of Cardiology, University of Health Sciences, Istanbul, Turkey
| | - Ibrahim Akin Izgi
- Kartal Kosuyolu High Specialization Health Application and Research Center, Department of Cardiology, University of Health Sciences, Istanbul, Turkey
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4
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Merino JL, Lip GYH, Heidbuchel H, Cohen AA, De Caterina R, de Groot JR, Ezekowitz MD, Le Heuzey JY, Themistoclakis S, Jin J, Melino M, Winters SM, Merkely B, Goette A. Determinants of left atrium thrombi in scheduled cardioversion: an ENSURE-AF study analysis. Europace 2020; 21:1633-1638. [PMID: 31436835 PMCID: PMC6826208 DOI: 10.1093/europace/euz213] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 08/07/2019] [Indexed: 12/17/2022] Open
Abstract
Aims ENSURE-AF (NCT 02072434) was the largest prospective randomized clinical trial of anticoagulation for cardioversion in atrial fibrillation (AF), which also provides the largest prospective dataset for transoesophageal echocardiography (TOE) prior to cardioversion. This ancillary analysis investigated determinants of TOE-detected left atrium thrombi (LAT) in patients scheduled for electrical cardioversion (ECV). Methods and results The ENSURE-AF multicentre PROBE evaluation trial compared edoxaban 60 mg once daily (QD) with enoxaparin/warfarin in 2199 subjects undergoing ECV of non-valvular AF. Patients were stratified by the use of TOE, anticoagulant experience, and selected edoxaban dose. Electrical cardioversion was cancelled or deferred when TOEdetected LAT. In total, 1183 subjects were stratified to the TOE arm and LAT was reported in 91 (8.2%). In univariate analysis, age ≥75 years (26.4% vs. 16.9%, P = 0.0308), lower weight (86.5 ± 15.0 vs. 90.7 ± 18.0 kg, P = 0.0309), lower creatinine clearance (80.1 ± 30.6 vs. 93.2 ± 33.9 mL/min, P = 0.0007), heart failure (59.3% vs. 43.0%, P = 0.0029), and diuretic treatment (53.9% vs. 40.1%, P = 0.0141) were more prevalent in the LAT group. Non-significant trends were seen for higher mean CHA2DS2-VASc score (3.0 ± 1.41 vs. 2.7 ± 1.48, P = 0.0571) and more prevalent anticoagulation use prior to enrolment (60.4% vs. 50.3%, P = 0.0795) in the LAT group. In logistic regression analysis, age (P = 0.0202) and heart failure (P = 0.0064) were independently associated with LAT. Conclusion Elective ECV is commonly cancelled or deferred due to TOE-detected LAT in patients with non-valvular AF. Age ≥75 years and heart failure were associated with the presence of LAT.
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Affiliation(s)
- Jose L Merino
- Arrhythmia and Robotic Electrophysiology Unit, Hospital Universitario La Paz, IDIPaz, Departamento de Medicina de la Universidad Autonoma de Madrid, P. Castellana, 261 (H. Gral, 1st Floor), Madrid, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Hein Heidbuchel
- Department of Cardiology, Antwerp University and University Hospital, Wijlrijkstraat 10, Antwerp, Edegem, Belgium
| | - Aron-Ariel Cohen
- Service de cardiologie, INSERM 856 and Hôpital Saint Antoine, Hôpital Tenon; Sorbonne-Université (Université Pierre et Marie Curie, Paris VI), 1 rue Victor Cousin, Paris, France
| | - Raffaele De Caterina
- Chair of Cardiology, University of Pisa and Cardiology Division, Pisa University Hospital, Pisa, Italy
| | - Joris R de Groot
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Heart Center, Meibergdreef 9, AZ, Amsterdam, The Netherlands
| | - Michael D Ezekowitz
- Department of Cardiovascular Medicine, Sidney Kimmel Jefferson Medical College at Thomas Jefferson University, 1025 Walnut St #100, Philadelphia, PA, USA; Lankenau Medical Center, 100 East Lancaster Avenue, Wynnewood, PA, USA and Bryn Mawr Hospital, 130 South Bryn Mawr Avenue Bryn Mawr, PA, USA
| | - Jean-Yves Le Heuzey
- Cardiology and Arrhythmology, Georges Pompidou Hospital, René Descartes University, 20 Rue Leblanc, Paris, France
| | - Sakis Themistoclakis
- Unit of Electrophysiology and Cardiac Pacing, Dell'Angelo Hospital, Via Paccagnella, 11, Venice-Mestre, Italy
| | - James Jin
- Daiichi Sankyo Pharma Development, 211 Mt Airy Rd, Basking Ridge, NJ, USA
| | - Michael Melino
- Daiichi Sankyo Pharma Development, 211 Mt Airy Rd, Basking Ridge, NJ, USA
| | | | - Béla Merkely
- Semmelweis University Heart and Vascular Center, Városmajor u.68, Budapest, Hungary
| | - Andreas Goette
- St. Vincenz-Hospital, Paderborn, Am Busdorf 2, Paderborn, Nordrhein-Westfalen, Germany.,Working Group: Molecular Electrophysiology, University Hospital Magdeburg, Leipziger Str. 44, Magdeburg, Germany
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5
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Fu Y, Li K, Gao Y, Wang L, Chen M, Yang X. A novel risk score for predicting left atrial and left atrial appendage thrombogenic milieu in patients with non-valvular atrial fibrillation. Thromb Res 2020; 192:161-166. [PMID: 32485419 DOI: 10.1016/j.thromres.2020.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Although the CHADS2 and CHA2DS2-VASc scoring systems are commonly used as measures of thromboembolic risk in patients with nonvalvular atrial fibrillation (NVAF), data are inconsistent as to their value in predicting the presence of left atrial (LA) and/or left atrial appendage (LAA) thrombogenic milieu (TM). The present study aimed to establish a novel risk score to assess the risk of LA and/or LAATM in NVAF patients. METHODS This is a retrospective case-control study that included 125 consecutive patients with NVAF plus TM, as evidenced by transesophageal echocardiography (TEE) during a period from1 January 2010 to 1 February 2017. The controls were 1098 NVAF patients without TM during the same period. Risk factors for LA and/or LAATM were identified using univariable analysis and multivariable logistic regression. The risk score model was developed based on 10-fold validation and multiple regression. Risk model performance was evaluated using receiver operating characteristic (ROC) curves. Net reclassification improvement (NRI) was used for the comparison of C-statistics. The AUCs were compared using the Z test. RESULTS Among all 1223 NVAF patients, 125 (10.22%) patients had LA and/or LAATM. A score system (0-12) was developed based on the following 6 independent variables identified by 10-fold validation with sequential methods. Different points were assigned for each variable, according to multivariable regression using relative coefficients (coefficient of the index risk factor divided by the lowest coefficient among the 6 risk factors; rounded to closest integer): 1 for blood type A and N-terminal B-type natriuretic peptide (NT-proBNP) ≥864.85 pg/mL; 2 for LAD ≥43.5 mm and age ≥ 73.5 years old; 3 for previous heart failure and previous stroke or TIA. The present risk score system had a sensitivity of 58.3%, specificity of 91.4 and accuracy of 81.6%. The area under the ROC curve (AUC) was 0.832, (95% CI: 0.784-0.881; P < 0.001). The negative predictive value (NPV) was 92% when we set the cut-off point at 4; when the cut-off point was set at 8, the positive predictive value (PPV) was 85.7%. Compared with CHADS2 and CHA2DS2-VASc score, the present novel risk score has better predictive power [net reclassification improvement (NRI) +96.3% and +66.2%, respectively; all P < 0.001]. CONCLUSION This study developed a novel risk score to help predicting LA and/or LAATM in NVAF patients, which had higher accuracy than CHADS2 and CHA2DS2-VASc score system.
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Affiliation(s)
- Yuan Fu
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Kuibao Li
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yuanfeng Gao
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Lefeng Wang
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Mulei Chen
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xinchun Yang
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China.
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Diagnosis and Management of Left Atrium Appendage Thrombosis in Atrial Fibrillation Patients Undergoing Cardioversion. ACTA ACUST UNITED AC 2019; 55:medicina55090511. [PMID: 31438560 PMCID: PMC6780583 DOI: 10.3390/medicina55090511] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/04/2019] [Accepted: 08/19/2019] [Indexed: 01/29/2023]
Abstract
Atrial fibrillation is the most common cardiac arrhythmia and is associated with an increased risk of stroke and thromboembolic complications. A rhythm control strategy with both electrical and pharmacological cardioversion is recommended for patients with symptomatic atrial fibrillation. Anticoagulant therapy for 3–4 weeks prior to cardioversion is recommended in order to avoid thromboembolic events deriving from restoring sinus rhythm. Transesophageal echocardiography has a pivotal role in this setting, excluding the presence of left atrial appendage thrombus before cardioversion. The aim of this review is to discuss the epidemiology and risk factors for left atrial appendage thrombosis, the role of echocardiography in the decision making before cardioversion, and the efficacy of different anticoagulant regimens on the detection and treatment of left atrial appendage thrombosis.
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7
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Squara F, Bres M, Scarlatti D, Moceri P, Ferrari E. Clinical outcomes after AF cardioversion in patients presenting left atrial sludge in trans-esophageal echocardiography. J Interv Card Electrophysiol 2019; 57:149-156. [PMID: 31119494 DOI: 10.1007/s10840-019-00561-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 05/06/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Direct-current cardioversion (DCC) for atrial fibrillation carries a risk of stroke, probably associated with the temporary atrial stunning following cardioversion. The presence of a cardiac thrombus, usually localized in the left atrial appendage (LAA), is recognized as a clear contra-indication to the cardioversion. However, the presence of atrial sludge without LAA thrombus in trans-esophageal echocardiography (TEE) remains, for many cardiologists, a relative contra-indication to the cardioversion. The aim of this study was to evaluate the safety of DCC in patients presenting atrial sludge without LAA thrombus. METHODS We prospectively included all consecutive patients demonstrating atrial sludge without LAA thrombus in TEE and undergoing DCC for persistent atrial fibrillation (AF). Safety of DCC was evaluated by the occurrence of clinical events at 1 month following cardioversion, i.e., up to the end of the atrial stunning period, as assessed by clinical examination and the standardized and validated Questionnaire for Verifying Stroke-Free Status (QVSFS). RESULTS Over a period of 2 years, 21 patients presenting atrial sludge without LAA thrombus underwent DCC for AF. During the follow-up period of 1 month after DCC, no clinical embolic event, cardiac event, or unscheduled consultations/hospitalizations occurred. At 1 month, 67% of the patients remained in sinus rhythm. CONCLUSION No clinical event occurred in patients demonstrating atrial sludge without thrombus and undergoing DCC for AF. These findings support current guidelines that only keep atrial thrombus as a contraindication to cardioversion, but warrant further investigation in large studies.
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Affiliation(s)
- Fabien Squara
- Hôpital Pasteur, Service de Cardiologie, 30 avenue de la Voie Romaine, CS 51069 06001, Nice Cedex 1, France.
| | - Mikael Bres
- Hôpital Pasteur, Service de Cardiologie, 30 avenue de la Voie Romaine, CS 51069 06001, Nice Cedex 1, France
| | - Didier Scarlatti
- Hôpital Pasteur, Service de Cardiologie, 30 avenue de la Voie Romaine, CS 51069 06001, Nice Cedex 1, France
| | - Pamela Moceri
- Hôpital Pasteur, Service de Cardiologie, 30 avenue de la Voie Romaine, CS 51069 06001, Nice Cedex 1, France
| | - Emile Ferrari
- Hôpital Pasteur, Service de Cardiologie, 30 avenue de la Voie Romaine, CS 51069 06001, Nice Cedex 1, France
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8
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Kizawa S, Ito T, Akamatsu K, Ichihara N, Nogi S, Miyamura M, Kanzaki Y, Sohmiya K, Hoshiga M. Chronic Kidney Disease as a Possible Predictor of Left Atrial Thrombogenic Milieu Among Patients with Nonvalvular Atrial Fibrillation. Am J Cardiol 2018; 122:2062-2067. [PMID: 30293657 DOI: 10.1016/j.amjcard.2018.08.058] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/22/2018] [Accepted: 08/28/2018] [Indexed: 11/17/2022]
Abstract
Patients with chronic kidney disease (CKD) experiencing atrial arrhythmia are hypothesized to have elevated CHADS2 and CHA2DS2-VASc scores, thereby predisposed to left atrial (LA) thrombus formation and subsequent thromboembolism. We examined possible association of LA thrombogenic milieu (TM) with CKD in patients with nonvalvular atrial fibrillation. A total of 581 patients (181 women; mean age, 67 years) who underwent transesophageal echocardiography were examined. Patients were divided into 4 groups based on the estimated glomerular filtration rate (eGFR) (ml/min/1.73 m2): eGFR ≥90 (n = 29), 60≤ eGFR <90 (n = 329), 30≤ eGFR <60 (n = 209), and eGFR <30 (n = 14). TM was defined as the presence of LA thrombus, dense spontaneous echo contrast, or LA appendage velocity ≤25 cm/s. Of 581 patients, 147 (25%) had TM. The prevalence of TM increased with decreasing eGFR (4%, 18%, 36%, and 86% for each group, p <0.001). Similar trends were observed for some of the clinical and echocardiographic variables including CHA2DS2-VASc score and LA size. Multivariate logistic regression analysis revealed that every 10 ml/min/1.73 m2 decrement in eGFR was a significant independent correlate of TM (odds ratio 0.80, p = 0.005), along with nonparoxysmal atrial fibrillation (AF) (odds ratio 0.45, p = 0.004), higher CHA2DS2-VASc score (odds ratio 1.24, p = 0.012), every 5 ml/m2 increment in LA volume index (odds ratio 1.57, p <0.001), and every 10% decrement in left ventricular ejection fraction (odds ratio 0.51, p <0.001). In conclusion, CKD may be a significant risk factor for LA thrombus formation in patients with nonvalvular atrial fibrillation.
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Affiliation(s)
- Shun Kizawa
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Takahide Ito
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, Japan.
| | - Kanako Akamatsu
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Noboru Ichihara
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Shimpei Nogi
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Masatoshi Miyamura
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Yumiko Kanzaki
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Koichi Sohmiya
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Masaaki Hoshiga
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, Japan
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9
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Borre ED, Goode A, Raitz G, Shah B, Lowenstern A, Chatterjee R, Sharan L, Allen LaPointe NM, Yapa R, Davis JK, Lallinger K, Schmidt R, Kosinski A, Al-Khatib SM, Sanders GD. Predicting Thromboembolic and Bleeding Event Risk in Patients with Non-Valvular Atrial Fibrillation: A Systematic Review. Thromb Haemost 2018; 118:2171-2187. [PMID: 30376678 DOI: 10.1055/s-0038-1675400] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of stroke. Medical therapy for decreasing stroke risk involves anticoagulation, which may increase bleeding risk for certain patients. In determining the optimal therapy for stroke prevention for patients with AF, clinicians use tools with various clinical, imaging and patient characteristics to weigh stroke risk against therapy-associated bleeding risk. AIM This article reviews published literature and summarizes available risk stratification tools for stroke and bleeding prediction in patients with AF. METHODS We searched for English-language studies in PubMed, Embase and the Cochrane Database of Systematic Reviews published between 1 January 2000 and 14 February 2018. Two reviewers screened citations for studies that examined tools for predicting thromboembolic and bleeding risks in patients with AF. Data regarding study design, patient characteristics, interventions, outcomes, quality, and applicability were extracted. RESULTS Sixty-one studies were relevant to predicting thromboembolic risk and 38 to predicting bleeding risk. Data suggest that CHADS2, CHA2DS2-VASc and the age, biomarkers, and clinical history (ABC) risk scores have the best evidence for predicting thromboembolic risk (moderate strength of evidence for limited prediction ability of each score) and that HAS-BLED has the best evidence for predicting bleeding risk (moderate strength of evidence). LIMITATIONS Studies were heterogeneous in methodology and populations of interest, setting, interventions and outcomes analysed. CONCLUSION CHADS2, CHA2DS2-VASc and ABC scores have the best prediction for stroke events, and HAS-BLED provides the best prediction for bleeding risk. Future studies should define the role of imaging tools and biomarkers in enhancing the accuracy of risk prediction tools. PRIMARY FUNDING SOURCE Patient-Centered Outcomes Research Institute (PROSPERO #CRD42017069999).
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Affiliation(s)
- Ethan D Borre
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States
| | - Adam Goode
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States.,Department of Orthopedic Surgery, Duke University School of Medicine, Durham, North Carolina, United States
| | - Giselle Raitz
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States
| | - Bimal Shah
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States.,Livongo, Mountain View, California, United States
| | - Angela Lowenstern
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Ranee Chatterjee
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States
| | - Lauren Sharan
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States
| | - Nancy M Allen LaPointe
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States.,Premier Inc., Charlotte, North Carolina, United States
| | - Roshini Yapa
- Department of Medicine, University of Colorado, Aurora, Colorado, United States
| | - J Kelly Davis
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, United States
| | - Kathryn Lallinger
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States.,Evidence-Based Practice Center, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
| | - Robyn Schmidt
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States.,Evidence-Based Practice Center, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
| | - Andrzej Kosinski
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States
| | - Sana M Al-Khatib
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Gillian D Sanders
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States.,Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, United States.,Evidence-Based Practice Center, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
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10
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Yang PS, Pak HN, Park DH, Yoo J, Kim TH, Uhm JS, Kim YD, Nam HS, Joung B, Lee MH, Heo JH. Non-cardioembolic risk factors in atrial fibrillation-associated ischemic stroke. PLoS One 2018; 13:e0201062. [PMID: 30028885 PMCID: PMC6054400 DOI: 10.1371/journal.pone.0201062] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 07/06/2018] [Indexed: 02/07/2023] Open
Abstract
Introduction Cardioembolic (CE) risks is usually considered as the main mechanism of ischemic stroke in non-valvular atrial fibrillation (NVAF) patients. However, a substantial number of ischemic strokes in NVAF patients are related to non-CE mechanisms. The aim of this study was to investigate the non-CE risk factors in ischemic stroke patients had NVAF. Methods We included 401 patients (65.6% male, 68.6 ± 9.6 years old) who had been hospitalized due to ischemic stroke and had a known or newly diagnosed NVAF. The CE (intracardiac thrombus, dense spontaneous echo contrast, or low left atrial appendage flow velocity) and non-CE (complex aortic plaque, significant carotid stenosis, or intracranial arterial stenosis) risk factors were investigated at the time of the index stroke. Results The number of CE and non-CE risk factors increased with increasing CHA2DS2-VASc scores (p for trends < 0.001). The presence of CE risk factors was independently associated with persistent atrial fibrillation (p < 0.001), body mass index (p = 0.003), heart failure (p = 0.003), and left atrial volume index (p < 0.001). In contrast, the presence of non-CE risk factors was independently associated with age (p < 0.001), hypertension (p = 0.049), diabetes (p = 0.030), and coronary artery calcium score (CACS; p < 0.001). CACS had the added value in predicting non-CE risk factors of ischemic stroke regardless of the CHA2DS2-VASc risk category (p < 0.001). Conclusion Non-CE risk factors in ischemic stroke patients with NVAF are associated with high CHA2DS2-VASc score and CACS. Atherosclerotic non-CE risk factors should be considered as potential mechanisms of stroke even in patients with AF-associated ischemic stroke.
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Affiliation(s)
- Pil-Sung Yang
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Republic of Korea
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Republic of Korea
- * E-mail: (HNP); (JHH)
| | - Dong-Hyuk Park
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Republic of Korea
| | - Joonsang Yoo
- Department of Neurology, Yonsei University Health System, Seoul, Republic of Korea
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Republic of Korea
| | - Jae-Sun Uhm
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Republic of Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University Health System, Seoul, Republic of Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University Health System, Seoul, Republic of Korea
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Republic of Korea
| | - Moon-Hyoung Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University Health System, Seoul, Republic of Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University Health System, Seoul, Republic of Korea
- * E-mail: (HNP); (JHH)
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11
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Kupczynska K, Kasprzak JD, Michalski BW, Miskowiec DL, Lipiec P. The impact of the latest echocardiographic chamber quantification recommendations on the prediction of left atrial appendage thrombus presence by transthoracic echocardiography. Acta Cardiol 2018; 73:91-95. [PMID: 28799449 DOI: 10.1080/00015385.2017.1351241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The latest recommendations for echocardiographic chamber quantification have implemented updated normal values for all cardiac chambers. PURPOSE To evaluate the incidence of normal and abnormal values of routine echocardiographic parameters such as left ventricular ejection fraction (LVEF) and left atrial volume indexed to body surface area (LAVi) in patients with non-valvular atrial fibrillation (AF) and to determine the influence of LVEF and LAVi reclassification on the prediction of LAAT by transthoracic echocardiography. METHODS We retrospectively analysed the database of 1674 transesophageal echocardiograms performed between 2012 and 2015 in our echo lab. The study involved patients (mean age 70 ± 7 years, 80% men) with paroxysmal or persistent AF (35 patients with left atrial appendage thrombus [LAAT] and 35 sex- and age-matched controls without LAAT). LVEF and LAVi were categorised in two ways: semi-quantitative using four-degree scale (normal or abnormal graded from mild and moderate to severe) and qualitative (normal vs. abnormal). RESULTS We reclassified 6 (9%) and 4 (6%) patients with regard to LVEF as well as 38 (54%) and 16 (23%) with regard to LAVi on semi-quantitative and qualitative scale, respectively. After adjustment for effective anticoagulation and approved risk factors in the multivariate models, we identified LVEF categorised in semi-quantitative manner according to both documents, LAVi categorised in a binary manner by new guidelines and semi-quantitative scale by both recommendations as independently associated with LAAT. CONCLUSIONS Differentiation between normal and abnormal value enhanced the diagnostic meaning of LAVi in the aspect of higher LAAT risk. LVEF reclassification had no significant influence.
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Affiliation(s)
- Karolina Kupczynska
- a Chair and Department of Cardiology , Medical University of Lodz , Lodz , Poland
| | - Jaroslaw D Kasprzak
- a Chair and Department of Cardiology , Medical University of Lodz , Lodz , Poland
| | - Blazej W Michalski
- a Chair and Department of Cardiology , Medical University of Lodz , Lodz , Poland
| | - Dawid L Miskowiec
- a Chair and Department of Cardiology , Medical University of Lodz , Lodz , Poland
| | - Piotr Lipiec
- a Chair and Department of Cardiology , Medical University of Lodz , Lodz , Poland
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12
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Hu XF, Zhan R, Xu S, Wang J, Wu J, Liu X, Li Y, Chen L. Growth differentiation factor 15 is associated with left atrial/left atrial appendage thrombus in patients with nonvalvular atrial fibrillation. Clin Cardiol 2018; 41:34-38. [PMID: 29363835 DOI: 10.1002/clc.22844] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 10/20/2017] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND There is evidence suggesting that growth differentiation factor 15 (GDF-15) appears to be associated with stroke in patients with atrial fibrillation (AF). AF-related thromboembolic stroke is predominantly attributed to the thrombus from the left atrium (LA) or left atrial appendage (LAA). HYPOTHESIS GDF-15 is related to LA/LAA thrombus in nonvalvular AF (NVAF) patients. METHODS A total of 894 patients with NVAF without anticoagulation therapy were included in this study. All patients routinely underwent transesophageal echocardiography for detection of LA/LAA thrombus. GDF-15 was measured by enzyme-linked immunosorbent assay. Logistic regression models were used to test for association. RESULTS LA/LAA thrombus was detected by transesophageal echocardiography in 69 (7.72%) patients with AF. The GDF-15 levels in the patients with LA/LAA thrombus were significantly higher than those without LA/LAA thrombus (log10 GDF-15: 2.989 ± 0.023 ng/L vs 2.831 ± 0.007 ng/L; P < 0.001). Logistic regression analysis showed that GDF-15 was an independent risk factor for LA/LAA thrombus (odds ratio [per quarter]: 1.799, 95% confidence interval: 1.381-2.344, P < 0.001) after adjusting for potential clinical risk factors. The optimal cutoff point for GDF-15 predicting LA/LAA thrombus was 809.9 ng/L (sensitivity, 75.3%; specificity, 61.5%), determined by ROC curve. The area under the curve was 0.709 (95% confidence interval: 0.644-0.770, P < 0.001). CONCLUSIONS Elevated GDF-15 indicated a significantly increased risk for LA/LAA thrombus in NVAF patients. Thus, GDF-15 might be a potentially useful adjunct in discriminating LA/LAA thrombus in NVAF patients.
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Affiliation(s)
- Xiao Feng Hu
- Department of Cardiology, Zhejiang Hospital, Hangzhou, Zhejiang Province, China
| | - Rui Zhan
- Department of Cardiology, Jiangxi Provincial People's Hospital, Nanchang, Jiangxi Province, China
| | - Shanhu Xu
- Department of Neurology, Zhejiang Hospital, Hangzhou, Zhejiang Province, China
| | - Junjun Wang
- Department of Neurology, Zhejiang Hospital, Hangzhou, Zhejiang Province, China
| | - Jiong Wu
- Department of Neurology, Zhejiang Hospital, Hangzhou, Zhejiang Province, China
| | - Xiaoli Liu
- Department of Neurology, Zhejiang Hospital, Hangzhou, Zhejiang Province, China
| | - Yaguo Li
- Department of Neurology, Zhejiang Hospital, Hangzhou, Zhejiang Province, China
| | - Linhui Chen
- Department of Neurology, Zhejiang Hospital, Hangzhou, Zhejiang Province, China
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13
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Ning W, Li Y, Ma C, Qiu L, Yu B. The Refinement of Risk Stratification for Atrial Thrombus or Spontaneous Echo Contrast in Nonvalvular Atrial Fibrillation. Int Heart J 2017; 58:885-893. [PMID: 29151480 DOI: 10.1536/ihj.16-444] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
As for nonvalvular atrial fibrillation (NVAF) patients with left atrial thrombus or spontaneous echo contrast (LAT/SEC), we evaluated the additional predictive value of serum uric acid (SUA) and Left atrial diameter (LAD) for CHADS2 and CHA2DS2-VASc, and explored the influence from the level of SUA and LAD to LAT/SEC in moderate risk group. Thus, we put forward the concept of a borderline high risk group to guide clinical anticoagulant therapy in patients with NVAF.A total of 284 NVAF patients without the history of anticoagulant prior to hospitalization were enrolled. They were divided into LAT/SEC group or No LAT/SEC group according to transesophageal echocardiography (TEE). Then, we explored and compared the additional predictive value of serological and ultrasonic indexes after combining them to CHADS2/CHA2DS2-VASc.61 patients (21.48%) had LAT/SEC. SUA and LAD were the independent risk factors of LAT/SEC. After being added with LAD and SUA, the predictive value of CHADS2 and CHA2DS2-VASc were increased much more than others. In the moderate risk group, the incidence of LAT/SEC rose significantly when SUA or LAD was higher than cut-off values.SUA and LAD enhanced the predictive ability of CHADS2 and CHA2DS2-VASc for LAT/SEC as additional factors. For patients in moderate risk group, if SUA or LAD was higher than cut-off values, the risk of thromboembolism events would rise accompanied by the elevated risk of LAT/SEC.
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Affiliation(s)
- Wenna Ning
- Department of Cardiology, The First Hospital Affiliated to China Medical University
| | - Yang Li
- Department of Cardiology, The First Hospital Affiliated to China Medical University
| | - Chunyan Ma
- Department of Ultrasonics, The First Hospital Affiliated to China Medical University
| | - Liangxian Qiu
- Department of Cardiology, The First Hospital Affiliated to China Medical University
| | - Bo Yu
- Department of Cardiology, The First Hospital Affiliated to China Medical University
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14
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Atkinson C, Hinton J, Gaisie EB, Yue AM, Roberts PR, Rakhit DJ, Shah BN. Use of the CHA 2DS 2VASc score to reduce utilisation of transoesophageal echocardiography prior to ablation for atrial fibrillation. Echo Res Pract 2017; 4:45-52. [PMID: 28864464 PMCID: PMC5633057 DOI: 10.1530/erp-17-0042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 08/17/2017] [Indexed: 01/15/2023] Open
Abstract
Transoesophageal echocardiography (TOE) is frequently performed prior to atrial fibrillation (AF) ablation to exclude left atrial appendage (LAA) thrombus. However, patients undergoing AF ablation are usually anticoagulated, thus making the presence of thrombus unlikely in most cases. This study aimed to determine whether the CHA2DS2VASc scoring system can be used to identify patients that do not require TOE prior to AF ablation. In this single-centre retrospective study, local institutional and primary care databases and electronic patient records were searched to identify patients that had undergone TOE prior to AF ablation. Patient demographics, CHA2DS2VASc score, TOE findings and anticoagulation status were collected for analysis. Over a 7-year period (2008–2014), 332 patients (age 57 ± 10 years; 74% male) underwent TOE prior to proposed AF ablation. CHA2DS2VASc scores of 0, 1, 2 and >2 were found in 39, 34, 15 and 12% of patients, respectively. The prevalence of LAA thrombus was 0.6% (2 patients) and these 2 patients had risk scores of 2 and 4. No patients with a score of 0 or 1 had LAA thrombus. Patients that are classed as low risk by the CHA2DS2VASc score do not require a pre-ablation TOE to screen for LAA thrombus provided they are adequately anticoagulated. This would lead to a significant reduction in health care expenditures by reducing unnecessary TOE requests and thereby improve patient experience.
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Affiliation(s)
- Charlotte Atkinson
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Jonathan Hinton
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Edmund B Gaisie
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Arthur M Yue
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Paul R Roberts
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Dhrubo J Rakhit
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Benoy N Shah
- Department of Cardiology, University Hospital Southampton, Southampton, UK
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15
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Fu Y, Li K, Yang X. ABO blood groups: A risk factor for left atrial and left atrial appendage thrombogenic milieu in patients with non-valvular atrial fibrillation. Thromb Res 2017; 156:45-50. [PMID: 28582641 DOI: 10.1016/j.thromres.2017.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 04/28/2017] [Accepted: 05/20/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Previous studies have identified ABO blood groups as predictors of thromboembolic diseases. In patients with atrial fibrillation (AF), however, potential association between ABO blood groups and the risk of left atrial (LA) and/or left atrial appendage (LAA) thrombogenic milieu (TM) has not been established. METHODS This is a retrospective case-control study that included 125 consecutive patients with non-valvular atrial fibrillation (NVAF) plus TM, as evidenced by transesophageal echocardiography (TEE) during a period from1 January 2010 to 31 December 2016. The controls were selected randomly from 1072 NVAF without TM at a 1:2 ratio. Potential association between ABO blood groups and TM was analyzed using multivariate logistic regression analysis. RESULTS The risk of TM was higher in patients with blood group A (33.6% vs. 20.2% in non-A blood groups, P=0.005). After adjusting for age, sex, oral anticoagulant use, AF type and duration, and relevant functional measures (e.g., NT-pro BNP level, left atrium diameter, and left ventricular ejection fraction), blood group A remained associated with an increased risk of TM (OR=2.99, 95% CI 1.4-6.388, P=0.005). CONCLUSION Blood group A is an independent risk factor for TM in NVAF patients.
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Affiliation(s)
- Yuan Fu
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Kuibao Li
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xinchun Yang
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China.
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16
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Association of CHADS 2 and CHA 2DS 2-VASc Scores with Left Atrial Thrombus with Nonvalvular Atrial Fibrillation: A Single Center Based Retrospective Study in a Cohort of 2695 Chinese Subjects. BIOMED RESEARCH INTERNATIONAL 2017; 2017:6839589. [PMID: 28373985 PMCID: PMC5360946 DOI: 10.1155/2017/6839589] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 01/16/2017] [Accepted: 02/14/2017] [Indexed: 11/17/2022]
Abstract
The main mechanism of the CHADS2 and CHA2DS2-VASc scores to predict stroke in nonvalvular atrial fibrillation (NVAF) is still controversial. We evaluated the association of the CHADS2 and CHA2DS2-VASc scores with left atrial thrombus (LAT) as detected by transesophageal echocardiographic (TEE) and compared the predictive ability of these risk stratification schemes with nonvalvular atrial fibrillation (NVAF). Data from 2,695 consecutive NVAF patients in whom TEE was performed for screening LAT from July 2007 to February 2014 were analyzed. Only 3% of the subjects had LAT. Presence of LAT was not significantly associated with either CHADS2 (P = 0.07) or CHA2DS2-VASc score (P = 0.12). The area under the curve (AUC) concerning LAT prediction using CHADS2 and CHA2DS2-VASc was 0.574 and 0.569, respectively. A composition model includes previous stroke or transient ischemic attack, nonparoxysmal AF, moderate to severe left ventricular systolic dysfunction, left atrial enlargement, and cardiomyopathy which improved the discrimination significantly (AUC = 0.743). In our cohort, both CHADS2 and CHA2DS2-VASc scores were of limited value for predicting LAT in patients with NVAF. This questions the CHADS2/CHA2DS2-VASc score predicting stroke mainly through the mechanism of cardiogenic embolism. A scoring scheme combining clinical and echocardiographic parameters may better predict LAT as a surrogate for cardioembolic risk in NVAF patients.
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17
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Efimova E, Ueberham L, Bode K, Arya A. A fortunate outcome after electrical cardioversion with a giant persistent left atrial thrombus. Is TOE-guided strategy more preferable in high risk patients? Int J Cardiol 2016; 208:1-3. [DOI: 10.1016/j.ijcard.2016.01.184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 01/13/2016] [Indexed: 11/26/2022]
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18
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Doukky R, Garcia-Sayan E, Patel M, Pant R, Wassouf M, Shah S, D'Silva O, Kehoe RF. Impact of Diastolic Function Parameters on the Risk for Left Atrial Appendage Thrombus in Patients with Nonvalvular Atrial Fibrillation: A Prospective Study. J Am Soc Echocardiogr 2016; 29:545-53. [PMID: 27021354 DOI: 10.1016/j.echo.2016.01.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND In patients with nonvalvular atrial fibrillation (NVAF), the impact of left ventricular diastolic function on the risk for left atrial appendage (LAA) thrombus has not been prospectively studied. METHODS At two academic medical centers, patients with NVAF were prospectively enrolled to undergo investigational transthoracic echocardiography immediately before clinically indicated transesophageal echocardiography. Mitral inflow E velocity and tissue Doppler septal and lateral mitral annulus velocities (e') were measured, and E/e' ratios were calculated. RESULTS Among 266 subjects (mean age, 65 years; 32% women), 17 (6.4%) had LAA thrombus. Patients with LAA thrombus had a higher mean CHA2DS2-VASc score (4.6 ± 1.7 vs 3.0 ± 1.8, P < .001), a higher mean lateral E/e' ratio (19.4 ± 10.1 vs 10.2 ± 5.6, P < .001), and a lower mean lateral e' velocity (7.0 ± 3.2 vs 10.4 ± 3.7 cm/sec, P = .001). There was a good discriminative capacity for E/e' (area under the curve, 0.83; P < .001) and e' velocity (area under the curve, 0.76; P = .001). None of the patients with normal E/e' ratios or normal e' velocities had LAA thrombus. Both E/e' (odds ratio, 1.13 per point; 95% CI, 1.06-1.20; P < .001) and e' velocity (odds ratio, 0.76 per 1 cm/sec; 95% CI, 0.63-0.92; P = .005) provided independent and incremental predictive value beyond the CHA2DS2-VASc score; however, E/e' provided greater incremental value than e' velocity (P = .036). Analyses using septal and averaged E/e' and septal e' velocity yielded similar results. Diastolic function parameters were also associated with the presence and intensity of left atrial spontaneous echo contrast, a precursor of LAA thrombus. CONCLUSIONS This prospective and concomitant evaluation of diastolic function and LAA thrombus in patients with NVAF demonstrates that E/e' ratio and e' velocity are associated with LAA thrombus, independent of CHA2DS2-VASc score, and may play a role in identifying patients at low risk for LAA thrombus. These data suggest that diastolic function assessment may improve stroke prediction in patients with NVAF.
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Affiliation(s)
- Rami Doukky
- Division of Adult Cardiology, John H. Stroger, Jr Hospital of Cook County, Chicago, Illinois; Division of Cardiology, Rush University Medical Center, Chicago, Illinois.
| | - Enrique Garcia-Sayan
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois; Division of Cardiology, Mount Sinai Hospital, Chicago, Illinois
| | - Mita Patel
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois; Division of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rojina Pant
- Division of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois
| | - Marwan Wassouf
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois; Department of Medicine, Fairview Hospital, Cleveland, Ohio
| | - Saurabh Shah
- Division of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois
| | - Oliver D'Silva
- Division of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois
| | - Richard F Kehoe
- Division of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois
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Nishikii-Tachibana M, Murakoshi N, Seo Y, Xu D, Yamamoto M, Ishizu T, Atsumi A, Machino-Ohtsuka T, Kuroki K, Yamasaki H, Igarashi M, Sekiguchi Y, Aonuma K. Prevalence and Clinical Determinants of Left Atrial Appendage Thrombus in Patients With Atrial Fibrillation Before Pulmonary Vein Isolation. Am J Cardiol 2015; 116:1368-73. [PMID: 26358509 DOI: 10.1016/j.amjcard.2015.07.055] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 07/21/2015] [Accepted: 07/21/2015] [Indexed: 10/23/2022]
Abstract
The CHADS2 score is considered a reliable predictor of stroke/thromboembolism risk in patients with atrial fibrillation (AF). However, thromboembolism can occasionally occur even in patients with AF with low CHADS2 score (CHADS2 score = 0 or 1). To investigate the incidence and predictors of left atrial appendage (LAA) thrombus (LAAT) formation in patients with AF, we studied consecutive 543 Japanese patients with AF who underwent transesophageal echocardiography before pulmonary vein isolation from 2008 to 2012. All patients were treated with anticoagulation therapy with warfarin, and their clinical and echocardiographic characteristics were evaluated. LAATs were observed in 35 (6.4%) of 543 patients, and the prevalence was clearly correlated with the patient's CHADS2 scores. Of 338 patients with low CHADS2 score, LAATs were observed in 7 patients (2.1%). By multivariate analysis, increased left atrial volume (≥50 ml), decreased ejection fraction (<56%), and increased brain natriuretic peptide level (>75 pg/ml) were significantly associated with increased prevalence of LAATs, even in patients with low CHADS2 score. Accordingly, we proposed a new scoring system to predict LAAT (left atrial volume ≥50 ml: score 2; ejection fraction <56%: score 1; brain natriuretic peptide >75 pg/ml: score 1). Patients with a score ≥2 have a greater risk of LAAT, whereas all patients with score ≤1 have no LAATs. Our scoring system is useful for evaluation of the risk of LAAT in patients with AF even with low CHADS2 score.
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20
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Kim MN, Kim SA, Choi JI, Park SM, Park SW, Kim YH, Shim WJ. Improvement of Predictive Value for Thromboembolic Risk by Incorporating Left Atrial Functional Parameters in the CHADS2 and CHA2DS2-VASc Scores. Int Heart J 2015; 56:286-92. [PMID: 25912904 DOI: 10.1536/ihj.14-380] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The discriminative ability of the widely used CHADS2 and CHA2DS2-VASc scores for risk stratification of thromboembolism in atrial fibrillation (AF) is known as modest. Some echocardiographic parameters are known risk factors for thromboembolism. This study aimed to evaluate whether combining echocardiographic parameters with CHADS2 and CHA2DS2-VASc scores can improve the predictive power for embolic risk in AF.A total of 526 (F/M = 83/433, mean age = 57.6 ± 10.7 years) patients with non-valvular AF were enrolled. The predictability for left atrial (LA) thrombus or dense spontaneous echo contrast (SEC) using clinical scores or echocardiographic parameters or combining clinical scores and echocardiographic parameters was calculated and compared.Dense SEC or thrombus was present in 51 patients. The predicting powers of the CHADS2 and CHADS2-VASc scores for the presence of dense SEC or thrombus were modest (c-statistics 0.65 and 0.68, respectively, 95% confidence interval [CI] 0.61-0.69 and 0.64-0.74, respectively, both P < 0.001). Impaired LA function was the most descriptive predictor for the presence of thrombus or dense SEC among echocardiographic parameters. Combining impaired LA function (LA emptying fraction < 30%) with the CHADS2 and CHA2DS2-VASc scores showed the improvement of predictive power in detecting dense SEC or thrombus (c-statistics 0.78 and 95% CI 0.74-0.81 and c-statistics 0.77 and 95% CI 0.73-0.81, respectively, both P < 0.001).Adding LA functional markers to the CHADS2 or CHA2DS2-VASc score improved the predictive value of the presence of thrombus or dense SEC. In clinical situations, anticoagulation should be considered to prevent embolism in patients with low-risk scores when they have LA dysfunction.
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Affiliation(s)
- Mi-Na Kim
- Division of Cardiology, Korea University Anam Hospital
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21
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Coleman CM, Khalaf S, Mould S, Wazni O, Kanj M, Saliba W, Cantillon D. Novel Oral Anticoagulants for DC Cardioversion Procedures: Utilization and Clinical Outcomes Compared with Warfarin. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:731-7. [PMID: 25721150 DOI: 10.1111/pace.12618] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 02/16/2015] [Accepted: 02/18/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Novel oral anticoagulant (NOAC) agents dabigatran, rivaroxaban, and apixaban are increasingly utilized as thromboembolic prevention for patients with atrial fibrillation undergoing direct current cardioversion (DCCV) with post hoc analyses of clinical trials suggesting satisfactory safety and efficacy. This study characterizes utilization, effectiveness, and complications of NOAC agents for stroke prophylaxis in the setting of DCCV. METHODS Comparison of warfarin and NOAC agents as periprocedural anticoagulation for DCCV procedures performed at Cleveland Clinic from January 2009 through December 2013. Variables of interest include utilization rates for each NOAC agent stratified by clinical parameters including CHADS2 score, and associated clinical outcomes including cerebrovascular accident (CVA), transient ischemic attack (TIA), peripheral arterial embolism (PAE), and bleeding events during 8 weeks of postprocedure follow-up. RESULTS Among 5,320 DCCV procedures, 673 (12.6%) cases were excluded due to inadequate follow-up. Warfarin was utilized in 3,721 (80.1%), dabigatran in 719 (15.5%), rivaroxaban in 159 (3.4%), and apixaban in 48 (1.0%) with a steady increase in NOAC utilization from 2011 to 2013. There were low rates of CVA/TIA (warfarin: 0.97% vs NOAC 1.62%, P = 0.162) and bleeding (warfarin: 1.02% vs NOAC: 0.5%, P = 0.247) and no significant differences detected between agents. Higher CHADS2 /CHA2 DS2 -VASC scores were associated with thromboembolic and bleeding risk. Increasing age, chronic kidney disease, diabetes, coronary disease, and deep vein thrombosis/pulmonary embolism were associated with increased bleeding risk. CONCLUSION In a high-volume, single-center experience, NOAC utilization has grown to account for over a third of cardioversion procedures, and these agents appear safe and effective compared to warfarin with low rates of thromboembolic and bleeding complications.
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Affiliation(s)
- Corey M Coleman
- From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Shaden Khalaf
- From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Steven Mould
- From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Oussama Wazni
- From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Mohamed Kanj
- From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Walid Saliba
- From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Daniel Cantillon
- From the Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
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Mitamura H, Nagai T, Watanabe A, Takatsuki S, Okumura K. Left atrial thrombus formation and resolution during dabigatran therapy: A Japanese Heart Rhythm Society report. J Arrhythm 2015; 31:226-31. [PMID: 26336564 DOI: 10.1016/j.joa.2014.12.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 12/22/2014] [Accepted: 12/26/2014] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Protocols on the use of novel oral anticoagulants for stroke prevention in patients with atrial fibrillation (AF) undergoing electrical cardioversion (ECV) are lacking. AIM The study was aimed at evaluating the efficacy of dabigatran (Dabi) treatment in preventing peri-ECV stroke. METHODS A retrospective survey of the incidence and fate of left atrial (LA) thrombus during Dabi therapy in patients with AF was conducted between December 2012 and January 2013 by the Japanese Heart Rhythm Society. RESULTS A total of 198 patients from 299 institutions underwent transesophageal echocardiography (TEE) to rule out LA thrombus before ECV. Of these, LA thrombus was found in eight patients (4%), who tended to be older (67.3 vs. 61.3 years, p=0.175), had higher CHADS2 scores (1.88 vs. 0.95, p=0.058), and a higher prevalence of prior stroke or transient ischemic attack (22.2% vs. 2.6%, p=0.034) than those without LA thrombus. Of the eight patients with LA thrombus, one had LA thrombus during a Dabi 150 mg b.i.d treatment, whereas the remaining seven were receiving 110 mg b.i.d for 3 weeks or longer. In 6 of the 8 patients with LA thrombus, a second TEE was performed, revealing complete resolution of LA thrombus in five; among these five patients, one received Dabi dosage of 150 mg b.i.d unchanged, two received an increased dosage from 110 mg to 150 mg b.i.d, and two were switched to warfarin. Two patients had a stroke 3 and 15 days after ECV, and one had a major large intestine bleeding episode during Dabi therapy. CONCLUSIONS LA thrombus developed in 4% of patients with AF receiving Dabi. Older patients with a higher CHADS2 score receiving a lower Dabi dosage were more likely to develop LA thrombus, which was resolved with a prolonged or increased dosage. A higher Dabi dosage may be more beneficial before ECV but prospective randomized studies would be needed to confirm these results.
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Affiliation(s)
- Hideo Mitamura
- Cardiovascular Center, Tachikawa Hospital, Federation of National Public Service Personnel Mutual Aid Associations, 4-2-22 Nishikicho, Tachikawa, Tokyo, Japan
| | - Takayuki Nagai
- Department of Cardiology, Pulmonology, Hypertension & Nephrology, Ehime University Graduate School of Medicine, Japan
| | | | - Seiji Takatsuki
- Department of Cardiology, Keio University School of Medicine, Japan
| | - Ken Okumura
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Japan
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23
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Sugioka K, Fujita S, Iwata S, Ito A, Matsumura Y, Hanatani A, Doi A, Takagi M, Naruko T, Ueda M, Yoshiyama M. Relationship between CHADS2 score and complex aortic plaques by transesophageal echocardiography in patients with nonvalvular atrial fibrillation. ULTRASOUND IN MEDICINE & BIOLOGY 2014; 40:2358-2364. [PMID: 25023106 DOI: 10.1016/j.ultrasmedbio.2014.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 04/16/2014] [Accepted: 05/07/2014] [Indexed: 06/03/2023]
Abstract
The CHADS2 score is widely used for risk stratification of thromboembolism in patients with non-valvular atrial fibrillation (NVAF). Although the correlation of CHADS2 score with left atrial (LA) abnormality as detected by transesophageal echocardiography (TEE) has been reported in previous studies, the relationship between CHADS2 score and complex aortic plaque, which is also a significant risk factor for thromboembolism, has not been fully investigated. We assessed aortic plaques by TEE in 150 patients age ≥ 55 y with NVAF. The prevalence of complex aortic plaques increased along with increases in CHADS2 score (p = 0.001). In a multivariate analysis that included atherosclerotic risk factors and LA abnormality, a CHADS2 score ≥2 was independently associated with the presence of complex aortic plaques (odds ratio [OR] 3.39; 95% confidence interval [CI], 1.29-8.90). A high CHADS2 score is closely associated with the presence of complex aortic plaques, which explains, in part, the increased risk of thromboembolism in NVAF patients with high CHADS2 score.
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Affiliation(s)
- Kenichi Sugioka
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan.
| | - Suwako Fujita
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shinichi Iwata
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Asahiro Ito
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Matsumura
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Akihisa Hanatani
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Atsushi Doi
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masahiko Takagi
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Takahiko Naruko
- Department of Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Makiko Ueda
- Department of Pathology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Minoru Yoshiyama
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
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24
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Cullen MW, Stulak JM, Li Z, Powell BD, White RD, Nkomo VT, Ammash NM. Transesophageal echocardiography-guided cardioversion after cardiac operations. Ann Thorac Surg 2014; 98:1325-30. [PMID: 25152384 DOI: 10.1016/j.athoracsur.2014.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 06/02/2014] [Accepted: 06/03/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Transesophageal echocardiography (TEE) is often performed during cardiac operations. The need to repeat TEE to exclude left atrial or left atrial appendage thrombus before direct current cardioversion (DCCV) in patients with a recent intraoperative TEE showing no thrombus is unclear. We sought to determine the incidence of and risk factors for new thrombus in patients undergoing TEE-guided DCCV after cardiac operations. METHODS We reviewed 817 patients referred for TEE-guided DCCV within 30 days of a cardiac operation and an intraoperative TEE. Patients were excluded if the intraoperative TEE showed thrombus or a surgical left atrial appendage intervention was performed. Univariate logistic regression identified risk factors for thrombus. RESULTS The study included 362 patients (71% male) with a mean age of 69 years. Median time from the operation to DCCV was 6 days. Thrombus was present in 13 patients (3.6%) on TEE before cardioversion; DCCV was cancelled in these patients. Heart failure was associated with a significantly higher risk of new thrombus formation (7% vs 2%; odds ratio, 3.26; 95% confidence interval, 1.07 to 9.95). Preoperative atrial arrhythmias, duration of perioperative arrhythmias, level of anticoagulation, and time from operation to DCCV were not significantly associated with thrombus. Thrombus was not associated with 30-day mortality. CONCLUSIONS Development of new thrombus in patients with atrial arrhythmias early after cardiac operations is not uncommon, especially in patients with heart failure. Patients at high risk for thromboembolic events should undergo TEE before DCCV, even if a recent intraoperative TEE showed no thrombus.
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Affiliation(s)
- Michael W Cullen
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
| | - John M Stulak
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Zhuo Li
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Brian D Powell
- Sanger Heart & Vascular Institute, Carolinas Health Care System, Charlotte, North Carolina
| | - Roger D White
- Division of Cardiovascular & Thoracic Anesthesiology, Mayo Clinic, Rochester, Minnesota
| | - Vuyisile T Nkomo
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Naser M Ammash
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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25
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Cohen A, Le Heuzey JY. Anticoagulants : stratification du risque en pathologie vasculaire. ARCHIVES OF CARDIOVASCULAR DISEASES SUPPLEMENTS 2014. [DOI: 10.1016/s1878-6480(14)71479-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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