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Kowalewski M, Święczkowski M, Kuźma Ł, Maesen B, Dąbrowski EJ, Matteucci M, Batko J, Litwinowicz R, Kowalówka A, Wańha W, Jiritano F, Raffa GM, Malvindi PG, Pannone L, Meani P, Lorusso R, Whitlock R, La Meir M, de Asmundis C, Cox J, Suwalski P. Systematic review and meta-analysis of left atrial appendage closure's influence on early and long-term mortality and stroke. JTCVS OPEN 2024; 19:131-163. [PMID: 39015454 PMCID: PMC11247209 DOI: 10.1016/j.xjon.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/17/2023] [Accepted: 02/08/2024] [Indexed: 07/18/2024]
Abstract
Objective Left atrial appendage closure (LAAC) concomitant to heart surgery in patients with underlying atrial fibrillation (AF) has gained attention because of long-term reduction of thromboembolic complications. As of mortality benefits in the setting of non-AF, data from both observational studies and randomized controlled trials are conflicting. Methods On-line databases were screened for studies comparing LAAC versus no LAAC concomitant to other heart surgery. End points assessed were all-cause mortality and stroke at early and longest-available follow-up. Subgroup analyses stratified on preoperative AF were performed. Risk ratios (RR) with 95% CIs served as primary statistics. Results Electronic search yielded 25 studies (N = 660 [158 patients]). There was no difference between LAAC and no LAAC in terms of early mortality. In the overall population analysis, LAAC reduced long-term mortality (RR, 0.86; 95% CI, 0.74-1.00; P = .05; I 2 = 88%), reduced early stroke risk by 19% (RR, 0.81; 95% CI, 0.72-0.93; P = .002; I 2 = 57%), and reduced late stroke risk by 13% (RR, 0.87; 95% CI, 0.84-0.90; P < .001; I 2 = 58%). Subgroup analysis showed lower mortality (RR, 0.85; 95% CI, 0.72-1.01; P = .06; I 2 = 91%), short-, and long-term stroke risk reduction only in patients with preoperative AF (RR, 0.81; 95% CI, 0.71-0.93; P = .003; I 2 = 71% and RR, 0.87; 95% CI, 0.84-0.91; P < .001; I 2 = 70%, respectively). No benefit of LAAC in patients without AF was found. Conclusions Concomitant LAAC was associated with reduced stroke rates at early and long-term and possibly reduced all-cause mortality at the long-term follow-up but the benefits were limited to patients with preoperative AF. There is not enough evidence to support routine concomitant LAAC in non-AF settings.
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Affiliation(s)
- Mariusz Kowalewski
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Michał Święczkowski
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Łukasz Kuźma
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Bart Maesen
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
| | - Emil Julian Dąbrowski
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Matteo Matteucci
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
| | - Jakub Batko
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Radosław Litwinowicz
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiac Surgery, Regional Specialist Hospital, Grudziądz, Poland
| | - Adam Kowalówka
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
- Department of Cardiac Surgery, Upper-Silesian Heart Center, Katowice, Poland
| | - Wojciech Wańha
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Invasive Cardiology and Structural Heart Diseases, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
| | - Federica Jiritano
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Pietro Giorgio Malvindi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, Ill
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Paolo Meani
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Policlinico, San Donato Milanese, Milan, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
| | | | - Mark La Meir
- Department of Cardiac Surgery, UZ Brussel, Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - James Cox
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, Ill
| | - Piotr Suwalski
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Thoracic Research Centre
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
- Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
- Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Cardiac Surgery, Regional Specialist Hospital, Grudziądz, Poland
- Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
- Department of Cardiac Surgery, Upper-Silesian Heart Center, Katowice, Poland
- Department of Invasive Cardiology and Structural Heart Diseases, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, Ill
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Policlinico, San Donato Milanese, Milan, Italy
- McMaster University, Hamilton, Canada
- Department of Cardiac Surgery, UZ Brussel, Brussels, Belgium
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Zeng R, Pu X, Chen S, Chen C, Chen Y, Chen W, Fu H. Oropharynx pain, discomfort, and economic impact of transesophageal echocardiography for planned radio-frequency catheter ablation in patients with atrial fibrillation: A cross-sectional survey study. IJC HEART & VASCULATURE 2023; 48:101266. [PMID: 37719868 PMCID: PMC10500450 DOI: 10.1016/j.ijcha.2023.101266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 08/26/2023] [Indexed: 09/19/2023]
Abstract
Background To survey the unmet medical needs associated with atrium thrombus screening in Chinese patients with atrial fibrillation (AF) who underwent transesophageal echocardiography (TEE) for planned radio-frequency catheter ablation (RFCA). Methods This cross-sectional survey study interviewed 300 patients who underwent their first TEE for planned RFCA. The surveyed information included patients' anxiety, oropharynx pain and discomfort, time expense, and patient satisfaction related to TEE examination. Patient preference for a new atrium thrombus screening technology, hospital length of stay (LOS) of RFCA, and hospital costs of RFCA in these surveyed patients were collected as well. Descriptive statistical methods were used to summarize the collected survey information. Results Of the 300 interviewed patients, 36.3% reported anxiety before TEE examination, 58.6% reported oropharynx pain related to TEE, and 76.2% reported oropharynx discomforts, mainly including foreign body sensation (54.3%), dry heaves (33.8%), nausea (31.9%), and bleeding (22.9%). Even though 62.3% were satisfied with TEE, 84.3% preferred a new technology to replace TEE. Conducting outpatient TEE took more wait time (4.4 days vs. 0.1 days, p = 0.016) but led to significantly shorter hospital LOS (3.8 days vs. 6.4 days, p < 0.001) and significant lower hospital costs for RFCA (¥74,097 vs. ¥85,843, p < 0.001) than conducting inpatient TEE. Conclusions Most AF patients experienced oropharynx pain and discomfort during or after TEE. Although more than half of AF patients were satisfied with TEE, most AF patients preferred a new technology to replace TEE for atrium thrombus screening. TEE was associated with economic impact on RFCA irrespective of TEE conducting settings.
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Affiliation(s)
- Rui Zeng
- West China Hospital of Sichuan University, Chengdu, China
| | - Xiaobo Pu
- West China Hospital of Sichuan University, Chengdu, China
| | - Shi Chen
- West China Hospital of Sichuan University, Chengdu, China
| | - Chunjia Chen
- Changsha Normin Health Technology Ltd., Changsha, China
| | - Yi Chen
- Changsha Normin Health Technology Ltd., Changsha, China
| | - Wendong Chen
- Normin Health Consulting Ltd., Mississauga, Ontario, Canada
- Toronto Health Economics and Technology Assessment Collaborative, University of Toronto, Toronto, Ontario, Canada
| | - Hua Fu
- West China Hospital of Sichuan University, Chengdu, China
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Zaigraev IA, Yavelov IS, Drapkina OM, Bazaeva EV. Predictors of thrombosis of left atrium and its appendage before catheter ablation or cardioversion in patients with non-valvular atrial fibrillation or atrial flutter. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2023. [DOI: 10.15829/1728-8800-2022-3443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
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.
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Affiliation(s)
- I. A. Zaigraev
- National Medical Research Center for Therapy and Preventive Medicine
| | - I. S. Yavelov
- National Medical Research Center for Therapy and Preventive Medicine
| | - O. M. Drapkina
- National Medical Research Center for Therapy and Preventive Medicine
| | - E. V. Bazaeva
- National Medical Research Center for Therapy and Preventive Medicine
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Left atrial appendage thrombus formation, potential of resolution and association with prognosis in a large real-world cohort. Sci Rep 2023; 13:889. [PMID: 36650206 PMCID: PMC9845308 DOI: 10.1038/s41598-023-27622-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 01/04/2023] [Indexed: 01/19/2023] Open
Abstract
Comprehensive data on factors influencing left atrial appendage (LAA) thrombus formation, resolution and impact on survival are limited. In this single-center, retrospective study 7759 (2010-2015) patients with symptomatic ongoing atrial fibrillation (AF) on admission were screened for LAA thrombi. 450 patients had LAA thrombi. 481 patients without LAA thrombi were randomly selected as controls. We assessed clinical, echocardiographic, laboratory parameters and long-term survival of both groups. Patients with LAA thrombi compared to controls were older, had more strokes, higher CHA2DS2 -VASc scores, worse renal function, less controlled diabetes, advanced heart failure, lower LAA emptying velocities, higher levels of cardiac and inflammatory markers (all p < 0.001). 56.3% of followed-up patients (304) dissolved their LAA thrombi. Chances of thrombus resolution increased with rising LAA flow velocities (OR 1.061, p = 0.022), whereas advanced age (OR 0.950, p < 0.001) and presence of permanent AF (OR 0.354, p < 0.001) decreased chances of thrombus resolution. Presence of LAA thrombi was associated with a markedly reduced 10-year survival probability (31% versus 69%). LAA thrombus formation is promoted by advanced structural heart disease, inflammation, diabetes and impaired renal function. Younger age, non-permanent AF and higher LAA flow velocities were predictors of thrombus resolution. Thrombus formation was associated with poor prognosis.
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Yang S, Zhang Y, Chen N, Shi J, Ju W, Chen H, Yang G, Wang Z, Liu H, Jiang X, Cui C, Chen M, Li M. Characteristics, Thrombus Resolution, and Long-Term Outcomes in Patients with Nonvalvular Atrial Fibrillation and Atrial Thrombus. Clin Appl Thromb Hemost 2023; 29:10760296231168097. [PMID: 37079758 PMCID: PMC10126607 DOI: 10.1177/10760296231168097] [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: 04/22/2023] Open
Abstract
To assess the prevalence and management of atrial thrombus in patients with nonvalvular atrial fibrillation (NVAF) and identify the risk factors of the nonresolution of atrial thrombus. This single-center retrospective observational study consecutively enrolled patients with NVAF and atrial thrombus detected using transesophageal echocardiography (TEE) or cardiac computed tomography angiography (CTA) from January 2012 to December 2020. Patients with prior left atrial appendage (LAA) intervention were excluded. The primary endpoint was the presence of atrial thrombus, while the secondary endpoint was the complete resolution of atrial thrombus. The prevalence of atrial thrombus in patients with NVAF was 1.4%. Ninety patients with atrial thrombus (mean age 62.8 ± 11.9 years and 61.1% men) were finally analyzed. Atrial thrombus was in the LAA in 82 (91.1%) patients. During follow up, 60% of the patients showed complete resolution of atrial thrombus. Congestive heart failure (odds ratio [OR]: 8.94; 95% confidence interval [CI]: 1.67-47.80) and a history of ischemic stroke (OR: 8.28; 95% CI: 1.48-46.42) were independently associated with the risk of the nonresolution of atrial thrombus. The presence of atrial thrombus in patients with NVAF who received anticoagulation therapy is non-negligible. Even in anticoagulated patients, TEE or cardiac CTA might still be needed. Congestive heart failure and a history of ischemic stroke are risk factors of the nonresolution of atrial thrombus.
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Affiliation(s)
- Shu Yang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yanjuan Zhang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ning Chen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jiaojiao Shi
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Weizhu Ju
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hongwu Chen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Gang Yang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zidun Wang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hailei Liu
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiaohong Jiang
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Chang Cui
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Minglong Chen
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Mingfang Li
- Division of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Liu X, Yu S, Liang T, Chen L, Zhang H. Mean Platelet Volume to Platelet Count Ratio Predicts Left Atrial Stasis in Patients with Non-Valvular Atrial Fibrillation. Int J Gen Med 2023; 16:847-858. [PMID: 36895511 PMCID: PMC9990455 DOI: 10.2147/ijgm.s395305] [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: 10/28/2022] [Accepted: 02/23/2023] [Indexed: 03/06/2023] Open
Abstract
Background The mean platelet volume to platelet count ratio (MPV/PC) has been investigated in the diagnosis, prognosis and risk stratification in several diseases. However, the predictive role of MPV/PC in left atrial stasis (LAS) of non-valvular atrial fibrillation (NVAF) patients remains unknown. Methods A total of 217 consecutive NVAF patients undergoing transesophageal echocardiogram (TEE) evaluation were retrospectively enrolled. The demographic, clinical, admission laboratory and TEE data were extracted and analyzed. Patients were categorized into those with or without LAS. The associations between the MPV/PC ratio and LAS were assessed by multivariate logistic regression analysis. Results There were 24.9% (n = 54) patients with LAS according to TEE. Compared with patients without LAS, the MPV/PC ratio was significantly higher in those with LAS (5.6±1.6 vs 4.8±1.0, P < 0.001). After multivariable adjustment, higher MPV/PC ratio levels (OR 1.747, 95% CI 1.193-2.559, P = 0.004) were positively associated with LAS, with the optimal cut-point for LAS prediction of 5.36 (area under the curve, AUC = 0.683, sensitivity 48%, specificity 73%, 95% CI 0.589-0.777, P < 0.001). The stratification analysis showed that a significant positive correlation between MPV/PC ratio ≥5.36 and LAS in patients of male, younger (<65 years), paroxysmal AF, without history of stroke/TIA, CHA2DS2-VASc score ≥2, left atrial diameter (LAD) ≥40mm and left atrial volume index (LAVI) >34mL/m2 (all P < 0.05). Conclusion Increasing MPV/PC ratio was associated with an increased risk of LAS, which was mainly reflected in the subgroups of male, younger (<65 years), paroxysmal AF, without history of stroke/TIA, CHA2DS2-VASc score ≥2, LAD ≥40mm and LAVI >34mL/m2 patients.
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Affiliation(s)
- Xiaoyan Liu
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Shandong Yu
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Tuo Liang
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Lizhu Chen
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Heping Zhang
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
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Marques T, Darrieux F, Gouvêa F, Garambone L, Lindoso AP, Lage J, Sacilotto L, Coimbra AL, Pinheiro M, Olivetti N, Lara S, Hardy C, Athayde G, Hachul D, Pisani C, Wu TC, Scanavacca M. Trombo Atrial Esquerdo e Contraste Espontâneo Denso no Uso de Anticoagulante Oral de Ação Direta em Fibrilação Atrial: Visão de Centro Referenciado. Arq Bras Cardiol 2022; 119:514-519. [PMID: 36169450 PMCID: PMC9563890 DOI: 10.36660/abc.20210658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 04/06/2022] [Indexed: 11/18/2022] Open
Abstract
Fundamento Objetivo Métodos Resultados Conclusão
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Pichler Sekulic S, Sekulic M. Case Report: Acute Thrombotic Angiopathy of Atrial Appendage Epicardial Veins: A Seemingly Innocuous Finding Portending a Fatal Outcome. Front Cardiovasc Med 2021; 8:621632. [PMID: 33791344 PMCID: PMC8006332 DOI: 10.3389/fcvm.2021.621632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/09/2021] [Indexed: 11/15/2022] Open
Abstract
Thrombotic angiopathy is a pathologic description to describe endothelial injury, and with sufficient and sustained injury can lead to exposure of underlying tissue factor and the deposition of associated fibrin material. We present briefly a case of an 87-year-old woman with mitral valve regurgitation and atrial fibrillation undergoing mitral valve annuloplasty, Cox-maze procedure, and excision of the left atrial appendage. Pathologic examination of the excised atrial appendage revealed commonly encountered cardiomyocyte hypertrophy and endocardial fibroelastosis, however also showed a non-occlusive, acute thrombotic angiopathy involving epicardial veins. The surgical and immediate post-operative course was unremarkable; however, 3 weeks after discharge, the patient would develop a fatal pulmonary embolism. While fibrin thrombosis developing within the atrial appendage chamber is a recognized concern in the setting of atrial fibrillation, the significance of an acute thrombotic angiopathy involving epicardial veins of the atrial appendage is less clear although in the presented case was the sole potential harbinger of a subsequent fatal thrombotic event.
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Affiliation(s)
- Simona Pichler Sekulic
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, United States
| | - Miroslav Sekulic
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, United States
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9
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Liu Y, Zhu D, Xiao Y, Zhu Y, Zhou Q, Ren L, Chen L. Risk factors of left atrial appendage thrombus in patients with non-valvular atrial fibrillation. Open Med (Wars) 2021; 16:361-366. [PMID: 33869773 PMCID: PMC8024551 DOI: 10.1515/med-2021-0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 09/16/2020] [Accepted: 09/26/2020] [Indexed: 12/15/2022] Open
Abstract
Objective To investigate the risk factors of left atrial appendage thrombus (LAAT) in patients with non-valvular atrial fibrillation (AF). Methods We collected the clinical data of patients with non-valvular AF who underwent transesophageal echocardiography (TEE) at the Zhongda Hospital of Southeast University between January 2016 and June 2019. The patients were divided into two groups, LAAT and non-LAAT. We performed comparative analysis, receiver operating characteristic (ROC) curve analysis and logistic regression analysis to estimate the risk factors of LAAT. Results A total of 442 patients with non-valvular AF were enrolled in the study. LAAT was detected by TEE in 20 cases (4.7%). Compared with patients without LAAT, patients with LAAT had higher CHA2DS2-VASc scores (3 vs 2, p = 0.001), higher values of D-dimer (180.0 vs 90.0 μg/L, p = 0.003), larger LA anteroposterior diameters (50.5 vs 41.0 mm, p < 0.001) and higher ratios of non-paroxysmal AF (85.0% vs 23.6%, p < 0.001). ROC curve analysis revealed that the cutoff value of LA anteroposterior diameter was 49.5 mm. After adjusting for other confounders, logistic regression analysis showed that enlarged LA (anteroposterior diameter ≥49.5 mm) and non-paroxysmal AF were independently associated with higher risks of LAAT (OR = 7.28, 95% CI: 2.36-22.47; OR = 8.89, 95% CI: 2.33-33.99, respectively). The proportions of LAAT in patients with larger LA (anteroposterior diameter ≥49.5 mm), non-paroxysmal AF and both larger LA and non-paroxysmal AF were 30% (12/40), 15.2% (17/112) and 39.1% (9/23), respectively. Conclusion Enlarged LA (anteroposterior diameter ≥49.5 mm) and non-paroxysmal AF were independent risk factors of LAAT in non-valvular AF patients.
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Affiliation(s)
- Yaowu Liu
- Department of Cardiology, Zhongda Hospital of Southeast University, Nanjing, 210009, China
| | - Didi Zhu
- Department of Cardiology, Zhongda Hospital of Southeast University, Nanjing, 210009, China
| | - Yunyun Xiao
- Department of Geriatrics, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, 210008, China
| | - Yeqian Zhu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Qianxing Zhou
- Department of Cardiology, Zhongda Hospital of Southeast University, Nanjing, 210009, China
| | - Liqun Ren
- Department of Cardiology, Zhongda Hospital of Southeast University, Nanjing, 210009, China
| | - Long Chen
- Department of Cardiology, Zhongda Hospital of Southeast University, Nanjing, 210009, China
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10
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Springer A, Schleberger R, Oyen F, Hoffmann BA, Willems S, Meyer C, Langer F, Schnabel RB, Kirchhof P, Schneppenheim R, Lemoine MD. Genetic and Clinical Predictors of Left Atrial Thrombus: A Single Center Case-Control Study. Clin Appl Thromb Hemost 2021; 27:10760296211021171. [PMID: 34184557 PMCID: PMC8246465 DOI: 10.1177/10760296211021171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/29/2021] [Accepted: 05/11/2021] [Indexed: 11/15/2022] Open
Abstract
Left atrial (LA) thrombus formation is the presumed origin of thromboembolic complications in patients with atrial fibrillation (AF). Beyond clinical risk factors, the factors causing formation of LA thrombi are not well known. In this case-control study, we analyzed clinical characteristics and genetic thrombophilia markers (factor V Leiden (FVL), prothrombin G20210A (FIIV), Tyr2561 variant of von Willebrand factor (VWF-V)) in 42 patients with AF and LA thrombus (LAT) and in 68 control patients with AF without LAT (CTR). Patients with LAT had more clinical conditions predisposing to stroke (mean CHA2DS2-VASc-score 3.4 ± 1.5 vs. 1.9 ± 1.4; P < 0.001), a higher LA volume (96 ± 32 vs. 76 ± 21 ml, P = 0.002) and lower LA appendage emptying velocity (0.21 ± 0.11vs. 0.43 ± 0.19 m/s, P < 0.001). Prevalence of FVL, FIIV and VWF-V mutations was not different, but in the subgroup of patients <65 years (y) there was a tendency for a higher incidence of VWF-V with a prevalence of 27% (LAT <65 y) vs. 7% (CTR <65 y, P = 0.066). These findings warrant further investigation of the VWF-V as a risk factor for LA thrombogenesis in younger patients.
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Affiliation(s)
- Adrian Springer
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany
- Asklepios Hospital St. Georg, Hamburg, Germany
| | - Ruben Schleberger
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany
| | - Florian Oyen
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Boris A. Hoffmann
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany
- Asklepios Hospital Harburg, Hamburg, Germany
| | - Stephan Willems
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany
- Asklepios Hospital St. Georg, Hamburg, Germany
- DZHK, partner Site Hamburg/Kiel/Lübeck, Germany
| | - Christian Meyer
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany
- DZHK, partner Site Hamburg/Kiel/Lübeck, Germany
- Division of Cardiology, Cardiac Neuro- and Electrophysiology Research Consortium (cNEP), EVK, Düsseldorf, Germany
| | - Florian Langer
- Department of Oncology and Hematology, University Cancer Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Renate B. Schnabel
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany
- DZHK, partner Site Hamburg/Kiel/Lübeck, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Reinhard Schneppenheim
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marc D. Lemoine
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany
- DZHK, partner Site Hamburg/Kiel/Lübeck, Germany
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11
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Kawamura M, Munetsugu Y. Editorial to "A novel scoring system for stroke risk stratification in Japanese patients with low CHADS2 scores: Study using a transesophageal-echocardiogram endpoint.". J Arrhythm 2020; 36:632-633. [PMID: 32782632 PMCID: PMC7411233 DOI: 10.1002/joa3.12348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 04/02/2020] [Indexed: 12/03/2022] Open
Affiliation(s)
- Mitsuharu Kawamura
- Division of CardiologyDepartment of MedicineShowa University School of MedicineTokyoJapan
| | - Yumi Munetsugu
- Division of CardiologyDepartment of MedicineShowa University School of MedicineTokyoJapan
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12
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Gorczyca I, Michalska A, Chrapek M, Budnik M, Starzyk K, Jelonek O, Uziębło-Życzkowska B, Kapłon-Cieślicka A, Gawałko M, Krzesiński P, Jurek A, Scisło P, Kochanowski J, Kiliszek M, Gielerak G, Filipiak KJ, Opolski G, Wożakowska-Kapłon B. Thrombus in the left atrial appendage in patients with atrial fibrillation treated with non-vitamin K antagonist oral anticoagulants in clinical practice-A multicenter registry. J Cardiovasc Electrophysiol 2020; 31:2005-2012. [PMID: 32458520 DOI: 10.1111/jce.14589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/16/2020] [Accepted: 05/19/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The prevalence and predictors of left atrial appendage thrombus (LAAT) in patients with non-valvular atrial fibrillation (AF) who have been treated with non-vitamin K antagonist oral anticoagulants (NOACs) are not well defined. We aimed to assess the occurrence and predictors of LAAT on transesophageal echocardiography (TOE) in patients with non-valvular AF treated with NOACs for at least 3 weeks. METHODS Consecutive patients with non-valvular AF who underwent TOE before catheter ablation or electrical cardioversion in three high-reference centers between 2014 and 2018 were included. Patients on apixaban were excluded from the study due to low numbers in this category. All patients received NOACs for at least 3 weeks before TOE. RESULTS A total of 1148 patients (female, 38.1%; mean age, 62.1 years) referred to our centers for catheter ablation of AF (52.1%) or electrical cardioversion (47.9%) were included. Patients were on rivaroxaban (51.9%) or dabigatran (48.1%). Preprocedural TOE revealed LAAT in 4.4% of all patients. Multivariable logistic regression analysis showed the CHA2DS2-VASc score ≥2 points (OR = 2.11; 95% CI, 1.15-3.88; P = .0161), non-paroxysmal AF (OR = 6.30; 95% CI, 2.22-17.91; P = .0005), and GFR <60 mL/min/1.73 m2 (OR = 2.05; 95% CI, 1.14-3.67; P = .0160) were independent predictors of LAAT in patients treated with NOACs. CONCLUSIONS In non-valvular AF patients treated with NOACs, the prevalence of LAAT was 4.4% before electrical cardioversion or ablation. In addition to the CHA2DS2-VASc score, the type of AF and renal function should be considered in the stratification of thromboembolism risk in AF patients and qualification for a preprocedural TOE.
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Affiliation(s)
- Iwona Gorczyca
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, Kielce, Poland.,Faculty of Medical and Health Sciences, The Jan Kochanowski University, Kielce, Poland
| | - Anna Michalska
- Faculty of Medical and Health Sciences, The Jan Kochanowski University, Kielce, Poland
| | - Magdalena Chrapek
- Faculty of Mathematics and Natural Sciences, The Jan Kochanowski University, Kielce, Poland
| | - Monika Budnik
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Starzyk
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, Kielce, Poland.,Faculty of Medical and Health Sciences, The Jan Kochanowski University, Kielce, Poland
| | - Olga Jelonek
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, Kielce, Poland
| | | | | | - Monika Gawałko
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Paweł Krzesiński
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Agnieszka Jurek
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Piotr Scisło
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Janusz Kochanowski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Marek Kiliszek
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Grzegorz Gielerak
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Krzysztof J Filipiak
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Grzegorz Opolski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Beata Wożakowska-Kapłon
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, Kielce, Poland.,Faculty of Medical and Health Sciences, The Jan Kochanowski University, Kielce, Poland
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13
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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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14
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Kawaji T, Numamoto H, Yamagami S, Mabuchi R, Kitamura T, Enoki N, Koizumi K, Kanao S, Kato M, Yokomatsu T, Shizuta S, Miki S, Ono K, Togashi K, Kimura T. Real-time surveillance of left atrial appendage thrombus during contrast computed tomography imaging for catheter ablation: THe Reliability of cOMputed tomography Beyond UltraSound in THROMBUS detection (THROMBUS) study. J Thromb Thrombolysis 2019; 47:42-50. [PMID: 30251193 DOI: 10.1007/s11239-018-1742-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Left atrial contrast computed tomography (LA-CT) as well as transesophageal echocardiography (TEE) can exclude left atrial appendage (LAA) thrombus, but is sometimes unable to evaluate LAA due to incomplete LAA filling. The aim of the current study was to validate the utility of real-time approach of LA-CT with real-time surveillance of LAA-filling defect (FD). We enrolled consecutive 894 patients with LA-CT studies acquired for catheter ablation and compared the diagnostic accuracy in demonstrating LAA-FD between conventional protocol (N = 474) and novel protocol with real-time surveillance of LAA-FD immediately after the initial scanning and, when necessary, adding delayed scanning in the supine or prone position (N = 420). Primary endpoint was severity of LAA-FD classified into the 3 groups: "Grade-0" for complete filling of contrast, "Grade-1" for incomplete filling of contrast, and "Grade-2" for complete FD of contrast. The prevalence of Grade-1 and Grade-2 FD was 17.3% and 11.2% in conventional protocol, whereas there was no patient with Grade-2 FD, and only 1 patient with Grade-1 FD after the additional scanning in novel protocol. In 5 patients with suspected LAA thrombus both by TEE and Grade-2 FD in LA-CT by the conventional protocol, ablation procedure was canceled due to diagnosis of LAA thrombus. Conversely, 4 patients with suspected LAA thrombus by TEE in novel protocol group was proved to have intact LAA by LA-CT with and without additional scanning. This novel approach with real-time surveillance improved the diagnostic accuracy of LA-CT in detecting LAA-FD, suggesting potential superiority of LA-CT over TEE in excluding LAA thrombus.
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Affiliation(s)
- Tetsuma Kawaji
- Department of Cardiology, Mitsubishi Kyoto Hospital, 1 Katsura Gosho-cho, Nishikyo-ku, Kyoto, 615-8087, Japan.
| | - Hitomi Numamoto
- Division of Clinical Radiology Service, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shintaro Yamagami
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryu Mabuchi
- Division of Clinical Radiology Service, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takaaki Kitamura
- Division of Clinical Radiology Service, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Naomi Enoki
- Division of Clinical Radiology Service, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koji Koizumi
- Division of Clinical Radiology Service, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shotaro Kanao
- Department of Radiology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masashi Kato
- Department of Cardiology, Mitsubishi Kyoto Hospital, 1 Katsura Gosho-cho, Nishikyo-ku, Kyoto, 615-8087, Japan
| | - Takafumi Yokomatsu
- Department of Cardiology, Mitsubishi Kyoto Hospital, 1 Katsura Gosho-cho, Nishikyo-ku, Kyoto, 615-8087, Japan
| | - Satoshi Shizuta
- Department of Cardiology, Mitsubishi Kyoto Hospital, 1 Katsura Gosho-cho, Nishikyo-ku, Kyoto, 615-8087, Japan
| | - Shinji Miki
- Department of Cardiology, Mitsubishi Kyoto Hospital, 1 Katsura Gosho-cho, Nishikyo-ku, Kyoto, 615-8087, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kaori Togashi
- Department of Radiology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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15
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Harada M, Koshikawa M, Motoike Y, Ichikawa T, Sugimoto K, Watanabe E, Ozaki Y. Left Atrial Appendage Thrombus Prior to Atrial Fibrillation Ablation in the Era of Direct Oral Anticoagulants. Circ J 2018; 82:2715-2721. [PMID: 30101809 DOI: 10.1253/circj.cj-18-0398] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND In atrial fibrillation (AF) patients, the effect of direct oral anticoagulant (DOACs) therapy on the incidence of left atrial appendage thrombus (LAT) remains poorly investigated. This study examined the prevalence and risk factors of LAT in AF patients on DOACs undergoing catheter ablation, and sought an anticoagulation strategy for LAT. Methods and Results: In 407 AF patients on DOACs, transesophageal echocardiography (TEE) was performed 1 day before ablation. If patients had LAT, initial DOACs were switched to dabigatran (300 mg) or warfarin based on their renal function; TEE was repeated after treatment for ≥4 weeks. LAT was detected in 18 patients (4.4%). The prevalence of persistent AF and low-dose treatment/inappropriate dose reduction of DOACs, CHADS2/CHA2DS2-VASc scores, serum N-terminal pro-brain natriuretic peptide levels, and LA dimension/LA volume index significantly increased in patients with LAT vs. those without LAT. AF rhythm on TEE and spontaneous echo contrast also increased in patients with LAT; LA appendage flow velocity decreased. In the multivariate analysis, persistent AF and inappropriately reduced DOAC dose were risk factors for LAT. On repeat TEE, LAT had disappeared in 13 of 16 patients treated with dabigatran and in 2 of 2 patients treated with warfarin. CONCLUSIONS DOACs still carry a finite risk of LAT in AF patients. Inappropriately reduced DOAC dose should be avoided to minimize the thromboembolic risk. Regular-dose dabigatran may have therapeutic efficacy against LAT.
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Affiliation(s)
| | | | - Yuji Motoike
- Department of Cardiology, Fujita Health University
| | | | - Kunihiko Sugimoto
- Department of Joint Research Laboratory of Clinical Medicine, Fujita Health University Hospital
| | | | - Yukio Ozaki
- Department of Cardiology, Fujita Health University
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16
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Zhan Y, Joza J, Al Rawahi M, Barbosa RS, Samuel M, Bernier M, Huynh T, Thanassoulis G, Essebag V. Assessment and Management of the Left Atrial Appendage Thrombus in Patients With Nonvalvular Atrial Fibrillation. Can J Cardiol 2018; 34:252-261. [DOI: 10.1016/j.cjca.2017.12.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 12/04/2017] [Accepted: 12/11/2017] [Indexed: 01/14/2023] Open
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17
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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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18
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Gunawardene MA, Dickow J, Schaeffer BN, Akbulak RÖ, Lemoine MD, Nührich JM, Jularic M, Sinning C, Eickholt C, Meyer C, Moser JM, Hoffmann BA, Willems S. Risk stratification of patients with left atrial appendage thrombus prior to catheter ablation of atrial fibrillation: An approach towards an individualized use of transesophageal echocardiography. J Cardiovasc Electrophysiol 2017. [DOI: 10.1111/jce.13279] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Melanie A. Gunawardene
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Jannis Dickow
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Benjamin N. Schaeffer
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Ruken Ö. Akbulak
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Marc D. Lemoine
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Jana M. Nührich
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Mario Jularic
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Christoph Sinning
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Christian Eickholt
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Christian Meyer
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Julia M. Moser
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Boris A. Hoffmann
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Stephan Willems
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
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Elbadawi A, Olorunfemi O, Ogunbayo GO, Saad M, Elgendy IY, Arif Z, Badran H, Saheed D, Ahmed HMA, Rao M. Cardiovascular Outcomes With Surgical Left Atrial Appendage Exclusion in Patients With Atrial Fibrillation Who Underwent Valvular Heart Surgery (from the National Inpatient Sample Database). Am J Cardiol 2017; 119:2056-2060. [PMID: 28438308 DOI: 10.1016/j.amjcard.2017.03.037] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/10/2017] [Accepted: 03/10/2017] [Indexed: 12/13/2022]
Abstract
Left atrial appendage (LAA) exclusion is a commonly performed procedure to reduce the embolic events in patients with atrial fibrillation (AF) who underwent cardiac surgeries. Our study aimed to evaluate the in-hospital outcomes of LAA exclusion in patients with AF who underwent valvular heart surgeries. We queried the Nationwide Inpatient Sample Database from 1998 to 2013 for patients with the International Classification of Diseases, Ninth Edition, Clinical Modification, diagnosis codes for AF and underwent any valvular heart surgery. We then performed a case-control matching based on the CHA2DS2VASc score for those who underwent LAA exclusion versus those who did not. Primary outcome was the incidence of in-hospital cerebrovascular events, whereas the secondary outcomes included all-cause mortality, length of hospital stay, and bleeding. Our analysis included 1,304 patients. Patients who underwent LAA exclusion had significantly less incidence of cerebrovascular events (2.5% vs 4.6%, p = 0.04), in-hospital death (1.5% vs 4.9%, p = 0.001), and shorter hospital stay (10.5 vs 12.9 days, p <0.01). The LAA exclusion cohort had more incidence of pericardial effusion (1.3% vs 0.5%, p = 0.04) but no difference in bleeding events (p = 0.55). In conclusion, in patients with AF who underwent valvular surgeries, LAA exclusion may be associated with lower in-hospital cerebrovascular events and mortality and shorter hospital stay.
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Affiliation(s)
- Ayman Elbadawi
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York.
| | - Odunayo Olorunfemi
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Gbolahan O Ogunbayo
- Department of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | - Marwan Saad
- Department of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Zainab Arif
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Haytham Badran
- Department of Cardiovascular Medicine, Ain Shams University, Cairo, Egypt
| | | | - Hamdy M A Ahmed
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Mohan Rao
- Sands Constellation Heart Institute, Rochester General Hospital, Rochester, New York
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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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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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Jun JH, Lee MH, Choi EM, Kim EM, Lee HK, Baek SH, Chung MH. Accidental left atrial appendage thrombus detected by intraoperative transesophageal echocardiography during coronary artery bypass graft -A case report-. Anesth Pain Med (Seoul) 2016. [DOI: 10.17085/apm.2016.11.4.389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Joo Hyun Jun
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Mi Hyeon Lee
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Eun Mi Choi
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Eun-mi Kim
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hyo-Keun Lee
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Seyng Hwa Baek
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Mi-Hwa Chung
- Department of Anesthesiology and Pain Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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23
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State-of-the-Art CT Imaging of the Left Atrium. CURRENT RADIOLOGY REPORTS 2016. [DOI: 10.1007/s40134-016-0171-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bejinariu AG, Härtel DU, Brockmeier J, Oeckinghaus R, Herzer A, Tebbe U. Left atrial thrombi and spontaneous echo contrast in patients with atrial fibrillation : Systematic analysis of a single-center experience. Herz 2016; 41:706-714. [PMID: 27100878 DOI: 10.1007/s00059-016-4423-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 01/30/2016] [Accepted: 02/14/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Atrial fibrillation is associated with a high risk for thromboembolic events. Thrombi in the left atrial appendage and spontaneous echo contrast (SEC) correlate positively with this embolic risk. We studied the laboratory, echocardiographic, and epidemiologic parameters that could predict left atrial thrombi and the intensity of the SEC. PATIENTS AND METHODS Between September 2013 and June 2015 we included 372 patients with atrial fibrillation before planned electrical cardioversion (transesophageal-guided strategy) in this study. After assessing the risk of stroke and bleeding (CHA2DS2-VASc and HAS-BLED scores), we measured the concentration of the D-dimer and B-type natriuretic peptide at the time of the transesophageal echocardiography as well as the left atrial volume and the ejection fraction during transthoracic echocardiography. RESULTS The ejection fraction and the CHA2DS2-VASc score were identified as independent predictors of both left atrial thrombi and SEC, whereas the left atrial volume could only predict the intensity of SEC. In contrast to the results of other studies, the biomarkers in this study failed to predict the outcome. CONCLUSION Only the echocardiographic and epidemiologic parameters were predictors of left atrial thrombi and SEC intensity, while the studied biomarkers had no predictive power. Using clinical data and transthoracic echocardiography, we can change the therapeutic strategy in high-risk patients.
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Affiliation(s)
- A G Bejinariu
- Clinic for Cardiology, Angiology and Intensive Care, Klinikum Lippe Detmold, Röntgenstr. 18, 32756, Detmold, Germany.
| | - D U Härtel
- Clinic for Cardiology, Angiology and Intensive Care, Klinikum Lippe Detmold, Röntgenstr. 18, 32756, Detmold, Germany
| | - J Brockmeier
- Clinic for Cardiology, Angiology and Intensive Care, Klinikum Lippe Detmold, Röntgenstr. 18, 32756, Detmold, Germany
| | - R Oeckinghaus
- Clinic for Cardiology, Angiology and Intensive Care, Klinikum Lippe Detmold, Röntgenstr. 18, 32756, Detmold, Germany
| | - A Herzer
- Clinic for Cardiology, Angiology and Intensive Care, Klinikum Lippe Detmold, Röntgenstr. 18, 32756, Detmold, Germany
| | - U Tebbe
- Clinic for Cardiology, Angiology and Intensive Care, Klinikum Lippe Detmold, Röntgenstr. 18, 32756, Detmold, Germany
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