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Lee JM, Cha MJ, Nam GB, Choi KJ, Sun BJ, Kim DH, Song JM, Kang DH, Song JK, Cho MS. Incidence and predictors of left atrial thrombus in patients with atrial fibrillation under anticoagulation therapy. Clin Res Cardiol 2024; 113:1242-1250. [PMID: 38446148 DOI: 10.1007/s00392-024-02422-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/22/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Left atrial thrombus (LAT) formation is associated with thromboembolic events. OBJECTIVE To investigate the incidence and associated factors of LAT in patients with atrial fibrillation (AF) who had been receiving anticoagulation therapy for more than 4 weeks, and to develop a prediction model using clinical and echocardiographic features. METHODS Medical records of 1,122 patients with AF (mean age, 59.4 ± 11.0 years, 58.3% male) who were on anticoagulation more than 4 weeks and underwent transesophageal echocardiography (TEE) were evaluated. The main outcome was the presence of LAT on TEE. RESULTS Warfarin and non-vitamin K oral anticoagulants were used in 74.4% and 25.6% of the patients at the time of examination, respectively. LAT was present in 60 patients (5.3%). Presence of LAT on TEE was associated with age ≥ 75 years (odds ratio [OR] 2.13 [95% confidence interval, 0.94-4.58]), persistent/permanent AF (OR 2.61 [1.42-4.93]), CHA2DS2-VASc score ≥ 3 points (OR 1.91 [1.05-3.48]), left ventricular ejection fraction < 40% (OR 2.35 [1.07-4.81]), and severe left atrial enlargement (OR 3.52 [1.89-6.79]). The presence of moderate-to-severe mitral regurgitation was associated with a lower risk of LAT (OR 0.13 [0.04-0.34]). A scoring system composed of the aforementioned predictors showed excellent discrimination performance (area under the curve 0.791 [95% CI, 0.727-0.854]). CONCLUSIONS LAT was present in a considerable number of patients who were already receiving anticoagulation therapy. A prediction model that combines clinical and echocardiographic predictors could be useful in distinguishing patients who require imaging evaluations before left atrial intervention.
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Affiliation(s)
- Joong Min Lee
- Department of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Myung-Jin Cha
- Department of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Gi-Byoung Nam
- Department of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Kee-Joon Choi
- Department of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Byung Joo Sun
- Department of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Dae-Hee Kim
- Department of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Jong-Min Song
- Department of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Duk-Hyun Kang
- Department of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Jae-Kwan Song
- Department of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea
| | - Min Soo Cho
- Department of Cardiology, Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, 05505, Korea.
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Maslova V, Demming T, Pantlik R, Geczy T, Falk P, Remppis BA, Frank D, Lian E. Omitting transesophageal echocardiography before catheter ablation of atrial fibrillation. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01825-8. [PMID: 38761295 DOI: 10.1007/s10840-024-01825-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/07/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Data about necessity of performing transesophageal echocardiography (TOE) prior to every catheter ablation (CA) of atrial fibrillation (AF) is scarce. We aimed to evaluate the safety of an individualized risk-based approach to TOE with respect to thromboembolic cerebrovascular events (CVE) in patients undergoing CA for AF or left atrial tachycardia (AT). METHODS We performed a retrospective clinical study based on our institutional registry database. Patients undergoing CA for AF or left-sided AT following initial AF ablation at two participating centers were enrolled. Prior to the procedure, patients were scheduled for TOE only if they had a history of thromboembolic stroke, left atrial appendage (LAA) thrombus, or inappropriate anticoagulation regimen in the previous 3 to 4 weeks. The incidence of periprocedural cerebrovascular thromboembolic events was assessed. RESULTS We analyzed 1155 patients (median age 70 years, 54.8% male, 48.1% had persistent AF/AT). In 261 patients, a TOE was performed; in 2 patients (0.7%), an LAA thrombus was detected, which led to cancellation of the catheter ablation; in 894 patients, the TOE was omitted. Of the 1153 (0.35%) patients who underwent ablation, 4 (0.35%) experienced a CVE (one TIA and three strokes). The rate of CVE in our study does not exceed that reported in most multicenter trials. The low event rates limited statistical analysis of possible risk factors for CVE. In all 4 patients with CVE, post-CVE imaging showed the absence of LAA thrombus. CONCLUSIONS An individualized selective approach to TOE before catheter ablation of AF or left AT showed a very low risk of overt intraprocedural thromboembolic events for the population in our study. A further randomized controlled study is needed to determine whether TOE prior to catheter ablation without ICE could be omitted in patients with uninterrupted OAC without previous thromboembolic events or a history of left atrial thrombus.
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Affiliation(s)
- Vera Maslova
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Thomas Demming
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Robert Pantlik
- Department of Cardiology, Cardiovascular Center Bad Bevensen, Bad Bevensen, Germany
| | - Tamas Geczy
- Department of Cardiology, Cardiovascular Center Bad Bevensen, Bad Bevensen, Germany
| | - Peter Falk
- Department of Cardiology, Cardiovascular Center Bad Bevensen, Bad Bevensen, Germany
| | | | - Derk Frank
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Evgeny Lian
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany.
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Mannewald C, Roijer A, Platonov PG, Holmqvist F. Prevalence of left atrial appendage thrombus and spontaneous echo contrast on transesophageal echocardiography in patients scheduled for pulmonary vein isolation. Ann Noninvasive Electrocardiol 2024; 29:e13119. [PMID: 38682420 PMCID: PMC11056845 DOI: 10.1111/anec.13119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/19/2024] [Accepted: 04/11/2024] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND To avoid causing a thromboembolic event in patients undergoing catheter ablation for atrial fibrillation (AF), patients are treated with oral anticoagulants (OAC) prior to the procedure. Despite being on anticoagulants, some patients develop a left atrial appendage thrombus (LAAT). To exclude the presence of LAAT, transesophageal ultrasound (TEE) is performed in all patients prior to the procedure. We hypothesized continuous treatment with anticoagulants would result in a low prevalence of LAAT, in patients with low CHA2DS2-VASc score. METHOD Medical records of consecutive patients planned to undergo AF ablation at Lund University Hospital during the years 2018-2020 were reviewed retrospectively. Examination protocols from transesophageal and transthoracic echocardiography were examined for LAAT and spontaneous echo contrast (SEC). Patients with LAAT and SEC were compared to patients without using Mann-Whitney U-test and Pearson Chi-squared analysis to test for correlation. RESULTS Of 553 patients, three patients (0.54%) had LAAT, and 18 (3.25%) had spontaneous contrast (SEC). Patients with LAAT or SEC had a higher CHA2DS2-VASc score, more often presented in AF at TEE and less often had a normal sized left atrium. CONCLUSION There is a low prevalence of LAAT and SEC in patients with AF scheduled for pulmonary vein isolation. Patients with SEC or LAAT tend to have paroxysmal AF less often and more often presented in AF at admission. No patients with CHA2DS2-VASc 0, paroxysmal AF, normal sized left atrium and sinus rhythm at TEE were found to have LAAT or SEC.
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Affiliation(s)
| | - Anders Roijer
- Department of Cardiology, Clinical SciencesLund UniversityLundSweden
| | - Pyotr G. Platonov
- Department of Cardiology, Clinical SciencesLund UniversityLundSweden
| | - Fredrik Holmqvist
- Department of Cardiology, Clinical SciencesLund UniversityLundSweden
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Dittrich S, Kece F, Scheurlen C, van den Bruck JH, Filipovic K, Wörmann J, Erlhöfer S, Pavel F, Schipper JH, Sultan A, Lüker J, Steven D. Implementation and first outcomes of a novel standard operating procedure for preprocedural transoesophageal echocardiography screening in course of atrial arrhythmia ablation. Europace 2023; 25:euad279. [PMID: 37713241 PMCID: PMC10516708 DOI: 10.1093/europace/euad279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/23/2023] [Accepted: 09/05/2023] [Indexed: 09/16/2023] Open
Abstract
AIMS Preprocedural transoesophageal echocardiography (TEE) screening for left atrial (LA) thrombi is the standard of care in many centres performing atrial fibrillation (AF) ablation. However, TEE imposes procedural risks for patients and is often challenging to implement in daily practice, besides causing patient discomfort. At our centre, a novel standard operating procedure (SOP) was implemented, aiming to identify patients that can be exempt from TEE screening. We aimed to assess whether this screening approach may reduce preprocedural TEEs without imposing patients of higher risks for cerebrovascular events (CVEs). METHODS AND RESULTS Data of 1874 consecutive patients treated by catheter ablation of LA arrhythmias between 2018 and 2022 were retrospectively analysed. A cohort of 937 patients, where decision to perform TEE screening was based on a new SOP (considering rhythm at admission, CHA2DS2-VASc score, and sufficient anticoagulation), was compared to a matched cohort receiving TEE before every procedure. Number of performed TEEs and incidences of CVEs were compared. Implementation of the new SOP led to a 67% reduction in TEEs performed (old SOP: 933 vs. new SOP: 305). No significant differences between the groups were detected regarding transitory ischaemic attack (old SOP: 5 vs. new SOP: 3; P = 0.48) and stroke (no events). No solid thrombi were detected during TEE screening. CONCLUSION The number of preprocedural screening TEEs before AF ablation procedures can be safely reduced by applying risk stratification based on rhythm at admission and CHA2DS2-VASc score, if anticoagulation was performed properly.
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Affiliation(s)
- Sebastian Dittrich
- Department of Electrophysiology, Heart Center, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Fehmi Kece
- Department of Electrophysiology, Heart Center, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Cornelia Scheurlen
- Department of Electrophysiology, Heart Center, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Jan-Hendrik van den Bruck
- Department of Electrophysiology, Heart Center, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Karlo Filipovic
- Department of Electrophysiology, Heart Center, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Jonas Wörmann
- Department of Electrophysiology, Heart Center, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Susanne Erlhöfer
- Department of Electrophysiology, Heart Center, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Friederike Pavel
- Department of Electrophysiology, Heart Center, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Jan-Hendrik Schipper
- Department of Electrophysiology, Heart Center, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Arian Sultan
- Department of Electrophysiology, Heart Center, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Jakob Lüker
- Department of Electrophysiology, Heart Center, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Daniel Steven
- Department of Electrophysiology, Heart Center, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
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5
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Wang Y, Zhao Y, Zhou K, Zei PC, Wang Y, Cheng H, Chen S, Tao Y, Mao Y, Liu Q, Bangash AB, Sheng X, Sun Y, Zhang P, Yu L, Lin J, Zhang Z, Fu G, Jiang R, Jiang C. Intracardiac echocardiography is a safe and effective alternative to transesophageal echocardiography for left atrial appendage thrombus evaluation at the time of atrial fibrillation ablation: The ICE-TEE study. Pacing Clin Electrophysiol 2023; 46:3-10. [PMID: 36301182 DOI: 10.1111/pace.14601] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 09/06/2022] [Accepted: 09/27/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intracardiac echocardiography (ICE) technology has been increasingly accepted as an integral part of atrial fibrillation (AF) ablation procedures. It is still unknown whether ICE can routinely replace transesophageal echocardiography (TEE) for routine thrombus screening in non-selective AF patients. OBJECTIVE To assess whether ICE can routinely replace TEE in screening for left atrial (LA)/left atrial appendage (LAA) thrombus in general patients undergoing catheter ablation for AF. METHODS A total of 2003 consecutive patients undergoing AF ablation were included. 1155 patients (ICE group) received intra-procedural ICE examination for LA/LAA thrombus screening, while 848 patients (TEE group) received pre-procedure TEE examination. The incidence of thrombus, peri-procedure complications, and hospital efficiency were assessed. RESULTS The LA and LAA were adequately visualized in all patients. Five patients in the ICE group and 15 patients in the TEE group were found to have LAA thrombus. The incidence of major periprocedural thrombo-embolic events was comparable between two groups (0.2% vs. 0.1%, p = .76), none were due to undetected LA/LAA thrombus. Other major periprocedural complications occurred at similar rates in both groups, while post-procedure fever was less common in the ICE group (12.7% vs. 17.4%, p < .001). Procedure times and hospital length of stay were both shorter in the ICE group (142 min [87-197 min] vs. 150 min [95-205 min], and 3[2-4] day vs. 4[3-5] day, respectively, both p < .001). CONCLUSIONS ICE can replace TEE for atrial thrombus screening in AF patients undergoing ablation without increased complications. An "ICE replacing TEE" workflow can also reduce the incidence of postoperative fever and improve hospital efficiency.
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Affiliation(s)
- Yuxing Wang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine, of Zhejiang Province, China
| | - Yi Zhao
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine, of Zhejiang Province, China
| | - Kuangshi Zhou
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine, of Zhejiang Province, China
| | - Paul C Zei
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yunhe Wang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hui Cheng
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shiquan Chen
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yuhang Tao
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yankai Mao
- Department of Diagnostic Ultrasound & Echocardiography, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qiang Liu
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Abdul Basit Bangash
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xia Sheng
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yaxun Sun
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Pei Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Lu Yu
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jianwei Lin
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Zuwen Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Guosheng Fu
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine, of Zhejiang Province, China.,Comprehensive Unit of National Regional Medical Center, Zhejiang Province, China
| | - Ruhong Jiang
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine, of Zhejiang Province, China.,Comprehensive Unit of National Regional Medical Center, Zhejiang Province, China
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine, of Zhejiang Province, China.,Comprehensive Unit of National Regional Medical Center, Zhejiang Province, China
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6
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Cheng YY, Tan S, Hong CT, Yang CC, Chan L. Left Atrial Appendage Thrombosis and Oral Anticoagulants: A Meta-Analysis of Risk and Treatment Response. J Cardiovasc Dev Dis 2022; 9:jcdd9100351. [PMID: 36286303 PMCID: PMC9604359 DOI: 10.3390/jcdd9100351] [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: 08/22/2022] [Revised: 09/23/2022] [Accepted: 10/05/2022] [Indexed: 11/07/2022] Open
Abstract
Left atrial appendage thrombus (LAAT) is the main cause of cardioembolism in patients with nonvalvular atrial fibrillation (AF). Emerging evidence indicates that direct oral anticoagulants (DOACs) may be a preferred, safer choice for patients with LAAT. However, current guidelines indicate vitamin K antagonist (VKA) as the preferred treatment for LAAT. We conducted a meta-analysis to compare the efficacy of VKA and DOAC for the treatment of LAAT. Methods: The search was conducted in the PubMed, Embase, Google Scholar, and Cochrane Library databases from inception to July 2022, with the language restricted to English. A first analysis was conducted to evaluate the risk of LAAT under VKA or DOAC treatment. A second analysis was conducted to compare the resolution of LAAT under VKA and DOAC treatment. Results: In 13 studies comparing LAAT incidence rates under VKA and DOAC treatment, significant superiority of DOAC was detected (pooled RR = 0.65, 95% CI = 0.47–0.90, p = 0.009) with moderate heterogeneity being identified in the pooled studies. In 13 studies comparing LAAT resolution under VKA and DOAC use, treatment with DOAC exhibited a significantly increased probability of LAAT resolution compared with VKA (pooled odds ratio = 1.52, 95% CI = 1.02–2.26, p = 0.040). Conclusions: This meta-analysis suggests a superiority of DOAC over VKA with respect to LAAT incidence in people with AF and the likelihood of LAAT resolution. Due to their established safety profile, DOAC is a preferable choice for anticoagulation, although further randomized controlled studies are warranted to provide further evidence of their suitability as a new recommended treatment.
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Affiliation(s)
- Yun-Yung Cheng
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei 235, Taiwan
| | - Shennie Tan
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei 235, Taiwan
| | - Chien-Tai Hong
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei 235, Taiwan
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 235, Taiwan
| | - Cheng-Chang Yang
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei 235, Taiwan
- Brain and Consciousness Research Center, Shuang Ho Hospital, Taipei Medical University, New Taipei 235, Taiwan
- Correspondence: (C.-C.Y.); (L.C.)
| | - Lung Chan
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei 235, Taiwan
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 235, Taiwan
- Correspondence: (C.-C.Y.); (L.C.)
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7
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Uziȩbło-Życzkowska B, Kapłon-Cieślicka A, Gawałko M, Budnik M, Starzyk K, Wożakowska-Kapłon B, Daniłowicz-Szymanowicz L, Kaufmann D, Wójcik M, Błaszczyk R, Hiczkiewicz J, Łojewska K, Mizia-Stec K, Wybraniec M, Kosmalska K, Fijałkowski M, Szymańska A, Gos A, Haberka M, Kucio M, Michalski B, Kupczyńska K, Tomaszuk-Kazberuk A, Wilk-Śledziewska K, Wachnicka-Truty R, Koziński M, Burchardt P, Krzesiński P. Risk factors for left atrial thrombus in younger patients (aged < 65 years) with atrial fibrillation or atrial flutter: Data from the multicenter left atrial thrombus on transesophageal echocardiography (LATTEE) registry. Front Cardiovasc Med 2022; 9:973043. [PMID: 36312270 PMCID: PMC9611536 DOI: 10.3389/fcvm.2022.973043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 09/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Methods Results Conclusions
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Affiliation(s)
- Beata Uziȩbło-Życzkowska
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland,*Correspondence: Beata Uziȩbło-Życzkowska
| | - Agnieszka Kapłon-Cieślicka
- “Club 30”, Polish Cardiac Society, Katowice, Poland,1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Monika Gawałko
- “Club 30”, Polish Cardiac Society, Katowice, Poland,1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland,West German Heart and Vascular Centre, Institute of Pharmacology, University Duisburg-Essen, Duisburg, Germany,Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Monika Budnik
- “Club 30”, Polish Cardiac Society, Katowice, Poland,1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | | | | | | | - Damian Kaufmann
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, Gdańsk, Poland
| | - Maciej Wójcik
- “Club 30”, Polish Cardiac Society, Katowice, Poland,Department of Cardiology, Medical University of Lublin, Lublin, Poland
| | - Robert Błaszczyk
- Department of Cardiology, Medical University of Lublin, Lublin, Poland
| | - Jarosław Hiczkiewicz
- Collegium Medicum, University of Zielona Góra, Zielona Góra, Poland,Clinical Department of Cardiology, Nowa Sól Multidisciplinary Hospital, Nowa Sol, Poland
| | - Katarzyna Łojewska
- Clinical Department of Cardiology, Nowa Sól Multidisciplinary Hospital, Nowa Sol, Poland
| | - Katarzyna Mizia-Stec
- “Club 30”, Polish Cardiac Society, Katowice, Poland,Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland,Members of the European Reference Network on Heart Diseases–ERN GUARD-HEART, Amsterdam, Netherlands
| | - Maciej Wybraniec
- “Club 30”, Polish Cardiac Society, Katowice, Poland,Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland,Members of the European Reference Network on Heart Diseases–ERN GUARD-HEART, Amsterdam, Netherlands
| | | | - Marcin Fijałkowski
- 1st Department of Cardiology, Medical University of Gdańsk, Gdańsk, Poland
| | - Anna Szymańska
- Department of Heart Diseases, Postgraduate Medical School, Warsaw, Poland
| | - Aleksandra Gos
- Department of Heart Diseases, Postgraduate Medical School, Warsaw, Poland
| | - Maciej Haberka
- “Club 30”, Polish Cardiac Society, Katowice, Poland,Department of Cardiology, School of Health Sciences, Medical University of Silesia, Katowice, Poland
| | - Michał Kucio
- Department of Cardiology, School of Health Sciences, Medical University of Silesia, Katowice, Poland
| | - Błazej Michalski
- “Club 30”, Polish Cardiac Society, Katowice, Poland,Department of Cardiology, Medical University of Lodz, Lodz, Poland
| | - Karolina Kupczyńska
- “Club 30”, Polish Cardiac Society, Katowice, Poland,Department of Cardiology, Medical University of Lodz, Lodz, Poland
| | | | | | - Renata Wachnicka-Truty
- Department of Cardiology and Internal Medicine, Medical University of Gdańsk, Gdynia, Poland
| | - Marek Koziński
- “Club 30”, Polish Cardiac Society, Katowice, Poland,Department of Cardiology and Internal Medicine, Medical University of Gdańsk, Gdynia, Poland
| | - Paweł Burchardt
- “Club 30”, Polish Cardiac Society, Katowice, Poland,Department of Hypertension, Angiology, and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Paweł Krzesiński
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland,“Club 30”, Polish Cardiac Society, Katowice, Poland
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8
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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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Lurie A, Wang J, Hinnegan KJ, McIntyre WF, Belley-Côté EP, Amit G, Healey JS, Connolly SJ, Wong JA. Prevalence of Left Atrial Thrombus in Anticoagulated Patients With Atrial Fibrillation. J Am Coll Cardiol 2021; 77:2875-2886. [PMID: 34112315 DOI: 10.1016/j.jacc.2021.04.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The prevalence of left atrial (LA) thrombus in patients with atrial fibrillation (AF) or atrial flutter (AFL) on guideline-directed anticoagulation is not well known, yet this may inform transesophageal echocardiogram (TEE) use before cardioversion or catheter ablation. OBJECTIVES The purpose of this study was to quantify LA thrombus prevalence among patients with AF/AFL on guideline-directed anticoagulation and to identify high-risk subgroups. METHODS EMBASE, MEDLINE, and CENTRAL were systematically searched from inception to July 2020 for studies reporting on LA thrombus prevalence among patients with AF/AFL undergoing TEE following at least 3 weeks of continuous therapeutic oral anticoagulation with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). Meta-analysis was performed using random effects models. RESULTS Thirty-five studies describing 14,653 patients were identified. The mean-weighted LA thrombus prevalence was 2.73% (95% confidence interval [CI]: 1.95% to 3.80%). LA thrombus prevalence was similar for VKA- and DOAC-treated patients (2.80%; 95% CI: 1.86% to 4.21% vs. 3.12%; 95% CI: 1.92% to 5.03%; p = 0.674). Patients with nonparoxysmal AF/AFL had a 4-fold higher LA thrombus prevalence compared with paroxysmal patients (4.81%; 95% CI: 3.35% to 6.86% vs. 1.03%; 95% CI: 0.52% to 2.03%; p < 0.001). LA thrombus prevalence was higher among patients undergoing cardioversion versus ablation (5.55%; 95% CI: 3.15% to 9.58% vs. 1.65%; 95% CI: 1.07% to 2.53%; p < 0.001). Patients with CHA2DS2-VASc scores ≥3 had a higher LA thrombus prevalence compared with patients with scores ≤2 (6.31%; 95% CI: 3.72% to 10.49% vs. 1.06%; 95% CI: 0.45% to 2.49%; p < 0.001). CONCLUSIONS LA thrombus prevalence is high in subgroups of anticoagulated patients with AF/AFL, who may benefit from routine pre-procedural TEE use before cardioversion or catheter ablation.
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Affiliation(s)
- Antony Lurie
- Population Health Research Institute, Hamilton, Ontario, Canada; University of Western Ontario, London, Ontario, Canada
| | - Jia Wang
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada
| | | | - William F McIntyre
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada
| | - Emilie P Belley-Côté
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Guy Amit
- Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jorge A Wong
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
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10
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Porphyromonas gingivalis and left atrial appendage spontaneous echo contrast in atrial fibrillation ablation candidates. Heart Vessels 2021; 36:1721-1729. [PMID: 34021383 DOI: 10.1007/s00380-021-01851-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/02/2021] [Indexed: 10/21/2022]
Abstract
Atrial fibrillation (AF) is associated with a fivefold risk of stroke and thrombotic embolism, which are usually derived from the left atrial appendage (LAA). Spontaneous echo contrast (SEC) is known as a risk factor for thrombosis. Porphyromonas gingivalis (P. gingivalis) has some prothrombotic effects and plays a key role in periodontitis and oral-systemic disease connection. We aimed to clarify the relationship between P. gingivalis and LAA SEC among AF patients. A total of 569 AF ablation candidates were enrolled in the present study. LAA SEC was categorized into nondense SEC and dense SEC based on transesophageal echocardiography. Serum immunoglobulin G antibody titers of P. gingivalis fimA subtypes (types I-IV) were measured with an enzyme-linked immunosorbent assay. The levels of antibody titers were categorized into high (> mean + 3 standard deviation) and low values. A total of 513 (90%) patients were included in the nondense SEC group, and 56 (10%) were included in the dense SEC group. Multivariate regression analysis revealed that the high-value serum antibody titers of P. gingivalis types II and IV were independently associated with dense SEC [type II: adjusted odds ratio (OR) 2.220; 95% confidence interval (CI) 1.062-4.643; P = 0.02; and type IV: adjusted OR 3.169; 95% CI 1.058-6.657; P = 0.002]. The results revealed that P. gingivalis types II and IV are related to LAA SEC severity among AF patients who receive appropriate anticoagulation therapy.
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11
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Alqarawi W, Grose E, Ramirez FD, Sikora L, Golian M, Nair GM, Nery PB, Klein A, Davis D, Green MS, Redpath CJ, Birnie DH, Burwash I, Sadek MM. Prevalence of Left Atrial Appendage Thrombus in Patients Anticoagulated With Direct Oral Anticoagulants: Systematic Review and Meta-analysis. CJC Open 2021; 3:658-665. [PMID: 34027370 PMCID: PMC8134939 DOI: 10.1016/j.cjco.2020.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/10/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Multiple studies have examined the prevalence of left atrial appendage thrombus (LAAT) in patients anticoagulated with direct oral anticoagulants (DOACs) and have reported conflicting results. METHODS Studies reporting the prevalence of LAAT on transesophageal echocardiography (TEE) after 3 or more weeks of DOAC therapy were identified. The proportions of anticoagulated patients diagnosed with LAAT were pooled using random-effects models. Prespecified subgroup analyses by the indication of TEE (pre-atrial fibrillation [AF] ablation vs cardioversion) and TEE strategy (routine use vs selective) were conducted via stratification. RESULTS Forty studies were identified: 22 full manuscripts and 18 abstracts. Only 11 studies performed TEE routinely. Most studies included patients with paroxysmal AF and low thromboembolic risk. The pooled prevalence of LAAT was 2.5% (95% confidence interval [1.6%-3.4%]). The prevalence of LAAT is lower in the pre-AF ablation group compared with pre-cardioversion (1.1% vs 4.0%, P = 0.033). Routine TEE strategy yielded a lower LAAT prevalence in both groups (0.1% vs 2.3%, P = 0.002 and 3.2% vs 5.8%, P = 0.432, respectively). CONCLUSION The reported prevalence of LAAT on TEE in patients treated with DOACs is highly variable. Factors associated with a high LAAT prevalence were pre-cardioversion indication and selective TEE strategy. Routine use of TEE before AF ablation may not be warranted.
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Affiliation(s)
- Wael Alqarawi
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Elysia Grose
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - F. Daniel Ramirez
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Hôpital Cardiologique du Haut-Lévêque, CHU Bordeaux, Bordeaux-Pessac, France
- L’Institut de Rythmologie et Modélisation Cardiaque (LIRYC), Université de Bordeaux, Bordeaux-Pessac, France
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada
| | - Mehrdad Golian
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Girish M. Nair
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Pablo B. Nery
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Andres Klein
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Darryl Davis
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Martin S. Green
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Calum J. Redpath
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David H. Birnie
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ian Burwash
- Echocardiography Laboratory, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Mouhannad M. Sadek
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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12
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Uziębło-Życzkowska B, Krzesiński P, Jurek A, Budnik M, Gorczyca I, Kapłon-Cieślicka A, Kiliszek M, Wójcik A, Gawałko M, Jelonek O, Michalska A, Starzyk K, Scisło P, Kochanowski J, Filipiak KJ, Wożakowska-Kapłon B, Opolski G, Gielerak G. Prevalence and risk factors of left atrial thrombus in patients with atrial fibrillation and lower class (IIa) recommendation to anticoagulants. Cardiovasc Diagn Ther 2020; 10:717-724. [PMID: 32968628 DOI: 10.21037/cdt-20-151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Oral anticoagulation therapy (OAT) prevents ischaemic incidents in patients with atrial fibrillation (AF). CHA2DS2-VASc risk score of ≥2 points in men and ≥3 in women is a class I indication for OAT. OAT should also be considered as a prevention of thromboembolism in AF men with a CHA2DS2-VASc score of 1 point and women with 2 points, but the class of recommendation is lower (IIa). This study aims to assess the occurrence of left atrial appendage thrombus (LAAT) and risk factors of its formation in patients with lower class recommendation to oral antiocoagulation treatment. Methods The study group consisted of 1,858 patients: 555 patients with class IIa indication to OAT (IIa group) and 1,303 patients with class I indication as a control group (I group). Patients were admitted to three cardiology departments. All subjects underwent transoesophageal echocardiography. Results The incidence of LAAT was comparable in both IIa and I group: LAAT was confirmed in 30 (5.4%) subjects of IIa group and in 77 (5.9%) of I group. The prevalence of LAAT in IIa group was higher on treatment with VKAs (in comparison to NOACs) (8.4% vs. 3.4%, P=0.010), and lower in case of paroxysmal AF (in comparison to non-paroxysmal AF) (2.4% vs. 9.8%, P=0.0002). Multivariate logistic regression revealed the following variables as the independent predictors of LAAT in IIa group: treatment with VKAs (OR 2.99, 95% CI: 1.33-6.69; P=0.007), paroxysmal AF (OR 0.26, 95% CI: 0.11-0.62; P=0.002) and eGFR <60 mL/min/1.73 m2 (OR 3.19, 95% CI: 1.42-7.16; P=0.005). Conclusions The prevalence of LAAT in AF patients with lower class (IIa) recommendation to anticoagulants was comparable to higher (I). Treatment with VKAs, along with non-paroxysmal type of AF and eGFR <60 mL/min/1.72 m2 were identified as the strongest predictors of LAAT in IIa group.
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Affiliation(s)
| | - 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
| | - Monika Budnik
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Iwona Gorczyca
- Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, Kielce, Poland
| | | | - Marek Kiliszek
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Agnieszka Wójcik
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Monika Gawałko
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Olga Jelonek
- Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, Kielce, Poland
| | - Anna Michalska
- Faculty of Medical and Health Sciences, The Jan Kochanowski University, Kielce, Poland
| | - Katarzyna Starzyk
- Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, Kielce, 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
| | - Krzysztof J Filipiak
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Beata Wożakowska-Kapłon
- Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, Kielce, Poland.,Faculty of Medical and Health Sciences, The Jan Kochanowski University, Kielce, Poland
| | - Grzegorz Opolski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Grzegorz Gielerak
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
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13
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Left Ventricular Ejection Fraction Is Associated with the Risk of Thrombus in the Left Atrial Appendage in Patients with Atrial Fibrillation. Cardiovasc Ther 2020; 2020:3501749. [PMID: 32411299 PMCID: PMC7201491 DOI: 10.1155/2020/3501749] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 02/21/2020] [Accepted: 03/25/2020] [Indexed: 11/24/2022] Open
Abstract
Introduction Atrial fibrillation (AF) is associated with high risk of ischemic stroke. The most frequent thrombus location in AF is the left atrial appendage (LAA). Transthoracic echocardiography (TTE) is a basic diagnostic examination in patients (pts) with AF. Objectives To analyse the relations between basic echocardiographic features, well-established stroke risk factors, type of AF, and anticoagulation therapy with the incidence of left atrial appendage thrombus (LAAT). Patients and Methods. The study group consisted of 768 pts with AF (mean age, 63 years), admitted to three high-reference cardiology departments. Five hundred and twenty-three pts were treated with non-vitamin K antagonist oral anticoagulants (NOACs) and 227 (30%) with vitamin K antagonists (VKAs). The subjects underwent TTE and transesophageal echocardiography (TEE) before cardioversion or ablation. Results LAAT was significantly more frequent in pts with reduced left ventricular ejection fraction (LVEF): in 10.6% (7 pts) with LVEF < 40% and in 9.0% (9 pts) with LVEF 40-49%, while only in 5.5% (33 pts) with LVEF > 50%. Compared to pts without LAAT, those with LAAT presented with lower LVEF and higher left atrial diameter (LAD). Multivariate logistic regression revealed the following variables as independent predictors of LAAT: previous bleeding, treatment with VKA, and LVEF. Conclusion LAAT is related to lower LVEF and higher LAD. LVEF is one of the independent predictors of LAAT. Even in the case of adequate anticoagulant therapy, it might be prudent to consider TEE before cardioversion or ablation in patients with low LVEF and LA enlargement, especially in the coexistence of other thromboembolic risk factors.
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14
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Yang J, Zhang X, Wang XY, Zhang C, Chen SZ, Hu SJ. Comparison of transesophageal echocardiography findings after different anticoagulation strategies in patients with atrial fibrillation: a systematic review and meta-analysis. BMC Cardiovasc Disord 2019; 19:261. [PMID: 31771529 PMCID: PMC6878716 DOI: 10.1186/s12872-019-1209-x] [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: 04/17/2019] [Accepted: 09/26/2019] [Indexed: 11/12/2022] Open
Abstract
Background High risk of embolic events exists in both patients with chronic atrial fibrillation (AF) and patients in the perioperative period of ablation (effective treatment for AF). Therefore, anticoagulant therapy is important. Oral anticoagulants can be divided into two major categories: vitamin K antagonists (VKAs) and non-vitamin K antagonist oral anticoagulants (NOACs). VKAs, represented by warfarin, have been widely used as traditional anticoagulants, whereas NOACs have been used in clinical practice, but their anticoagulant effects and side effects are still the focus of research. We used a meta-analysis to compare the incidence of left atrial thrombi (LAT) between different anticoagulants. Methods We searched PubMed, EMBASE, Web of Science, and the Cochrane Library databases for observational studies that compared the transesophageal echocardiography (TEE) findings for patients treated with NOACs and VKAs. The incidence of LAT and dense spontaneous echocardiographic contrast (dense SEC) were extracted as the basis of the meta-analysis. Results Fifteen studies were included in the meta-analysis. We found that patients anticoagulated with NOACs and VKAs had similar incidence of LAT (OR = 0.74, 95%CI: 0.55–1.00). After excluding the heterogeneous article by sensitivity analysis, we found the incidence of LAT in patients anticoagulated with NOACs is lower than VKAs (OR = 0.59, 95%CI: 0.42–0.84). The results of subgroup analysis showed that the incidence of LAT among three types of NOACs have no significant difference (dabigatran vs. rivaroxaban, OR = 1.16 [0.75, 1.81]; rivaroxaban vs. apixaban, OR = 0.97 [0.54, 1.74]; dabigatran vs. apixaban, OR = 1.09 [0.55, 2.16]). Conclusion Patients anticoagulated with NOACs may have lower incidence of LAT than VKAs. The incidence of LAT among different type of NOACs are similar.
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Affiliation(s)
- Jian Yang
- Department of Cardiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xuan Zhang
- Department of Cardiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xi-Ying Wang
- Department of Cardiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Chi Zhang
- Department of Cardiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Song-Zan Chen
- College of Medicine, Zhejiang University, Hangzhou, China
| | - Shen-Jiang Hu
- Department of Cardiology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.
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15
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Göldi T, Krisai P, Knecht S, Aeschbacher S, Spies F, Zeljkovic I, Kaufmann BA, Schaer B, Conen D, Reichlin T, Osswald S, Sticherling C, Kühne M. Prevalence and Management of Atrial Thrombi in Patients With Atrial Fibrillation Before Pulmonary Vein Isolation. JACC Clin Electrophysiol 2019; 5:1406-1414. [PMID: 31857039 DOI: 10.1016/j.jacep.2019.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 09/05/2019] [Accepted: 09/06/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVES This study aimed to investigate the prevalence and management of left atrial (LA) thrombi detected by transesophageal echocardiography (TEE) in patients with atrial fibrillation undergoing pulmonary vein isolation (PVI). BACKGROUND Little data are available on LA thrombi before PVI. METHODS All patients scheduled for PVI between April 2010 and April 2018 undergoing pre-procedural TEE were analyzed. Management of LA thrombus was at the discretion of the treating physician. RESULTS In this study, 1,753 pre-procedural TEE from 1,358 patients (mean age 61 ± 10 years, 28% female) were included. Anticoagulation was used in 86% of all TEE (51% with direct oral anticoagulants [DOAC], 35% with vitamin K antagonists [VKA]). Thrombi were found in 11 TEE (0.6%), all in the LA appendage. Of the 11 patients with a thrombus, 5 (46%) had paroxysmal atrial fibrillation, 2 (18%) had a CHA2DS2-VASc (Congestive Heart Failure, Hypertension, Age ≥75 Years, Diabetes Mellitus, Prior Stroke or Transient Ischemic Attack or Thromboembolism, Vascular Disease, Age 65 to 74 Years, Sex) score of 1, and 5 (46%) were in sinus rhythm at the time of TEE. Of the 8 patients (72%) on anticoagulation therapy, 5 were treated with DOAC and 3 with VKA. Starting anticoagulation (n = 3), switching to VKA with a target international normalized ratio of 2.5 to 3 (n = 3), or switching to a DOAC (n = 1) or a different DOAC (n = 4) resulted in thrombus resolution in 9 of 11 patients (82%). CONCLUSIONS In patients with atrial fibrillation scheduled for PVI, LA thrombi are rare and present in <1%. Thrombi were found in patients on VKA and DOAC, in low-risk patients, and despite sinus rhythm. Thrombus resolution was achieved in the majority of patients by changing the anticoagulation regimen.
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Affiliation(s)
- Tobias Göldi
- Department of Cardiology, University Hospital of Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Philipp Krisai
- Department of Cardiology, University Hospital of Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Sven Knecht
- Department of Cardiology, University Hospital of Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Stefanie Aeschbacher
- Department of Cardiology, University Hospital of Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Florian Spies
- Department of Cardiology, University Hospital of Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | | | - Beat A Kaufmann
- Department of Cardiology, University Hospital of Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Beat Schaer
- Department of Cardiology, University Hospital of Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - David Conen
- Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland; Population Health Research Institute, McMaster University and Department of Cardiology, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Osswald
- Department of Cardiology, University Hospital of Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Christian Sticherling
- Department of Cardiology, University Hospital of Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Michael Kühne
- Department of Cardiology, University Hospital of Basel, Basel, Switzerland; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland.
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16
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Al Rawahi M, Samuel M, Galatas C, Joza J, Lima PY, Barbosa R, Thanassoulis G, Bernier ML, Huynh T, Essebag V. Incidence and Predictors of Intracardiac Thrombus on Pre-electrophysiological Procedure Transesophageal Echocardiography. CJC Open 2019; 1:231-237. [PMID: 32159114 PMCID: PMC7063624 DOI: 10.1016/j.cjco.2019.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 06/17/2019] [Indexed: 01/19/2023] Open
Abstract
Background Cerebral thromboembolism is a potentially devastating complication of atrial fibrillation (AF) and atrial flutter (AFl). The use of transesophageal echocardiogram (TEE) before electrophysiological procedures in anticoagulated patients is variable. Our objective was to determine the incidence and identify predictors of intracardiac left atrial appendage (LAA) thrombus on TEE in patients with AF/AFl before electrical cardioversion or ablation. Methods We reviewed TEEs of 401 patients undergoing an electrical cardioversion, AF, or AFl ablation from April 2013 to September 2015 at the McGill University Health Center. Clinical and echocardiographic variables were collected at the time of the TEE and follow-up visits. Multivariate logistic regression was used to determine predictors of LAA thrombus. Results Of 401 patients, 11.2% had LAA thrombus on TEE. The majority (87%) of patients were anticoagulated for at least 3 weeks before the TEE. The incidence of LAA thrombus was 21% (23/110) in patients taking warfarin vs 6.4% (15/236) in patients taking direct oral anticoagulants. Multivariate analysis identified prior stroke (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.1-6.9) and heart failure (OR, 2.2; 95% CI, 1.0-4.7) as predictors of thrombus, whereas direct oral anticoagulant use (OR, 0.4; 95% CI, 0.2-0.8) was associated with reduced odds of thrombus. Conclusions LAA thrombus was identified in a significant proportion of patients undergoing TEE before cardioversion or ablation of AF/AFl despite preprocedural anticoagulation. Patients at increased risk of LAA thrombus (heart failure and prior stroke) may benefit from TEE before cardioversion, AF, or AFl ablation.
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Affiliation(s)
- Mohamed Al Rawahi
- McGill University Health Center, Division of Cardiology, Montreal, Quebec, Canada.,Sultan Qaboos University Hospital, Muscat, Oman
| | - Michelle Samuel
- McGill University Health Center, Division of Cardiology, Montreal, Quebec, Canada
| | - Christos Galatas
- McGill University Health Center, Division of Cardiology, Montreal, Quebec, Canada.,Hôpital Cité-de-la-Santé, Laval, Quebec, Canada
| | - Jacqueline Joza
- McGill University Health Center, Division of Cardiology, Montreal, Quebec, Canada
| | - Pedro Y Lima
- McGill University Health Center, Division of Cardiology, Montreal, Quebec, Canada
| | | | - George Thanassoulis
- McGill University Health Center, Division of Cardiology, Montreal, Quebec, Canada
| | - Martin L Bernier
- McGill University Health Center, Division of Cardiology, Montreal, Quebec, Canada
| | - Thao Huynh
- McGill University Health Center, Division of Cardiology, Montreal, Quebec, Canada
| | - Vidal Essebag
- McGill University Health Center, Division of Cardiology, Montreal, Quebec, Canada.,Hôpital Sacré-Coeur de Montréal, Montreal, Quebec, Canada
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17
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Bertog S, Sievert H. Left atrial appendage closure: prevalence and risk of device-associated thrombus formation. Cardiovasc Diagn Ther 2019; 9:104-109. [PMID: 30881888 DOI: 10.21037/cdt.2018.10.05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Stefan Bertog
- CardioVascular Center Frankfurt, Frankfurt, Germany.,Minneapolis Veterans Affairs Medical Center, Minneapolis, USA
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18
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Ueberham L, Bollmann A. Same-day discharge following atrial fibrillation catheter ablation: the perfect blend? Europace 2019; 21:363-365. [PMID: 30060187 DOI: 10.1093/europace/euy169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Laura Ueberham
- Department of Electrophysiology, Helios Heart Center Leipzig, Leipzig, Germany.,Leipzig Heart Institute, Leipzig, Germany
| | - Andreas Bollmann
- Department of Electrophysiology, Helios Heart Center Leipzig, Leipzig, Germany.,Leipzig Heart Institute, Leipzig, Germany
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Okamatsu H, Okumura K. Is Transesophageal Echocardiography Necessary in Every Case of Atrial Fibrillation Ablation? Circ J 2018; 82:2701-2702. [PMID: 30298853 DOI: 10.1253/circj.cj-18-1042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hideharu Okamatsu
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
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