Atrial Thrombi-A Prospective Follow-up Study over 3 Years with Transesophageal Echocardiography and Cranial Magnetic Resonance Imaging

Percutaneous left atrial appendage closure in patients with hypertrophic cardiomyopathy and persistent atrial fibrillation: 3-year-followed case series

Hypertrophic cardiomyopathy (HCM) patients with atrial fibrillation (AF) are at high risk for stroke. Left atrial appendage closure (LAAC) is a promising alternative for stroke prevention in AF patients. We aimed to review the clinical outcomes of patients with AF and HCM at our center. We reviewed 673 patients who underwent LAAC implantation from 2014 to 2021 in a tertiary center, of whom 15 had HCM. AF Patients with HCM were compared with sex and age matched controls who also underwent LAAC. From 2014 to 2021, 673 AF patients received LAAC in a single center, of whom, 15 patients had HCM. LAAC devices were successfully implanted in 14 HCM patients and 59 patients in the control group. During the follow-up period (median 1151 days range: 132-2457 days), 2 HCM patient had ischemic strokes. There were another 2 HCM patients who had sudden cardiac death (SCD). Compared with the control, HCM patients had higher cumulative rate of combined death and stroke (26.67% vs 3.33%, P = .024). In our initial clinical experience, the cumulative stroke and death rate of the HCM patients was significantly higher than that of the non-HCM patients.

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

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

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

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

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

Risk of Cardiovascular Complications in Patients with Persistent Atrial Fibrillation after Dissolution of a Thrombus in the Left Atrial Appendage

Aim      To compare the incidence of cardiovascular complications (CVC) in patients with persistent atrial fibrillation (AF) following thrombus dissolution in the left atrial appendage (LAA) and in patients with persistent AF without preceding LAA thrombosis.Material and methods  The main group included 43 patients who had been diagnosed with LAA thrombosis on the first examination, transesophageal echocardiography, and who showed dissolution of the thrombus on a repeated study performed after 7.1+2.0 weeks of the anticoagulant treatment. The control group consisted of 123 patients with a risk score &gt;0 for men without LAA thrombosis and score &gt;1 for women without LAA thrombosis according to the CHA2DS2‑VASc scale. The patients were followed up for 47.3±17.9 months. The following unfavorable outcomes were recorded: all-cause mortality, ischemic stroke or systemic thromboembolism, hemorrhagic stroke or severe bleeding, and myocardial infarction (MI).Results Unfavorable clinical outcomes were observed in 39.5 % of patients in the main group and in 3.3 % of patients in the control group (p&lt;0.001). Furthermore, the incidence of ischemic stroke (relative risk (RR), 12.9; 95 % confidence interval (CI), 2.89-57.2), and MI (RR, 5.72; 95 % CI, 1.09-30.1) was higher in the main group. However, the number of MI cases in both groups and the number of stroke cases in the control group increased during the entire follow-up period, while the number of stroke cases rapidly increased only during the first year of follow-up.Conclusion      In patients with persistent AF, the risk of CVC after LAA thrombus dissolution remains significantly higher than in patients with AF without LAA thrombosis.

Decreased left atrial appendage emptying velocity as a link between atrial fibrillation type, heart failure and older age and the risk of left atrial thrombus in atrial fibrillation

INTRODUCTION

Decreased left atrial appendage emptying velocity (LAAV) is a known predictor of LAA thrombus in atrial fibrillation (AF). The aim of our study was to identify which of the clinical risk factors for LAA thrombus are associated with decreased LAAV.

METHODS

The study included 1476 consecutive AF patients who underwent transesophageal echocardiography (TEE) before AF direct current cardioversion or ablation in two high-reference cardiology departments. Patients were divided into two groups: 71 (4.8%) patients with LAAV < 20 cm/s and 1405 patients (95%) with LAAV ≥ 20 cm/s.

RESULTS

Compared with patients with LAAV ≥ 20 cm/s, those with decreased LAAV were older, more often had non-paroxysmal AF, were burdened with more concomitant diseases (including hypertension, diabetes, vascular disease, and heart failure [HF]) with higher median CHA₂ DS₂ -VASc score (3 [2-4] vs 2 [1-3], P < .0001), and had lower glomerular filtration rate (GFR). Prevalence of LAA thrombus was higher in patients with decreased LAAV compared with those with LAAV ≥ 20cm/s (20% vs 4.6%, P < .0001). In patients with decreased LAAV, there was no difference in the frequency of LAA thrombus between those treated with VKA and those receiving NOAC, while in patients with LAAV ≥ 20 cm/s a trend was observed towards a benefit with NOAC. In multivariate logistic regression, non-paroxysmal AF, HF and age ≥ 65 years predicted both LAAV < 20 cm/s and LAA thrombus, while GFR < 60 mL/min/1.73 m² predicted only the presence of LAA thrombus.

CONCLUSION

One in five AF patients with decreased LAAV had LAA thrombus, regardless of the type of OAC. Non-paroxysmal AF, HF and age ≥ 65 years might increase LAA thrombus risk via reduced LAAV.

Submassive Pulmonary Embolism and Left Atrial Thrombus

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

The Refinement of Risk Stratification for Atrial Thrombus or Spontaneous Echo Contrast in Nonvalvular Atrial Fibrillation

As for nonvalvular atrial fibrillation (NVAF) patients with left atrial thrombus or spontaneous echo contrast (LAT/SEC), we evaluated the additional predictive value of serum uric acid (SUA) and Left atrial diameter (LAD) for CHADS₂ and CHA₂DS₂-VASc, and explored the influence from the level of SUA and LAD to LAT/SEC in moderate risk group. Thus, we put forward the concept of a borderline high risk group to guide clinical anticoagulant therapy in patients with NVAF.A total of 284 NVAF patients without the history of anticoagulant prior to hospitalization were enrolled. They were divided into LAT/SEC group or No LAT/SEC group according to transesophageal echocardiography (TEE). Then, we explored and compared the additional predictive value of serological and ultrasonic indexes after combining them to CHADS₂/CHA₂DS₂-VASc.61 patients (21.48%) had LAT/SEC. SUA and LAD were the independent risk factors of LAT/SEC. After being added with LAD and SUA, the predictive value of CHADS₂ and CHA₂DS₂-VASc were increased much more than others. In the moderate risk group, the incidence of LAT/SEC rose significantly when SUA or LAD was higher than cut-off values.SUA and LAD enhanced the predictive ability of CHADS₂ and CHA₂DS₂-VASc for LAT/SEC as additional factors. For patients in moderate risk group, if SUA or LAD was higher than cut-off values, the risk of thromboembolism events would rise accompanied by the elevated risk of LAT/SEC.

Hemoglobin A1c and risk of left atrial thrombus and spontaneous echo contrast in non-valvular atrial fibrillation patients

OBJECTIVES

To evaluate the relationship between hemoglobin A1c (HbA1c) and risk of left atrial thrombus/spontaneous echo contrast (LAT/SEC) in non-valvular atrial fibrillation (AF) patients.

METHODS

In this retrospective study, 1158 consecutive non-valvular AF patients undergoing transesophageal echocardiography prior to radiofrequency catheter ablation or electric cardioversion were enrolled. Baseline characteristics were collected and analyzed.

RESULTS

There were 87 (7.5%) patients with LAT/SEC. The HbA1c levels in the patients with LAT/SEC were significantly higher than that in patients without LAT/SEC (6.13 ± 0.41 vs. 5.89 ± 0.45 μmol/L, P < 0.001). The optimal cut-off point for HbA1c predicting LAT/SEC was 6.1% determined by receiver-operating characteristic curve. The area under the curve is 0.788 (95% confidence interval: 0.764-0.812). HbA1c ≥6.1% was an independent risk factor for LAT/SEC (odds ratio, 1.74; 95% confidence interval, 1.01-2.98; P = 0.045).

CONCLUSIONS

Elevated HbA1c indicated a significantly increased risk for LAT/SEC in non-valvular AF patients. HbA1c might have significance in predicting the risk for prothrombotic state in non-valvular AF patients.

Transesophageal Echocardiography in Atrial Fibrillation

Transesophageal echocardiography (TEE) plays an important role in atrial fibrillation (AF), mainly to detect the presence of left atrial appendage (LAA) thrombus. It is useful in direct current cardioversion (DCC) guidance and for AF ablation and LAA occlusion. With the increasing number of patients affected by AF, the use of TEE will grow and become an important screening modality for LAA thrombus. Future direction includes broader multi-institutional use; further tools to risk stratify patients; and the use of a new spectrum of oral anticoagulants and their cost-effectiveness in patients with AF undergoing DCC, AF ablation, and LAA occlusion.

Recurrent Cardioembolic Stroke Treated Successfully with Repeated Mechanical Thrombectomy within the Acute Index Stroke Period

Background

The safety of repeated mechanical thrombectomy within the acute stroke period has not yet been clearly demonstrated. We describe herein a patient who was successfully treated with repeated mechanical thrombectomy within the acute index stroke period.

Case Report

A 50-year-old woman with atrial fibrillation presented with left-sided weakness caused by occlusion of the right middle cerebral artery (MCA). Emergent mechanical thrombectomy with the Solitaire device achieved complete recanalization. The left MCA occlusion redeveloped at 6 days after the first treatment, at which time her international normalized ratio (INR) was 2.3. Endovascular thrombectomy was reattempted rapidly and complete recanalization was achieved again. Her neurologic symptoms resolved after the thrombectomy.

Conclusions

This case demonstrates that repeated mechanical thrombectomy can be safely and successfully performed even in a patient with a high INR and a recurrent stroke during the acute period after the index stroke.

Evaluation of left atrial deformation to predict left atrial stasis in patients with non-valvular atrial fibrillation - a pilot-study

BACKGROUND

Speckle tracking-derived strain and strain rate are recently available parameters to assess left atrial (LA) deformation. We hypothesized that such new parameters could be of interest to evaluate the risk of LA stasis among patients with atrial fibrillation (AF).

METHODS

Single-centre study enrolling all patients with non-valvular AF lasting longer than 48 hours for whom no therapeutic anticoagulation was given in the preceding 3 weeks and who were assessed through transesophageal and transthoracic echocardiogram during a 6 month time interval. LA deformation was assessed by transthoracic echocardiogram through speckle tracking analysis, whereas LA stasis parameters were sought on transesophageal echocardiogram.

RESULTS

Among the 82 assessed patients, LA appendage thrombi or sludge were found in 16 (19.5%). A moderate positive correlation was found between peak positive strain rate and maximum emptying velocity (r = 0.589; P <0.001) and peak positive strain rate and maximum filling velocity of the LA appendage (r = 0.651; P <0.001). Peak negative strain rate was also found to be associated with both maximum emptying velocity (r = -0.513; P <0.001) and maximum filling velocity of the LAA (r = -0.552; P <0.001). AF duration, peak negative strain rate and time-to-peak positive strain were independent predictors of LAA thrombi or sludge on multivariate analysis logistic regression. The area under the curve for the estimated probabilities using the obtained logistic regression model was 0.89 (95%CI 0.81-0.96; P <0.001).

CONCLUSION

Our findings suggest that LA mechanical dysfunction assessed through speckle tracking may be of interest to predict LA stasis in the setting of AF.

Recent Advances in Percutaneous Cardioscopy

Percutaneous cardioscopy, using high-resolution fiberoptic imaging, enables direct visualization of the cardiac interior, thereby enabling macroscopic pathological diagnosis. Percutaneous cardioscopy has demonstrated that the endocardial surface exhibits various colors characteristic of different heart diseases. This imaging modality can now be used for evaluation of the severity of myocardial ischemia, and staging of myocarditis. Myocardial blood flow recovery induced by vasodilating agents or percutaneous coronary interventions can be clearly visualized. Morphological and functional changes in the cardiac valves can also be evaluated. Cardioscope-guided endomyocardial biopsy enables pin-point biopsy of the diseased myocardium. Recently, dye-image cardioscopy and fluorescence cardioscopy were developed for evaluation of the subendocardial microcirculation. Cardioscope-guided intracardiac therapies such as myotomy, myectomy, valvulotomy, and transendocardial angiogenic and myogenic therapy have been trialed using animal models in anticipation of future clinical applications. Percutaneous cardioscopy has the potential to contribute to our understanding of heart disease, and to assist in guidance for intracardiac therapies.

Cardioscopic detection of left ventricular thrombi. -With special reference to a comparison with left ventriculography and echocardiography-

BACKGROUND

Thrombosis occurs in the left ventricle and causes ischemic cerebral attacks. However, differences in the incidence of left ventricular thrombi (LVT) among various categories of heart diseases are not known.

METHODS AND RESULTS

From April 2000 to 31 March 2008, 258 patients (104 females and 154 males; age 63 ± 6 years) with a heart disease underwent cardioscopy of the left ventricle. LVT were detected by cardioscopy in 78 of 258 patients; 12.5% of 57 patients with stable angina, 0% of 9 with unstable angina, 45.2% of 42 with acute myocardial infarction, 23.2% of 43 with old myocardial infarction, 61.9% of 21 with idiopathic acute myocarditis, 44.3% of 68 with idiopathic chronic myocarditis, 33.3% of 6 with rheumatic valvular disease, 25.7% of 31 with idiopathic dilated cardiomyopathy and in 8.0% of 12 with idiopathic hypertrophic cardiomyopathy. Nine of 78 thrombi were globular and 69 were mural. The detection rate of LVT by cardioscopy, left venticulography, non-contrast and contrast echocardiography was 30.2%, 2.7%, 1.9% and 7.0%, respectively.

CONCLUSIONS

LVT were frequently detected by cardioscopy in patients with heart diseases. Although invasive, cardioscopy was more sensitive in detecting LVT than left ventriculography, and non-contrast and contrast echocardiography.

Left atrial giant thrombus infected by Escherichia Coli. Case report

Background

Left atrial thrombi are mostly related to mitral valve disease. The differential diagnosis of clots and myxomas in the left atrium is mostly based on echocardiography. Infection of intracardiac thrombi is extremely rare and mostly reported in ventricular clots or aneurysms following myocardial infarction.

Case presentation

We present the case of a 65 year old female with a history of mitral valve disease and chronic atrial fibrillation who suffered repeated embolic strokes and a giant infected clot in the left atrium. Although the patient underwent prompt surgery with removal of the clot and valve replacement the complication of septic emboli to the CNS led her to death. To the best of our knowledge this is the second report of an infected left atrial thrombus.

Conclusion

The case is a representative example of a neglected and undertreated patient with catastrophic consequences. Anticoagulant therapy in patients with mitral valve disease and atrial fibrillation should be applied according the currently available guidelines and standards in order to avoid analogous paradigms in the future. Mitral valve substitution should be considered in patients with mitral valve disease presenting thromboembolic complications. Surgery should be considered as the treatment of choice in cases of organized left atrial thrombus and suspected tumor or infected mass.

Clinical and Echocardiographic Risk Factors for Embolization in the Presence of Left Atrial Thrombus

AIMS

The aim of our study was to evaluate the factors leading to embolization in patients with left atrial thrombi (LAT). With this purpose, we retrospectively analyzed clinical, transthoracic, transesophageal echocardiographic data of patients with LAT in the transesophageal echocardiographic evaluation.

METHODS AND RESULTS

One hundred ninety-two patients with LAT not on anticoagulant therapy were divided into two groups according to the presence of prior ischemic stroke. The group with ischemic stroke included more patients with sinus rhythm and less patients with mitral stenosis. They had smaller left atrial diameter, more left atrial appendage spontaneous echo-contrast, higher appendage ejection fraction, and emptying velocity.

CONCLUSION

Once the thrombus has been formed, cerebral embolization seems to be higher in patients with relatively preserved appendage ejection fraction and emptying velocity. Presence of atrial appendage spontaneous echo-contrast also favor embolization. Factors leading to embolization seem to differ in some respects from the causes of thrombus formation.