Left atrial appendage closure in patients with left atrial appendage thrombus guided by intracardiac echocardiography

BACKGROUND

Data regarding left atrial appendage closure (LAAC) in patients with left atrial appendage (LAA) thrombus are limited. Recently published cases have mostly been guided by transesophageal echocardiography. Intracardiac echocardiography (ICE) is now widely used during LAAC procedures.

OBJECTIVE

This is the first study to report the feasibility of LAAC in patients with LAA thrombus guided by ICE.

METHODS

Patients with persistent LAA thrombus despite anticoagulation or contraindications to anticoagulation who underwent a modified ICE-guided LAAC procedure between June 2021 and April 2023 were included. Periprocedural events and clinical outcomes during follow-up were recorded.

RESULTS

A total of 12 patients (mean age 65 ± 7 years; 92% male) were included: 10 with persistent LAA thrombus and 2 with contraindications to anticoagulation. Most of the thrombus was at the apex (n = 6), followed by the body (n = 3) and the ostium (n = 3). A LAmbre device was used and successfully implanted in all patients with the guidance of ICE. No thrombotic material was retrieved from patients with the protection of cerebral protection device (n = 11). No patient experienced severe periprocedural complications. All patients completed transesophageal echocardiography follow-up, and no device-related thrombus or peridevice leak > 3 mm was detected. None of the patients experienced stroke/transient ischemic attack, systemic embolism, or major bleeding events during a median follow-up of 147 days (interquartile range 80-306 days).

CONCLUSION

LAAC using the LAmbre device guided by ICE may be feasible in patients with LAA thrombus when performed by experienced operators.

The Prognostic Nutritional Index May Predict Left Atrial Appendage Thrombus or Dense Spontaneous Echo Contrast in Patients With Atrial Fibrillation

Objectives

The prognostic nutritional index (PNI) is an independent predictor of adverse outcomes in patients with cardiovascular diseases. The presence of left atrial appendage thrombus (LAAT) or spontaneous echo contrast (SEC) is associated with ischemic stroke. The present study aimed to investigate the relationship between the PNI and LAAT/dense SEC in patients with non-valvular atrial fibrillation (AF).

Methods

In patients with non-valvular AF, we compared demographics, clinical characteristics, and prevalence of LAAT/dense SEC according to the levels of the PNI. The relationship between the PNI and LAAT/dense SEC was observed.

Results

A total of 406 patients with non-valvular AF were consecutively included from March 2015 to February 2019. Of the study population, 53 patients had LAAT/dense SEC. The percentages of LAAT/dense SEC were 20.4, 14.1, and 4.5% in subjects from the lowest to the highest tertile of the PNI, respectively. Multivariate logistic analysis demonstrated that the PNI was an independent predictor for LAAT/dense SEC (OR 0.89; 95% CI, 0.82–0.97; P = 0.007). Receiver operating characteristic curve analysis revealed that the optimal cutoff value of the PNI for predicting LAAT/dense SEC was 48.0 (area under the curve: 0.68; 95% CI, 0.61–0.75; P < 0.001). The sensitivity and specificity were 83.0 and 47.6%, respectively. The risk of LAAT/dense SEC in patients with a PNI ≤ 48.0 was 2.57-fold higher than that in those with a PNI > 48.0.

Conclusion

The PNI, calculated based on serum albumin and lymphocyte count, was inversely correlated with LAAT/dense SEC in patients with non-valvular AF. Therefore, it may be considered a predictor for LAAT/dense SEC.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Prevalence and Rate of Resolution of Left Atrial Thrombus in Patients with Non-Valvular Atrial Fibrillation: A Two-Center Retrospective Real-World Study

Background and aim. Thromboembolic events due to left atrial appendage (LAA) thrombosis are the main complication of non-valvular atrial fibrillation (NVAF). Although anticoagulants are effective in patients with NVAF, a minimal residual thromboembolic risk persists. Little is known about the prevalence of LAA thrombus and the rate of resolution after the recommended period of anticoagulation therapy, including vitamin K antagonists (VKA), heparin, and non-vitamin K antagonist oral anticoagulants (NOACs). Methods and results. We aimed to study the prevalence of LAA thrombus in an unselected cohort of patients undergoing transesophageal echocardiogram (TEE), and the determinants of LAA thrombus resolution. We retrospectively analyzed 8888 consecutive TEEs performed over five years in two high-volume centers and included all patients with LAA thrombus. A total of 265 patients (3%) had an LAA thrombus. Among these, 97% presented with AF. Fifty-eight percent of patients were on anticoagulants at least three weeks before the diagnosis. After the LAA thrombus diagnosis, VKAs were prescribed in 52%, heparin in 18.5%, and NOAC in 27% of patients. Among the 183 patients with repeat TEE, performed at (25–75th) 39 days (21–84), 67% showed resolution of the LAA thrombus. Although the rate of thrombus resolution was higher in patients treated with NOACs (NOACs 71%, VKA 66%, Heparin 60%) the difference between anticoagulants was statistically non-significant (VKA, OR 0.9, p = 0.83; NOAC, OR 1.23, p = 0.42; heparin, OR 0.69, p = 0.35). Thus, NOACs were demonstrated to be at least as effective as other anticoagulants in the rate of LAA thrombus resolution. Upon multivariate-adjusted analysis, higher LAA emptying velocities were the only predictor of thrombus resolution. In conclusion, the majority of patients were already on anticoagulants. NOACs could be at least as effective as other anticoagulants, yielding an LAA thrombus resolution in two-thirds of patients. This may have clinical relevance, especially in patients undergoing cardioversion or catheter ablation.

The Safety and Efficacy of Standard-Dose versus Low-Dose Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Nonvalvular Atrial Fibrillation and Left Atrial Appendage Thrombus

Background

Data comparing different doses of non-vitamin K antagonist oral anticoagulants (NOACs) regarding resolution of left atrial appendage thrombus (LAAT) in patients with nonvalvular atrial fibrillation (AF) are scarce. This study aimed to investigate the safety and efficacy of standard-dose versus low-dose NOACs in patients with nonvalvular AF and LAAT.

Methods

Patients with nonvalvular AF who underwent transesophageal echocardiography (TEE) before interventional procedures for the detection of LAAT and treated with NOACs from October 2014 to September 2020 in Ningbo First Hospital were retrospectively screened. The study population was divided into two groups according to the doses of NOACs: standard-dose group (dabigatran 150 mg, twice daily; rivaroxaban 20 mg, once daily) and low-dose group (aged ≥75 years, body weight <50 kg, or creatinine clearance <50 mL/min; dabigatran 110 mg, twice daily; rivaroxaban 15 mg, once daily). Repeated TEE was performed 1, 2, and 3 months later. The rate of LAAT completely resolved and incidence of thromboembolic and major bleeding events were compared between the two groups.

Results

A total of 24 patients were included, 14 patients in the standard-dose group and 10 in the low-dose group. After 3 months, LAAT was completely resolved in 12 out of 14 (85.7%) and 8 out of 10 (80%) patients treated with standard- and low-dose NOACs, respectively. The rate of LAAT completely resolved was comparable between groups. No thromboembolic or major bleeding events occurred during the follow-up.

Conclusion

Low-dose NOACs are a safe and effective option for the treatment of LAAT in some special subset patients. However, the results warrant validation in a prospective study.

Direct oral anticoagulants vs. vitamin K antagonists for left ventricular thrombus: a systematic review and meta-analysis

BACKGROUND

Current guidelines recommend vitamin K antagonists (VKAs) to reduce the risk of systemic thromboembolic (STE) events in patients with left ventricular (LV) thrombus. Direct oral anticoagulants (DOACs) are an emerging alternative to VKAs; however, data supporting DOAC use in LV thrombus are still lacking. We conducted this systematic review and meta-analysis to compare the efficacy and safety between DOACs and VKAs in this population.

METHODS

We searched MEDLINE, Embase, and the Cochrane Library databases from inception to October 2020 to identify studies that compared clinical outcomes of interest, including stroke or any STE, LV thrombus resolution, and bleeding, between patients who used DOACs and VKAs for LV thrombus. Data from each study were combined using the random-effects model.

RESULTS

Eight cohort studies with a total of 1771 patients (426 in DOAC group, 1345 in VKA group) were included. There were no statistically significant differences between VKA group and DOAC group on rates of STE events (pooled RR = 1.12, 95% confidence interval [CI]: 0.91-1.39, p = .286), LV thrombus resolution (pooled RR = 1.09, 95% CI: 0.94-1.27, p = .242), or bleeding events (pooled RR = 0.94, 95% CI: 0.59-1.51, p = .808).

CONCLUSIONS

Our meta-analysis found no significant differences in rates of STE events, LV thrombus resolution, or bleeding events between the use of DOACs and VKAs in LV thrombus. Further randomised controlled trials are needed to confirm our findingsHighlightsThere is limited evidence comparing the use of direct oral anticoagulants (DOACs) to vitamin K antagonists (VKAs) in left ventricular (LV) thrombus.Our systematic review and meta-analysis showed that DOACs are not inferior to VKAs in the incidence of systemic thromboembolism (STE), the rate of LV thrombus resolution, and the risk of bleeding.Current evidence is based on observational studies only. Further randomised controlled trials are needed to confirm the findings.

Direct oral anticoagulants to treat left ventricular thrombus-A systematic review and meta-analysis: ELECTRAM investigators

INTRODUCTION

Though current guidelines currently recommend using warfarin, there is also a growing interest in the utilization of direct oral anticoagulants (DOACs) to treat left ventricular (LV) thrombus.

METHODS

We performed a systematic search using PubMed, SCOPUS, EMBASE, Google Scholar, and ClinicalTrials.gov from inception to September 30, 2020, for studies that had reported outcomes in patients with left ventricular thrombus treated with DOACs (PROSPERO registration number CRD42020219761).

RESULTS

Twelve studies (n = 867 patients) were included in the analysis. The pooled incidence of the systemic embolic events (SEE) with DOACs was 2.7%, whereas the thrombus resolution rate was 86.6%. The pooled incidence of overall bleeding (composite of major and minor bleeding) and major bleeding with DOACs were 5.6% and 1.1%, respectively. No significant difference was observed in terms of SEE (OR 0.81, 95% confidence interval [CI] 0.44-1.52, p = .54), major bleeding (OR 0.29, 95% CI 0.07-1.26, p = .24), and failure of LV thrombus resolution (OR 0.86, 95% CI 0.28-2.58, p = .68); whereas overall bleeding was significantly low in patients with LV thrombus treated with DOACs compared to vitamin K antagonists (VKAs) (OR 0.33, 95% CI 0.14-0.81, p = .02).

CONCLUSION

Our study demonstrates no significant difference in SEE, major bleeding, or failure of LV thrombus resolution between the two groups, thus demonstrating that DOACs are an efficacious and safe alternative for the treatment of LV thrombus compared to VKAs. However, further well-designed prospective trials are needed to answer important clinical questions-optimal dosing/duration of DOACs and its safety in the background of antiplatelet therapy.