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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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Lin C, Bao Y, Hua W, Zhang N, Jin Q, Xie Y, Wei Y, Luo Q, Liu Z, Ling T, Pan W, Xie Y, Wu L. Differences in D-dimer blood concentration in atrial fibrillation patients with left atrial thrombus or severe left atrial spontaneous echo contrast. J Interv Card Electrophysiol 2021; 64:341-347. [PMID: 33937955 DOI: 10.1007/s10840-021-00991-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/05/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Severe left atrial spontaneous echo contrast (SLASEC) is considered the prior stage to thrombosis and a high-risk factor for thrombotic events. Studies have suggested an effect of D-dimer blood concentration on exclusion of left atrial thrombus (LAT), but it remains unclear whether D-dimer concentrations differ between atrial fibrillation (AF) patients with SLASEC or LAT. METHODS Nonvalvular AF patients scheduled to undergo catheter ablation or cardioversion in Shanghai Ruijin Hospital between January 2017 and July 2020 were screened for this prospective study. All patients underwent transesophageal echocardiography (TEE) to detect SLASEC or LAT. D-dimer concentrations were measured at the time of TEE. Clinical data including CHA2DS2-VASc score were evaluated. Major complications with thromboembolism in the SLASEC group were followed up at least 6 months after therapy. RESULTS Among 920 consecutively enrolled nonvalvular AF patients, 30 patients with SEC grade 0, 35 patients with SLASEC, and 22 patients with LAT were included. D-dimer concentration and CHA2DS2-VASc score were significantly lower in the SLASEC group compared with the LAT group (D-dimer, 0.26±0.13 vs. 0.86±0.9 mg/L, P<0.05; CHA2DS2-VASc score, 2.3±0.9 vs. 3.1±1.5, P=0.02). The cut-off value for D-dimer concentration (0.285 mg/L) had sensitivity of 77.3% and specificity of 80.0% for prediction of LAT. D-dimer concentration showed a decreasing trend with a significant difference (0.42±0.22 vs. 0.33±0.18 mg/L, P=0.03) for 9 patients in the LAT group after complete thrombus resolution by anticoagulation treatment. No major or fatal bleeding, ischemic stroke, or systemic thromboembolism events occurred in the SLASEC group during the 6-month follow-up. CONCLUSIONS This study demonstrated a significantly lower D-dimer concentration and CHA2DS2-VASc score in AF patients with SLASEC than in those with LAT. The D-dimer cut-off value (0.285 mg/L) can be used as an effective reference index to distinguish the pre-thrombotic state of LAT from LAT. D-dimer blood concentration may be a predictor of LAT thrombolysis.
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Affiliation(s)
- Changjian Lin
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Yangyang Bao
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Wei Hua
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Ning Zhang
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Qi Jin
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Yun Xie
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Yue Wei
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Qingzhi Luo
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Zhuhui Liu
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Tianyou Ling
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Wenqi Pan
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Yucai Xie
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China.
| | - Liqun Wu
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China.
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Efremidis M, Bazoukis G, Vlachos K, Prappa E, Megarisiotou A, Dragasis S, Ramirez FD, Bourier F, Mililis P, Saplaouras A, Tse G, Liu T, Efremidis T, Kitsoulis P, Thomopoulos C, Sideris A, Letsas KP. Safety of catheter ablation of atrial fibrillation without pre- or peri-procedural imaging for the detection of left atrial thrombus in the era of uninterrupted anticoagulation. J Arrhythm 2021; 37:28-32. [PMID: 33664883 PMCID: PMC7896446 DOI: 10.1002/joa3.12466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/18/2020] [Accepted: 11/04/2020] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The need for pre- or peri-procedural imaging to rule out the presence of left atrial thrombus in patients undergoing catheter ablation of atrial fibrillation (AF) is unclear in the era of uninterrupted direct oral anticoagulant (DOAC) regimen. We sought to examine the safety of catheter ablation in appropriately selected patients with paroxysmal AF without performing screening for left atrial thrombus. PATIENTS AND METHODS Consecutive patients planned for radiofrequency AF catheter ablation between January 2016 and June 2020 were enrolled, and prospectively studied. All subjects were receiving uninterrupted anticoagulation with DOACs for at least 4 weeks before the procedure. All subjects were in sinus rhythm the day of the procedure. The primary outcome of the study was ischemic stroke or transient ischemic attack (TIA) during at 30 days. RESULTS A total of 451 patients (age 59.7 ± 10.2 years, 289 males) with paroxysmal AF were included in the study. The mean CHA2DS2-VASc score was 1.4 ± 1.2. The mean left ventricular ejection fraction and left atrial diameter were 60 ± 5% and 39.3 ± 4 mm, respectively. Regarding the anticoagulation regimen, apixaban was used in 197 (43.6%) patients, rivaroxaban in 148 (32.8%) patients, and dabigatran in 106 (23.5%) patients. None of the patients developed clinical ischemic stroke or TIA during the 30-day post-discharged period. CONCLUSIONS Catheter ablation can be safely performed in low-risk patients with paroxysmal AF without imaging for the detection of left atrial thrombus in the era of uninterrupted DOAC anticoagulation.
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Affiliation(s)
- Michael Efremidis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - George Bazoukis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Konstantinos Vlachos
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Efstathia Prappa
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Athanasia Megarisiotou
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Stylianos Dragasis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - F. Daniel Ramirez
- Hôpital Cardiologique du Haut LévèqueCHU de Bordeaux and IHU‐LIRYCPessacFrance
| | - Felix Bourier
- Department of ElectrophysiologyGerman Heart CenterTechnical UniversityMunichGermany
| | - Panagiotis Mililis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Athanasios Saplaouras
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Gary Tse
- Xiamen Cardiovascular HospitalXiamen UniversityXiamenPeople's Republic of China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular DiseaseDepartment of CardiologyTianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinPeople's Republic of China
| | - Theodore Efremidis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Panagiotis Kitsoulis
- Laboratory of Anatomy‐Histology‐EmbryologySchool of MedicineUniversity of IoanninaIoanninaGreece
| | | | - Antonios Sideris
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Konstantinos P. Letsas
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
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