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Characteristics of non-valvular atrial fibrillation with left atrial appendage thrombus who are undergoing appropriate oral anticoagulation therapy

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Abstract

We investigated the characteristics of patients with non-valvular atrial fibrillation (NVAF) and left atrial (LA) appendage (LAA) thrombus who had been given appropriate oral anticoagulation therapy. We studied 737 NVAF patients who were scheduled for catheter ablation or electrical cardioversion. All patients received appropriate oral anticoagulation therapy for at least 3 weeks prior to echocardiography in accordance with the guidelines. Whether LAA thrombus was present or absent on transesophageal echocardiography (TEE) was determined by at least three senior echocardiologists. LAA thrombi were observed in 22 patients (3.0%). Multivariate logistic regression analysis showed that LAA flow and LA volume index were both independent predictors of LAA thrombus formation; however, LAA flow (≤ 18 cm/s) was indicated as a more powerful predictor. Moreover, the prevalence of LAA thrombus formation in patients with NVAF without LA enlargement (LA volume index ≤ 34 mL/m2) was extremely rare (0.4%). LAA thrombus formation in patients with a mildly dilated LA volume index of 34–49.9 mL/m2 and paroxysmal AF was also extremely rare (0.0%). LAA flow is strongly associated with LAA thrombus formation, even in NVAF patients treated with appropriate oral anticoagulation therapy. Augmented oral anticoagulation therapy or transcatheter or surgical LAA closure should be considered for such patients, especially for those with an LAA flow < 18 cm/s. Furthermore, TEE for evaluating LAA thrombus before catheter ablation or electrical cardioversion may be unnecessary for NVAF patients who are undergoing appropriate oral anticoagulation therapy, depending on LA size.

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References

  1. Benjamin EJ, Wolf PA, D’Agostino RB, Silbershatz H, Kannel WB, Levy D (1998) Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation 98:946–952

    Article  CAS  Google Scholar 

  2. Stewart S, Hart CL, Hole DJ, McMurray JJ (2002) A population-based study of the long-term risks associated with atrial fibrillation: 20-year follow-up of the Renfrew/Paisley study. Am J Med 113:359–364

    Article  Google Scholar 

  3. Hart RG, Benavente O, McBride R, Pearce LA (1999) Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis. Ann Intern Med 131:492–501

    Article  CAS  Google Scholar 

  4. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B et al (2016) ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 37(2016):2893–2962

    Article  Google Scholar 

  5. January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr et al (2014) AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 64(2014):e1-76

    Article  Google Scholar 

  6. Reers S, Karanatsios G, Borowski M, Kellner M, Reppel M, Waltenberger J (2018) Frequency of atrial thrombus formation in patients with atrial fibrillation under treatment with non-vitamin K oral anticoagulants in comparison to vitamin K antagonists: a systematic review and meta-analysis. Eur J Med Res 23:49

    Article  CAS  Google Scholar 

  7. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomstrom-Lundqvist C et al (2021) ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 42:373–498

    Article  Google Scholar 

  8. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L et al (2015) Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 16:233–270

    Article  Google Scholar 

  9. Andrade JG, Macle L, Nattel S, Verma A, Cairns J (2017) Contemporary atrial fibrillation management: a comparison of the current AHA/ACC/HRS, CCS, and ESC Guidelines. Can J Cardiol 33:965–976

    Article  Google Scholar 

  10. Stoddard MF, Singh P, Dawn B, Longaker RA (2003) Left atrial thrombus predicts transient ischemic attack in patients with atrial fibrillation. Am Heart J 145:676–682

    Article  Google Scholar 

  11. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K et al (2010) Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 23:685–713 (quiz 786-688)

    Article  Google Scholar 

  12. Blackshear JL, Odell JA (1996) Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg 61:755–759

    Article  CAS  Google Scholar 

  13. Zhan Y, Joza J, Al Rawahi M, Barbosa RS, Samuel M, Bernier M et al (2018) Assessment and management of the left atrial appendage thrombus in patients with nonvalvular atrial fibrillation. Can J Cardiol 34:252–261

    Article  Google Scholar 

  14. Wallace TW, Atwater BD, Daubert JP, Voora D, Crowley AL, Bahnson TD et al (2010) Prevalence and clinical characteristics associated with left atrial appendage thrombus in fully anticoagulated patients undergoing catheter-directed atrial fibrillation ablation. J Cardiovasc Electrophysiol 21:849–852

    PubMed  Google Scholar 

  15. Kawabata M, Goya M, Sasaki T, Maeda S, Shirai Y, Nishimura T et al (2017) Left atrial appendage thrombi formation in Japanese non-valvular atrial fibrillation patients during anticoagulation therapy- Warfarin vs. direct oral anticoagulants. Circ J 81:645–651

    Article  CAS  Google Scholar 

  16. Harada M, Koshikawa M, Motoike Y, Ichikawa T, Sugimoto K, Watanabe E et al (2018) Left atrial appendage thrombus prior to atrial fibrillation ablation in the era of direct oral anticoagulants. Circ J 82:2715–2721

    Article  CAS  Google Scholar 

  17. Fatema K, Bailey KR, Petty GW, Meissner I, Osranek M, Alsaileek AA et al (2008) Increased left atrial volume index: potent biomarker for first-ever ischemic stroke. Mayo Clin Proc 83:1107–1115

    Article  Google Scholar 

  18. Tsang TS, Barnes ME, Gersh BJ, Bailey KR, Seward JB (2002) Left atrial volume as a morphophysiologic expression of left ventricular diastolic dysfunction and relation to cardiovascular risk burden. Am J Cardiol 90:1284–1289

    Article  Google Scholar 

  19. Tsang TS, Abhayaratna WP, Barnes ME, Miyasaka Y, Gersh BJ, Bailey KR et al (2006) Prediction of cardiovascular outcomes with left atrial size: is volume superior to area or diameter? J Am Coll Cardiol 47:1018–1023

    Article  Google Scholar 

  20. Knight BP (2009) Transesophageal echocardiography before atrial fibrillation ablation: looking before cooking. J Am Coll Cardiol 54:2040–2042

    Article  Google Scholar 

  21. Di Biase L, Santangeli P, Anselmino M, Mohanty P, Salvetti I, Gili S et al (2012) Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation? Results from a multicenter study. J Am Coll Cardiol 60:531–538

    Article  Google Scholar 

  22. Shimada M, Akaishi M, Kobayashi T (2020) Left atrial appendage morphology and cardiac function in patients with sinus rhythm. J Echocardiogr 18:117–124

    Article  Google Scholar 

  23. Kishima H, Mine T, Ashida K, Sugahara M, Kodani T, Masuyama T (2015) Does left atrial appendage morphology influence left atrial appendage flow velocity? Circ J 79:1706–1711

    Article  Google Scholar 

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Authors and Affiliations

  1. Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan

    Hiroaki Shiraki, Hidekazu Tanaka, Yuki Yamauchi, Yuko Yoshigai, Kentaro Yamashita, Yusuke Tanaka, Keiko Sumimoto, Ayu Shono, Makiko Suzuki, Shun Yokota, Kensuke Matsumoto, Koji Fukuzawa & Ken-ichi Hirata

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  1. Hiroaki Shiraki
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  2. Hidekazu Tanaka
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  3. Yuki Yamauchi
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Correspondence to Hidekazu Tanaka.

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Hiroaki Shiraki, Hidekazu Tanaka, Yuki Yamauchi, Yuko Yoshigai, Kentaro Yamashita, Yusuke Tanaka, Keiko Sumimoto, Ayu Shono, Makiko Suzuki, Shun Yokota, Kensuke Matsumoto, Koji Fukuzawa, Ken-ichi Hirata declare that have no conflict of interest.

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Shiraki, H., Tanaka, H., Yamauchi, Y. et al. Characteristics of non-valvular atrial fibrillation with left atrial appendage thrombus who are undergoing appropriate oral anticoagulation therapy. Int J Cardiovasc Imaging 38, 941–951 (2022). https://doi.org/10.1007/s10554-021-02403-z

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  • DOI: https://doi.org/10.1007/s10554-021-02403-z

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