We present a case of a 64-year-old female who was supported with an HVAD as bridge-to-transplant (BTT) who presented with a gastrointestinal (GI) bleeding and underwent esophagogastroduodenoscopy (EGD) and colonoscopy. Her waveforms changed abruptly following the procedure, and she decompensated. With various imaging modalities and hemodynamic monitoring, we felt that she had thrombus in her outflow graft, which improved following systemic heparinization. She was listed for cardiac transplantation and remained hospitalized. At the time of surgery, her outflow graft was noted to be compressed externally and pathology was consistent with platelet-fibrin thrombus deposition.
IntroductionNonvalvular atrial fibrillation (NVAF) is a highly prevalent arrhythmia where loss of synchronized atrial contraction increases the risk of intracardiac thrombus particularly within the left atrial appendage (LAA). Anticoagulation is the mainstay of stroke prevention based on the CHA2DS2‐VASc score; however, it does not account for LAA structural characteristics.MethodsThe research comprises a retrospective matched case–control study of 196 subjects with NVAF who underwent transesophageal echo (TEE). The control group, without thrombus (n = 117), was selected from two different groups, both pools had: NVAF and CHA2DS2‐VASc score ≥ 3. One group underwent screening TEE before Watchman closure device placement from January 2015 to December 2019 (n = 74) the second underwent TEE before cardioversion from February to October 2014 (n = 43). The study group, with thrombus (n = 79), included patients with NVAF, TEE study performed between February 2014 and December 2020, and LAA thrombus. The propensity score method was utilized to determine the matched controls while accounting for confounding from prognostic variables resulting in 61 matched pairs included in the analysis data set. LAA ostial area (OA) (calculated from orthogonal measurements 0°, 90° or 45°, 135°), LAA maximal depth, and peak LAA outflow velocity were measured.ResultsPatient characteristics and TEE data were collected and compared using the t test or χ2 analysis. We observed a lower LAA peak exit velocity in the thrombus group as compared to the control group. Additionally, we found that patients in the thrombus group had smaller LAA OA at 0° and 90°, at 45° and 135°, using largest diameter, as well as using aggregate OA, and smaller maximum LAA depth compared to patients in the control group. Candidate conditional logistic regression models for the outcome of the presence of thrombus were evaluated. Statistical results from the best‐fitting conditional regression model were calculated showing a significant association between aggregate OA and LAA exit velocity with presence of thrombus.ConclusionUtilizing LAA structural characteristics to predict thrombus formation may help refine current cardioembolic stroke (CES) risk estimation.
Introduction:
Non-valvular atrial fibrillation (NVAF) is a highly prevalent arrhythmia where loss of synchronized atrial contraction increases the risk of intracardiac thrombus particularly within the left atrial appendage (LAA). Anticoagulation is the mainstay of stroke prevention based on the CHA2DS2-VASc score that does not account for LAA structural characteristics.
Methods:
The research comprises a retrospective case-control study of 196 subjects with NVAF who underwent TEE. The control group, without thrombus (n=117), was selected from two different groups, both pools had: NVAF and CHA2DS2-VASc score ≥ 3. One group underwent screening TEE prior to Watchman closure device placement from January 2015 to December 2019 (n=74) the second underwent TEE for any indication from February to October 2014 (n=43). The study group, with thrombus (n=79), included patients with NVAF, a TEE study performed between February 2014 and December 2020, and LAA thrombus. LAA ostial areas (calculated from orthogonal measurements 0, 90° or 45, 135°), maximal depth, and peak outflow velocity were measured, and the rhythm during TEE was interpreted. The control and study groups were compared using Student’s or Welch’s t-test based on variance ratios.
Results:
Patient characteristics and TEE data were collected (Table 1). Patients in the control group compared to the study group had significantly greater LV EF, LAA exit velocities, LAA ostial areas, and maximal LAA depth, and were more likely to be in sinus rhythm at the time of TEE. There were no significant differences between the groups in overall CHA2DS2-VASc scores.
Conclusion:
Cardiac structural and functional characteristics are associated with left atrial appendage thrombus among patients with NVAF.
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