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What's new?Patients with atrial fibrillation (AF) are at risk of stroke. However, the risk stratification remains complicated. It is currently unknown whether left atrial appendage thrombus (LAAT) in patients with AF on chronic anticoagulation contributes significantly to that risk. In this study, during a 12-month follow-up period, we investigated mortality, stroke, and systemic thromboembolic events in patients with AF on oral anticoagulation and transesophageal echocardiography confirmed LAAT. No stroke or thromboembolic events were recorded, and deaths (1.01%) in the LAAT group were not considered LAAT-related. We speculate that the presence of LAAT might not serve as a real indicator of inadequacy of oral anticoagulation in patients with AF.

Despite constantly updating our knowledge on atrial fibrillation and flutter there are many questions and doubts about the nature and extent of arrhythmic and non-arrhythmic consequences of these arrhythmias. In part 1 of the state-of-the-art paper the diagnostic work-up of patients with the 2 arrhythmias was summarized. The management of patients with atrial fibrillation and flutter requires a multidisciplinary approach in the risk assessment (including stroke) and treatment strategy. Regardless of the type of antiarrhythmic or anticoagulant therapy, benefits must always surpass or at least offset potential adverse effects and drug toxicity. In part 2 of the state-of-the-art paper, current therapeutic strategies have been summarized.

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A 48-year-old man with insignificant family history and without cardiovascular risk factors was admitted due to typical retrosternal chest pain of 30 min duration. Physical examination was within normal limits. Transthoracic echocardiography revealed anterior wall basal segments hypokinesis. Signs of ongoing myocardial ischemia in admission electrocardiogram (ST-segment depression in V 1 -V 4 ) together with a significant rise in cardiac troponin T level (from 4.9 to 143.4 ng/L) resulted in a diagnosis of acute coronary syndrome without ST-segment elevation as most probable. Coronary angiography revealed a critical stenosis of a marginal branch ( Fig. 1A) and coronary artery fistula (CAF) originating from the left main coronary artery (Fig. 1C, D). A successful percutaneous coronary intervention of the marginal branch with drug-eluting stent implantation was performed (Fig. 1B). The patient's further recovery was uneventful. A repeat careful echocardiographic examination was able to detect flow to the right pulmonary artery (Fig. 1E, F). Moreover, diameter measurements of cardiac chambers, pulmonary and systemic flow ratios (Qp/ /Qs) and systolic pulmonary artery pressure determined by Doppler echocardiography were normal. Multidetector computed tomography is commonly used to detect and enhance visualization of the complex geometry of coronary fistulas, however, in this case the computed tomography scan was not performed related to an absence of pressure and volume overload on echocardiographic study, the patient was asymptomatic with CAF (unexplained relation of CAFs to incidence of atherosclerotic coronary artery disease) and radiological protection. This patient was recommended conservative management of CAF as the first-line treatment option and further follow-up. CAF is a rare vascular anomaly with an estimated prevalence of 0.002% in the general population and it can reach up to 5% in patients undergoing coronary angiography. In adults, about 30% of CAF cases are associated with coronary atherosclerosis -however, the relationship between CAFs and coronary atherosclerosis has not yet been clarified.