Objective: To investigate whether or not the CHA2DS2-VASc score predicts left atrial (LA) thrombus detected on pre-cardioversion transoesophageal echocardiography (TEE). Materials and Methods: The medical records of patients who had undergone TEE were reviewed to assess the presence of LA thrombus prior to direct-current cardioversion for atrial fibrillation (AF). The CHA2DS2-VASc score was calculated for each patient. Clinical TEE reports were reviewed for the presence of LA thrombus. Patients with a valve prosthesis or rheumatic mitral valve disease were excluded from this study. Results: A total of 309 patients were identified. The mean age was 70.1 ± 9.8 years and 151 (49%) patients were males and 158 (51%) were females. LA thrombus was seen in 32 (10.3%) of the 309 patients. Fifty (16.2%) patients had a low CHA2DS2-VASc score (0-1), 230 (74.4%) had an intermediate score (2-4) and 29 (9.4%) had a high score (5-9). The incidence of LA thrombus in the low, intermediate and high CHA2DS2-VASc score groups was 0, 4.4 and 68.7%, respectively. The LA thrombus risk increased with increasing CHA2DS2-VASc scores. On multivariate logistic analysis, the CHA2DS2-VASc score (OR 3.26, 95% CI 2.3-4.65; p = 0.001) and age (OR 0.93, 95% CI 0.88-0.98; p = 0.004) were independent risk factors for LA thrombus in patients with non-valvular AF. Conclusion: A high CHA2DS2-VASc score was independently associated with the presence of LA thrombus in patients with non-valvular AF.
A 59-year-old woman was a candidate for lumbar disc hernia surgery. She was complaining of shortness of breath on mild exertion. Preoperative cardiac assessment was performed. On physical examination, her blood pressure was 110/60 mm Hg and heart rate was 75 bpm. A grade II/VI holosystolic murmur and a diastolic rumble were heard at the cardiac apex. Electrocardiography (ECG) showed normal sinus rhythm with normal axis (Fig. 1A). Chest X-ray showed prominent hilar vasculature (Fig. 1B -red arrow), right atrial enlargement ( Fig. 1B -black arrow), and absence of left atrial enlargement (Fig. 1B). Evaluation by two-dimensional (2D) transthoracic echocardiography (TTE) revealed coexistence of ostium secundum atrial septal defect (ASD) and rheumatic mitral stenosis. Mitral valve leaflets appeared thickened and restricted in motion but calcification and subvalvular involvement could not be defined exactly (Figs. 2A, B). Planimetric mitral valve area (MVA) was 2.1 cm 2 , maximum diastolic gradient was 9 mm Hg, and mean gradient was 3 mm Hg. Also there was a mild-to-moderate mitral regurgitation. The diameter of ASD was estimated to be 2.2 cm 2 and colour flow mapping revealed left-to-right shunt across the defect (Figs. 2C, D). Subsequently, 3D TTE study was performed in order to achieve more accurate assessment of mitral valve apparatus. By 3D echocardiography (Figs. 2E, F), planimetric MVA was 1.7 cm 2 and subvalvular thickening including calcification was seen, indicating that limitations of 2D echocardiography should be recognised and determination of planimetric MVA should be performed accurately by 3D echocardiography before treatment. Soon after, the patient was referred for open-heart surgery. Lutembacher syndrome is a rare combination of congenital ASD and acquired mitral stenosis. Due to the limitations of 2D echocardiography, particularly for distinguishing calcification and subvalvular involvement and for accurate determination of planimetric MVA, mitral valve apparatus should be assessed by 3D echocardiography before treatment.
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