Incidence of intracardiac thrombus formation prior to electrical cardioversion in respect to the mode of oral anticoagulation

Schaeffer, Benjamin; Rüden, Lea; Salzbrunn, Tim; Pinnschmidt, Hans O.; Akbulak, Ruken Ö.; Moser, Julia; Jularic, Mario; Meyer, Christian; Sultan, Arian; Lüker, Jakob; Steven, Daniel; Willems, Stephan; Hoffmann, Boris

doi:10.1111/jce.13447

Cited by 18 publications

(14 citation statements)

References 29 publications

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“…Study characteristics and quality evaluation: Overall, 6,860 patients from 13 studies were included in the analysis, of which 3,683 patients were treated with NOACs and 3,177 patients were treated with VKAs [Schaeffer 2018;Reers 2016;Kawabata 2017;Wyrembak 2017;Kim 2013;Maddox 2013;Nagarakanti 2011;Barysienė 2017;Ţînţ 2017;Frenkel 2016;Gunawardene 2017;Somani 2014]. All patients were examined by TEE prior to cardioversion or catheter ablation.…”

Section: Resultsmentioning

confidence: 99%

“…One study indicated that among initiators of oral anticoagulation, direct-acting oral anticoagulants use was low [Essien 2020]. In this meta-analysis, we included studies that evaluated the efficacy of LAT/LAAT prevention between NOACs and VKAs in patients undergoing cardioversion [Schaeffer 2018;Barysienė 2017;Ţînţ 2017], or catheter ablation [Frenkel 2016;Gunawardene 2017;Somani 2014], or both [Reers 2016]. Additionally, some studies focus on the AF patients undergoing cardiac surgery, elective cardioversion, or catheter ablation.…”

Section: Discussionmentioning

confidence: 99%

“…There is still controversy regarding the efficacy of NOACs for LAT prevention in NVAF compared with VKAs. Some studies indicate that the incidence of left atrial thrombus was lower in patients treated with NOAC than patients treated with warfarin [Yang 2019;Schaeffer 2018], while others do not [Reers 2016;Kawabata 2017]. Furthermore, the clinical trials of NOACs inconsistently reported race/ethnicity [Jackson 2018].…”

Section: E734mentioning

confidence: 99%

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The Efficacy of Non–Vitamin K Antagonist Oral Anticoagulants in the Prevention of Left Atrial Thrombus in Patients With Atrial Fibrillation Compared With Vitamin K Antagonists: A Meta-Analysis

et al. 2020

HSF

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Background: There is still a paucity of data on the efficacy of non–vitamin K antagonist oral anticoagulants (NOACs) in the prevention of left atrial thrombus (LAT) formation before cardioversion or catheter ablation. To assess the efficacy of NOACs in the prevention of LAT in patients with non-valvular atrial fibrillation (NVAF) compared with vitamin K antagonists (VKAs), we conducted a meta-analysis. Methods: We searched PubMed, Embase, and the Cochrane Library databases. For meta-analysis, dichotomous variables were analyzed by using the odds ratios (OR) computed using the Mantel Haenszel method (random models). All results were reported with 95% confidence intervals (CI). Results: A total of 13 studies (one randomized controlled investigation and 12 observational studies) were included in the meta-analysis. There was no statistically significant difference between the NOACs and VKAs groups with respect to the odds of LAT/LAAT formations (OR 0.79; 95% CI: 0.52-1.21; P = .29; (I2 = 14%). Conclusions: NOACs were as effective as VKAs in the prevention of LAT/LAAT formation in patients with NVAF. Though patients on NOACs therapy showed a lower incidence of LAT/LAAT formation compared with VKAs, it was not significant (P = .29).

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: E734mentioning

confidence: 99%

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The Efficacy of Non–Vitamin K Antagonist Oral Anticoagulants in the Prevention of Left Atrial Thrombus in Patients With Atrial Fibrillation Compared With Vitamin K Antagonists: A Meta-Analysis

et al. 2020

HSF

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“…In addition to the limitations that are intrinsic to a nonrandomized study, there are a few other issues to point out regarding the work of Schaeffer et al . First, there is no standardized grading system for spontaneous echo contrast.…”

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confidence: 99%

“…In this issue of the Journal of Cardiovascular Electrophysiology , Schaeffer et al. shed further light on the adequacy of NOAC versus vitamin K antagonist (VKA) as a means of anticoagulation by providing real‐world TEE data regarding the incidence of intracardiac thrombi and dense spontaneous echo contrast in patients who are about to be cardioverted . They found a significantly lower incidence of thrombus formation in patients on NOACs compared with patients taking VKA (2.5% vs. 5.3%, P = 0.019).…”

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confidence: 99%

Assessing intracardiac thrombus prior to cardioversion: A story yet to be told

Anouti

Kowey

2018

Cardiovasc electrophysiol

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Direct current cardioversion was invented by Bernard Lown in 1962,and has been used for over half a century to restore sinus rhythm in patients with atrial fibrillation. Unfortunately, electrical cardioversion without anticoagulation has an inherent risk of thromboembolism that ranges from 5% to 7%, usually within the first week after the procedure. Patients undergoing electric cardioversion are therefore treated with therapeutic doses of anticoagulation for 3 weeks before the procedure and, for those without a reason to take chronic anticoagulation, for at least 4 weeks after. 1 The rationale for 3 weeks of therapeutic anticoagulation (that is maintaining an international normalized ratio [INR] > 2 for 3 consecutive weeks) prior to cardioversion is based on a number of lines of evidence. First of all, in nonrandomized studies, the incidence of thromboembolism in patients who have been properly treated with warfarin is a small fraction of what it is in patients who are not so treated. 2 In addition, Goldman et al. proposed that within 14 days there is sufficient fibroblastic infiltration to cause firm adherence of the thrombus to the atrial endocardium, thus reducing the likelihood of dislodgment. 3 Four weeks of anticoagulation following cardioversion is supported by Doppler echocardiographic studies showing restoration of the transmitral atrial (A) wave. 4The Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) study showed that transesophageal echocardiography (TEE)-guided cardioversion with short-term anticoagulation was a safe and an effective alternative to warfarin pretreatment. 5 Since then, TEE has provided a reliable and expedient tool for detection of left atrial appendage thrombus before cardioversion. A major breakthrough in the management of atrial fibrillation and its associated thromboembolic risk was the advent of novel oral anticoagulant (NOAC) drugs, each showing noninferiority, and in some cases superiority, to warfarin in rates of all-cause stroke and systemic embolism. Though none of the NOAC trials had detection of left atrial thrombus as a primary endpoint, subgroup analyses of these trials revealed a low thromboembolic risk that was comparable to warfarin in patients treated with a NOAC for ≥3 weeks prior to cardioversion. In a subgroup analysis of patients in the RELY trial (Randomized Evaluation of Long Term Anticoagulant Therapy), the rate of detection of left atrial thrombus among patients undergoing TEE cardioversion was in the range of 1.2-1.8% and 2.9% for patients on dabigatran and warfarin, respectively. 6 In the ARISTOTLE trial (Apixaban for the Prevention of Stroke in Subjects with Atrial Fibrillation), none of the 86 patients who underwent TEE cardioversion had an LA thrombus. 7 The efficacy and safety of NOACs prior to cardioversion was further evaluated in three large prospective randomized trials: X-VeRT (eXplore the efficacy and safety of once-daily oral riVaroxaban for the prevention of caRdiovascular events in patients with non-valvular aTrial fibri...

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Electrical cardioversion of atrial arrhythmias with cardiac amyloidosis in the era of direct oral anticogulants

Touboul¹,

Algalarrondo

Oghina³

et al. 2022

ESC Heart Failure

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Aims Atrial fibrillation (AF)/atrial flutter is common during cardiac amyloidosis (CA). Electrical cardioversion (EC) is a strategy to restore sinus rhythm (SR). However, left atrial thrombus (LAT) represents a contraindication for EC. CA patients with AF/atrial flutter have a high prevalence of LAT. We aimed to evaluate EC characteristics, LAT prevalence and risk factors, and AF/atrial flutter outcome in CA patients undergoing EC, predominantly treated with direct oral anticoagulants (DOACs). Methods and resultsAll patients with CA and AF/atrial flutter referred for the first time to our national referral centre of amyloidosis for EC from June 2017 to February 2021 were included in this study. In total, 66 patients (median age 74.5 [70;80.75] years, 67% male) were included with anticoagulation consisted of DOAC in 74% of cases. All patients underwent cardiac imaging before EC to rule out LAT. EC was cancelled due to LAT in 14% of cases. Complete thrombus resolution was observed in only 17% of cases. The two independent parameters associated with LAT were creatinine [hazard ratio (HR) = 1.01; confidence interval (CI) = 1.00-1.03, P = 0.036] and the use of antiplatelet agents (HR = 13.47; CI = 1.85-98.02). EC acute success rate was 88%, and we observed no complication after EC. With 64% of patients under amiodarone, AF/atrial flutter recurrence rate following EC was 51% after a mean follow-up of 30 ± 27 months. Conclusions Left atrial thrombus was observed in 14% of CA patients listed for EC and mainly treated with DOAC. The acute EC success rate was high with no complication. The long-term EC success rate was acceptable (49%).

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Incidence of intracardiac thrombus formation prior to electrical cardioversion in respect to the mode of oral anticoagulation

Cited by 18 publications

References 29 publications

The Efficacy of Non–Vitamin K Antagonist Oral Anticoagulants in the Prevention of Left Atrial Thrombus in Patients With Atrial Fibrillation Compared With Vitamin K Antagonists: A Meta-Analysis

The Efficacy of Non–Vitamin K Antagonist Oral Anticoagulants in the Prevention of Left Atrial Thrombus in Patients With Atrial Fibrillation Compared With Vitamin K Antagonists: A Meta-Analysis

Assessing intracardiac thrombus prior to cardioversion: A story yet to be told

Electrical cardioversion of atrial arrhythmias with cardiac amyloidosis in the era of direct oral anticogulants

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