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

Reers, Stefan; Karanatsios, Georg; Borowski, Matthias; Kellner, Michael A; Reppel, Michael; Waltenberger, Johannes

doi:10.1186/s40001-018-0350-9

Cited by 20 publications

(34 citation statements)

References 44 publications

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“…A left atrial thrombus may be found in 4% to 5% of patients with AF despite the treatment with VKA or DOACS, and the best clinical practice in this scenario is ill‐defined. In the lack of definitive data, the usual treatment of LAAT is a continued or intensified OAC.…”

Section: Discussionmentioning

confidence: 99%

“…1,2 However, there are patients that present with thrombus formation in the LAA despite therapeutic anticoagulation. 3 Left atrial appendage closure (LAAC) was demonstrated to be an alternative to OAC in selected patients. 4 The presence of an LAA thrombus (LAAT) is however considered a contraindication to LAAC, therefore these patients were excluded from all major trials on LAAC.…”

Section: Introductionmentioning

confidence: 99%

“…Atrial fibrillation (AF) is associated with an increased incidence of stroke and oral anticoagulation (OAC) based on stroke risk scores is considered first‐line therapy . However, there are patients that present with thrombus formation in the LAA despite therapeutic anticoagulation . Left atrial appendage closure (LAAC) was demonstrated to be an alternative to OAC in selected patients .…”

Section: Introductionmentioning

confidence: 99%

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Percutaneous left atrial appendage closure in the presence of thrombus: A feasibility report

Bordignon

Bologna

Chen

et al. 2019

Cardiovasc electrophysiol

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Background Patients with a left atrial appendage thrombus (LAAT) despite oral anticoagulation (OAC) are at high risk of thromboembolism (TE) and a relevant proportion of LAAT do not resolve under continued OAC. Left atrial appendage closure (LAAC) in the presence of LAAT was anecdotally described as a therapeutic option to prevent TE in the patients. Objective To describe the feasibility of LAAC despite LAAT in consecutive patients. Methods We searched the LAAC database of our center to identify patients in whom a LAAC was performed despite evidence of a thrombus in the LAA. All procedures were performed under transesophageal echocardiography guidance, no angiographies were performed to avoid LAAT dislocation. An Amulet Occluder device was preferred to allow proximal implantation and sealing of the LAA. Results Nine patients were identified. The mean age was 68.1 ± 10.7 years, four were female, mean CHADSVASC and HASBLED were 3.6 ± 1.7 and 3.0 ± 1.0. Eight of nine patients were on OAC, one patient was under lone aspirin therapy because of bleeding. The mean distance between the LAAT and the estimated landing zone was 18 ± 6 mm, the minimal distance was 11 mm. The mean landing zone was 21 ± 3 mm, devices with a mean size of 25 ± 4 mm were chosen for implantation. All implantation succeeded, only two patients required an intraprocedural replacement. No procedural complication nor short term thromboembolic complication during a follow up of 138 ± 149 days were recorded. Conclusion In the presented series a percutaneous LAAC despite a LAAT resulted to be feasible and safe.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Percutaneous left atrial appendage closure in the presence of thrombus: A feasibility report

Bordignon

Bologna

Chen

et al. 2019

Cardiovasc electrophysiol

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“…In our study, 26% of patients constituted those from the study of Gawalko et al [ 18 ]. A meta-analysis by Reers et al [ 6 ] showed that the approximately 5% rate of LAAT formation is considerably higher than the average stroke rate of <1%. This suggests that not all thrombi present during or after electrical cardioversion cause a cerebral thromboembolic event.…”

Section: Discussionmentioning

confidence: 99%

“…Some patients had LAAT despite optimal anticoagulation therapy, but this did not necessarily explain the development of thromboembolism in AF patients. Many studies show that the frequency of LAAT in patients with AF varies depending on type and duration of anticoagulation therapy, type of AF, echocardiographic parameters, and concomitant diseases [ 6 – 9 ].…”

Section: Introductionmentioning

confidence: 99%

Left Atrial Appendage Thrombus Formation Despite Continuous Non-Vitamin K Antagonist Oral Anticoagulant Therapy in Atrial Fibrillation Patients Undergoing Electrical Cardioversion or Catheter Ablation: A Comparison of Dabigatran and Rivaroxaban

Gorczyca

Chrapek

Jelonek

et al. 2020

Cardiology Research and Practice

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Left atrial appendage thrombus (LAAT) may be detected by transesophageal echocardiography (TOE) in patients with atrial fibrillation (AF) despite continuous anticoagulation therapy. We examined the factors predisposing to LAAT in patients treated with the anticoagulants dabigatran and rivaroxaban. We retrospectively evaluated 1,256 AF patients from three centres who underwent TOE before electrical cardioversion (n = 611, 51.4%) or catheter ablation (n = 645, 48.6%) from January 2013 to December 2019 and had been on at least three weeks of continuous dabigatran (n = 603, 48%) or rivaroxaban (n = 653, 52%) therapy. Preprocedural TOE diagnosed LAAT in 51 patients (4.1%), including 30 patients (5%) treated with dabigatran and 21 patients (3.2%) treated with rivaroxaban (p=0.1145). In multivariate logistic regression, predictors of LAAT in patients treated with dabigatran were non-paroxysmal AF (vs. paroxysmal AF) (OR = 6.2, p=0.015), heart failure (OR = 3.22, p=0.003), and a eGFR <60 ml/min/1.73 m2 (OR = 2.65, p=0.012); the predictors in patients treated with rivaroxaban were non-paroxysmal AF (vs. paroxysmal AF) (OR = 5.73, p=0.0221) and heart failure (OR = 3.19, p=0.116). In ROC analysis of the dabigatran group, the area under the curve (AUC) for the CHA2DS2-VASc-RAF score was significantly higher (0.78) than those for the CHADS2, CHA2DS2-VASc, and R2CHADS2 scores (0.67, 0.70, and 0.72, respectively). In the rivaroxaban group, the CHA2DS2-VASc-RAF score also performed significantly better (AUC of 0.77) than the CHADS2, CHA2DS2-VASc, and R2CHADS2 scores (AUC of 0.66, 0.64, and 0.67, respectively). The risk of LAAT was the same for patients in both treatment groups. In all patients, non-paroxysmal AF or heart failure, and in patients treated with dabigatran an eGFR <60 ml/min/1.73 m2, were independent predictors of LAAT. The new CHA2DS2-VASc-RAF scale had the highest predictive value for LAAT in the entire study population.

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

Shiraki

Tanaka

Yamauchi

et al. 2022

Int J Cardiovasc Imaging

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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. Methods: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.Results: 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/m 2 ) was extremely rare (0.4%). LAA thrombus formation in patients with a mildly dilated LA volume index of 34-49.9 mL/m 2 and paroxysmal AF was also extremely rare (0.0%). Conclusion: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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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

Cited by 20 publications

References 44 publications

Percutaneous left atrial appendage closure in the presence of thrombus: A feasibility report

Percutaneous left atrial appendage closure in the presence of thrombus: A feasibility report

Left Atrial Appendage Thrombus Formation Despite Continuous Non-Vitamin K Antagonist Oral Anticoagulant Therapy in Atrial Fibrillation Patients Undergoing Electrical Cardioversion or Catheter Ablation: A Comparison of Dabigatran and Rivaroxaban

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

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