Incidence and predictors of left atrial appendage thrombus on transesophageal echocardiography before elective cardioversion

Wegner, Felix K.; Radke, Robert; Ellermann, Christian; Wolfes, Julian; Fischer, Alicia Jeanette; Baumgartner, Helmut; Eckardt, Lars; Diller, Gerhard‐Paul; Orwat, Stefan

doi:10.1038/s41598-022-07428-5

Cited by 7 publications

(4 citation statements)

References 10 publications

(7 reference statements)

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“…Both studies report relatively high rates of LAAT including dense SEC influencing treatment strategy (10% and 11.7%, respectively). 9 , 31 In the present study, age applied as a continuous or categorical covariate in regression analysis was not an independent predictor of LAAT.…”

Section: Discussioncontrasting

confidence: 58%

“… 9 , 30 A recent observational study described no association between increasing CHADS 2 VASc score and LAAT, with LAAT observed in individuals with low CHADS 2 VASc score. 31 …”

Section: Discussionmentioning

confidence: 99%

“…Moreover, age, sex, and hypertension have not consistently been demonstrated to independently predict LAAT risk despite the heightened association with stroke risk in the AF population. 31 , 33 Contemporary studies suggest that female sex should be considered as a risk modifier rather than an independent risk factor in the absence of accompanying thromboembolic risk factors for AF, leading to its removal from the score in some AF guidelines. 34 , 35 This may in part explain the lower predictive performance of the CHADS 2 VASc score for LAAT risk prediction in the present and prior LAAT studies.…”

Section: Discussionmentioning

confidence: 99%

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Identifying Patients at High Risk of Left Atrial Appendage Thrombus Before Cardioversion: The CLOTS‐AF Score

Segan

Nanayakkara

Spear

et al. 2023

JAHA

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Background Transesophageal echocardiography–guided direct cardioversion is recommended in patients who are inadequately anticoagulated due to perceived risk of left atrial appendage thrombus (LAAT); however, LAAT risk factors remain poorly defined. Methods and Results We evaluated clinical and transthoracic echocardiographic parameters to predict LAAT risk in consecutive patients with atrial fibrillation (AF)/atrial flutter undergoing transesophageal echocardiography before cardioversion between 2002 and 2022. Regression analysis identified predictors of LAAT, combined to create the novel CLOTS‐AF risk score (comprising clinical and echocardiographic LAAT predictors), which was developed in the derivation cohort (70%) and validated in the remaining 30%. A total of 1001 patients (mean age, 62±13 years; 25% women; left ventricular ejection fraction, 49.8±14%) underwent transesophageal echocardiography, with LAAT identified in 140 of 1001 patients (14%) and dense spontaneous echo contrast precluding cardioversion in a further 75 patients (7.5%). AF duration, AF rhythm, creatinine, stroke, diabetes, and echocardiographic parameters were univariate LAAT predictors; age, female sex, body mass index, anticoagulant type, and duration were not (all P >0.05). CHADS 2 VASc, though significant on univariate analysis ( P <0.001), was not significant after adjustment ( P =0.12). The novel CLOTS‐AF risk model comprised significant multivariable predictors categorized and weighted according to clinically relevant thresholds (Creatinine >1.5 mg/dL, Left ventricular ejection fraction <50%, Overload (left atrial volume index >34 mL/m 2 ), Tricuspid Annular Plane Systolic Excursion (TAPSE) <17 mm, Stroke, and AF rhythm). The unweighted risk model had excellent predictive performance with an area under the curve of 0.820 (95% CI, 0.752–0.887). The weighted CLOTS‐AF risk score maintained good predictive performance (AUC, 0.780) with an accuracy of 72%. Conclusions The incidence of LAAT or dense spontaneous echo contrast precluding cardioversion in patients with AF who are inadequately anticoagulated is 21%. Clinical and noninvasive echocardiographic parameters may identify patients at increased risk of LAAT better managed with a suitable period of anticoagulation before undertaking cardioversion.

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Section: Discussioncontrasting

confidence: 58%

“… 9 , 30 A recent observational study described no association between increasing CHADS 2 VASc score and LAAT, with LAAT observed in individuals with low CHADS 2 VASc score. 31 …”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Identifying Patients at High Risk of Left Atrial Appendage Thrombus Before Cardioversion: The CLOTS‐AF Score

Segan

Nanayakkara

Spear

et al. 2023

JAHA

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“…Recently, Wegner et al 24 were able to demonstrate an association of QRS width and the presence of LAA thrombus and reduced LAA flow in 512 patients receiving transoesophageal echocardiography before cardioversion. However, in this study, left ventricular ejection fraction differed between the group with normal LAA flow and LAA thrombus (55% vs. 35%).…”

Section: Discussionmentioning

confidence: 99%

P‐wave parameters and their association with thrombi and spontaneous echo contrast in the left atrial appendage

Kreimer

Backhaus

Krogias

et al. 2023

Clinical Cardiology

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Background The aim of this study was to examine the prevalence of abnormal P‐wave parameters in patients with thrombus and/or spontaneous echo contrast (SEC) in the left atrial appendage (LAA), and to identify P‐wave parameters particularly associated with thrombus and SEC formation. Hypothesis We presume a significant relationship of P‐wave parameters with thrombi and SEC. Methods All patients in whom a thrombus or SEC was detected in the LAA on transoesophageal echocardiography were included in this study. Patients at risk (CHA2DS2‐VASc Score ≥3) and routine transoesophageal echocardiography to exclude thrombi served as the control group. A detailed ECG analysis was performed. Results Of a total of 4062 transoesophageal echocardiographies, thrombi and SEC were detected in 302 patients (7.4%). Of these patients, 27 (8.9%) presented with sinus rhythm. The control group included 79 patients. There was no difference in mean CHA2DS2‐VASc score in the two groups (p = .182). A high prevalence of abnormal P‐wave parameters was detected in patients with thrombus/SEC. Indicators for the presence of thrombi or SEC in the LAA were P‐wave duration >118 ms (Odds ratio (OR) 3.418, Confidence interval (CI) 1.522–7.674, p < .001), P‐wave dispersion >40 ms (OR 2.521, CI 1.390–4.571, p < .001) and advanced interatrial block (OR 1.431, CI 1.033–1.984, p = .005). Conclusion Our study revealed that several P‐wave parameters are associated with thrombi and SEC in the LAA. The results may help identify patients who are at particularly high risk for thromboembolic events (e.g., in patients with embolic stroke of undetermined source).

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Incidence and predictors of left atrial thrombus in patients with atrial fibrillation under anticoagulation therapy

Lee,

Cha,

Nam

et al. 2024

Clin Res Cardiol

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Incidence and predictors of left atrial appendage thrombus on transesophageal echocardiography before elective cardioversion

Cited by 7 publications

References 10 publications

Identifying Patients at High Risk of Left Atrial Appendage Thrombus Before Cardioversion: The CLOTS‐AF Score

Identifying Patients at High Risk of Left Atrial Appendage Thrombus Before Cardioversion: The CLOTS‐AF Score

P‐wave parameters and their association with thrombi and spontaneous echo contrast in the left atrial appendage

Incidence and predictors of left atrial thrombus in patients with atrial fibrillation under anticoagulation therapy

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