Incidence of left atrial appendage thrombus despite 3 weeks of anticoagulation and the need for precardioversion echocardiography

Abstract

Background: One of the most catastrophic complications of Atrial fibrillation (AF) is thromboembolic stroke. Current guidelines recommend that 3 weeks of anticoagulation is adequate prior to direct current cardioversion (DCCV) to prevent thromboembolism. Here we present data regarding, which anticoagulant is most likely to show a presence of an Left atrial appendage thrombus (LAAT) on trans esophageal echocardiogram (TEE) for DCCV despite 3 weeks of anticoagulation.Objective: To investigate the effectiveness of both vitamin k antagonist (VKA) and direct oral anticoagulants (DOAC) in patients with AF as an anticoagulant for LAAT after 3 weeks of medication.Methods: This is a single-high volume tertiary center, where TEE precardioversion is the standard practice. We reviewed data over 10 months where DCCV was intended on individuals with AF who were fully anticoagulated for at least 3 weeks with either a VKA or taking a DOAC. Results:The data showed a statistical difference between patients who were fully anticoagulated for at least 3 weeks with VKA in comparison to DOACs. Patients on DOACs are significantly less likely to have an LAAT after at least 3 weeks of anticoagulation. OR = 0.04 (CI 95% 0.005-0.42; p-value < .05). Despite anticoagulation for at least 3 weeks, 40% of our patients still had a LAAT. Conclusion:Our data indicates that all patients should be required to undergo a TEE

Effectiveness of Transesophageal Echocardiography in Preventing Thromboembolic Complications Before Cardioversion: A Narrative Review

“…The formation of intracardiac thrombosis, mainly within the left ventricle and atrium, is influenced by Virchow’s triad factors (stasis, damage to the endothelial lining, and increased coagulation tendency). Various factors contribute to thrombus formation, such as AFib, irregularities in the heart’s inner lining, atrial enlargement due to valvular pathologies, and conditions following MI [ 13 ]. Conditions such as low cardiac output, unusual blood flow patterns in dilated heart chambers, and weakened heart contractions can promote intracardiac thrombus formation and subsequent thromboembolism [ 12 ].…”

“…A study from McGill University Health Center showed that a small proportion of patients had LAA thrombi on TEE with three weeks of anticoagulation, with patients on DOAC having fewer thrombus instances compared to those on warfarin [ 28 ]. Similarly, a retrospective study from 2022 found that almost half of patients still had LAA thrombi after three weeks of anticoagulation therapy [ 13 ]. This study reported a higher incidence of thromboembolic events in patients treated with warfarin, but approximately a fourth of the patients on DOAC had LAA thrombi as well [ 13 ].…”

“…Similarly, a retrospective study from 2022 found that almost half of patients still had LAA thrombi after three weeks of anticoagulation therapy [ 13 ]. This study reported a higher incidence of thromboembolic events in patients treated with warfarin, but approximately a fourth of the patients on DOAC had LAA thrombi as well [ 13 ].…”

Treatment of Persistent Left Atrial Appendage Thrombus in Patients with Atrial Fibrillation on Adequate Oral Anticoagulation: Pathways of Care for All-comers and Heart Failure Patients

“…10 A recent retrospective cohort study showed that, despite anticoagulation for the recommended 3 weeks before cardioversion, a significant proportion of patients (40%) were found to have LA/LAA thrombus (LAT), especially those on warfarin who had a much higher incidence of this finding compared with on NOACs. 11 In patients with nonvalvular AF, LAA thrombosis increases the risk of thromboembolic events. 12,13 Implications for long-term stroke and thromboembolism risks due to persistent LAT to long-term anticoagulation are poorly understood.…”