Intracardiac Thrombosis and Anticoagulation Therapy in Cardiac Amyloidosis

Abstract

Background-Primary amyloidosis has a poor prognosis as a result of frequent cardiac involvement. We recently reported a high prevalence of intracardiac thrombus in cardiac amyloid patients at autopsy. However, neither the prevalence nor the effect of anticoagulation on intracardiac thrombus has been evaluated antemortem. Methods and Results-We studied all transthoracic and transesophageal echocardiograms of cardiac amyloid patients at the Mayo Clinic. The prevalence of intracardiac thrombosis, clinical and transthoracic/transesophageal echocardiographic risks for intracardiac thrombosis, and effect of anticoagulation were investigated. We identified 156 patients with cardiac amyloidosis who underwent transesophageal echocardiograms. Amyloidosis was the primary type (AL) in 80; other types occurred in 76 patients, including 56 with the wild transthyretin type, 17 with the mutant transthyretin type, and 3 with the secondary type. Fifth-eight intracardiac thrombi were identified in 42 patients (27%). AL amyloid had more frequent intracardiac thrombus than the other types (35% versus 18%; Pϭ0.02), although the AL patients were younger and had less atrial fibrillation. Multivariate analysis showed that atrial fibrillation, poor left ventricular diastolic function, and lower left atrial appendage emptying velocity were independently associated with increased risk for intracardiac thrombosis, whereas anticoagulation was associated with a significantly decreased risk (odds ratio, 0.09; 95% CI, 0.01 to 0.51; PϽ0.006). Conclusions-Intracardiac thrombosis occurs frequently in cardiac amyloid patients, especially in the AL type and in those with atrial fibrillation. Risk for thrombosis increased if left ventricular diastolic dysfunction and atrial mechanical dysfunction were present. Anticoagulation therapy appears protective. Timely screening in high-risk patients may allow early detection of intracardiac thrombus. Anticoagulation should be carefully considered. (Circulation.

Transesophageal Echocardiography for Thrombus Screening Prior to Left Atrial Catheter Ablation

“…16, 17 Feng et al reported that AF, poor left ventricular diastolic function were independently associated with increased risk for intracardiac thrombosis in patients with amyloidosis. 16 However, we focused on the possibility that E/E', representative parameter of diastolic function, might be one of the predictors of LA thrombus prior to LA ablation, our study revealed that E/E' could not predict LA thrombus in this population.…”

Effect of Combined Systolic and Diastolic Functional Parameter Assessment for Differentiation of Cardiac Amyloidosis From Other Causes of Concentric Left Ventricular Hypertrophy

“…No intracardiac thrombus formation was detected in patients with CA, although autopsy and in vivo transesophageal echocardiogram studies suggest a prevalence rate between 15% and 30%. 34,35 Because the systematic search for thrombotic disease was outside the focus of this investigation, the reason for this discrepancy may be related to the low specificity of transesophageal echocardiogram in detecting intracardiac thrombus.…”

Treatment of End Stage Heart Failure Related to Cardiac Amyloidosis

“…In AL amyloid nephrotic syndrome can also contribute to hypercoagulopathy and thrombus formation. Although debated, these risks may warrant a relatively liberal use of anticoagulation as discussed below [39]- [41] [42].…”

“…Transesophageal echocardiography may help to identify patients in sinus rhythm with higher risk for thrombosis such as those with spontaneous echo contrast or low left atrial appendage velocities. A cutoff of <40cm/ sec was initially suggested [109] but this may be considerably lower (reported as 13±5cm/sec for patients with and 27±15cm/sec for patients without thrombosis) [41].…”