Left Atrial Appendage Thrombosis and Oral Anticoagulants: A Meta-Analysis of Risk and Treatment Response

Abstract

Background: Left atrial appendage thrombus (LAAT) is the main cause of cardioembolism in patients with nonvalvular atrial fibrillation (AF). Emerging evidence indicates that direct oral anticoagulants (DOACs) may be a preferred, safer choice for patients with LAAT. However, current guidelines indicate vitamin K antagonist (VKA) as the preferred treatment for LAAT. We conducted a meta-analysis to compare the efficacy of VKA and DOAC for the treatment of LAAT. Methods: The search was conducted in the PubMed, Embase, Google Scholar, and Cochrane Library databases from inception to July 2022, with the language restricted to English. A first analysis was conducted to evaluate the risk of LAAT under VKA or DOAC treatment. A second analysis was conducted to compare the resolution of LAAT under VKA and DOAC treatment. Results: In 13 studies comparing LAAT incidence rates under VKA and DOAC treatment, significant superiority of DOAC was detected (pooled RR = 0.65, 95% CI = 0.47–0.90, p = 0.009) with moderate heterogeneity being identified in the pooled studies. In 13 studies comparing LAAT resolution under VKA and DOAC use, treatment with DOAC exhibited a significantly increased probability of LAAT resolution compared with VKA (pooled odds ratio = 1.52, 95% CI = 1.02–2.26, p = 0.040). Conclusions: This meta-analysis suggests a superiority of DOAC over VKA with respect to LAAT incidence in people with AF and the likelihood of LAAT resolution. Due to their established safety profile, DOAC is a preferable choice for anticoagulation, although further randomized controlled studies are warranted to provide further evidence of their suitability as a new recommended treatment.

Complications of a Giant Left Atrium - Extensive Thrombus Formation Despite Therapeutic Anticoagulation

“…An enlarged left atrium also predisposes patients to thrombus formation. While there have been multiple definitions of a giant left atrium, recent reports have followed the definition that a giant left atrium consists of a left atrial size greater than 65 mm by M-mode on echocardiography along with a left ventricular posterobasal wall bent inward and lying between the DOACs of achieving left atrial appendage thrombus resolution compared to warfarin [15], however, this would not be able to apply to patients with valvular atrial fibrillation of with mechanical valves. Some have also suggested switching to unfractionated heparin or low molecular weight heparin or adding aspirin [16].…”

A case report of a giant coronary artery aneurysm masquerading as a ventricular mass

“…Current literature suggests that direct oral anticoagulants are the safest choice in treating an LAA thrombus and should be continued for at least 4–6 months with re-evaluation. 7 , 8 He continued to demonstrate this clot on follow-up TEEs and thus was continued on apixaban in the long term.…”

New Perspectives on Risk Stratification and Treatment in Patients with Atrial Fibrillation: An Analysis of Recent Contributions on the Journal of Cardiovascular Disease and Development

“…In these years, many efforts have been made to consolidate the evidence regarding traditional pharmacological and non-pharmacological treatments in AF patients, including non-vitamin K antagonists (NOACs), LA appendage occlusion (LAAO), catheter ablation and promising treatments, such as sodium–glucose co-transporter (SGLT) inhibitors [ 38 , 39 ].…”