Prevalence of extra-appendage thrombosis in non-valvular atrial fibrillation and atrial flutter in patients undergoing cardioversion: a large transoesophageal echo study

Abstract

Aims:The aim of our study was to evaluate the prevalence of left atrial cavity and appendage thrombosis in patients undergoing cardioversion for non-valvular atrial tachyarrhythmias. In persistent atrial tachyarrhythmias, 90% of thromboses are reported to be located inside the left atrial appendage. This prevalence refers to old studies and meta-analysis in a mixed population of valvular and non-valvular atrial fibrillation. Left atrial cavity thrombosis in non-valvular atrial fibrillation has not been investigated recently in largescale studies.Methods and results: A total of 1,420 consecutive adult patients with paroxysmal or persistent atrial tachyarrhythmias, candidates to cardioversion, who opted for a transoesophageal echocardiography-guided strategy, were enrolled in the study. Mitral stenosis, rheumatic valve disease and mechanical prostheses were excluded. In total there were 91 thrombi in 87 patients with a prevalence of 6.13% (87/1,420). Patients with left atrial thrombosis had predisposing clinical and echo characteristics (heart failure, lower ventricular function and higher atrial volume). Except for one case in which the thrombus was located in the left atrial cavity (0.07%), and three in the right appendage, all thromboses were detected in the left atrial appendage.Conclusions: Extra-appendage thrombosis is a very rare finding in non-valvular persistent and paroxysmal atrial tachyarrhythmias and, when present, a left appendage thrombus is usually concomitant.

The predictive value of a concise classification of left atrial appendage morphology to thrombosis in non‐valvular atrial fibrillation patients

“…9 The recommended level of AF catheter ablation is I, IIA, or IIB. 4 Age and gender are not limited. Transesophageal echocardiography (TEE) and left atrial enhanced computed tomography angiography (CTA) were performed in all patients.…”

“…2 More than 90% of ischemic stroke thrombus in patients with non-valvular atrial fibrillation (NVAF) was derived from the left atrial appendage (LAA). 3,4 Due to the special anatomical structure and functional characteristics of LAA, the thrombus is easy to form in the AF state. The complexity of LAA in patients with AF is closely related to LAA thrombosis and stroke incidence.…”

‘Will the king ever be dethroned?’ The relationship and the future of oral anticoagulation therapy versus LAA closure devices

“…Since most but not all thrombi form in the left atrial appendage [11,12], LAAO may not protect against thromboembolic stroke's overall risk related to atrial cardiomyopathy. Another critical point is that in LAAO patients, the postprocedure therapy provides one or two antiplatelet agents, stopping OAT [13].…”

Off-label device closure of residual shunt after surgical ligation of the left atrial appendage

“…Is known to be the main thromboembolic source, responsible for more than 90% of left atrial (LA) thrombus in non-valvular AF. 1,2 This knowledge led to consider LAA exclusion for thromboembolic prophylaxis, initially performed by surgery in 1949, widely adopted during valvar surgery in 1990's. 1 Although becoming a promising method for prophylaxis of thromboembolic accidents, residual flow after surgical LAA ligation limits its therapeutic efficacy.…”