Prevalence of left atrial thrombus by real time three‐dimensional echocardiography in patients undergoing electrical cardioversion of atrial fibrillation: A contemporary cohort study

Abstract

Background:The prevalence of left atrial thrombi in patients scheduled for electrical cardioversion (ECV) of atrial fibrillation (AF) remains unknown in contemporary real-life practice. Methods and Results:Patients scheduled for ECV underwent transesophageal echocardiography (TEE) regardless of AF duration and type of anticoagulant. Of 277 consecutive patients (65% men, mean age 71 ± 10 years, CHA 2 DS 2 -VASc 3.1 ± 1.4), 92 were on direct oral anticoagulants (DOACs) and 99 on antivitamin K (AVK) oral agents for at least 3 weeks before and 4 after ECV. Eighty-five patients with paroxysmal AF on low-molecular-weight heparin were also considered. Real time threedimensional TEE detected left atrial appendage (LAA) thrombus in 7% of patients, without significant difference among three groups (P = .334). Anticoagulation was ineffective in eight patients on AVK oral agents, two of them had thrombus. Eight patients assumed incorrectly DOACs, four of them had thrombus. Among the 175 patients on effective anticoagulation, five showed thrombus, three on AVK oral agents, and two on DOACs (P = .716). Effective anticoagulation was associated with reduced risk of thrombosis (OR: 0.16, 95%CI: 0.06-0.45, P = .001). In patients with correct anticoagulation, predictors of thrombus were CHA 2 DS 2 VASc (for each point of increment OR: 1.97, 95%CI: 1.08-3.61, P = .029), low left ventricular ejection fraction (OR: 0.92, 95%CI: 0.86-0.99, P = .026), and degree of spontaneous echo-contrast (for each point increase OR: 10, 95%CI: 2-39, P < .0001). Conclusion:Patients with AF, on effective anticoagulation, had a prevalence of thrombus not negligible regardless of type of anticoagulant. TEE is prudent before ECV and mandatory if unsuccessful anticoagulation is proved or suspected.

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

“…These studies were published between 2016 and 2022. Among the studies, four were conducted in Poland [ 27 , 29 , 30 , 33 ], two were conducted in Japan [ 25 , 32 ], two were conducted in the United States [ 24 , 28 ], and one was conducted each in the EU [ 26 ], Germany [ 31 ], Canada [ 21 ], Turkey [ 23 ], and Italy [ 22 ]. The selected studies were mostly conducted in Western countries, and only two were conducted in an Asian population (Japan).…”

“…The selected studies were mostly conducted in Western countries, and only two were conducted in an Asian population (Japan). Six studies were prospective [ 21 , 22 , 23 , 26 , 29 , 33 ], and seven were retrospective [ 24 , 25 , 27 , 28 , 30 , 31 , 32 ].…”

“…The studies included different parameters for predicting the risk of LAAT. A higher CHA2DS2-VASc score [ 22 , 23 , 25 , 33 ], reduced left ventricular ejection fraction [ 22 , 23 , 27 , 33 ], reduced left atrial flow velocity [ 23 , 25 , 30 , 32 ], reduced B-type natriuretic peptide, and larger left atrium [ 25 ] were associated with the risk of LAAT. The demographic predictors of the risk of LAAT included aging, a lower body weight, lower creatinine clearance, heart failure, and diuretic treatment were also listed.…”

Emergency department management of atrial fibrillation: 2023 consensus from the Spanish Society of Emergency Medicine (SEMES), the Spanish Society of Cardiology (SEC), and the Spanish Society of Thrombosis and Hemostasis (SETH)

“…Se debe anticoagular previamente al paciente durante un mínimo de 3 semanas y continuar con la anticoagulación durante un mínimo de 4 semanas después de la misma. La duración exacta de la anticoagulación antes y después de la cardioversión no se ha analizado en ensayos clínicos aleatorizados 77 , e incluso algunos estudios demuestran la persistencia de trombos o "efecto humo" en la orejuela a pesar del tratamiento anticoagulante 77,78 . El periodo de 3 semanas se ha establecido de forma arbitraria y se basa en el tiempo presumiblemente necesario para la endotelización o resolución de trombos preexistentes.…”

Current Status of Left Atrial Appendage Thrombus with Atrial Fibrillation

“…As previously mentioned, TEE is the gold standard for the diagnosis of LAAT. [33] The location and characteristics of LAAT under dynamic conditions can be visually assessed by TEE [Figure 1]. The diagnosis of LAAT by TEE is highly specific, but smaller thrombi can still be missed.…”