Disclosures: The authors and Sinning report no relevant financial disclosures. Kirchhof reports he received research support from several drug and device companies active in AF and is listed as inventor on two patents held by the University of Birmingham.
June 11, 2021
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TEE can detect left atrial thrombus in patients with AF undergoing procedures

Disclosures: The authors and Sinning report no relevant financial disclosures. Kirchhof reports he received research support from several drug and device companies active in AF and is listed as inventor on two patents held by the University of Birmingham.
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The prevalence of left atrial thrombus is high in certain anticoagulated patients with atrial fibrillation, which suggests a role for transesophageal echocardiogram imaging before procedures in that population, researchers reported.

Antony Lurie, BMSc, from the Population Health Research Institute in Hamilton, Ontario, Canada, and colleagues conducted a meta-analysis of data from 35 studies of 14,653 patients with AF or atrial flutter who underwent transesophageal echocardiogram (TEE) after at least 3 weeks of oral anticoagulation therapy to determine the prevalence of left atrial (LA) thrombus and assess risk in the population.

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In the meta-analysis population, the mean-weighted LA thrombus prevalence of 2.73% (95% CI, 1.95-3.8). Heterogeneity among studies was high (I2 = 91%).

According to the researchers, exclusion of studies of fewer than 150 patients modestly reduced the prevalence of LA thrombus to 2.4% (95% CI, 1.68-3.42; P = .048).

There was no difference in LA thrombus prevalence between patients treated with vitamin K antagonists and those treated with direct oral anticoagulants (vitamin K antagonist group, 2.8%; 95% CI, 1.86-4.21; direct oral anticoagulant group, 3.12%; 95% CI, 1.92-5.03; P = .674), according to the researchers.

LA thrombus prevalence was higher in patients with nonparoxysmal AF or atrial flutter compared with those with paroxysmal AF or atrial flutter (4.81%; 95% CI, 3.35-6.86; vs. 1.03%; 95% CI, 0.52-2.03; P < .001).

Patients who underwent cardioversion had greater prevalence of LA thrombus (5.55%; 95% CI, 3.15-9.58) compared with patients undergoing catheter ablation (1.65%; 95% CI, 1.07-2.53; P < .001), according to the researchers.

Lurie and colleagues found that patients with CHA2DS2-VASc scores of at least 3 had greater LA thrombus prevalence compared with patients who had scores of 2 or less (higher score, 6.31%; 95% CI, 3.72-10.49; lower score, 1.06%; 95% CI, 0.45-2.49; P < .001).

“The meta-analysis by Lurie et al now shows that LA appendage thrombi can be detected after a few weeks of oral anticoagulation, at least in patients with a clinical indication for a TEE. Their analysis also identifies factors related to the presence of LA appendage thrombus,” Paulus Kirchhof, MD, director of the department of cardiology, and Christoph Sinning, MD, head of the echocardiography lab, both at the University Heart and Vascular Center in Hamburg, Germany, wrote in an editorial. “Based on this new analysis of existing data, a risk-based use of TEE imaging in anticoagulated patients could enable further improvement in the safe delivery of rhythm control interventions in patients with AF.”

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Editor's Note: This article was updated on June 14, 2021 to fix a typo in the data. The Editors regret the error.