Atrial thrombus detection on transoesophageal echocardiography in patients with atrial fibrillation undergoing cardioversion or catheter ablation: A pooled analysis of rates and predictors

Noubiap, Jean Jacques; Agbaedeng, T.; Ndoadoumgue, Aude Laetitia; Nyaga, Ulrich Flore; Kengne, André Pascal

doi:10.1111/jce.15082

Cited by 17 publications

(22 citation statements)

References 26 publications

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“…Similar to our study, in a recent meta-analysis of observational studies, the prevalence of LA thrombus in 9772 anticoagulated patients undergoing TEE before cardioversion or catheter ablation was 6.7%, with higher prevalence in patients on VKA (12% on VKA vs. 4.7% on NOAC) [ 8 ]. In meta-analyses of randomized controlled trials compared to VKA, NOACs were shown to reduce all-cause mortality, as well as the risk of stroke or systemic embolism; the latter driven mainly by a ~50% reduction in hemorrhagic stroke [ 9 ].…”

Section: Discussionsupporting

confidence: 89%

“…In terms of prevention of ischemic stroke, NOACs have demonstrated similar efficacy to VKA, with only a trend towards benefit with NOACs [ 10 ]. Lower relative efficacy of VKA in observational studies reporting on the prevalence of LA thrombus on TEE [ 8 , 11 ] could be explained by lower time in therapeutic range (TTR) in real-world patients [ 12 ] compared to TTR achieved in patients enrolled in clinical trials [ 13 ], and could imply even more benefit with NOACs compared to VKA in real-world AF population. Still, not every LA thrombus results in ischemic stroke and, thus, the higher prevalence of LA thrombus under VKA treatment might not necessarily translate into a higher risk of thromboembolic events.…”

Section: Discussionmentioning

confidence: 99%

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Left Atrial Thrombus in Atrial Fibrillation/Flutter Patients in Relation to Anticoagulation Strategy: LATTEE Registry

Kapłon‐Cieślicka

Gawałko

Budnik

et al. 2022

JCM

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Background: Atrial fibrillation (AF) and flutter (AFl) increase the risk of thromboembolism. The aim of the study was to assess the prevalence of left atrial thrombus (LAT) in AF/AFl in relation to oral anticoagulation (OAC). Methods: LATTEE (NCT03591627) was a multicenter, prospective, observational study enrolling consecutive patients with AF/AFl referred for transesophageal echocardiography before cardioversion or ablation. Results: Of 3109 patients enrolled, 88% were on chronic, 1.5% on transient OAC and 10% without OAC. Of patients on chronic OAC, 39% received rivaroxaban, 30% dabigatran, 14% apixaban and 18% vitamin K antagonists (VKA). Patients on apixaban were oldest, had the worst renal function and were highest in both bleeding and thromboembolic risk, and more often received reduced doses. Prevalence of LAT was 8.0% (7.3% on chronic OAC vs. 15% without OAC; p < 0.01). In patients on VKA, prevalence of LAT was doubled compared to patients on non-VKA-OACs (NOACs) (13% vs. 6.0%; p < 0.01), even after propensity score weighting (13% vs. 7.5%; p < 0.01). Prevalence of LAT in patients on apixaban was higher (9.8%) than in those on rivaroxaban (5.7%) and dabigatran (4.7%; p < 0.01 for both comparisons), however, not after propensity score weighting. Conclusions: The prevalence of LAT in AF is non-negligible even on chronic OAC. The risk of LAT seems higher on VKA compared to NOAC, and similar between different NOACs.

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Section: Discussionsupporting

confidence: 89%

Section: Discussionmentioning

confidence: 99%

Left Atrial Thrombus in Atrial Fibrillation/Flutter Patients in Relation to Anticoagulation Strategy: LATTEE Registry

Kapłon‐Cieślicka

Gawałko

Budnik

et al. 2022

JCM

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“…Schaefer et al [28] had a higher incidence of LAAT (9.6%), which may be related to the lack of anticoagulation. Te prevalence rate of sludge and SEC was 1.0% and 9.7% in patients undergoing catheter ablation according to the recent meta-analysis [27], and basically the same rate as ours. AF type, LAD, age, BNP, and E/e' ratio were independent risk factors for predicting LA or LAA thrombi in this study.…”

Section: Discussionsupporting

confidence: 86%

“…However, almost all patients included in our center were first-diagnosed AF patients, and the proportion of oral anticoagulants was deficient. Based on a recent meta-analysis of left atrial appendage thrombi [ 27 ], we screened out studies that did not give oral anticoagulants before TEE. The incidence of LAAT in the selected studies ranged from 0% to 9.6% ( Table S1 ), which is basically in line with our incidence of LAAT.…”

Section: Discussionmentioning

confidence: 99%

Construction of a Clinical Predictive Model of Left Atrial and Left Atrial Appendage Thrombi in Patients with Nonvalvular Atrial Fibrillation

Yin

Zheng

et al. 2022

Journal of Interventional Cardiology

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Background. The purpose of this study was to investigate the risk factors of left atrial (LA) or left atrial appendage (LAA) thrombi in patients with nonvalvular atrial fibrillation (NVAF) and to establish and validate relevant predictive models. It might improve thromboembolic risk stratification in patients with NVAF. Methods. This study retrospectively included 1210 consecutive patients with NVAF undergoing transesophageal echocardiography (TEE), of whom 139 patients had thrombi in LA or in LAA. Through literature review and the ten events per variable (10EPV) principle, 13 variables were finally identified for inclusion in multivariate analysis. Models were constructed by multivariate logistic stepwise regression and least absolute shrinkage and selection operator (lasso) regression. Results. After logistic regression, five variables (AF type, age, B-type natriuretic peptide, E/e’ ratio, and left atrial diameter) were finally screened out as model 1. After Lasso regression, AF type, age, gender, B-type natriuretic peptide, E/e’ ratio, left atrial diameter, and left ventricular ejection fraction were finally screened as model 2. After comparing the two models, the simpler model 1 was finally selected. The area under the ROC curve (AUC) of the model 1 was 0.865 (95% CI: 0.838–0.892), the Hosmer–Lemeshow test = 0.898, and the AUC = 0.861 after internal validation. The clinical decision curve showed that the new clinical prediction model could achieve a net clinical benefit when the expected threshold was between 0 and 0.6. Conclusion. This study constructed a new clinical prediction model of LA or LAA thrombi, with a higher discriminative degree than the CHADS2 and CHA2DS2-VASc scoring systems (AUC: 0.865 vs. 0.643; AUC: 0.865 vs 0.652).

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“…If early CV is desirable, current guidelines recommend transesophageal echocardiography to exclude intracardiac thrombi [ 2 ]. In a recent meta-analysis, the pooled prevalence of left atrial thrombus in patients who were not on oral anticoagulation but were undergoing CV or catheter ablation was 1.8%; and the prevalence was significantly higher among patients with non-paroxysmal AF [ 34 ]. The main shortcoming of transesophageal echocardiography is that it only detects the pre-existing thrombi in the left atrium or left atrial appendage, and it cannot protect from thromboembolic complications caused by thrombi that are formed later, during the stunning phase after CV.…”

Section: How To Minimize the Risk Of Thromboembolic Complications Aft...mentioning

confidence: 99%

How to Optimize Cardioversion of Atrial Fibrillation

Airaksinen

2022

JCM

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Cardioversion (CV) is an essential component of rhythm control strategy in the treatment of atrial fibrillation (AF). Timing of CV is an important manageable factor in optimizing the safety and efficacy of CV. Based on observational studies, the success rate of CV seems to be best (≈95%) at 12–48 h after the onset of arrhythmic symptoms compared with a lower success rate of ≈85% in later elective CV. Early AF recurrences are also less common after acute CV compared with later elective CV. CV causes a temporary increase in the risk of thromboembolic complications. Effective anticoagulation reduces this risk, especially during the first 2 weeks after successful CV. However, even during therapeutic anticoagulation, each elective CV increases the risk of stroke 4-fold (0.4% vs. 0.1%) during the first month after the procedure, compared with acute (<48 h) CV or avoiding CV. Spontaneous CVs are common during the early hours of AF. The short wait-and-see approach, up to 24–48 h, is a reasonable option for otherwise healthy but mildly symptomatic patients who are using therapeutic anticoagulation, since they are most likely to have spontaneous rhythm conversion and have no need for active CV. The probability of early treatment failure and antiarrhythmic treatment options should be evaluated before proceeding to CV to avoid the risks of futile CVs.

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Atrial thrombus detection on transoesophageal echocardiography in patients with atrial fibrillation undergoing cardioversion or catheter ablation: A pooled analysis of rates and predictors

Cited by 17 publications

References 26 publications

Left Atrial Thrombus in Atrial Fibrillation/Flutter Patients in Relation to Anticoagulation Strategy: LATTEE Registry

Left Atrial Thrombus in Atrial Fibrillation/Flutter Patients in Relation to Anticoagulation Strategy: LATTEE Registry

Construction of a Clinical Predictive Model of Left Atrial and Left Atrial Appendage Thrombi in Patients with Nonvalvular Atrial Fibrillation

How to Optimize Cardioversion of Atrial Fibrillation

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