Difference in the prevalence of intracardiac thrombus on the first presentation of atrial fibrillation versus flutter in the pediatric and congenital heart disease population

Abstract

Introduction: Guidelines recommend trans-esophageal echocardiography (TEE) for patients with atrial fibrillation (AF) or atrial flutter (AFL) for >48 h, due to risk of intracardiac thrombus formation. With growing evidence that AFL in adults with structurally normal hearts has less thrombogenic potential compared to AF, and the need for TEE questioned, we compared prevalence of intracardiac thrombus detected by TEE in pediatric and congenital heart disease (CHD) patients presenting in AF and AFL. Methods/Results: Single-center, cross-sectional analysis for unique first-time presentations of patients for either AF, AFL, or intra-atrial reentrant tachycardia (IART) between 2000 and 2019. Patients were categorized by presenting arrhythmia (AF vs. AFL/IART), with the exclusion of other forms of atrial tachycardia, hemodynamic instability, chronic anti-coagulation before TEE, and presentation for a reason other than TEE examination for thrombus. A total of 201 patients had TEE with co-diagnosis of AF or AFL. Of these, 105 patients (29 AF, 76 AFL) met inclusion criteria, with no difference in age between AF (median 24.9 years; IQR 18.6-38.3 years) and AFL/IART (23.3 years; 15.4-38.4 years). The prevalence of thrombus in the entire cohort was 9.5%, with no difference between AF (13.8%) and AFL groups (7.9%), p = .46. Patients with thrombus demonstrated no difference in age, systemic ventricular function, cardiac complexity, or CHADS2/CHA2DS2VASc score at presentation. Conclusions: The risk for intracardiac thrombus is high in the pediatric and CHD population, with no apparent distinguishing factors to warrant a change in the recommendations for TEE, with all levels of cardiac complexity being at risk for clot.

A gray zone: Role of transesophageal echocardiography before atrial tachycardia catheter ablation

“…Atrial tachycardia is electromechanically different from AF, and differences in atrial contraction likely carry significantly different thromboembolic risks. 22 In a study investigating LAA thrombus, SEC was detected in low-risk patients with younger age and low CHA 2 DS 2 -VASc scores and LAVI values who did not take anticoagulants and had AFL, while no thrombus was detected in any of them. 23 In contrast, in our study, when examining patients with thrombus, it was observed that the AT type was predominantly sustained, more common in females, mostly occurring in individuals aged 65 and above, with high CHA 2 DS 2 -VASc scores and elevated LAVIs.…”

“…Clinicians are more concerned with the risk of thrombus presence in the LA/LAA before radiofrequency ablation to determine the need for preprocedural anticoagulation and TEE in patients with AT, rather than whether these patients need anticoagulant therapy. Atrial tachycardia is electromechanically different from AF, and differences in atrial contraction likely carry significantly different thromboembolic risks 22 . In a study investigating LAA thrombus, SEC was detected in low‐risk patients with younger age and low CHA 2 DS 2 ‐VASc scores and LAVI values who did not take anticoagulants and had AFL, while no thrombus was detected in any of them 23 .…”

Congenital Complete Heart Block Complicated by Atrial flutter Diagnosis and Management

“…In general, treatment may involve medications, cardiac pacing, cardioversion, radio-frequency catheter ablation, or surgical procedures. The guidelines recommend trans-esophageal echocardiography (TEE) for patients with atrial fibrillation (AF) or atrial flutter (AFL) for >48 h, due to the risk of intracardiac thrombus formation [ 8 ].…”