Left Atrial Appendage Thrombus Formation Despite Continuous Non-Vitamin K Antagonist Oral Anticoagulant Therapy in Atrial Fibrillation Patients Undergoing Electrical Cardioversion or Catheter Ablation: A Comparison of Dabigatran and Rivaroxaban

Abstract

Left atrial appendage thrombus (LAAT) may be detected by transesophageal echocardiography (TOE) in patients with atrial fibrillation (AF) despite continuous anticoagulation therapy. We examined the factors predisposing to LAAT in patients treated with the anticoagulants dabigatran and rivaroxaban. We retrospectively evaluated 1,256 AF patients from three centres who underwent TOE before electrical cardioversion (n = 611, 51.4%) or catheter ablation (n = 645, 48.6%) from January 2013 to December 2019 and had been on at least three weeks of continuous dabigatran (n = 603, 48%) or rivaroxaban (n = 653, 52%) therapy. Preprocedural TOE diagnosed LAAT in 51 patients (4.1%), including 30 patients (5%) treated with dabigatran and 21 patients (3.2%) treated with rivaroxaban (p=0.1145). In multivariate logistic regression, predictors of LAAT in patients treated with dabigatran were non-paroxysmal AF (vs. paroxysmal AF) (OR = 6.2, p=0.015), heart failure (OR = 3.22, p=0.003), and a eGFR <60 ml/min/1.73 m2 (OR = 2.65, p=0.012); the predictors in patients treated with rivaroxaban were non-paroxysmal AF (vs. paroxysmal AF) (OR = 5.73, p=0.0221) and heart failure (OR = 3.19, p=0.116). In ROC analysis of the dabigatran group, the area under the curve (AUC) for the CHA2DS2-VASc-RAF score was significantly higher (0.78) than those for the CHADS2, CHA2DS2-VASc, and R2CHADS2 scores (0.67, 0.70, and 0.72, respectively). In the rivaroxaban group, the CHA2DS2-VASc-RAF score also performed significantly better (AUC of 0.77) than the CHADS2, CHA2DS2-VASc, and R2CHADS2 scores (AUC of 0.66, 0.64, and 0.67, respectively). The risk of LAAT was the same for patients in both treatment groups. In all patients, non-paroxysmal AF or heart failure, and in patients treated with dabigatran an eGFR <60 ml/min/1.73 m2, were independent predictors of LAAT. The new CHA2DS2-VASc-RAF scale had the highest predictive value for LAAT in the entire study population.

Left atrial appendage thrombus in patients with atrial fibrillation who underwent oral anticoagulation

“…In comparison to the aforementioned studies, in our study, the incidence of LAA thrombus was slightly higher. It is worth noting that our study group had a higher incidence of comorbidities and known predictors of embolic complications, such as mean age (73.4 years), a higher mean CHA 2 DS 2 VASc score (3.83), and higher incidence of hypertension (89.4%), heart failure (33.1%), diabetes mellitus (37.5%), and vascular disease (26.9%), in comparison to previously published studies [ 12 – 14 , 16 , 18 , 19 ].…”

“…In a study by Frenkiel et al [ 16 ], thrombus was found in 5.4% of patients treated with dabigatran, 4.8% treated with rivaroxaban, and 0% treated with apixaban. Also, Gorczyca et al [ 18 ], showed that the incidence of LAA thrombus was comparable between dabigatran and rivaroxaban, at 5% and 3.2%, respectively.…”

Left atrial appendage thrombus in patients referred to electrical cardioversion for atrial fibrillation: a prospective single-center study

“…Gorczyca et al retrospectively evaluated 1,256 AF patients on dabigatran or rivaroxaban and revealed a 4.1% TEE thrombus detection rate prior to DCC or catheter ablation, regardless of the anticoagulant agent used. However, the significant LAAT predictors in patients treated with dabigatran were non-paroxysmal AF (vs. paroxysmal AF), heart failure, and an eGFR <60 ml/min/1.73 m 2 ; the predictors in patients treated with rivaroxaban were non-paroxysmal AF (vs. paroxysmal AF) and heart failure [33]. Jaroch et al retrospectively evaluated 202 patients with persistent AF who underwent TEE before electrical cardioversion and revealed presence of LAAT/sludge in 31 and a spontaneous echo contrast in 25 subjects.…”

Czy wynik CHA2DS2-VASc determinuje leczenie przeciwzakrzepowe u pacjentów z migotaniem przedsionków? Dane z POLish Atrial Fibrillation (POL-AF) Registry?

“…Interestingly, in the presented study, AF type or impaired kidney function were not shown to be the predictors of OAC use in patients at low thromboembolic risk. It has been reported that the aforementioned factors increase the risk of thromboembolic complications in patients with AF or predispose them to thrombus formation in the left atrial appendage [8][9][10][11][12][13][14][15][16][17][18][19][20]. Study results connected with anticoagulant overtreatment of patients with AF prove that it is common and most likely stems from using OACs due to temporary indications to anticoagulant therapy and from the presence of thromboembolic risk factors not included in the CHA 2 DS 2 -VASc score.…”