Clin Res Cardiol (2021)
DOI DOI https://doi.org/10.1007/s00392-021-01843-w
Incidence of left atrial appendage thrombus on TEE before electrical cardioversion in a contemporary cohort
F. K. Wegner1, C. Ellermann1, J. Wolfes1, A. Fischer2, S. Orwat2, H. Baumgartner2, L. Eckardt1, G. P. Diller2
1Klinik für Kardiologie II - Rhythmologie, Universitätsklinikum Münster, Münster; 2Klinik für Kardiologie III: Angeborene (EMAH) und Herzklappenfehler, Universitätsklinikum Münster, Münster;

Introduction: Guidelines recommend transesophageal echocardiography (TEE) before cardioversion in thrombogenic arrhythmias when the requirement of ≥ 3 weeks of uninterrupted effective anticoagulation is not met. Current data to support this approach, especially with direct oral anticoagulants (DOAC), are scarce.

Methods: We analyzed consecutive elective pre-cardioversion TEE in a high-volume electrophysiology center for the occurrence of LAA thrombi or a relevant flow reduction in the LAA defined as LAA sludge or pronounced spontaneous echo contrast. Possible predictors were recorded and compared in a multivariate logistic regression analysis.

Results: 512 consecutive pre-cardioversion TEE in 507 patients were included. In all patients, indication for TEE was either intake of anticoagulation <3 weeks before cardioversion or uncertain adherence to the prescribed anticoagulation regimen. Baseline characteristics of the patient population are shown in the table. Of the 512 TEE, 19 (3.7%) depicted a LAA thrombus. An additional 41 patients (8%) showed a marked reduction in LAA flow velocity defined as sludge or pronounced spontaneous echo contrast. While a high CHA2DS2-VaSc-Score was associated with a higher likelihood of the composite endpoint of LAA thrombus and reduced LAA flow (p=0.01), no other clinical parameters were independently predictive in a multivariate logistic regression analysis (see table). Noteworthy, LAA thrombi were even found in patients with a CHA2DS2-VaSc-Score of 0 (n=1) or 1 (n=1). In our patient collective, there was no statistically significant difference in the occurrence of LAA thrombi between DOAC and Phenprocoumon.

Conclusion: The presence of LAA thrombus before an elective cardioversion is a rare event in the age of direct oral anticoagulants. While the CHA2DS2-VaSc-Score may identify patients with a higher likelihood of reduced LAA flow velocity, LAA thrombi occur even in supposed low-risk individuals. DOAC intake as compared to phenprocoumon was not significantly associated with a lower likelihood of an LAA thrombus.

 

 

Normal LAA flow

(n=452)

 

 

Reduced LAA flow

(n=41)

 

LAA thrombus

(n=19)

 

 

p-value

Gender (m/f)

321 (71%) / 131 (29%)

30 (73%) /

11 (27%)

13 (68%) /

6 (32%)

0.40

Age in years

67 ± 13

72 ± 13

69 ± 11

0.55

BMI in kg/m2

28 ± 6

27 ± 10

27 ± 6

0.31

Underlying rhythm

·         Atrial fibrillation

·         Atrial flutter

 

406 (90%)

46 (10%)

 

38 (93%)

3 (7%)

 

18 (95%)

1 (5%)

 

0.99

0.97

CHA2DS2-VaSc-Score

2.7 ± 1.7

3.0 ± 1.5

3.0 ± 1.9

0.01

EHRA-Score

2.1 ± 0.8

2.0 ± 0.9

1.5 ± 0.7

0.65

Coronary heart disease

75 (17%)

9 (22%)

1 (5%)

0.99

Diabetes

74 (16%)

7 (17%)

3 (16%)

0.59

Hypertension

267 (59%)

22 (54%)

11 (58%)

0.24

Previous stroke

15 (3%)

2 (5%)

2 (11%)

0.71

Peripheral artery disease

24 (5%)

4 (10%)

2 (11%)

0.37

Anticoagulation on admission

·         DOAC

·         Phenprocoumon

·         LMWH

·         ASS

·         None

  

259 (57%)

119 (26%)

1 (<1%)

14 (3%)

59 (13%)

 

24 (59%)

12 (29%)

0

1 (2%)

4 (10%)

  

9 (47%)

7 (37%)

1 (5%)

1 (5%)

1 (5%)

  

0.85

0.88

0.99

0.99

0.99

 

Table: Comparison between pre-cardioversion patients with normal LAA flow, patients with significantly reduced flow and patients with a LAA thrombus. Statistical significance was calculated between the group with normal flow and a combination of the other two groups (n=60) in a multivariate logistic regression analysis. LMWH= low molecular weight heparin
https://dgk.org/kongress_programme/jt2021/aP61.html