Predictors of spontaneous echo contrast and left atrial appendage thrombosis in nonvalvular atrial fibrillation

Aim. To identify predictors of spontaneous echo contrast (SEC) and/or left atrial appendage (LAA) thrombosis in patients with nonvalvular atrial fibrillation (AF) who are referred for elective cardioversion or catheter ablation (CA).

Material and methods. A retrospective analysis of data from 638 patients with nonvalvular AF who were hospitalized from 2014 to 2017 for cardioversion or CA was performed. All patients underwent diagnostic tests, including transthoracic and transesophageal echocardiography (TEE).

Results. According to the TEE results, two groups of patients were formed: group 1 — 95 patients (14,9%) with signs of SEC and/or thrombosis in LAA; group 2 — 543 patients (85,1%) without SEC or thrombosis in LAA. Patients with the phenomenon of SEC and/or LAA thrombosis were older, had a higher risk on the CHA2DS2-VASc score. These patients were more likely to have coronary heart disease (CAD), hypertension, stage IIA chronic heart failure, obese class >II, persistent or permanent AF Patients in both groups did not differ in anticoagulant therapy. Patients in group 1 had a larger size of the left and right atria, right ventricle, left ventricular (LV) end-systolic and end-diastolic diameters, higher LV mass index, lower values of LV ejection fraction and blood flow velocity in LAA. Logistic regression revealed following independent predictors of SEC and/or LAA thrombosis: CAD (odds ratio (OR) 2,289; 95% confidence interval (CI) 1,313-3,990; p=0,003), persistent or permanent AF (OR 2,071; 95% CI 1,222-3,510; p=0,007), LA diameter >43 mm (OR 3,569; 95% CI 2,0822-6,117; p<0,001), concentric or eccentric LV hypertrophy (OR 2,230; 95% CI 1,302-3,819; p=0,003).

Conclusion. As the result, all patients referring for CA or cardioversion, regardless of the CHA2DS2-VASc score, should underwent LAA. According to this study, the presence of CAD, persistent or permanent AF, LA diameter >43 mm, concentric or eccentric LV hypertrophy are independent predictors of SEC and/or LAA thrombosis.

1. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37:2893-962. doi:10.1093/eurheartj/ehw210.

2. Posada-Martinez E, Trejo-Paredes C, Ortiz-Leon XA, et al. Differentiating spontaneous echo contrast, sludge, and thrombus in the left atrial appendage: can ultrasound enhancing agents help? Echocardiography. 2019;36(7):1413-7 doi:10.1111/echo.14405.

3. Zabalgoitia М, Halperin JL, Pearce LA, et al. Transesophageal echocardiographic correlates of clinical risk of thromboembolism in nonvalvular atrial fibrillation. J am coll cardiol. 1998;31:1622-6. doi:10.1016/s0735-1097(98)00146-6.

4. Calkins H, Hindricks G, Cappato R, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm. 2017;14(10):e275-444. doi:10.1016/j.hrthm.2017.05.012.

5. Jia F, Tian Y, Lei S, et al. Incidence and predictors of left atrial thrombus in patients with atrial fibrillation prior to ablation in the real world of China. Indian Pacing and Electrophysiol J. 2019;19(4):134-9. doi:10.1016/j.ipej.2019.01.005.

6. Ganau A, Devereux RB, Roman MJ, et al. Patterns of left ventricular hypertrophy and geometric remodeling in essential hypertension. Journal of the American College of Cardiology. 1992;19(7):1550-58. doi:10.1016/0735-1097(92)90617-V.

7. Huang J, Wu SL, Xue YM, et al. Association of CHADS2 and CHA2DS2-VASc scores with left atrial thrombus with nonvalvular atrial fibrillation: a single center based retrospective study in a cohort of 2695 Chinese subjects. Biomed Res Int. 2017;2017:6839589. doi:10.1155/2017/6839589.

8. Golukhova EZ, Gromova OI, Arakelyan MG, et al. Risk factors of left atrial thrombus and/ or thromboembolism in patients with nonvalvular, nonishemic atrial fibrillation. Creative Cardiology. 2017;11(3):262-72. (In Russ.) doi:10.24022/1997-3187-2017-11-3-262-272.

9. Kishima H, Mine T, Fukuhara E, et al. Predictors of left atrial thrombi and spontaneous echocardiographic contrast in the acute phase after cardioembolic stroke in patients with atrial fibrillation. Journal of Stroke and Cerebrovascular Diseases. 2019;28(6):1571-7. doi:10.1016/j.jstrokecerebrovasdis.2019.03.003.

10. Staerk L, Sherer JA, Ko D, et al. Atrial fibrillation epidemiology, pathophysiology, and clinical outcomes. Circ Res. 2017;120(9):1501-17 doi:10.1161/CIRCRESAHA.117.309732.

11. Karnialiuk IU, Rabtsevich VA, Karnialiuk AM. Echocardiography predictors of the left atrial appendage thrombus in patients with persistent atrial fibrillation. Annals of Arrhithmology. 2014;11(3): 170-6. (In Russ.) doi:10.15275/annaritmol.2014.3.5.

12. Apostolakis S, Sullivan RM, Olshansky B, Lip GY. Left ventricular geometry and outcomes in patients with atrial fibrillation: the AFFIRM Trial. Int J Cardiol. 2014;170(3):303-8. doi:10.1016/j.ijcard.2013.11.002.

13. Seko Y, Kato T, Haruna T, et al. Association between atrial fibrillation, atrial enlargement, and left ventricular geometric remodeling. Scientific reports. 2018;8(1):6366. doi:10.1038/s41598-018-24875-1.

14. Doukky R, Garcia-Sayan E, Gage H, et al. The value of diastolic function parameters in the prediction of left atrial appendage thrombus in patients with nonvalvular atrial fibrillation. Cardiovascular Ultrasound. 2014;12:10. doi:10.1186/1476-7120-12-10.

15. Dushina AG, Lopina EA, Libis RA. Features of chronic heart failure depending on the left ventricular ejection fraction. Russian Journal of Cardiology. 2019;(2):7-11. (In Russ.) doi:10.15829/1560-4071-2019-2-7-11.