Log in to MyACC
Thrombus on TEE Before Pulmonary Vein Isolation
Study Questions:
What is the prevalence of left atrial (LA) thrombi detected by transesophageal echocardiography (TEE) in patients with atrial fibrillation (AF) undergoing pulmonary vein isolation (PVI), and how does the presence of an LA thrombus affect patient management?
Methods:
All patients scheduled for PVI between April 2010 and April 2018 undergoing preprocedural TEE were analyzed.
Results:
A total of 1,753 preprocedural TEEs from 1,358 patients (mean age 61, 28% female) were included. Anticoagulation was used in 86% of all TEEs (51% with non–vitamin K anticoagulants [NOACs], 35% with vitamin K antagonists [VKAs]). Thrombi were found in 11 (0.6%) TEEs, all in the LA appendage. Of the 11 patients with a thrombus, five (46%) had paroxysmal AF, two (18%) had a CHA2DS2-VASc score of 1, and five (46%) were in sinus rhythm at the time of TEE. Of the eight (72%) patients on anticoagulation therapy, five were treated with NOACs and three with VKAs. Starting anticoagulation (n = 3), switching to VKA with a target international normalized ratio of 2.5-3 (n = 3), or switching to a NOAC (n = 1) or a different NOAC (n = 4) resulted in thrombus resolution in 9 of 11 patients (82%).
Conclusions:
In patients with AF scheduled for PVI, LA thrombi are rare and present in <1%. Thrombi were found in patients on VKAs and NOACs, in low-risk patients, and despite sinus rhythm. Thrombus resolution was achieved in the majority of patients by changing the anticoagulation regimen.
Perspective:
A number of studies have been published on this topic. Low risk factors suggesting no routine need for preprocedural TEE have been identified, including a normal left ventricular ejection fraction (LVEF), normally sized left atria, a CHADS2 score of 0 points or a CHA2DS2-VASc score ≤1, and NOACs with paroxysmal AF, but other studies provided varying data. In the current study, LA appendage thrombi were detected in patients with paroxysmal AF, independent of the type of oral anticoagulation, with a CHA2DS2-VASc score ≤1, in patients with preserved LVEF, and in sinus rhythm before PVI. Since the number of identified thrombi was very small, it remains unclear how hard outcomes might have been affected had the clots not been identified.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Noninvasive Imaging, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Echocardiography/Ultrasound
Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Appendage, Atrial Fibrillation, Diagnostic Imaging, Echocardiography, Transesophageal, Pulmonary Veins, Risk Factors, Stroke Volume, Thromboembolism, Thrombosis, Vitamin K
< Back to Listings
