October 9, 2025IJC Heart & Vasculature1 citationsOpen Access

Left atrial appendage thrombi despite oral anticoagulation in transthyretin amyloid cardiomyopathy patients undergoing electrical cardioversion for atrial fibrillation or − flutter

MPMichael PoledniczekMedical University of Vienna CKChristina KronbergerHeart Failure & Transplant BGBernhard GregshammerMedical University of Vienna

Structured PICO

Population

46 patients with transthyretin amyloid cardiomyopathy (ATTR-CM) scheduled to undergo direct current electrical cardioversion (DCCV) for atrial fibrillation or atrial flutter. Mean age 77.2 ± 6.5 years, 89.1% male, from a single center in Austria. Key comorbidities: arterial hypertension (63.0%), chronic kidney disease (60.9%), median CHA2DS2-VA score 4.

Intervention

Direct current electrical cardioversion (DCCV) with prior exclusion of left atrial appendage thrombus (LAAT) utilizing transesophageal echocardiography (TEE) or computed tomography (CT).

Outcome

Left atrial appendage thrombus (LAAT) formation rates leading to DCCV cancellation, immediate success rates of DCCV, and 3-month rhythm control.

Patients with transthyretin amyloid cardiomyopathy have a high risk of left atrial appendage thrombus despite oral anticoagulation, necessitating routine TEE or CT prior to electrical cardioversion.

Abstract

Electrical Cardioversion in Transthyretin Amyloid Cardiomyopathy – Left Atrial Appendage Thrombi Despite Oral Anticoagulants: In a study involving 46 transthyretin amyloid cardiomyopathy patients, 62 electrical cardioversion procedures were conducted. Of these, 39 patients underwent transoesophageal echocardiography or computed tomography scans. Thrombus formation was identified in 8 cases (20.5%), including 5 patients (12.8%) who developed thrombi despite receiving anticoagulation therapy. The immediate success rate of cardioversion was 92.3% (n = 48), while the success rate at 3 months declined to 61.9% (n = 26). CT indicates computed tomography; TEE, transoesophageal echocardiography. Patients with cardiac amyloidosis undergoing direct current electrical cardioversion (DCCV) are at risk of left atrial appendage thrombus (LAAT). We investigated LAAT formation rates, success rates, and long-term recurrence rates in transthyretin amyloid cardiomyopathy (ATTR-CM) patients. ATTR-CM patients scheduled to undergo DCCV were included in the study. LAAT exclusion was performed utilizing transesophageal echocardiography or computed tomography. A total of 62 (1.35 per patient) DCCVs were recorded among 46 patients (77 ± 6.5 years, 89 % male) with ATTR-CM. In 39 DCCVs, LAAT exclusion was performed (62.9 %). In total, 10 DCCVs (16.1 %) were canceled due to (I) spontaneous conversion to sinus rhythm (n = 2, 5.1 %) or (II) definitive/suspected LAAT (n = 8, 20.5 %). Of these, five patients with LAAT had been receiving sufficient doses of oral anticoagulants for more than three weeks prior to DCCV. The immediate success rate was 92.3 %, and 3-month rhythm control was achieved in 27 (62.8 %) procedures. Notably, one stroke event was recorded two months following DCCV. A high rate of left atrial appendage thrombus was observed in ATTR-CM, leading to DCCV cancellation in 20.5% of patients. Despite a high immediate success rate (92.3%), sustained sinus rhythm control was achieved in only 62.8% following DCCV. These findings advise using TEE or CT prior to DCCV to exclude LAAT in ATTR-CM patients, even in those with oral anticoagulation.

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