Predictors of Left Atrial Appendage Thrombus on Transesophageal Echocardiography before Elective Cardioversion

Objective: To determine the frequency of left atrial appendage thrombus(LAA), and its predictors on transesophageal echocardiography(TEE) before elective cardioversion. Study Design: Cross-sectional study. Place and Duration of Study: Sheikh Mohammad Bin Zayed Al-Nahyan Institute of Cardiology, Quetta Pakistan, from Oct 2025 to Jan 2026. Methodology: Overall, fifty-five patients with non-valvular atrial fibrillation or atrial flutter, aged 18-80 years and referred for elective cardioversion, were recruited and non-probability consecutive sampling was employed. Comprehensive clinical assessment was done, and CHA₂DS₂VASc score, baseline lab parameters, and TEE to assess LAA thrombus and associated echocardiographic parameters were documented for all the selected patients. Cases with valvular atrial fibrillation, recent stroke or systemic embolism, or contraindications to TEE were excluded. Results: Majority participants were males 39(70.9%), and a composite median age was 62.00(55.00-68.00) years. LAA thrombus was detected in 5(9.1%) patients. Patients with thrombus had significantly (p<0.05) higher CHA₂DS₂-VASc scores [4.00(4.00-5.00) vs 2.00(1.00-3.00)], lower left ventricular ejection fraction(LVEF) [35.00%(35.00-40.00) vs 58.00%(50.00–60.00)], larger left atrial volume index (LAVI) [47.84(43.09-95.06) vs 37.29 (30.53-42.83)ml/m²], and markedly reduced left atrial emptying velocity [15.00(15.00-20.00) vs 48.00(40.00–55.00)cm/s]. Higher CHA₂DS₂-VASc score (aOR=2.16; 95%CI: 1.01–4.41; p=0.049), LVEF (aOR=0.88; 95%CI: 0.85–0.97; p=0.04), increased left atrial diameter (aOR=1.86; 95%CI: 1.14–2.87; p=0.005), and higher LAVI (aOR=1.05; 95%CI: 1.004–1.07; p=0.023), emerged as independent predictors of LAA thrombus. Conclusion: LAA thrombus remains prevalent in patients undergoing pre-cardioversion TEE and is influenced by both clinical and echocardiographic factors. Integration of echocardiographic parameters with clinical risk scores may improve thromboembolic risk stratification before elective cardioversion.