Key result
DOAC-treated AF carries a ~2.5% prevalence of LAA thrombus on TEE, lower before ablation than cardioversion.
Why the study?
Multiple studies evaluating the prevalence of left atrial appendage thrombus in patients anticoagulated with direct oral anticoagulants reported conflicting results.
Meta-Analysis
Effect estimate: 2.5% (95% CI 1.6%-3.4%)
The very low prevalence of left atrial appendage thrombus in systematically screened patients prior to AF ablation suggests that routine TEE may not be warranted in those who have received at least 3 weeks of DOAC therapy.
Low LAAT prevalence after ≥3 weeks of DOAC supports omitting routine TEE before ablation; extends observational data questioning universal preprocedural imaging.
Background Multiple studies have examined the prevalence of left atrial appendage thrombus (LAAT) in patients anticoagulated with direct oral anticoagulants (DOACs) and have reported conflicting results. Methods Studies reporting the prevalence of LAAT on transesophageal echocardiography (TEE) after 3 or more weeks of DOAC therapy were identified. The proportions of anticoagulated patients diagnosed with LAAT were pooled using random-effects models. Prespecified subgroup analyses by the indication of TEE (pre–atrial fibrillation [AF] ablation vs cardioversion) and TEE strategy (routine use vs selective) were conducted via stratification. Results Forty studies were identified: 22 full manuscripts and 18 abstracts. Only 11 studies performed TEE routinely. Most studies included patients with paroxysmal AF and low thromboembolic risk. The pooled prevalence of LAAT was 2.5% (95% confidence interval [1.6%-3.4%]). The prevalence of LAAT is lower in the pre-AF ablation group compared with pre-cardioversion (1.1% vs 4.0%, P = 0.033). Routine TEE strategy yielded a lower LAAT prevalence in both groups (0.1% vs 2.3%, P = 0.002 and 3.2% vs 5.8%, P = 0.432, respectively). Conclusion The reported prevalence of LAAT on TEE in patients treated with DOACs is highly variable. Factors associated with a high LAAT prevalence were pre-cardioversion indication and selective TEE strategy. Routine use of TEE before AF ablation may not be warranted.
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Alqarawi et al. (2020) conducted a meta-analysis in Atrial fibrillation. Direct oral anticoagulants (DOACs) was evaluated on Prevalence of left atrial appendage thrombus (LAAT) on TEE (2.5%, 95% CI 1.6%-3.4%). The pooled prevalence of left atrial appendage thrombus on TEE in patients with atrial fibrillation anticoagulated with DOACs for at least 3 weeks was 2.5%, with a significantly lower prevalence before ablation compared to cardioversion (1.1% vs 4.0%, P=0.033).
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