May 6, 2025Clinical Research in CardiologyOpen Access

Comparative analysis of therapeutic strategies in atrial fibrillation patients with left atrial appendage thrombus despite optimal NOAC therapy

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Why the study?

Although NOACs reduce LAA thrombus prevalence, the optimal treatment strategy for NOAC-resistant thrombus remains unclear.

Does modification of antithrombotic therapy improve LAA thrombus resolution in atrial fibrillation patients with NOAC-resistant thrombus?

Structured PICO

Does modification of antithrombotic therapy improve LAA thrombus resolution in atrial fibrillation patients with NOAC-resistant thrombus?

Population

120 patients with atrial fibrillation scheduled for cardioversion or catheter ablation between 2014 and 2023, with left atrial appendage (LAA) thrombus on transesophageal echocardiography (TEE) despite optimal NOAC therapy.

Intervention

Modification of antithrombotic therapy (change to a different NOAC [41%], transition to a VKA [30%], or supplementation with antiplatelet therapy [11%]).

Comparator

Unchanged NOAC therapy (18% of patients).

Outcome

Thrombus resolution on follow-up imaging at 65 [44 - 95] days.surrogate

In AF patients with LAA thrombus despite optimal NOAC therapy, modifying the antithrombotic regimen—particularly switching to a VKA—significantly improves the likelihood of thrombus resolution.

Implication

Should not yet change practice for NOAC-resistant LAA thrombus; leaves open whether therapy modification, especially to VKA, improves resolution.

Abstract

BACKGROUND AND AIMS: Left atrial appendage (LAA) thrombus is the primary cause of stroke and systemic embolism in atrial fibrillation (AF). Non-vitamin-K oral anticoagulants (NOACs) effectively reduce LAA thrombus prevalence and stroke risk. However, the optimal treatment of a NOAC-resistant thrombus remains unclear. We aimed to evaluate therapeutic strategies for resolving LAA thrombus in patients on optimal NOAC therapy. METHODS: We retrospectively analyzed patients scheduled for cardioversion or catheter ablation of AF between 2014 and 2023 with LAA thrombus on transesophageal echocardiography (TEE) despite being on optimal NOAC therapy. We assessed how the applied management strategy affected thrombus resolution. RESULTS: Among the analyzed 120 patients, a change to a different NOAC occurred in 41% of cases, a transition to a VKA in 30%, and the supplementation with antiplatelet therapy in 11%. In contrast, 18% of the patients received unchanged therapy. Follow-up imaging at 65 [44 - 95] days showed successful thrombus resolution in 92 (77%) of cases, predicted by a lower CHA2DS2-VASc score (p = 0.01). Any modification of antithrombotic therapy was an independent predictor of thrombus resolution (OR 5.28 [1.55-18], p = 0.01). Of the four strategies, there was a trend toward better thrombus resolution with switching to a VKA (OR 3.23 [1.03-10.1], p = 0.04). CONCLUSION: Resolution of LAA thrombus in patients already on adequate NOAC treatment may require a revision of the anticoagulation strategy. In addition, transitioning from NOAC to VKA might be considered.