Thrombus in the left atrial appendage in patients with atrial fibrillation treated with non‐vitamin K antagonist oral anticoagulants in clinical practice—A multicenter registry

Iwona Gorczyca−Michta; Anna Michalska; Magdalena Chrapek; Monika Budnik; Katarzyna Starzyk; Olga Jelonek; Beata Uziębło‐Życzkowska; Agnieszka Kapłon‐Cieślicka; Monika Gawałko; Paweł Krzesiński; Agnieszka Jurek; Piotr Ścisło; Janusz Kochanowski; Marek Kiliszek; Grzegorz Gielerak; Krzysztof J. Filipiak‬; Grzegorz Opolski; Beata Wożakowska−Kapłon

doi:10.1111/jce.14589

Why the study?

The prevalence and predictors of left atrial appendage thrombus in patients with non-valvular AF treated with NOACs were not well defined.

What are the prevalence and predictors of left atrial appendage thrombus in patients with non-valvular atrial fibrillation treated with NOACs prior to cardioversion or ablation?

Structured PICO

What are the prevalence and predictors of left atrial appendage thrombus in patients with non-valvular atrial fibrillation treated with NOACs prior to cardioversion or ablation?

P

Population

1,148 consecutive patients with non-valvular atrial fibrillation referred for catheter ablation (52.1%) or electrical cardioversion (47.9%), mean age 62.1 years, 38.1% female.

I

Intervention

Non-vitamin K antagonist oral anticoagulants (NOACs) - specifically rivaroxaban (51.9%) or dabigatran (48.1%) - administered for at least 3 weeks before transesophageal echocardiography.

O

Outcome

Occurrence and predictors of left atrial appendage thrombus (LAAT) on transesophageal echocardiography (TOE)surrogate

Implication

In patients with non-valvular AF treated with NOACs for at least 3 weeks, the prevalence of LAAT is 4.4%, with higher risk in those with CHA2DS2-VASc ≥2, non-paroxysmal AF, and reduced renal function.

Abstract

Background The prevalence and predictors of left atrial appendage thrombus (LAAT) in patients with non‐valvular atrial fibrillation (AF) who have been treated with non‐vitamin K antagonist oral anticoagulants (NOACs) are not well defined. We aimed to assess the occurrence and predictors of LAAT on transesophageal echocardiography (TOE) in patients with non‐valvular AF treated with NOACs for at least 3 weeks. Methods Consecutive patients with non‐valvular AF who underwent TOE before catheter ablation or electrical cardioversion in three high‐reference centers between 2014 and 2018 were included. Patients on apixaban were excluded from the study due to low numbers in this category. All patients received NOACs for at least 3 weeks before TOE. Results A total of 1148 patients (female, 38.1%; mean age, 62.1 years) referred to our centers for catheter ablation of AF (52.1%) or electrical cardioversion (47.9%) were included. Patients were on rivaroxaban (51.9%) or dabigatran (48.1%). Preprocedural TOE revealed LAAT in 4.4% of all patients. Multivariable logistic regression analysis showed the CHA2DS2‐VASc score ≥2 points (OR = 2.11; 95% CI, 1.15‐3.88; P = .0161), non‐paroxysmal AF (OR = 6.30; 95% CI, 2.22‐17.91; P = .0005), and GFR <60 mL/min/1.73 m 2 (OR = 2.05; 95% CI, 1.14‐3.67; P = .0160) were independent predictors of LAAT in patients treated with NOACs. Conclusions In non‐valvular AF patients treated with NOACs, the prevalence of LAAT was 4.4% before electrical cardioversion or ablation. In addition to the CHA2DS2‐VASc score, the type of AF and renal function should be considered in the stratification of thromboembolism risk in AF patients and qualification for a preprocedural TOE.