Advertisement

Left atrial thrombus despite continuous direct oral anticoagulant or warfarin therapy in patients with atrial fibrillation: insights into rates and timing of thrombus resolution

  • Michael S. Wu
  • James Gabriels
  • Mohammad Khan
  • Nada Shaban
  • Salvatore A. D’Amato
  • Christopher F. Liu
  • Steven M. Markowitz
  • James E. Ip
  • George Thomas
  • Parmanand Singh
  • Bruce B. Lerman
  • Apoor Patel
  • Jim W. Cheung
Article
  • 149 Downloads

Abstract

Purpose

Left atrial thrombus (LAT) may be detected by transesophageal echocardiography (TEE) in patients with atrial fibrillation (AF) or flutter (AFL) despite continuous anticoagulation therapy. We sought to examine the rates and timing of LAT resolution in response to changes in anticoagulation regimen.

Methods

A retrospective study of 1517 consecutive patients on ≥ 4 weeks continuous oral anticoagulation (OAC) undergoing TEE prior to either direct current cardioversion or catheter ablation for AF or AFL was performed. Patients who had LAT on index TEE imaging and had follow-up TEEs were analyzed.

Results

Despite ≥ 4 weeks of continuous anticoagulation therapy, 63 (4.2%) patients had LAT. Forty-four patients (median age 67 [IQR 58, 74]; 33 [75%] male; 25 [57%] on direct oral anticoagulant [DOAC]) had follow-up TEEs performed. Upon detection of LAT on index TEE, 8 patients switched from warfarin to a DOAC, 21 patients switched from a DOAC to warfarin or another DOAC, and 15 patients remained on the same OAC. Over median 4.2 months (IQR 2.9, 6.6), LAT resolution was seen in 25 (57%) patients. Of the 25 patients who had LAT resolution, 7 (28%) required TEE imaging > 6 months after index TEE to show clearance of thrombus. Rates of LAT resolution were similar between patients who had alterations in OAC and those who did not (52 vs. 60%; P = 0.601).

Conclusions

After initial detection of left atrial thrombus despite uninterrupted anticoagulation for atrial fibrillation or flutter, > 40% patients have persistent clot despite additional extended anticoagulation.

Keywords

Oral anticoagulants Persistent left atrial thrombus Atrial fibrillation Atrial flutter Catheter ablation Direct current cardioversion 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Al-Saady NM, Obel OA, Camm AJ. Left atrial appendage: structure, function, and role in thromboembolism. Heart. 1999;82:547–54.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Manning WJ, Silverman DI, Gordon SP, Krumholz HM, Douglas PS. Cardioversion from atrial fibrillation without prolonged anticoagulation with use of transesophageal echocardiography to exclude the presence of atrial thrombi. N Engl J Med. 1993;328:750–5.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Seidl K, Rameken M, Drogemuller A, Vater M, Brandt A, Schwacke H, et al. Embolic events in patients with atrial fibrillation and effective anticoagulation: value of transesophageal echocardiography to guide direct-current cardioversion. Final results of the Ludwigshafen observational cardioversion study. J Am Coll Cardiol. 2002;39:1436–42.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Frenkel D, Al-Kazaz M, Markowitz SM, Liu CF, Thomas G, Ip JE, et al. Prevalence of left atrial thrombus by transesophageal echocardiography: a comparison of continuous non-vitamin k antagonist oral anticoagulant versus warfarin therapy in patients undergoing catheter ablation for atrial fibrillation. JACC Clin Electrophysiol. 2016;2:295–303.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Wu M, Gabriels J, Khan M, Shaban N, D'Amato S, Liu CF, et al. Left atrial thrombus and dense spontaneous echocardiographic contrast in patients on continuous direct oral anticoagulant therapy undergoing catheter ablation of atrial fibrillation: comparison of dabigatran, rivaroxaban, and apixaban. Heart Rhythm. 2018 April;15(4):496–502.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Lip GY, Hammerstingl C, Marin F, Cappato R, Meng IL, Kirsch B, et al. Rationale and design of a study exploring the efficacy of once-daily oral rivaroxaban (X-TRA) on the outcome of left atrial/left atrial appendage thrombus in nonvalvular atrial fibrillation or atrial flutter and a retrospective observational registry providing baseline data (CLOT-AF). Am Heart J. 2015;169:464–71. e462CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Lip GY, Hammerstingl C, Marin F, Cappato R, Meng IL, Kirsch B, et al. Left atrial thrombus resolution in atrial fibrillation or flutter: results of a prospective study with rivaroxaban (X-TRA) and a retrospective observational registry providing baseline data (CLOT-AF). Am Heart J. 2016;178:126–34.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro heart survey on atrial fibrillation. Chest. 2010;137:263–72.CrossRefPubMedGoogle Scholar
  9. 9.
    Jaber WA, Prior DL, Thamilarasan M, Grimm RA, Thomas JD, Klein AL, et al. Efficacy of anticoagulation in resolving left atrial and left atrial appendage thrombi: a transesophageal echocardiographic study. Am Heart J. 2000;140:150–6.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Vidal A, Vanerio G. Dabigatran and left atrial appendage thrombus. J Thromb Thrombolysis. 2012;34:545–7.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Takasugi J, Yamagami H, Okata T, Toyoda K, Nagatsuka K. Dissolution of the left atrial appendage thrombus with rivaroxaban therapy. Cerebrovasc Dis. 2013;36:322–3.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Hammerstingl C, Potzsch B, Nickenig G. Resolution of giant left atrial appendage thrombus with rivaroxaban. Thromb Haemost. 2013;109:583–4.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Dobashi S, Fujino T, Ikeda T. Use of apixaban for an elderly patient with left atrial thrombus. BMJ Case Rep. 2014;2014:bcr2014203870.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace. 2016;18:1609–78.CrossRefPubMedGoogle Scholar
  15. 15.
    January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association task force on practice guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64:e1–76.CrossRefPubMedGoogle Scholar
  16. 16.
    Bernhardt P, Schmidt H, Hammerstingl C, Hackenbroch M, Sommer T, Luderitz B, et al. Fate of left atrial thrombi in patients with atrial fibrillation determined by transesophageal echocardiography and cerebral magnetic resonance imaging. Am J Cardiol. 2004;94:801–4.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Lip GY, Lane DA. Matching the NOAC to the patient: remember the modifiable bleeding risk factors. J Am Coll Cardiol. 2015;66:2282–4.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Berger M, Schweitzer P. Timing of thromboembolic events after electrical cardioversion of atrial fibrillation or flutter: a retrospective analysis. Am J Cardiol. 1998;82:1545–7.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Nagarakanti R, Ezekowitz MD, Oldgren J, Yang S, Chernick M, Aikens TH, et al. Dabigatran versus warfarin in patients with atrial fibrillation: an analysis of patients undergoing cardioversion. Circulation. 2011;123:131–6.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Michael S. Wu
    • 1
  • James Gabriels
    • 2
  • Mohammad Khan
    • 2
  • Nada Shaban
    • 2
  • Salvatore A. D’Amato
    • 1
  • Christopher F. Liu
    • 1
  • Steven M. Markowitz
    • 1
  • James E. Ip
    • 1
  • George Thomas
    • 1
  • Parmanand Singh
    • 1
  • Bruce B. Lerman
    • 1
  • Apoor Patel
    • 2
  • Jim W. Cheung
    • 1
  1. 1.Department of Medicine, Division of Cardiology, Weill Cornell MedicineNew York Presbyterian HospitalNew YorkUSA
  2. 2.Department of CardiologyNorth Shore University Hospital-Northwell HealthManhassetUSA

Personalised recommendations