Imaging of thrombi and assessment of left atrial appendage function: a prospective study comparing transthoracic and transoesophageal echocardiography

Abstract Background The left atrial appendage (LAA) is the main source of thromboembolism in atrial fibrillation (AF). Transcatheter closure is non-inferior to warfarin therapy in preventing stroke. Case summary A patient with two consecutive strokes associated with AF was referred for transcatheter LAA occlusion (LAAO). Preprocedural cardiac CT and transoesophageal echocardiography demonstrated a spontaneously occluded LAA with a smooth left atrial surface, with stationary results at 6- and 12-month imaging follow-up. Warfarin was discontinued, and life-long aspirin instigated. Discussion Left atrial appendage occlusion has shown non-inferiority to warfarin for prevention of stroke, cardiovascular death, and all-cause mortality. No benefits from anticoagulation have been demonstrated in patients with embolic stroke of undetermined source. In the present case, we observed that the LAA was occluded and, therefore, treated with aspirin monotherapy assuming similar efficacy as transcatheter LAAO.

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Transoesophageal and intracardiac echocardiography

10.1093/med/9780199599639.003.0004 ◽

2011 ◽

Author(s):

Christian Rost ◽

Frank A. Flachskampf

Keyword(s):

Left Atrial ◽

Left Atrial Appendage ◽

Transoesophageal Echocardiography ◽

Intracardiac Echocardiography ◽

Left Ventricular ◽

Atrial Appendage ◽

Minimal Risk ◽

Cardiac Procedures ◽

Valve Pathology ◽

The Right

Transoesophageal echocardiography (TOE), a minimal-risk, semi-invasive imaging procedure is nowadays an indispensable part of routine echocardiography. It is mainly necessary and indicated: ◆ To analyse some structures insufficiently seen transthoracically, such as the left atrial appendage or the thoracic aorta. ◆ In situations that prohibit the use of conventional transthoracic windows, such as the patient undergoing cardiac surgery.As in transthoracic echocardiography (TTE), the TOE examination consists of a sequence of views defined by internal landmarks; unlike TTE, depending on the patient’s tolerance and the clinical question, not all of these have to be obtained in every examination. Important typical indications for TOE are the search for signs of endocarditis, the search for cardiogenic emboli, diagnosis of left atrial (appendage) thrombi before cardioversion, diagnosis of aortic dissection, characterization of mitral and aortic valve pathology especially in the context of surgical repair, intraoperative monitoring of left ventricular function, and monitoring of interventional cardiac procedures monitored.For some indications, intracardiac echocardiography has been found useful. This procedure involves insertion of a transducer-tipped catheter into the caval vein and advancement to the right heart, or intra-aortic placement. Applications are electrophysiological procedures, interventional closure of atrial septal defect, aortic stent placement, and others.

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Prevalence of left atrial appendage thrombus detected by transoesophageal echocardiography before catheter ablation of atrial fibrillation in patients anticoagulated with non-vitamin K antagonist oral anticoagulants

EP Europace ◽

10.1093/europace/euy129 ◽

2018 ◽

Vol 21 (1) ◽

pp. 48-53 ◽

Cited By ~ 7

Author(s):

Wael Alqarawi ◽

David H Birnie ◽

Stewart Spence ◽

F Daniel Ramirez ◽

Calum J Redpath ◽

...

Keyword(s):

Atrial Fibrillation ◽

Catheter Ablation ◽

Vitamin K ◽

Left Atrial ◽

Left Atrial Appendage ◽

Oral Anticoagulants ◽

Transoesophageal Echocardiography ◽

Vitamin K Antagonist ◽

Atrial Appendage ◽

Left Atrial Appendage Thrombus

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Left Atrial Appendage (LAA) Function by Transesophageal Echocardiography before and after Percutaneous Balloon Mitral Valvuloplasty (PBMV)- A Comparative Study

Academia Journal of Medicine ◽

10.47008/ajm.2020.3.1.13 ◽

2020 ◽

Vol 3 (1) ◽

pp. 64-69

Author(s):

Satyendra Kumar A ◽

Magesh B

Keyword(s):

Atrial Fibrillation ◽

Left Atrial ◽

Left Atrial Appendage ◽

Age Groups ◽

Transoesophageal Echocardiography ◽

Atrial Appendage ◽

Medical College ◽

Percutaneous Balloon ◽

Before And After ◽

Balloon Valvotomy

Background: In the past, the left atrial appendage (LAA) has been considered to be a relatively insignificant portion of cardiac anatomy. It is now recognized that it is a structure with important pathological associations. First, thrombus has a predilection to form within the LAA in patients with non-valvar atrial fibrillation and to a lesser extent in those with mitral valve disease (both in atrial fibrillation and in sinus rhythm). Second, the use of transoesophageal echocardiography has made clear imaging of the LAA possible, so that its size, shape, flow pattern, and content can be assessed in health and disease. Subjects and Methods: This study population consisted of 40 patients with symptomatic mitral stenosis who underwent percutaneous mitral balloon valvotomy in the cardiology department of GSL medical college, Rajahmundry over a time period of 1 April 2017 to 30 March2018. Patients in all age groups, with evidence of severe MS (MVA<1.0cm2) admitted in our institution, in whom PBMV was feasible were included. Those who were fulfilling the PBMV intervention criteria and those who had good results only were included. Results: Left atrial appendage late emptying velocity, LAALF: Left atrial appendage late filling velocity Spontaneous echocontrast (SEC) was present in 10 of the 40 patients before a procedure but completely disappeared (6 patients) or decreased (4 patients) after the procedure. LAALE & LAALF velocities measured by Doppler were increased significantly after PBMV and at 6 months follow up compared with baseline (P <0.001). Conclusion: Successful Percutaneous balloon mitral valvotomy decreases the intensity of spontaneous LA contrast, reduces the size of the LA, and improves LA and LAA function. Relief of MS may confer not only hemodynamic benefits for improvement of symptoms but also have a favorable influence on future thromboembolism.

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P765 Does detection of thrombus in left atrial appendage increase risk of ischemic stroke and mortality?

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.427 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

E Kagawa ◽

M Kato ◽

N Oda ◽

E Kunita ◽

M Nagai ◽

...

Keyword(s):

Ischemic Stroke ◽

Left Atrial ◽

Left Atrial Appendage ◽

Anticoagulation Therapy ◽

Transoesophageal Echocardiography ◽

Atrial Appendage ◽

Increase Risk ◽

Baseline Characteristics ◽

Free Rate

Abstract Background Left atrial appendage (LAA) thrombus is one of causes of cardiogenic stroke and detection of LAA thrombus by transoesophageal echocardiography (TOE) strongly suggest cardiogenic stroke. It was reported that cardiogenic stroke patients had higher in-hospital mortality about 19%; however, little is known about LAA thrombus and mortality after indexed detection of LAA thrombus. We investigated LAA thrombus detection and their prognosis including ischemic stroke and survival. Methods The patients who were performed TOE between 2005 and 2016 in our hospital were enrolled in this study. Patients were divided into 2 groups based on thrombus detection in the LAA, and baseline characteristics and outcomes including prevalence of 5-y stroke-free and survival from the indexed TOE were compared. Results Among the 1260 study patients, the follow-up duration was median 971 d (interquartile range 345 d – 2017 d), and 67% of the patients were performing TOE for atrial fibrillation (AF), 20% for cerebral infarction, and 14% for valvular heart disease. Non-valvular AF was seen in 64% of the study patients and rheumatic AF was in 2%. The age (74 y [66 y – 79 y] vs 70 y [62 y – 76 y], p < 0.001), the prevalence of male sex (67% vs 69%, p = 0.63), and hemoglobin level (13.9 g/dl [12.5 – 15.1 g/dl] vs 13.8 g/dl [12.4 – 14.9 g/dl], p = 0.49) were similar between the patients with LAA thrombus and those without. The CHA2DS2-VASc score (p = 0.008), the prevalence of receiving anticoagulation before TOA (34% vs 24%, p = 0.01), those of after TOA (98% vs 66%, p < 0.001), serum creatinine (0.92 mg/dl [0.80 – 1.10 mg/dl] vs 0.85 mg/dl [0.71 – 1.00 mg/dl], p < 0.001), d-dimer level (1.7 mcg/ml [0.9 – 3.5 mcg/ml] vs 0.8 mcg/ml [0.5 – 2.2 mcg/ml], p < 0.001), and plasma brain natriuretic peptide (315 pg/ml [128 – 515 pg/ml] vs 126 pg/ml [47 – 284 pg/ml], p < 0.001) were higher in the patients with LAA thrombus than those without. The 5-y ischemic stroke-free rate was lower in the patients with LAA thrombus than those without (p < 0.001) (Figure, Panel A); however, the 5-y survival was similar between the 2 groups (p = 0.93) (Panel B). Conclusions The patients who were detected thrombus in the LAA had higher incidence of ischemic stroke, but the survival rate were similar. The higher rate of receiving anticoagulation therapy in the patients with LAA thrombus may be the cause of this discrepancy. Further studies are necessary to clarify this issue. Abstract P765 Figure

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