Author + information
- Received May 30, 2019
- Revision received September 5, 2019
- Accepted September 6, 2019
- Published online October 30, 2019.
- Tobias Göldi, MDa,b,∗,
- Philipp Krisai, MDa,b,∗,
- Sven Knecht, PhDa,b,
- Stefanie Aeschbacher, PhDa,b,
- Florian Spies, MSca,b,
- Ivan Zeljkovic, MDc,
- Beat A. Kaufmann, MDa,b,
- Beat Schaer, MDa,b,
- David Conen, MD, MPHb,d,
- Tobias Reichlin, MDe,
- Stefan Osswald, MDa,b,
- Christian Sticherling, MDa,b and
- Michael Kühne, MDa,b,∗ ()
- aDepartment of Cardiology, University Hospital of Basel, Basel, Switzerland
- bCardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
- cSestre Milosrdnice University Hospital, Zagreb, Croatia
- dPopulation Health Research Institute, McMaster University and Department of Cardiology, Hamilton Health Sciences, Hamilton, Ontario, Canada
- eDepartment of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- ↵∗Address for correspondence:
Dr. Michael Kühne, Department of Cardiology, Universitätsspital Basel, Petersgraben 4, 4031 Basel, Switzerland.
Objectives This study aimed to investigate the prevalence and management of left atrial (LA) thrombi detected by transesophageal echocardiography (TEE) in patients with atrial fibrillation undergoing pulmonary vein isolation (PVI).
Background Little data are available on LA thrombi before PVI.
Methods All patients scheduled for PVI between April 2010 and April 2018 undergoing pre-procedural TEE were analyzed. Management of LA thrombus was at the discretion of the treating physician.
Results In this study, 1,753 pre-procedural TEE from 1,358 patients (mean age 61 ± 10 years, 28% female) were included. Anticoagulation was used in 86% of all TEE (51% with direct oral anticoagulants [DOAC], 35% with vitamin K antagonists [VKA]). Thrombi were found in 11 TEE (0.6%), all in the LA appendage. Of the 11 patients with a thrombus, 5 (46%) had paroxysmal atrial fibrillation, 2 (18%) had a CHA2DS2-VASc (Congestive Heart Failure, Hypertension, Age ≥75 Years, Diabetes Mellitus, Prior Stroke or Transient Ischemic Attack or Thromboembolism, Vascular Disease, Age 65 to 74 Years, Sex) score of 1, and 5 (46%) were in sinus rhythm at the time of TEE. Of the 8 patients (72%) on anticoagulation therapy, 5 were treated with DOAC and 3 with VKA. Starting anticoagulation (n = 3), switching to VKA with a target international normalized ratio of 2.5 to 3 (n = 3), or switching to a DOAC (n = 1) or a different DOAC (n = 4) resulted in thrombus resolution in 9 of 11 patients (82%).
Conclusions In patients with atrial fibrillation scheduled for PVI, LA thrombi are rare and present in <1%. Thrombi were found in patients on VKA and DOAC, in low-risk patients, and despite sinus rhythm. Thrombus resolution was achieved in the majority of patients by changing the anticoagulation regimen.
↵∗ Drs. Göldi and Krisai contributed equally to this work and are joint first authors.
Dr. Schaer serves on the Speakers Bureau of Medtronic. Dr. Conen has received speaker honoraria from Servier, Canada. Dr. Kühne has received grants from Bayer, Pfizer-BMS, the Swiss National Science Foundation, and the Swiss Heart Foundation; and lecture or consulting fees from Daiichi-Sankyo, Boehringer Ingelheim, Bayer, Pfizer-BMS, AstraZeneca, Sanofi, Novartis, Merck Sharp & Dohme, Medtronic, Boston Scientific, St. Jude Medical, Biotronik, Sorin, Zoll, Biosense Webster, and Abbott. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received May 30, 2019.
- Revision received September 5, 2019.
- Accepted September 6, 2019.
- 2019 American College of Cardiology Foundation
This article requires a subscription or purchase to view the full text. If you are a subscriber or member, click Login or the Subscribe link (top menu above) to access this article.