Register
Forgot your password?

Risk factors of left atrial thrombus and/or thromboembolism in patients with nonvalvular, nonischemic atrial fibrillation

Authors: Golukhova E.Z., Gromova O.I., Arakelyan M.G., Bulaeva N.I., Zholbaeva A.Z., Mashina T.V., Dzhanketova V.S., Shlyappo M.A.

Company: Bakoulev National Scientific and Practical Center for Cardiovascular Surgery, Ministry of Health of the Russian Federation, Rublevskoe shosse, 135, Moscow, 121552, Russian Federation

For correspondence:  Sign in or register.

Type:  Heart rhythm disorders


DOI: https://doi.org/10.24022/1997-3187-2017-11-3-262-272

For citation: Golukhova E.Z., Gromova O.I., Arakelyan M.G., Bulaeva N.I., Zholbaeva A.Z., Mashina T.V., Dzhanketova V.S., Shlyappo M.A. Risk factors of left atrial thrombus and/or thromboembolism in patients with nonvalvular, nonishemic atrial fibrillation. Kreativnaya Kardiologiya (Creative Cardiology). 2017; 11 (3): 262–72 (in Russ.). DOI: 10.24022/1997-3187-2017-11-3-262-272

Received / Accepted:  June 16, 2017 / June 30, 2017

Keywords: atrial fibrillation left atrium appendage thrombosis insult risk factors CHA2DS2VASc risk score

Download
Full text:  

 

Abstract

Introduction. Atrial fibrillation (AF) is associated with a high risk for thromboembolic events. The CHA2DS2VASc risk scale is very reliable, but has some limitations. Thromboembolism can occasionally occur even in patients with AF with low CHA2DS2VASc score.

Objective. To determine clinical and instrumental parameters, associated with left atrial thrombosis and/or development of thromboembolic complications in patients with nonvalvular atrial fibrillation without concomitant coronary artery disease.

Material and methods. The retrospective analysis included 112 patients with AF who were hospitalized to Bakoulev Center for Cardiovascular Surgery between 2012 and 2015 for radiofrequency ablation (RFA). All patients had proper anticoagulation. All patients underwent transthoracic echocardiography. Contrast-enhanced computed tomography (CT) of LA was performed in 95 (85%) patients with diagnostic of anatomy pulmonary veins connection and definition one of three morphological types of left atrial appendage (LAA). Transesophageal echocardiography (TEE) was performed in 45 (40%) of patients with calculation of LAA blood velocity and identification of spontaneous ECHO contrast. Fifteen (13%) patients had LAA thrombosis by TEE or CT and/or history of thromboembolic (TE) complications (ischemic stroke or TIA).

Results. The following clinical parameters were significantly associated with LAA thrombosis and/or ischemic stroke or TIA in anamnesis: age older than 65 years (RR 2.1; 95% CI 4.5–7.8; p=0.01), chronic AF (ОR 6.13; 95% CI 1.48–25.47; p=0.03) (risk increases proportionally from paroxysmal to permanent type) and 5 points or more CHA2DS2VASc risk score (ОR 8.0; 95% CI 1.03–62.13; p=0.005). The following TEE parameters had predictive value: low LAA flow velosity (<30 cm/s) (RR 2.72; 95% CI 1.03–7.21; p=0.001), the spontaneous ECHO contrast (RR 3.89; 95% CI 1.35–11.19; p=0.03). According to CT the morphological LAA type III had a predictive value (RR 5.8; 95% CI 1.09–30.66; p=0.01).

Сonclusion. Thus, in addition to traditional risk factors, such as CHA2DS2VASc scale, we identified quite reliable risk factors of LA thrombosis and/or TE events, which are: age >65, chronic AF, low LAA blood flow velocity, the phenomenon of spontaneous ECHO contrast at LA and the morphological LAA type III by CT.

References

  1. Heeringa J., van der Kuip D.A., Hofman A., Kors J.A., van Herpen G. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur. Heart J. 2006; 27: 949–53.

  2. Lloyd-Jones D.M., Wang T.J., Leip E.P., Larson M.G., Levy D. Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation. 2004; 110: 1042–6.

  3. Kishore A., Vail A., Majid A., Dawson J., Lees K.R. Detection of atrial fibrillation after ischemic stroke or transient ischemic attack: a systematic review and meta-analysis. Stroke. 2014; 45: 520–6.

  4. Grond M., Jauss M., Hamann G., Stark E., Veltkamp R. Improved detection of silent atrial fibrillation using 72-hour Holter ECG in patients with ischemic stroke: a prospective multicenter cohort study. Stroke. 2013; 44: 3357–64.

  5. Blackshear J.L., Odell J.A. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann. Thorac. Surg. 1996; 61: 755–9.

  6. Kornelyuk I.V., Rabtsevich V.A., Kornelyuk O.M. Echocardiography predictors of the left atrial appendage thrombus in patients with persistent atrial fibrillation. Annaly Aritmologii (Annals of Arrhithmology). 2014; 11 (3): 170–6. DOI: 10.15275/annaritmol. 2014.3.5.

  7. Singer D.E., Albers G.W., Dalen J.E., Fang M.C., Go A.S. Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th ed.). Chest. 2008; 133 (6 Suppl.): 546S–92S.

  8. Lip G.Y., Andreotti F., Fauchier L., Huber K., Hylek E. Bleeding risk assessment and management in atrial fibrillation patients: a position document from the European Heart Rhythm Association, endorsed by the European Society of Cardiology Working Group on Thrombosis. Europace. 2011; 13: 723–46.

  9. Fang M.C., Go A.S., Chang Y., Hylek E.M., Henault L.E. Death and disability from warfarinassociated intracranial and extracranial hemorrhages. Am. J. Med. 2007; 120: 700–5.

  10. Gage B.F., Waterman A.D., Shannon W., Boechler M., Rich M.W. Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA. 2001; 285: 2864–70.

  11. Lip G.Y., Nieuwlaat R., Pisters R., Lane D.A., Crijns H.J. 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.

  12. Kirchhof P., Benussi S., Kotecha D., Ahlsson A., Atar D. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur. Heart J. 2016; 37: 2893–962.

  13. Oldgren J., Hijazi Z., Lindbäck J., Alexander J.H., Connolly S.J., Eikelboom J.W. et al. RE-LY and ARISTOTLE Investigators. Performance and validation of a novel biomarker-based stroke risk score for atrial fibrillation. Circulation. 2016; 134 (22): 1697–707. DOI: 10.1161/CIRCULATIONAHA. 116.022802

  14. Bejinariu A.G., Härtel D.U., Brockmeier J., Oeckinghaus R., Herzer A. Left atrial thrombi and spontaneous echo contrast in patients with atrial fibrillation: Systematic analysis of a single-center experience. Herz. 2016; 41 (8): 706–14.

  15. Di Biase L., Santangeli P., Anselmino M. et al. Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation? Results from a multicenter study. J. Am. Coll. Cardiol. 2012; 60: 531–8.

  16. Halkin A., Cohen C., Rosso R., Chorin E., Schnapper M. Left atrial appendage and pulmonary artery anatomic relationship by cardiacgated computed tomography: Implications for late pulmonary artery perforation by left atrial appendage closure devices. Heart Rhythm. 2016; 13 (10): 2064–9. DOI: 10.1016/j.hrthm.2016. 07.015.

  17. Khurram I.M., Dewire J., Mager M. et al. Relationship between left atrial appendage morphology and stroke in patients with atrial fibrillation. Heart Rhythm. 2013; 10: 1843–9.

  18. Zhu W., Wan R., Liu F., Hu J., Huang L. Relation of body mass index with adverse outcomes among patients with atrial fibrillation: A metaanalysis and systematic review. J. Am. Heart Assoc. 2016; 5: 1–13.

  19. Karasoy D., Bo Jensen T., Hansen M.L., Schmiegelow M., Lamberts M., Gislason G.H. et al. Obesity is a risk factor for atrial fibrillation among fertile young women: a nationwide cohort study. Europace. 2013; 15: 781–6.

  20. Ganesan A.N., Chew D.P., Hartshorne T., Selvanayagam J.B., Aylward P.E. The impact of atrial fibrillation type on the risk of thromboembolism, mortality, and bleeding: a systematic review and meta-analysis. Eur. Heart J. 2016; 37: 1591–602.

  21. Goette A., Kalman J.M., Aguinaga L., Akar J., Cabrera J.A., Chen S.A. et al. EHRA/HRS/ APHRS/SOLAECE expert consensus on atrial cardiomyopathies: definition, characterization, and clinical implication. Europace. 2016. DOI: 10.1093/europace/euw161.

  22. Zhao Y., Ji L., Liu J., Wu J., Wang Y., Shen S. et al. Intensity of left atrial spontaneous echo contrast as a correlate for stroke risk stratification in patients with nonvalvular atrial fibrillation. Sci. Rep. 2016; 6: 27650. DOI: 10.1038/srep27650.

  23. Wang X.F., Liu L., Cheng T.O. et al. The relationship between intravascular smoke-like echo and erythrocyte rouleaux formation. Am. Heart J. 1992; 124: 961–5.

  24. Handke M., Harloff A., Hetzel A., Olschewski M., Bode C. Left atrial appendage flow velocity as a quantitative surrogate parameter for thromboembolic risk: determinants, and relationship to spontaneous echocontrast and thrombus formation – a transesophageal echocardiographic study in 500 patients with cerebral ischemia. J. Am. Soc. Echocardiogr. 2005; 18: 1366–72.

  25. Wang Y., Di Biase L., Horton R.P., Nguyen T., Morhanty P. Left atrial appendage studied by computed tomography to help planning for appendage closure device placement. J. Cardiovasc. Electrophysiol. 2010; 21: 973–82.

  26. Fountain R., Holmes D.R. Jr., Hodgson P.K., Chandrasekaran K., Van Tassel R. Potential applicability and utilization of left atrial appendage occlusion devices in patients with atrial fibrillation. Am. Heart J. 2006; 152: 720–3.

  27. Lacomis J.M., Goitein O., Deible C., Moran P.L., Mamone G., Madan S., Schwartzman D. Dynamic multidimensional imaging of the human left atrial appendage. Europace. 2007; 9: 1134–140. DOI: 10.1093/europace/eum227.

About Authors

  • Golukhova Elena Zelikovna, Dr. Med. Sc., Academician of Russian Academy of Sciences, Head of Department for Noninvasive Arrhythmology and Surgical Treatment of Combined Pathology, orcid.org/0000-0002-6252-0322;
  • Gromova Ol’ga Igorevna, Cand. Med. Sc., Cardiologist, Researcher, orcid.org/0000-0002-5785-3421;
  • Arakelyan Mari Genrikovna, Researcher, Postgraduate, orcid.org/0000-0001-5089-0169;
  • Bulaeva Naida Ibadulaevna, Cand. Biol. Sc., Senior Researcher, orcid.org/0000-0002-5091-0518;
  • Zholbaeva Aygerim Zamirbekovna, Researcher, Postgraduate;
  • Mashina Tat’yana Vasil’evna, Cand. Med. Sc., Senior Researcher;
  • Dzhanketova Violeta Sultanovna, Cand. Med. Sc., Cardiologist, Researcher, orcid.org/0000-0002-9519-9889;
  • Shlyappo Mariya Aleksandrovna, Researcher, Postgraduate, orcid.org/0000-0001-6264-8919

Chief Editor

Leo A. Bockeria, MD, PhD, DSc, Professor, Academician of Russian Academy of Sciences, President of Bakoulev National Medical Research Center for Cardiovascular Surgery


Sort by