Predictors of left atrial spontaneous echo contrast and thrombi in patients with mitral stenosis and atrial fibrillation

doi:10.1016/S0002-9149(00)01007-9

The American Journal of Cardiology

Volume 86, Issue 5, 1 September 2000, Pages 529-534

https://doi.org/10.1016/S0002-9149(00)01007-9 Get rights and content

Abstract

The purpose of this study was to investigate the independent factors associated with the presence of left atrial (LA) spontaneous echo contrast (SEC) and thromboembolic events in patients with mitral stenosis (MS) in chronic atrial fibrillation (AF). Factors independently associated with LASEC, thrombi, and embolic events have been mainly investigated in patients with nonvalvular AF or inhomogeneous populations with rheumatic heart disease. Transesophageal and transthoracic echo studies were performed in 129 patients with MS in chronic AF. Previous embolic events were documented in 45 patients, 20 of them within 6 months, and 65 patients were receiving long-term anticoagulation. The intensity of LASEC and mitral regurgitation, the presence of thrombi and active LA appendage flow (peak velocities ≥20 cm/s), and LA volume as well as other conventional echo-Doppler determinations were investigated in every patient. The prevalences of significant LASEC (degrees 3+ and 4+), thrombus, active LA appendage flow, and significant mitral regurgitation (>2+) were: 52% (67 patients), 29.5% (38 patients), 32% (41 patients), and 36% (47 patients), respectively. Multivariate analysis showed that decreasing mitral regurgitation severity, absence of active LA appendage flow, and mitral valve area were the independent correlates of LASEC (odds ratio [OR] 3.7, 5.4, and 0.17, respectively; all p <0.02). Active LA appendage flow and anticoagulant therapy were associated negatively, whereas the severity of LASEC was associated positively with the finding of LA thrombus (OR 9.6, 3.9, and 1.6, respectively; all p <0.05). The intensity of LASEC and previous anticoagulant therapy (OR 1.74 and 4.5, respectively; p <0.005) were the independent covariates of thrombi and/or recent embolic events. In conclusion, the severity of mitral regurgitation and lack of active LA appendage flow were, respectively, the strongest independent correlates of significant LASEC and thrombus in patients with MS in chronic AF. LASEC remains the cardiac factor most strongly associated with thrombus and/or recent embolic events in these patients.

Section snippets

Patients

During the period 1993 to 1998, 140 patients with MS (mitral valve area ≤2 cm²) in chronic AF (>2 weeks)14 were studied by transthoracic and transesophageal echo-Doppler techniques. Patients with previous commissurotomy or percutaneous mitral valvuloplasty as well as those with atrial flutter or atrial tachycardia were excluded. The clinical reasons for the study were: evaluation before mitral valvuloplasty (84 patients), assessment of mitral regurgitation (17 patients), inadequate

Prevalences in the study population

The combined finding of LA thrombus and/or recent embolism was observed in 48 patients. The intensity of LASEC was as follows: 0 (16 patients), 1+ (26 patients), 2+ (20 patients), 3+ (51 patients), and 4+ (16 patients); thus, we detected the presence of LASEC (degrees 3+ and 4+) in 67 patients (52%). LA appendage thrombi were observed in 38 patients (29.5%); in 9 of them this finding was associated with thrombus within the LA main cavity. In 41 patients (32%), we detected an active LA appendage

Discussion

Our study constitutes the first multivariate analysis that incorporates the information provided by conventional and transesophageal echo-Doppler studies in the last few years on the different factors associated with the presence of LASEC, LA thrombi, and embolic phenomena in patients with MS during chronic persistent AF. In contrast to previous studies assessing heterogenous populations, this homogenous high-risk study group reinforces the results of such analysis and is even more suitable

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Effect of Mitral Regurgitation on Thrombotic Risk in Patients With Nonrheumatic Atrial Fibrillation: A New CHA<inf>2</inf>DS<inf>2</inf>-VASc Score Risk Modifier?
2021, American Journal of Cardiology
The current study assessed the effect of mitral regurgitation (MR) on thrombotic risk in nonrheumatic atrial fibrillation (AF). AF carries a thrombotic risk related to left atrial blood stasis. The prevalence of atrial thrombosis, defined as the presence of left atrial appendage thrombus and/or left atrial spontaneous echo contrast grade >2, was determined in 686 consecutive nonrheumatic AF patients without (adequate) anticoagulation scheduled for transesophageal echocardiography before electrical cardioversion and was related to the severity of MR adjusted for the CHA₂DS₂-VASc score. A total of 103 (15%) patients had severe MR, 210 (31%) had moderate MR, and 373 (54%) had no-mild MR; the median CHA₂DS₂-VASc score was 3.0 (interquartile range 2.0 to 4.0). Atrial thrombosis was observed in 118 patients (17%). The prevalence of atrial thrombosis decreased with increasing MR severity: 19.9% versus 15.2% versus 11.6% for no-mild, moderate, and severe MR, respectively (p value for trend = 0.03). Patients with moderate and severe MR had a lower risk of atrial thrombosis than patients with no-mild MR, with adjusted odds ratios of 0.51 (95% confidence interval 0.31 to 0.84) and 0.24 (95% confidence interval 0.11 to 0.49), respectively. The protective effect of MR was present across all levels of the CHA₂DS₂-VASc risk score and the presence of moderate-severe MR in patients with an intermediate CHA₂DS₂-VASc score (2 to 3) lowered the atrial thrombotic risk to the level of patients with a low CHA₂DS₂-VASc score (0 to 1). In conclusion, our data show that the presence of MR attenuated the atrial thrombotic risk by more than 50% in patients with nonrheumatic AF.
Comparison of chronological changes in blood characteristics in the atrium and peripheral vessels after the development of non-valvular atrial fibrillation
2018, Thrombosis Research
Changes in blood characteristics in the atrium and peripheral vessels in patients with non-valvular atrial fibrillation (NVAF) are unclear. We investigated chronological changes in blood characteristics in the atrium and peripheral vessels in a dog model of NVAF by using a total thrombus-formation analysis system (T-TAS).
In NVAF model dogs (n = 8, 390 bpm rapid atrial pacing), atrial and peripheral blood samples were collected. Using this blood, T-TAS was performed before and 1, 2, and 3 weeks after the onset of rapid atrial pacing.
Occlusion time (OT: time to +80 and +60 kPa in the AR and PL chips, respectively) and area under the flow pressure curve (AUC) were measured using the AR chip (for mixed white thrombus analysis) and PL chip (for platelet thrombus analysis). OT of the AR chip showed shortening as early as 1 week after NVAF onset, which continued for 3 weeks. OT of the PL chip showed significant shortening in atrium blood only 3 weeks after NVAF onset. By contrast, peripheral blood showed no significant changes in OT or AUC with both AR and PL chips.
In our dog model of NVAF, thrombus formation accelerated in the atrium as early as 1 week after NVAF onset and continued for 3 weeks, but no significant changes were found in peripheral blood. We conclude that antithrombotic therapy should be started early after NVAF onset even if no changes in coagulation activity are observed in peripheral blood.
Frequency and significance of right atrial appendage thrombi in patients with persistent atrial fibrillation or atrial flutter
2014, Journal of the American Society of Echocardiography
Atrial fibrillation (AF) and atrial flutter (AFL) are strong atrial thrombosis (THR) risk factors. In recent-onset tachyarrhythmias, the incidence of left atrial appendage (LAA) THR, detected by transesophageal echocardiography (TEE), has been widely studied, ranging from 6% to 18% (AF) and 4% to 11% (AFL). On the contrary, few studies have assessed right atrial appendage (RAA) THR, and there is no information on the relation between the RAA flow characteristics and the presence of RAA THR. The aims of this study were to evaluate the incidence of RAA THR in a population of patients undergoing TEE-guided cardioversion for recent-onset atrial tachyarrhythmias and to analyze RAA Doppler flow and its relation to thrombus formation.
From 1998 to 2012, patients admitted to the emergency department for persistent, non-self-terminating atrial tachyarrhythmia lasting >2 days who gave informed consent for TEE-guided cardioversion were prospectively enrolled in the study. Among 1,042 patients, complete anatomic and functional studies of the LAA and RAA were feasible in 983 (AF, n = 810 [23%]; AFL, n = 173 [5%]). The presence of RAA and LAA THR, appendage emptying velocities, and the presence of severe spontaneous echocardiographic contrast were studied.
The overall incidence of atrial THR was 9.7% (96 of 983). The incidence of THR was 9.3% (91 of 983) in the LAA and 0.73% (seven of 983) in the RAA (P < .01). In the AF and AFL groups, the incidence of LAA THR was 10.3% (83 of 805), compared with 0.75% (six of 805) for RAA THR (P < .01). Among patients with AFL, the incidence of LAA THR was 6% (10 of 178), compared with 0.6% (one of 178) for RAA THR (P < .01). The mean LAA peak emptying velocity was 24 cm/sec (range, 10–32 cm/sec) in patients with LAA THR, compared with 38 cm/sec (range, 20–59 cm/sec) in those without THR; the mean RAA peak emptying velocity was 17 ± 7 cm/sec in patients with RAA THR, compared with 34 ± 13 cm/sec in those without THR (P < .001).
RAA thrombi are significantly less frequent than LAA thrombi but may reach large dimensions. Multiplane TEE allows RAA morphologic and functional assessment. Before TEE-guided cardioversion, both the LAA and the RAA must be routinely studied.
Spontaneous Echo Contrast in Internal Jugular Veins: A Probable Indicator for Systemic Inflammation and a Prothrombotic State
2012, Ultrasound in Medicine and Biology
Citation Excerpt :
SEC in IJV could be a putative marker of some pathological alterations in cerebral circulation. Previous reports demonstrated that regions characterized by a low flow and low shear rate have been correlated with increased incidence of SEC (Sigel et al. 1981; Gonzalez-Torrecilla et al. 2000; Sadanandan and Sherrid 2000). Low flow velocities in IJVs significantly correlated with the higher grades of SEC in our study.
The hypothesis that spontaneous echo contrast (SEC) in the internal jugular vein (IJV) is a clinical indicator for systemic inflammation and thrombogenesis is investigated in this study. Fifty-two patients with cardiovascular diseases and 25 nondiseased subjects were evaluated. SEC was observed in 96 of 154 IJVs. The visual grading of SEC showed good interobserver agreement on SEC grades (κ value: 0.846, p < 0.001). Generalized estimating equations analysis was used for univariate and multivariate analysis. Univariate analysis showed that peak flow velocity in corresponding IJV (coefficient −0.001 [95% CI −0.019, −0.001], p = 0.031), jugular venous reflux (JVR, −0.010 [–0.019, −0.001], p = 0.002), plasma levels of fibrinogen (0.464 [0.208, 0.719], p < 0.001) and hs–C-reactive protein (hs-CRP) (0.479 [0.184, 0.774], p = 0.001) and previous history of ischemic stroke (0.779 [0.139, 1.417]; p = 0.017) correlated with the grades of SEC in IJV. Increased plasma levels of fibrinogen and hs-CRP, previous ischemic stroke, lower peak velocity in corresponding IJV and JVR were also independent predictors for the higher grades of SEC in IJV in multivariate regression analysis. SEC in IJV could be evaluated easily and semiquantitatively. SEC in IJVs could be a putative marker of cerebral circulation disturbance and an indicator of systemic inflammatory or prothrombotic state.
Prognostic value of low left atrial appendage wall velocity in patients with ischemic stroke and atrial fibrillation
2012, Journal of the American Society of Echocardiography
Citation Excerpt :
It is well known that LAA dysfunction is a major thromboembolic source in patients with stroke with AF.3,4 Many clinical studies have shown that TEE parameters indicating LAA dysfunction, such as reduction of the LAA eV and/or the development of SEC, can reflect atrial mechanical remodeling and thrombus formation.5,6,22 Because these established predictors of LAA dysfunction are evaluated using TEE imaging, it is difficult to routinely screen all patients with AF for the presence of LAA dysfunction in clinical practice.
It is important to evaluate left atrial appendage (LAA) dysfunction for primary and secondary prevention of stroke in patients with atrial fibrillation (AF). LAA dysfunction can reportedly be evaluated by LAA wall velocity (LAWV) measured by transthoracic echocardiographic (TTE) imaging. The aim of this study was to examine whether TTE-LAWV can predict long-term cerebrovascular events in patients with ischemic stroke with AF.
TTE imaging and transesophageal echocardiographic imaging were performed <7 days after onset in 179 consecutive patients with stroke with AF. TTE-LAWV was measured using Doppler tissue imaging at the LAA tip from the parasternal short-axis view on TTE imaging, as previously reported. All patients were followed up prospectively.
Cerebrovascular events were defined as cerebrovascular death and/or recurrent ischemic stroke requiring hospitalization. There were 32 cerebrovascular events during a median follow-up period of 397 days. TTE-LAWV was significantly lower in patients with cerebrovascular events than in patients without (8.3 ± 2.8 vs 11.3 ± 4.0 cm/sec, P < .01). Cox multivariate hazard analysis showed that low TTE-LAWV (<8.7 cm/sec) was an independent predictor of cerebrovascular events (hazard ratio, 3.460; P < .05). Kaplan-Meier analysis showed that cerebrovascular event rates were significantly higher in patients with low TTE-LAWV (<8.7 cm/sec) compared with those with high TTE-LAWV (34% vs 7%, P < .01).
Impaired LAA function was associated with long-term cerebrovascular events in patients with stroke with AF. TTE-LAWV may be a feasible parameter for risk stratification in patients with AF.
2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society
2011, Journal of the American College of Cardiology
Citation Excerpt :
This phenomenon relates to fibrinogen-mediated erythrocyte aggregation (220) and is not resolved by anticoagulation (221). There is evidence that SEC is a marker of stasis caused by AF (222–224). Independent predictors of SEC in patients with AF include LA enlargement, reduced LAA flow velocity (213,225).

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Valvular heart diseasePredictors of left atrial spontaneous echo contrast and thrombi in patients with mitral stenosis and atrial fibrillation

Abstract

Section snippets

Patients

Prevalences in the study population

Discussion

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

Am J Cardiol

Am Heart J

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Am J Cardiol

Am J Cardiol

Valvular heart disease
Predictors of left atrial spontaneous echo contrast and thrombi in patients with mitral stenosis and atrial fibrillation