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21 Intracardiac thrombi in cardiac amyloidosis, a common finding
  1. Tushar Kotecha1,
  2. Esther Gonzalez-Lopez2,
  3. Andrej Corovic1,
  4. Sarah Anderson1,
  5. Liza Chacko1,
  6. James Brown1,
  7. Dan S Knight1,
  8. A John Baksi3,
  9. James C Moon4,
  10. Peter Kellman5,
  11. Pablo Garcia-Pavia2,
  12. Julian D Gillmore1,
  13. Philip N Hawkins1,
  14. Marianna Fontana1
  1. 1Royal Free Hospital, London, UK
  2. 2University Hospital Puerta de Hierro Majadahonda, Madrid, Spain
  3. 3Royal Brompton Hospital, London, UK
  4. 4Barts Health NHS Trust, London, UK
  5. 5National Institutes of Health, National Heart, Lung and Blood Institute, Bethesda, USA


Background Cardiac amyloidosis (CA) has been associated with a high prevalence of intracardiac thrombi, but this was reported in small cohorts of high risk patients (with a clinical indication for transoesophageal echocardiography). It is therefore not known whether such observations are applicable to the general CA population.

Purpose To assess the prevalence of intracardiac thrombi in patients with CA.

Methods 324 consecutive patients with CA were studied prospectively using a standard CMR protocol at 1.5T, including early and late gadolinium imaging and T1 mapping. Early gadolinium images (segmented imaging, trigger 2) of the left atrial appendage (LAA) were acquired using a 5 mm contiguous stack and a TI of 440 ms.

Results The study participants comprised 155 with light chain CA (AL), 166 with transthyretin amyloidosis (ATTR), 2 with Apo A-I, and 1 with Apo A-IV CA. The prevalence of intracardiac thrombi was 5.2% in AL, 7.2% in ATTR; 6.2% overall. 90% of thrombi were in the LAA. This was higher when there was atrial fibrillation (9.1% AL, 14.3% ATTR) but intracardiac thrombi were also present in sinus rhythm (SR) 3.1% (4.5% AL, 1.1% ATTR). In all patients with AF the thrombi were present despite long term anticoagulation. The presence of intracardiac thrombi was associated with a greater degree of systolic dysfunction and myocardial amyloid infiltration (higher native T1 and ECV).

Abstract 21 Figure 1

Acquisition of stack through the LAA. Early gadolinium ¡mages of the LAA (bottom row) acquired using a 5 mm contiguous stack through the LAA (top row) and an inversion time of 440 ms to confirm the presence or absence of thrombus vs normal pectinate muscle. The thrombus in the left atrial appendage can only be visualised in the last two images (red arrows in panel 4 and 5) and could have been missed with the acquisition of only one image

Conclusions The prevalence of intracardiac thrombi in CA and AF is high despite long term anticoagulation, with significant thrombus prevalence even in SR, meriting vigilance for intracardiac thrombi in all. CMR with early gadolinium imaging of the LAA is a valuable screening tool for thrombi in the LAA and should be routine part of the clinical protocol when amyloidosis is suspected. Current guidelines for electrical cardioversion after prolonged anticoagulation without screening forthrombus in the LAA should not be applied to patients with CA.

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