Atrial fibrillation: relation between clinical risk factors and transoesophageal echocardiographic risk factors for thromboembolism

S Illien; S Maroto-Järvinen; G von der Recke; C Hammerstingl; H Schmidt; S Kuntz-Hehner; B Lüderitz; H Omran

doi:10.1136/heart.89.2.165

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Cardiovascular medicine

Atrial fibrillation: relation between clinical risk factors and transoesophageal echocardiographic risk factors for thromboembolism

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Author's reply
Stefan Illien
Published on: 11 March 2003
The relevance of spontaneous echo contrast and reduced left atrial appendage flow velocities as inde
Claudia Stöllberger
Published on: 5 February 2003

Published on: 11 March 2003
Author's reply
- Stefan Illien, Physician
- Other Contributors:
  Berndt Lüderitz, Heyder Omran
Dear Editor
We wish to thank Claudia Stöllberger and Josef Finsterer very much for their comments on our paper.
The primary aim of our study was to correlate clinical risk factors for thromboembolism with transoesephageal markers of a thrombogenic milieu. Actually, we could demonstrate that those parameters were related closely. 58.8% of patients with clinical risk factors had a thrombogenic milieu. An incre...
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Dear Editor
We wish to thank Claudia Stöllberger and Josef Finsterer very much for their comments on our paper.
The primary aim of our study was to correlate clinical risk factors for thromboembolism with transoesephageal markers of a thrombogenic milieu. Actually, we could demonstrate that those parameters were related closely. 58.8% of patients with clinical risk factors had a thrombogenic milieu. An increasing number of clinical risk factors was correlated with a higher incidence of a thrombogenic milieu. Stöllberger et al. is correct that we also observed the absence of a thrombogenic milieu on transoesophageal echocardiography (TOE) despite the presence of clinical risk factors in a small number of patients (17.4%). Since a number of studies demonstrated that patients with atrial fibrillation and a TOE finding of a thrombogenic milieu have an increased thromboembolic risk we suggested that patients without clinical risk factors and a thrombogenic milieu may have an increased thromboembolic risk.[1,2] In contrast to the latter studies, Stöllberger and coworkers did not analyze peak emptying velocities in their study and did not account for different degrees of spontaneous echo contrast.[3] This may explain, why Stöllberger et al. did not identify a thrombogenic milieu as an independent risk factor for thromboembolism in their study. The technical aspects of analyzing left atrial appendage function was published in a number of studies by our study group and others.[4-9] We agree that the value of systematic TOE screening in all patients with atrial fibrillation has to be assessed in future prospective studies as already stated in our paper. Nevertheless, it would be useful for planning large scale prospective studies to know the incidence of a thrombogenic milieu in patients with and without clinical risk factors.
References (1) Leung DY, Black IW, Cranney GB, Hopkins AP, Walsh WF. Prognostic implications of left atrial spontaneous echo contrast in nonvalvular atrial fibrillation. J Am Coll Cardiol 1994;24:755-762
(2) The Stroke Prevention in Atrial Fibrillation Committee on Echocardiography. Transesophageal echocardiographic correlates of thromboembolism in high-risk patients with nonvalvular atrial fibrillation. Ann Intern Med 1998;128:639-647
(3) Stöllberger C, Chnupa P, Kronik G, Brainin M, Finsterer J, Schneider B, Slany J. Transesophageal echocardiography to assess embolic risk in patients with atrial fibrillation. Ann Intern Med 1998;128:630-638
(4) Chan SK, Kannam JP, Douglas PS, Manning WJ. Multiplane transesophageal assessment of left atrial appendage anatomy and function. Am J Cardiol 1995;76(7):528-530
(5) Agmon Y, Khandheria BK, Gentile F, Seward JB. Echocardiographic assessment of the left atrial appendage. J Am Coll Cardiol 1999;34(7):1867-1877
(6) Omran H, Jung W, Rabahieh R, Schimpf R, Wolpert C, Hagendorff A, Fehske W, Lüderitz B. Left atrial chamber and appendage function after internal atrial defibrillation: a prospective and serial transesophageal echocardiographic study. J Am Coll Cardiol 1997;29(1):131-8.
(7) Omran H, Jung W, Rabahieh R, Wirtz P, Becher H, Illien S, Schimpf R, Lüderitz B. Imaging of thrombi and assessment of left atrial appendage function: a prospective study comparing transthoracic and transoesophageal echocardiography. Heart 1999;81(2):192-8.
(8) Omran H, Rang B, Schmidt H, Illien S, Schimpf R, MacCarter D, Kubini R, von der Recke G, Tiemann K, Becher H, Lüderitz B. Incidence of left atrial thrombi in patients in sinus rhythm and with a recent neurologic deficit. Am Heart J 2000 Oct;140(4):658-62.
(9) Schmidt H, von der Recke G, Illien S, Lewalter T, Schimpf R, Wolpert C, Becher H, Lüderitz B, Omran H. Prevalence of left atrial chamber and appendage thrombi in patients with atrial flutter and its clinical significance. J Am Coll Cardiol 2001;38(3):778-84.
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Conflict of Interest:
None declared.
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Published on: 5 February 2003
The relevance of spontaneous echo contrast and reduced left atrial appendage flow velocities as inde
- Claudia Stöllberger, Cardiologist
- Other Contributors:
  Josef Finsterer
Dear Editor
In their interesting study, Illien et al.[1] recently reported that among 302 consecutive patients with nonrheumatic atrial fibrillation(AF), 8 were detected who had no clinical risk factors for stroke/embolism (age>65, previous stroke/embolism, arterial hypertension, diabetes mellitus, heart failure) but a transesophageal echocardiographic(TEE) finding of a “thrombogenic milieu”, either sponta...
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Dear Editor
In their interesting study, Illien et al.[1] recently reported that among 302 consecutive patients with nonrheumatic atrial fibrillation(AF), 8 were detected who had no clinical risk factors for stroke/embolism (age>65, previous stroke/embolism, arterial hypertension, diabetes mellitus, heart failure) but a transesophageal echocardiographic(TEE) finding of a “thrombogenic milieu”, either spontaneous echo contrast(SEC) or decreased left atrial appendage(LAA) flow velocities. From these findings, the authors conclude that AF patients without clinical risk factors and a thrombogenic milieu constitute a subgroup of patients with increased risk for stroke/embolism. Patients of this subgroup will be missed at clinical risk stratification. Thus, the practical consequences of these assumptions would be to perform TEE in all AF patients without clinical risk factors for stroke/embolism in order to look for a thrombogenic milieu. There are several objections that have to be raised against these hypotheses:
1. The authors did not demonstrate that in any of these 8 patients stroke/embolism had occurred, neither in their previous history nor at follow-up investigations, which were not carried out. Based on this lack of information, it is not justified to conclude that these patients have an increased thromboembolic risk.
2. We have previously shown in a prospective study including 409 AF patients that SEC and LAA thrombi were no independent risk factors for stroke/embolism during a follow-up period of 5[2] and 10[3] years.
3. According to the retrospective design of Illien’s study, thromboembolic risk was only assessed by presence or absence of clinical risk factors. It has been repeatedly confirmed that there is an association between the prevalence of spontaneous echo contrast, LAA thrombi, decreased LAA velocities and clinical risk factors for stroke/embolism. However, no prospective study demonstrated so far, that spontaneous echo contrast and decreased LAA flow velocities are risk factors for stroke/embolism independent from the clinical risk factors.
4. Additionally, no clinical information is provided about the 8 patients with thrombogenic milieu in the absence of clinical risk factors for stroke/embolism. Particularly, it is not mentioned, whether they were treated with betablockers, a condition reported to induce SEC, decrease LAA flow velocity and promote thrombus formation.[4]
5. Furthermore, measurements of LAA flow velocities in AF are flawed by influences like heart rate and especially the duration of diastole [5]. It is not mentioned, how many heart cycles were taken for calculation of the mean LAA flow velocity, which is of particular importance when investigating AF patients. Blood pressure values, which also influence LAA flow velocity, are not given [4,5].
From these objections we conclude that it is still reasonable to assess the risk for stroke/embolism of AF patients on well established clinical criteria and not on TEE findings. It would be useful, however, to assess the risk for stroke/embolism in patients without clinical risk factors for stroke/embolism, but with spontaneous echo contrast or decreased LAA flow, by means of a prospective long-term follow-up study.
References
(1) Illien S, Maroto-Järvinen S, von der Recke G, Hammerstingl C, Schmidt H, Kuntz-Hehner S, Lüderitz B, Omran H. Atrial fibrillation: relation between clinical risk factors and transesophageal echocardiographic risk factors for thromboembolism. Heart 2003;89:165-8.
(2) Stöllberger C, Chnupa P, Kronik G, Brainin M, Finsterer J, Schneider B, Slany J, for the ELAT Study Group. Transesophageal echocardiography to assess embolic risk in patients with atrial fibrillation. Ann Intern Med 1998:128;630-8.
(3) Stöllberger C, Chnupa P, Abzieher C, Länger T, Finsterer J, Klem I, Hartl E, Wehinger C, Schneider B. Mortality and rate of stroke or embolism in atrial fibrillation during long-term follow-up in the ELAT (Embolism in Left Atrial Thrombi) study. Clin Cardiol 2003 (in press).
(4) Bilge M, Güler N, Eryonucu B, Erkoc M. Does acute-phase beta blockade reduce left atrial appendage function in patients with chronic nonvalvular atrial fibrillation? J Am Soc Echocardiogr 2001;14:194-9.
(5) Noda T, Arakawa M, Miwa H, Ito Y, Kagawa K, Nishigaki K, Hirakawa S, Fujiwara H. Effects of heart rate on flow velocity of the left atrial appendage in patients with nonvalvular atrial fibrillation. Clin Cardiol 1996;19:295-300.
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Conflict of Interest:
None declared.
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