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Original research
Risk of left atrial appendage thrombus and stroke in patients with atrial fibrillation and mitral regurgitation
  1. Rowlens Melduni1,
  2. Vuyisile T Nkomo1,
  3. Waldemar Wysokinski1,
  4. Bernard J Gersh1,
  5. Abhishek Deshmukh1,
  6. Ratnasari Padang1,
  7. Eddie L Greene2,
  8. Jae K Oh1,
  9. Hon-Chi Lee1
  1. 1Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
  2. 2Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
  1. Correspondence to Dr Rowlens Melduni, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA; melduni.rowlens{at}


Objective To investigate the association of mitral regurgitation (MR) on thromboembolic risk of patients with non-valvular atrial fibrillation (NVAF) undergoing transoesophageal echocardiography (TEE)-guided cardioversion.

Methods Data for consecutive patients who underwent TEE-guided cardioversion for NVAF between 2000 and 2012 were analysed. MR severity was assessed by Doppler echocardiography and classified as ≤mild, moderate or severe. Left atrial appendage emptying velocities were averaged for five consecutive cycles. Multivariable regression models were used to identify independent predictors of left atrial appendage thrombus (LAAT) and stroke.

Results 2950 patients (age, 69.3±12.2 years, 67% men) were analysed. 2173 (73.7%) had ≤mild MR; 631 (21.4%), moderate MR; and 146 (4.9%), severe MR. Patients with moderate (age, 72.4±10.7 years) and severe (age, 72.8±12.1 years) MR were older than those with ≤mild MR (age, 68.2±12.5 years). The prevalence of LAAT was 1.5% (n=43). CHA2DS2-VASc scores (≤mild MR, 3.0±1.6; moderate MR, 3.5±1.5; severe MR, 3.9±1.5; p<0.001) and heart failure frequency (≤mild MR, 38.4%; moderate MR, 48.0%; severe MR, 69.2%; p<0.001) were increasingly higher with greater MR severity. Multivariable logistic regression analysis showed no association of moderate MR (OR 0.77, 95% CI 0.38 to 1.56) or severe MR (OR 0.55, 95% CI 0.21 to 1.49) with LAAT. During a mean follow-up of 7.3±5.1 years (median 7.5, IQR, 2.7–10.9), 216 patients had an ischaemic stroke. Adjusted Cox regression analysis showed no significant association of moderate MR (HR 1.22, 95% CI 0.88 to 1.68) or severe MR (HR 0.73, 95% CI 0.31 to 1.46) with stroke.

Conclusions Among patients with NVAF, the presence or severity of MR was not associated with a decreased risk of LAAT or stroke.

  • echocardiography
  • atrial fibrillation
  • stroke

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  • Contributors RM took the lead in drafting the manuscript. All authors and coauthors helped to conceive the original idea, developed the hypothesis, provided critical feedback and helped shape the research, analysis and manuscript, performed the performed the analytical calculations, contributed to the interpretation of the results, or discussed the results and contributed to the final version of the manuscript.

  • Funding RM is supported by the National Institutes of Health KO1 (HL 135288).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were involved in the design, conduct, reporting or dissemination plans of this research. Refer to the Methods section for further details.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the Mayo Clinic Institutional Review Board, Rochester, Minnesota, USA.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

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