Influence of mitral regurgitation on left atrial thrombus and spontaneous echocardiographic contrast in patients with rheumatic mitral valve disease

doi:10.1016/S0002-9149(99)80081-2

The American Journal of Cardiology

Volume 76, Issue 4, 1 August 1995, Pages 279-281

https://doi.org/10.1016/S0002-9149(99)80081-2 Get rights and content

Abstract

The aim of this study was to investigate the influence of mitral regurgitation (MR) on left atrial (LA) thrombus formation and spontaneous echocardiographic contrast in patients with rheumatic mitral valve disease. LA thrombus and spontaneous contrast are considered risk factors for embolic complications. The presence of MR has been related to a low incidence of embolization; however, its effect on thrombus formation and spontaneous contrast has not been clarified. We studied by transesophageal echocardiography 55 patients with rheumatic mitral valve disease, who were receiving anticoagulant treatment. Atrial thrombus was detected in 13 patients who had a lower incidence of significant MR (p <0.03), a smaller regurgitant jet (p <0.02), and a higher incidence of atrial fibrillation (p <0.05) than the rest of the group. Spontaneous contrast was detected in 34 patients with larger atria (p <0.006), smaller regurgitant jets (p <0.05), a smaller mitral valve area (p <0.008), and a higher incidence of atrial fibrillation (p <0.002) than the rest of the group. Patients without significant MR are at high risk for LA thrombus formation and subsequent embolization and represent a subgroup in whom careful anticoagulation is needed. Conversely, the presence of significant MR correlates with a lower incidence of spontaneous contrast, thrombi, and embolization.

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Cited by (49)

Effect of mitral regurgitation on stroke risk in patients with non-rheumatic atrial fibrillation
2022, Archives of Cardiovascular Diseases
Citation Excerpt :
We can distinguish two scenarios: (1) patients with rheumatic valve disease and AF and (2) patients with non-rheumatic AF. In the first case, several studies have demonstrated a significant reduction in the formation of atrial thrombus or systemic embolism [4–7]. However, in patients without rheumatic valve disease, some studies have pointed to a reduction in the formation of atrial thrombus and systemic embolism [8–14] and other studies have shown neutral results [15–18].
Atrial fibrillation (AF) carries a thrombotic risk related to blood stasis in the left atrium. In patients with rheumatic valve disease and AF, the presence of severe mitral regurgitation (MR) has been shown to reduce the risk of atrial thrombosis and stroke. However, in patients without rheumatic disease, the results are controversial.
To analyse the association between MR and the incidence of stroke in patients with non-rheumatic AF.
We analysed data from the retrospective CardioCHUVI-AF registry, which includes 15,720 patients with AF (without mechanical prostheses or rheumatic valvular disease) in the Vigo area of Spain, during 2014–2018. We grouped the patients according to MR grades: 0–2 (n = 15,194) and 3–4 (n = 526). We performed univariate and multivariable competitive risk analyses to analyse the association between MR and stroke, with death as the competitive event.
During a median (interquartile range [IQR]) follow-up of 4.9 (2.8–4.9) years, 859 patients (5.5%) suffered a stroke. The stroke incidence was 1.3 per 100 person-years (95% confidence interval [95% CI]: 1.2–1.4), with no difference between the MR groups. In univariate analysis, no relationship was observed between MR grade and stroke (subdistribution hazard ratio [sHR]: 1.12, 95% CI: 0.79–1.60; P = 0.53); likewise after multivariable analysis (sHR: 0.98, 95% CI: 0.68–1.41; P = 0.90). This same relationship was evaluated in subgroups of interest (patients with and without: oral anticoagulation, CHA₂DS₂-VASc ≥ 2, prior heart failure, aortic valve disease, left ventricular ejection fraction ≤ 40%, and moderate–severe left atrial dilation), with results consistent with the overall population.
In our large registry of patients with non-rheumatic AF, we did not find a protective effect of grade 3–4 MR on the risk of stroke.
La fibrillation auriculaire (FA) comporte un risque thrombotique lié à la stase sanguine produite dans l’oreillette gauche. Chez les patients atteints de valvulopathie rhumatismale et de FA, il a été démontré que la présence d’une régurgitation mitrale (RM) sévère réduit le risque de thrombose auriculaire et d’accident vasculaire cérébral (AVC). Chez les patients sans maladie rhumatismale, les résultats sont controversés.
D’analyser l’association entre la RM et l’incidence des AVC chez les patients atteints de FA non rhumatismale.
Nous avons analysé les données du registre rétrospectif CardioCHUVI-AF, qui comprend 15 720 patients atteints de FA (à l’exclusion des patients porteurs de prothèses valvulaires et de valvulopathies rhumatismales) dans la région de Vigo en Espagne, de 2014 à 2018. Nous avons regroupé les patients selon les grades RM : 0–2 (n = 15 194) et 3–4 (n = 526). Nous avons effectué une analyse multivariée du risque concurrentiel pour analyser l’association entre la RM et l’AVC avec un modèle de risque compétitif, la mort étant l’événement compétitif.
Au cours d’un suivi médian (intervalle interquartile [IQR]) de 4,9 (2,9–4,9) ans, 859 patients (5,5 %) ont subi un AVC. Le taux d’incidence d’AVC était de 1,3 pour 100 années-personnes (intervalle de confiance à 95 % [IC95 %] : 1,2–1,4), sans différence entres les groupes de RM. Dans l’analyse univariée, aucune relation n’a été observée entre les grades de RM et l’AVC (rapport de risque de sous-distribution [sHR] : 1,12, IC95 % : 0,79–1,60 ; p = 0,53). Après l’analyse multivariée, aucune association significative n’a été observée entre les grades de RM et l’AVC (sHR : 0,98, IC95 % : 0,68–1,41 ; p = 0,90). Cette même relation a été évaluée par sous-groupes d’intérêt (patients avec et sans: anticoagulation orale, CHA₂DS₂-VASc ≥ 2, insuffisance cardiaque antérieure, fraction d’éjection ventriculaire gauche ≤ 40 %, maladie de la valve aortique et dilatation auriculaire gauche), avec des résultats cohérents avec l’échantillon global.
Dans notre vaste registre de patients atteints de FA non rhumatismale, nous n’avons pas trouvé d’effet protecteur d’une RM significative (grades 3–4) sur le risque d’AVC.
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.
Identification of Intracardiac Thrombus
2019, Essential Echocardiography: A Companion to Braunwald's Heart Disease
Echocardiographic imaging to detect intracardiac thrombi is commonly done to identify source of systemic embolism and for risk assessment to prevent subsequent embolism. Additionally, intracardiac thrombi are occasionally identified incidentally on echocardiograms done for other indications. Several intracardiac structures can mimic thrombi and embolism may be related by nonthrombotic etiologies as well including tumor, vegetations, and atheromata. The following chapter reviews the etiology, prevalence, risk factors, echocardiographic appearance of intracardiac thrombi as well as the role of follow-up and multimodality imaging in the evaluation of a patient with suspected thrombus. Additionally, risk factors and prevention of thromboembolism are reviewed.
Formation of a left atrial thrombus during percutaneous mitral valve edge-to-edge repair induced by acute reduction of mitral regurgitation
2018, Journal of Cardiology Cases
Citation Excerpt :
Patients with atrial fibrillation and mitral valve disease have an increased risk of a thromboembolic event. In these patients especially in combination with severely impaired left ventricular function a high graded MR is associated with antithrombotic properties [5]. Some cases with post-interventional thrombus formation in the LA and LV have been reported [2,3,6,7].
Percutaneous mitral valve repair (PMVR) using the MitraClip system (Abbott, Abbott Park, IL, USA) is an innovative method allowing treatment of mitral regurgitation (MR) for patients that are not accessible by conventional operation. Thrombogenicity in the left atrium (LA) in general is increased in the presence of atrial fibrillation and mitral valve disease. We observed in a patient who underwent PMVR an acute change in thrombogenicity in the LA with thrombus formation in the left atrial appendix (LAA) immediately after clip placement. Thrombus formation occurred under verified therapeutic anticoagulation using unfractionated heparin. To our knowledge this is the first patient with documented acute and solid intra-interventional thrombus formation. The observation implies that acute reduction of mitral valve regurgitation and changes in hemodynamics within the LA enhances the risk of thrombus formation.
<Learning objective: Percutaneous mitral valve repair is associated with acute changes in the thrombogenicity within the left atrium despite adequate periinterventional anticoagulation.>
Acute left atrial spontaneous echocardiographic contrast and suspicious thrombus formation following mitral regurgitation reduction with the mitraclip system
2014, JACC: Cardiovascular Interventions
Relation of the severity of mitral regurgitation to thromboembolic risk in patients with atrial fibrillation
2011, International Journal of Cardiology
Citation Excerpt :
Recent guidelines for the management of patients with AF recommend that anticoagulation treatment should be tailored individually according to comorbidities [2]. Although several studies have demonstrated lower prevalence of embolic events in patients with mitral regurgitation (MR), [5–10] others have not [11–13]. It remains unclear, therefore, whether MR can reduce embolic events in AF.
Patients with atrial fibrillation (AF) are at risk for thromboembolism. Although mitral regurgitation (MR) could be protective against left atrial (LA) blood stasis, the relationship between the severity of MR and thromboembolic risk has not been clarified in patients with AF.
271 patients with permanent AF underwent transesophageal echocardiography (TEE). The severity of MR was assessed by Doppler echocardiography. LA blood stasis on TEE and plasma D-dimer levels were used to evaluate the thromboembolic risk.
Patients with severe MR (n = 20) had significantly higher LA appendage peak flow velocity compared to those with no MR (n = 114) and those with only mild MR (n = 92) (p < 0.05). The grade of LA spontaneous echo contrast (SEC) was lower in patients with severe MR compared to those with no, mild or moderate MR (severe MR 0.7 ± 0.7 grade vs moderate MR 1.7 ± 1.0 grade, mild MR 2.2 ± 1.3 grade, and no MR 1.9 ± 1.3 grade, p < 0.05). Multivariate analysis revealed severe MR as a negative predictor of LA blood stasis on TEE findings (odds ratio 0.27; 95% confidence interval 0.09-0.86, p < 0.05). By contrast, D-dimer level was significantly higher in patients with moderate MR compared to those with any other type of severity of MR (moderate MR 1.72 ± 1.45 µg/ml vs severe MR 0.76 ± 0.95 µg/ml, mild MR 0.97 ± 1.09 µg/ml, and no MR 0.82 ± 1.15 µg/ml, p < 0.05).
There is a protective effect of MR on LA blood stasis, but this beneficial effect on thromboembolic risk appears to be limited to patients with severe MR.

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Influence of mitral regurgitation on left atrial thrombus and spontaneous echocardiographic contrast in patients with rheumatic mitral valve disease

Abstract

Left atrial spontaneous echo contrast in mitral valve disease: an indicator for an increased thromboembolic risk

J Am Coll Cardiol

Transesophageal two dimensional echocardiography for the detection of left atrial appendage thrombus

J Am Coll Cardiol

Superiority of transesophageal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology

J Am Coll Cardiol

Atrial fibrillation and atrial enlargement in patients with mitral stenosis

Am Heart J

Atrial fibrillation and left atrial thrombus: an insufferable couple

Am Heart J

Systemic embolism in mitral valve disease

Br Heart J

Diseases of the Heart and Circulation

Significant mitral regurgitation is protective against left atrial spontaneous echo contrast and thrombus as assessed by transoesophageal echocardiography

J Am Soc Echocardiogr

Smoke-like echo in the left atrial cavity in mural valve disease: its features and significance

J Am Coll Cardiol

Left atrial spontaneous echo contrast: a clinical and echocardiographic analysis

J Am Coll Cardiol