Real-Time Pathophysiologic Correlates of Left Atrial Appendage Thrombus in Patients Who Underwent Transesophageal-Guided Electrical Cardioversion for Atrial Fibrillation

Although current guidelines advocate using the CHA₂DS₂-VASc score to assess the risk of stroke in patients with atrial fibrillation (AF), compared with transesophageal echocardiography (TEE), its ability to predict left atrial appendage thrombus (LAAT) is limited. We studied 3,324 consecutive patients with sustained AF from our prospective registry of patients who underwent first-time TEE-guided electrical cardioversion (ECV) from May 2000 through March 2012. The association of CHA₂DS₂-VASc score or TEE risk factors with the occurrence of LAAT was analyzed. The mean (SD) age was 69 (12.5) years and 67% were men. LAAT was identified in 49 (1.5%) during pre-ECV TEE. Compared with patients without LAAT, those with LAAT had lower peak left atrial appendage emptying velocity (LAAEV) (17.2 ± 8.5 vs 36.6 ± 20.8; p <0.001) and left ventricular ejection fraction (LVEF) (39.9 ± 17.6 vs 51.4 ± 13.7; p <0.001); their CHA₂DS₂-VASc score also was higher, but the difference was not statistically significant (3.6 ± 1.4 vs 3.2 ± 1.6; p = 0.06). Multivariate logistic regression analysis identified an LVEF ≤40% (adjusted odds ratio 2.48, 95% confidence interval 1.38 to 4.46), LAAEV 20.3 to 33.9 cm/s (odds ratio 12.19, 95% confidence interval 1.53 to 96.86), and LAAEV ≤20.2 cm/s as independent predictors of LAAT. An LAAEV cut-point of 20 cm/s and an LVEF ≤40% were optimal for detecting LAAT (sensitivity 75% and 62%; specificity 77% and 75%; area under the curve 0.822 and 0.776, respectively). On follow-up, LAAT was an independent risk factor of subsequent ischemic stroke but did not influence survival. In conclusion, reduced LVEF and reduced LAAEV are important pathophysiologic correlates of left atrial appendage thrombogenesis and subsequent ischemic stroke in patients who underwent TEE-guided ECV for AF.