Cardiac Center, Creighton University, Omaha, NE, USA.
Am J Ther. 2009 Sep-Oct;16(5):385-92. doi: 10.1097/MJT.0b013e3181727b42.
The incidence of cerebrovascular events (CVEs) was investigated in 95 consecutive patients with atrial fibrillation (AF) with left atrial thrombus (LAT) diagnosed by transesophageal echocardiography (TEE) and in 131 age- and sex-matched AF patients without LAT. Compared with patients without LAT, patients with LAT had a larger left atrial diameter (49 versus 44 mm, P < 0.0001), a lower left ventricular ejection fraction (40% versus 50%, P < 0.0001), a higher prevalence of spontaneous echocardiographic contrast (88% versus 25%, P < 0.001), a reduced left atrial appendage emptying velocity (0.25 versus 0.41 cm/s, P < 0.0001), and less use of antiarrhythmic drugs (61% versus 76%, P = 0.03). Before TEE, the prevalence of prior CVE was higher in LAT patients (20%) compared with patients without LAT (8%) (P = 0.01). Fifty-four of 95 LAT patients (57%) and 81 of 131 non-LAT patients (62%) were on warfarin before TEE. The incidence of prior CVE in LAT patients without warfarin (32%) was higher than that in non-LAT patients without warfarin (10%) (P = 0.02). The mortality rate in LAT patients with an international normalized ratio (INR) >or= 2.0 (42%) was higher than that in patients without LAT and an INR >or= 2.0 (11%) (P < 0.001). Fifty-one of 95 LAT patients (54%) underwent repeat TEE before cardioversion (48 patients received warfarin therapy). The thrombus resolved in 40 of 51 patients (78%) after the first TEE. There was no significant difference in INR between the patients with persistent and resolved LAT. AF patients with persistent LAT had a higher incidence of CVE (45%) than the patients with resolved LAT (5%) (P = 0.003). We suggest that patients with LAT be treated with warfarin to maintain an INR between 2.5 and 3.5 rather than between 2.0 and 3.0 because they are at a high risk for new thromboembolism.
本研究调查了 95 例经食管超声心动图（TEE）诊断为左心房血栓（LAT）的持续性心房颤动（AF）患者和 131 例年龄和性别相匹配的无 LAT 的 AF 患者的脑血管事件（CVE）发生率。与无 LAT 的患者相比，LAT 患者的左心房直径更大（49 毫米比 44 毫米，P < 0.0001），左心室射血分数更低（40%比 50%，P < 0.0001），自发性超声对比的发生率更高（88%比 25%，P < 0.001），左心耳排空速度更低（0.25 厘米/秒比 0.41 厘米/秒，P < 0.0001），抗心律失常药物的使用率更低（61%比 76%，P = 0.03）。TEE 前，LAT 患者（20%）的既往 CVE 发生率高于无 LAT 患者（8%）（P = 0.01）。95 例 LAT 患者中，54 例（57%）和 131 例非 LAT 患者中，81 例（62%）在 TEE 前服用华法林。未服用华法林的 LAT 患者（32%）的既往 CVE 发生率高于未服用华法林的非 LAT 患者（10%）（P = 0.02）。INR >或= 2.0 的 LAT 患者的死亡率（42%）高于无 LAT 且 INR >或= 2.0 的患者（11%）（P < 0.001）。95 例 LAT 患者中有 51 例（54%）在电复律前接受了重复 TEE（48 例接受了华法林治疗）。首次 TEE 后，51 例患者中有 40 例（78%）血栓溶解。持续 LAT 患者和已溶解 LAT 患者的 INR 无显著差异。持续性 LAT 的 AF 患者的 CVE 发生率（45%）高于已溶解 LAT 的患者（5%）（P = 0.003）。我们建议 LAT 患者的 INR 维持在 2.5 到 3.5 之间，而不是 2.0 到 3.0 之间，因为他们有发生新血栓栓塞的高风险。
