McGill University Health Centre, Montreal, Quebec, Canada.
McGill University Health Centre, Montreal, Quebec, Canada; Research Institute of McGill University Health Centre, Montreal, Quebec, Canada.
Can J Cardiol. 2018 Mar;34(3):252-261. doi: 10.1016/j.cjca.2017.12.008. Epub 2017 Dec 15.
Intracardiac thrombi arising in the left atrial appendage (LAA) are the principal cause of stroke in nonvalvular atrial fibrillation (AF). Predicting the presence of LAA thrombi is of vital importance in stratifying patients that would need further LAA imaging prior to cardioversion or AF ablation.
We comprehensively searched PubMed from its inception to November 2017 for randomized controlled trials, cohort and case control studies, as well as for case series on LAA thrombi risk factors, imaging, prevention, and anticoagulation management in atrial fibrillation.
A systematic review of the literature identified 106 articles that investigated the presence of LAA thrombi in AF patients. We classified the articles according to topic and reported on: (1) risk factors; (2) diagnostic imaging modalities; (3) prevention strategies before cardioversion; (4) prevention strategies before AF ablation; and (5) management of detected LAA thrombi.
Integration of clinical, biomarker, and imaging risk factors can improve overall prediction for the presence of LAA thrombi, translating into improved patient selection for imaging. The gold standard for the diagnosis of LAA thrombi remains transesophageal echocardiography, although intracardiac ultrasound, cardiac computed tomography, and cardiovascular magnetic imaging are promising alternative modalities. When LAA thrombi are discovered, the treatment regimen remains variable, although direct oral anticoagulants might have efficacy similar to vitamin K antagonists. Future trials will help further elucidate direct oral anticoagulant use for the treatment of LAA thrombi.
左心耳（LAA）内形成的心腔内血栓是导致非瓣膜性心房颤动（AF）患者发生中风的主要原因。预测 LAA 血栓的存在对于在电复律或 AF 消融之前对需要进一步进行 LAA 成像的患者进行分层非常重要。
我们全面检索了从创建到 2017 年 11 月的 PubMed 数据库，以获取有关 LAA 血栓危险因素、成像、预防和 AF 抗凝管理的随机对照试验、队列和病例对照研究以及病例系列研究。
对文献的系统回顾确定了 106 篇研究 AF 患者 LAA 血栓存在的文章。我们根据主题对文章进行了分类，并报告了：（1）危险因素；（2）诊断成像方式；（3）电复律前的预防策略；（4）AF 消融前的预防策略；和（5）检测到的 LAA 血栓的管理。
整合临床、生物标志物和影像学危险因素可以提高 LAA 血栓存在的整体预测，从而改善对成像的患者选择。LAA 血栓的诊断标准仍然是经食管超声心动图，尽管腔内超声、心脏计算机断层扫描和心血管磁共振成像等都是有前途的替代方式。当发现 LAA 血栓时，治疗方案仍然存在差异，尽管直接口服抗凝剂可能与维生素 K 拮抗剂具有相似的疗效。未来的试验将有助于进一步阐明直接口服抗凝剂在 LAA 血栓治疗中的应用。
