Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California.
Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
Am J Cardiol. 2019 Jan 1;123(1):63-68. doi: 10.1016/j.amjcard.2018.09.027. Epub 2018 Sep 26.
Left atrial appendage (LAA) thrombus in nonvalvular atrial fibrillation or flutter (AF) is a major cause of stroke and presents a therapeutic dilemma in a rhythm-control strategy. The prevalence and resolution of LAA thrombus has not been studied well in the era of non-vitamin K antagonist oral anticoagulant use. This study sought to establish (1) the prevalence of LAA thrombus (2) the prevalence of LAA thrombus despite antithrombotic therapy, (3) the rate of persistence of LAA thrombus despite appropriate anticoagulant prescriptions, and (4) determinants of LAA thrombus persistence. Consecutive transesophageal echocardiograms (TEE) performed in patients with AF were reviewed to estimate the overall prevalence of LAA thrombus and the resolution rate in those with repeat studies. Multivariable logistic regression was used to identify clinical and echocardiographic predictors of thrombus resolution. Of 1,485 patients with AF, 117 (8%) had LAA thrombus. Of those, 62 had repeat TEE within 1 year and 58 (94%) were prescribed adequate anticoagulation in TEE studies (mean interval 96 ± 72 days). Thirty-seven patients (60%) had LAA thrombus resolution. Thrombus resolution rate was only 79% in patients considered on appropriate anticoagulation. Patients with persistent LAA thrombus were more likely to have diabetes; no other clinical or echocardiographic variable was independently associated with thrombus resolution. There was no significant difference in LAA thrombus resolution between non-vitamin K antagonist oral anticoagulants and warfarin. LAA thrombus persistence despite adequate anticoagulation is relatively common and difficult to predict clinically; TEE before electrical cardioversion should be considered regardless of anticoagulation status.
左心耳（LAA）血栓在非瓣膜性心房颤动或房扑（AF）中是中风的主要原因，并在节律控制策略中带来治疗困境。在非维生素 K 拮抗剂口服抗凝剂使用时代，尚未很好地研究 LAA 血栓的发生率和消退情况。本研究旨在确定：（1）LAA 血栓的发生率；（2）尽管进行了抗血栓治疗，但仍存在 LAA 血栓的发生率；（3）尽管开具了适当的抗凝药物，但 LAA 血栓持续存在的比例；（4）LAA 血栓持续存在的决定因素。回顾性分析了在 AF 患者中进行的连续经食管超声心动图（TEE），以评估 LAA 血栓的总体发生率以及重复检查时的消退率。采用多变量逻辑回归分析来确定血栓消退的临床和超声心动图预测因素。在 1485 例 AF 患者中，有 117 例（8%）存在 LAA 血栓。其中 62 例在 1 年内进行了重复 TEE，58 例（94%）在 TEE 研究中接受了充分的抗凝治疗（平均间隔 96±72 天）。37 例（60%）患者的 LAA 血栓得到了消退。在被认为接受了适当抗凝治疗的患者中，血栓消退率仅为 79%。持续存在 LAA 血栓的患者更可能患有糖尿病；没有其他临床或超声心动图变量与血栓消退独立相关。非维生素 K 拮抗剂口服抗凝剂与华法林在 LAA 血栓消退方面无显著差异。尽管进行了充分抗凝，但 LAA 血栓持续存在的情况仍较为常见，且难以在临床上预测；无论抗凝状态如何，在进行电复律之前，都应考虑进行 TEE。
