Kurzawski Jacek, Janion-Sadowska Agnieszka, Zandecki Lukasz, Piatek Lukasz, Koziel Dorota, Sadowski Marcin
Swietokrzyskie Cardiology Centre, Kielce, Poland.
The Jan Kochanowski University, ul. Stefana Zeromskiego 5, 25-001, Kielce, Poland.
Cardiovasc Ultrasound. 2020 Feb 15;18(1):7. doi: 10.1186/s12947-020-00188-0.
Peak left atrial longitudinal strain (PALS) can help identify left atrial appendage thrombus (LAAT) in patients with atrial fibrillation. Nevertheless, few studies have been performed in patients in sinus rhythm without established indications for anticoagulation but with increased risk of LAAT, such as heart failure (HF) with severe left ventricular systolic dysfunction patients. The primary aim of this study was to identify clinical and transthoracic echocardiography predictors of LAAT in HF patients with very low left ventricular ejection fraction and sinus rhythm. The secondary objective was to analyze frequencies and predictors of a composite clinical endpoint of death or hospitalization for ischemic stroke.
We included 63 patients with HF, left ventricular ejection fraction < 25%, sinus rhythm at presentation, no history of atrial fibrillation, and without any established indications for anticoagulation. We determined whether clinical and transthoracic echocardiography parameters, including left atrial strain analysis, predicted LAAT. Transesophageal echocardiography was performed in all patients. When LAAT was detected, anticoagulation was recommended. The participants were followed for a median of 28.6 months (range 4-40) to determine the composite endpoint.
LAAT was found in 20 (31.7%) patients. Global PALS was the best independent predictor of LAAT in univariate and multivariate logistic regression analyses (Gini coefficient 0.65, area under the receiver-operating characteristic curve 0.83). A global PALS value below 8% was a good discriminator of LAAT presence (odds ratio 30.4, 95% CI 7.2-128, p < 0.001). During follow-up, 18 subjects (28.6%) reached the composite clinical endpoint. CHADS-VASc score, use of angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers, and body surface area were significant predictors for the composite endpoint of death or hospitalization for ischemic stroke in the multivariate regression model.
LAAT was relatively common in our group of HF patients and PALS has shown prognostic potential in LAAT identification. Further research is needed to determine whether initiation of anticoagulation or additional screening supported by PALS measurements will improve clinical outcomes in these patients.
左心房纵向应变峰值（PALS）有助于识别心房颤动患者的左心耳血栓（LAAT）。然而，针对无既定抗凝指征但LAAT风险增加的窦性心律患者，如重度左心室收缩功能不全的心力衰竭（HF）患者，开展的研究较少。本研究的主要目的是确定左心室射血分数极低且为窦性心律的HF患者中LAAT的临床及经胸超声心动图预测因素。次要目标是分析死亡或缺血性卒中住院这一复合临床终点的发生频率及预测因素。
我们纳入了63例HF患者，其左心室射血分数<25%，就诊时为窦性心律，无房颤病史，且无任何既定抗凝指征。我们确定临床及经胸超声心动图参数（包括左心房应变分析）是否可预测LAAT。所有患者均接受经食管超声心动图检查。检测到LAAT时，建议进行抗凝治疗。对参与者进行了为期28.6个月（范围4 - 40个月）的随访，以确定复合终点。
20例（31.7%）患者发现有LAAT。在单因素和多因素逻辑回归分析中，整体PALS是LAAT的最佳独立预测因素（基尼系数0.65，受试者工作特征曲线下面积0.83）。整体PALS值低于8%是LAAT存在的良好判别指标（比值比30.4，95%置信区间7.2 - 128，p < 0.001）。随访期间，18名受试者（28.6%）达到复合临床终点。在多因素回归模型中，CHADS - VASc评分、血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂的使用以及体表面积是死亡或缺血性卒中住院这一复合终点的显著预测因素。
LAAT在我们的HF患者组中相对常见，且PALS在LAAT识别中显示出预后潜力。需要进一步研究以确定通过PALS测量启动抗凝治疗或进行额外筛查是否会改善这些患者的临床结局。
