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Published on: November 28, 2018
Left atrial thrombus and spontaneous echo-contrast in nonanticoagulated mitral stenosis. A transesophageal
C Vigna1, V de Rito, G M Criconia
1Department of Cardiology, Ospedale Casa Sollievo della Sofferenza, IRCSC, San Giovanni Rotondo, Italy.
Insights
In nonanticoagulated mitral stenosis (MS), atrial fibrillation and left atrial (LA) size predict LA spontaneous echo-contrast (SEC). However, predicting LA thrombus requires transesophageal echocardiography (TEE) even with LA SEC.
Area of Science:
- Cardiovascular Imaging
- Cardiac Surgery
- Interventional Cardiology
Background:
- Left atrial (LA) thrombus and spontaneous echo-contrast (SEC) are indicators of embolization risk in mitral stenosis (MS).
- Predicting these findings using transthoracic echocardiography (TTE) can guide clinical decisions in nonanticoagulated patients.
Purpose of the Study:
- To determine if clinical and TTE variables can predict LA thrombus and LA SEC in nonanticoagulated MS patients.
- To assess the utility of TEE for detecting LA thrombus and LA SEC.
Main Methods:
- Clinical data (age, NYHA class, rhythm, prior embolization) and TTE variables (mitral area, gradient, LA size, regurgitation) were collected.
- Transesophageal echocardiography (TEE) was used to confirm LA thrombus and LA SEC.
- Multivariate regression analysis identified predictors of LA thrombus and LA SEC.
Main Results:
- LA thrombus was detected in 20.3% of patients, predominantly those with atrial fibrillation.
- LA SEC was found in 67.8% of patients by TEE, significantly more than by TTE.
- Atrial fibrillation and larger LA end-systolic area predicted both LA thrombus and LA SEC; smaller mitral area predicted LA SEC.
- LA SEC was accurately predicted by atrial fibrillation and LA area ≥ 30 cm², but LA thrombus detection within the LA SEC group remained challenging without TEE.
Conclusions:
- Transesophageal echocardiography (TEE) may not be routinely necessary for detecting LA spontaneous echo-contrast (SEC) in mitral stenosis (MS) patients.
- TEE remains essential for definitive LA thrombus detection when clinically indicated for decision-making in MS patients.
Objective:
The aim of the study was to investigate if evidence at transthoracic echocardiography (TTE) of left atrial (LA) thrombus and LA spontaneous echo-contrast (LA SEC), which are potential precursors of embolization, can be predicted by clinical and TTE variables in nonanticoagulated mitral valve stenosis (MS).
Design:
Clinical (age, NYHA class, rhythm, previous embolization) and TTE variables were related to transesophageal echocardiography (TEE) evidence of LA thrombus and/or LA SEC.
Setting:
Nonanticoagulated MS was the setting.
Patients:
Fifty-nine patients had MS, and they were not receiving anticoagulant or antiplatelet therapy (24 in sinus rhythm and 35 in atrial fibrillation). Previous arterial embolization had occurred in 12 patients (20.3 percent).
Measurements:
The following TTE variables were analyzed: mitral orifice area (pressure half-time method), mitral gradient (Bernouilli's equation), LA end-systolic area, and mitral regurgitation (color Doppler grading). LA thrombus and LA SEC were analyzed by monoplane TEE.
Results:
LA thrombus was found by TEE in 12 patients (20.3 percent). Of these 12, 11 (91.6 percent) were in atrial fibrillation. LA SEC was found by TTE in 2 patients (3.5 percent) and by TEE in 40 (67.8 percent) (p < 0.001). Previous embolization had occurred only in patients with LA SEC, of whom 5 had and 7 did not have LA thrombus. Patients with LA SEC, compared with those without LA SEC, were characterized by more frequent advanced NYHA class, atrial fibrillation, smaller mitral valve area, and larger LA size. By multivariate regression analysis, atrial fibrillation and LA end-systolic area were factors related to both LA thrombus and LA SEC, whereas mitral area was related only to LA SEC. However, whereas LA SEC was accurately predicted by the presence of atrial fibrillation (sensitivity: 87.5 percent; specificity: 100 percent) and a LA area > or = 30 cm2 (sensitivity: 72.5 percent; specificity: 89.5 percent), among patients with LA SEC no clinical or TTE variable accurately identified those with actual LA thrombus.
Conclusions:
TEE is not necessary in many patients with MS in order to recognize LA SEC. However, when actual LA thrombus detection is necessary for clinical decision making, TEE should be performed.
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