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CLINICAL STUDY: STROKE

Prevalence of left atrial chamber and appendage thrombi in patients with atrial flutter and its clinical significance

^a Department of Medicine–Cardiology, University of Bonn, Bonn, Germany

Manuscript received October 5, 2000; revised manuscript received March 19, 2001, accepted June 8, 2001.

Reprint requests and correspondence: Dr. Heyder Omran, Department of Medicine–Cardiology, University of Bonn, Sigmund-Freud-Str. 25, D-53105 Bonn, Germany
Omran{at}uni-bonn.de

OBJECTIVES

The study was done to assess the prevalence of left atrial (LA) chamber and appendage thrombi in patients with atrial flutter (AFl) scheduled for electrophysiologic study (EPS), to evaluate the prevalence of thromboembolic complications after transesophageal echocardiographic (TEE)-guided restoration of sinus rhythm and to evaluate clinical risk factors for a thrombogenic milieu.

BACKGROUND

Recent studies showed controversial results on the prevalence of atrial thrombi and the risk of thromboembolism after restoring sinus rhythm in patients with AFl.

METHODS

Between 1995 and 1999, patients with AFl who were scheduled for EPS were included in the study. After transesophageal assessment of the left atrial appendage and exclusion of thrombi, an effective anticoagulation was initiated and patients underwent EPS within 24 h.

RESULTS

We performed 202 EPSs (radiofrequency catheter ablation, n = 122; overdrive stimulation, n = 64; electrical cardioversion, n = 16) in 139 consecutive patients with AFl. Fifteen patients with a thrombogenic milieu were identified. All of them had paroxysmal atrial fibrillation (AF). Transesophageal echocardiography revealed LA thrombi in two cases (1%). After EPS no thromboembolic complications were observed. Diabetes mellitus, arterial hypertension and a decreased left ventricular ejection fraction were found to be independent risk factors associated with a thrombogenic milieu.

CONCLUSIONS

The findings of a low prevalence of LA appendage thrombi (1%) in patients with AFl and a close correlation between a history of previous embolism and paroxysmal AF support the current guidelines that patients with pure AFl do not require anticoagulation therapy, whereas patients with AFl and paroxysmal AF should receive anticoagulation therapy. In addition, the presence of clinical risk factors should alert the physician to an increased likelihood for a thrombogenic milieu.

Abbreviations and Acronyms   AFl = atrial flutter   AF = atrial fibrillation   DC = direct current   ECG = electrocardiogram   EPS = electrophysiologic study   INR = International Normalized Ratio   IV = intravenous   LA = left atrium/atrial   LVEF = left ventricular ejection fraction   TEE = transesophageal echocardiography/echocardiographic   TTE = transthoracic echocardiography/echocardiographic

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