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CLINICAL STUDY: VALVE DISEASE

A prognostic model for predicting the disappearance of left atrial thrombi among candidates for percutaneous transvenous mitral commissurotomy

Songkwan Silaruks, MD^*,*, Bandit Thinkhamrop, PhD, Wirote Tantikosum, MD^*, Chaiyasith Wongvipaporn, MD^*, Pyatat Tatsanavivat, MD^* and Virat Klungboonkrong, MD, FACC^*

^* Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen University, Khon Kaen, ThailandThis paper was presented as an abstract form at the 50th Annual Scientific Sessions of the American College of Cardiology in Orlando, Florida on March 18–21, 2001.

Manuscript received August 14, 2001; revised manuscript received November 28, 2001, accepted December 14, 2001.

^* Reprint requests and correspondence: Dr. Songkwan Silaruks, Department of Medicine, Faculty of Medicine, Khon Kaen University, Mitrapap Road, Khon Kaen, 40002, Thailand.
songkw-s{at}medlib2.kku.ac.th

OBJECTIVES: We sought to develop a prognostic model to predict the disappearance of left atrial thrombi (LAT) among candidates for percutaneous transvenous mitral commissurotomy (PTMC).

BACKGROUND: Complete LAT resolution can be achieved with oral anticoagulation, allowing a number of patients to safely undergo PTMC.

METHODS: We randomly allocated 108 PTMC candidates with LAT into two subsets—one to derive the model and the other to validate it. The existence of LAT and its size were measured by transesophageal echocardiography. Patients were given oral anticoagulation and followed up for 6 to 34 months. There was a 62% disappearance rate of LAT.

RESULTS: We developed the following model: where NYHA = New York Heart Association functional class (from I to IV), and area = LAT area (in cm²). The model was well calibrated (goodness-of-fit test, p = 0.82) and well discriminated (area under the receiver-operating characteristics [ROC] curve = 0.92). Performance in the validating sample was equally good (area under the ROC curve = 0.94; goodness-of-fit test, p = 0.16). When a cut-off point of p > 0.7 was used to designate the LAT disappearance in the validating set, the model had a sensitivity, specificity and positive and negative predictive values of 93.3%, 79.2%, 84.9% and 90.5%, respectively.

CONCLUSIONS: Combined clinical (NYHA functional class) and echocardiographic (LAT area) variables are predictive of the 34-month outcome of oral anticoagulation for LAT resolution among PTMC candidates. This simple and highly predictive model might be potentially useful for clinical assessment and proper management.

Abbreviations and Acronyms   LASEC   CI   confidence interval   INR   international normalized ratio   LASEC   left atrial spontaneous echo contrast   LAT   left atrial thrombus   NYHA   New York Heart Association   PTMC   percutaneous transvenous mitral commissurotomy   ROC   receiver-operating characteristics   TEE   transesophageal echocardiography   TTE   transthoracic echocardiography

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