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Left atrial thrombus despite continuous direct oral anticoagulant or warfarin therapy in patients with atrial fibrillation: insights into rates and timing of thrombus resolution

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Abstract

Purpose

Left atrial thrombus (LAT) may be detected by transesophageal echocardiography (TEE) in patients with atrial fibrillation (AF) or flutter (AFL) despite continuous anticoagulation therapy. We sought to examine the rates and timing of LAT resolution in response to changes in anticoagulation regimen.

Methods

A retrospective study of 1517 consecutive patients on ≥ 4 weeks continuous oral anticoagulation (OAC) undergoing TEE prior to either direct current cardioversion or catheter ablation for AF or AFL was performed. Patients who had LAT on index TEE imaging and had follow-up TEEs were analyzed.

Results

Despite ≥ 4 weeks of continuous anticoagulation therapy, 63 (4.2%) patients had LAT. Forty-four patients (median age 67 [IQR 58, 74]; 33 [75%] male; 25 [57%] on direct oral anticoagulant [DOAC]) had follow-up TEEs performed. Upon detection of LAT on index TEE, 8 patients switched from warfarin to a DOAC, 21 patients switched from a DOAC to warfarin or another DOAC, and 15 patients remained on the same OAC. Over median 4.2 months (IQR 2.9, 6.6), LAT resolution was seen in 25 (57%) patients. Of the 25 patients who had LAT resolution, 7 (28%) required TEE imaging > 6 months after index TEE to show clearance of thrombus. Rates of LAT resolution were similar between patients who had alterations in OAC and those who did not (52 vs. 60%; P = 0.601).

Conclusions

After initial detection of left atrial thrombus despite uninterrupted anticoagulation for atrial fibrillation or flutter, > 40% patients have persistent clot despite additional extended anticoagulation.

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Authors and Affiliations

  1. Department of Medicine, Division of Cardiology, Weill Cornell Medicine, New York Presbyterian Hospital, 525 East 68th Street, Starr 4, New York, NY, 10021, USA

    Michael S. Wu, Salvatore A. D’Amato, Christopher F. Liu, Steven M. Markowitz, James E. Ip, George Thomas, Parmanand Singh, Bruce B. Lerman & Jim W. Cheung

  2. Department of Cardiology, North Shore University Hospital-Northwell Health, Manhasset, NY, 10030, USA

    James Gabriels, Mohammad Khan, Nada Shaban & Apoor Patel

Authors
  1. Michael S. Wu
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  2. James Gabriels
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  3. Mohammad Khan
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  4. Nada Shaban
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  5. Salvatore A. D’Amato
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  6. Christopher F. Liu
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  7. Steven M. Markowitz
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  8. James E. Ip
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  9. George Thomas
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  10. Parmanand Singh
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  11. Bruce B. Lerman
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  12. Apoor Patel
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  13. Jim W. Cheung
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Corresponding author

Correspondence to Jim W. Cheung.

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The authors declare that they have no conflict of interest.

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Wu, M.S., Gabriels, J., Khan, M. et al. Left atrial thrombus despite continuous direct oral anticoagulant or warfarin therapy in patients with atrial fibrillation: insights into rates and timing of thrombus resolution. J Interv Card Electrophysiol 53, 159–167 (2018). https://doi.org/10.1007/s10840-018-0432-1

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  • DOI: https://doi.org/10.1007/s10840-018-0432-1

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