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Left atrial appendage thrombi despite oral anticoagulation in transthyretin amyloid cardiomyopathy patients undergoing electrical cardioversion for atrial fibrillation or − flutter

Year: 2025

Type: article

Abstract: Electrical Cardioversion in Transthyretin Amyloid Cardiomyopathy – Left Atrial Appendage Thrombi Despite Oral Anticoagulants: In a study involving 46 transthyretin amyloid cardiomyopathy patients, 62 electrical cardioversion procedures were conducted. Of these, 39 patients underwent transoesophageal echocardiography or computed tomography scans. Thrombus formation was identified in 8 cases (20.5%), including 5 patients (12.8%) who developed thrombi despite receiving anticoagulation therapy. The immediate success rate of cardioversion was 92.3% (n = 48), while the success rate at 3 months declined to 61.9% (n = 26). CT indicates computed tomography; TEE, transoesophageal echocardiography. Patients with cardiac amyloidosis undergoing direct current electrical cardioversion (DCCV) are at risk of left atrial appendage thrombus (LAAT). We investigated LAAT formation rates, success rates, and long-term recurrence rates in transthyretin amyloid cardiomyopathy (ATTR-CM) patients. ATTR-CM patients scheduled to undergo DCCV were included in the study. LAAT exclusion was performed utilizing transesophageal echocardiography or computed tomography. A total of 62 (1.35 per patient) DCCVs were recorded among 46 patients (77 ± 6.5 years, 89 % male) with ATTR-CM. In 39 DCCVs, LAAT exclusion was performed (62.9 %). In total, 10 DCCVs (16.1 %) were canceled due to (I) spontaneous conversion to sinus rhythm (n = 2, 5.1 %) or (II) definitive/suspected LAAT (n = 8, 20.5 %). Of these, five patients with LAAT had been receiving sufficient doses of oral anticoagulants for more than three weeks prior to DCCV. The immediate success rate was 92.3 %, and 3-month rhythm control was achieved in 27 (62.8 %) procedures. Notably, one stroke event was recorded two months following DCCV. A high rate of left atrial appendage thrombus was observed in ATTR-CM, leading to DCCV cancellation in 20.5% of patients. Despite a high immediate success rate (92.3%), sustained sinus rhythm control was achieved in only 62.8% following DCCV. These findings advise using TEE or CT prior to DCCV to exclude LAAT in ATTR-CM patients, even in those with oral anticoagulation.

Source: IJC Heart & Vasculature

DOI: 10.1016/j.ijcha.2025.101790