Vol.:(0123456789) 1 3 The International Journal of Cardiovascular Imaging https://doi.org/10.1007/s10554-020-01811-x ORIGINAL PAPER Left atrial thrombus in patients with atrial fbrillation and under oral anticoagulant therapy; 3‑D transesophageal echocardiographic study Eser Durmaz 1  · Mehmet Hakan Karpuz 1  · Karadag Bilgehan 1  · Baris Ikitimur 1  · Emre Ozmen 1  · Cansu Ebren 1  · Fuat Polat 1  · Damla Koca 1  · Kardelen Ohtaroglu Tokdil 1  · Sedat Giray Kandemirli 2  · Adem Atici 3  · Zeki Ongen 1 Received: 16 October 2019 / Accepted: 28 February 2020 © Springer Nature B.V. 2020 Abstract Ischemic stroke is the major complication of atrial fbrillation (AF) and only proven preventive therapy is oral anticoagulant therapy (OAC). Previous studies reported the presence of thrombus in the left atrium (LA) or left atrial appendage (LAA) despite anticoagulant therapy. We aim to investigate the predictors of LA/LAA thrombus in patients under OAC therapy and long-term clinical impact of thrombus. We prospectively enrolled consecutive patients with permanent AF under OAC therapy. Patients baseline characteristics were recorded. Transesophageal echocardiographic study performed after complete transthoracic echocardiographic study. 3-D evaluation of LAA was made using 3-D zoom mode and thrombus was defned when echo refecting, mobile mass detected. Patients clinical outcomes were decided according to hospital records or via phone calls. Among 184 patients, 28 LAT were detected. Mean CHA2DS2-VASc score was signifcantly higher in patients with LAT in comparison to patients without LAT. CHA2DS2-VASc score (p: 0.001), left atrial volume (p: 0.001), left atrial fow velocity (p: 0.006) and left ventricular ejection fraction (p: 0.014) were independently associated with LAT. Among the parameters in CHA2DS2-VASc score, the previous history of stroke and age were independently related to LAT. After 12 months of follow-up, patients with LAT had more ischemic stroke than patients without LAT (7.1% vs 4.4%, p: 0.001 respectively). Although oral anticoagulation is the default treatment strategy for prevention of LAT and thromboembolism in patients with non-valvular AF, LAT still can be detected especially in patients with a high CHA2DS2-VASc score. Fur- thermore, the presence of LAT is signifcantly associated with future ischemic stroke. Keywords Left atrial appendage thrombus · Atrial fbrillation · Transesophageal echocardiography · Three-dimensional echocardiography Introduction Rapid and ineffective contraction of the left atrium in patients with atrial fibrillation (AF) causes blood sta- sis which could eventually result in thrombus formation. Thrombus in left atrial appendage (LAA) and/or left atrium (LA) is believed to be the primary source of systemic embo- lism in patients with AF [1]. Thromboembolism, especially ischemic stroke, is the major complication of AF. Anticoag- ulant therapy is the only efective preventive and therapeutic treatment option for left atrial thrombus. Anticoagulation therapy reduces the risk of thromboembolism about 60%, therefore current guidelines recommend oral anticoagu- lant therapy especially in those with intermediate to high CHA2DS2-VASc score [2, 3]. On the other hand, there is still a risk of thromboembo- lism in patients who are under anticoagulant therapy. Previ- ous studies reported the presence of thrombus in the LA with diferent prevalence ranging from 2.3 to 10.6% [4, 5] in patients under oral anticoagulant treatment. To the best of our knowledge, all of these reports were based on the patients with low to intermediate CHA2DS2-VASc score who were undergoing cardioversion of AF or pulmonary vein isolation. Besides, these studies did not report long- term clinical consequences of the presence of LA/LAA * Eser Durmaz durmazeser@hotmail.com 1 Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa street, Cerrahpasa/Fatih, 34098 Istanbul, Turkey 2 Department of Radiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey 3 Goztepe Research and Training Hospital, Istanbul, Turkey