Impact of the Covid-19 Pandemic on Electrophysiology Procedural Volume in the United States: A Nationwide Analysis

Background: The COVID-19 pandemic has had an unprecedented impact on the United States health system and its ability to deliver care. In particular, surgical and interventional procedures suffered a significant decline in the early stages of the pandemic for a multitude of reasons including, PPE and personnel shortages, the deference of elective procedures, and governmental bans on elective procedures. The impact of these factors on electrophysiology (EP) procedural rates in the United States is unknown. Objective(s): To study the impact of the COVID-19 pandemic on EP procedural volume in the United States (2019-2020). Method(s): We analyzed the National inpatient sample (2019-2020) to identify hospitalizations involving EP procedures using ICD-10-PCS codes. Weighted analysis was performed to determine the number of procedures performed on a monthly basis. The US census data was employed to ascertain procedure rates per million population, the trends of which are displayed in Figure 1. Result(s): A total of 236,991 EP procedures were performed in 2020 - a 9% decrease from 2019 (n= 260,615). This included an annualized 11.25% decrease in device implantations (ICD and PPM), a 7.7% drop in AF ablations, and a 5.4% decrease in VT ablations as compared to 2019. Interestingly rates of left atrial appendage occlusion (LAAO) procedures saw an annualized 3.7% increase in 2020. The maximal per-month decline in procedural volume was noted in April 2020. An overall decline of 48% in EP procedures was noted, with the most precipitous drop with LAAO (90%), followed by AF Ablation (65%), PPM (4.3%), ICD (3.8%), and least with VT ablation (2.5%). Conclusion(s): The COVID-19 pandemic has had a significant and heterogonous impact on EP procedural volume. Despite a precipitous 48% decline in April 2020, overall, 2020 procedure rates have recovered to a 9% drop from 2019. [Formula presented]Copyright © 2023

Possibilities of computed and magnetic resonance imaging of the heart in patients with atrial fibrillation

Computed and magnetic resonance imaging of the heart has been widely used in recent years in patients with atrial fibrillation. They are used to determine the morphology of the heart, the presence of intracardiac thrombi, quantify the structures of the heart, thrombosis of intracardiac devices, determine tactics for surgical interventions, and other purposes. These methods of instrumental diagnostics can be used as an alternative to transesophageal echocardiography, which has a number of limitations and disadvantages compared to computed tomography and magnetic resonance imaging. Computed and magnetic resonance imaging of the heart are used to avoid invasiveness in the study of the heart, to improve the accuracy of measuring heart structures, to reduce the number of diagnostic methods used before various surgical interventions in patients with atrial fibrillation, and also, according to epidemic indications, as part of the prevention of the spread of coronavirus infection. In addition, magnetic resonance imaging allows to avoid radiation exposure to the patient. The review presents the results of studies, meta-analyses of pooled samples, as well as a description of the clinical possibilities of computed and magnetic resonance imaging of the heart in patients with atrial fibrillation. Publications on the use of these methods for visualization of thrombi in the left atrium and its appendage, in pulmonary vein ablation and occlusion of the left atrial appendage, as well as data on visualization of the residual flow around the occlusive device and thrombosis of intracardiac devices are presented. According to the results of a literature review, computed tomography and magnetic resonance imaging of the heart have similar or higher imaging capabilities compared to transesophageal echocardiography, as well as some advantages over it, primarily the non-invasiveness of the procedure. The works demonstrating the possibilities of computed tomography of the heart for the diagnosis of coronary heart disease in patients with atrial fibrillation are presented. In preparing the review, the literature search method in PubMed databases for the period 2013–2022 was used. © Eco-Vector, 2023. All rights reserved.

CRT-200.02 National Trends of Structural Heart Disease Interventions From 2016 to 2020 in the United States and the Associated Impact of COVID-19 Pandemic

Introduction: The Coronavirus Disease-2019 (COVID-19) pandemic placed an enormous strain on the healthcare system. Data on the impact of COVID-19 on the utilization and outcomes of structural heart disease (SHD) interventions in the United States are scarce. Method(s): The National Inpatient Sample from 2016 to 2020 was queried to identify adult admissions for transcatheter aortic valve replacement (TAVR), left atrial appendage occlusion (LAAO), and transcatheter end-to-end repair (TEER). The primary outcome was temporal trends of procedure utilization rate per 100,000 admissions over quarters from 2016 to 2020. The secondary outcomes were adjusted rates of in-hospital mortality, major complications, and length of stay (LOS). Result(s): Among 434,630 weighted admissions (TAVR: 305,550;LAAO: 89,300;TEER: 40,160), 95,010 admissions (22%) were during the COVID-19 era. There was a decline during the second quarter of 2020 followed by an increase to the pre pandemic levels (TAVR: 220 to 253, LAAO: 57 to 109, and TEER:31 to 36 per 100,000 admissions, Ptrend<0.001) (Figure). There were no differences in the mortality or major complication rates. Median LOS has decreased in TAVR (4 days to 1 day) and in TEER (3 days to 1 day) but remained stable in LAAO (1 day). Conclusion(s): This nationwide analysis showed that SHD interventions decreased during the early waves of COVID-19 pandemic. There was a significant reduction in hospital LOS without differences in in-hospital mortality or complication rates during the pandemic. These data suggest that hospitals adapted to the unprecedent challenges during the pandemic to provide advanced cardiac care to patients. [Formula presented]Copyright © 2023

Imaging Cascade - the Importance of Pre-Procedural 3-D Planning in Transcatheter Left Atrial Appendage Closure

Background With the COVID-19 pandemic and referral from out-reach centers, there has been a change in practice of assessing left atrial appendage (LAA) via TEE on the day of LAA closure (LAAC). We present a challenging case of inadequate LAAC with WATCHMAN FLX due to suboptimal TEE images. Follow up TEE and CT revealed a much larger LAA ostium that was mostly uncovered. Case An 84 yo male with AF and recent hepatic hematoma, was referred for LAAC. LAA dimensions were measured using a technically difficult intraprocedural (IP) 2D TEE and a 24mm Watchman FLX was successfully implanted. Follow up 3D TEE at 45 days revealed incomplete LAAC with a large PDL. Retrospective review of fluoroscopic images revealed unrecognized filling of a posterior LAA lobe. Decision-making Anticoagulation (AC) was continued for 3 more months, and Cardiac CT was performed which showed persistent under-coverage of the LAA with large PDL of 16.5 x 11.3 mm (159mm2). A much larger ostium was measured on 45 days TEE (27 mm max 2 D dimension) and 145 days CT (18 X 25 mm) vs. 12.9 mm on IP-TEE. AC was continued with consideration of a 2nd adjacent device placement in future. Conclusion TEE on the day of LAAC although implemented in several centers, has its limitations. In the presence of sub-optimal image quality, it can lead to incorrect device sizing and incomplete LAAC as in our case. Cardiac CT with 3D evaluation or 3D TEE are crucial for pre-planning to achieve successful device implantation. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

The Impact of COVID-19 Pandemic on the Clinical Practice Patterns in Atrial Fibrillation: A Multicenter Clinician Survey in China.

The COVID-19 pandemic has severely impacted healthcare systems worldwide. This study investigated cardiologists' opinions on how the COVID-19 pandemic impacted clinical practice patterns in atrial fibrillation (AF). A multicenter clinician survey, including demographic and clinical questions, was administered to 300 cardiologists from 22 provinces in China, in April 2022. The survey solicited information about their treatment recommendations for AF and their perceptions of how the COVID-19 pandemic has impacted their clinical practice patterns for AF. The survey was completed by 213 cardiologists (71.0%) and included employees in tertiary hospitals (82.6%) and specialists with over 10 years of clinical cardiology practice (53.5%). Most respondents stated that there were reductions in the number of inpatients and outpatients with AF in their hospital during the pandemic. A majority of participants stated that the pandemic had impacted the treatment strategies for all types of AF, although to different extents. Compared with that during the assumed non-pandemic period in the hypothetical clinical questions, the selection of invasive interventional therapies (catheter ablation, percutaneous left atrial appendage occlusion) was significantly decreased (all p < 0.05) during the pandemic. There was no significant difference in the selection of non-invasive therapeutic strategies (the management of cardiovascular risk factors and concomitant diseases, pharmacotherapy for stroke prevention, heart rate control, and rhythm control) between the pandemic and non-pandemic periods (all p > 0.05). The COVID-19 pandemic has had a profound impact on the clinical practice patterns of AF. The selection of catheter ablation and percutaneous left atrial appendage occlusion was significantly reduced, whereas pharmacotherapy was often stated as the preferred option by participating cardiologists.

Spanish cardiac catheterization and coronary intervention registry. 31st official report of the Interventional Cardiology Association of the Spanish Society of Cardiology (1990-2021)

Introduction and objectives: The Interventional Cardiology Association of the Spanish Society of Cardiology (ACI-SEC) presents its annual activity report for 2021. Methods: All Spanish centers with catheterization laboratories were invited to participate. Data were collected online and were analyzed by an external company, together with the members of the ACI-SEC. Results: A total of 121 centers participated (83 public and 38 private). Compared to 2020, both diagnostic coronary angiograms and percutaneous coronary interventions (PCI) increased by 11,4% and 10,3%, respectively. The radial approach was the most used access (92,8%). Primary PCI also increased by 6.2% whereas rescue PCI (1,8%) and facilitated PCI (2,4%) were less frequently conducted. Transcatheter aortic valve implantation was one of the interventions with the most relevant increase. A total of 5720 transcatheter aortic valve implantation procedures were conducted with an increase of 34,9% compared to 2020 (120 per million in 2021 and 89,4 per million in 2020). Other structural interventions like transcatheter mitral or tricuspid repair, left atrial appendage occlusion and patent foramen oval closure also experienced a significant increase. Conclusions: The 2021 registry demonstrates a clear recovery of the activity both in coronary and structural interventions showing a relevant increase compared to 2020, the year of the COVID-19 pandemic.

Capabilities of transesophageal echocardiography in patients with atrial fibrillation

Transesophageal echocardiography is widely used in clinical practice in patients with atrial fibrillation and it is mainly applied to determine the morphology of the heart, the presence of intracardiac thrombi, quantify the structures of the heart, as well as to determine the tactics for surgical interventions. Transesophageal echocardiography has an advantage over transthoracic echocardiography in visualizing the left atrium and left atrial appendage, common sites of thrombus formation in patients with atrial fibrillation. Due to the anatomical proximity of the esophagus to the heart, the transesophageal access avoids signal fading and incorrect interpretation of the study results. The possibilities of transesophageal echocardiography in patients with atrial fibrillation have expanded with the development of medical technology, and three-dimensional transesophageal echocardiography has become widespread. In recent years, the studies on the use of the transesophageal echocardiography in patients with atrial fibrillation during the coronavirus pandemic have been published. The review presents the results of studies, meta-analyzes of pooled samples, as well as clinical cases, demonstrating capabilities of transesophageal echocardiography in patients with atrial fibrillation. A brief history of the development of the method, work on the study of the technology features and capabilities of transesophageal echocardiography for pulmonary vein ablation, cardioversion, occlusion of the left atrial appendage in patients with atrial fibrillation, as well as studies on disadvantages of the transesophageal echocardiography and possible options for their elimination are presented. Comparison of the transesophageal echocardiography with transthoracic and intracardial echocardiography is also highlighted. In preparing the review, the literature search method in PubMed databases for the period 2012–2021 was used, as well as data from an earlier period to indicate the history of the method development. © Eco-Vector, 2022. All rights reserved.

Epidemiology, management, and outcomes of atrial fibrillation among 30 million citizens in Shanghai, China from 2015 to 2020: A medical insurance database study.

Background: Atrial fibrillation(AF) has become a significant public health concern in China, with population aging and urbanization. Methods: Data screening was performed for 30,244,930 subjects with medical insurance in the Shanghai Municipal Health Commission database between 2015 and 2020. Patients diagnosed with AF were identified and further assessed for treatment information and clinical outcomes, as well as sex differences and impact of COVID-19 pandemic on AF managment. Findings: AF prevalence was 0.88% in Shanghai, which increased with age and reached 6.70% at subjects 80 years and over. AF was more prevalent in women compared with men (0.89% vs. 0.88%, p<0.0001), which could be attributed to higher AF burden in women over 80 years. Driven by increased prescription of non-vitamin K antagonist oral anticoagulants, anticoagulant use increased from 19.46% in 2015 to 56.57% in 2020. The number of left atrial appendage closure increased from 0.16% in 2015 to 1.23% in 2020. Rhythm control strategy was increasingly adopted, as the use of antiarrhythmic drugs doubled and ablation increased by 21% in 2020 compared to 2015. Compared with men, women were less prone to receive rhythm control treatments, including antiarrhythmics, ablation and cardioversion, but more likely to adopt rate control drugs. During the 5.5 years follow-up, the incidences of stroke, transient ischemic attack, systemic embolism, bleeding, myocardial infarction, and in-hospital death were 6.09%, 5.74%, 1.44%, 5.11%, 8.41%, and 12.84% in patients with index diagnosis of AF in 2015, respectively. Interpretation: The burdens of AF and AF-related outcomes in Shanghai are high. Management of AF is markedly improved in recent years, and was not or only slightly impeded by the COVID-19 pandemic. There are sex differences in the prevalence, management, and outcomes of AF. Funding: Shanghai Hospital Development Center, National Natural Science Foundation of China and Shanghai Municipal Science and Technology Commission.

Advances in Clinical Cardiology 2021: A Summary of Key Clinical Trials.

INTRODUCTION: Over the course of 2021, numerous key clinical trials with valuable contributions to clinical cardiology were published or presented at major international conferences. This review seeks to summarise these trials and reflect on their clinical context. METHODS: The authors reviewed clinical trials presented at major cardiology conferences during 2021 including the American College of Cardiology (ACC), European Association for Percutaneous Cardiovascular Interventions (EuroPCR), European Society of Cardiology (ESC), Transcatheter Cardiovascular Therapeutics (TCT), American Heart Association (AHA), European Heart Rhythm Association (EHRA), Society for Cardiovascular Angiography and Interventions (SCAI), TVT-The Heart Summit (TVT) and Cardiovascular Research Technologies (CRT). Trials with a broad relevance to the cardiology community and those with potential to change current practice were included. RESULTS: A total of 150 key cardiology clinical trials were identified for inclusion. Interventional cardiology data included trials evaluating the use of new generation novel stent technology and new intravascular physiology strategies such as quantitative flow ratio (QFR) to guide revascularisation in stable and unstable coronary artery disease. New trials in acute coronary syndromes focused on shock, out of hospital cardiac arrest (OOHCA), the impact of COVID-19 on ST-elevation myocardial infarction (STEMI) networks and optimal duration/type of antiplatelet treatment. Structural intervention trials included latest data on transcatheter aortic valve replacement (TAVR) and mitral, tricuspid and pulmonary valve interventions. Heart failure data included trials with sodium-glucose cotransporter 2 (SGLT2) inhibitors, sacubitril/valsartan and novel drugs such as mavacamten for hypertrophic cardiomyopathy (HCM). Prevention trials included new data on proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. In electrophysiology, new data regarding atrial fibrillation (AF) screening and new evidence for rhythm vs. rate control strategies were evaluated. CONCLUSION: This article presents a summary of key clinical cardiology trials published and presented during the past year and should be of interest to both practising clinicians and researchers.

An Unusual Congenital Heart Disease: Giant Left Atrial Appendage.

A 52-year-old female was admitted to our hospital in April 2021 with dyspnea. She was discharged from the hospital 3 weeks ago due to the diagnosis of pneumonia caused by coronavirus disease 2019 (COVID-19). Physical examination revealed an oxygen desaturation of 82%. The patient underwent computed tomography angiography (CTA) that showed a ground-glass pattern and a giant left atrial appendage ( Figure 1A ). Film array respiratory panel was negative, and pulmonary aspergillosis was diagnosed after bronchoscopy. Cardiac magnetic resonance corroborated the huge left atrial appendage ( Figure 1B ). No other structural or functional heart abnormalities were diagnosed. A giant left atrial appendage is a rare cardiac anomaly that can be congenital or acquired. In the literature, it is called a left atrial appendage aneurysm. The dilatation can be generalized or focused. Although it can occur in all age groups, it is predominant in patients in their 30s to 50s and most common in females.1 Patients can be asymptomatic or present with symptoms such as palpitations, chest pain, or dyspnea. A number of recent cases in the literature have highlighted the diagnostic utility of CTA.2 While there is no standard treatment for this condition, surgical resection is the most frequent therapy. Another option reported in the literature is anticoagulant treatment for select cases.3 Closure of the left atrial appendage is a more recent and emerging intervention that can be considered. In our patient, we initiated anticoagulant therapy to reduce the risk of thromboembolic events; however, we recommended left atrial appendage occlusion or surgical resection after completing the treatment for pulmonary aspergillosis.

Safety, Efficacy, and Cost-Effectiveness of Same-Day Discharge for Left Atrial Appendage Occlusion

BACKGROUND: Percutaneous left atrial appendage occlusion (LAAO) with the Watchman device is FDA approved for stroke prevention in patients with nonvalvular atrial fibrillation who have an appropriate indication. During the COVID-19 pandemic, a same-day discharge protocol (SDDP) was employed to improve resource utilization, relieve hospital occupation, and reduce the possible risk of in-hospital virus transmission. OBJECTIVES: We sought to analyze the safety, feasibility, and cost effectiveness for SDDP in patients receiving LAAO. METHODS: A prospective analysis of 142 consecutive patients, 119 treated prior to SDDP and 23 who underwent SDDP following LAAO with cardiac computed tomography angiography (CTA)-guided pre-procedural planning and intracardiac echocardiogram (ICE). Procedures were performed in a single, large academic hospital in the United States. In-hospital and 45-day procedural success, adverse events, length of procedure, and length-of-stay were evaluated. RESULTS: Baseline patient characteristics including mean CHA2DS2VASc scores and mean HAS-BLED scores were similar in both groups. All procedures were successful. There was no significant difference in rates of procedural complications or in-hospital adverse events. The mean procedure time in the SDDP group was 11 minutes longer than in the conventional group (62.1 ± 5.9 vs 51.1 ± 21;P=.01). Outcomes at 45-day follow-up were similar. SDDP was associated with a reduced length of stay compared with conventional strategy and a 15% reduction in total costs. CONCLUSIONS: Same-day discharge strategy for LAAO appears safe, feasible and could become the new standard approach for LAAO. A protocol including CTA pre-procedural planning, ICE-guided deployment and conscious sedation reduces hospital occupation and lowers costs.

Mechanical concordance between left atrium and left atrial appendage in nonvalvular atrial fibrillation: can it be exploited to avoid transesophageal echocardiography prior to electrical cardioversion during Covid-19 pandemic?

Transesophageal echocardiography (TEE) is the gold standard for assessing left atrial appendage (LAA) mechanic and thrombosis (LAAT); however, TEE is a high-risk procedure for viral transmission during coronavirus disease 2019 (COVID-19) pandemic. We investigated whether deformation indices of left atrium (LA) at transthoracic echocardiography (TTE) correlate with those of LAA assessed by TEE in nonvalvular atrial fibrillation (NVAF) patients undergoing electrical cardioversion (ECV). Consecutive patients with NVAF of ≥ 48 h or unknown duration, who underwent TEE and TTE at our Institution before ECV were retrospectively investigated. Standard echo-Doppler and LA and LAA myocardial strain and strain rate parameters were analyzed. A total of 115 NVAF patients (71.3 ± 8.1 yr/o, 59.1% men) were included: LAAT was diagnosed in 25 (21.7%) patients. Compared to patients without LAAT, those with LAAT had significantly higher CHA2DS2-VASc Risk score (4.5 ± 1.4 vs. 3.5 ± 1.1, p < 0.001), and lower ejection fraction (46.0 ± 14.8 vs. 57.6 ± 8.6%, p < 0.001). In LAAT patients, global strain of LA (8.7 ± 2.6 vs. 16.3 ± 4.5%, p < 0.001) and LAA (7.0 ± 1.7 vs. 11.7 ± 2.0%, p < 0.001) was significantly reduced compared to non-LAAT patients. A close relationship between left atrial strain reservoir (LASr) and LAA-global strain was demonstrated (r = 0.81). By univariable analysis, CHA2DS2-VASc Risk Score (OR 2.01, 95%CI 1.34-3.00), NT-proBNP (OR 1.36, 95%CI 1.19-1.54), ejection fraction (OR 0.92, 95%CI 0.88-0.96), E/e' ratio (OR 2.07, 95%CI 1.51-2.85), and LASr (OR 0.39, 95%CI 0.25-0.62) were strongly associated with LAAT presence at TEE. By multivariable analysis, only LASr (OR 0.40, 95%CI 0.24-0.70) retained statistical significance. ROC curve analysis revealed that an LASr cut-off value ≤ 9.3% had 98.9% sensibility and 100% specificity to identify LAAT by TEE (AUC = 0.98). In patients with NVAF of ≥ 48 h or unknown duration, scheduled to undergo ECV, LA deformation assessment by TTE might substitute invasive measurement of LAA function by TEE, simplifying diagnostic approach and possibly contributing to reduce COVID-19 infection diffusion.

Unusual echocardiographic evidence of hypercoagulation in usual left atrial appendage as the first and only sign of COVID-19.

Coronavirus disease 2019 (COVID-19) is a condition caused by a novel virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease's course ranges from entirely asymptomatic to severely ill patients. Hypercoagulation is often a complication of this disease, worsening the prognosis, which is extremely important in patients at higher risk of thromboembolic events, such as atrial fibrillation (AF), where thrombus formation in the left atrial appendage (LAA) is frequent. LAA could be of various sizes, volumes, and shapes, distinguish several morphologies, from which the WindSock LAA is the most frequent. In contrast, thromboembolic complications occur most frequently in patients with AF and the Cactus LAA. We present a clinical case of a 70-year-old woman with an initial negative real-time polymerase chain reaction (RT-PCR) test for SARS-CoV-2, suspicion of device-related infection after dual pacemaker implantation, AF, and LAA without thrombus in the initial transoesophageal echocardiography (TEE). Despite apixaban treatment, spontaneous restoration of sinus rhythm, and WindSock LAA morphology, the sludge in LAA was diagnosed in control TEE. The patient did not present any typical clinical COVID-19 symptoms but re-checked the RT-PCR test for SARS-CoV-2 infection was positive. The described case presents echocardiographic evidence of hypercoagulation as the first and only feature of SARS-CoV-2 condition besides the usual morphological presentation of the WindSock LAA.

Transition from transesophageal echocardiography to cardiac computed tomography for the evaluation of left atrial appendage thrombus prior to atrial fibrillation ablation and incidence of cerebrovascular events during the COVID-19 pandemic.

BACKGROUND: Transesophageal echocardiography (TEE) is variably performed before atrial fibrillation (AF) ablation to evaluate left atrial appendage (LAA) thrombus. We describe our experience with transitioning to the pre-ablation cardiac computed tomography (CT) approach for the assessment of LAA thrombus during the COVID-19 pandemic. METHODS: We studied consecutive patients undergoing AF ablation at our center. The study cohort was divided into pre- versus post-COVID groups. The pre-COVID cohort included ablations performed during the 1 year before the COVID-19 pandemic; pre-ablation TEE was used routinely to evaluate LAA thrombus in high-risk patients. Post-COVID cohort included ablations performed during the 1 year after the COVID-19 pandemic; pre-ablation CT was performed in all patients, with TEE performed only in patients with LAA thrombus by CT imaging. The demographics, clinical history, imaging, and ablation characteristics, and peri-procedural cerebrovascular events (CVEs) were recorded. RESULTS: A total of 637 patients (pre-COVID n = 424, post-COVID n = 213) were studied. The mean age was 65.6 ± 10.1 years in the total cohort, and the majority were men. There was a significant increase in pre-ablation CT imaging from pre- to post-COVID cohort (74.8% vs. 93.9%, p ≤ .01), with a significant reduction in TEEs (34.6% vs. 3.7%, p ≤ .01). One patient in the post-COVID cohort developed CVE following negative pre-ablation CT. However, the incidence of peri-procedural CVE between both cohorts remained statistically unchanged (0% vs. 0.4%, p = .33). CONCLUSION: Implementation of pre-ablation CT-only imaging strategy with selective use of TEE for LAA thrombus evaluation is not associated with increased CVE risk during the COVID-19 pandemic.

Incremental diagnostic role of left atrial strain analysis in thrombotic risk assessment of nonvalvular atrial fibrillation patients planned for electrical cardioversion.

During the COVID-19 pandemic, transesophageal echocardiography (TEE) for left atrial appendage thrombosis (LAAT) detection should be limited to situations of absolute necessity. We sought to identify the main conventional and functional echocardiographic parameters associated with LAAT on TEE in non-valvular atrial fibrillation (NVAF) patients planned for electrical cardioversion (ECV). This retrospective study included 125 consecutive NVAF patients (71.5±7.8 yrs, 75 males), who underwent TEE at our Institution between April 2016 and January 2020, to exclude LAAT before scheduled ECV. All patients underwent a transthoracic echocardiography (TTE) implemented with speckle tracking echocardiography (STE) analysis of left atrial (LA) strain and strain rate (SR) parameters. 28% of patients were diagnosed with LAAT, while 72% without LAAT. Compared to controls, patients with LAAT had significantly higher CHA2DS2-Vasc Score and average E/e' ratio, and significantly lower left ventricular ejection fraction (LVEF). Moreover, LA-peak positive global atrial strain (GSA+) and LA-SR parameters were significantly reduced in patients with LAAT. Multivariate logistic regression revealed that, differently from CHA2DS2-Vasc Score, LVEF (OR 0.88, 95%CI 0.81-0.97, p = 0.01), average E/e' ratio (OR 2.36, 95%CI 1.41-3.98, p = 0.001), and LA-GSA+ (OR 0.57, 95%CI 0.36-0-90, p = 0.01) were independently associated with LAAT. LA-GSA+ (optimal cut-off ≤ 9.1%, AUC 0.95) showed the highest diagnostic performance. Finally, a strong linear correlation of LA peak-to-peak SR with both LA appendage filling (r = 0.86) and emptying (r = 0.83) velocities was demonstrated. TTE implemented with STE analysis of LA mechanics improves thrombotic risk assessment of NVAF patients.