Features of Left Atrial Appendage Thrombosis in Patients With Persistent Nonvalvular Atrial Fibrillation After COVID-19.

Aim      To evaluate the incidence and characteristic features of left atrial appendage (LAA) thrombosis in patients with persistent nonvalvular atrial fibrillation (AF) after COVID-19.Material and methods  Transesophageal echocardiography (TEE) was performed for 469 patients (57.4 % males; mean age, 64.0 [58.0; 70.0] years) with persistent nonvalvular AF before scheduled sinus rhythm restoration. In 131 of these patients (27.9 %), the most recent episode of arrhythmia developed during the coronavirus infection. The time from the onset of COVID-19 to TEE was 145 [62; 303] days. All patients received an adequate anticoagulant therapy, in most cases, with direct oral anticoagulants for at least 3 weeks preceding the study.Results A LAA thrombus was detected in 20 (5.9 %) patients who have had no coronavirus infection and in 19 (14.5 %) patients after COVID-19 (р=0.0045). 18 of 19 (94.7 %) thrombi found in patients who have had COVID-19 were mural whereas only 5 (25.0 %) of such thrombi were found in patients who have had no COVID-19 (p<0.0001). In the absence of LAA thrombus, the LAA emptying velocity was 32.0 [25.0; 40.0] cm/sec whereas in the presence of a mural thrombus, it was 25.0 [20.0; 32.3] cm/sec, and in the presence of a typical thrombus, it was 17.0 [13.5; 20.0] cm/sec (р<0.0001). A Kaplan-Meier analysis showed that the median time of mural thrombus dissolution was 35.0 (95 % confidence interval (CI), 24.0-55.0) days and for a typical thrombus, this time was 69.0 (95 % CI, 41.0-180.0) days (р=0.0018).Conclusion      Patients with persistent AF who have had COVID-19 had LAA thrombosis 2,5 times more frequently and, in most cases, the thrombus was mural. Mural thrombi, in contrast to typical, are not associated with a pronounced decrease in LAA emptying velocity and dissolve twice as fast as typical thrombi with an adequate anticoagulant treatment.

Cardiac Computed Tomography to exclude left atrial appendage thrombus in atrial arrhythmias prior to electrical cardioversion during the COVID-19 pandemic.

Nil.

The left atrial appendage thrombosis of in patients with persistent atrial fibrillation after the novel coronavirus infection.

Aim      To evaluate the incidence and features of left atrial appendage (LAA) thrombosis in patients with persistent atrial fibrillation (AF) after novel coronavirus infection (COVID-19).Material and methods  Percutaneous echocardiography (pcEchoCG) was performed for 128 patients with persistent AF prepared for cardioversion, 36 (28.1 %) of whom had had COVID-19. In 3 (8.3 %) patients, the lung lesion area was 50-75 %; in 31 (86.1 %) patients, 25-50 %; in 1 (2.8 %) patient, less than 25 %. One patient had no lung lesion. Median time from the onset of COVID-19 to the patient enrollment in the study was 76.5 days. At the time of enrollment, the polymerase chain reaction test for SARS-CoV-2 was negative in all patients.Results Patients after COVID-19 and those who had not had COVID-19 were comparable by age (62.5±9.2 and 62.4±9.1 years, respectively; р=0.956), gender (men 52.8 and 59.8 %, respectively; р=0.471), and risk of stroke (score 2.19±1.28 and score 1.95±1.35, respectively; р=0.350). Duration of the last arrhythmia episode was longer for patients after COVID-19 than for the comparison group (76.5 and 45.0 days, respectively; р=0.011). All patients received oral anticoagulants. 55.6 % of COVID-19 patients received rivaroxaban, whereas 62.0% of patients who had not had COVID-19 were treated with apixaban. Median duration of the anticoagulant treatment was longer for COVID-19 patients than for the comparison group (61.5 and 32.0 days; р=0.051). LAA thrombus was detected in 7 (19.4 %) patients after COVID-19 and in 6 (6.5 %) patients of the comparison group (р=0.030). In COVID-19 patients, the thrombus adhered to LAA wall over the entire thrombus length whereas in patients who had not have COVID-19, the thrombus had a free part that formed a sharp angle with LAA walls. In the presence of LAA thrombus, the LAA blood flow velocity was considerably higher for COVID-19 patients than for the comparison group (31.0±8.9 and 18.8±4.9 cm/sec, respectively; p=0.010). At the follow-up examination performed at 24.0 days on the average, the thrombus was found to be dissolved in 80 and 50% of patients after and without COVID-19, respectively (р=0.343).Conclusion      In patients with persistent AF after the novel coronavirus infection, LAA thrombosis was detected more frequently than in patients who had never had COVID-19; it was characterized by mural localization and was not associated with a decrease in LAA blood flow velocity.

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.

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.