Natural History of Left Atrial Spontaneous Echo Contrast in Nonrheumatic Atrial Fibrillation

doi:10.1016/S0002-9149(97)00543-2

The American Journal of Cardiology

Volume 80, Issue 7, 1 October 1997, Pages 897-900

https://doi.org/10.1016/S0002-9149(97)00543-2 Get rights and content

Abstract

A prospective study was designed to investigate potential changes of left atrial (LA) spontaneous echo contrast with time and the effects of antithrombotic therapy on its presence in 77 patients with chronic nonrheumatic atrial fibrillation (AF), using serial transesophageal echocardiography (TEE). During a mean follow-up period of 20 ± 15 months (range 6 to 77), a total of 197 TEE studies were performed in these patients. Baseline TEE revealed that LA spontaneous echo contrast was absent in 43 patients (group 1) and present in 34 (group 2). LA thrombus was found in 8 of group 2 but in none of the group 1 patients. During the follow-up period, only 2 of the group 1 patients were receiving antithrombotic agents; the patients in group 2 without LA thrombus were treated with either warfarin or aspirin, whereas those with LA thrombus were treated with warfarin. On the latest TEE study, LA spontaneous echo contrast was observed in 19 of the group 1 patients (44%) and was persistently found in all of the group 2 patients. During the study period, no patient was found to develop new LA thrombus formation and only 4 episodes of transient ischemic attack were recorded in 4 patients (embolic event rate = 3.1% per year). Of these, 2 were observed in group 1 and the remaining 2 were from group 2 and under aspirin therapy (event rate = 2.2% and 4.7% per year, respectively). In the subgroup of patients with LA thrombus receiving warfarin therapy, follow-up TEE revealed complete resolution of the thrombi in 6 and partial resolution in the remaining 2 in spite of the persistence of LA spontaneous echo contrast; none of these patients developed clinical thromboembolic events during the study period. Thus, future occurrence of LA spontaneous echo contrast could be observed by serial TEE at a substantial rate in patients with nonrheumatic AF who have no LA spontaneous echo contrast; follow-up TEE should be recommended for these patients to detect early the potential occurrence of LA spontaneous echo contrast if preventive antithrombotic therapy is not considered. Although warfarin therapy is associated with resolution of LA thrombus, neither warfarin nor aspirin is effective for suppressing the presence of LA spontaneous echo contrast in nonrheumatic AF.

Section snippets

Study Population

Between January 1989 and July 1996, a total of 236 patients with chronic nonrheumatic AF underwent TEE in this hospital. Chronic nonrheumatic AF was diagnosed if there were no physical or echocardiographic evidence of rheumatic mitral stenosis or prosthetic mitral valve, and if AF was persistent for >30 days as documented by serial electrocardiography. All these patients were clinically followed up after initial TEE. To investigate the natural history of LA spontaneous echo contrast, those who

Patient Characteristics

LA spontaneous echo contrast was absent in 43 patients (group 1) and present in 34 patients (group 2) on initial TEE study. The baseline clinical and echocardiographic variables of both groups are listed in Table 1. Group 2 patients were more frequently associated with history of thromboembolism than group 1. LA thrombi were found in 8 patients of group 2 but in none of group 1 patients. Age, sex, LA dimension, left ventricular dimensions, left ventricular ejection fraction, duration of AF, and

Discussion

To understand the natural history of LA spontaneous echo contrast in patients with nonrheumatic AF is mandatory for providing the optimal preventive strategy. Although patients without LA spontaneous echo contrast were associated with a relatively low thromboembolic risk, our serial TEE study showed that 44% of these patients developed new occurrence of LA spontaneous echo contrast during a mean follow-up period of 25 months. The result may not be applicable to the general population because

Acknowledgements

We thank Huei-Chen Hsu for expert technical assistance.

References (14)

IW Black et al.
Left atrial spontaneous echo contrast: a clinical and echocardiographic analysis
J Am Coll Cardiol
(1991)
DYC Leung et al.
Prognostic implications of left atrial spontaneous echo contrast in nonvalvular atrial fibrillation
J Am Coll Cardiol
(1994)
WG Daniel et al.
Left atrial spontaneous echo contrast in mitral valve disease: an indicator for an increased thromboembolic risk
J Am Coll Cardiol
(1988)
LE Teichholz et al.
Problems in echocardiographic volume determinations: echocardiographic-angiographic correlations in the presence or absence of asynergy
Am J Cardiol
(1976)
S Beppu et al.
Smoke-like echo in the left atrial cavity in mitral valve disease: its features and significance
J Am Coll Cardiol
(1985)
LM Tsai et al.
Resolution of left atrial appendage thrombus in mitral stenosis after warfarin therapy
Am Heart J
(1991)
LM Tsai et al.
Clinical implications of left atrial spontaneous echo contrast in nonrheumatic atrial fibrillation
Am J Cardiol
(1992)

There are more references available in the full text version of this article.

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Citation Excerpt :
AF is associated with the progressive decline of LA contractile function which may result in the development of blood stasis in left atrium. The blood stasis in the left atrium is known to be associated with SEC and LA/LAA thrombi [20,24,25]. LA thrombi were found 16 times more frequently in stroke patients with AF than in those without [4].
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^fn1: This study was supported in part by Grant DOH84-HR-206 from the National Health Research Institute, Taipei, Taiwan, Republic of China.

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Arrhythmias and Conduction DisturbancesNatural History of Left Atrial Spontaneous Echo Contrast in Nonrheumatic Atrial Fibrillationfn1

Abstract

Section snippets

Study Population

Patient Characteristics

Discussion

Acknowledgements

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am Heart J

Clinical implications of left atrial spontaneous echo contrast in nonrheumatic atrial fibrillation

Am J Cardiol

Arrhythmias and Conduction Disturbances
Natural History of Left Atrial Spontaneous Echo Contrast in Nonrheumatic Atrial Fibrillationfn1