LAUSR

We read with great interest the article by Angelini et al. [1] evaluating the prevalence and predictors of left atrial (LA) thrombosis in atrial fibrillation (AF) patients treated with nonvitamin K antagonist oral anticoagulants. In this study, it was reported that LA/Left Atrial Appendage (LAA) thrombus was seen in 7.7% of non-valvular AF patients treated with direct oral anticoagulants (DOACs). The main predictors of LA thrombosis have been noted to be CHA2DS2-VASc score > 3 and obesity. Here, in the light of the results of present study, we would like to discuss other predictors that affect LA/LAA thrombus formation. In a study conducted by Gorczyca et al. which included 1148 consecutive patients with non-valvular AF, who underwent transoesophageal echocardiography (TEE) before scheduled electrical cardioversion (ECV) or catheter ablation (CA) showed that the prevalence of LAA thrombus was 4.4% and CHA2DS2-VASc score 2, non-paroxysmal AF and glomerular filtration rate were independent predictors of LAA thrombus in patients treated with DOACs [2]. A large meta-analysis conducted in 2021 also evaluated the prevalence and predictors of atrial thrombus in AF patients who underwent TEE before ECV and CA. The pooled prevalence of LA/LAA thrombus in patients using DOACs and undergoing CA and ECV was reported to be 1.3% and 3.5%, respectively. It has been underlined that the predictors of LA/LAA thrombus detection are AF type, especially nonparoxysmal AF, presence of hypertension and heart failure, previous stroke, and CHADS2 score 2 [3]. In another prospective study evaluating periprocedural thromboembolic complications in patients with AF treated with DOACs performed CA without LAA imaging, these complications were reported to be rare in patients using DOAC. Approximately 60% of the patients included in the study had nonparoxysmal AF and their median CHA2DS2-VASc score was 2 [4]. In conclusion, the predictors and prevalence of LA/ LAA thrombus in AF patients undergoing ECV or CA varies widely, mainly due to differences in patient risk profiles, comorbidities, kidney function, CHADVASC score, left atrium structure and functions, left atrial appendage type and DOACs types and doses. Pooled evaluations of these factors seem important to improve pre-procedural patient management and post-procedure patient follow-up.