A Large prolapsing left Atrial Appendage Thrombus in Sinus Rhythm - PDF document

21/07/2017 A Large prolapsing left Atrial Appendage Thrombus in Sinus Rhythm Sudish Lal Advanced Cardiology Trainee Dunedin Hospital Disclosures: none Case • 69yr old male • Past Medical History: OSA on CPAP, Asthma, Hypertension, CKD, L) THJR • Presenting complaint: NYHA class III HF • Investigations: • ECG: SR, nil ischaemic changes • Hs-TnT 32 ng/L, NT-proBNP 210pmol/L, Cr 150mmol/L • FBC/LFT’s/Normal coagulation screen 1

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21/07/2017 Diagnosis • Ischaemic cardiomyopathy • LV thrombus - akinetic apex • Probable LAA thrombus 4

21/07/2017 Management Plan • Warfarin commenced with heparin bridging • Evidence based HF medications commenced • Inpatient for a week to optimise medications – sinus rhythm recorded throughout • Repeat TTE 5

21/07/2017 Management • Discussed at cardio surgical meeting • Surgical revascularisation 6

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21/07/2017 Post-op • Uncomplicated recovery • No evidence of AF • Medications: Aspirin, Carvedilol, Spironolactone, Candesartan Cardioembolic systemic embolus/stroke • ~15 - 20million people worldwide have a stroke each year • 90% ischaemic vs 10% haemorrhagic stroke • Emboli of cardiac origin accounts for 1/5 of all ischaemic strokes • Often associated with higher morbidity and mortality 8

21/07/2017 Cardiac Source of Emboli • AF is the most common cardiac abnormality associated with ischaemic strokes • LAA source of emboli: • 90% of cases with non-valvular AF • 50% in valvular AF LAA - Anatomy • LAA is a complex structure, embryologic origin distinct from LA • LAA is trabeculated, blind-ended projection; LA cavity is smooth walled • 2 lobes 50% • 3 lobes 25% • 1 lobe 20% • 4 lobes <5% 9

21/07/2017 LAA - Morphology 30% 50% 3% 19% Lee ML et al. Why is Left Atrial Appendage Morphology Related to Strokes? An Analysis of the Flow Velocity and Orifice Size of the Left Atrial Appendage. J Cardiovasc Electrophysiol 2015;26.922-927. Beigel R et al. The Left Atrial Appendage: Anatomy, Function, and Noninvasive Evaluation. J Am Coll cardiol Img 2014;7:1251-65 LAA Morphology & Stroke Risk Lee ML et al. Why is Left Atrial Appendage Morphology Related to Strokes? An Analysis of the Flow Velocity and Orifice Size of the Left Atrial Appendage. J Cardiovasc Electrophysiol 2015;26.922-927. 10

21/07/2017 LA and LAA Dimension as Risk factors • LA AP diameter OR 2.5 • LAA orifice area OR 1.38 Lee ML et al. Why is Left Atrial Appendage Morphology Related to Strokes? An Analysis of the Flow Velocity and Orifice Size of the Left Atrial Appendage. J Cardiovasc Electrophysiol 2015;26.922-927. LAA Flow Velocities in AF • In AF decrease in LAA function is indicated by a decrease in Doppler flow velocities • AF subgroups with normal vs low velocities Lee ML et al. Why is Left Atrial Appendage Morphology Related to Strokes? An Analysis of the Flow Velocity and Orifice Size of the Left Atrial Appendage. J Cardiovasc Electrophysiol 2015;26.922-927. 11

21/07/2017 LAA flow velocity in AF and risk of Thrombus • Flow velocity <40cm/s • Presence of SEC • Velocities <20cm/s Lee ML et al. Why is Left Atrial Appendage Morphology Related to Strokes? An Analysis of the Flow Velocity and Orifice Size of the Left Atrial Appendage. J Cardiovasc Electrophysiol 2015;26.922-927. LAA Thrombus in Sinus Rhythm • Incidence of LA thrombus in combination with SR ~0.1% Agmon Y et al. Clinical and Echocardiographic Characteristics of Patients With Left Atrial Thrombus and Sinus Rhythm. Circulation. 2002;105:27-31 12

21/07/2017 LAA Thrombus in Sinus Rhythm • “High - risk” factors identified • Significant left-sided VHD • Severe LV dysfunction • Previous documentation of AF Agmon Y et al. Clinical and Echocardiographic Characteristics of Patients With Left Atrial Thrombus and Sinus Rhythm. Circulation. 2002;105:27-31 Other Imaging modalities for assessing thrombus in LA/LAA Romero J et al. Cardiac imaging for assessment of left atrial appendage stasis and thrombosis. Nat Rev Cardiol 2014;11:470-480 13

21/07/2017 CONCLUSION • Thrombus within the LAA is very rare in sinus rhythm • Factors independent of AF associated with increasing risk of LAA thrombus are specific cardiac abnormalities and intrinsic LAA properties • This case demonstrates the unexpected heterogeneous potential of LAA thrombus formation in a patient in sinus rhythm THANK YOU 14