Prognostic significance of left atrial appendage "sludge" in patients with atrial fibrillation: A new transesophageal echocardiographic thromboembolic risk factor

Boris S. Lowe, Kenya Kusunose, Hirohiko Motoki, Brandon Varr, Kevin Shrestha, Christine Whitman, W. H Wilson Tang, James D. Thomas, Allan L. Klein*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

34 Scopus citations

Abstract

Background When stratifying thromboembolic risk to patients with atrial fibrillation (AF), left atrial appendage (LAA) thrombus is currently the only echocardiographic index that absolutely contraindicates cardioversion. The aim of this study was to identify the predictors of LAA "sludge" and its impact on subsequent thromboembolism and survival in patients with AF.

Methods A total of 340 patients (mean age, 66 ± 12 years; 75% men) who underwent transesophageal echocardiography to exclude LAA thrombus before electrical cardioversion or radiofrequency pulmonary vein isolation) for AF were retrospectively studied. LAA sludge was defined as a dynamic, viscid, layered echodensity without a discrete mass, visualized throughout the cardiac cycle. Follow-up was obtained after a mean of 6.7 ± 3.7 years, and patients were analyzed according to LAA thrombus (n = 62 [18%]), sludge (n = 47 [14%]), or spontaneous echocardiographic contrast (n = 84 [25%]). Patients without these transesophageal echocardiographic characteristics served as controls (n = 147 [43%]).

Results LAA sludge was independently predicted by enlarged left atrial area (odds ratio, 4.54; 95% confidence interval [CI], 2.38-8.67; P <.001), reduced LAA emptying velocity (odds ratio, 12.7; 95% CI, 6.11-26.44; P <.001), and reduced left ventricular ejection fraction (odds ratio, 2.11; 95% CI, 1.03-4.32; P <.001). Thromboembolic event and all-cause mortality rates in patients with sludge were 23% and 57%, respectively. Multiple logistic regression analyses identified the presence of LAA sludge to be independently associated with thromboembolic complications (adjusted hazard ratio, 3.43; 95% CI, 1.42-8.28; P =.006) and all-cause mortality (adjusted hazard ratio, 2.02; 95% CI, 1.22-3.36; P =.007).

Conclusion Sludge within the LAA is independently associated with subsequent thromboembolic events and all-cause mortality in patients with AF.

Original languageEnglish (US)
Pages (from-to)1176-1183
Number of pages8
JournalJournal of the American Society of Echocardiography
Volume27
Issue number11
DOIs
StatePublished - Nov 1 2014

Keywords

  • Atrial fibrillation
  • Cardioversion
  • Echocardiography
  • Mortality
  • Stroke

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Cardiology and Cardiovascular Medicine

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