PhD Scientific Days 2024

Cardiovascular Medicine and Research I.

Comparative analysis of therapeutic strategies in patients with left atrial appendage thrombus despite optimal NOAC therapy

Text of the abstract

Aims
We aimed to analyze patients diagnosed with an left atrial appendage (LAA) thrombus despite adequate novel oral anticoagulant (NOAC) therapy and to compare the efficacy of various therapeutic strategies in achieving thrombus resolution.
Methods
We retrospectively analyzed patients scheduled for cardioversion or catheter ablation of AF between 2014 and 2023 who were diagnosed with LAA thrombus despite being on optimal NOAC therapy. These patients underwent follow-up transesophageal echocardiography (TEE) or cardiac CT angiography. Changes in treatment modalities were divided into four groups: transition to an alternative NOAC, switch to a vitamin K antagonist (VKA), the addition of an antiplatelet agent, or the deliberate maintenance of the current treatment.
Results
We analyzed the data of 107 patients. Patients were either on rivaroxaban (42%), apixaban (33%), dabigatran (12%), or edoxaban (13%) at the time of the initial TEE. A change to a different NOAC occurred in 33% of cases, a transition to a VKA in 29%, the supplementation with antiplatelet therapy in 11%, while the deliberate absence of treatment modification was observed in 25% of cases. Follow-up TEE (or CT angiography in a minority of cases) was performed at a median of 71 [43 – 105] days from the baseline evaluation. Thrombus resolution was achieved in 81 (76%) of cases and was predicted by a lower CHA2DS2-VASc score (p = 0.009) and higher ejection fraction (p = 0.04). Evaluation of therapeutic strategies revealed that any modification of treatment was on average four times more effective than the deliberate no change; thrombus resolution was observed in 67 (83%) vs. 14 (54%) cases (OR 4.1 [1.57 - 10.7], p = 0.004). Nevertheless, no particular strategy demonstrated superior efficacy over others.
Conclusion
Resolution of LAA thrombus in patients already on adequate NOAC treatment may require a revision of the prior anticoagulation strategy; however, none of the commonly employed strategies appears to exhibit distinct superiority over the rest.