avkАрхивъ внутренней медициныThe Russian Archives of Internal Medicine2226-67042411-6564“SINAPS” LLC10.20514/2226-6704-2021-12-2-129-135avk-1406Research ArticleОРИГИНАЛЬНЫЕ СТАТЬИORIGINAL ARTICLEПредикторы растворения тромбов в ушке левого предсердия у больных персистирующей неклапанной фибрилляцией предсердийPredictors of Thrombus Dissolution in the Left Atrial Appendage in Patients with Persistent Nonvalvular Atrial Fibrillationhttps://orcid.org/0000-0002-8879-3791МазурЕ. С.MazurE. S.

кафедра госпитальной терапии и профессиональных болезней

Тверь

Tver 

https://orcid.org/0000-0003-4818-434XМазурВ. В.MazurV. V.

кафедра госпитальной терапии и профессиональных болезней

Тверь

Tver 

https://orcid.org/0000-0003-0511-7366БаженовН. Д.BazhenovN. D.

кафедра госпитальной терапии и профессиональных болезней

Тверь

Tver 

https://orcid.org/0000-0001-9114-0436ОрловЮ. А.OrlovYu. A.

кафедра госпитальной терапии и профессиональных болезней

Тверь

Tver 

ФГБОУ ВО Тверской ГМУ Минздрава РоссииРоссияTver State Medical UniversityRussian Federation202230032022122129135Copyright © Мазур Е.С., Мазур В.В., Баженов Н.Д., Орлов Ю.А., 20222022Мазур Е.С., Мазур В.В., Баженов Н.Д., Орлов Ю.А.Mazur E.S., Mazur V.V., Bazhenov N.D., Orlov Y.A.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.medarhive.ru/jour/article/view/1406

Цель работы — выявить факторы, влияющие на вероятность растворения тромба в ушке левого предсердия у больных персистирующей неклапанной фибрилляцией предсердий. Материал и методы. Повторное чреспищеводное эхокардиографическое исследование выполнено 88 больным персистирующей неклапанной фибрилляцией предсердий, у которых при первом исследовании был выявлен тромб в ушке левого предсердия. Результаты. При повторном исследовании, которое выполнялось в среднем через 30,0 (22,0; 40,0) дня после первого, растворение тромба в ушке левого предсердия было констатировано у 60 (68,2%) из 88 включенных в исследование пациентов. Анализ многофакторной логистической регрессии показал, что шансы растворения выявленного в ушке левого предсердия тромба возрастают в 5,789 (1,907–17,568) раза при размере тромба не более 25 мм, в 5,318 (1,325–21,353) раза при скорости кровотока в ушке левого предсердия не менее 20 см/с и в 3,687 (1,229–11,059) раза в случае использования прямых оральных антикоагулянтов, а не варфарина. При сочетании двух и более из указанных факторов вероятность растворения тромба достигает 89,6%. Заключение. Вероятность растворения тромба в ушке левого предсердия у больных персистирующей неклапанной фибрилляцией предсердий возрастает при небольшом размере тромба, высокой скорости изгнания крови из ушка левого предсердия и использовании прямых оральных антикоагулянтов.

The aim of this study is to identify factors influencing the likelihood of the thrombus dissolution in the left atrial appendage in patients with persistent nonvalvular atrial fibrillation. Material and methods. A repeated transesophageal echocardiography was performed in 88 patients with persistent nonvalvular atrial fibrillation and with the left atrial appendage thrombus at the first transesophageal echocardiography. Results. The second transesophageal echocardiography was performed on average 30.0 (22.0; 40.0) days after the first one, the thrombus dissolution in the left atrial appendage was revealed in 60 (68.2%) patients. The multivariate logistic regression analysis showed that the chances of the thrombus dissolution increased by 5.789 (1.907–17.568) times with the thrombus size not more 25 mm, by 5.318 (1.325–21.353) times with the left atrial appendage emptying flow velocity not less 20 cm/s and 3.687 (1.229–11.059) times when prescribing the direct oral anticoagulants, and not warfarin. Combination of two or more factors give the probability of the thrombus dissolution of more than 89.6%. Conclusion. The probability of the thrombus dissolution in left atrial appendage in patients with persistent nonvalvular atrial fibrillation increases with a small thrombus size, a high the left atrial appendage emptying flow velocity, and if direct oral anticoagulants were prescribed.

персистирующая фибрилляция предсердийчреспищеводная эхокардиографиятромбоз ушка левого предсердияпероральные антикоагулянтыpersistent atrial fibrillationtransesophageal echocardiographyleft atrial appendage thrombosisoral anticoagulantsReferencesАракелян М.Г., Бокерия Л.А., Васильева Е.Ю., и др. Фибрилляция и трепетание предсердий. Клинические рекомендации 2020. Российский кардиологический журнал. 2021; 26(7): 4594. doi:10.15829/1560-4071-2021-4594.Arakelyan M.G., Bockeria L.A., Vasilieva E.Yu., et al. 2020 Clinical guidelines for Atrial fibrillation and atrial flutter. Russian Journal of Cardiology. 2021; 26(7): 4594. doi:10.15829/1560-4071-2021-4594 [In Russian].Hindricks G., Potpara T., Dagres N., et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2020; 00: 1–125. doi: 10.1093/eurheartj/ehaa612.Hindricks G., Potpara T., Dagres N., et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2020; 00: 1–125. doi: 10.1093/eurheartj/ehaa612.Lip G.Y.H., Hammerstingl C, Marin F. et al. Left atrial thrombus resolution in atrial fibrillation or flutter: Results of a prospective study with rivaroxaban (X-TRA) and a retrospective observational registry providing baseline data (CLOT-AF). American Heart Journal. 2016; 178: 126-34. doi:10.1016/j.ahj.2016.05.007.Lip G.Y.H., Hammerstingl C, Marin F. et al. Left atrial thrombus resolution in atrial fibrillation or flutter: Results of a prospective study with rivaroxaban (X-TRA) and a retrospective observational registry providing baseline data (CLOT-AF). American Heart Journal. 2016; 178: 126-34. doi:10.1016/j.ahj.2016.05.007.Hussain A., Katz W.E., Genuardi M.V., et al. Non-vitamin K oral anticoagulants versus warfarin for left atrial appendage thrombus resolution in nonvalvular atrial fibrillation or flutter. Pacing Clin Electrophysiol. 2019; 42(9): 1183–1190. doi: 10.1111/pace.13765.Hussain A., Katz W.E., Genuardi M.V., et al. Non-vitamin K oral anticoagulants versus warfarin for left atrial appendage thrombus resolution in nonvalvular atrial fibrillation or flutter. Pacing Clin Electrophysiol. 2019; 42(9): 1183–1190. doi: 10.1111/pace.13765.Saeed M., Rahman A., Afzal A., et al. Role of transesophageal echocardiography guided cardioversion in patients with atrial fibrillatio, previous left atrial thrombus and effective anticoagulation. Int J Cardiol. 2006; 113(3): 401–405. doi: 10.1016/j.ijcard.2006.03.036.Saeed M., Rahman A., Afzal A., et al. Role of transesophageal echocardiography guided cardioversion in patients with atrial fibrillatio, previous left atrial thrombus and effective anticoagulation. Int J Cardiol. 2006; 113(3): 401–405. doi: 10.1016/j.ijcard.2006.03.036.Mumoli N., Amellone C., Antonelli G., et al. Clinical discussions in antithrombotic therapy management in patients with atrial fibrillation: a delphi consensus panel. CJC Open. 2020; 2: 641–651. doi:10.1016/j.cjco.2020.07.016.Mumoli N., Amellone C., Antonelli G., et al. Clinical discussions in antithrombotic therapy management in patients with atrial fibrillation: a delphi consensus panel. CJC Open. 2020; 2: 641–651. doi:10.1016/j.cjco.2020.07.016.Hahn R.T., Abraham T., Adams M.S., et al. Guidelines for Performing a Comprehensive Transesophageal Echocardiographic Examination: Recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2013; 26: 921-64. doi: 10.1016/j.echo.2013.07.009Hahn R.T., Abraham T., Adams M.S., et al. Guidelines for Performing a Comprehensive Transesophageal Echocardiographic Examination: Recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2013; 26: 921-64. doi: 10.1016/j.echo.2013.07.009Lattuca B., Bouziri N., Kerneis M. et al. Antithrombotic Therapy for Patients With Left Ventricular Mural Thrombus. J Am Coll Cardiol 2020; 75: 1676–85. doi: 10.1016/j.jacc.2020.01.057Lattuca B., Bouziri N., Kerneis M. et al. Antithrombotic Therapy for Patients With Left Ventricular Mural Thrombus. J Am Coll Cardiol 2020; 75: 1676–85. doi: 10.1016/j.jacc.2020.01.057Oh J.K., Park J-H., Lee J-H., et al. Shape and Mobility of a Left Ventricular Thrombus Are Predictors of Thrombus Resolution. Korean Circ J. 2019; 49(9): 829-837. doi: 10.4070/kcj.2018.0346.Oh J.K., Park J-H., Lee J-H., et al. Shape and Mobility of a Left Ventricular Thrombus Are Predictors of Thrombus Resolution. Korean Circ J. 2019; 49(9): 829-837. doi: 10.4070/kcj.2018.0346.Goldman М.Е., Pearce L.A., Hart R.G., et al. Pathophysiologic Correlates of Thromboembolism in Nonvalvular Atrial Fibrilla- tion: I. Reduced Flow Velocity in the Left Atrial Appendage (The Stroke Prevention in Atrial Fibrillation [SPAF-III] Study). Journal of American Society of Echocardiography. 1999; 12: 1080–1087. doi:10.1016/s0894-7317(99)70105-7.Goldman М.Е., Pearce L.A., Hart R.G., et al. Pathophysiologic Correlates of Thromboembolism in Nonvalvular Atrial Fibrilla- tion: I. Reduced Flow Velocity in the Left Atrial Appendage (The Stroke Prevention in Atrial Fibrillation [SPAF-III] Study). Journal of American Society of Echocardiography. 1999; 12: 1080–1087. doi:10.1016/s0894-7317(99)70105-7.Lee J.M., Shim J., Uhm J.S., et al. Impact of Increased Orifice Size and Decreased Flow Velocity of Left Atrial Appendage on Stroke in Nonvalvular Atrial Fibrillation. American Journal of Cardiology. 2014; 113: 963-969. doi: 10.1016/j. amjcard.2013.11.058.Lee J.M., Shim J., Uhm J.S., et al. Impact of Increased Orifice Size and Decreased Flow Velocity of Left Atrial Appendage on Stroke in Nonvalvular Atrial Fibrillation. American Journal of Cardiology. 2014; 113: 963-969. doi: 10.1016/j. amjcard.2013.11.058.Cresti A., Garcia-Fernandez M.A., De Sensi F., et al. Prevalence of auricular thrombosis before atrial flutter cardioversion: a 17-year transoesophageal echocardiographic study. Europace 2016; 18: 450–456. doi:10.1093/europace/euv128Cresti A., Garcia-Fernandez M.A., De Sensi F., et al. Prevalence of auricular thrombosis before atrial flutter cardioversion: a 17-year transoesophageal echocardiographic study. Europace 2016; 18: 450–456. doi:10.1093/europace/euv128Lee J.M., Kim J-B., Uhm J-S. et al. Additional value of left atrial appendage geometry and hemodynamics when considering anticoagulation strategy in patients with atrial fibrillation with low CHA2DS2-VASc scores. Heart Rhythm 2017; 14(1): 297– 1301. doi: 10.1016/j.hrthm.2017.05.034Lee J.M., Kim J-B., Uhm J-S. et al. Additional value of left atrial appendage geometry and hemodynamics when considering anticoagulation strategy in patients with atrial fibrillation with low CHA2DS2-VASc scores. Heart Rhythm 2017; 14(1): 297– 1301. doi: 10.1016/j.hrthm.2017.05.034Голухова Е.З., Громова О.И., Аракелян М.Г. и др. Предикторы тромбоза ушка левого предсердия и тромбоэмболических осложнений у больных с фибрилляцией предсердий без сопутствующей клапанной патологии и ишемической болезни сердца. Креативная кардиология. 2017; 11(3): 262-72. doi: 10.24022/1997-3187-2017-11-3-262-272.Golukhova E.Z., Gromova O.I., Arakelyan M.G. et al. Risk factors of left atrial thrombus and/or thromboembolism in patients with nonvalvular, nonishemic atrial fibrillation. Kreativnaya Kardiologiya (Creative Cardiology). 2017; 11(3): 262-72. doi: 10.24022/1997-3187-2017-11-3-262-272 [in Russian].Beigel R., Wunderlich N.C., Ho S.Y. et al. The Left Atrial Appendage: Anatomy, Function, and Noninvasive Evaluation. Journal of American College of Cardiology: Cardiovascular Imaging. 2014; 7(12): 1251-65. doi:10.1016/j.jcmg.2014.08.009.Beigel R., Wunderlich N.C., Ho S.Y. et al. The Left Atrial Appendage: Anatomy, Function, and Noninvasive Evaluation. Journal of American College of Cardiology: Cardiovascular Imaging. 2014; 7(12): 1251-65. doi:10.1016/j.jcmg.2014.08.009.Zateyshchikov D.A., Brovkin A.N., Chistiakov D.A., et al. Advanced age, low left atrial appendage velocity, and Factor V promoter sequence variation as predictors of left atrial thrombosis in patients with nonvalvular atrial fibrillation. Journal of Thrombosis and Thrombolysis. 2010; 30: 192-199. doi: 10.1007/s11239-010-0440-1.Zateyshchikov D.A., Brovkin A.N., Chistiakov D.A., et al. Advanced age, low left atrial appendage velocity, and Factor V promoter sequence variation as predictors of left atrial thrombosis in patients with nonvalvular atrial fibrillation. Journal of Thrombosis and Thrombolysis. 2010; 30: 192-199. doi: 10.1007/s11239-010-0440-1.Niku A.D., Shiota T., Siegel R.J., et al. Prevalence and Resolution of Left Atrial Thrombus in Patients with Nonvalvular Atrial Fibrillationand Flutter with Oral Anticoagulation. Am. J. Cardiol. 2019; 123: 63–68. doi: 10.1016/j.amjcard.2018.09.027Niku A.D., Shiota T., Siegel R.J., et al. Prevalence and Resolution of Left Atrial Thrombus in Patients with Nonvalvular Atrial Fibrillationand Flutter with Oral Anticoagulation. Am. J. Cardiol. 2019; 123: 63–68. doi: 10.1016/j.amjcard.2018.09.027

The authors declare that there are no conflicts of interest present.