Incremental diagnostic role of left atrial strain analysis in thrombotic risk assessment of nonvalvular atrial fibrillation patients planned for electrical cardioversion

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Abstract
During the COVID-19 pandemic, transesophageal echocardiography (TEE) for left atrial appendage thrombosis (LAAT)
detection should be limited to situations of absolute necessity. We sought to identify the main conventional and functional
echocardiographic parameters associated with LAAT on TEE in non-valvular atrial fibrillation (NVAF) patients planned
for electrical cardioversion (ECV). This retrospective study included 125 consecutive NVAF patients (71.5±7.8 yrs, 75
males), who underwent TEE at our Institution between April 2016 and January 2020, to exclude LAAT before scheduled
ECV. All patients underwent a transthoracic echocardiography (TTE) implemented with speckle tracking echocardiography
(STE) analysis of left atrial (LA) strain and strain rate (SR) parameters. 28% of patients were diagnosed with LAAT, while
72% without LAAT. Compared to controls, patients with LAAT had significantly higher CHA2DS2-
Vasc Score and average
E/e’ ratio, and significantly lower left ventricular ejection fraction (LVEF). Moreover, LA-peak positive global atrial strain
(GSA+) and LA-SR parameters were significantly reduced in patients with LAAT. Multivariate logistic regression revealed
that, differently from CHA2DS2-
Vasc Score, LVEF (OR 0.88, 95%CI 0.81–0.97, p = 0.01), average E/e’ ratio (OR 2.36,
95%CI 1.41–3.98, p = 0.001), and LA-GSA+ (OR 0.57, 95%CI 0.36-0-90, p = 0.01) were independently associated with
LAAT. LA-GSA+ (optimal cut-off ≤ 9.1%, AUC 0.95) showed the highest diagnostic performance. Finally, a strong linear
correlation of LA peak-to-peak SR with both LA appendage filling (r = 0.86) and emptying (r = 0.83) velocities was demonstrated.
TTE implemented with STE analysis of LA mechanics improves thrombotic risk assessment of NVAF patients.