This Article Full Text Full Text (PDF) All Versions of this Article: 119/18/2490    most recent CIRCULATIONAHA.108.785014v1 Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Feng, D. Articles by Klarich, K. W. Search for Related Content PubMed PubMed Citation Articles by Feng, D. Articles by Klarich, K. W. Related Collections Myocardial cardiomyopathy disease Thrombosis risk factors Echocardiography Anticoagulants Related Article

(Circulation. 2009;119:2490-2497.)
© 2009 American Heart Association, Inc.

Imaging

Intracardiac Thrombosis and Anticoagulation Therapy in Cardiac Amyloidosis

DaLi Feng, MD; Imran S. Syed, MD; Matthew Martinez, MD; Jae K. Oh, MD; Allan S. Jaffe, MD; Martha Grogan, MD; William D. Edwards, MD; Morie A. Gertz, MD; Kyle W. Klarich, MD

From the Metropolitan Heart and Vascular Institute, Minneapolis, Minn (D.F.), and Divisions of Cardiovascular Diseases (D.F., I.S.S., M.M., J.K.O., A.S.J., M.G., K.W.K.), Anatomic Pathology (W.D.E.), and Hematology (M.A.G.), Mayo Clinic, Mayo Clinic College of Medicine, Rochester, Minn.

Correspondence to DaLi Feng, MD, or Kyle W. Klarich, MD, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail dali.feng{at}metrocardiology.com or klarich.kyle@mayo.edu

Received April 7, 2008; accepted February 10, 2009.

Background— Primary amyloidosis has a poor prognosis as a result of frequent cardiac involvement. We recently reported a high prevalence of intracardiac thrombus in cardiac amyloid patients at autopsy. However, neither the prevalence nor the effect of anticoagulation on intracardiac thrombus has been evaluated antemortem.

Methods and Results— We studied all transthoracic and transesophageal echocardiograms of cardiac amyloid patients at the Mayo Clinic. The prevalence of intracardiac thrombosis, clinical and transthoracic/transesophageal echocardiographic risks for intracardiac thrombosis, and effect of anticoagulation were investigated. We identified 156 patients with cardiac amyloidosis who underwent transesophageal echocardiograms. Amyloidosis was the primary type (AL) in 80; other types occurred in 76 patients, including 56 with the wild transthyretin type, 17 with the mutant transthyretin type, and 3 with the secondary type. Fifth-eight intracardiac thrombi were identified in 42 patients (27%). AL amyloid had more frequent intracardiac thrombus than the other types (35% versus 18%; P=0.02), although the AL patients were younger and had less atrial fibrillation. Multivariate analysis showed that atrial fibrillation, poor left ventricular diastolic function, and lower left atrial appendage emptying velocity were independently associated with increased risk for intracardiac thrombosis, whereas anticoagulation was associated with a significantly decreased risk (odds ratio, 0.09; 95% CI, 0.01 to 0.51; P<0.006).

Conclusions— Intracardiac thrombosis occurs frequently in cardiac amyloid patients, especially in the AL type and in those with atrial fibrillation. Risk for thrombosis increased if left ventricular diastolic dysfunction and atrial mechanical dysfunction were present. Anticoagulation therapy appears protective. Timely screening in high-risk patients may allow early detection of intracardiac thrombus. Anticoagulation should be carefully considered.

---

 

CLINICAL PERSPECTIVE

Related Article:

Clinical Summaries
Circulation 2009 119: 2417-2419. [Extract] [Full Text]