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

Left atrial appendage (LAA) thrombus is the primary cause of stroke and systemic embolism in atrial fibrillation (AF). Non-vitamin-K oral anticoagulants (NOACs) effectively reduce LAA thrombus prevalence and stroke risk. However, optimal treatment of a NOAC-resistant thrombus remains unclear.

We aimed to evaluate therapeutic strategies for resolving LAA thrombus in patients on optimal NOAC therapy.

We retrospectively analyzed patients scheduled for cardioversion or catheter ablation of AF between 2014 and 2023 with LAA thrombus on transesophageal echocardiography (TEE) despite being on optimal NOAC therapy. We assessed how the applied management strategy affected thrombus resolution.

Among the analyzed 120 patients, a change to a different NOAC occurred in 41% of cases, a transition to a VKA in 30%, and the supplementation with antiplatelet therapy in 11%, while in 18% of cases, no change occurred. Follow-up imaging at 65 [44 – 95] days showed successful thrombus resolution in 92 (77%) of cases, predicted by a lower CHA2DS2-VASc score (p = 0.01). Any modification of antithrombotic therapy was an independent predictor of thrombus resolution (OR 5.28 [1.55-18], p=0.01). Of the four strategies, there was a trend toward better thrombus resolution with switching to a VKA (OR 3.23 [1.03-10.1], p=0.04).

Resolution of LAA thrombus in patients already on adequate NOAC treatment may require a revision of the anticoagulation strategy. Additionally, transitioning from NOAC to VKA might be considered.

Sankey diagram