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\begin{document}

\title{Echocardiography in Left Atrial Thrombosis}



\author[1]{Tara Moghaddasfar}%
\author[1]{Hamed Vahidi}%
\author[1]{Maryam Faramarzpour}%
\author[1]{Farnoosh Larti}%
\affil[1]{Tehran University of Medical Sciences}%


\vspace{-1em}



  
  \date{May 14, 2024}


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\begin{abstract}
Atrial fibrillation is associated with low-flow state and increased
thrombogenicity in the left atrium (LA). Multiple echocardiographic
presentations, including thrombosis, sludge, and smoke formation, have
been demonstrated in just one biplane transesophageal echocardiographic
view, along with normal structures, i.e., pectinate muscles and Coumadin
ridge, which are highly educational for cardiologists.%
\end{abstract}%



\sloppy


\textbf{Echocardiography in Left Atrial Thrombosis}

Tara Moghaddasfar\textsuperscript{1}, Hamed Vahidi\textsuperscript{1},
Maryam Faramarzpour\textsuperscript{1}, Farnoosh
Larti\textsuperscript{1*}

1-Department of Cardiology, Imam Khomeini Hospital Complex, Tehran
University of Medical Sciences, Tehran, Iran

*Name and a complete address for correspondence:

Farnoosh Larti, Email: Farnooshlarti@gmail.com, Postal code: 1419733141,
Cardiology Department, Imam Khomeini Hospital Complex, Keshavarz
Boulevard, Tehran, Iran, telephone number: +989188319061, +9861192647.

ORCID ID:0000-0001-7939-9306

Data availability statement: The data of this study is available for
assessment

Funding statement: No funding was received for this study

Patient consent statement: Written informed consent was obtained from
the patient regarding this research process

Conflict of interest disclosure: No conflict of interest was present to
be disclosed

Keywords: Echocardiography, Left atrial thrombosis

Abstract

Atrial fibrillation is associated with low-flow state and increased
thrombogenicity in the left atrium (LA). Multiple echocardiographic
presentations, including thrombosis, sludge, and smoke formation, have
been demonstrated in just one \emph{biplane} transesophageal
echocardiographic view, along with normal structures, i.e., pectinate
muscles and Coumadin ridge, which are highly educational for
cardiologists.

Case Presentation

A 54-year-old man with a history of mitral valve repair nine years ago
due to a flail posterior mitral valve leaflet was admitted to our
hospital. He also had a history of permanent atrial fibrillation (AF)
and was taking warfarin, but his International Normalized Ratio (INR)
was subtherapeutic. Transesophageal echocardiography (TEE) for
assessment of LA thrombosis was performed. Interestingly, different
echocardiographic presentations of the increased thrombogenicity in the
left atrium (LA) have been detected in just one biplane view (Figure 1,
Video S1). A large LA thrombosis, LA appendage sludge, severe
spontaneous echo contrast (smoke) in the LA, and normal structures, such
as pectinate muscles and Coumadin ridge, were detected.

\emph{Spontaneous echo contrast (SEC) or smoke} is defined as an
echogenic, dynamic, swirling blood flow pattern mainly observed as a
marker of a low-flow state in the LA. The presence and the grade of SEC
are related to an increased risk of thrombosis formation in the LA. The
severity is graded from 0 to 4+, with grade 0 indicating the absence of
echogenicity and grade 4+ indicating severe echogenicity and very slow
swirling patterns in the LAA, usually with similar density in the LA
cavity (1).

Among patients with AF, the prevalence of spontaneous echo contrast in
LA was 8 percent, and the rate of sludge was 1-3.4 percent based on
different studies. Between 2 to 12.4 percent of patients with AF taking
vitamin k antagonists (VKA) may have LA or LAA thrombosis depending on
the study population (2).

Pectinate muscles are normal ridge-like structures within the LAA wall
that may be difficult to distinguish from LAA thrombosis, specifically
at the tip of the LAA. Coumadin ridge is a band-like structure between
LAA and the left upper pulmonary vein that may cause a reverberation
artifact resembling a thrombosis in the LAA (3).

References

1. Fatkin D, Kelly RP, Feneley MP. Relations between left atrial
appendage blood flow velocity, spontaneous echocardiographic contrast,
and thromboembolic risk in vivo. Journal of the American College of
Cardiology. 1994 Mar 15;23(4):961-9.

2. Noubiap JJ, Agbaedeng TA, Ndoadoumgue AL, Nyaga UF, Kengne AP. Atrial
thrombus detection on transoesophageal echocardiography in patients with
atrial fibrillation undergoing cardioversion or catheter ablation: A
pooled analysis of rates and predictors. Journal of Cardiovascular
Electrophysiology. 2021 Aug;32(8):2179-88.

3. Wheeler R, Masani ND. The role of echocardiography in the management
of atrial fibrillation. European Journal of Echocardiography. 2011 Oct
1;12(10):i33-8.

Figure Legend

Biplane view in transesophageal echocardiography demonstrating left
atrial thrombosis, left atrial smoke, left atrial appendage sludge,
pectinate muscle in the left atrial appendage, and Coumadin ridge.

Red arrow: Pectinate muscle

Yellow arrow: Left atrial appendage sludge

Red arrowhead: Left atrial smoke

Yellow arrowhead: Coumadin ridge

Red star: Left atrial thrombosis\selectlanguage{english}
\begin{figure}[H]
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\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

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