REPLY
Predictors of Systemic Embolism in Mitral Stenosis
Cheng-Wen Chiang, MD
15 December 1998 | Volume 129 Issue 12 | Pages 1077-1078
IN RESPONSE
Transesophageal echocardiography has been shown to be better than TTE for detection of left atrial thrombi [1, 2]. In our subgroup of 164 patients (including 36 patients in sinus rhythm and 128 patients in atrial fibrillation) who underwent baseline TEE, the prevalence of left atrial thrombi detected by TEE was 56.7% and that by TTE was 29.9%. The difference in the occurrence of systemic embolism during follow-up between those with and those without left atrial thrombi (detected by either TTE or TEE) did not reach statistical significance in this subgroup, presumably because of the small sample and the high percentage of censored observation (only 9.5% developed systemic embolism). In daily clinical practice, we would advocate performing TEE for patients with mitral stenosis who are in sinus rhythm and have no left atrial thrombi detectable by TTE, and giving anticoagulants to those with left atrial thrombi detected by either TTE (TEE can be omitted for these patients) or TEE.
As for patients with mitral stenosis who are in atrial fibrillation, anticoagulants should be given regardless of the presence or absence of left atrial thrombi [3, 4]. The presence of left atrial thrombi detectable with TTE was not identified as a predictor of systemic embolism in patients with atrial fibrillation in our study. This could be partly due to the fact that in these patients, some thrombi detected at baseline examination may have been organized and less likely to dislodge; in contrast, patients who had no thrombi at baseline examination may have developed new thrombi (which were prone to dislodge) during follow-up.
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Author and Article Information
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Chang Gung Memorial Hospital; Taipei, Taiwan, Republic of China
1. Mugge A, Daniel WG, Haverich A, Lichtlen PR. Diagnosis of non-infective cardiac mass lesions by two-dimensional echocardiography. Comparison of the transthoracic and transesophageal approaches. Circulation. 1991; 83:70-8.
2. Manning WJ, Weintraub RM, Waksmonski CA, Haering JM, Rooney PS, Maslow AD, et al. Accuracy of transesophageal echocardiography for identifying left atrial thrombi. A prospective, intraoperative study. Ann Intern Med. 1995; 123:817-22.
3. Coulshed N, Epstein EJ, McKendrick CS, Galloway RW, Walker E. Systemic embolism in mitral valve disease. Br Heart J. 1970; 32:26-34.
4. Black IW, Fatkin D, Sagar KB, Khandheria BK, Leung DY, Galloway JM, et al. Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation. A multicenter study. Circulation. 1994; 89:2509-13.
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