Predictors of left atrial thrombus in mitral valve disease

Objective:To determine the risk factors for left atrial thrombus (LAT) and the prevalence of thrombi in cases of mitral valve disease whose severity was fudged to necessitate surgical intervention. Design:Hospital record review of all operative cases from 1982 to 1985. Setting:A community serving a referral population encompassing 1.5 million people. Only two hospitals in the geographic area performed cardiac surgery, and both hospitals’ records were reviewed. Patients:All 372 patients who underwent either mitral valve replacement or open mitral commissurotomy. Main results:Twenty-six patients (7%) were noted to have LAT at surgery. Five preselected factors were significantly (p<0.05) associated with LAT in univariate analysis: female gender, prior history of embolism, prior anticoagulant therapy, mitral stenosis (MS), and atrial fibrillation (AF). In logistic regression analysis, only MS and AF remained as significant independent predictors of LAT. Mitral stenosis patients in sinus rhythm had a relatively low [2.4±3.3% (observed ±95% confidence interval)] likelihood of having an LAT. Likewise, mitral regurgitation patients in sinus rhythm (n=139)had an extremely low (0.7±1.4%) prevalence of LAT. In contrast, MS patients in AF (n=122)had a prevalence of LAT of 18.0±6.8%. Conclusions:These findings indicate that, overall, LAT in mitral valve disease may be less common than previous studies have suggested. In addition, mitral valve disease patients who remain in sinus rhythm appear to have a low risk of barboring an LAT. Conversely, MS patients, especially those in AF, appear to be at high risk of barboring an LAT. These results may be helpful in formulating strategies for the use of prophylactic anticoagulation in categories of patients with clinically severe mitral valve disease, or perhaps in estimating the likelihood of a cardiac source of embolism in mitral valve disease patients with suspected cerebral or peripheral emboli. Received from the General Medicine and Cardiology Units, Department of Medicine, the University of Rochester School of Medicine and Dentistry, Rochester, New York. Dr. Davison is currently at Washington University, St. Louis, Missouri.