Clinical and echocardiographic predictors of left atrial clot and spontaneous echo contrast in patients with severe rheumatic mitral stenosis: a prospective study in 200 patients by transesophageal echocardiography

The objective of this study was to prospectively investigate various clinic al and echocardiographic variables to predict the Left atrial and left atri al appendage clot and spontaneous echo contrast in patients with severe rhe umatic mitral stenosis. We studied 200 consecutive patients (112 males and 88 females; mean age 29.6+/-9.6 years). Left atrial clot and spontaneous ec ho contrast were present in 26 and 53.5% of cases, respectively. There were no significant differences in the mitral valve area, mean transmitral dias tolic gradient and left ventricular ejection fraction between patients with and without clot. Patients with clot were older (34.4+/-11.4 vs. 28.2+/-8. 5 years, P<0.001), had longer duration of symptoms (41.4+/-36.0 vs. 28.8+/- 22.9 months, P<0.001), more frequent atrial fibrillation and spontaneous ec ho contrast (69.2 vs. 16.9%, P<0.00001 and 76.9 vs. 45.3%, P<0.00001, respe ctively) and larger left atrial area and diameter (41.0+/-12.7 vs. 29.9+/-7 .4 cm(2), P<0.00001 and 53.9+/-8.3 vs. 47.6+/-7.4 mm, P<0.0001, respectivel y) as compared to patients without clot. Similarly patients with spontaneou s echo contrast were older (31+/-10.4 vs. 27.8+/-8.3 years, P<0.01), had mo re frequent atrial fibrillation (48.6 vs. 9.7%, P<0.0001), left atrial clot (37.4 vs. 12.9%, P<0.0001), larger left atrial area and diameter (37.6+/-1 1.2 vs. 28.1+/-6.7 cm(2), P<0.0001 and 52.2+/-8.3 vs, 45.9+/-6.5 mm, P<0.00 01, respectively) and smaller mitral valve area (0.77+/-0.14 vs. 0.84+/-0.1 3 cm(2), P<0.01) as compared to patients without spontaneous echo contrast. There were no significant differences in the mean transmitral diastolic gr adient and left ventricular ejection fraction. On multiple regression and d iscriminant function analysis, atrial fibrillation and left atrial area wer e independent predictors of left atrial clot formation. In a subgroup of pa tients with sinus rhythm, Larger left atrial area and presence of spontaneo us echo contrast were significantly associated with the presence of clot in left atrium and appendage. We conclude that in patients with severe mitral stenosis, the presence of atrial fibrillation and in the subgroup of the p atients with sinus rhythm the presence of large left atrium (greater than o r equal to 40 cm(2)) and spontaneous echo contrast were associated with hig her risk of clot formation in the left atrium and might be benefited by pro phylactic anticoagulation. (C) 2000 Elsevier Science Ireland Ltd. All right s reserved.