Location of Thrombus in Non-Rheumatic Atrial Fibrillation SettingNAppendage(%) LA Body (%)Ref. TEE (21%) 1 (0.3%) Stoddard; JACC ’95 TEE (15%) 1 (0.4%) Manning; Circ ’94 Autopsy (7%) 12 (2.4%) Aberg; Acta Med Scan ’69 TEE52 2 (4%) 2 (3.8%) Tsai; JFMA ’90 TEE48 12 (25%) 1 (2.1%) Klein; Int J Card Imag ’93 TEE & Operation (5%) 3 (1.8%) Manning; Circ ’94 SPAF III TEE (5%) 1 (0.3%) Klein; Circ ’94 TEE (7%) 0 (0.0%) Leung; JACC ’94 TEE60 6 (10%) 0 (0.0%) Hart; Stroke ‘94 Total (10%) 21 (1.0%) From: Blackshear & Odell; 1996

Prevalence of Left Atrial Thrombus in Rheumatic Mitral Stenosis With Atrial Fibrillation and its Response to Anticoagulation: A Transesophageal Echocardiographic Study 1. Left atrial clots 1/3 with severe rheumatic MS and AF. 2. Isolated left atrial appendage clots can disappear with long-term anticoagulation 3. Thrombi that extend into the left atrial body may persist despite optimal anticoagulation Indian Heart J 2003; 55: 358–361

Thrombus in AppendageNormal Appendage

LA appendageAccessory LA appendage Circulation. 2008;117:

Risk Stratification for Patients with AFib-Flutter Annual Stroke Rate % AGE Years No other Risk Factors One or More Additional Risk Factors < >

Risk Factor Stratification High Risk FactorsModerate Risk Factors History of CVT/TIAAge years HypertensionDiabetes Reduced LV FunctionCAD without LV dysfunction Age > 75 years Mitral stenosis Prosthetic Heart Valve

Guidelines for Long-term Anticoagulation AgeRisk Factors*Recommendation  65 years Absent Present ASA Warfarin † years Absent Present ASA or Warfarin Warfarin †  75 years All patientsWarfarin † * Prior TIA, systemic embolism or stroke, HTN, poor LV function, Rheumatic MVD, prosthetic heart valve † Target INR 2.5 (range ) Laupacis et al. Chest 1998;114:579S-589S.

Class I 1. Patients of any age with abrupt occlusion of a major peripheral or visceral artery. 2. Younger patients (typically less than 45 years) with cerebrovascular events. 3. Older patients (typically more than 45 years) with neurological events without evidence of cerebrovascular disease or other obvious cause. 4. Patients for whom a clinical therapeutic decision (eg, anticoagulation) will depend on the results of echocardiography. Class IIa Patients with suspicion of embolic disease and with cerebrovascular disease of questionable significance. Recommendations for Echocardiography in Patients With Neurological Events or Other Vascular Occlusive Events

Class IIb Patients with a neurological event and intrinsic cerebrovascular disease of a nature sufficient to cause the clinical event. Class III Patients for whom the results of echocardiography will not impact a decision to institute anticoagulant therapy or otherwise alter the approach to diagnosis or treatment.