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Predictors of Systemic Embolism in Mitral Stenosis
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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.
Cheng-Wen Chiang, MD
Chang Gung Memorial Hospital; Taipei, Taiwan, Republic of China
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
