{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T10:49:07Z","timestamp":1785408547032,"version":"3.56.0"},"reference-count":38,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2026,6,10]],"date-time":"2026-06-10T00:00:00Z","timestamp":1781049600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100007771","name":"Medical University of Silesia","doi-asserted-by":"publisher","award":["PCN-1\/217\/N\/2\/K"],"award-info":[{"award-number":["PCN-1\/217\/N\/2\/K"]}],"id":[{"id":"10.13039\/100007771","id-type":"DOI","asserted-by":"publisher"}]},{"award":["PCN-1\/217\/N\/2\/K"],"award-info":[{"award-number":["PCN-1\/217\/N\/2\/K"]}],"id":[{"id":"https:\/\/ror.org\/005k7hp45","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: Predictors of left atrial appendage thrombus (LAAT) in adequately anticoagulated patients with atrial fibrillation (AF) referred for direct current cardioversion (DCCV) remain insufficiently defined, particularly in populations with a high prevalence of cardiac implantable electronic devices (CIEDs). The aim of this study was to identify clinical and echocardiographic determinants of LAAT and\/or dense spontaneous echocardiographic contrast (SEC) in patients with persistent AF referred for DCCV. Methods: This prospective observational study included 510 consecutive patients with persistent AF who had received at least 3 weeks of effective anticoagulation and underwent transthoracic and transesophageal echocardiography prior to elective DCCV. The primary endpoint was the presence of LAAT and\/or dense SEC (Fatkin grade 3\u20134). Independent predictors were identified using multivariable logistic regression. Results: LAAT and\/or dense SEC were detected in 192 patients (37.6%)\u2014of whom 73 had overt LAAT, 19 had borderline LAAT, and the remainder had dense SEC (Fatkin grade 3\u20134). Independent predictors included lower left ventricular ejection fraction (OR 0.95 per 1% increase, 95% CI 0.94\u20130.97, p &lt; 0.0001), reduced right ventricular fractional area change (OR 0.93 per 1% increase, 95% CI 0.91\u20130.94, p &lt; 0.0001), larger left atrial area (OR 1.05 per 1 cm2 increase, 95% CI 1.01\u20131.09, p = 0.011), and female sex (OR 1.78, 95% CI 1.14\u20132.79, p = 0.012). Moderate or greater mitral regurgitation was associated with a lower risk (OR 0.50, 95% CI 0.30\u20130.82, p = 0.007). The CHA2DS2-VASc score and the presence of right ventricular leads were not independently associated with LAAT\/SEC. The model showed good discrimination (AUC 0.81, 95% CI 0.77\u20130.84). Conclusions: In anticoagulated patients with persistent AF, LAAT and\/or dense SEC remain common and are primarily driven by echocardiographic markers of biventricular dysfunction and left atrial remodeling rather than by traditional clinical risk scores or the presence of cardiac devices.<\/jats:p>","DOI":"10.3390\/jcm15124500","type":"journal-article","created":{"date-parts":[[2026,6,11]],"date-time":"2026-06-11T02:59:31Z","timestamp":1781146771000},"page":"4500","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Left Atrial Appendage Thrombus and Dense Spontaneous Echo Contrast in Anticoagulated Atrial Fibrillation Patients Referred for Cardioversion: Beyond CHA2DS2-VASc and Cardiac Implantable Electronic Devices"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0140-4712","authenticated-orcid":false,"given":"Kinga","family":"Go\u015bci\u0144ska-Bis","sequence":"first","affiliation":[{"name":"Department of Electrocardiology and Heart Failure, Upper-Silesian Medical Center, Ziolowa 45\/47 Str., 40-635 Katowice, Poland"},{"name":"Department of Electrocardiology and Heart Failure, Medical University of Silesia in Katowice, Ziolowa 45\/47 Str., 40-635 Katowice, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Micha\u0142","family":"Pieczara","sequence":"additional","affiliation":[{"name":"Department of Electrocardiology and Heart Failure, Upper-Silesian Medical Center, Ziolowa 45\/47 Str., 40-635 Katowice, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-5347-462X","authenticated-orcid":false,"given":"Jolanta","family":"Pol-Romik","sequence":"additional","affiliation":[{"name":"Department of Electrocardiology and Heart Failure, Upper-Silesian Medical Center, Ziolowa 45\/47 Str., 40-635 Katowice, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jolanta","family":"Biernat","sequence":"additional","affiliation":[{"name":"Department of Electrocardiology and Heart Failure, Upper-Silesian Medical Center, Ziolowa 45\/47 Str., 40-635 Katowice, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3308-9991","authenticated-orcid":false,"given":"Magdalena","family":"Cybulska","sequence":"additional","affiliation":[{"name":"Voxel S.A. Medical Diagnostic Center, Radiowa 2 Str., 44-121 Gliwice, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kamil","family":"Kempa","sequence":"additional","affiliation":[{"name":"Department of Electrocardiology and Heart Failure, Upper-Silesian Medical Center, Ziolowa 45\/47 Str., 40-635 Katowice, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eugeniusz","family":"Pi\u0142at","sequence":"additional","affiliation":[{"name":"Department of Electrocardiology and Heart Failure, Upper-Silesian Medical Center, Ziolowa 45\/47 Str., 40-635 Katowice, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1370-7369","authenticated-orcid":false,"given":"Tomasz","family":"Roleder","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Wroclaw University of Science and Technology, 27 Wybrze\u017ce Stanis\u0142awa Wyspia\u0144skiego Str., 50-370 Wroc\u0142aw, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5722-7976","authenticated-orcid":false,"given":"Krzysztof S.","family":"Go\u0142ba","sequence":"additional","affiliation":[{"name":"Department of Electrocardiology and Heart Failure, Upper-Silesian Medical Center, Ziolowa 45\/47 Str., 40-635 Katowice, Poland"},{"name":"Department of Electrocardiology and Heart Failure, Medical University of Silesia in Katowice, Ziolowa 45\/47 Str., 40-635 Katowice, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,10]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"3314","DOI":"10.1093\/eurheartj\/ehae176","article-title":"2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)","volume":"45","author":"Rienstra","year":"2024","journal-title":"Eur. Heart J."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"233","DOI":"10.1016\/j.thromres.2020.07.055","article-title":"Determinants of left atrial thrombus or spontaneous echo contrast in nonvalvular atrial fibrillation","volume":"195","author":"Han","year":"2020","journal-title":"Thromb. Res."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Kaufmann, D., Wabich, E., Kap\u0142on-Cie\u015blicka, A., Gawa\u0142ko, M., Budnik, M., Uzi\u0119b\u0142o-\u017byczkowska, B., Krzesi\u0144ski, P., Starzyk, K., Wo\u017cakowska-Kap\u0142on, B., and W\u00f3jcik, M. (2022). Echocardiographic predictors of thrombus in left atrial appendage\u2014The role of novel transthoracic parameters. Front. Cardiovasc. Med., 9.","DOI":"10.3389\/fcvm.2022.1059111"},{"key":"ref_4","first-page":"4717","article-title":"Effects of permanent cardiac pacemaker implantation on vascular endothelial function, blood coagulation and cardiac function in patients with bradycardia","volume":"16","author":"Zhang","year":"2018","journal-title":"Exp. Ther. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.echo.2014.10.003","article-title":"Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging","volume":"28","author":"Lang","year":"2015","journal-title":"J. Am. Soc. Echocardiogr."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"961","DOI":"10.1016\/0735-1097(94)90644-0","article-title":"Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast and thromboembolic risk in vivo","volume":"23","author":"Fatkin","year":"1994","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1191","DOI":"10.1016\/0301-5629(95)02006-3","article-title":"Quantification of blood echogenicity: Evaluation of a semiquantitative method of grading spontaneous echo contrast","volume":"21","author":"Fatkin","year":"1995","journal-title":"Ultrasound Med. Biol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"298","DOI":"10.1136\/bmj.310.6975.298","article-title":"Statistics Notes: The Normal Distribution","volume":"310","author":"Altman","year":"1995","journal-title":"BMJ"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"55","DOI":"10.7326\/M14-0697","article-title":"Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD): The TRIPOD statement","volume":"162","author":"Collins","year":"2015","journal-title":"Ann. Intern. Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"51","DOI":"10.7326\/M18-1376","article-title":"PROBAST: A Tool to Assess the Risk of Bias and Applicability of Prediction Model Studies","volume":"170","author":"Wolff","year":"2019","journal-title":"Ann. Intern. Med."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Kap\u0142on-Cie\u015blicka, A., Gawa\u0142ko, M., Budnik, M., Uzi\u0119b\u0142o-\u017byczkowska, B., Krzesi\u0144ski, P., Starzyk, K., Gorczyca-G\u0142owacka, I., Dani\u0142owicz-Szymanowicz, L., Kaufmann, D., and W\u00f3jcik, M. (2022). Left Atrial Thrombus in Atrial Fibrillation\/Flutter Patients in Relation to Anticoagulation Strategy: LATTEE Registry. J. Clin. Med., 11.","DOI":"10.3390\/jcm11102705"},{"key":"ref_12","first-page":"101590","article-title":"Spontaneous echo contrast in the left atrial appendage is linked to a higher risk of thromboembolic events and mortality in patients with atrial fibrillation","volume":"56","author":"Traub","year":"2024","journal-title":"Int. J. Cardiol. Heart Vasc."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Turek, \u0141., Sadowski, M., Kurzawski, J., and Janion, M. (2024). Left Atrial Appendage Thrombus as a Marker of Disease Severity in 500 Patients with Atrial Fibrillation on Oral Anticoagulation: A 13-Year Follow-Up Study. J. Clin. Med., 13.","DOI":"10.3390\/jcm13175258"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"e029259","DOI":"10.1161\/JAHA.122.029259","article-title":"Identifying Patients at High Risk of Left Atrial Appendage Thrombus Before Cardioversion: The CLOTS-AF Score","volume":"12","author":"Segan","year":"2023","journal-title":"J. Am. Heart Assoc."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"839","DOI":"10.1016\/j.jstrokecerebrovasdis.2017.10.025","article-title":"Comparative Risks of Ischemic Stroke in Atrial Flutter versus Atrial Fibrillation","volume":"27","author":"Omran","year":"2018","journal-title":"J. Stroke Cerebrovasc. Dis."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"11795468231221404","DOI":"10.1177\/11795468231221404","article-title":"The Risk of Left Atrial Appendage Thrombus in Patients with Atrial Flutter Versus Atrial Fibrillation","volume":"18","author":"Moady","year":"2024","journal-title":"Clin. Med. Insights Cardiol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1884","DOI":"10.1136\/heartjnl-2019-315174","article-title":"Left atrial dimension and cardiovascular outcomes in patients with and without atrial fibrillation: A systematic review and meta-analysis","volume":"105","author":"Froehlich","year":"2019","journal-title":"Heart"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Karakasis, P., Theofilis, P., Vlachakis, P.K., Ktenopoulos, N., Patoulias, D., Antoniadis, A.P., and Fragakis, N. (2025). Atrial Cardiomyopathy in Atrial Fibrillation: Mechanistic Pathways and Emerging Treatment Concepts. J. Clin. Med., 14.","DOI":"10.3390\/jcm14093250"},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Karakasis, P., Vlachakis, P.K., Theofilis, P., Ktenopoulos, N., Patoulias, D., Fyntanidou, B., Antoniadis, A.P., and Fragakis, N. (2025). Atrial Cardiomyopathy in Atrial Fibrillation: A Multimodal Diagnostic Framework. Diagnostics, 15.","DOI":"10.3390\/diagnostics15101207"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"101","DOI":"10.2143\/AC.57.2.2005380","article-title":"Effects of left ventricular systolic dysfunction on left atrial appendage and left atrial functions in patients with chronic nonvalvular atrial fibrillation","volume":"57","author":"Cemri","year":"2002","journal-title":"Acta Cardiol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1342","DOI":"10.1016\/j.amjcard.2005.06.085","article-title":"Predictors of Left Atrial Spontaneous Echocardiographic Contrast or Thrombus Formation in Stroke Patients with Sinus Rhythm and Reduced Left Ventricular Function","volume":"96","author":"Handke","year":"2005","journal-title":"Am. J. Cardiol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"429","DOI":"10.1111\/j.1540-8175.1993.tb00054.x","article-title":"The Role of Echocardiography in the Evaluation of Cardiac Source of Embolism: Left Atrial Spontaneous Echo Contrast","volume":"10","author":"Black","year":"1993","journal-title":"Echocardiography"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1455","DOI":"10.1093\/europace\/euw161","article-title":"EHRA\/HRS\/APHRS\/SOLAECE expert consensus on atrial cardiomyopathies: Definition, characterization, and clinical implication","volume":"18","author":"Goette","year":"2016","journal-title":"Europace"},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Forado-Benatar, I., Caravaca-P\u00e9rez, P., Rodriguez-Espinosa, D., Guzman-Bofarull, J., Cuadrado-Pay\u00e1n, E., Moayedi, Y., Broseta, J.J., and Farrero, M. (2023). Tricuspid regurgitation, right ventricular function, and renal congestion: A cardiorenal triangle. Front. Cardiovasc. Med., 10.","DOI":"10.3389\/fcvm.2023.1255503"},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Ogawa, M., Kuwajima, K., Yamane, T., Hasegawa, H., Yagi, N., and Shiota, T. (2023). Effect of right ventricular free wall longitudinal strain on all-cause death in patients with isolated severe tricuspid regurgitation and atrial fibrillation. Front. Cardiovasc. Med., 10.","DOI":"10.3389\/fcvm.2023.1188005"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"29","DOI":"10.1136\/heartjnl-2020-317659","article-title":"Risk of left atrial appendage thrombus and stroke in patients with atrial fibrillation and mitral regurgitation","volume":"108","author":"Melduni","year":"2022","journal-title":"Heart"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"e944114","DOI":"10.12659\/MSM.944114","article-title":"Incidence, Risk Factors, and Outcomes of Left Atrial Enlargement in Patients Requiring Right Ventricular Pacing: A Retrospective Study of 461 Cases from 2012 to 2020","volume":"30","author":"Lee","year":"2024","journal-title":"Med. Sci. Monit."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1294","DOI":"10.1111\/pace.12210","article-title":"Risk Factors and Prognosis for Clot Formation on Cardiac Device Leads","volume":"36","author":"Rahbar","year":"2013","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"bcr2015210314","DOI":"10.1136\/bcr-2015-210314","article-title":"Pacemaker lead-associated thrombosis in cardiac resynchronisation therapy","volume":"2015","author":"Buttigieg","year":"2015","journal-title":"BMJ Case Rep."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"429","DOI":"10.1111\/j.0742-2822.2004.03078.x","article-title":"Early Pacemaker Lead Thrombosis Leading to Massive Pulmonary Embolism","volume":"21","author":"Karavidas","year":"2004","journal-title":"Echocardiography"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"385","DOI":"10.1160\/TH13-04-0347","article-title":"Female sex as an independent risk factor for stroke in atrial fibrillation: Possible mechanisms","volume":"112","author":"Cove","year":"2014","journal-title":"Thromb. Haemost."},{"key":"ref_32","first-page":"16301","article-title":"Differences in the predictors of left atrial appendage thrombus between men and women treated with dabigatran or rivaroxaban","volume":"132","author":"Budnik","year":"2022","journal-title":"Pol. Arch. Intern. Med."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"263","DOI":"10.1378\/chest.09-1584","article-title":"Refining Clinical Risk Stratification for Predicting Stroke and Thromboembolism in Atrial Fibrillation Using a Novel Risk Factor-Based Approach","volume":"137","author":"Lip","year":"2010","journal-title":"Chest"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"2679539","DOI":"10.1155\/2020\/2679539","article-title":"CHA2 DS2-VASc Score as a Predictor for Left Atrial Thrombus or Spontaneous Echo Contrast in Patients with Nonvalvular Atrial Fibrillation: A Meta-Analysis","volume":"2020","author":"Sun","year":"2020","journal-title":"BioMed Res. Int."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"e20570","DOI":"10.1097\/MD.0000000000020570","article-title":"Does the CHA2DS2-VASc scale sufficiently predict the risk of left atrial appendage thrombus in patients with diagnosed atrial fibrillation treated with non-vitamin K oral anticoagulants?","volume":"99","author":"Michalska","year":"2020","journal-title":"Medicine"},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Cheng, Y.Y., Tan, S., Hong, C.T., Yang, C.C., and Chan, L. (2022). Left Atrial Appendage Thrombosis and Oral Anticoagulants: A Meta-Analysis of Risk and Treatment Response. J. Cardiovasc. Dev. Dis., 9.","DOI":"10.3390\/jcdd9100351"},{"key":"ref_37","first-page":"823","article-title":"Comparison of different oral anticoagulant regimens in patients with atrial fibrillation undergoing ablation or cardioversion","volume":"127","author":"Budnik","year":"2017","journal-title":"Pol. Arch. Intern. Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"461","DOI":"10.5603\/CJ.a2022.0054","article-title":"Left atrial appendage thrombus in patients with atrial fibrillation who underwent oral anticoagulation","volume":"31","author":"Karwowski","year":"2024","journal-title":"Cardiol. J."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/12\/4500\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,17]],"date-time":"2026-06-17T04:20:28Z","timestamp":1781670028000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/12\/4500"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,10]]},"references-count":38,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["jcm15124500"],"URL":"https:\/\/doi.org\/10.3390\/jcm15124500","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,10]]}}}