Enhancing Thromboembolic Risk Prediction in Non-valvular Atrial Fibrillation: The Critical Role of Transesophageal Echocardiography (TEE)

Introduction Atrial fibrillation (AF), the most common cardiac arrhythmia, poses challenges in predicting thromboembolic risk. While the CHA₂DS₂-VASc (congestive heart failure, hypertension, age ≥ 75 years (doubled), type 2 diabetes mellitus, previous stroke, transient ischemic attack, or thromboembolism (doubled), vascular disease, age 65-74 years, and sex category) score remains essential, its limitations include failure to identify left atrial (LA) thrombus in some patients. Transesophageal echocardiography (TEE) provides superior detection of LA thrombi and thrombogenic factors compared to transthoracic echocardiography (TTE), improving risk stratification, especially in intermediate-risk groups. Our study highlights the value of TEE in addressing gaps left by clinical scoring systems in certain subgroups of patients. Purpose and methodology This descriptive, prospective study aims to evaluate the role of transthoracic and transesophageal echocardiography in stratifying thromboembolic risk in patients with non-valvular AF. A total of 100 patients, from two hospitals in Morocco, were included. Data were collected through clinical and paraclinical assessments, with echocardiography examining morphological and functional atrial parameters. Results Among the 100 patients, 73% were male, with a mean age of 67 years. AF was permanent in 84.8% of cases, with dyspnea and palpitations being the most common symptoms. Hypertension was the leading underlying cause. Echocardiographic findings showed a correlation between LA enlargement, reduced left atrial appendage (LAA) emptying velocities, and increased thromboembolic risk. In patients with low clinical scores, 30.7% exhibited echocardiographic signs of a thrombogenic environment, while protrusive aortic atheroma was more prevalent in those with higher clinical risk scores. Discussion The findings confirm the utility of echocardiography, particularly transesophageal, in detecting parameters associated with heightened thromboembolic risk, including LAA emptying velocities, spontaneous contrast, and aortic abnormalities. These echocardiographic markers, combined with clinical scores, may enhance the precision of risk stratification and allow for more targeted anticoagulation therapy. Conclusion Atrial fibrillation remains a common and potentially serious arrhythmia. Echocardiography provides valuable information that complements clinical risk stratification, especially for patients at moderate thromboembolic risk. This study highlights the benefit of incorporating echocardiographic parameters into risk assessment to optimize strategies for preventing thromboembolic events in patients with AF.