Reviews in cardiovascular medicine · 2026
The "Floating Lotus" Sign on Intracardiac Echocardiography: Characterization and Predictors of a Novel Left Atrial Appendage Pseudo-Thrombus.
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Zhang Liang, Bai Yanyan, Zhu Yanhua, Sun Jianhua, Feng Liuliu, Zhang Jingyu, Huang Songqun
Аннотация
BACKGROUND: Intracardiac echocardiography (ICE) is increasingly used for left atrial appendage (LAA) assessment during atrial fibrillation (AF) procedures. We describe a novel, thrombus-mimicking artifact on ICE, termed the "Floating Lotus" sign.
METHODS: In this retrospective multicenter study, we analyzed data from 172 patients undergoing ICE-guided AF ablation and/or LAA occlusion. The incidence, imaging features, and clinical correlates of the "Floating Lotus" sign were assessed.
RESULTS: The "Floating Lotus" sign was observed in 48 patients (27.9%). It manifested as a mobile, echogenic mass within an anechoic space, revealing an underlying pericardial effusion. Patients exhibiting the sign had a higher prevalence of recent stroke (35.4% vs. 15.3%, p = 0.004), heart failure (64.6% vs. 8.1%, p < 0.001), and larger left atrial diameter (44.3 ± 6.8 vs. 39.7 ± 5.4 mm, p < 0.001). In multivariable analysis, only heart failure (left ventricular ejection fraction (LVEF) <55%) remained an independent predictor (odds ratio [OR] 14.39, 95% confidence interval [CI] 5.51-37.58, p < 0.001). Lower LAA emptying velocity was independently associated with persistent AF, higher CHA2DS2-VASc score, and recent stroke (all p < 0.05).
CONCLUSION: The "Floating Lotus" sign is a common ICE pseudo-thrombus, often associated with heart failure. Accurate recognition of this sign, based on its dynamic imaging features, is therefore critical to prevent misdiagnosis and avoid unnecessary procedural cancellation or anticoagulation changes.
METHODS: In this retrospective multicenter study, we analyzed data from 172 patients undergoing ICE-guided AF ablation and/or LAA occlusion. The incidence, imaging features, and clinical correlates of the "Floating Lotus" sign were assessed.
RESULTS: The "Floating Lotus" sign was observed in 48 patients (27.9%). It manifested as a mobile, echogenic mass within an anechoic space, revealing an underlying pericardial effusion. Patients exhibiting the sign had a higher prevalence of recent stroke (35.4% vs. 15.3%, p = 0.004), heart failure (64.6% vs. 8.1%, p < 0.001), and larger left atrial diameter (44.3 ± 6.8 vs. 39.7 ± 5.4 mm, p < 0.001). In multivariable analysis, only heart failure (left ventricular ejection fraction (LVEF) <55%) remained an independent predictor (odds ratio [OR] 14.39, 95% confidence interval [CI] 5.51-37.58, p < 0.001). Lower LAA emptying velocity was independently associated with persistent AF, higher CHA2DS2-VASc score, and recent stroke (all p < 0.05).
CONCLUSION: The "Floating Lotus" sign is a common ICE pseudo-thrombus, often associated with heart failure. Accurate recognition of this sign, based on its dynamic imaging features, is therefore critical to prevent misdiagnosis and avoid unnecessary procedural cancellation or anticoagulation changes.