Exclusion of Left Atrial Appendage Thrombus Using Single Phase Coronary Computed Tomography as Compared to Transesophageal Echocardiography in Patients Undergoing Pulmonary Vein Isolation

Abstract

Background. Transesophageal echocardiography (TEE) is used for the evaluation of the presence of left atrial appendage (LAA) thrombus prior to pulmonary vein isolation (PVI), while coronary computed tomography angiography (CCTA) is used for anatomic mapping during PVI. Methods. We compared the diagnostic performance of single phase CCTA to TEE in excluding the presence of LAA thrombus in patients undergoing PVI in 172 subjects performed during index hospitalization. Results. The mean age was 51 ± 13 years, a median CHADS2 score of 1 [IQR25,75 0,1, range 0–3] and a mean periprocedural INR of 2.1 ± 0.6. The prevalence of an LAA filling defect on single phase CCTA was 9.3% (6/183) and on TEE was 1.2% (2/183). Sensitivity, specificity, positive predictive value, and negative predictive value were 100% (95% CI, 19.8–100%), 91.8% (95% CI, 94–99%), 12.5% (95% CI, 60–76%), and 91.8% (95% CI, 97–100%) for the detection of LAA filling defect, respectively. Conclusion. Given the utility of a preprocedural single phase CCTA for the performance of PVI, the absence of a filling defect negates the need for a subsequent TEE as an adjunct for exclusion of LAA thrombus.

One day interruption of NOAC is associated with low risk of periprocedural adverse events during pulmonary vein isolation if combined with left atrial thrombus exclusion with computed tomography

“…As already shown, CTA is a safe method for the exclusion of LAAT [21]. Although our study is underpowered to estimate the thromboembolic event rate with one day interruption of NOACs before PVI, we did not see any stroke event during the three month follow-up of the patients.…”

Use of Cardiac Tomography and Cardiac Magnetic Resonance to Predict the Absence of Intracardiac Thrombus in Anticoagulated Patients Undergoing Atrial Fibrillation Ablation.

“…A metanalysis from Romero et al showed an overall high accuracy of CT scan compared to TEE for the detection of LA/LAA thrombus. Other metanalysis of prospective studies comparing CT with TEE have had similar results and support the use of CT to rule out LA thrombus, especially when delayed imaging, ECG gating and heart rate control are performed (14)(15)(16)(17).…”

Cardiac Tomography and Cardiac Magnetic Resonance to Predict the Absence of Intracardiac Thrombus in Anticoagulated Patients Undergoing Atrial Fibrillation Ablation

“…However, TEE is an invasive procedure that requires sedation and sometimes intubation. Therefore, other alternatives have been investigated: ICE can both rule out the presence of thrombus and guide the procedure [14,15], but at a higher cost. Despite the non-negligible economic aspect, ICE presents important advantages, allowing the direct visualization of the endocardium and locating the needle and the sheath exactly against the interatrial septum.…”