The Role of Repeat Transesophageal Echocardiography in Patients without Atrial Thrombus Prior to Cardioversion or Ablation

Smith, Sakima A.; Binkley, Philip F.; Foraker, Randi E.; Nagaraja, Haikady N.; Orsinelli, David A.

doi:10.1016/j.echo.2012.06.003

Cited by 9 publications

(7 citation statements)

References 24 publications

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“…There is only one previous study demonstrating a 0.8% rate of thrombi detection in 263 patients who underwent repeat TEE within 365 days. 13 Nonetheless, all patients were prescribed warfarin, a vitamin K antagonist, in the previous study which was conducted over a long period of time. In contrast, an alternative anticoagulant, DOAC, which is mostly used in AF ablation, has the advantage of quickly promoting and maintaining its anticoagulant effect, which could support the suppression of thrombus development after ablation.…”

Section: Discussionmentioning

confidence: 99%

“…Moreover, a possible association with the risk of thrombus development in patients with decreased LVEF and non-paroxysmal atrial arrhythmia was mentioned in a previous report. 13 Although a sub-therapeutic dose of warfarin should be avoided considering its significant relation to thrombus development despite less frequent use of warfarin to date, inappropriate DOAC dose use also increases the periprocedural risk of thrombi. 13,14 Nonetheless, with an expandable use of DOAC uninterruptedly during ablation, it may be possible to selectively screen patients to identify those at low risk of developing thrombi and those at high risk and who require TEE at repeat ablation.…”

Section: Discussionmentioning

confidence: 99%

“…13 Although a sub-therapeutic dose of warfarin should be avoided considering its significant relation to thrombus development despite less frequent use of warfarin to date, inappropriate DOAC dose use also increases the periprocedural risk of thrombi. 13,14 Nonetheless, with an expandable use of DOAC uninterruptedly during ablation, it may be possible to selectively screen patients to identify those at low risk of developing thrombi and those at high risk and who require TEE at repeat ablation. 15 As long as patients with a low-risk profile continue on oral anticoagulants and undergo early repeat ablation, any imaging modality to determine the presence of LA thrombi may be omitted.…”

Section: Discussionmentioning

confidence: 99%

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Incidence and predictors of left atrial thrombus development in patients scheduled for repeat catheter ablation for atrial fibrillation: Is transesophageal echocardiography always mandatory?

Inden

Riku

Suga

et al. 2021

Preprint

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Introduction: The risk of developing left atrial (LA) thrombi after initial catheter ablation for atrial fibrillation (AF) and requirements for imaging evaluation for thrombi screening at repeat ablation is unclear. This study aimed to assess the occurrence of thrombus development and frequency of any imaging study evaluating thrombus formation during repeat ablation for AF. Methods: Of 2,066 patients undergoing initial catheter ablation for AF with uninterrupted oral anticoagulation, 615 patients underwent repeat ablation after 258.0 (105.0-882.0) days. We investigated which factors were associated with safety outcomes and requirements for thrombi screening. Results: All patients underwent at least one imaging examination to screen for thrombi in the first session, but the examination rate decreased to 476 patients (77%) before the repeat procedure. The frequency of imaging evaluations was 5.0%, 11%, 21%, 84%, and 91% for transesophageal echocardiography and 18%, 33%, 49%, 98%, and 99% for any imaging modality at repeat ablation performed ≤60 days, ≤90 days, ≤180 days, >180 days, and >1 year after the initial procedure, respectively. Three patients (0.5%) developed LA thrombi at repeat ablation due to identifiable causes, and no patients had thromboembolic events when no imaging evaluation was performed. Multivariate analysis revealed that repeat ablation >180 days, non-paroxysmal atrial arrhythmias, and lower left ventricular ejection fraction were predictors of the risk of thrombus development. Conclusions: The risk development of thrombus at repeat ablation for AF was low. There needs to be a risk stratification for the requirement of imaging screening for thrombi at repeat ablation for AF.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Incidence and predictors of left atrial thrombus development in patients scheduled for repeat catheter ablation for atrial fibrillation: Is transesophageal echocardiography always mandatory?

Inden

Riku

Suga

et al. 2021

Preprint

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show abstract

“…This is especially the case after the introduction of NOACs when more patients permanently remain in the therapeutic anticoagulation range compared to VKA. Moreover, repeated TOE is unlikely to detect LAA thrombus in patients without LAA thrombus in the baseline study [34]. All this prompted us to adopt a selective approach to TOE in patients already receiving anticoagulation.…”

Section: What Is the Likelihood Of Finding An Laa Thrombus On Toe?mentioning

confidence: 99%

Omitting transesophageal echocardiography before catheter ablation of atrial fibrillation

Maslova,

Demming,

Pantlik

et al. 2024

J Interv Card Electrophysiol

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Background Data about necessity of performing transesophageal echocardiography (TOE) prior to every catheter ablation (CA) of atrial fibrillation (AF) is scarce. We aimed to evaluate the safety of an individualized risk-based approach to TOE with respect to thromboembolic cerebrovascular events (CVE) in patients undergoing CA for AF or left atrial tachycardia (AT). Methods We performed a retrospective clinical study based on our institutional registry database. Patients undergoing CA for AF or left-sided AT following initial AF ablation at two participating centers were enrolled. Prior to the procedure, patients were scheduled for TOE only if they had a history of thromboembolic stroke, left atrial appendage (LAA) thrombus, or inappropriate anticoagulation regimen in the previous 3 to 4 weeks. The incidence of periprocedural cerebrovascular thromboembolic events was assessed. Results We analyzed 1155 patients (median age 70 years, 54.8% male, 48.1% had persistent AF/AT). In 261 patients, a TOE was performed; in 2 patients (0.7%), an LAA thrombus was detected, which led to cancellation of the catheter ablation; in 894 patients, the TOE was omitted. Of the 1153 (0.35%) patients who underwent ablation, 4 (0.35%) experienced a CVE (one TIA and three strokes). The rate of CVE in our study does not exceed that reported in most multicenter trials. The low event rates limited statistical analysis of possible risk factors for CVE. In all 4 patients with CVE, post-CVE imaging showed the absence of LAA thrombus. Conclusions An individualized selective approach to TOE before catheter ablation of AF or left AT showed a very low risk of overt intraprocedural thromboembolic events for the population in our study. A further randomized controlled study is needed to determine whether TOE prior to catheter ablation without ICE could be omitted in patients with uninterrupted OAC without previous thromboembolic events or a history of left atrial thrombus.

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“…Therefore, the LAA is considered the primary source of cardio-embolic stroke in patients with non-valvular AF [ 25 , 38 ], although thrombi can develop outside the LAA [ 3 ]. Accordingly, transesophageal echocardiography (TEE) is the key examination for diagnosing thrombus formation in the LAA [ 35 , 37 , 39 ], and direct current conversion to sinus rhythm has proved to be safe in the absence of thrombi in the LAA during TEE [ 33 , 34 , 40 – 42 ].…”

Section: Introductionmentioning

confidence: 99%

Does Left Atrial Appendage Amputation During Routine Cardiac Surgery Reduce Future Atrial Fibrillation and Stroke?

et al. 2018

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Purpose of ReviewStroke is the most feared complication of atrial fibrillation. To prevent stroke, left atrial appendage exclusion has been targeted, as it is the prevalent site for formation of heart thrombi during atrial fibrillation.We review the historic development of methods for exclusion of the left atrial appendage and the evidence to support its amputation during routine cardiac surgery.Recent FindingsEvidence is not yet sufficient to routinely recommend left atrial exclusion during heart surgery, despite a high prevalence of postoperative atrial fibrillation. Observational studies indicate that electrical isolation of scarring from clip or suture techniques reduces the arrhythmogenic substrate.SummaryRandomized studies comparing different methods of closure of the left atrial appendage before amputation do not exist. Such studies are therefore warranted, as well as studies that can elucidate whether amputation is superior to leaving the left atrial appendage stump. Potentially, thrombogenic remaining pouch after closure should be addressed.

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The Role of Repeat Transesophageal Echocardiography in Patients without Atrial Thrombus Prior to Cardioversion or Ablation

Cited by 9 publications

References 24 publications

Incidence and predictors of left atrial thrombus development in patients scheduled for repeat catheter ablation for atrial fibrillation: Is transesophageal echocardiography always mandatory?

Incidence and predictors of left atrial thrombus development in patients scheduled for repeat catheter ablation for atrial fibrillation: Is transesophageal echocardiography always mandatory?

Omitting transesophageal echocardiography before catheter ablation of atrial fibrillation

Does Left Atrial Appendage Amputation During Routine Cardiac Surgery Reduce Future Atrial Fibrillation and Stroke?

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