Use of the CHA ₂ DS ₂ VASc score to reduce utilisation of transoesophageal echocardiography prior to ablation for atrial fibrillation

Abstract

Transoesophageal echocardiography (TOE) is frequently performed prior to atrial fibrillation (AF) ablation to exclude left atrial appendage (LAA) thrombus. However, patients undergoing AF ablation are usually anticoagulated, thus making the presence of thrombus unlikely in most cases. This study aimed to determine whether the CHA2DS2VASc scoring system can be used to identify patients that do not require TOE prior to AF ablation. In this single-centre retrospective study, local institutional and primary care databases and electronic patient records were searched to identify patients that had undergone TOE prior to AF ablation. Patient demographics, CHA2DS2VASc score, TOE findings and anticoagulation status were collected for analysis. Over a 7-year period (2008–2014), 332 patients (age 57 ± 10 years; 74% male) underwent TOE prior to proposed AF ablation. CHA2DS2VASc scores of 0, 1, 2 and >2 were found in 39, 34, 15 and 12% of patients, respectively. The prevalence of LAA thrombus was 0.6% (2 patients) and these 2 patients had risk scores of 2 and 4. No patients with a score of 0 or 1 had LAA thrombus. Patients that are classed as low risk by the CHA2DS2VASc score do not require a pre-ablation TOE to screen for LAA thrombus provided they are adequately anticoagulated. This would lead to a significant reduction in health care expenditures by reducing unnecessary TOE requests and thereby improve patient experience.

Safety of catheter ablation of atrial fibrillation without pre‐ or peri‐procedural imaging for the detection of left atrial thrombus in the era of uninterrupted anticoagulation

“…We demonstrated the excellent safety of AF CA on uninterrupted DOAC regimen without imaging for LA thrombus in a carefully selected population with paroxysmal AF displaying low thromboembolic risk (mean CHA 2 DS 2 -VASc score of 1.4 ± 1.2) and absence of significant LA enlargement. Based on our findings, patients without risk factors for the presence of LA thrombus such as persistent AF, structural heart disease, and dilated LA, 2,3,5,6,[12][13][14] can safely undergo AF CA without pre-or peri-procedural imaging.…”

“…In addition, the CHA 2 DS 2 VASc score has been shown to identify patients that do not require TOE prior to AF CA in a study adopting an interrupted anticoagulation strategy. None of the patients with a score of 0 or 1 displayed LA thrombus 12 . Based on these initial reports incorporating an interrupted anticoagulation approach with VKAs, patients with LA thrombus commonly display certain high‐risk features.…”