Cardiac Computed Tomography Versus Transesophageal Echocardiography for the Detection of Left Atrial Appendage Thrombus: A Systemic Review and Meta‐Analysis

Abstract

Background Transesophageal echocardiography (TEE) has been considered the gold standard for left atrial appendage (LAA) thrombus detection. Nevertheless, TEE may sometimes induce discomfort and cause complications. Cardiac computed tomography has been studied extensively for LAA thrombus detection. We performed this systemic review and meta‐analysis to assess the diagnostic accuracy of cardiac computed tomography for LAA thrombus detection compared with TEE. Methods and Results A systemic search was conducted in the PubMed, Embase, and Cochrane Library databases from January 1977 to February 2021. Studies performed for assessment diagnostic accuracy of cardiac computed tomography on LAA thrombus compared with TEE were included. Summary sensitivity, specificity, and posterior probability of LAA thrombus was calculated by using bivariate random‐effects model. The Quality Assessment of Diagnostic Accuracy Studies‐2 tool was used for the quality assessment. A total of 27 studies involving 6960 patients were included in our study. The summary sensitivity of early imaging studies was 0.95 (95% CI, 0.79–0.99), and the specificity was 0.89 (95% CI, 0.85–0.92). The positive posterior probability was 19.11%, and the negative posterior probability was 0.16%. The summary sensitivity of delayed imaging studies was 0.98 (95% CI, 0.92–1.00), and the specificity was 1.00 (95% CI, 0.98–1.00). The positive posterior probability was 95.76%, and the negative posterior probability was 0.12%. The delayed imaging method significantly improved the specificity (1.00 versus 0.89; P <0.05) and positive posterior probability (95.76% versus 19.11%; P <0.05). Conclusions Cardiac computed tomography with a delayed imaging is a reliable alternative to TEE. It may save the patient and health care from an excess TEE. Registration URL: https://www.crd.york.ac.uk/PROSPERO ; Unique identifier: CRD42021236352.

Use of computed tomography left atrial appendage as an alternative to trans‐oesophageal echocardiography during the COVID‐19 pandemic

“…Our findings should be considered in the context of the published international meta‐analyses. 3 , 4 Further longitudinal research within the Australian setting is required.…”

“…This was subsequently shown again in the most recent meta‐analysis by Yu et al . 3 which had a greater proportion of delayed phase imaging. This highlights the need for appropriate protocolling when using CTLAA, with a delayed phase essential to allow adequate time for contrast mixing in the LAA (Fig.…”

“…Computed tomography left atrial appendage has excellent evidence for excluding LAA thrombus with a negative predictive value of 99% when delayed phase imaging is used. 3 Early studies of CTLAA had heterogenous results for positive predictive value in diagnosing LAA thrombus, likely due to the presence of sluggish contrast mixing on early arterial phase imaging (Fig. 1 ).…”

Incidence and Predictors of Left Atrial Appendage Thrombus before Catheter Ablation of Thrombogenic Arrhythmias

“…In our center, TEE is routinely performed before catheter ablation as it has a very low incidence of complications and does not confer the risks of ionizing radiation associated with CT [ 19 , 20 , 21 , 22 ]. Cardiac CT was reserved for specific circumstances such as equivocal TEE findings, an inability to perform TEE or additional pre-procedural characterization of pulmonary veins in select cases.…”

Stroke risk evaluation for patients with atrial fibrillation: Insights from left atrial appendage

“…Therefore, CT has been considered as the gold standard for visualizing the LAA ( 106 , 107 ), and it is widely applied in the evaluation of shape and morphology parameters. Meanwhile, some studies have also considered cardiac CT with a delayed imaging as a useful modality for the detection of LAA thrombi ( 108 ), and therefore it is routinely performed to screen the LA/LAA thrombi before the AF ablation procedure in clinics. However, compared to TEE, CT imaging modality is limited in the time resolution, it cannot get the real-time visualization of the hemodynamics and LAA structure with the cardiac cycle.…”