Effectiveness of integrating delayed computed tomography angiography imaging for left atrial appendage thrombus exclusion into the care of patients undergoing ablation of atrial fibrillation

Bilchick, Kenneth C.; Mealor, Augustus; González, Jorge A.; Norton, Patrick T.; Zhuo, David; Mason, Pamela; Ferguson, John; Malhotra, Rohit; Mangrum, J. Michael; Darby, Alistair C.; DiMarco, John P.; Hagspiel, Klaus D.; Dent, John; Kramer, Christopher M.; Stukenborg, George J.; Salerno, Michael

doi:10.1016/j.hrthm.2015.09.002

Cited by 47 publications

(32 citation statements)

References 22 publications

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“…Recently, a novel clinical protocol was presented for safely integrating results of CTA delayed imaging of the LAA into pre-procedure care [8]. Based on this protocol, TEE in addition to delayed-phase CTA was still necessary to exclude LAA thrombus in 24 % of patients.…”

Section: Discussionmentioning

confidence: 99%

“…Earlier single-phase CTA studies showed a mean weighted sensitivity of 91 %, specificity of 95 %, PPV of 33 % and NPV of 100 % for LAA thrombus detection [7]. Recent studies using delayed-phase CTA demonstrated a sensitivity and NPV of 100 %, specificity of 99 % and PPVs ranging from 79 to 100 % [8, 16–19]. In case of LAA filling defects, delayed imaging seems more capable of differentiating between thrombus and slow flow [7].…”

Section: Discussionmentioning

confidence: 99%

“…In order to distinguish better between thrombus and slow flow, different delayed CTA imaging protocols have been developed. Previous studies showed 99 % specificity of a second delayed-phase CTA [7, 8]. However, the extra radiation exposure of a delayed scan remains a concern.…”

Section: Introductionmentioning

confidence: 99%

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Double-contrast, single-phase computed tomography angiography for ruling out left atrial appendage thrombus prior to atrial fibrillation ablation

Teunissen

Habets

Velthuis

et al. 2016

Int J Cardiovasc Imaging

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Prior to atrial fibrillation (AF) ablation, computed tomography angiography (CTA) is increasingly used for left atrial appendage (LAA) thrombus detection. LAA filling defects on CTA may represent thrombus or incomplete contrast mixing with blood. A pre-bolus of contrast material with delay before the CTA contrast bolus can help distinguish between thrombus and incomplete contrast mixing. We present results from a double-contrast, single-phase CTA protocol used in our daily clinical practice. In patients who underwent AF ablation between 2011 and 2015, double-contrast, single-phase CTA was performed prior to ablation. Two contrast boluses (30 and 70 ml) with 25-s interbolus delay were administered followed by prospectively triggered cardiac CTA. Only patients with left atrial (LA) or LAA filling defects underwent transesophageal echocardiography (TEE) to rule out thrombus. Prior to ablation, 605 CTA-scans were performed (median radiation dose: 3.1 mSv). In 579 CTA-scans (95.7 %), the LA and LAA completely filled with contrast. In 26 CTA-scans (4.3 %) the LAA showed a filling defect whereby thrombus could not be excluded. In 2 of those 26 patients (7.7 % and 0.3 % of the total population), TEE verified LAA thrombus. Low-risk LAA filling defects on CTA (n = 7/26) with an inhomogeneous aspect, Houndsfield Unit values >100, and an indefinite border were all caused by incomplete contrast mixing. No thromboembolic complications occurred perioperatively or during 6 months follow-up. Prior to AF ablation, incidence of LAA filling defects on double-contrast, single-phase CTA is low. TEE remains warranted in all but low-risk filling defects to rule out thrombus.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Double-contrast, single-phase computed tomography angiography for ruling out left atrial appendage thrombus prior to atrial fibrillation ablation

Teunissen

Habets

Velthuis

et al. 2016

Int J Cardiovasc Imaging

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“…This is consistent with previous studies, which also showed that the delayed phase of CCT is effective for thrombus detection, 7,22-24 and suggests the possibility of decreasing the need for pre-procedural TEE. 25 We did not use CCT during the delayed phase in the present study, however, because CCT was performed to evaluate the LA anatomy but not to detect thrombi. To simplify the CCT protocol, we performed CCT prior to AF ablation during the same coronary CT phase.…”

Section: Cctmentioning

confidence: 99%

Identification of Left Atrial Appendage Thrombi in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation Using Intra-Cardiac Echocardiography and Cardiac Computed Tomography

Ikegami

Tanimoto

Inagawa

et al. 2018

Circ J

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with type of AF, 8 the advantages of ICE or CCT in the case of persistent and long-standing persistent AF remain unclear.In the present study, we investigated the safety and advantages of additional pre-procedural LAA thrombus evaluation using ICE and the clinical value of CCT in the evaluation of LAA thrombi in patients with persistent and long-standing persistent AF before ablation. Methods SubjectsWe analyzed data from 108 consecutive patients with persistent or long-standing persistent AF. These patients were scheduled to undergo their first AF ablation session at National Hospital Organization, Tokyo Medical Center between September 2013 and September 2015. This was a non-randomized retrospective study. The definitions of persistent AF and long-standing persistent AF were based T he detection of any thrombus in the left atrial appendage (LAA) is essential prior to ablation therapy for atrial fibrillation (AF) to avoid procedure-related thrombotic events. Although transesophageal echocardiography (TEE) is the clinical standard for the diagnosis of thrombi in the LAA prior to AF ablation, 1 the detection of thrombi is not always accurate because of the inability of some patients to swallow the TEE probe or because of anatomic limitations to clear imaging. 2 Intracardiac echocardiography (ICE) has been used during ablation. ICE of the LAA from the pulmonary artery (PA) provides similar or better-quality images than those obtained with TEE; therefore, ICE could serve as an alternative to TEE for detecting an LAA thrombus prior to AF ablation. 3-6 Furthermore, cardiac computed tomography (CCT) is reportedly effective for evaluating LAA thrombi. 7 These reports, however, mainly describe cases of paroxysmal AF. Because the incidence of LAA thrombus differs Background: Intracardiac echocardiography (ICE) and cardiac computed tomography (CCT), in addition to standard transesophageal echocardiography (TEE), have been used to identify left atrial (LA) thrombi prior to ablation for atrial fibrillation (AF). The clinical advantages of this, however, remain unclear. This study therefore investigated the advantages of additional pre-procedural LA appendage (LAA) thrombus evaluation using ICE and the clinical value of CCT in persistent and long-standing persistent AF.

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“…With the advent of delayed imaging, LAA assessment for clot with CT has been shown in multiple reports to detect LAA thrombus with high accuracy. 5 In this issue of HeartRhythm, Bilchick et al 6 report the results of a proposed protocol using the results of preablation cardiac CT with delayed imaging of the LAA. In this study, a total of 320 patients underwent preablation cardiac CT with the delayed imaging of the LAA.…”

Section: Nilesh Mathuria MDmentioning

confidence: 99%

Role of TEE before atrial fibrillation ablation: Is less really more?

Mathuria

2016

Heart Rhythm

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Catheter ablation of atrial fibrillation has become standard therapy for patients with refractory symptoms despite antiarrhythmic drugs. 1 Aside from long-term stroke risk in this patient population, 2 a periprocedural transient ischemic attack (TIA) or stroke is a potential complication with reported event rates of o1%. 3,4 In most centers, preprocedural transesophageal echocardiography (TEE) is standard to assess left atrial appendage (LAA) thrombus. In addition, preprocedure computed tomography (CT) is performed to assess pulmonary vein anatomy, which guides pulmonary vein isolation. With the advent of delayed imaging, LAA assessment for clot with CT has been shown in multiple reports to detect LAA thrombus with high accuracy. 5 In this issue of HeartRhythm, Bilchick et al 6 report the results of a proposed protocol using the results of preablation cardiac CT with delayed imaging of the LAA. In this study, a total of 320 patients underwent preablation cardiac CT with the delayed imaging of the LAA. An initial experience with 88 patients revealed agreement with negative CT findings for LAA clot with TEE (in patients who underwent TEE). After this initial period, a defined protocol was created that allowed for deferment of TEE if CT findings were negative. Patients who were deemed to be high risk for LAA clot (CHADS 2 -VASc score 44 and persistent AF, previous TIA/stroke, and history of LAA clot) were still to undergo TEE. The authors found over the course of the protocol period a substantial decrease in the use of TEE before ablation from nearly 58% to 24% over the course of 1 year. In addition, over time fewer TEE protocols were performed on patients with higher CHAD 2 -VASc scores. Despite the protocol mandating TEE in this higher-risk patient subgroup, there was increased confidence in using the CT findings in clinical decision making per the authors. Furthermore, there were no periprocedural TIA or stroke and no esophageal complications. The authors conclude that preprocedure CT with delayed imaging of the LAA can be used to assess LAA clot and this may lead to a reduction in the need for preprocedure TEE.This report adds to a growing body of literature that delayed imaging on cardiac CT can accurately assess LAA clot.In addition, a negative CT finding was associated with a 100% negative predictive value for LAA clot. Given the relatively low event rate for LAA clot, the advantage of this proposed protocol is the potential dramatic decrease in the need for TEE. As the authors discuss, despite its common use, TEE can be associated with esophageal and/or oropharyngeal irritation and rare reports of esophageal perforation. In our current era of scrutinizing health care costs, the marked reduction in the need for TEE in this experience could certainly reduce potential costs as well as perhaps improve patient satisfaction.Despite these positive findings in the present study, certain questions remain. Given the relatively low event rate for LAA clot, further data from multiple centers would further clarify the ro...

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Effectiveness of integrating delayed computed tomography angiography imaging for left atrial appendage thrombus exclusion into the care of patients undergoing ablation of atrial fibrillation

Cited by 47 publications

References 22 publications

Double-contrast, single-phase computed tomography angiography for ruling out left atrial appendage thrombus prior to atrial fibrillation ablation

Double-contrast, single-phase computed tomography angiography for ruling out left atrial appendage thrombus prior to atrial fibrillation ablation

Identification of Left Atrial Appendage Thrombi in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation Using Intra-Cardiac Echocardiography and Cardiac Computed Tomography

Role of TEE before atrial fibrillation ablation: Is less really more?

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