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Derivation and validation of E/e′ ratio as a parameter in the evaluation of left atrial appendage thrombus formation in patients with nonvalvular atrial fibrillation

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Abstract

We sought to determine and prospectively validate, with concomitantly performed transthoracic (TTE) and transesophageal echocardiograms (TEE), a TTE-assessed E/e′ threshold that can be useful in predicting left atrial appendage (LAA) thrombus in patients with nonvalvular atrial fibrillation (NVAF). The retrospective derivation cohort was comprised of 297 patients with NVAF with TTE performed within 1 year of TEE. The validation cohort was comprised of 266 prospectively enrolled patients with TTE performed immediately prior to TEE. LAA thrombus was detected by TEE in 6.4 % of patients in both cohorts. Receiver operating characteristic (ROC) analyses demonstrated a good discriminatory capacity of lateral E/e′ in predicting LAA thrombus in the derivation cohort (AUC 0.72; CI 0.63–0.82; P = 0.001) which was confirmed in the validation cohort (AUC 0.83; CI 0.75–0.91; P < 0.001). In the derivation cohort, ROC curve point-coordinates identified E/e′ thresholds of both 9.0 and 8.0 to be associated with 100 % sensitivity, with specificities of 36 and 30 %, respectively. An E/e′ threshold of ≥8 was selected a priori for prospective validation, and was associated with 100 % sensitivity and 41 % specificity for LAA thrombus, with positive and negative predictive values of 10 and 100 %, respectively, and positive and negative likelihood ratios of 1.69 and 0, respectively. We determined and validated an E/e′ threshold of 8 as a highly sensitive and useful parameter that can aid in identifying patients at very low risk for LAA thrombus and potentially obviate the need for a TEE prior to electrophysiology procedures and restoration of sinus rhythm.

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Abbreviations

AUC:

Area under the curve

CI:

95 % confidence intervals

LA:

Left atrial

LAA:

Left atrial appendage

LV:

Left ventricular

NVAF:

Nonvalvular atrial fibrillation

ROC:

Receiver operating characteristic

SEC:

Spontaneous echo contrast

TEE:

Transesophageal echocardiogram

TTE:

Transthoracic echocardiogram

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Acknowledgments

The study was funded by a Rush-County collaborative research grant. The grant fiduciary was Rush University Medical Center; the principal investigator was Dr. Doukky. The funding source had no input into the study design, execution, data analysis and interpretation, or manuscript preparation and approval.

Disclosures

Dr. Doukky receives research funding from Astellas Pharma US and serves on the Advisory Board of Astellas Pharma US; none of these conflicts are relevant to the present work. Other authors report no conflicts.

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Authors and Affiliations

  1. Division of Cardiology, Rush University Medical Center, Chicago, IL, USA

    Enrique Garcia-Sayan, Mita Patel, Marwan Wassouf & Rami Doukky

  2. Division of Cardiology, Mount Sinai Hospital, Chicago, IL, USA

    Enrique Garcia-Sayan

  3. Division of Cardiology, Medical College of Wisconsin, Milwaukee, WI, USA

    Mita Patel

  4. Department of Medicine, Fairview Hospital, Cleveland, OH, USA

    Marwan Wassouf

  5. Division of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA

    Rojina Pant, Oliver D’Silva & Richard F. Kehoe

  6. Division of Adult Cardiology, John H. Stroger, Jr. Hospital of Cook County, 1901 W. Harrison St, Chicago, IL, 60612, USA

    Rami Doukky

Authors
  1. Enrique Garcia-Sayan
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  2. Mita Patel
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  3. Marwan Wassouf
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  4. Rojina Pant
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  6. Richard F. Kehoe
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  7. Rami Doukky
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Correspondence to Rami Doukky.

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Garcia-Sayan, E., Patel, M., Wassouf, M. et al. Derivation and validation of E/e′ ratio as a parameter in the evaluation of left atrial appendage thrombus formation in patients with nonvalvular atrial fibrillation. Int J Cardiovasc Imaging 32, 1349–1356 (2016). https://doi.org/10.1007/s10554-016-0916-y

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  • DOI: https://doi.org/10.1007/s10554-016-0916-y

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