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Journal of Interventional Cardiac Electrophysiology

, Volume 43, Issue 3, pp 227–236 | Cite as

Detection of left atrial thrombus by intracardiac echocardiography in patients undergoing ablation of atrial fibrillation

  • Chenni S. Sriram
  • Javier E. Banchs
  • Talal Moukabary
  • Raman Moradkhan
  • Mario D. GonzalezEmail author
MULTIMEDIA REPORT

Abstract

Background

The role of intracardiac echocardiography (ICE) to detect thrombus within left atrium (LA) before atrial fibrillation (AF) ablation despite a recent transesophageal echocardiogram (TEE) is not well defined. We examined the prevalence of LA/left atrial appendage (LAA) thrombus using ICE immediately prior to AF ablation in patients in whom anticoagulation was not withheld.

Methods

We analyzed 122 consecutive patients (62.6 ± 10.8 years, 90 males, CHA 2 DS 2 -VASc score 2.4 ± 1.5, persistent AF 29.5 %) who underwent an ICE-guided AF ablation 1 day after a negative (n = 120) or inconclusive (n = 2) TEE for LA thrombus. LA was imaged with ICE from the right atrium, coronary sinus, and right ventricular inflow tract (RVIT). ICE and TEE images were compared for LAA area, thrombus, and spontaneous echo contrast (SEC).

Results

LAA was adequately visualized in 99 and 100 % of patients with TEE and ICE, respectively. RVIT was the best ICE view for LAA visualization. The LAA 2-D-area measured by TEE was 4.9 ± 0.5 vs. 5 ± 0.5 cm2 by ICE (P = NS). ICE identified a thrombus in seven patients with a previous negative TEE, leading to cancellation of ablation. It ruled out a thrombus in two patients with an inconclusive TEE. Thrombi were found in the LAA (n = 4), atrial septum (n = 2), and left superior pulmonary vein (n = 1). SEC during TEE was more frequent in patients with thrombus on ICE than those without (85.7 vs. 17.4 %; p = 0.03; positive predictive value 23.1 %, negative predictive value 98.9 %).

Conclusions

The results of our staged imaging approach suggest that ICE has a complimentary value in re-screening the LA/LAA for thrombus after a recent negative or equivocal TEE. The presence of SEC during TEE increases the probability of finding a thrombus with ICE, which could potentially be dislodged during catheter manipulation.

Keywords

Atrial fibrillation Left atrium Left atrial appendage Intracardiac echocardiography Spontaneous echo contrast Thrombus Transesophageal echocardiography 

Abbreviations

AF

Atrial fibrillation

BMI

Body mass index

CI

Confidence interval

ICE

Intracardiac echocardiography

INR

International normalized ratio

LA

Left atrium

LAA

Left atrial appendage

LVEF

Left ventricular ejection fraction

RVIT

Right ventricular inflow tract

SEC

Spontaneous echo contrast

TEE

Transesophageal echocardiography

Notes

Sources of funding

None

Disclosures

Dr. Gonzalez is a consultant for Biosense Webster and Janssen Pharmaceuticals. He has also received research grants and fellowship support from Biosense Webster. Dr. Banchs has received speaker’s honoraria from St. Jude Medical. The other authors have no relevant financial disclosures.

Supplementary material

10840_2015_8_MOESM1_ESM.mpg (1 mb)
Cine Clip 1 A left atrial (LA) thrombus is noted at the junction of the superior part of fossa ovalis with inferior rim of the septum secundum. (MPG 1062 kb)
10840_2015_8_MOESM2_ESM.mpg (1.1 mb)
Cine Clip 2 A thrombus is seen with the left atrial appendage (LAA). (MPG 1080 kb)

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Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Chenni S. Sriram
    • 1
  • Javier E. Banchs
    • 1
  • Talal Moukabary
    • 1
  • Raman Moradkhan
    • 1
  • Mario D. Gonzalez
    • 1
    • 2
    Email author
  1. 1.Heart & Vascular InstitutePenn State UniversityHersheyUSA
  2. 2.Penn State Heart & Vascular Institute, Milton S. Hershey Medical CenterPenn State UniversityHersheyUSA

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