Detection of left atrial thrombus by intracardiac echocardiography in patients undergoing ablation of atrial fibrillation
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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.
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).
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 %).
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.
KeywordsAtrial fibrillation Left atrium Left atrial appendage Intracardiac echocardiography Spontaneous echo contrast Thrombus Transesophageal echocardiography
Body mass index
International normalized ratio
Left atrial appendage
Left ventricular ejection fraction
Right ventricular inflow tract
Spontaneous echo contrast
Sources of funding
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.
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