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

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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.

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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

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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.

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Authors and Affiliations

  1. Heart & Vascular Institute, Penn State University, Hershey, PA, USA

    Chenni S. Sriram, Javier E. Banchs, Talal Moukabary, Raman Moradkhan & Mario D. Gonzalez

  2. Penn State Heart & Vascular Institute, Milton S. Hershey Medical Center, Penn State University, 500 University Drive, Hershey, PA, 17033, USA

    Mario D. Gonzalez

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  1. Chenni S. Sriram
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  2. Javier E. Banchs
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  3. Talal Moukabary
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Correspondence to Mario D. Gonzalez.

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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)

Cine Clip 2

A thrombus is seen with the left atrial appendage (LAA). (MPG 1080 kb)

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Sriram, C.S., Banchs, J.E., Moukabary, T. et al. Detection of left atrial thrombus by intracardiac echocardiography in patients undergoing ablation of atrial fibrillation. J Interv Card Electrophysiol 43, 227–236 (2015). https://doi.org/10.1007/s10840-015-0008-2

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  • DOI: https://doi.org/10.1007/s10840-015-0008-2

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