Risk stratification of patients with left atrial appendage thrombus prior to catheter ablation of atrial fibrillation: An approach towards an individualized use of transesophageal echocardiography

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Abstract

Introduction:

The need for transesophageal echocardiography (TEE) before catheter ablation of atrial fibrillation (CA-AF) is still being questioned. The aim of this study is to analyze patients’ (patients) risk factors of left atrial appendage thrombus (LAAT) prior to CA-AF in daily clinical practice, according to oral anticoagulation (OAC) strategies recommended by current guidelines.

Methods and results:

All patients scheduled for CA-AF from 01/2015 to 12/2016 in our center were included and either treated with NOACs (novel-OAC; paused 24-hours preablation) or continuous vitamin K antagonists (INR 2.0–3.0). All patients received a preprocedural TEE at the day of ablation. Two groups were defined: (1) patients without LAAT, (2) patients with LAAT.

Methods and results:

The incidence of LAAT was 0.78% (13 of 1,658 patients). No LAAT was detected in patients with a CHA2DS2-VASc score of ≤1 (n = 640 patients) irrespective of the underlying AF type. Independent predictors for LAAT are: higher CHA2DS2-VASc scores (odds ratio [OR] 1.54, 95%-confidence interval [CI]: 1.07–2.23, P = 0.0019), a history of nonparoxysmal AF (OR 7.96, 95%-CI: 1.52–146.64, P = 0.049), hypertrophic cardiomyopathy (HCM; OR 9.63, 95% CI: 1.36–43.05, P = 0.007), and a left ventricular ejection fraction (LVEF) < 30% (OR 8.32, 95% CI: 1.18–36.29, P = 0.011). The type of OAC was not predictive (P = 0.70).

Conclusions:

The incidence of LAAT in patients scheduled for CA-AF is low. Therefore, periprocedural OAC strategies recommended by current guidelines seem feasible. Preprocedural TEE may be dispensed in patients with a CHA2DS2-VASc score ≤1. However, a CHA2DS2-VASc score ≥2, reduced LVEF, HCM, or history of nonparoxysmal AF are independently associated with an increased risk for LAAT.

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