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Multidetector computed tomography may be an adequate screening test to reduce periprocedural stroke in atrial
Sung-Jin Hong1, Jong-Yun Kim2, Jin-Bae Kim3
1Cardiology Division, Department of Internal Medicine, Yonsei University Medical College, Seoul, Korea.
Insights
Routine transesophageal echocardiography (TEE) is not necessary before atrial fibrillation (AF) ablation if cardiac MDCT shows no thrombus. Multidetector computed tomography (MDCT) alone is sufficient for screening to prevent periprocedural stroke.
Area of Science:
- Cardiology
- Medical Imaging
- Electrophysiology
Background:
- The incremental value of routine transesophageal echocardiography (TEE) alongside multidetector computed tomography (MDCT) for preventing periprocedural stroke before atrial fibrillation (AF) ablation remains uncertain.
- Assessing the necessity of TEE screening in AF patients undergoing ablation is crucial for optimizing procedural safety and efficiency.
Purpose of the Study:
- To determine if multidetector computed tomography (MDCT) screening alone is adequate for preventing periprocedural stroke in patients undergoing atrial fibrillation (AF) ablation.
- To evaluate the diagnostic performance of MDCT in detecting left atrial appendage thrombus compared to TEE.
Main Methods:
- A comparative study involving 1147 patients undergoing AF ablation across four tertiary centers.
- Patients were divided into two groups: routine TEE plus MDCT (n=678) and selective TEE based on MDCT findings (n=469).
- Propensity score analysis created matched pairs (n=412 per group) to compare outcomes, focusing on periprocedural stroke incidence and thrombus detection rates.
Main Results:
- Multidetector computed tomography (MDCT) demonstrated 100% sensitivity and negative predictive value for thrombus detection.
- Periprocedural stroke incidence was low and statistically similar between the routine TEE and selective TEE groups (0.2% in both).
- Thrombi were identified in 1.0% of patients via TEE in the routine group and 1.7% via MDCT in the selective group.
Conclusions:
- Preprocedural transesophageal echocardiography (TEE) may not be essential before atrial fibrillation (AF) ablation in patients with low thrombus risk who have undergone cardiac MDCT.
- Multidetector computed tomography (MDCT) screening appears sufficient for identifying left atrial appendage thrombus, thus potentially obviating the need for routine TEE.
- The findings suggest a streamlined approach to preprocedural screening for AF ablation, enhancing patient care and resource utilization.
Background:
Whether routine transesophageal echocardiography (TEE) in addition to multidetector computed tomography (MDCT) has incremental value in preventing periprocedural stroke before atrial fibrillation (AF) ablation is unclear.
Objective:
The purpose of this study was to evaluate whether screening with MDCT is sufficient for preventing periprocedural stroke.
Methods:
From 4 tertiary centers, we enrolled 1147 patients (902 males, age 57 ± 11 years) with optimal anticoagulation and preserved left ventricular ejection function who had undergone MDCT and routine TEE (group 1, n = 678) or selective TEE (group 2, n = 469) as screening tests before AF ablation. Based on a propensity score analysis, 2 groups with 412 matched pairs were created.
Results:
Patient baseline characteristics were comparable between the matched groups. In group 1 (n = 412), thrombi were detected in 4 patients (1.0%) on TEE, and ablation was not performed. These patients also showed thrombi (n = 3) or blood stasis (n = 1) on MDCT. For thrombi detection, MDCT had sensitivity and negative predictive value of 100%. In group 2 (n = 412), thrombi were detected in 7 patients (1.7%) on MDCT. Of these patients , 2 (0.5%) also showed thrombi on TEE. Periprocedural stroke incidence did not differ between the groups (0.2% each, P = 1.0).
Conclusion:
The incidence of periprocedural stroke was low and did not differ significantly between the group assigned to routine TEE vs selective TEE screening in AF patients undergoing anticoagulation therapy if the patients had conditions associated with low thrombus risk. Thus, preprocedural TEE may not be necessary before AF ablation in patients who have undergone preprocedural cardiac MDCT that shows no evidence of left atrial appendage thrombus.
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