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Computed Tomography to Exclude Cardiac Thrombus in Atrial Fibrillation-An 11-Year Experience from an Academic
Sophie Gupta1, Martin Lutnik2, Filippo Cacioppo1
1Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria.
Insights
Computed tomography effectively excludes left atrial appendage thrombus (LAAT) in emergency department patients with atrial fibrillation (AF) and atrial flutter (AFL) before cardioversion. This strategy resulted in no ischemic strokes during follow-up.
Area of Science:
- Cardiology
- Emergency Medicine
- Radiology
Background:
- Atrial fibrillation (AF) and atrial flutter (AFL) are common arrhythmias.
- Left atrial appendage thrombus (LAAT) poses a risk for cardioversion.
- Computed tomography (CT) is a potential imaging modality for LAAT exclusion.
Purpose of the Study:
- To evaluate the utility of CT for acute LAAT exclusion in emergency department patients with AF/AFL.
- To assess the rate of LAAT and ischemic stroke following CT-guided cardioversion.
Main Methods:
- Registry-based observational study of consecutive AF/AFL patients undergoing CT for LAAT exclusion.
- Study period: January 2012 - January 2023.
- Follow-up via telephone and electronic medical records.
Main Results:
- 234 patients analyzed; 3% (8 patients) had LAAT detected.
- 72% of patients with LAAT exclusion by CT were successfully cardioverted.
- 0% incidence of ischemic stroke at follow-up (median 506 days).
Conclusions:
- LAAT is uncommon in ED patients with AF/AFL undergoing pre-cardioversion CT.
- CT-guided LAAT exclusion appears safe and effective in preventing stroke.
- Further prospective studies are needed to confirm this strategy in the emergency setting.
Background:
Computed tomography (CT) could be a suitable method for acute exclusion of left atrial appendage thrombus (LAAT) prior to cardioversion of atrial fibrillation (AF) and atrial flutter (AFL) at the emergency department. Our aim was to present our experiences with this modality in recent years.
Methods:
This registry-based observational study was performed at the Department of Emergency Medicine at the Medical University of Vienna, Austria. We studied all consecutive patients with AF and AFL who underwent CT between January 2012 and January 2023 to rule out LAAT before cardioversion to sinus rhythm was attempted. Follow-ups were conducted by telephone and electronic medical records. The main variables of interest were the rate of LAAT and ischemic stroke at follow-up.
Results:
A total of 234 patients (143 [61%] men; median age 68 years [IQR 57-76], median CHA2DS2-VASc 2 [IQR 1-4]) were analyzed. Follow-up was completed in 216 (92%) patients after a median of 506 (IQR 159-1391) days. LAAT was detected in eight patients (3%). A total of 163 patients (72%) in whom LAAT was excluded by CT were eventually successfully cardioverted to sinus rhythm. No adverse events occurred during their ED stay. All patients received anticoagulation according to the CHA2DS2-VASc risk stratification, and no patient had suffered an ischemic stroke at follow-up, resulting in an incidence risk of ischemic strokes of 0% (95% CI 0.0-1.2%).
Conclusion:
LAAT was rare in patients admitted to the ED with AF and AFL who underwent cardiac CT prior to attempted cardioversion. At follow-up, no patient had suffered an ischemic stroke. Prospective studies need to show whether this strategy is suitable for the acute treatment of symptomatic AF in the emergency setting.
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