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Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
Published on: February 26, 2013
Determinants of Left Atrial Thrombus in Patients Undergoing Catheter Ablation for Atrial Fibrillation and Atrial
Alessandro Barbarossa1, Francesca Coraducci2, Lorenzo Torselletti2
1Cardiology and Arrhythmology Clinic, Azienda Ospedaliero-Universitaria delle Marche, Ancona, Italy.
Insights
Left atrial thrombus (LAT) is rare in patients undergoing catheter ablation (CA). Transesophageal echocardiography (TOE) is recommended for those with persistent atrial fibrillation (AF), coronary artery disease (CAD), heart failure (HF), or high pulmonary artery pressure (sPAP).
Area of Science:
- Cardiology
- Electrophysiology
Background:
- Catheter ablation (CA) is a primary treatment for atrial fibrillation (AF) and atrial flutter (AFL).
- Left atrial thrombus (LAT) is a contraindication for CA due to stroke risk.
- Transesophageal echocardiography (TOE) is often used to screen for LAT before CA, especially in specific patient groups.
Purpose of the Study:
- To evaluate the incidence of LAT in patients undergoing CA.
- To identify risk factors for LAT in patients considered for CA.
- To assess the utility of TOE screening for LAT.
Main Methods:
- Consecutive patients undergoing TOE before AF or AFL CA between January 2019 and April 2024 were enrolled.
- Inclusion criteria included AF/AFL with <3 weeks of optimal oral anticoagulant therapy (OAT), persistent AF/AFL, or paroxysmal AF/AFL with CHA2DS2-VASc ≥ 2.
- Risk factors for LAT were analyzed using regression analysis.
Main Results:
- 14 thrombi (2.4%) were identified in 586 patients, all in the left atrial appendage.
- LAT patients had higher rates of coronary artery disease (CAD), heart failure (HF), and persistent AF, along with lower left ventricular ejection fraction (LVEF) and higher systolic pulmonary artery pressure (sPAP).
- No LAT was found in patients with atrial flutter (AFL).
Conclusions:
- LAT is uncommon in patients undergoing CA.
- Patients with persistent AF, CAD, HF (especially with low LVEF), and elevated sPAP are at higher risk for LAT and may benefit from pre-procedural TOE.
- Patients with AFL and no structural heart disease have a very low risk of LAT.
Background:
Catheter ablation (CA) is a first-line therapy for rhythm control in patients with atrial fibrillation (AF) and atrial flutter (AFL). Left atrial thrombus (LAT) is an absolute contraindication to CA due to the increased risk of periprocedural ischemic complications. A recent consensus statement from the European Heart Rhythm Association (EHRA) recommended the exclusion of LAT before CA in patients receiving oral anticoagulant therapy (OAT) for less than three weeks or in patients at high risk, despite the substantial reduction in the rate of periprocedural stroke achieved by anticoagulation in recent years. Consequently, many patients are frequently screened by transesophageal echocardiography (TOE) despite the lack of evidence that such a procedure is actually useful.
Methods:
All consecutive patients undergoing TOE before AF or AFL CA were enrolled between January 2019 and April 2024. Inclusion criteria were AF/AFL with less than 3 weeks of optimal OAT, persistent AF/AFL, or paroxysmal AF/AFL with CHA2DS2-VASc ≥ 2. Three experienced operators performed all TOEs and were blinded to the clinical data. Risk factors associated with LAT were tested by regression analysis.
Results:
Five hundred eighty-six patients were enrolled (age 66 ± 6 years; 72% male). A total of 14 thrombi were identified (2.4% of all patients), all located in the left atrial appendage. Patients with LAT had a higher prevalence of coronary artery disease (CAD), heart failure (HF), and persistent AF (11 vs. 3 patients, p = 0.048) as well as lower left ventricular ejection fraction (56 vs. 49%, p = 0.01) and higher systolic pulmonary artery pressure (sPAP). No LAT was found in patients with atrial flutter. According to univariate analysis, higher sPAP, CAD, HF, and persistent AF were identified as predictors of LAT formation, while LVEF > 50% was associated with lower LAT prevalence.
Conclusions:
LAT is a rare occurrence in candidates for CA. Patients with persistent AF, a history of CAD or HF (particularly with low ejection fraction), and higher sPAP present an elevated risk and should be considered for TOE prior to CA. Patients with AFL and no structural disease have an extremely low risk of LAT.
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