Do all patients undergoing catheter ablation of atrial fibrillation need a pre-procedural transesophageal echocardiography?

    Authors

    Keywords

    QT prolongation, drug induced arrhythmia

    DOI

    https://doi.org/10.15836/ccar2016.426

    Full Text

    **Background:** Pulmonary vein isolation (PVI) is a cornerstone of catheter ablation of atrial fibrillation (AF). Current European Heart Rhythm Association Guidelines suggests that all patients undergoing catheter ablation should be anticoagulated for three weeks prior the procedure. (1) All patients with high thromboembolic (TE) risk or in AF should undergo transesophageal echocardiography (TEE) to exclude left atrial thrombus (LAT). Whether patients with low TE risk (estimated with CHA2DS2VASc score) who are in sinus rhythm need TEE routinely remains unclear. The aim of our study was to determine the incidence of LAT in patients undergoing PVI regardless of their risk for TE event. **Patients and Methods:** Patients hospitalized at the Departmet of Arrhythmology, University Hospital Center “Sestre milosrdnice” Zagreb from January 2013 to May 2016 undergoing PVI were included in the study. Following routine protocol all patients underwent a pre-procedural TEE to exclude LAT. The TE risk was calculated for each patient using a CHA2DS2-VASc score. **Results:** A total of 241 consecutive patients (mean age of 59±11 years, 76% male) were included in the study. The overall incidence of left atrial thrombus was 39/241 (16.18%). As shown in **Table 1**, 129 patients had CHA2DS2VASc score 0 or 1 (low TE risk) and 18 of them (18/129; 13.95%) had LAT detected (46.15% of all patients with thrombi). 12 patients with LAT in a low TE risk group were adequately anticoagulated while 8 of them were in sinus rhythm. There were 6 low TE risk patients who were adequately anticoagulated and were in sinus rhythm who had LAT (4.5% of low risk patients, 2.4% of all patients). There was no difference in the LAT incidence between the low and high risk groups (13.95% vs 18.75%, p= 0.29). ### Table 1: Incidence of left atrial thrombus in different thromboembolic risk groups. | **CHA2DS2-VASc** | **Number of patients** | **Number of patients with thrombus** | **%** | | --- | --- | --- | --- | | 0 | 57 | 7 | 12.28 | | 1 | 72 | 11 | 15.28 | | 2 | 52 | 8 | 15.38 | | 3 | 43 | 8 | 18.60 | | 4 | 7 | 1 | 14.2 | | 5 | 5 | 3 | 60 | | 6 | 0 | 0 | 0 | | 7 | 5 | 1 | 20 | | **Total** | **241** | **39** | **16.18** | **Conclusion:** Due to the presence of thrombi in all TE risk groups, even in patients with a low TE risk who were in sinus rhythm and were adequately anticoagulated, TEE (or other imaging modality) could be routinely performed in all patients prior to planned PVI to exclude LAT. The main limitations of the study are relatively small number of patients, lack of standardized follow up of patients with vitamin K antagonists and small proportion of patients on novel anticoagulants. Also, INR data for some patients are lacking which could have influenced the results significantly.

    Literature

    1. European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery, Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010;31(19):2369–429. https://doi.org/10.1093/eurheartj/ehq278
    Cardiologia Croatica
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    Do all patients undergoing catheter ablation of atrial fibrillation need a pre-procedural transesophageal echocardiography?

    Extended Abstract
    Issue10-11
    Published
    Pages426-427
    PDF via DOIhttps://doi.org/10.15836/ccar2016.426
    QT prolongation
    drug induced arrhythmia

    Authors

    Nikola KosORCIDUniversity Hospital Center “Sestre milosrdnice”, Zagreb, Croatia
    Krešimir KordićORCIDUniversity Hospital Center “Sestre milosrdnice”, Zagreb, Croatia
    Šime ManolaORCIDUniversity Hospital Center “Sestre milosrdnice”, Zagreb, Croatia
    Vjekoslav RadeljićORCIDUniversity Hospital Center “Sestre milosrdnice”, Zagreb, Croatia
    Nikola BuljORCIDUniversity Hospital Center “Sestre milosrdnice”, Zagreb, Croatia
    Ivan ZeljkovićORCIDUniversity Hospital Center “Sestre milosrdnice”, Zagreb, Croatia
    Ines ZadroORCIDGeneral Hospital “Dr. Ivo Pedišić”, Sisak, Croatia
    Karlo GolubićORCIDUniversity Hospital Center “Sestre milosrdnice”, Zagreb, Croatia
    Diana Delić-BrkljačićORCIDUniversity Hospital Center “Sestre milosrdnice”, Zagreb, Croatia
    Nikola Pavlović*ORCIDUniversity Hospital Center “Sestre milosrdnice”, Zagreb, Croatia

    *Correspondence email: nikolap12@yahoo.com

    Full Text

    Background: Pulmonary vein isolation (PVI) is a cornerstone of catheter ablation of atrial fibrillation (AF). Current European Heart Rhythm Association Guidelines suggests that all patients undergoing catheter ablation should be anticoagulated for three weeks prior the procedure. (1) All patients with high thromboembolic (TE) risk or in AF should undergo transesophageal echocardiography (TEE) to exclude left atrial thrombus (LAT). Whether patients with low TE risk (estimated with CHA2DS2VASc score) who are in sinus rhythm need TEE routinely remains unclear. The aim of our study was to determine the incidence of LAT in patients undergoing PVI regardless of their risk for TE event.

    Patients and Methods: Patients hospitalized at the Departmet of Arrhythmology, University Hospital Center “Sestre milosrdnice” Zagreb from January 2013 to May 2016 undergoing PVI were included in the study. Following routine protocol all patients underwent a pre-procedural TEE to exclude LAT. The TE risk was calculated for each patient using a CHA2DS2-VASc score.

    Results: A total of 241 consecutive patients (mean age of 59±11 years, 76% male) were included in the study. The overall incidence of left atrial thrombus was 39/241 (16.18%). As shown in Table 1, 129 patients had CHA2DS2VASc score 0 or 1 (low TE risk) and 18 of them (18/129; 13.95%) had LAT detected (46.15% of all patients with thrombi). 12 patients with LAT in a low TE risk group were adequately anticoagulated while 8 of them were in sinus rhythm. There were 6 low TE risk patients who were adequately anticoagulated and were in sinus rhythm who had LAT (4.5% of low risk patients, 2.4% of all patients). There was no difference in the LAT incidence between the low and high risk groups (13.95% vs 18.75%, p= 0.29).

    Table 1: Incidence of left atrial thrombus in different thromboembolic risk groups.

    0
    Number of patients
    57
    Number of patients with thrombus
    7
    %
    12.28
    1
    Number of patients
    72
    Number of patients with thrombus
    11
    %
    15.28
    2
    Number of patients
    52
    Number of patients with thrombus
    8
    %
    15.38
    3
    Number of patients
    43
    Number of patients with thrombus
    8
    %
    18.60
    4
    Number of patients
    7
    Number of patients with thrombus
    1
    %
    14.2
    5
    Number of patients
    5
    Number of patients with thrombus
    3
    %
    60
    6
    Number of patients
    0
    Number of patients with thrombus
    0
    %
    0
    7
    Number of patients
    5
    Number of patients with thrombus
    1
    %
    20
    Total
    Number of patients
    241
    Number of patients with thrombus
    39
    %
    16.18

    Conclusion: Due to the presence of thrombi in all TE risk groups, even in patients with a low TE risk who were in sinus rhythm and were adequately anticoagulated, TEE (or other imaging modality) could be routinely performed in all patients prior to planned PVI to exclude LAT. The main limitations of the study are relatively small number of patients, lack of standardized follow up of patients with vitamin K antagonists and small proportion of patients on novel anticoagulants. Also, INR data for some patients are lacking which could have influenced the results significantly.

    Literature

    1. 1.
      European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery, Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010;31(19):2369–429.DOI