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Journal of Interventional Cardiac Electrophysiology

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01-09-2015 | MULTIMEDIA REPORT

Detection of left atrial thrombus by intracardiac echocardiography in patients undergoing ablation of atrial fibrillation

Authors: Chenni S. Sriram, Javier E. Banchs, Talal Moukabary, Raman Moradkhan, Mario D. Gonzalez

Published in: Journal of Interventional Cardiac Electrophysiology | Issue 3/2015

Abstract

Background

The role of intracardiac echocardiography (ICE) to detect thrombus within left atrium (LA) before atrial fibrillation (AF) ablation despite a recent transesophageal echocardiogram (TEE) is not well defined. We examined the prevalence of LA/left atrial appendage (LAA) thrombus using ICE immediately prior to AF ablation in patients in whom anticoagulation was not withheld.

Methods

We analyzed 122 consecutive patients (62.6 ± 10.8 years, 90 males, CHA ₂ DS ₂ -VASc score 2.4 ± 1.5, persistent AF 29.5 %) who underwent an ICE-guided AF ablation 1 day after a negative (n = 120) or inconclusive (n = 2) TEE for LA thrombus. LA was imaged with ICE from the right atrium, coronary sinus, and right ventricular inflow tract (RVIT). ICE and TEE images were compared for LAA area, thrombus, and spontaneous echo contrast (SEC).

Results

LAA was adequately visualized in 99 and 100 % of patients with TEE and ICE, respectively. RVIT was the best ICE view for LAA visualization. The LAA 2-D-area measured by TEE was 4.9 ± 0.5 vs. 5 ± 0.5 cm² by ICE (P = NS). ICE identified a thrombus in seven patients with a previous negative TEE, leading to cancellation of ablation. It ruled out a thrombus in two patients with an inconclusive TEE. Thrombi were found in the LAA (n = 4), atrial septum (n = 2), and left superior pulmonary vein (n = 1). SEC during TEE was more frequent in patients with thrombus on ICE than those without (85.7 vs. 17.4 %; p = 0.03; positive predictive value 23.1 %, negative predictive value 98.9 %).

Conclusions

The results of our staged imaging approach suggest that ICE has a complimentary value in re-screening the LA/LAA for thrombus after a recent negative or equivocal TEE. The presence of SEC during TEE increases the probability of finding a thrombus with ICE, which could potentially be dislodged during catheter manipulation.

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Ali, S., George, L. K., Das, P., & Koshy, S. K. (2011). Intracardiac echocardiography: clinical utility and application. Echocardiography, 28(5), 582–590.PubMedCrossRef

Asrress, K. N., & Mitchell, A. R. (2009). Intracardiac echocardiography. Heart, 95(4), 327–331.PubMedCrossRef

Banchs, J. E., Patel, P., Naccarelli, G. V., & Gonzalez, M. D. (2010). Intracardiac echocardiography in complex cardiac catheter ablation procedures. Journal of Interventional Cardiac Electrophysiology, 28(3), 167–184.PubMedCrossRef

Callans, D. J., & Wood, M. A. (2007). How to use intracardiac echocardiography for atrial fibrillation ablation procedures. Heart Rhythm, 4(2), 242–245.PubMedCrossRef

Chu, E., Kalman, J. M., Kwasman, M. A., Jue, J. C., Fitzgerald, P. J., Epstein, L. M., et al. (1994). Intracardiac echocardiography during radiofrequency catheter ablation of cardiac arrhythmias in humans. Journal of the American College of Cardiology, 24(5), 1351–1357.PubMedCrossRef

Epstein, L. M., Mitchell, M. A., Smith, T. W., & Haines, D. E. (1998). Comparative study of fluoroscopy and intracardiac echocardiographic guidance for the creation of linear atrial lesions. Circulation, 98(17), 1796–1801.PubMedCrossRef

Mangrum, J. M., Mounsey, J. P., Kok, L. C., DiMarco, J. P., & Haines, D. E. (2002). Intracardiac echocardiography-guided, anatomically based radiofrequency ablation of focal atrial fibrillation originating from pulmonary veins. Journal of the American College of Cardiology, 39(12), 1964–1972.PubMedCrossRef

Marrouche, N. F., Martin, D. O., Wazni, O., Gillinov, A. M., Klein, A., Bhargava, M., et al. (2003). Phased-array intracardiac echocardiography monitoring during pulmonary vein isolation in patients with atrial fibrillation: impact on outcome and complications. Circulation, 107(21), 2710–2716.PubMedCrossRef

Morton, J. B., Sanders, P., Sparks, P. B., Morgan, J., & Kalman, J. M. (2002). Usefulness of phased-array intracardiac echocardiography for the assessment of left atrial mechanical “stunning” in atrial flutter and comparison with multiplane transesophageal echocardiography(*). American Journal of Cardiology, 90(7), 741–746.PubMedCrossRef

10.

Packer, D. L., Stevens, C. L., Curley, M. G., Bruce, C. J., Miller, F. A., Khandheria, B. K., et al. (2002). Intracardiac phased-array imaging: methods and initial clinical experience with high resolution, under blood visualization: initial experience with intracardiac phased-array ultrasound. Journal of the American College of Cardiology, 39(3), 509–516.PubMedCrossRef

11.

Ren, J. F., Marchlinski, F. E., Callans, D. J., & Herrmann, H. C. (2002). Clinical use of acunav diagnostic ultrasound catheter imaging during left heart radiofrequency ablation and transcatheter closure procedures. Journal of the American Society of Echocardiography, 15(10), 1301–1308.PubMedCrossRef

12.

Ren, J. F., & Marchlinski, F. E. (2007). Utility of intracardiac echocardiography in left heart ablation for tachyarrhythmias. Echocardiography, 24(5), 533–540.PubMedCrossRef

13.

Ren, J. F., Schwartzman, D., Callans, D. J., Brode, S. E., Gottlieb, C. D., & Marchlinski, F. E. (1999). Intracardiac echocardiography (9 mhz) in humans: methods, imaging views and clinical utility. Ultrasound in Medicine and Biology, 25(7), 1077–1086.PubMedCrossRef

14.

Khan, F., Banchs, J. E., Skibba, J. B., Grando-Ting, J., Kelleman, J., Singh, J., et al. (2015). Determination of left atrium volume by fast anatomical mapping and intracardiac echocardiography. The contribution of respiratory gating. Journal of Interventional Cardiac Electrophysiology (accepted for publication).

15.

Camm, A. J., Kirchhof, P., Lip, G. Y., Schotten, U., Savelieva, I., Ernst, S., et al. (2010). Guidelines for the management of atrial fibrillation: the task force for the management of atrial fibrillation of the European Society of Cardiology (esc). European Heart Journal, 31(19), 2369–2429.PubMedCrossRef

16.

Cappato, R., Calkins, H., Chen, S. A., Davies, W., Lesaka, Y., Kalman, J., et al. (2010). Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation. Arrhythmia and Electrophysiology, 3(1), 32–38.PubMedCrossRef

17.

Naccarelli, G. V., & Gonzalez, M. D. (2013). Catheter ablation of atrial fibrillation: the need for studies to assess the efficacy and safety of novel anticoagulants. Journal of Interventional Cardiac Electrophysiology, 36(1), 3–4.PubMedCrossRef

18.

Lip, G. Y., Nieuwlaat, R., Pisters, R., Lane, D. A., & Crijns, H. J. (2010). Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on atrial fibrillation. Chest, 137(2), 263–272.PubMedCrossRef

19.

Cooper, J. M., & Epstein, L. M. (2001). Use of intracardiac echocardiography to guide ablation of atrial fibrillation. Circulation, 104(25), 3010–3013.PubMedCrossRef

20.

Black, I. W., Hopkins, A. P., Lee, L. C., & Walsh, W. F. (1991). Left atrial spontaneous echo contrast: a clinical and echocardiographic analysis. Journal of the American College of Cardiology, 18(2), 398–404.PubMedCrossRef

21.

Ren, J. F., Marchlinski, F. E., & Callans, D. J. (2004). Left atrial thrombus associated with ablation for atrial fibrillation: identification with intracardiac echocardiography. Journal of the American College of Cardiology, 43(10), 1861–1867.PubMedCrossRef

22.

Saksena, S., Sra, J., Jordaens, L., Kusumoto, F., Knight, B., Natale, A., et al. (2010). A prospective comparison of cardiac imaging using intracardiac echocardiography with transesophageal echocardiography in patients with atrial fibrillation: the intracardiac echocardiography guided cardioversion helps interventional procedures study. Circulation. Arrhythmia and Electrophysiology, 3(6), 571–577.PubMedCrossRef

23.

Hajjiri, M., Bernstein, S., Saric, M., Benenstein, R., Aizer, A., Dym, G., et al. (2014). Atrial fibrillation ablation in patients with known sludge in the left atrial appendage. Journal of Interventional Cardiac Electrophysiology, 40(2), 147–151.PubMedCrossRef

24.

Shanewise, J. S., Cheung, A. T., Aronson, S., Stewart, W. J., Weiss, R. L., Mark, J. B., et al. (1999). Ase/sca guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for intraoperative echocardiography and the society of cardiovascular anesthesiologists task force for certification in perioperative transesophageal echocardiography. Journal of the American Society of Echocardiography, 12(10), 884–900.PubMedCrossRef

25.

Ho, S. Y., & Nihoyannopoulos, P. (2006). Anatomy, echocardiography, and normal right ventricular dimensions. Heart, 92(Suppl 1), i2–i13.PubMedCentralPubMedCrossRef

26.

Black, I. W., Chesterman, C. N., Hopkins, A. P., Lee, L. C., Chong, B. H., & Walsh, W. F. (1993). Hematologic correlates of left atrial spontaneous echo contrast and thromboembolism in nonvalvular atrial fibrillation. Journal of the American College of Cardiology, 21(2), 451–457.PubMedCrossRef

27.

Chimowitz, M. I., DeGeorgia, M. A., Poole, R. M., Hepner, A., & Armstrong, W. M. (1993). Left atrial spontaneous echo contrast is highly associated with previous stroke in patients with atrial fibrillation or mitral stenosis. Stroke, 24(7), 1015–1019.PubMedCrossRef

28.

Fatkin, D., Herbert, E., & Feneley, M. P. (1994). Hematologic correlates of spontaneous echo contrast in patients with atrial fibrillation and implications for thromboembolic risk. American Journal of Cardiology, 73(9), 672–676.PubMedCrossRef

29.

Fatkin, D., Kelly, R. P., & Feneley, M. P. (1994). Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast and thromboembolic risk in vivo. Journal of the American College of Cardiology, 23(4), 961–969.PubMedCrossRef

30.

Kamensky, G., Drahos, P., & Plevova, N. (1996). Left atrial spontaneous echo contrast: its prevalence and importance in patients undergoing transesophageal echocardiography and particularly those with a cerebrovascular embolic event. Journal of the American Society of Echocardiography, 9(1), 62–70.PubMedCrossRef

31.

Kleemann, T., Becker, T., Strauss, M., Schneider, S., & Seidl, K. (2009). Prevalence and clinical impact of left atrial thrombus and dense spontaneous echo contrast in patients with atrial fibrillation and low CHADS2 score. European Journal of Echocardiography, 10(3), 383–388.PubMedCrossRef

32.

Kronik, G., Stollberger, C., Schuh, M., Abzieher, F., Slany, J., & Schneider, B. (1995). Interobserver variability in the detection of spontaneous echo contrast, left atrial thrombi, and left atrial appendage thrombi by transoesophageal echocardiography. British Heart Journal, 74(1), 80–83.PubMedCentralPubMedCrossRef

33.

Klein, A. L., Grimm, R. A., Murray, R. D., Apperson-Hansen, C., Asinger, R. W., Black, I. W., et al. (2001). Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. New England Journal of Medicine, 344(19), 1411–1420.PubMedCrossRef

34.

Aschenberg, W., Schluter, M., Kremer, P., Schroder, E., Siglow, V., & Bleifeld, W. (1986). Transesophageal two-dimensional echocardiography for the detection of left atrial appendage thrombus. Journal of the American College of Cardiology, 7(1), 163–166.PubMedCrossRef

35.

Black, I. W., Fatkin, D., Sagar, K. B., Khandheria, B. J., Leung, D. Y., Galloway, J. M., et al. (1994). Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation. A multicenter study. Circulation, 89(6), 2509–2513.PubMedCrossRef

36.

Baran, J., Stec, S., Pilichowska-Paszkiet, E., Zaborska, B., Sikora-Frac, M., Krynski, T., et al. (2013). Intracardiac echocardiography for detection of thrombus in the left atrial appendage: comparison with transesophageal echocardiography in patients undergoing ablation for atrial fibrillation: the Action-ICE I Study. Circulation. Arrhythmia and Electrophysiology, 6(6), 1074–1081.PubMedCrossRef

37.

Ren, J. F., Marchlinski, F. E., Supple, G. E., Hutchinson, M. D., Garcia, F. C., Riley, M. P., et al. (2013). Intracardiac echocardiographic diagnosis of thrombus formation in the left atrial appendage: a complementary role to transesophageal echocardiography. Echocardiography, 30(1), 72–80.PubMedCrossRef

38.

Anter, E., Silverstein, J., Tschabrunn, C. M., Shvilkin, A., Haffajee, C. I., Zimetbaum, P. J., et al. (2014). Comparison of intracardiac echocardiography and transesophageal echocardiography for imaging of the right and left atrial appendages. Heart Rhythm, 11(11), 1890–1897.PubMedCrossRef

39.

Reddy, V. Y., Neuzil, P., & Ruskin, J. N. (2005). Intracardiac echocardiographic imaging of the left atrial appendage. Heart Rhythm, 2(11), 1272–1273.PubMedCrossRef

40.

Bernhardt, P., Schmidt, H., Hammersting, l. C., Luderitz, B., & Omran, H. (2005). Patients with atrial fibrillation and dense spontaneous echo contrast at high risk a prospective and serial follow-up over 12 months with transesophageal echocardiography and cerebral magnetic resonance imaging. Journal of the American College of Cardiology, 45(11), 1807–1812.PubMedCrossRef

41.

Hwang, J. J., Ko, F. N., Li, Y. H., Ma, H. M., Wu, G. J., Chang, H., et al. (1994). Clinical implications and factors related to left atrial spontaneous echo contrast in chronic nonvalvular atrial fibrillation. Cardiology, 85(2), 69–75.PubMedCrossRef

42.

Obarski, T. P., Salcedo, E. E., Castle, L. W., & Stewart, W. J. (1990). Spontaneous echo contrast in the left atrium during paroxysmal atrial fibrillation. American Heart Journal, 120(4), 988–990.PubMedCrossRef

43.

Tsai, L. M., Chen, J. H., Fang, C. J., Lin, L. J., & Kwan, C. M. (1992). Clinical implications of left atrial spontaneous echo contrast in nonrheumatic atrial fibrillation. American Journal of Cardiology, 70(3), 327–331.PubMedCrossRef

44.

Floria, M., De Roy, L., Xhaet, O., Blommaert, D., Jamart, J., Gerard, M., et al. (2013). Predictive value of thromboembolic risk scores before an atrial fibrillation ablation procedure. Journal of Cardiovascular Electrophysiology, 24(2), 139–145.PubMedCrossRef

Title: Detection of left atrial thrombus by intracardiac echocardiography in patients undergoing ablation of atrial fibrillation
Authors: Chenni S. Sriram
Javier E. Banchs
Talal Moukabary
Raman Moradkhan
Mario D. Gonzalez
Publication date: 01-09-2015
Publisher: Springer US
Published in: Journal of Interventional Cardiac Electrophysiology / Issue 3/2015
Print ISSN: 1383-875X
Electronic ISSN: 1572-8595
DOI: https://doi.org/10.1007/s10840-015-0008-2

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Detection of left atrial thrombus by intracardiac echocardiography in patients undergoing ablation of atrial fibrillation

Abstract

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Results

Conclusions

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