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Maslova V, Demming T, Pantlik R, Geczy T, Falk P, Remppis BA, Frank D, Lian E. Omitting transesophageal echocardiography before catheter ablation of atrial fibrillation. J Interv Card Electrophysiol 2024; 67:1781-1791. [PMID: 38761295 PMCID: PMC11607098 DOI: 10.1007/s10840-024-01825-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 05/07/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Data about necessity of performing transesophageal echocardiography (TOE) prior to every catheter ablation (CA) of atrial fibrillation (AF) is scarce. We aimed to evaluate the safety of an individualized risk-based approach to TOE with respect to thromboembolic cerebrovascular events (CVE) in patients undergoing CA for AF or left atrial tachycardia (AT). METHODS We performed a retrospective clinical study based on our institutional registry database. Patients undergoing CA for AF or left-sided AT following initial AF ablation at two participating centers were enrolled. Prior to the procedure, patients were scheduled for TOE only if they had a history of thromboembolic stroke, left atrial appendage (LAA) thrombus, or inappropriate anticoagulation regimen in the previous 3 to 4 weeks. The incidence of periprocedural cerebrovascular thromboembolic events was assessed. RESULTS We analyzed 1155 patients (median age 70 years, 54.8% male, 48.1% had persistent AF/AT). In 261 patients, a TOE was performed; in 2 patients (0.7%), an LAA thrombus was detected, which led to cancellation of the catheter ablation; in 894 patients, the TOE was omitted. Of the 1153 (0.35%) patients who underwent ablation, 4 (0.35%) experienced a CVE (one TIA and three strokes). The rate of CVE in our study does not exceed that reported in most multicenter trials. The low event rates limited statistical analysis of possible risk factors for CVE. In all 4 patients with CVE, post-CVE imaging showed the absence of LAA thrombus. CONCLUSIONS An individualized selective approach to TOE before catheter ablation of AF or left AT showed a very low risk of overt intraprocedural thromboembolic events for the population in our study. A further randomized controlled study is needed to determine whether TOE prior to catheter ablation without ICE could be omitted in patients with uninterrupted OAC without previous thromboembolic events or a history of left atrial thrombus.
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Affiliation(s)
- Vera Maslova
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Thomas Demming
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Robert Pantlik
- Department of Cardiology, Cardiovascular Center Bad Bevensen, Bad Bevensen, Germany
| | - Tamas Geczy
- Department of Cardiology, Cardiovascular Center Bad Bevensen, Bad Bevensen, Germany
| | - Peter Falk
- Department of Cardiology, Cardiovascular Center Bad Bevensen, Bad Bevensen, Germany
| | | | - Derk Frank
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Evgeny Lian
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany.
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2
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Milhem A, Anselme F, Da Costa A, Abbey S, Mansourati J, Bader H, Winum PF, Badenco N, Maury P, Dompnier A, Shah D, Johner N, Taieb J, Bertrand J, Tréguer F, Amelot M, Ingrand P, Allix-Béguec C. ATE Score Diagnostic Accuracy for Predicting the Absence of Intra-Atrial Thrombi Before AF Ablation. JACC Clin Electrophysiol 2023; 9:2550-2557. [PMID: 37804261 DOI: 10.1016/j.jacep.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 08/14/2023] [Accepted: 08/20/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND In a preliminary study in patients hospitalized for catheter ablation of atrial fibrillation (AF), the atrial thrombus exclusion (ATE) score (stroke, hypertension, heart failure, and D-dimers >270 ng/mL) was developed to rule out the diagnosis of intra-atrial thrombus, with a negative predictive value (NPV) of 100%, and to avoid performing transesophageal echocardiography (TEE). OBJECTIVES The present study was designed to prospectively confirm the NPV of the ATE score in an independent population. METHODS Consecutive patients hospitalized for catheter ablation of AF or left atrial tachycardia (LAT) were prospectively enrolled in a multicenter study. D-dimer levels were measured within 48 hours before ablation. An ATE score of 0 was considered predictive of no thrombus. TEE was routinely performed at the beginning or just before the ablation procedure. The primary endpoint was the presence of atrial thrombus diagnosed by TEE. RESULTS The analysis included 3,072 patients (53.3% paroxysmal AF, 36.7% persistent AF, and 10% LAT). A thrombus was detected in 29 patients (0.94%; 95% CI: 0.63%-1.35%), all on appropriate anticoagulant therapy. An ATE score of 0 was observed in 818 patients (26.6%), and the sensitivity, specificity, positive predictive value, and NPV were 93.1%, 26.8%, 1.2%, and 99.8%, respectively. Follow-up of the 2 false negative patients revealed the persistence of chronic organized thrombi. CONCLUSIONS In patients hospitalized for catheter ablation of AF or LAT, the ATE score identifies a population at very low risk for atrial thrombus. In consultation with the patient, the cardiologist may consider not performing a preoperative TEE in case of an ATE score of 0.
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Affiliation(s)
- Antoine Milhem
- Department of Cardiology, CH la Rochelle, La Rochelle, France.
| | | | - Antoine Da Costa
- Department of Cardiology, CHU Saint-Etienne, Saint-Etienne, France
| | - Sélim Abbey
- Department of Cardiology, Nouvelles Cliniques Nantaises, Groupe Confluent, Nantes, France
| | | | | | | | - Nicolas Badenco
- Department of Cardiology, APHP, Hôpital Pitié Salpêtrière, Paris, France; Sorbonne Université, INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Philippe Maury
- Department of Cardiology, CHU Toulouse, Toulouse, France
| | | | - Dipen Shah
- Department of Cardiology, University Hospital Geneva, Geneva, Switzerland
| | - Nicolas Johner
- Department of Cardiology, University Hospital Geneva, Geneva, Switzerland
| | - Jérôme Taieb
- Department of Cardiology, CH Pays d'Aix, Aix-en-Provence, France
| | - Julien Bertrand
- Department of Cardiology, CHR Metz-Thionville, Ars-Laquenexy, France
| | | | | | - Pierre Ingrand
- Epidemiology and Biostatistics, INSERM CIC 1402, Université de Poitiers, CHU Poitiers, Poitiers, France
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Liu C, Lai Y, Guan T, Zeng Q, Pei J, Zhang S, Wu D, Wu D. Association of Digoxin Application Approaches With Long-Term Clinical Outcomes in Rheumatic Heart Disease Patients With Heart Failure: A Retrospective Study. Front Cardiovasc Med 2021; 8:711203. [PMID: 34616781 PMCID: PMC8488133 DOI: 10.3389/fcvm.2021.711203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/16/2021] [Indexed: 12/03/2022] Open
Abstract
Objective: This retrospective, case–control study was executed to assess the effects of digoxin (DGX) use approaches [continuous use of DGX (cDGX) vs. intermittent use of DGX (iDGX)] on the long-term prognosis in rheumatic heart disease (RHD) patients with heart failure (HF). Methods: A total of 642 RHD patients were enrolled to this study after propensity matching. The associations of DGX application approaches with the risks of all-cause mortality, cardiovascular death (CVD), HF re-hospitalization (1-, 3-, and 5-year), and new-onset atrial fibrillation (AF) were analyzed by multivariate Cox proportional hazards or binary logistic regression models, respectively. Results: cDGX was associated with increased risks of all-cause mortality (adjusted HR = 1.84, 95% CI: 1.27–2.65, P = 0.001) and CVD (adjusted HR = 2.23, 95% CI: 1.29–3.83, P = 0.004) in RHD patients with HF compared to iDGX. With exception of 1-year HF re-hospitalization risk, cDGX was associated with increased HF re-hospitalization risk of 3-year (adjusted OR = 1.53, 95% CI: 1.03–2.29, P = 0.037) and 5-year (adjusted OR = 1.61, 95% CI: 1.05–2.50, P = 0.031) as well as new-onset AF (adjusted OR = 2.06, 95% CI: 1.09–3.90, P = 0.027). Conclusion: cDGX was significantly associated with increased risks of all-cause mortality, CVD, medium-/long-term HF re-hospitalization, and new-onset AF in RHD patients with HF.
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Affiliation(s)
- Cheng Liu
- Department of Cardiology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, China.,Department of Cardiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Yanxian Lai
- Department of Cardiology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, China
| | - Tianwang Guan
- Department of Cardiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Qingchun Zeng
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jingxian Pei
- Department of Cardiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Shenghui Zhang
- Department of Cardiology, Guangzhou First People's Hospital, South China University of Technology, Guangzhou, China
| | - Daihong Wu
- Department of Cardiology, Guangzhou First People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Deping Wu
- Guangzhou Center for Disease Control and Prevention, Guangzhou, China
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Zhang M, Wang Y, Wei J, Peng Q, Pan X, Ma A. BNP combined with echocardiographic parameters to predict the risk of cardioembolic stroke. J Clin Neurosci 2021; 88:213-218. [PMID: 33992186 DOI: 10.1016/j.jocn.2021.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/24/2021] [Accepted: 04/04/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous studies have found that BNP and some indicators of cardiac structure and function are closely associated with atrial fibrillation, so we aim to investigate the potential role of BNP and echocardiographic parameters to identify the acute ischemic stroke with atrial fibrillation patients who have high risks of cardioembolic stroke based on it. METHODS 436 AIS patients were divided into an AF group and non-AF group on the basis of the electrocardiogram and Holter results. Then we compared vascular risk factors, laboratory test indicators, and echocardiographic parameters among different groups. RESULTS AIS with AF group had significantly higher age, CHD, previous medication, creatinine, d-dimer, fibrinogen, CRP, BNP, LAD, LVDd, LVDs and lower cholesterol, triglyceride, LDL and ejection fraction than the non-AF group (P < 0.05). Increased BNP, LAD, LVDd, LVDs and ejection fraction reduction were independent risk factors to predict cardioembolic stroke. BNP and LAD could be the two most effective indicators of the high risk of cardioembolic stroke. The area under the curve (AUC) of BNP and LAD were 0.791 [95%CI (0.743-0.838), p < 0.001), 0.786 [95%CI (0.739-0.833), p < 0.001]. The combined score we designed improved the prediction effect of single-indicator. The AUC of it was 0.822 with a sensitivity of 69.5% and specificity of 83.9%.There was an apparent positive correlation between BNP and LAD in AIS patients (r = 0.327, P < 0.001). CONCLUSION BNP combined with echocardiographic parameters has outstanding value to predict the risk of cardioembolic stroke, especially for BNP and LAD.
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Affiliation(s)
- Meng Zhang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Yuan Wang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Jin Wei
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Qing Peng
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Xudong Pan
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao 266000, China.
| | - Aijun Ma
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao 266000, China.
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Bursi F, Santangelo G, Ferrante G, Massironi L, Carugo S. Prevalence of left atrial thrombus by real time three-dimensional echocardiography in patients undergoing electrical cardioversion of atrial fibrillation: A contemporary cohort study. Echocardiography 2021; 38:518-524. [PMID: 33665895 DOI: 10.1111/echo.15015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/04/2021] [Accepted: 02/15/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The prevalence of left atrial thrombi in patients scheduled for electrical cardioversion (ECV) of atrial fibrillation (AF) remains unknown in contemporary real-life practice. METHODS AND RESULTS Patients scheduled for ECV underwent transesophageal echocardiography (TEE) regardless of AF duration and type of anticoagulant. Of 277 consecutive patients (65% men, mean age 71 ± 10 years, CHA2 DS2 -VASc 3.1 ± 1.4), 92 were on direct oral anticoagulants (DOACs) and 99 on antivitamin K (AVK) oral agents for at least 3 weeks before and 4 after ECV. Eighty-five patients with paroxysmal AF on low-molecular-weight heparin were also considered. Real time three-dimensional TEE detected left atrial appendage (LAA) thrombus in 7% of patients, without significant difference among three groups (P = .334). Anticoagulation was ineffective in eight patients on AVK oral agents, two of them had thrombus. Eight patients assumed incorrectly DOACs, four of them had thrombus. Among the 175 patients on effective anticoagulation, five showed thrombus, three on AVK oral agents, and two on DOACs (P = .716). Effective anticoagulation was associated with reduced risk of thrombosis (OR: 0.16, 95%CI: 0.06-0.45, P = .001). In patients with correct anticoagulation, predictors of thrombus were CHA2 DS2 VASc (for each point of increment OR: 1.97, 95%CI: 1.08-3.61, P = .029), low left ventricular ejection fraction (OR: 0.92, 95%CI: 0.86-0.99, P = .026), and degree of spontaneous echo-contrast (for each point increase OR: 10, 95%CI: 2-39, P < .0001). CONCLUSION Patients with AF, on effective anticoagulation, had a prevalence of thrombus not negligible regardless of type of anticoagulant. TEE is prudent before ECV and mandatory if unsuccessful anticoagulation is proved or suspected.
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Affiliation(s)
- Francesca Bursi
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
| | - Gloria Santangelo
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
| | - Giulia Ferrante
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
| | - Laura Massironi
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
| | - Stefano Carugo
- Division of Cardiology, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy.,Division of Cardiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
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6
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Efremidis M, Bazoukis G, Vlachos K, Prappa E, Megarisiotou A, Dragasis S, Ramirez FD, Bourier F, Mililis P, Saplaouras A, Tse G, Liu T, Efremidis T, Kitsoulis P, Thomopoulos C, Sideris A, Letsas KP. Safety of catheter ablation of atrial fibrillation without pre- or peri-procedural imaging for the detection of left atrial thrombus in the era of uninterrupted anticoagulation. J Arrhythm 2021; 37:28-32. [PMID: 33664883 PMCID: PMC7896446 DOI: 10.1002/joa3.12466] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/18/2020] [Accepted: 11/04/2020] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The need for pre- or peri-procedural imaging to rule out the presence of left atrial thrombus in patients undergoing catheter ablation of atrial fibrillation (AF) is unclear in the era of uninterrupted direct oral anticoagulant (DOAC) regimen. We sought to examine the safety of catheter ablation in appropriately selected patients with paroxysmal AF without performing screening for left atrial thrombus. PATIENTS AND METHODS Consecutive patients planned for radiofrequency AF catheter ablation between January 2016 and June 2020 were enrolled, and prospectively studied. All subjects were receiving uninterrupted anticoagulation with DOACs for at least 4 weeks before the procedure. All subjects were in sinus rhythm the day of the procedure. The primary outcome of the study was ischemic stroke or transient ischemic attack (TIA) during at 30 days. RESULTS A total of 451 patients (age 59.7 ± 10.2 years, 289 males) with paroxysmal AF were included in the study. The mean CHA2DS2-VASc score was 1.4 ± 1.2. The mean left ventricular ejection fraction and left atrial diameter were 60 ± 5% and 39.3 ± 4 mm, respectively. Regarding the anticoagulation regimen, apixaban was used in 197 (43.6%) patients, rivaroxaban in 148 (32.8%) patients, and dabigatran in 106 (23.5%) patients. None of the patients developed clinical ischemic stroke or TIA during the 30-day post-discharged period. CONCLUSIONS Catheter ablation can be safely performed in low-risk patients with paroxysmal AF without imaging for the detection of left atrial thrombus in the era of uninterrupted DOAC anticoagulation.
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Affiliation(s)
- Michael Efremidis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - George Bazoukis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Konstantinos Vlachos
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Efstathia Prappa
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Athanasia Megarisiotou
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Stylianos Dragasis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - F. Daniel Ramirez
- Hôpital Cardiologique du Haut LévèqueCHU de Bordeaux and IHU‐LIRYCPessacFrance
| | - Felix Bourier
- Department of ElectrophysiologyGerman Heart CenterTechnical UniversityMunichGermany
| | - Panagiotis Mililis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Athanasios Saplaouras
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Gary Tse
- Xiamen Cardiovascular HospitalXiamen UniversityXiamenPeople's Republic of China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular DiseaseDepartment of CardiologyTianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinPeople's Republic of China
| | - Theodore Efremidis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Panagiotis Kitsoulis
- Laboratory of Anatomy‐Histology‐EmbryologySchool of MedicineUniversity of IoanninaIoanninaGreece
| | | | - Antonios Sideris
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Konstantinos P. Letsas
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
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7
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Song Z, Xu K, Hu X, Jiang W, Wu S, Qin M, Liu X. A Study of Cardiogenic Stroke Risk in Non-valvular Atrial Fibrillation Patients. Front Cardiovasc Med 2020; 7:604795. [PMID: 33244472 PMCID: PMC7683797 DOI: 10.3389/fcvm.2020.604795] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/12/2020] [Indexed: 11/13/2022] Open
Abstract
Objectives: We attempted to develop more precisely quantified risk models for predicting cardiogenic stroke risk in non-valvular atrial fibrillation (NVAF) patients. Methods: We conducted a case-control study, using data from hospitalized patients with AF who underwent transesophageal echocardiography at Shanghai Chest Hospital. A total of 233 high cardiogenic stroke risk patients with left atrial appendage thrombus (LAT) or left atrial spontaneous echo contrast (LA-SEC) and 233 controls matched for age, sex, AF type. Results: AF history, LA diameter enlargement, larger left ventricular end diastolic diameter, lower ejection fraction, greater serum uric acid (SUA), and brain natriuretic peptide (BNP) levels showed association with high stroke risk. The multivariate logistic regression analysis revealed that AF duration, left atrial diameter (LAd), left ventricular ejection fraction (LVEF), SUA, and BNP were independent risk factors of the LAT/LA-SEC. We used LAd, LVEF, SUA, and BNP to construct a combined predictive model for high stroke risk in NVAF patients (the area under ROC curve: 0.784; sensitivity 66.1%; specificity 76.8%; 95% CI 0.744-0.825, P < 0.001). Conclusion: Comprehensive evaluation of LAd, LVEF, SUA, and BNP may help stratify the cardiogenic stroke risk among non-valvular AF patients, guiding anticoagulation therapy.
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Affiliation(s)
| | | | | | | | | | - Mu Qin
- Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Xu Liu
- Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
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Diab M, Wazni OM, Saliba WI, Tarakji KG, Ballout JA, Hutt E, Rickard J, Baranowski B, Tchou P, Bhargava M, Chung M, Varma N, Martin DO, Dresing T, Callahan T, Cantillon D, Kanj M, Hussein AA. Ablation of Atrial Fibrillation Without Left Atrial Appendage Imaging in Patients Treated With Direct Oral Anticoagulants. Circ Arrhythm Electrophysiol 2020; 13:e008301. [DOI: 10.1161/circep.119.008301] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background:
Many centers continue to routinely perform transesophageal echocardiograms before atrial fibrillation (AF) ablation procedures in patients treated with direct oral anticoagulants (DOACs). One study suggested that the procedures could be done without transesophageal echocardiogram but used intracardiac echocardiography imaging of the appendage from the right ventricular outflow. This study aimed to assess the safety of ablation for AF without transesophageal echocardiogram screening or intracardiac echocardiography imaging of the appendage in DOAC compliant patients.
Methods:
All patients undergoing AF ablation at the Cleveland Clinic (2011–2018) were enrolled in a prospectively maintained data registry. All consecutive patients presenting with AF or atrial flutter on DOAC were included. Periprocedural thromboembolic complications were assessed.
Results:
A total of 900 patients were included. Their median CHA
2
DS
2
-VASc score was 2 (interquartile range 1–3). All were on DOACs (333 rivaroxaban, 285 dabigatran, 281 apixaban, and 1 edoxaban). Thromboembolic complications occurred in 4 patients (0.3%): 2 ischemic strokes, 1 transient ischemic attack without residual deficit, and 1 splenic infarct; all with no further complications. Bleeding complications occurred in 5 patients (0.4%): 2 pericardial effusions (1 intraoperative, 1 after 30 days, both drained), 3 groin hematomas (1 of them due to needing heparin for venous thrombosis, none required interventions). No patients required emergent surgeries.
Conclusions:
In DOAC compliant patients who present for ablation in AF/atrial flutter, the procedures could be performed without transesophageal echocardiogram screening or intracardiac echocardiography imaging of the appendage; with low risk of complications.
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Affiliation(s)
- Mohamed Diab
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Oussama M. Wazni
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Walid I. Saliba
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Khaldoun G. Tarakji
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Jad A. Ballout
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Erika Hutt
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, OH
| | - John Rickard
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Bryan Baranowski
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Patrick Tchou
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Mandeep Bhargava
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Mina Chung
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Niraj Varma
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, OH
| | - David O. Martin
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Thomas Dresing
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Thomas Callahan
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Daniel Cantillon
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Mohamed Kanj
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Ayman A. Hussein
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, OH
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9
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Patel K, Natale A, Yang R, Trivedi C, Romero J, Briceno D, Mohanty S, Alviz I, Natale V, Sanchez J, Della Rocca DG, Tarantino N, Zhang XD, Mohanty P, Horton R, Burkhardt D, Gopinathannair R, Joseph Gallinghouse G, Lakkireddy D, Di Biase L. Is transesophageal echocardiography necessary in patients undergoing ablation of atrial fibrillation on an uninterrupted direct oral anticoagulant regimen? Results from a prospective multicenter registry. Heart Rhythm 2020; 17:2093-2099. [PMID: 32681991 DOI: 10.1016/j.hrthm.2020.07.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/06/2020] [Accepted: 07/12/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Thromboembolic stroke is a rare but devastating consequence of atrial fibrillation (AF) ablation. Transesophageal echocardiography (TEE) is recommended to rule out left atrial appendage thrombus; however, its use is variable. OBJECTIVE The purpose of this study was to assess whether TEE is mandatory in patients undergoing AF ablation on uninterrupted direct oral anticoagulants (DOACs). METHODS Data from our prospective multicenter registry of patients with AF undergoing radiofrequency catheter ablation on uninterrupted DOACs were analyzed. All the included patients were on anticoagulation for at least 4 weeks before ablation. All AF ablation procedures were performed under intracardiac echocardiography guidance. Before transseptal puncture, heparin bolus was administered, followed by continuous infusion, with a target activated clotting time of >300 seconds. RESULTS A total of 6186 patients (3180 on apixaban [51.4%], 2528 on rivaroxaban [40.9%], 404 on dabigatran [6.5%], and 74 on edoxaban [1.2%]) were analyzed. The mean age of the study population was 69.4 ± 10.3 years; 4194 patients (67.8%) were male, and 5120 patients (82.8%) had persistent and long-standing persistent AF. The mean CHA2DS2-VASc score was 2.86 ± 1.58; the mean CHADS2 score was 1.65 ± 1.14. Intracardiac echocardiography ruled out left atrial appendage and left atrial thrombi in all patients and revealed "smoke" in 1672 patients (27.03%). Transient ischemic attack was noted in 1 patient with long-standing persistent AF in the setting of a missed dose of rivaroxaban before ablation. CONCLUSION Our study showed that performing AF ablation in patients on uninterrupted DOACs without TEE is safe and feasible in high stroke risk patients. Elimination of routine preablation TEE would have significant economic and clinical implications.
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Affiliation(s)
- Kavisha Patel
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Andrea Natale
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Ruike Yang
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; Department of Cardiology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Chintan Trivedi
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Jorge Romero
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - David Briceno
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Sanghamitra Mohanty
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Isabella Alviz
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Veronica Natale
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Javier Sanchez
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Domenico G Della Rocca
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Nicola Tarantino
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Xiao-Dong Zhang
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Prasant Mohanty
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Rodney Horton
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - David Burkhardt
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Rakesh Gopinathannair
- Department of Electrophysiology, Kansas City Heart Rhythm Institute, Overland Park, Kansas
| | - G Joseph Gallinghouse
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Dhanunjaya Lakkireddy
- Department of Electrophysiology, Kansas City Heart Rhythm Institute, Overland Park, Kansas
| | - Luigi Di Biase
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas.
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10
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Left Ventricular Ejection Fraction Is Associated with the Risk of Thrombus in the Left Atrial Appendage in Patients with Atrial Fibrillation. Cardiovasc Ther 2020; 2020:3501749. [PMID: 32411299 PMCID: PMC7201491 DOI: 10.1155/2020/3501749] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 02/21/2020] [Accepted: 03/25/2020] [Indexed: 11/24/2022] Open
Abstract
Introduction Atrial fibrillation (AF) is associated with high risk of ischemic stroke. The most frequent thrombus location in AF is the left atrial appendage (LAA). Transthoracic echocardiography (TTE) is a basic diagnostic examination in patients (pts) with AF. Objectives To analyse the relations between basic echocardiographic features, well-established stroke risk factors, type of AF, and anticoagulation therapy with the incidence of left atrial appendage thrombus (LAAT). Patients and Methods. The study group consisted of 768 pts with AF (mean age, 63 years), admitted to three high-reference cardiology departments. Five hundred and twenty-three pts were treated with non-vitamin K antagonist oral anticoagulants (NOACs) and 227 (30%) with vitamin K antagonists (VKAs). The subjects underwent TTE and transesophageal echocardiography (TEE) before cardioversion or ablation. Results LAAT was significantly more frequent in pts with reduced left ventricular ejection fraction (LVEF): in 10.6% (7 pts) with LVEF < 40% and in 9.0% (9 pts) with LVEF 40-49%, while only in 5.5% (33 pts) with LVEF > 50%. Compared to pts without LAAT, those with LAAT presented with lower LVEF and higher left atrial diameter (LAD). Multivariate logistic regression revealed the following variables as independent predictors of LAAT: previous bleeding, treatment with VKA, and LVEF. Conclusion LAAT is related to lower LVEF and higher LAD. LVEF is one of the independent predictors of LAAT. Even in the case of adequate anticoagulant therapy, it might be prudent to consider TEE before cardioversion or ablation in patients with low LVEF and LA enlargement, especially in the coexistence of other thromboembolic risk factors.
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11
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Aksu T, Yalin K, Guler TE, Bozyel S, Heeger CH, Tilz RR. Acute Procedural Complications of Cryoballoon Ablation: A Comprehensive Review. J Atr Fibrillation 2019; 12:2208. [PMID: 32435335 DOI: 10.4022/jafib.2208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 08/14/2019] [Accepted: 08/26/2019] [Indexed: 12/15/2022]
Abstract
Catheter ablation is increasingly performed for treatment of atrial fibrillation (AF). Balloon based procedures have been developed aiming at safer, easier and more effective treatment as compared to point to point ablation. In the present review article, we aimed to discuss acute procedural complications of cryoballoon ablation.
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Affiliation(s)
- Tolga Aksu
- Department of Cardiology, University of Health Sciences, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
| | - Kivanc Yalin
- Istanbul University- Cerrahpasa, Faculty of Medicine, Department of Cardiology, Istanbul, Turkey.,University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Tumer Erdem Guler
- Department of Cardiology, University of Health Sciences, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
| | - Serdar Bozyel
- Department of Cardiology, University of Health Sciences, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey
| | - Christian-H Heeger
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Roland R Tilz
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine), University Hospital Schleswig-Holstein, Lübeck, Germany
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12
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Kosmalska K, Rzyman M, Miękus P, Gilis-Malinowska N, Nowak R, Fijałkowski M. Usefulness of transesophageal echocardiography before cardioversion in atrial arrhythmias. Cardiol J 2019; 28:101-109. [PMID: 31225630 DOI: 10.5603/cj.a2019.0056] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 05/27/2019] [Accepted: 05/28/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Although many thromboembolism risk factors are well defined, formation of thrombus or dense spontaneous contrast (sludge) in the left atrium remains enigmatic and confounding. Exclusion of the thrombus is extremely important with respect to planned reversal of sinus rhythm. Data regarding the routine transesophagal echocardiography (TEE) before cardioversion are inconclusive. The authors focused on analyzing the usefulness of TEE before cardioversion by assessment of factors influencing the risk of thrombus and/or dense spontaneous echo contrast with the intention of extending indications for TEE in the group with a high risk of thrombus or to forgo TEE in the low risk group. METHODS Two hundred sixty-nine consecutive patients with persistent (> 48 h) atrial fibrillation or atrial flutter, in whom a direct current cardioversion was planned, were undergoing TEE for the detection of the left atrial thrombus or dense spontaneous echo contrast. Additional clinical and echocardiographic data were collected. The relationship between both thrombus and dense spontaneous echo contrast and covariates was analyzed with the use of binary logistic regression. RESULTS Left atrium (LA) appendage (LAA) thrombus and/or sludge were detected in 79 (29%) patients. Signs of dementia in mini-mental state examination (hazard ratio [HR]: 1.16; p = 0.005), low velocities in LAA (HR: 3.38; p = 0.032); presence of spontaneous echo contrast in LA (HR: 3.38; p = 0,003) consecutive episode of AF (HR: 2.27; p = 0,046); longer duration of atrial fibrillation (HR: 1.009; p = 0.022); were significant predictors of thrombus and/or dense spontaneous echo contrast. None of the patients with a CHA2DS2VASc score ≤ 1 had thrombus or sludge in the LAA. Among patients with a CHA2DS2VASc score > 1, the prevalence of thrombus or sludge in LAA was independent of the CHA2DS2VASc score value. CONCLUSIONS Amongst many factors, including an established as risk for thromboembolism only a few of them increased the risk for the presence of thrombus in LAA: low velocities in LAA, presence of spontaneous echo contrast, longer duration of arrhythmia, consecutive (not first) arrhythmia episode and signs of dementia from a mini-mental state examination questionnaire. It was believed that there could be a need for an extension of indications of TEE in vast majority of the patients with atrial arrhythmias, due most often to an unpredictable occurrence of thrombus and potentially disastrous thromboembolism. The only exception could have been the group of the patients with a CHA2DS2VASc score ≤ 1.
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Affiliation(s)
| | - Małgorzata Rzyman
- St Vincent Hospital in Gdynia, Wójta Radtkego1, 81-348 Gdynia, Poland
| | - Paweł Miękus
- St Vincent Hospital in Gdynia, Wójta Radtkego1, 81-348 Gdynia, Poland
| | - Natasza Gilis-Malinowska
- First Department of Cardiology, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Radosław Nowak
- First Department of Cardiology, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Marcin Fijałkowski
- First Department of Cardiology, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
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13
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Whiteside HL, Nagabandi A, Brown K, Ayyala DN, Sharma GK. Prevalence and clinical characteristics associated with left atrial thrombus detection: Apixaban. World J Cardiol 2019; 11:84-93. [PMID: 30820278 PMCID: PMC6391620 DOI: 10.4330/wjc.v11.i2.84] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/18/2018] [Accepted: 01/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The prevalence of left atrial appendage (LAA) thrombus detection by transesophageal echocardiogram (TEE) in patients with non-valvular atrial fibrillation (AF) anticoagulated with apixaban is not well defined and identification of additional risk factors may help guide the selection process for pre-procedural TEE. The purpose of our study was to retrospectively analyze the prevalence of LAA thrombus detection by TEE in patients continuously anticoagulated with apixaban for ≥ 4 wk and evaluate for any cardiac risk factors or echocardiographic characteristics which may serve as predictors of thrombus formation.
AIM To retrospectively analyze the prevalence of LAA thrombus detection by TEE in patients continuously anticoagulated with apixaban.
METHODS Clinical and echocardiographic data for 820 consecutive patients with AF undergoing TEE at Augusta University Medical Center over a four-year period were retrospectively analyzed. All patients (apixaban: 226) with non-valvular AF and documented compliance with apixaban for ≥ 4 wk prior to index TEE were included.
RESULTS Following ≥ 4 wk of continuous anticoagulation with apixaban, the prevalence of LAA thrombus and LAA thrombus/dense spontaneous echocardiographic contrast was 3.1% and 6.6%, respectively. Persistent AF, left ventricular ejection fraction < 30%, severe LA dilation, and reduced LAA velocity were associated with thrombus formation. Following multivariate logistic regression, persistent AF (OR: 7.427; 95%CI: 1.02 to 53.92; P = 0.0474), and reduced LAA velocity (OR: 1.086; 95%CI: 1.010 to 1.187; P = 0.0489) were identified as independent predictors of LAA thrombus. No Thrombi were detected in patients with a CHA2DS2-VASc score ≤ 1.
CONCLUSION Among patients with non-valvular AF and ≥ 4 wk of anticoagulation with apixaban, the prevalence of LAA thrombus detected by TEE was 3.1%. This suggests that continuous therapy with apixaban does not completely eliminate the risk of LAA thrombus and that TEE prior to cardioversion or catheter ablation may be of benefit in patients with multiple risk factors.
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Affiliation(s)
- Hoyle L Whiteside
- Division of Internal Medicine, Medical College of Georgia at Augusta University, Augusta, GA 30912, United States
| | - Arun Nagabandi
- Division of Cardiology, Medical College of Georgia at Augusta University, Augusta, GA 30912, United States
| | - Kristen Brown
- Division of Internal Medicine, Medical College of Georgia at Augusta University, Augusta, GA 30912, United States
| | - Deepak N Ayyala
- Division of Biostatistics and Data Science, Department of Population Health Sciences, Medical College of Georgia at Augusta University, Augusta, GA 30912, United States
| | - Gyanendra K Sharma
- Division of Cardiology, Medical College of Georgia at Augusta University, Augusta, GA 30912, United States
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14
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Milhem A, Ingrand P, Tréguer F, Cesari O, Da Costa A, Pavin D, Rivat P, Badenco N, Abbey S, Zannad N, Winum PF, Mansourati J, Maury P, Bader H, Savouré A, Sacher F, Andronache M, Allix-Béguec C, De Chillou C, Anselme F, Al Arnaout A, Amara W, Amelot M, Bars C, Becoulet L, Bru P, Chevalier P, Darmon JP, Deharo JC, Dompnier A, Duplantier-Duchene C, Extramiana F, Faugier JP, Guenancia C, Horvilleur J, Jourda F, Laurent G, Lellouche N, Magnin Poull I, Piot O, Roux A, Saludas Y, Seitz J, Taieb J. Exclusion of Intra-Atrial Thrombus Diagnosis Using D-Dimer Assay Before Catheter Ablation of Atrial Fibrillation. JACC Clin Electrophysiol 2019; 5:223-230. [DOI: 10.1016/j.jacep.2018.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/20/2018] [Accepted: 09/11/2018] [Indexed: 11/25/2022]
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15
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Harada M, Koshikawa M, Motoike Y, Ichikawa T, Sugimoto K, Watanabe E, Ozaki Y. Left Atrial Appendage Thrombus Prior to Atrial Fibrillation Ablation in the Era of Direct Oral Anticoagulants. Circ J 2018; 82:2715-2721. [PMID: 30101809 DOI: 10.1253/circj.cj-18-0398] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND In atrial fibrillation (AF) patients, the effect of direct oral anticoagulant (DOACs) therapy on the incidence of left atrial appendage thrombus (LAT) remains poorly investigated. This study examined the prevalence and risk factors of LAT in AF patients on DOACs undergoing catheter ablation, and sought an anticoagulation strategy for LAT. METHODS AND RESULTS In 407 AF patients on DOACs, transesophageal echocardiography (TEE) was performed 1 day before ablation. If patients had LAT, initial DOACs were switched to dabigatran (300 mg) or warfarin based on their renal function; TEE was repeated after treatment for ≥4 weeks. LAT was detected in 18 patients (4.4%). The prevalence of persistent AF and low-dose treatment/inappropriate dose reduction of DOACs, CHADS2/CHA2DS2-VASc scores, serum N-terminal pro-brain natriuretic peptide levels, and LA dimension/LA volume index significantly increased in patients with LAT vs. those without LAT. AF rhythm on TEE and spontaneous echo contrast also increased in patients with LAT; LA appendage flow velocity decreased. In the multivariate analysis, persistent AF and inappropriately reduced DOAC dose were risk factors for LAT. On repeat TEE, LAT had disappeared in 13 of 16 patients treated with dabigatran and in 2 of 2 patients treated with warfarin. CONCLUSIONS DOACs still carry a finite risk of LAT in AF patients. Inappropriately reduced DOAC dose should be avoided to minimize the thromboembolic risk. Regular-dose dabigatran may have therapeutic efficacy against LAT.
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Affiliation(s)
| | | | - Yuji Motoike
- Department of Cardiology, Fujita Health University
| | | | - Kunihiko Sugimoto
- Department of Joint Research Laboratory of Clinical Medicine, Fujita Health University Hospital
| | | | - Yukio Ozaki
- Department of Cardiology, Fujita Health University
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16
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Yao Y, Shang MS, Gao LJ, Zhao JH, Yang XH, Liu T, Tang RB, Jiang CX, Long DY, Ning M, Zhu H, Lv Q, Hu R, Du X, Dong JZ. Elevated homocysteine increases the risk of left atrial/left atrial appendage thrombus in non-valvular atrial fibrillation with low CHA2DS2-VASc score. Europace 2018; 20:1093-1098. [PMID: 28637244 DOI: 10.1093/europace/eux189] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 05/10/2017] [Indexed: 12/20/2022] Open
Abstract
AIMS To assess the association and the predictive value of plasma homocysteine (Hcy) levels with LA/LAA thrombus in non-valvular Atrial fibrillation (AF) patients with low CHA2DS2-VASc score. METHODS AND RESULTS Eight hundred and eighty-eight consecutive patients in non-valvular AF with CHA2DS2-VASc score of 0 and 1 were enrolled. All patients routinely underwent transthoracic echocardiography and transoesophageal echocardiography. A total of thirty-two patients had LA/LAA thrombus. Compared with patients without LA/LAA thrombus, plasma Hcy levels were significantly higher in patients with LA/LAA thrombus (16.5 ± 4.8 mmol/L vs. 13.4 ± 4.1 mmol/L, P = 0.009). In multivariate analysis, Hcy was independently associated with LA/LAA thrombus (OR 1.048, 95% CI 1.007-1.090, P = 0.022). Hcy demonstrated a significant predictive value with area under the curve of 0.722 (95% CI 0.662-0.781, P < 0.001). The optimal cut-off point for Hcy predicting LA/LAA thrombus was 13.5 mmol/L (sensitivity 67%, specificity 65%). Patients with Hcy ≥13.5 mmol/L had higher prevalence of LA/LAA thrombus compared with those with Hcy <13.5 mmol/L (6.1% vs. 2.1%, P < 0.001). Elevated Hcy significantly increased the risk of LA/LAA thrombus in patients with CHA2DS2-VASc score of 0 and 1 (OR 11.789, 95% CI 1.437-96.746, P = 0.022; OR 2.256, 95% CI 1.007-5.155, P = 0.048, respectively). CONCLUSION Elevated plasma Hcy increases the risk of LA/LAA thrombus in non-valvular AF patients with low CHA2DS2-VASc score, thus it should be taken into account in prediction of thromboembolism.
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Affiliation(s)
- Yan Yao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, People's Republic of China
| | - Mei-Sheng Shang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, People's Republic of China
| | - Li-Jian Gao
- Center for coronary heart disease, Department of Cardiology, Cardiovascular Institute & Fuwai Hospital, CAMS & PUMC, National Center for Heart Disease, No 167 Beilishi Road, Xicheng District, Beijing, P. R. China
| | - Jing-Hua Zhao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, People's Republic of China
| | - Xiao-Hui Yang
- Beijing Municipal Office for Cardiovascular Disease Prevention & Control, Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, P. R. China
| | - Tong Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, People's Republic of China
| | - Ri-Bo Tang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, People's Republic of China
| | - Chen-Xi Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, People's Republic of China
| | - De-Yong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, People's Republic of China
| | - Man Ning
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, People's Republic of China
| | - Hui Zhu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, People's Republic of China
| | - Qiang Lv
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, People's Republic of China
| | - Rong Hu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, People's Republic of China
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, People's Republic of China
| | - Jian-Zeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No 2 Anzhen Road, Chaoyang District, Beijing, People's Republic of China
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17
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Tzou WS. Pre-Ablation Transesophageal Echocardiography in the Era of Minimally Interrupted or Uninterrupted Anticoagulation: Performance Does Not Guarantee Future Results. JACC Clin Electrophysiol 2018; 3:337-340. [PMID: 29759445 DOI: 10.1016/j.jacep.2016.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 11/03/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Wendy S Tzou
- Section of Cardiac Electrophysiology, University of Colorado, Aurora, Colorado.
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18
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Left atrial thrombus and dense spontaneous echocardiographic contrast in patients on continuous direct oral anticoagulant therapy undergoing catheter ablation of atrial fibrillation: Comparison of dabigatran, rivaroxaban, and apixaban. Heart Rhythm 2018; 15:496-502. [DOI: 10.1016/j.hrthm.2017.12.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Indexed: 12/19/2022]
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19
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Zhan Y, Joza J, Al Rawahi M, Barbosa RS, Samuel M, Bernier M, Huynh T, Thanassoulis G, Essebag V. Assessment and Management of the Left Atrial Appendage Thrombus in Patients With Nonvalvular Atrial Fibrillation. Can J Cardiol 2018; 34:252-261. [DOI: 10.1016/j.cjca.2017.12.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 12/04/2017] [Accepted: 12/11/2017] [Indexed: 01/14/2023] Open
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20
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Atkinson C, Hinton J, Gaisie EB, Yue AM, Roberts PR, Rakhit DJ, Shah BN. Use of the CHA 2DS 2VASc score to reduce utilisation of transoesophageal echocardiography prior to ablation for atrial fibrillation. Echo Res Pract 2017; 4:45-52. [PMID: 28864464 PMCID: PMC5633057 DOI: 10.1530/erp-17-0042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 08/17/2017] [Indexed: 01/15/2023] Open
Abstract
Transoesophageal echocardiography (TOE) is frequently performed prior to atrial fibrillation (AF) ablation to exclude left atrial appendage (LAA) thrombus. However, patients undergoing AF ablation are usually anticoagulated, thus making the presence of thrombus unlikely in most cases. This study aimed to determine whether the CHA2DS2VASc scoring system can be used to identify patients that do not require TOE prior to AF ablation. In this single-centre retrospective study, local institutional and primary care databases and electronic patient records were searched to identify patients that had undergone TOE prior to AF ablation. Patient demographics, CHA2DS2VASc score, TOE findings and anticoagulation status were collected for analysis. Over a 7-year period (2008–2014), 332 patients (age 57 ± 10 years; 74% male) underwent TOE prior to proposed AF ablation. CHA2DS2VASc scores of 0, 1, 2 and >2 were found in 39, 34, 15 and 12% of patients, respectively. The prevalence of LAA thrombus was 0.6% (2 patients) and these 2 patients had risk scores of 2 and 4. No patients with a score of 0 or 1 had LAA thrombus. Patients that are classed as low risk by the CHA2DS2VASc score do not require a pre-ablation TOE to screen for LAA thrombus provided they are adequately anticoagulated. This would lead to a significant reduction in health care expenditures by reducing unnecessary TOE requests and thereby improve patient experience.
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Affiliation(s)
- Charlotte Atkinson
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Jonathan Hinton
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Edmund B Gaisie
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Arthur M Yue
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Paul R Roberts
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Dhrubo J Rakhit
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Benoy N Shah
- Department of Cardiology, University Hospital Southampton, Southampton, UK
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Laish-Farkash A, Suleiman M. Evaluation of left atrial thrombus prior to catheter ablation of atrial fibrillation: Is it time for an individualized approach? J Cardiovasc Electrophysiol 2017; 28:1137-1139. [DOI: 10.1111/jce.13303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 07/18/2017] [Accepted: 07/19/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Avishag Laish-Farkash
- Electrophysiology and Pacing Unit, Department of Cardiology; Rambam Health Care Campus; Haifa Israel
| | - Mahmoud Suleiman
- Electrophysiology and Pacing Unit, Department of Cardiology; Rambam Health Care Campus; Haifa Israel
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22
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Gunawardene MA, Dickow J, Schaeffer BN, Akbulak RÖ, Lemoine MD, Nührich JM, Jularic M, Sinning C, Eickholt C, Meyer C, Moser JM, Hoffmann BA, Willems S. Risk stratification of patients with left atrial appendage thrombus prior to catheter ablation of atrial fibrillation: An approach towards an individualized use of transesophageal echocardiography. J Cardiovasc Electrophysiol 2017. [DOI: 10.1111/jce.13279] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Melanie A. Gunawardene
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Jannis Dickow
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Benjamin N. Schaeffer
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Ruken Ö. Akbulak
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Marc D. Lemoine
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Jana M. Nührich
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Mario Jularic
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Christoph Sinning
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Christian Eickholt
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Christian Meyer
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Julia M. Moser
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Boris A. Hoffmann
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
| | - Stephan Willems
- Department of Cardiology - Electrophysiology, University Heart Center; University Hospital Hamburg Eppendorf; Hamburg Germany
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23
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Usefulness of multidetector computed tomography before and after pulmonary vein isolation. RADIOLOGIA 2017. [DOI: 10.1016/j.rxeng.2017.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Briceño DF, Madan N, Romero J, Londoño A, Villablanca PA, Natale A, Di Biase L. Thromboembolic and bleeding risks in patients undergoing atrial fibrillation ablation: oral anticoagulation perspectives. Expert Opin Drug Saf 2017; 16:769-777. [PMID: 28475380 DOI: 10.1080/14740338.2017.1325867] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Atrial fibrillation (AF) is a cause of significant morbidity and mortality. Catheter ablation for AF (CAAF) has emerged as an effective treatment option of rhythm control for patients with symptomatic AF. However, the risk of thromboembolism and bleeding in the periprocedural period represent a worrisome complication of this therapy. The reported incidence of thromboembolic and bleeding events associated with CAAF varies from 0.9% to 5% depending on the CAAF strategy and the anticoagulation regimen used in the periprocedural period. Areas covered: The different anticoagulation regimens used prior to, during, and after CAAF to minimize the risk of thromboembolic and bleeding events are reviewed. The use of uninterrupted oral anticoagulation and appropriate heparin dosing to achieve safe activated clotting time levels are also detailed. A comprehensive approach with assessment of individual risk for thromboembolic and bleeding complications, and understanding the pharmacokinetics of the anticoagulant agents available is also reviewed. Expert opinion: The key advances done in the periprocedural anticoagulation field include the use of uninterrupted anticoagulation strategies in patients undergoing AF ablation and efforts to simplify the selection of patients who need LAA thrombus screening prior to ablation.
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Affiliation(s)
- David F Briceño
- a Division of Cardiovascular Disease , Montefiore Medical Center, Albert Einstein College of Medicine , Bronx , NY , USA
| | - Nidhi Madan
- a Division of Cardiovascular Disease , Montefiore Medical Center, Albert Einstein College of Medicine , Bronx , NY , USA
| | - Jorge Romero
- a Division of Cardiovascular Disease , Montefiore Medical Center, Albert Einstein College of Medicine , Bronx , NY , USA
| | - Alejandra Londoño
- a Division of Cardiovascular Disease , Montefiore Medical Center, Albert Einstein College of Medicine , Bronx , NY , USA
| | - Pedro A Villablanca
- a Division of Cardiovascular Disease , Montefiore Medical Center, Albert Einstein College of Medicine , Bronx , NY , USA
| | - Andrea Natale
- a Division of Cardiovascular Disease , Montefiore Medical Center, Albert Einstein College of Medicine , Bronx , NY , USA.,b Texas Cardiac Arrhythmia Institute, Heart & Vascular Department , St. David's Medical Center , Austin , TX , USA
| | - Luigi Di Biase
- a Division of Cardiovascular Disease , Montefiore Medical Center, Albert Einstein College of Medicine , Bronx , NY , USA.,b Texas Cardiac Arrhythmia Institute, Heart & Vascular Department , St. David's Medical Center , Austin , TX , USA
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25
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Revilla Orodea A, Sánchez Lite I, Gallego Beuth JC, Sevilla Ruiz T, Sandín Fuentes MG, Amat Santos IJ, San Román Calvar JA. Usefulness of multidetector computed tomography before and after pulmonary vein isolation. RADIOLOGIA 2017; 59:321-328. [PMID: 28457532 DOI: 10.1016/j.rx.2017.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 02/20/2017] [Accepted: 03/11/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To analyze the usefulness of multidetector computed tomography (MDCT) in the preprocedural evaluation and follow-up of patients undergoing radiofrequency ablation of pulmonary veins and the impact of the MDCT findings on the approach to treatment. METHOD We retrospectively analyzed 92 consecutive MDCT studies done in 80 patients between January 2011 and June 2013; 70 (76%) studies were done before a first ablation procedure and 22 (24%) were done in patients who had undergone an ablation procedure. RESULTS Findings were useful in 34% of the patients who underwent MDCT before the first ablation procedure and in 68% of the studies done after a procedure. The incidence of stroke associated with the ablation procedure was 3%, similar to the incidence recorded in our center before we started to use MDCT to evaluate the anatomy of the left atrium. All symptomatic patients had some pulmonary vein stenosis, and 80% had significant stenosis. Furthermore, the stenoses progressed very rapidly; treatment with balloon angioplasty was associated with early restenosis. Stenting was an alternative in cases of failed angioplasty. CONCLUSION In the preprocedural evaluation and postprocedural follow-up of patients undergoing pulmonary vein isolation, MDCT is useful for guiding treatment and detecting complications.
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Affiliation(s)
- Ana Revilla Orodea
- Unidad de Imagen Cardiaca, Servicio de Cardiología Hospital Clínico Universitario, Valladolid, España; CIBER de Enfermedades Cardiovasculares (CIBERCV), España.
| | | | | | - Teresa Sevilla Ruiz
- Unidad de Imagen Cardiaca, Servicio de Cardiología Hospital Clínico Universitario, Valladolid, España; CIBER de Enfermedades Cardiovasculares (CIBERCV), España
| | | | - Ignacio Jesús Amat Santos
- CIBER de Enfermedades Cardiovasculares (CIBERCV), España; Servicio de Cardiología, Hospital Clínico Universitario, Valladolid, España
| | - José Alberto San Román Calvar
- CIBER de Enfermedades Cardiovasculares (CIBERCV), España; Servicio de Cardiología, Hospital Clínico Universitario, Valladolid, España
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26
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Balouch M, Gucuk Ipek E, Chrispin J, Bajwa RJ, Zghaib T, Berger RD, Ashikaga H, Calkins H, Nazarian S, Marine JE, Spragg DD. Trends in Transesophageal Echocardiography Use, Findings, and Clinical Outcomes in the Era of Minimally Interrupted Anticoagulation for Atrial Fibrillation Ablation. JACC Clin Electrophysiol 2017; 3:329-336. [DOI: 10.1016/j.jacep.2016.09.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 09/06/2016] [Accepted: 09/15/2016] [Indexed: 12/11/2022]
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27
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Tarnowski D, Poitz DM, Plichta L, Heidrich FM, Wiedemann S, Ruf T, Mierke J, Löhn T, Jellinghaus S, Strasser RH, Ibrahim K, Pfluecke C. Comparison of diverse platelet activation markers as indicators for left atrial thrombus in atrial fibrillation. Platelets 2017; 29:41-47. [PMID: 28287031 DOI: 10.1080/09537104.2017.1293805] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Atrial fibrillation (AF) is well known for being a major risk factor of thromboembolic stroke. We could recently demonstrate an association of monocyte-platelet aggregates (MPAs) with the degree of thrombogenicity in patients with AF. This study investigated platelet activation markers, as potential biomarkers for the presence of left atrial (LA) thrombus in patients with AF. One hundred and eight patients with symptomatic AF underwent transesophageal echocardiography (TEE) before scheduled cardioversion or pulmonary vein isolation. In order to determine the content of MPAs by flow-cytometric quantification analyses, blood was drawn on the day of TEE. The soluble CD40 Ligand (sCD40L) and soluble P-selectin (sP-selectin) were obtained by Cytometric Bead Arrays (CBA). D-dimer levels were detected by quantitative immunological determination of fibrin degradation products. Clinical, laboratory, and echocardiographic standard parameters were obtained from all patients, including the determination of the flow in the left atrial appendage (LAA). Patients with detected LA thrombus (n = 28) compared with patients without thrombus (n = 80) showed an increased number of common risk factors, such as age, diabetes, heart failure, and coronary artery disease (CAD). The presence of LA thrombus was associated with significantly increased levels of MPAs (147 ± 12 vs. 304 ± 29 per µl; p < 0.00), sCD40L (106.3 ± 31.0 vs. 33.5 ± 2.1 pg/ml, p = 0.027), and D-dimer (0.13 ± 0.02 vs. 0.69 ± 0.21 mg FEU/l, p = 0.015). In contrast, sP-selectin showed no association with LA thrombus. A multivariate regression analysis showed that MPAs, sCD40L as well as D-dimers were independent indicators for the existence of LA thrombus. MPAs above 170 cells/µl indicated LA thrombus with a high sensitivity of 93% and a specificity of 73% (OR 62, 95% CI. 6.9-557.2, p < 0.001) in patients with AF, whereas the D-dimer lost their quality as independent indicator by using the conventional cut-off of 0.5 mg/l within the regression analysis. MPAs, as well as the D-dimer, correlated significantly negatively with the flow in the LAA measured during TEE. The content of MPAs, sCD40L, and D-dimer, but not sP-selectin showed an increased dependence on LA thrombus in patients with AF. In our study group, MPAs showed the best diagnostic test accuracy of the compared platelet markers. The different results of the examined platelet activation markers could be an indication of diverse mechanisms of LA thrombus in AF. Further studies should evaluate whether determination of MPAs in clinical routine may suffice to indicate the presence of LA thrombus in patients with AF.
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Affiliation(s)
- Daniel Tarnowski
- a Technische Universität Dresden , Heart Center Dresden, University Hospital, Dresden , Germany
| | - David M Poitz
- a Technische Universität Dresden , Heart Center Dresden, University Hospital, Dresden , Germany
| | - Lina Plichta
- a Technische Universität Dresden , Heart Center Dresden, University Hospital, Dresden , Germany
| | - Felix M Heidrich
- a Technische Universität Dresden , Heart Center Dresden, University Hospital, Dresden , Germany
| | - Stephan Wiedemann
- a Technische Universität Dresden , Heart Center Dresden, University Hospital, Dresden , Germany
| | - Tobias Ruf
- a Technische Universität Dresden , Heart Center Dresden, University Hospital, Dresden , Germany
| | - Johannes Mierke
- a Technische Universität Dresden , Heart Center Dresden, University Hospital, Dresden , Germany
| | - Tobias Löhn
- a Technische Universität Dresden , Heart Center Dresden, University Hospital, Dresden , Germany
| | - Stefanie Jellinghaus
- a Technische Universität Dresden , Heart Center Dresden, University Hospital, Dresden , Germany
| | - Ruth H Strasser
- a Technische Universität Dresden , Heart Center Dresden, University Hospital, Dresden , Germany
| | - Karim Ibrahim
- a Technische Universität Dresden , Heart Center Dresden, University Hospital, Dresden , Germany
| | - Christian Pfluecke
- a Technische Universität Dresden , Heart Center Dresden, University Hospital, Dresden , Germany
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28
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Briceno DF, Madan N, Villablanca PA, Lupercio F, Cyrille N, Ramakrishna H, Di Biase L. Periprocedural Anticoagulation for Catheter Ablation of Atrial Fibrillation: Practical Implications for Perioperative Management. J Cardiothorac Vasc Anesth 2017; 31:1519-1526. [PMID: 29335195 DOI: 10.1053/j.jvca.2016.09.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Indexed: 12/12/2022]
Affiliation(s)
- David F Briceno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Nidhi Madan
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Pedro A Villablanca
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Florentino Lupercio
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Nicole Cyrille
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic in Arizona, Phoenix, AZ.
| | - Luigi Di Biase
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY; Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX; Department of Biomedical Engineering, University of Texas at Austin, Austin, TX; Department of Cardiology, University of Foggia, Foggia, Italy
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29
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Di Biase L, Briceno DF, Trivedi C, Mohanty S, Gianni C, Burkhardt JD, Mohanty P, Bai R, Gunda S, Horton R, Bailey S, Sanchez JE, Al-Ahmad A, Hranitzky P, Gallinghouse GJ, Reddy YM, Zagrodzky J, Hongo R, Beheiry S, Lakkireddy D, Natale A. Is transesophageal echocardiogram mandatory in patients undergoing ablation of atrial fibrillation with uninterrupted novel oral anticoagulants? Results from a prospective multicenter registry. Heart Rhythm 2016; 13:1197-202. [DOI: 10.1016/j.hrthm.2016.03.024] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Indexed: 01/09/2023]
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31
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Sanchis L, Prat S, Sitges M. Cardiovascular Imaging in the Electrophysiology Laboratory. ACTA ACUST UNITED AC 2016; 69:595-605. [PMID: 27107802 DOI: 10.1016/j.rec.2016.01.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 01/09/2016] [Indexed: 10/21/2022]
Abstract
In recent years, rapid technological advances have allowed the development of new electrophysiological procedures that would not have been possible without the parallel development of imaging techniques used to plan and guide these procedures and monitor their outcomes. Ablation of atrial fibrillation is among the interventions with the greatest need for imaging support. Echocardiography allows the appropriate selection of patients and the detection of thrombi that would contraindicate the intervention; cardiac magnetic resonance imaging and computed tomography are also essential in planning this procedure, by allowing a detailed anatomical study of the pulmonary veins. In addition, in cardiac resynchronization therapy, echocardiography plays a central role in both patient selection and, later, in device adjustment and in assessing the effectiveness of the technique. More recently, ablation of ventricular tachycardias has been established as a treatment option; this would not be possible without planning using an imaging study such as cardiac magnetic resonance imaging of myocardial scarring.
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Affiliation(s)
- Laura Sanchis
- Instituto Cardiovascular, Hospital Clínic, IDIBAPS, Universidad de Barcelona, IDIBAPS-Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Susanna Prat
- Instituto Cardiovascular, Hospital Clínic, IDIBAPS, Universidad de Barcelona, IDIBAPS-Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Marta Sitges
- Instituto Cardiovascular, Hospital Clínic, IDIBAPS, Universidad de Barcelona, IDIBAPS-Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain.
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32
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Frenkel D, D'Amato SA, Al-Kazaz M, Markowitz SM, Liu CF, Thomas G, Ip JE, Sharma SK, Yang H, Singh P, Lerman BB, Cheung JW. Prevalence of Left Atrial Thrombus Detection by Transesophageal Echocardiography: A Comparison of Continuous Non-Vitamin K Antagonist Oral Anticoagulant Versus Warfarin Therapy in Patients Undergoing Catheter Ablation for Atrial Fibrillation. JACC Clin Electrophysiol 2016; 2:295-303. [PMID: 29766887 DOI: 10.1016/j.jacep.2016.01.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 12/02/2015] [Accepted: 01/07/2016] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The purpose of this study is to determine whether patients on ≥4 weeks of continuous non-vitamin K antagonist oral anticoagulant (NOAC) therapy require transesophageal echocardiography (TEE) before catheter ablation of atrial fibrillation (AF) or atrial flutter and to compare rates of left atrial (LA) thrombus and dense spontaneous echocardiographic contrast (SEC) in patients on NOAC versus warfarin therapy. BACKGROUND The impact of NOAC therapy on the rates of LA thrombus detection by TEE in patients undergoing catheter ablation of AF is unknown. METHODS Initial TEEs for 388 patients (median age, 65 years; 74% male) on ≥4 weeks of continuous NOAC (n = 183) or warfarin therapy (n = 205) undergoing catheter ablation of AF and flutter were reviewed. RESULTS After ≥4 weeks of therapy, the prevalence of LA thrombus and LA thrombus/dense SEC among patients on NOACs was 4.4% and 6.0%, respectively, which was comparable with that of patients on warfarin. LA thrombus rates among patients on dabigatran, rivaroxaban, and apixaban were 5.4%, 4.8%, and 0%, respectively (p = 0.46). Predictors of LA thrombus were congestive heart failure (odds ratio [OR]: 5.38; 95% confidence interval [CI]: 1.79 to 16.2; p = 0.003); and persistent AF (OR: 3.27; 95% CI: 1.06 to 10.2; p = 0.040). CONCLUSIONS Despite ≥4 weeks of anticoagulation, the rate of LA thrombus in patients on NOACs before catheter ablation of AF or atrial flutter was 4.4%. This suggests that continuous NOAC therapy does not eliminate the need for TEE before catheter ablation of AF.
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Affiliation(s)
- Daniel Frenkel
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Salvatore A D'Amato
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Mohamed Al-Kazaz
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Steven M Markowitz
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Christopher F Liu
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - George Thomas
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - James E Ip
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Sandeep K Sharma
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Hua Yang
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Parmanand Singh
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Bruce B Lerman
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA
| | - Jim W Cheung
- Department of Medicine, Division of Cardiology, Weill Cornell Medical College, New York, New York, USA.
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Nishiyama T, Katsumata Y, Inagawa K, Kimura T, Nishiyama N, Fukumoto K, Tanimoto Y, Aizawa Y, Tanimoto K, Fukuda K, Takatsuki S. Visualization of the left atrial appendage by phased-array intracardiac echocardiography from the pulmonary artery in patients with atrial fibrillation. Europace 2015; 17:546-51. [DOI: 10.1093/europace/euu383] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 12/07/2014] [Indexed: 12/21/2022] Open
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34
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Arbelo E, Guiu E, Ramos P, Bisbal F, Borras R, Andreu D, Tolosana JM, Berruezo A, Brugada J, Mont L. Benefit of left atrial roof linear ablation in paroxysmal atrial fibrillation: a prospective, randomized study. J Am Heart Assoc 2014; 3:e000877. [PMID: 25193295 PMCID: PMC4323787 DOI: 10.1161/jaha.114.000877] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Isolation of the pulmonary veins (PVs) for the treatment of atrial fibrillation (AF) is often supplemented with linear lesions within the left atrium (LA). However, there are conflicting data on the effects of creating a roof line (RL) joining the superior PVs in paroxysmal atrial fibrillation (PAF). METHODS AND RESULTS A cohort of 120 patients with drug-refractory PAF referred for ablation were prospectively randomized into 2 strategies: (1) PV isolation in combination with RL ablation (LA roof ablation [LARA]-1: 59 patients) or (2) PV isolation (LARA-2: 61 patients). Follow-up was performed at 1, 3, and 6 months after the procedure and every 6 months thereafter. After a 3-month blanking period, recurrence was defined as the ocurrence of any atrial tachyarrhythmia lasting ≥30 seconds. PV isolation was achieved in 89% and complete RL block in 81%. RF duration, fluoroscopy, and procedural times were slightly, but not significantly, longer in the LARA-1 group. After 15±10 months, there was no difference in the arrhythmia-free survival after a single AF ablation procedure (LARA-1: 59% vs. LARA-2: 56% at 12 months; log rank P=0.77). The achievement of complete RL block did not influence the results. The incidence of LA macroreentrant tachycardias was 5.1% in the LARA-1 group (n=3) versus 8.2% in the LARA-2 (n=5) (P=ns). Univariate analysis only identified AF duration as a covariate associated with arrhythmia recurrence (hazard ratio, 1.01 [95% confidence interval, 1.002 to 1.012]; P<0.01). CONCLUSION The linear block at the LA roof is not associated with an improved clinical outcome compared with PV isolation alone. CLINICAL TRIAL REGISTRATION URL ClinicalTrials.gov. Unique identifier: NCT01203241.
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Affiliation(s)
- Elena Arbelo
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
| | - Esther Guiu
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
| | - Pablo Ramos
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
| | - Felipe Bisbal
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
| | - Roger Borras
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
| | - David Andreu
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
| | - José María Tolosana
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
| | - Antonio Berruezo
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
| | - Josep Brugada
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
| | - Lluís Mont
- Unitat de Fibril lació Auricular (UFA), Institut del Tòrax, Hospital Clínic Universitat de Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (E.A., E.G., P.R., F.B., R.B., D.A., J.M.T., A.B., J.B., L.M.)
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Yashiro Y, Arimoto T, Hashimoto N, Tamura H, Iwayama T, Ishigaki D, Kumagai Y, Nishiyama S, Takahashi H, Shishido T, Miyamoto T, Watanabe T, Kubota I. Predictors of Left Atrial Coagulation Activity Among Paroxysmal Atrial Fibrillation Patients. Circ J 2014; 79:61-9. [DOI: 10.1253/circj.cj-14-0630] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yoshinori Yashiro
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Takanori Arimoto
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Naoaki Hashimoto
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Harutoshi Tamura
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Tadateru Iwayama
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Daisuke Ishigaki
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Yu Kumagai
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Satoshi Nishiyama
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Hiroki Takahashi
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Tetsuro Shishido
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Takuya Miyamoto
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Isao Kubota
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
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Blomstrom Lundqvist C, Auricchio A, Brugada J, Boriani G, Bremerich J, Cabrera JA, Frank H, Gutberlet M, Heidbuchel H, Kuck KH, Lancellotti P, Rademakers F, Winkels G, Wolpert C, Vardas PE. The use of imaging for electrophysiological and devices procedures: a report from the first European Heart Rhythm Association Policy Conference, jointly organized with the European Association of Cardiovascular Imaging (EACVI), the Council of Cardiovascular Imaging and the European Society of Cardiac Radiology. Europace 2013; 15:927-36. [DOI: 10.1093/europace/eut084] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Bhave PD, Knight BP. Optimal Strategies Including Use of Newer Anticoagulants for Prevention of Stroke and Bleeding Complications Before, During, and After Catheter Ablation of Atrial Fibrillation and Atrial Flutter. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 15:450-66. [PMID: 23568665 DOI: 10.1007/s11936-013-0242-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Prashant D Bhave
- Cardiology Division/Electrophysiology Section, Northwestern University Feinberg School of Medicine, 676 North St. Claire, Suite 600, Chicago, IL, 60611, USA,
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Herring N, Page SP, Ahmed M, Burg MR, Hunter RJ, Earley MJ, Sporton SC, Newton JD, Sabharwal NK, Myerson SG, Bashir Y, Betts TR, Schilling RJ, Rajappan K. The Prevalence of Low Left Atrial Appendage Emptying Velocity and Thrombus in Patients Undergoing Catheter Ablation for Atrial Fibrillation on Uninterrupted Peri-procedural Warfarin Therapy. J Atr Fibrillation 2013; 5:761. [PMID: 28496828 DOI: 10.4022/jafib.761] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 03/11/2013] [Accepted: 03/16/2013] [Indexed: 01/18/2023]
Abstract
Introduction: The 2012 HRS/EHRA/ECAS guidelines encourage pre-procedural transesophageal echocardiography (TEE) prior to ablation for atrial fibrillation (AF), but acknowledge a lack of consensus in patients maintained on therapeutic warfarin before, during and after the procedure. This is partly because the incidence of left atrial appendage (LAA) thrombus is so low, that it is hard to draw clear conclusion regarding the characteristics of patients who develop thrombus. We hypothesize that the presence of low LAA emptying velocities, which predisposes to thrombus, and/or thrombus itself can be predicted in patients undergoing ablation, based upon clinical characteristics and transthoracic echocardiography (TTE). Methods: In this multicentre study, we undertook TTE and transesophageal echocardiograms (TEE) in 586 patients (age 59.9±0.4 years old, 64.5% male) undergoing catheter ablation for AF who were anticoagulated on warfarin (target international normalized ratio 2-3.5) for ≥3 consecutive weeks prior to procedure and maintained on warfarin for the procedure. Results: Low peak LAA emptying velocities (<40cm/s) were identified in 111 (24.7%) patients and LAA thrombus was identified in 3 patients (0.5%) despite having therapeutic INRs. The 3 patients with thrombus had LAA emptying velocities of 23, 29 and 31 cm/s. None of the remaining patients had a peri-procedural stroke. Patients with peak LAA emptying velocities <40cm/s or thrombus on TEE had significantly (p<0.05) higher CHA2DS2-VASc scores (1.7± 0.1 v's 1.4±0.1), and were more likely to have impaired LVSF (odds ratio [95% CI]: 2.66 [1.52-4.66]), a LA diameter >4.6cm on TTE (2.40 [2.13-5.41]), or persistent AF (2.60 [1.63-4.14]) compared to those with a higher LAA velocity without thrombus. Conclusion: In patients on uninterrupted warfarin therapy, a CHA2DS2-VASc score ≥1 or LA diameter >4.6cm on TTE identifies 91.5% of those at risk of developing thrombus with LAA emptying velocity of <40 cm/s and 100% of those with thrombus in our cohort.
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Affiliation(s)
- Neil Herring
- Oxford Heart Centre, John Radcliffe Hospital, Oxford, UK and
| | - Stephen P Page
- Barts and the London Cardiovascular Biomedical Research Unit, London, UK
| | - Mohammed Ahmed
- Oxford Heart Centre, John Radcliffe Hospital, Oxford, UK and
| | - Melanie R Burg
- Oxford Heart Centre, John Radcliffe Hospital, Oxford, UK and
| | - Ross J Hunter
- Barts and the London Cardiovascular Biomedical Research Unit, London, UK
| | - Mark J Earley
- Barts and the London Cardiovascular Biomedical Research Unit, London, UK
| | - Simon C Sporton
- Barts and the London Cardiovascular Biomedical Research Unit, London, UK
| | - James D Newton
- Oxford Heart Centre, John Radcliffe Hospital, Oxford, UK and
| | | | - Saul G Myerson
- Oxford Heart Centre, John Radcliffe Hospital, Oxford, UK and
| | - Yaver Bashir
- Oxford Heart Centre, John Radcliffe Hospital, Oxford, UK and
| | - Tim R Betts
- Oxford Heart Centre, John Radcliffe Hospital, Oxford, UK and
| | | | - Kim Rajappan
- Oxford Heart Centre, John Radcliffe Hospital, Oxford, UK and
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Oude Velthuis B, Stevenhagen J, van Opstal JM, Scholten MF. Continuation of vitamin K antagonists as acceptable anticoagulation regimen in patients undergoing pulmonary vein isolation. Neth Heart J 2012; 20:12-5. [PMID: 22161077 DOI: 10.1007/s12471-011-0223-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Recent studies have demonstrated that radiofrequency isolation of the pulmonary veins (PVI) is an effective treatment for symptomatic atrial fibrillation. Based on these positive results, non- pharmacological therapy has been incorporated in the guidelines for drug refractory atrial fibrillation, resulting in an increased popularity. The prevention of thromboembolic complications remains an important issue. METHODS In January 2010, we adopted an anticoagulation strategy based on continuation of vitamin K antagonists (VKAs) and selective use of transoesophageal echocardiogram (TEE). We retrospectively analysed the results of this strategy in all patients referred for PVI treatment. VKAs were started for all patients 2 months prior to treatment. Discontinuation of oral anticoagulation was considered 3 months after treatment based on thromboembolic and bleeding risk profile. Bleeding and thromboembolic complications were registered during outpatient clinic follow-up up until 3 months. RESULTS We performed 151 PVI procedures from January 2010 to March 2011. All patients were seen 6 weeks after discharge. No transient ischaemic accidents or ischaemic cerebrovascular incidents occurred pre-, peri- or postprocedure. Four (2.7%) procedures were complicated by tamponade requiring pericardiocentesis. CONCLUSIONS Our data support the increasing evidence for continuation of periprocedural administration of VKAs complemented by a selective TEE approach as a safe therapy for thromboembolic complications.
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Affiliation(s)
- B Oude Velthuis
- Department of Cardiology, Thoraxcentrum Twente, Medisch Spectrum Twente, P.O. Box 50000, 7500, KA, Enschede, the Netherlands
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Bourke T, Moriarty J, Boyle NG, Shivkumar K. Atrial Fibrillation Ablation: Do We Really Need Preprocedural Imaging? Card Electrophysiol Clin 2012; 4:305-315. [PMID: 26939950 DOI: 10.1016/j.ccep.2012.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Atrial fibrillation is the most common human arrhythmia, causing significant mortality and morbidity. Because of the potential for complications, it is important that procedures be made as safe and effective as possible by combining safe procedural planning with effective therapy delivery. To change the current approach, large randomized studies are needed to guide the selection of patients who may safely undergo ablation without transesophageal echocardiography to exclude thrombus. For institutions routinely using computed tomography and magnetic resonance imaging to assess pulmonary vein anatomy before procedures, the possibility of excluding intracardiac thrombi using these imaging modalities should be considered.
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Affiliation(s)
- Tara Bourke
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, UCLA Health System, 100 UCLA Medical Plaza, Suite 660, Los Angeles, CA 90095, USA; Department of Cardiology, Karolinska University Hospital, 141 86 Stockholm, Sweden
| | - John Moriarty
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, UCLA Health System, 100 UCLA Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
| | - Noel G Boyle
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, UCLA Health System, 100 UCLA Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, UCLA Health System, 100 UCLA Medical Plaza, Suite 660, Los Angeles, CA 90095, USA
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Wheeler R, Masani ND. The role of echocardiography in the management of atrial fibrillation. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2011; 12:i33-8. [DOI: 10.1093/ejechocard/jer124] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Geller JC, Brunelli M. Catheter ablation of atrial fibrillation without prior transoesophageal echocardiography: are we there yet? Europace 2011; 13:453-4. [PMID: 21343240 DOI: 10.1093/europace/eur030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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