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Clinical Research in Cardiology

, Volume 108, Issue 2, pp 150–156 | Cite as

Exclusion of left atrial thrombus by dual-source cardiac computed tomography prior to catheter ablation for atrial fibrillation

  • Marc KottmaierEmail author
  • Clemens Jilek
  • Sophie Berglar
  • Tilko Reents
  • Felix Bourier
  • Verena Semmler
  • Martha Telishevska
  • Katharina Koch-Büttner
  • Sarah Lengauer
  • Marielouise Kornmayer
  • Elena Rousseva
  • Stephanie Brooks
  • Martin Hadamitzky
  • Christoph Kolb
  • Gabriele Hessling
  • Isabel Deisenhofer
Original Paper
  • 105 Downloads

Abstract

Objectives

Thromboembolic complications during atrial fibrillation (AF) ablation due to mobilisation of a pre-existing thrombus formation (TF) in the left atrium (LA) are devastating. The gold standard to exclude LA TF is transesophageal echocardiography (TEE). The present study compares sensitivity and specificity of a dual-source cardiac-computed tomography (DS-CT) with TEE for TF exclusion prior to AF ablation. In addition, CT protocols with and without ECG synchronized were evaluated.

Methods

In 622 patients, DS-CT as well as TEE to exclude TF was performed less than 48 h prior to AF ablation. Mean age of patients was 60 ± 10 years (69% males, 61% paroxysmal AF). During DS-CT, 280 patients (45%) were in AF. An ECG-synchronized DS-CT was performed in 332 patients, whereas 290 patients underwent DS-CT without ECG synchronization.

Results

In all patients without suspected TF on DS-CT (n = 552; 88.7%), no thrombus was found on TEE. A TF was suspected on DS-CT in 70 patients, of whom only three patients showed TF on TEE. No TF was detected in the other 67 patients (Fig. 1). Overall, sensitivity for TF detection in DS-CT was 100% and specificity was 89.2% (positive predictive value 4.3%, negative predictive value 100%). The CT protocol (ECG-synchronized versus non-ECG-synchronized) had no significant influence on diagnostic accuracy. Mean dose length product during DS CT was 282 ± 287 mGy cm (synchronized) versus 136 ± 55 mGy cm (non-synchronized) with p < 0.0001.

Conclusions

DS-CT is a highly sensitive method for LA thrombus detection in patients undergoing AF ablation. It delivers additional anatomic details of pulmonary veins and LA anatomy with an acceptable radiation exposure. Non-ECG-synchronized DS-CT showed a significantly lower radiation exposure, whereas diagnostic accuracy was comparable. Therefore, DS-CT might serve as primary method to exclude LA TF in patients undergoing AF ablation.

Keywords

Atrial fibrillation Ablation Dual-source cardiac-computed tomography Thrombus exclusion 

Notes

Compliance with ethical standards

Conflict of interest

None declared.

References

  1. 1.
    Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Cosedis Nielsen J, Curtis AB, Davies DW, Day JD, d’Avila A, Natasja de Groot NMS, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ, Yamane T, Document R (2018) 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace; 20:e1–e160CrossRefGoogle Scholar
  2. 2.
    Manning WJ, Weintraub RM, Waksmonski CA, Haering JM, Rooney PS, Maslow AD, Johnson RG, Douglas PS (1995) Accuracy of transesophageal echocardiography for identifying left atrial thrombi. A prospective, intraoperative study. Ann intern med; 123:817–822CrossRefGoogle Scholar
  3. 3.
    Kallmeyer IJ, Collard CD, Fox JA, Body SC, Shernan SK (2001) The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients. Anesth Analg 92:1126–1130CrossRefGoogle Scholar
  4. 4.
    Daniel WG, Erbel R, Kasper W, Visser CA, Engberding R, Sutherland GR, Grube E, Hanrath P, Maisch B, Dennig K et al (1991) Safety of transesophageal echocardiography. A multicenter survey of 10,419 examinations. Circulation 83:817–821CrossRefGoogle Scholar
  5. 5.
    Budoff MJ, Shittu A, Hacioglu Y, Gang E, Li D, Bhatia H, Alvergue J, Karlsberg RP (2014) Comparison of transesophageal echocardiography versus computed tomography for detection of left atrial appendage filling defect (thrombus). Am J Cardiol 113:173–177CrossRefGoogle Scholar
  6. 6.
    Kim YY, Klein AL, Halliburton SS, Popovic ZB, Kuzmiak SA, Sola S, Garcia MJ, Schoenhagen P, Natale A, Desai MY (2007) Left atrial appendage filling defects identified by multidetector computed tomography in patients undergoing radiofrequency pulmonary vein antral isolation: a comparison with transesophageal echocardiography. Am Heart J 154:1199–1205CrossRefGoogle Scholar
  7. 7.
    Homsi R, Nath B, Luetkens JA, Schwab JO, Schild HH, Naehle CP (2016) Can contrast-enhanced multi-detector computed tomography replace transesophageal echocardiography for the detection of thrombogenic milieu and thrombi in the left atrial appendage: a prospective study with 124 patients. Fortschr Röntgenstr 188:45–52CrossRefGoogle Scholar
  8. 8.
    Hur J, Pak HN, Kim YJ, Lee HJ, Chang HJ, Hong YJ, Choi BW (2013) Dual-enhancement cardiac computed tomography for assessing left atrial thrombus and pulmonary veins before radiofrequency catheter ablation for atrial fibrillation. Am J Cardiol 112:238–244CrossRefGoogle Scholar
  9. 9.
    Pathan F, Hecht H, Narula J, Marwick TH (2018) Roles of transesophageal echocardiography and cardiac computed tomography for evaluation of left atrial thrombus and associated pathology. JACC Cardiovasc Imaging 11(4):616–627CrossRefGoogle Scholar
  10. 10.
    Fatkin D, Kelly R, Feneley M (1994) Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast and thromboembolic risk in vivo. J Am Coll Cardiol 23(4):961–969CrossRefGoogle Scholar
  11. 11.
    Leschka S, Scheffel H, Desbiolles L, Plass A, Gaemperli O, Valenta I, Hussmann L, Flohr TG, Genoni M, Marincek B, Kaufmann PA, Alkadhi H (2007) Image quality and reconstruction intervals of dual-source CT coronary angiography: recommendations for ECG-pulsing windowing. Invest Radiol 42(8):543–549CrossRefGoogle Scholar
  12. 12.
    Trattner S, Chelliah A, Prinsen P, Ruzal-Shapiro CB, Xu Y, Jambawalikar S, Amurao M, Einstein AJ (2017) Estimating effective dose of radiation from pediatric cardiac CT angiography using a 64-MDCT scanner: new conversion factors relating dose-length product to effective dose. AJR Am J Roentgenol 208(3):585–594CrossRefGoogle Scholar
  13. 13.
    Singh NK, Nallamothu N, Zuck VP, Issa ZF (2009) Left atrial appendage filling defects on 64-slice multidetector computed tomography in patients undergoing pulmonary vein isolation: predictors and comparison to transesophageal echocardiography. J Comput Assist Tomogr 33:946–951CrossRefGoogle Scholar
  14. 14.
    Romero J, Husain SA, Kelesidis I, Sanz J, Medina HM, Garcia MJ (2013) Detection of left atrial appendage thrombus by cardiac computed tomography in patients with atrial fibrillation: a meta-analysis. Circ Cardiovasc Imaging 6:185–194CrossRefGoogle Scholar
  15. 15.
    Bilchick KC, Mealor A, Gonzalez J, Norton P, Zhuo D, Mason P, Ferguson JD, Malhotra R, Michael Mangrum J, Darby AE, DiMarco J, Hagspiel K, Dent J, Kramer CM, Stukenborg GJ, Salerno M (2016) Effectiveness of integrating delayed computed tomography angiography imaging for left atrial appendage thrombus exclusion into the care of patients undergoing ablation of atrial fibrillation. Heart Rhythm 13:12–19CrossRefGoogle Scholar
  16. 16.
    Della Bella P, Fassini G, Cireddu M, Riva S, Carbucicchio C, Giraldi F, Maccabelli G, Trevisi N, Moltrasio M, Pepi M, Galli CA, Andreini D, Ballerini G, Pontone G (2009) Image integration-guided catheter ablation of atrial fibrillation: a prospective randomized study. J Cardiovasc Electrophysiol 20:258–265CrossRefGoogle Scholar
  17. 17.
    Bertaglia E, Bella PD, Tondo C, Proclemer A, Bottoni N, De Ponti R, Landolina M, Bongiorni MG, Coro L, Stabile G, Dello Russo A, Verlato R, Mantica M, Zoppo F (2009) Image integration increases efficacy of paroxysmal atrial fibrillation catheter ablation: results from the CartoMerge Italian Registry. Europace 11:1004–1010CrossRefGoogle Scholar
  18. 18.
    Maurer T, Rottner L, Makimoto H, Reissmann B, Heeger CH, Lemes C, Fink T, Riedl J, Santoro F, Wohlmuth P, Volkmer M, Mathew S, Metzner A, Ouyang F, Kuck KH, Sohns C (2018) The best of two worlds? Pulmonary vein isolation using a novel radiofrequency ablation catheter incorporating contact force sensing technology and 56-hole porous tip irrigation. Clin Res Cardiol  https://doi.org/10.1007/s00392-018-1270-y [Epub ahead of print] Google Scholar
  19. 19.
    Bourier F, Ammar S, Reents T, Hessling G, Deisenhofer I (2015) CT-fusion-guided transseptal puncture in a patient with atrial fibrillation and absent right superior vena cava. HeartRhythm Case Rep 1:323–325CrossRefGoogle Scholar
  20. 20.
    Bourier F, Reents T, Ammar-Busch S, Semmler V, Telishevska M, Kottmaier M, Lennerz C, Grebmer C, Kolb C, Deisenhofer I, Hessling G (2016) Transseptal puncture guided by CT-derived 3D-augmented fluoroscopy. J Cardiovasc Electrophysiol 27:369–372CrossRefGoogle Scholar
  21. 21.
    Murray MI, Arnold A, Younis M, Varghese S, Zeiher AM (2018) Cryoballoon versus radiofrequency ablation for paroxysmal atrial fibrillation: a meta-analysis of randomized controlled trials. Clin Res Cardiol.  https://doi.org/10.1007/s00392-018-1232-4 [Epub ahead of print]
  22. 22.
    Hausleiter J, Meyer T, Hadamitzky M, Huber E, Zankl M, Martinoff S, Kastrati A, Schomig A (2006) Radiation dose estimates from cardiac multislice computed tomography in daily practice: impact of different scanning protocols on effective dose estimates. Circulation 113:1305–1310CrossRefGoogle Scholar
  23. 23.
    Coles DR, Smail MA, Negus IS, Wilde P, Oberhoff M, Karsch KR, Baumbach A (2006) Comparison of radiation doses from multislice computed tomography coronary angiography and conventional diagnostic angiography. J Am Coll Cardiol 47:1840–1845CrossRefGoogle Scholar
  24. 24.
    Hausleiter J, Bischoff B, Hein F, Meyer T, Hadamitzky M, Thierfelder C, Allmendinger T, Flohr TG, Schömig A, Martinoff S (2009) Feasibility of dual-source cardiac CT angiography with high-pitch scan protocols. J Cardiovasc Comput Tomogr 3(4):236–242CrossRefGoogle Scholar
  25. 25.
    Annoni AD, Andreini D, Pontone G, Formenti A, Petullà M, Consiglio E, Nobili E, Baggiano A, Conte E, Mushtaq S, Bertella E, Billi F, Bartorelli AL, Montorsi P, Pepi M (2015) Ultra-low-dose CT for left atrium and pulmonary veins imaging using new model-based iterative reconstruction algorithm. Eur Heart J Cardiovasc Imaging 16(12):1366–1373CrossRefGoogle Scholar
  26. 26.
    Lazoura O, Ismail TF, Pavitt C, Lindsay A, Sriharan M, Rubens M, Padley S, Duncan A, Wong T, Nicol E (2016) A low-dose, dual-phase cardiovascular CT protocol to assess left atrial appendage anatomy and exclude thrombus prior to left atrial intervention. Int J Cardiovasc Imaging 32:347–354CrossRefGoogle Scholar
  27. 27.
    Teunissen C, Habets J, Velthuis BK, Cramer MJ, Loh P (2017) Double-contrast, single-phase computed tomography angiography for ruling out left atrial appendage thrombus prior to atrial fibrillation ablation. Int J Cardiovasc Imaging 33:121–128CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Marc Kottmaier
    • 1
    Email author
  • Clemens Jilek
    • 1
  • Sophie Berglar
    • 1
  • Tilko Reents
    • 1
  • Felix Bourier
    • 1
  • Verena Semmler
    • 1
  • Martha Telishevska
    • 1
  • Katharina Koch-Büttner
    • 1
  • Sarah Lengauer
    • 1
  • Marielouise Kornmayer
    • 1
  • Elena Rousseva
    • 1
  • Stephanie Brooks
    • 1
  • Martin Hadamitzky
    • 1
  • Christoph Kolb
    • 1
  • Gabriele Hessling
    • 1
  • Isabel Deisenhofer
    • 1
  1. 1.Department of Electrophysiology, German Heart Center MunichTechnische Universitaet MunichMunichGermany

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