Derivation and validation of E/e′ ratio as a parameter in the evaluation of left atrial appendage thrombus formation in patients with nonvalvular atrial fibrillation
- 147 Downloads
We sought to determine and prospectively validate, with concomitantly performed transthoracic (TTE) and transesophageal echocardiograms (TEE), a TTE-assessed E/e′ threshold that can be useful in predicting left atrial appendage (LAA) thrombus in patients with nonvalvular atrial fibrillation (NVAF). The retrospective derivation cohort was comprised of 297 patients with NVAF with TTE performed within 1 year of TEE. The validation cohort was comprised of 266 prospectively enrolled patients with TTE performed immediately prior to TEE. LAA thrombus was detected by TEE in 6.4 % of patients in both cohorts. Receiver operating characteristic (ROC) analyses demonstrated a good discriminatory capacity of lateral E/e′ in predicting LAA thrombus in the derivation cohort (AUC 0.72; CI 0.63–0.82; P = 0.001) which was confirmed in the validation cohort (AUC 0.83; CI 0.75–0.91; P < 0.001). In the derivation cohort, ROC curve point-coordinates identified E/e′ thresholds of both 9.0 and 8.0 to be associated with 100 % sensitivity, with specificities of 36 and 30 %, respectively. An E/e′ threshold of ≥8 was selected a priori for prospective validation, and was associated with 100 % sensitivity and 41 % specificity for LAA thrombus, with positive and negative predictive values of 10 and 100 %, respectively, and positive and negative likelihood ratios of 1.69 and 0, respectively. We determined and validated an E/e′ threshold of 8 as a highly sensitive and useful parameter that can aid in identifying patients at very low risk for LAA thrombus and potentially obviate the need for a TEE prior to electrophysiology procedures and restoration of sinus rhythm.
KeywordsAtrial fibrillation Left atrial appendage thrombus Transesophageal echocardiogram (TEE) Transthoracic echocardiogram (TTE) E/e′ ratio
Area under the curve
95 % confidence intervals
Left atrial appendage
Nonvalvular atrial fibrillation
Receiver operating characteristic
Spontaneous echo contrast
The study was funded by a Rush-County collaborative research grant. The grant fiduciary was Rush University Medical Center; the principal investigator was Dr. Doukky. The funding source had no input into the study design, execution, data analysis and interpretation, or manuscript preparation and approval.
Dr. Doukky receives research funding from Astellas Pharma US and serves on the Advisory Board of Astellas Pharma US; none of these conflicts are relevant to the present work. Other authors report no conflicts.
- 2.January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC, Jr et al (2014) AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 64(21):e1–e76CrossRefPubMedGoogle Scholar
- 5.Bernhardt P, Schmidt H, Hammerstingl C, Luderitz B, Omran H. (2005) Patients with atrial fibrillation and dense spontaneous echo contrast at high risk a prospective and serial follow-up over 12 months with transesophageal echocardiography and cerebral magnetic resonance imaging. J Am Coll Cardiol 45(11):1807–1812CrossRefPubMedGoogle Scholar
- 7.Zabalgoitia M, Halperin JL, Pearce LA, Blackshear JL, Asinger RW, Hart RG (1998) Transesophageal echocardiographic correlates of clinical risk of thromboembolism in nonvalvular atrial fibrillation. Stroke Prevention in Atrial Fibrillation III Investigators. J Am Coll Cardiol 31(7):1622–1626CrossRefPubMedGoogle Scholar
- 9.Chen R, Wu X, Jin H, Wang B, Ma M, Zhao B. (2016) Assessment of left atrial appendage morphology and function in patients with non-valvular paroxysmal atrial fibrillation with different rhythms using real-time 3D transesophageal echocardiography. Ultrasound Med Biol 42(1):118–124CrossRefPubMedGoogle Scholar
- 16.Pant R, Patel M, Garcia-Sayan E, Wassouf M, D’Silva O, Kehoe RF et al (2016) Impact of B-type natriuretic peptide level on the risk of left atrial appendage thrombus in patients with nonvalvular atrial fibrillation: a prospective study. Cardiovasc Ultrasound 14(1):4CrossRefPubMedPubMedCentralGoogle Scholar
- 20.Nagueh SF, Smiseth OA, Appleton CP, Byrd BF 3rd, Dokainish H, Edvardsen T et al (2016) Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 29(4):277–314CrossRefPubMedGoogle Scholar
- 22.Doukky R, Garcia-Sayan E, Patel M, Pant R, Wassouf M, Shah S et al (2016) Impact of diastolic function parameters on the risk of left atrial appendage thrombus in patients with nonvalvular atrial fibrillation: a prospective study. J Am Soc Echocardiogr (in press)Google Scholar
- 24.Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L et al (2015) Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 28(1):1–39.e14CrossRefPubMedGoogle Scholar
- 25.Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA et al (2005) Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 18(12):1440–1463CrossRefPubMedGoogle Scholar
- 28.Puwanant S, Varr BC, Shrestha K, Hussain SK, Tang WH, Gabriel RS et al (2009) Role of the CHADS2 score in the evaluation of thromboembolic risk in patients with atrial fibrillation undergoing transesophageal echocardiography before pulmonary vein isolation. J Am Coll Cardiol 54(22):2032–2039CrossRefPubMedGoogle Scholar
- 30.Lowe BS, Kusunose K, Motoki H, Varr B, Shrestha K, Whitman C et al (2014) Prognostic significance of left atrial appendage “sludge” in patients with atrial fibrillation: a new transesophageal echocardiographic thromboembolic risk factor. J Am Soc Echocardiogr 27(11):1176–1183CrossRefPubMedGoogle Scholar