ROUVIERE Héloïse, DE MEESTER Antoine, DESCAMPS Olivier, NICAISE Grégory, MARCOVITCH Olivier,BADOT Damien, TUTUS Caroline, BENAHMED Ahmed
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1 Left atrial appendage thrombus detection in patients with atrial fibrillation: Comparison between multidetector computed tomography and transesophageal echocardiography ROUVIERE Héloïse, DE MEESTER Antoine, DESCAMPS Olivier, NICAISE Grégory, MARCOVITCH Olivier,BADOT Damien, TUTUS Caroline, BENAHMED Ahmed Cardiology department, Jolimont, Haine Saint Paul, Belgium December, 2010
2 Background 1. AF is a major contributor to stroke and TE (4.5x risk) stroke : substantial neurologic disability microemboli : reduced cognitive function 2. Cardioembolic sources : LAA+++, LV apex, Aorta 3. The detection of left atrial appendage thrombus has important clinical and prognostic implications. 4. Multidetector Computed Tomography (MDCT) to confirm the presence of a left atrial appendage (LAA) thrombus : A alternative to transesophageal echocardiography (TEE)?
3 Methods Prospective study (2010) Inclusion : (In- and Out-) Patients with AF (persistent or paroxysmal) hospitlized for electrical external cardioversion, pulmonary veins RF ablation, recent stroke. Exclusion : allergy to iodinated contrast, renal failure, delay too long between the 2 exams, lack of informed consent. Procedures : one-phase MDCT and TEE.
4 TEE (gold standard) versus MDCT TEE MDCT Cost Duration 10 minutes 10 minutes Sedation + - Interpretation Operator-dependent Reproducible Disadvantage Contraindications Semi-invasive technique Fasting status (4h) Zenker diverticulum? Stress? Injection of contrast Radiation exposure HR < 60 bpm Iodine allergy, Renal failure, Pregnancy
5 Transesophageal echocardiography (TEE) Normal LAA Peak Flow velocity
6
7 Multidetector Computed Tomography (MDCT) Complete opacification of LAA considered as normal Intracavitary filling defect is suspected to be a thrombus
8 Thrombus
9 Results Clinical characteristics of patients n F/M 5 (38%) / 8 (62%) Age (years) 61 +/- 15 Reason for admission: Electrical cardioversion Pulmonary veins RF ablation Recent stroke 7 (54%) 5 (38%) 1 (8%) Permanent atrial fibrillation 5 (38%) CHADS 2 score: (15%) 7 (54%) 4 (31%) Anticoagulation therapy - (optimal) 7 (54%) (0 (0%)
10 Results TEE + TEE - MDCT MDCT - (1) Filamentous residous (remnants of a thrombus) on OAC (delay = 6 days) 6 Concordance between MDCT and TEE for the detection of a thrombus Is HIGH
11 Results : good agreement between CT and TEE Studies Pts Thrombus at MDCT Thrombus at TEE Delay Jaber, USA, h Hur, stroke week Our study days CT angiography is a noninvasive and sensitive modality for detecting thrombi in the LAA of patients. Although TEE is currently considered the reference standard modality for detecting LAA thrombi,64-section cardiac CT angiography has the potential to become a useful modality for detection of intracardiac thrombus
12 Limitations of the 3 studies Small number of patients. Problem of standardization of the examination (type of contrast, variability of slice thickness). Significant delay between the two examinations. MDCT : The method could probably be improved (published by Jin Hur, radiology 2009) Realization of late phase images (early phase : evaluation of the coronary arteries and intracardiac abnormalities). Left Atrial Appendage/Ascending Aorta density ratio (HU)
13 Possible improvements (MDCT) Examination at later phase after contrast infusion (30 sec) allows better distribution of the contrast (no pseudo-filling defects) and better discrimination between stasis and thrombus
14 Possible improvements (MDCT) Reduction of false positive scan, using the LAA/Ascending Aorta ratio (in Hounsfield Units (HU))(density ratio to a reference region like the ascending aorta and at the left atrium) : more sensitive to confirm the probability of a thrombus
15 Conclusions This empirical study does not allow to conclude because of the small number of patients, but it emphasizes the need of further investigations... MDCT seems to be an attractive alternative method to detect LAA thrombus but different conditions must be met : CT must be realized in two phases, with thin sections and LAA/AA HU ratio measurement on late-phase CT and TEE should be performed on the same day
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