Should transesophageal echocardiography be done in all patients who underwent catheter ablation of atrial fibrillation? A case report and review of the literature

2017 consensus of the Asia Pacific Heart Rhythm Society on stroke prevention in atrial fibrillation

Atrial fibrillation (AF) is the most common sustained arrhythmia, causing a 2-fold increase in mortality and a 5-fold increase in stroke. The Asian population is rapidly aging, and in 2050, the estimated population with AF will reach 72 million, of whom 2.9 million may suffer from AF-associated stroke. Therefore, stroke prevention in AF is an urgent issue in Asia. Many innovative advances in the management of AF-associated stroke have emerged recently, including new scoring systems for predicting stroke and bleeding risks, the development of non-vitamin K antagonist oral anticoagulants (NOACs), knowledge of their special benefits in Asians, and new techniques. The Asia Pacific Heart Rhythm Society (APHRS) aimed to update the available information, and appointed the Practice Guideline sub-committee to write a consensus statement regarding stroke prevention in AF. The Practice Guidelines sub-committee members comprehensively reviewed updated information on stroke prevention in AF, emphasizing data on NOACs from the Asia Pacific region, and summarized them in this 2017 Consensus of the Asia Pacific Heart Rhythm Society on Stroke Prevention in AF. This consensus includes details of the updated recommendations, along with their background and rationale, focusing on data from the Asia Pacific region. We hope this consensus can be a practical tool for cardiologists, neurologists, geriatricians, and general practitioners in this region. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician׳s decision remains the most important factor in the management of AF.

CHADS(2) and CHA(2)DS (2)-VASc score of patients with atrial fibrillation or flutter and newly detected left atrial thrombus

BACKGROUND

The risk of developing a stroke or systemic embolus due to a left atrial (LA) thrombus in patients with atrial fibrillation (AF) and/or atrial flutter (AFL) is estimated by the CHADS(2) score and more recently the CHA(2)DS(2)-VASc score. We aimed to further characterize AF/AFL patients who were found to have a LA thrombus on a transesophageal echocardiogram (TEE).

METHODS AND RESULTS

Of 3,165 TEE between 2005 and 2011 for a broad spectrum of indications, we detected 65 AF patients with LA thrombus (2 %). There were 40 men and 25 women, mean age was 65 ± 13 years (range 36-88 years). Mean CHADS(2) score was 1.8 ± 1.1 and mean CHA(2)DS(2)-VASc score was 3.0 ± 1.6. 11 patients (17 %) had a CHADS(2) score of 0, 12 patients (18 %) of 1, 28 patients (43 %) of 2 and 12 patients (18 %) of 3. Hypertension was the most frequent risk factor (72 %), followed by congestive heart failure (32 %), diabetes (23 %) and age ≥75 years (23 %). Mean difference between CHADS(2) and CHA(2)DS(2)-VASc was 1.25 ± 0.91. Of the 11 patients (17 %) with a LA thrombus despite a CHADS(2) score of 0, five had a CHA(2)DS(2)-VASc score of 0, four a CHA(2)DS(2)-VASc score of 1 and two a CHA(2)DS(2)-VASc score of 2.

CONCLUSION

In an unselected TEE population with newly detected LA thrombus about one-third of patients fell into the low-risk group when classified based on the CHADS(2) score, while a much lower population fell in the same low-risk group when classified according to the CHA(2)DS(2)-VASc score. However, this does not prove clinical superiority of the CHA(2)DS(2)-VASc score over the established CHADS(2) score. Whether our observation has clinical implications (e.g. TEE prior to LA ablation irrespective of CHADS(2) score), or argues for use of the CHA(2)DS(2)-VASc score needs to be evaluated in prospective studies.