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Sposato LA, Ayan D, Ahmed M, Fridman S, Mandzia JL, Lodol FF, Elrayes M, Pandey S, Bagur R. Extended Computed Tomography Angiography for the Successful Diagnosis of Cardioaortic Thrombus in Acute Ischemic Stroke and TIA: Study Protocol for a Randomized Controlled Trial. Cerebrovasc Dis 2024:1-10. [PMID: 38934129 DOI: 10.1159/000540034] [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: 05/24/2024] [Accepted: 06/21/2024] [Indexed: 06/28/2024] Open
Abstract
INTRODUCTION Cardiac imaging is one of the main components of the etiological investigation of ischemic strokes. However, basic and advanced cardiac imaging remain underused in most stroke centers globally. Computed tomography angiography (CTA) of the supra-aortic and intracranial arteries is the most frequent imaging modality applied during the evaluation of patients with acute ischemic stroke to identify the presence of a large vessel occlusion. Recent evidence from retrospective observational studies has shown a high detection of cardiac thrombi, ranging from 6.6 to 17.4%, by extending a CTA a few cm below the carina to capture cardiac images. However, this approach has never been prospectively compared against usual care in a randomized controlled trial. The Extended Computed Tomography Angiography for the Successful Screening of Cardioaortic Thrombus in Acute Ischemic Stroke and TIA (DAYLIGHT) prospective, randomized, controlled trial evaluates whether an extended CTA (eCTA) + standard-of-care stroke workup results in higher detection rates of cardiac and aortic source of embolism compared to standard-of-care CTA (sCTA) + standard-of-care stroke workup. METHODS DAYLIGHT is a single-center, prospective, randomized, open-blinded endpoint trial, aiming to recruit 830 patients with suspected acute ischemic stroke or transient ischemic attack (TIA) being assessed under acute code stroke at the emergency department or at a dedicated urgent stroke prevention clinic. Patients are randomized 1:1 to eCTA versus sCTA. The eCTA expands image acquisition caudally, 6 cm below the carina. All patients receive standard-of-care cardiac imaging and diagnostic stroke workup. The primary efficacy endpoint is the diagnosis of a cardioaortic thrombus after at least 30 days of follow-up. The primary safety endpoint is door-to-CTA completion time. The diagnosis of a qualifying ischemic stroke or TIA is independently adjudicated by a stroke neurologist, blinded to the study arm allocation. Patients without an adjudicated ischemic stroke or TIA are excluded from the analysis. The primary outcome events are adjudicated by a board-certified radiologist with subspecialty training in cardiothoracic radiology and a cardiologist with formal training in cardiac imaging. The primary analysis is performed according to the modified intention-to-diagnose principle and without adjustment by logistic regression models. Results are presented with odds ratios and 95% confidence intervals. CONCLUSION The DAYLIGHT trial will provide evidence on whether extending a CTA to include the heart results in an increased detection of cardioaortic thrombi compared to standard-of-care stroke workup.
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Affiliation(s)
- Luciano A Sposato
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada
- Heart and Brain Laboratory, Western University, London, Ontario, Canada
- Robarts Research Institute, Western University, London, Ontario, Canada
- Lawson Health Research Institute, London, Ontario, Canada
| | - Diana Ayan
- Heart and Brain Laboratory, Western University, London, Ontario, Canada
| | - Mobeen Ahmed
- Division of Radiology, Department of Medical Imaging, Western University, London, Ontario, Canada
| | - Sebastian Fridman
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada
| | - Jennifer L Mandzia
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada
| | - Facundo F Lodol
- Heart and Brain Laboratory, Western University, London, Ontario, Canada
| | - Maged Elrayes
- Division of Cardiology, Department of Medicine, Western University, London, Ontario, Canada
| | - Sachin Pandey
- Division of Radiology, Department of Medical Imaging, Western University, London, Ontario, Canada
| | - Rodrigo Bagur
- Division of Cardiology, Department of Medicine, Western University, London, Ontario, Canada
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Parenti VG, Vijay K, Maroules CD, Majdalany BS, Koweek LM, Khaja MS, Ghoshhajra BB, Agarwal PP, Contrella BN, Keefe NA, Lo BM, Malik SB, Surasi DS, Waite K, Williamson EE, Abbara S, Dill KE. ACR Appropriateness Criteria® Workup of Noncerebral Systemic Arterial Embolic Source. J Am Coll Radiol 2023; 20:S285-S300. [PMID: 37236749 DOI: 10.1016/j.jacr.2023.02.005] [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: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 05/28/2023]
Abstract
Noncerebral systemic arterial embolism, which can originate from cardiac and noncardiac sources, is an important cause of patient morbidity and mortality. When an embolic source dislodges, the resulting embolus can occlude a variety of peripheral and visceral arteries causing ischemia. Characteristic locations for noncerebral arterial occlusion include the upper extremities, abdominal viscera, and lower extremities. Ischemia in these regions can progress to tissue infarction resulting in limb amputation, bowel resection, or nephrectomy. Determining the source of arterial embolism is essential in order to direct treatment decisions. This document reviews the appropriateness category of various imaging procedures available to determine the source of the arterial embolism. The variants included in this document are known arterial occlusion in the upper extremity, lower extremity, mesentery, kidneys, and multiorgan distribution that are suspected to be of embolic etiology. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Vincent G Parenti
- Research Author, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | | | - Lynne M Koweek
- Panel Chair, Duke University Medical Center, Durham, North Carolina
| | | | | | | | | | - Nicole A Keefe
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Bruce M Lo
- Sentara Norfolk General Hospital/Eastern Virginia Medical School, Norfolk, Virginia; American College of Emergency Physicians
| | - Sachin B Malik
- VA Palo Alto Health Care System, Palo Alto, California and Stanford University, Stanford, California
| | - Devaki Shilpa Surasi
- The University of Texas MD Anderson Cancer Center, Houston, Texas; Commission on Nuclear Medicine and Molecular Imaging
| | - Kathleen Waite
- Duke University Medical Center, Durham, North Carolina, Primary care physician
| | - Eric E Williamson
- Mayo Clinic, Rochester, Minnesota; Society of Cardiovascular Computed Tomography
| | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas
| | - Karin E Dill
- Specialty Chair, Emory University Hospital, Atlanta, Georgia
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Kauw F, Velthuis BK, Takx RAP, Guglielmo M, Cramer MJ, van Ommen F, Bos A, Bennink E, Kappelle LJ, de Jong HWAM, Dankbaar JW. Detection of Cardioembolic Sources With Nongated Cardiac Computed Tomography Angiography in Acute Stroke: Results From the ENCLOSE Study. Stroke 2023; 54:821-830. [PMID: 36779342 PMCID: PMC9951793 DOI: 10.1161/strokeaha.122.041018] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
BACKGROUND Identifying cardioembolic sources in patients with acute ischemic stroke is important for the choice of secondary prevention strategies. We prospectively investigated the yield of admission (spectral) nongated cardiac computed tomography angiography (CTA) to detect cardioembolic sources in stroke. METHODS Participants of the ENCLOSE study (Improved Prediction of Recurrent Stroke and Detection of Small Volume Stroke) with transient ischemic attack or acute ischemic stroke with assessable nongated head-to-heart CTA at the University Medical Center Utrecht were included between June 2017 and March 2022. The presence of cardiac thrombus on cardiac CTA was based on a Likert scale and dichotomized into certainly or probably absent versus possibly, probably, or certainly present. The diagnostic certainty of cardiac thrombus was evaluated again on spectral computed tomography reconstructions. The likelihood of a cardioembolic source was determined post hoc by an expert panel in patients with cardiac thrombus on CTA. Parametric and nonparametric tests were used to compare the outcome groups. RESULTS Forty four (12%) of 370 included patients had a cardiac thrombus on admission CTA: 35 (9%) in the left atrial appendage and 14 (4%) in the left ventricle. Patients with cardiac thrombus had more severe strokes (median National Institutes of Health Stroke Scale score, 10 versus 4; P=0.006), had higher clot burden (median clot burden score, 9 versus 10; P=0.004), and underwent endovascular treatment more often (43% versus 20%; P<0.001) than patients without cardiac thrombus. Left atrial appendage thrombus was present in 28% and 6% of the patients with and without atrial fibrillation, respectively (P<0.001). The diagnostic certainty for left atrial appendage thrombus was higher for spectral iodine maps compared with the conventional CTA (P<0.001). The presence of cardiac thrombus on CTA increased the likelihood of a cardioembolic source according to the expert panel (P<0.001). CONCLUSIONS Extending the stroke CTA to cover the heart increases the chance of detecting cardiac thrombi and helps to identify cardioembolic sources in the acute stage of ischemic stroke with more certainty. Spectral iodine maps provide additional value for detecting left atrial appendage thrombus. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04019483.
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Affiliation(s)
- Frans Kauw
- Department of Radiology (F.K., B.K.V., R.A.P.T., F.v.O., A.B., E.B., H.W.A.M.d.J., J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands.,Brain Center, Department of Neurology and Neurosurgery (F.K., L.J.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Birgitta K Velthuis
- Department of Radiology (F.K., B.K.V., R.A.P.T., F.v.O., A.B., E.B., H.W.A.M.d.J., J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Richard A P Takx
- Department of Radiology (F.K., B.K.V., R.A.P.T., F.v.O., A.B., E.B., H.W.A.M.d.J., J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Marco Guglielmo
- Department of Cardiology (M.G., M.J.C.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Maarten J Cramer
- Department of Cardiology (M.G., M.J.C.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Fasco van Ommen
- Department of Radiology (F.K., B.K.V., R.A.P.T., F.v.O., A.B., E.B., H.W.A.M.d.J., J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Anneloes Bos
- Department of Radiology (F.K., B.K.V., R.A.P.T., F.v.O., A.B., E.B., H.W.A.M.d.J., J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Edwin Bennink
- Department of Radiology (F.K., B.K.V., R.A.P.T., F.v.O., A.B., E.B., H.W.A.M.d.J., J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - L Jaap Kappelle
- Brain Center, Department of Neurology and Neurosurgery (F.K., L.J.K.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Hugo W A M de Jong
- Department of Radiology (F.K., B.K.V., R.A.P.T., F.v.O., A.B., E.B., H.W.A.M.d.J., J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Jan W Dankbaar
- Department of Radiology (F.K., B.K.V., R.A.P.T., F.v.O., A.B., E.B., H.W.A.M.d.J., J.W.D.), University Medical Center Utrecht, Utrecht University, the Netherlands
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Rinkel LA, Beemsterboer CFP, Groeneveld NS, Lobé NHJ, Boekholdt SM, Bouma BJ, Muller FF, Beenen LFM, Marquering HA, Majoie CBLM, Roos YBWEM, van Randen A, Planken RN, Coutinho JM. Cardiac thrombi detected by CT in patients with acute ischemic stroke: A substudy of Mind the Heart. Eur Stroke J 2022; 8:168-174. [PMID: 37021199 PMCID: PMC10069221 DOI: 10.1177/23969873221130838] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 09/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Cardiac thrombi are a major risk factor for ischemic stroke, but are rarely diagnosed in the acute phase. We examined characteristics and functional outcome of patients with ischemic stroke and a concomitant cardiac thrombus detected on cardiac CT performed in the acute phase. Patients and Methods: We used data from “Mind the Heart,” a prospective cohort study in which consecutive adult patients with acute ischemic stroke underwent prospective ECG-gated cardiac CT during their acute stroke imaging protocol. We compared characteristics, functional outcome (modified Rankin scale) and stroke recurrence rate at 90 days of patients with a cardiac thrombus on CT (defined as filling defect <100 Hounsfield Units) to those without a cardiac thrombus. Results: Among 452 included patients, cardiac CT detected 41 thrombi in 38 (8%) patients. Thrombi were most often located in the left atrial appendage (31/38 [82%]). Patients with a cardiac thrombus more frequently had intracranial occlusions in multiple vascular territories (5% vs 0.5%, p = 0.04) and a higher baseline NIHSS score (17 [IQR 6–22] vs 5 [IQR 2–3], p < 0.001) compared to patients without a cardiac thrombus. In 13/38 (34%) patients with a cardiac thrombus, no atrial fibrillation was detected. A cardiac thrombus was associated with worse functional outcome (adjusted common odds ratio 3.18 95%CI 1.68–6.00). Recurrence rate was not significantly different (8% vs 4%, aOR 1.50 (0.39–5.82). Discussion and Conclusion: Cardiac CT detected a cardiac thrombus in one in every 12 patients with acute ischemic stroke, and these patients had more severe deficits, multivessel occlusions, and a worse functional outcome.
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Affiliation(s)
- Leon A Rinkel
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Chiel FP Beemsterboer
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Nick HJ Lobé
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fenna F Muller
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ludo FM Beenen
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Henk A Marquering
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Departments of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles BLM Majoie
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo BWEM Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Adrienne van Randen
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R Nils Planken
- Departments of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Li W, Liu M, Yu F, Zhu W, Yu X, Guo X, Yang Q. Detection of left atrial appendage thrombus by dual-energy computed tomography-derived imaging biomarkers in patients with atrial fibrillation. Front Cardiovasc Med 2022; 9:809688. [PMID: 35935656 PMCID: PMC9354661 DOI: 10.3389/fcvm.2022.809688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 06/29/2022] [Indexed: 11/22/2022] Open
Abstract
Aims This study aimed to assess the diagnostic performances of dual-energy computed tomography (CT)-derived iodine concentration and effective atomic number (Zeff) in early-phase cardiac CT in detecting left atrial appendage (LAA) thrombus and differentiating thrombus from spontaneous echo contrast (SEC) in patients with atrial fibrillation using transesophageal echocardiography (TEE) as the reference standard. Methods and results A total of 389 patients with atrial fibrillation were prospectively recruited. All patients underwent a single-phase cardiac dual-energy CT scan using a third-generation dual-source CT. The iodine concentration, Zeff, and conventional Hounsfield units (HU) in the LAA were measured and normalized to the ascending aorta (AA) of the same slice to calculate the LAA/AA ratio. Of the 389 patients, TEE showed thrombus in 15 (3.9%), SEC in 33 (8.5%), and no abnormality in 341 (87.7%) patients. Using TEE findings as the reference standard, the respective sensitivity, specificity, positive predictive value, and negative predictive value of the LAA/AA HU ratio for detecting LAA thrombus were 100.0, 96.8, 55.6, and 100.0%; those of the LAA/AA iodine concentration ratio were 100.0, 99.2, 83.3, and 100.0%; and those of the LAA/AA Zeff ratio were 100.0, 98.9, 79.0, and 100.0%. The areas under the receiver operator characteristic curve (AUC) of the LAA/AA iodine concentration ratio (0.978; 95% CI 0.945–1.000) and Zeff ratio (0.962; 95% CI 0.913–1.000) were significantly larger than that of the LAA/AA HU ratio (0.828; 95% CI 0.714–0.942) in differentiating the thrombus from the SEC (both P < 0.05). Although the AUC of the LAA/AA iodine concentration ratio was larger than that of the LAA/AA Zeff ratio, no significant difference was found between them (P = 0.259). Conclusion The dual-energy CT-derived iodine concentration and the Zeff showed better diagnostic performance than the conventional HU in early-phase cardiac CT in detecting LAA thrombus and differentiating the thrombus from the circulatory stasis. However, these results need to be validated in large-cohort studies with late-phase images.
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Affiliation(s)
- Wenhuan Li
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Mingxi Liu
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Fangfang Yu
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Weiwei Zhu
- Department of Echocardiography, Heart Center, Capital Medical University, Beijing, China
| | - Xianbo Yu
- CT Collaboration, Siemens Healthineers Ltd., Beijing, China
| | - Xiaojuan Guo
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Xiaojuan Guo,
| | - Qi Yang
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- *Correspondence: Qi Yang,
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Steinbrecher KL, Marquis KM, Bhalla S, Mellnick VM, Ohman JW, Raptis CA. CT of the Difficult Acute Aortic Syndrome. Radiographics 2021; 42:69-86. [PMID: 34951836 DOI: 10.1148/rg.210098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute aortic syndrome (AAS) is classically attributed to three underlying pathologic conditions-aortic dissection (AD), intramural hematoma (IMH), and penetrating atherosclerotic ulcer (PAU). In the majority of cases, the basics of image interpretation are not difficult and have been extensively reviewed in the literature. In this article, the authors extend existing imaging overviews of AAS by highlighting additional factors related to the diagnosis, classification, and characterization of difficult AAS cases. It has been well documented that AAS is caused not only by an AD but by a spectrum of lesions that often have overlap in imaging features and are not clearly distinguishable. Specifically, phase of contrast enhancement, flow artifacts, and flapless AD equivalents can complicate diagnosis and are discussed. While the A/B dichotomy of the Stanford system is still used, the authors subsequently emphasize the Society for Vascular Surgery's new guidelines for the description of acute aortic pathologic conditions given the expanded use of endovascular techniques used in aortic repair. In the final section, atypical aortic rupture and pitfalls are described. As examples of pericardial and shared sheath rupture become more prevalent in the literature, it is important to recognize contrast material third-spacing and mediastinal blood as potential mimics. By understanding these factors related to difficult cases of AAS, the diagnostic radiologist will be able to accurately refine CT interpretation and thus provide information that is best suited to directing management. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Kacie L Steinbrecher
- From the Mallinckrodt Institute of Radiology (K.L.S., K.M.M., S.B., V.M.M., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - Kaitlin M Marquis
- From the Mallinckrodt Institute of Radiology (K.L.S., K.M.M., S.B., V.M.M., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - Sanjeev Bhalla
- From the Mallinckrodt Institute of Radiology (K.L.S., K.M.M., S.B., V.M.M., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - Vincent M Mellnick
- From the Mallinckrodt Institute of Radiology (K.L.S., K.M.M., S.B., V.M.M., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - J Westley Ohman
- From the Mallinckrodt Institute of Radiology (K.L.S., K.M.M., S.B., V.M.M., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
| | - Constantine A Raptis
- From the Mallinckrodt Institute of Radiology (K.L.S., K.M.M., S.B., V.M.M., C.A.R.) and Department of Surgery (J.W.O.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110
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Yu S, Zhang H, Li H. Cardiac Computed Tomography Versus Transesophageal Echocardiography for the Detection of Left Atrial Appendage Thrombus: A Systemic Review and Meta-Analysis. J Am Heart Assoc 2021; 10:e022505. [PMID: 34796743 PMCID: PMC9075398 DOI: 10.1161/jaha.121.022505] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background Transesophageal echocardiography (TEE) has been considered the gold standard for left atrial appendage (LAA) thrombus detection. Nevertheless, TEE may sometimes induce discomfort and cause complications. Cardiac computed tomography has been studied extensively for LAA thrombus detection. We performed this systemic review and meta-analysis to assess the diagnostic accuracy of cardiac computed tomography for LAA thrombus detection compared with TEE. Methods and Results A systemic search was conducted in the PubMed, Embase, and Cochrane Library databases from January 1977 to February 2021. Studies performed for assessment diagnostic accuracy of cardiac computed tomography on LAA thrombus compared with TEE were included. Summary sensitivity, specificity, and posterior probability of LAA thrombus was calculated by using bivariate random-effects model. The Quality Assessment of Diagnostic Accuracy Studies-2 tool was used for the quality assessment. A total of 27 studies involving 6960 patients were included in our study. The summary sensitivity of early imaging studies was 0.95 (95% CI, 0.79-0.99), and the specificity was 0.89 (95% CI, 0.85-0.92). The positive posterior probability was 19.11%, and the negative posterior probability was 0.16%. The summary sensitivity of delayed imaging studies was 0.98 (95% CI, 0.92-1.00), and the specificity was 1.00 (95% CI, 0.98-1.00). The positive posterior probability was 95.76%, and the negative posterior probability was 0.12%. The delayed imaging method significantly improved the specificity (1.00 versus 0.89; P<0.05) and positive posterior probability (95.76% versus 19.11%; P<0.05). Conclusions Cardiac computed tomography with a delayed imaging is a reliable alternative to TEE. It may save the patient and health care from an excess TEE. Registration URL: https://www.crd.york.ac.uk/PROSPERO; Unique identifier: CRD42021236352.
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Affiliation(s)
- Shandong Yu
- Department of CardiologyCardiovascular CenterBeijing Friendship HospitalBeijingChina
| | - Heping Zhang
- Department of CardiologyCardiovascular CenterBeijing Friendship HospitalBeijingChina
| | - Hongwei Li
- Department of CardiologyCardiovascular CenterBeijing Friendship HospitalBeijingChina
- Department of Internal MedicineMedical Health CenterBeijing Friendship HospitalBeijingChina
- Beijing Key Laboratory of Metabolic Disorder‐Related Cardiovascular DiseaseBeijingChina
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Tanaka M, Yasuoka R, Nagano T, Kotake Y, Maruyama M, Yamamoto H, Iwanaga Y, Hirano Y, Nakazawa G, Kurita T. A novel method to demonstrate thrombus formation of the left atrial appendage in patients with persistent atrial fibrillation by cardiac computed tomography. IJC HEART & VASCULATURE 2021; 36:100866. [PMID: 34527805 PMCID: PMC8433278 DOI: 10.1016/j.ijcha.2021.100866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/24/2021] [Indexed: 11/28/2022]
Abstract
We created a new algorism to detect a left atrial appendage (LAA) thrombus on CT. We measured HU density at one proximal (ostium) and seven distal sites of LAA. A distal/proximal ratio and a standard deviation of HU density were analyzed by ROC. Combination of the two parameters demonstrated a high accuracy for LAA thrombus.
Background Transesophageal echocardiography (TEE) is currently the gold standard technique for diagnosing left atrial appendage (LAA) thrombi. Cardiac computed tomography (CT) has been expected to become an alternative method to TEE; however, a reliable quantitative evaluation method has not been established. Methods and results We enrolled 177 patients with persistent atrial fibrillation who underwent both cardiac CT and TEE before catheter ablation. The patients were classified into two groups according to the TEE results: the thrombus group (13 patients) and non-thrombus group (164 patients). The Hounsfield unit (HU) density at the proximal LAA (LAAp) and distal LAA (LAAd) was measured on cardiac CT images. The LAAd/LAAp HU ratio and standard deviation of HU density (HU-SD) at the LAAd were evaluated. We created an algorithm by decision tree analysis to predict LAA thrombus formation using the HU ratio and HU-SD. Definite absence of LAA thrombus (Category-I) was diagnosed for 139 patients by combining the first and second branching of the decision tree (Category-Ia: HU ratio of ≥0.26, Category-Ib: HU ratio of <0.26, HD-SD of ≥26.94). Definite presence of LAA thrombus (Category-Ⅱ) was diagnosed for 3 patients using the third branching of the decision tree (Category-Ⅱ: HU ratio of <0.26 and HU-SD of <13.85). Highly possibility of LAA thrombus (Category-III), but not definite, was diagnosed for the remaining 35 patients; therefore, these patients required diagnostic TEE. The diagnostic accuracy of this algorithm was 0.95. Conclusion We have proposed a reliable algorithm to diagnose LAA thrombus formation using the HU ratio and HU-SD.
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Affiliation(s)
- Motohide Tanaka
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Ryobun Yasuoka
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Tomoya Nagano
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Yasuhito Kotake
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Masahiro Maruyama
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Hiromi Yamamoto
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Yoshitaka Iwanaga
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Yutaka Hirano
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Gaku Nakazawa
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Takashi Kurita
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
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Gwak DS, Choi W, Kim YW, Kim YS, Hwang YH. Impact of Left Atrial Appendage Morphology on Recurrence in Embolic Stroke of Undetermined Source and Atrial Cardiopathy. Front Neurol 2021; 12:679320. [PMID: 34239496 PMCID: PMC8258144 DOI: 10.3389/fneur.2021.679320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/03/2021] [Indexed: 11/15/2022] Open
Abstract
Background: The left atrial appendage (LAA) is a major source of thrombus and non-chicken wing (CW). LAA morphology is a risk factor for embolic events in atrial fibrillation. However, the association of non-CW morphology with embolic stroke recurrence is unknown in patients with embolic stroke of undetermined source (ESUS) and atrial cardiopathy. Methods: We conducted retrospective analyses using a prospective institutional stroke registry (2013–2017). Patients with ESUS and atrial cardiopathy were enrolled. Atrial cardiopathy was diagnosed if an increased left atrial diameter (>40 mm, men; >38 mm, women), supraventricular tachycardia, or LAA filling defect on computed tomography (CT) were present. Patients admitted >24 h after onset were excluded. LAA morphology was evaluated using CT and categorized into CW vs. non-CW types. The primary outcome was embolic stroke recurrence. Multivariable Cox proportional hazards models were used to examine the independent association between LAA morphology and outcome. Results: Of 157 patients, 81 (51.6%) had CW LAA morphology. The median follow-up was 41.5 (interquartile range 12.3–58.5) months corresponding to 509.8 patient years. In total, 18 participants experienced embolic stroke recurrences (3.80 per 100 patient-years). Non-CW morphology was more associated with embolic stroke recurrence than CW morphology (hazard ratio (HR), 3.17; 95% confidence interval (CI), 1.13–8.91; p = 0.029). After adjusting for CHA2DS2-VASc score and number of potential embolic sources, non-CW morphology showed an independent association with outcome (adjusted HR, 2.90; 95% CI, 1.02–8.23; p = 0.045). Conclusions: The LAA morphology types may help identify high risk of embolic stroke recurrence in ESUS with atrial cardiopathy. LAA morphology in atrial cardiopathy may provide clues for developing therapies tailored to specific mechanisms.
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Affiliation(s)
- Dong-Seok Gwak
- Department of Neurology, Kyungpook National University Hospital, Daegu, South Korea
| | - WooChan Choi
- Department of Neurology, Kyungpook National University Hospital, Daegu, South Korea
| | - Yong-Won Kim
- Department of Neurology, Kyungpook National University Hospital, Daegu, South Korea.,Department of Neurology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Yong-Sun Kim
- Department of Radiology, Kyungpook National University Hospital, Daegu, South Korea.,Department of Radiology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University Hospital, Daegu, South Korea.,Department of Neurology, School of Medicine, Kyungpook National University, Daegu, South Korea
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10
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Chaosuwannakit N, Makarawate P. Prevalence of intracardiac thrombi on cardiac computed tomography angiography: Outcome and impact on consequent management. Eur J Radiol Open 2021; 8:100330. [PMID: 33665232 PMCID: PMC7902280 DOI: 10.1016/j.ejro.2021.100330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/04/2021] [Accepted: 02/08/2021] [Indexed: 11/27/2022] Open
Abstract
Objective Intracardiac thrombi are intermittently come across on cardiac computed tomography angiography (CCTA). This study aimed to examine the prevalence, outcome, and prognosis in patients with incidental found left-sided cardiac thrombi on CCTA. Material and Methods The Ethics Committee approved the present study of the Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. A retrospective review of CCTA was performed for incidental left-sided cardiac thrombi. Results A total of 1080 CCTAs were enrolled with the prevalence of incidental left-sided cardiac thrombi is 4.53%. Of the 49 patients with CCTA incidental left-sided cardiac thrombi, 16 had left atrial thrombi, and 33 had left ventricular thrombi. All thrombi were undetermined before the CCTA, and their identification subsequently generated anticoagulation treatment. In 10 patients, embolic complications happened, 4 of which were fatal. Patients with incidental detected left-sided intracardiac thrombi seen by CCTA had more embolic event than patients who did not discover left-sided intracardiac thrombi by CCTA (HR = 8.07; 95% CI 1.48-44.06; p = 0.016). Conclusions Incidental left-sided cardiac thrombi on CCTA guided to management adjustments and seemed to present substantial mortality and morbidity in the present study. Physicians who interpret CCTA should ensure a dedicated effort not to disregard these prospective pitfalls.
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Affiliation(s)
- Narumol Chaosuwannakit
- Radiology Department, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40000, Thailand
| | - Pattarapong Makarawate
- Cardiology Unit, Internal medicine Department, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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11
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Spagnolo P, Giglio M, Di Marco D, Cannaò PM, Agricola E, Della Bella PE, Monti CB, Sardanelli F. Diagnosis of left atrial appendage thrombus in patients with atrial fibrillation: delayed contrast-enhanced cardiac CT. Eur Radiol 2020; 31:1236-1244. [PMID: 32886202 PMCID: PMC7880950 DOI: 10.1007/s00330-020-07172-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 06/05/2020] [Accepted: 08/10/2020] [Indexed: 12/11/2022]
Abstract
Objectives The current reference standard for diagnosing LAA thrombi is transesophageal echocardiography (TEE), a semi-invasive technique. We aimed to devise an optimal protocol for cardiac computed tomography (CCT) in diagnosing left atrial appendage (LAA) thrombus in patients with atrial fibrillation (AF), using TEE as reference standard. Methods Two hundred sixty consecutive patients referred for radiofrequency ablation for AF were prospectively enrolled. All patients underwent CCT and TEE within 2 hours. The CCT protocol included one standard angiographic phase and three delayed acquisitions at 1-, 3-, and 6-min after contrast injection. Thrombi were defined as persisting defects at 6-min delayed acquisition. Results TEE demonstrated spontaneous contrast in 52 (20%) patients and thrombus in 10 (4%). In 63 patients (24%), CCT demonstrated LAA early filling defects at angiographic phase. Among them, 15 (6%) had a persistent defect at 1-min, 12 (5%) at 3-min, and 10 (4%) at 6-min. All 10 thrombi diagnosed on TEE were correctly identified by delayed CCT, without any false positives. For all phases, sensitivity and negative predictive were 100%. Specificity increased from 79% for the angiographic phase to 100% at 6-min. Positive predictive value increased from 16% to 100%. Estimated radiation exposure was 2.08 ± 0.76 mSv (mean ± standard deviation) for the angiographic phase and 0.45 ± 0.23 mSv for each delayed phase. Conclusion A CCT protocol adding a 6-min delayed phase to the angiographic phase can be considered optimized for the diagnosis of LAA thrombi, with a low radiation dose. Key Points • In patients with persistent atrial fibrillation referred for ablation procedures, a cardiac CT examination comprising an angiographic-phase acquisition and, in case of filling defects, a 6-min delayed phase may help reduce the need for transesophageal echocardiography. • Cardiac CT would provide morphological and volumetric data, along with the potential to exclude the presence of thrombi in the left atrial appendage.
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Affiliation(s)
- Pietro Spagnolo
- Department of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Manuela Giglio
- Department of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Daniela Di Marco
- Department of Radiology, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Paola M Cannaò
- Department of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Eustachio Agricola
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo E Della Bella
- Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Caterina B Monti
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy.
| | - Francesco Sardanelli
- Department of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
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Differentiation of left atrial appendage thrombus from circulatory stasis using cardiac CT radiomics in patients with valvular heart disease. Eur Radiol 2020; 31:1130-1139. [PMID: 32812175 DOI: 10.1007/s00330-020-07173-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/19/2020] [Accepted: 08/10/2020] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To determine whether quantitative radiomic features from cardiac CT could differentiate the left atrial appendage (LAA) thrombus from circulatory stasis in patients with valvular heart disease. METHODS Ninety-five consecutive patients with valvular heart disease and filling defects in LAA on two-phase cardiac CT from March 2016 to August 2018 were retrospectively enrolled and classified as having thrombus or stasis by transesophageal echocardiography or cardiac surgery. The ratio of Hounsfield units in the filling defects to those in the ascending aorta (AA) was calculated on early- and late-phase CT (LAA/AAE and LAA/AAL, respectively). Radiomic features were extracted from semi-automated three-dimensional segmentation of the filling defect on early-phase CT. The diagnostic ability of radiomic features for differentiating thrombus from stasis was assessed and compared to LAA/AAE and LAA/AAL by comparing the AUC of ROC curves. Diagnostic performances of CT attenuation ratios and radiomic features were validated with an independent validation set. RESULTS Thrombus was diagnosed in 25 cases and stasis in 70. Sixty-eight radiomic features were extracted. Values of 8 wavelet-transformed features were lower in thrombus than in stasis (p < 0.001). The AUC value of a radiomic feature, wavelet_LHL, for diagnosing thrombus was 0.78, which was higher than that of LAA/AAE (AUC = 0.54, p = 0.025) and similar to that of LAA/AAL (AUC = 0.76, p = 0.773). In the validation set, the AUC of wavelet_LHL was 0.71, which was higher than that of LAA/AAE (AUC = 0.57, p = 0.391) and similar to that of LAA/AAL (AUC = 0.75, p = 0.707). CONCLUSIONS Quantitative radiomic features from the early phase of cardiac CT may help diagnose LAA thrombus in patients with valvular heart disease. KEY POINTS • Wavelet-transformed grey-level non-uniformity values from radiomic analysis are significantly lower for LAA thrombus than for circulatory stasis. • Radiomic features may have an additional value for differentiating LAA thrombus from circulatory stasis when interpreting single-phase cardiac CT. • Radiomic features extracted from single-phase images may show similar diagnostic ability as conventional quantitative analysis from two-phase images.
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Arabia L, Lucino S, Tibaldi J, Gambi DL, García R, Pérez ME, Bottello F. Use of Computed Tomography Scan to Rule Out Phantom Thrombus in the Left Atrial Appendage. JOURNAL OF CARDIAC ARRHYTHMIAS 2020. [DOI: 10.24207/jca.v33i1.3392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Occurrence of left atrial appendage (LAA) thrombus is a frequent complication of atrial fibrillation (AF) and it increase thromboembolic risk. Transesophageal echocardiography (TEE) is considered the gold standard to ensure that this chamber is thrombus free. Multidetector computed tomography (CT) scan has some advantages such the possibility to get 3D reconstruction and explore another structures in relationship with the LAA. However, lack of specificity in case of false positive images with filling defects due to slow velocities in the LAA. Methods and Results: 34 patiens with suspected thrombus by a previous CT scan or transesophageal echo were included in analisys. The aim of study was evaluated the utility of CT scan with delayed acquisition protocol to exclude LAA thrombus. In all of patients, complete LAA filling was observed, with a sensitivity, specificity and negative predictive value of 100% to differentiate circulatory stasis from thrombus. Conclusion: Perform a CT scan with a delayed acquisition protocol and in prone position are safe techniques to rule out fake thrombus.
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A Predictor for Defects in Filling of the Left Atrial Appendage on Cardiac Computed Tomography in Patients With Atrial Fibrillation. J Comput Assist Tomogr 2020; 44:284-288. [DOI: 10.1097/rct.0000000000000984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Approach to Abnormal Chest Computed Tomography Contrast Enhancement in the Hospitalized Patient. Radiol Clin North Am 2020; 58:93-103. [DOI: 10.1016/j.rcl.2019.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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16
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Detection of left atrial appendage thrombi by third-generation dual-source dual-energy CT: Iodine concentration versus conventional enhancement measurements. Int J Cardiol 2019; 292:265-270. [PMID: 31072634 DOI: 10.1016/j.ijcard.2019.04.079] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/31/2019] [Accepted: 04/25/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Dual-energy computed tomography (DECT) can differentiate iodine from other materials through the material decomposition technique. The purpose of this study was to compare the diagnostic performance of DECT-derived iodine concentration (mg/ml) with conventional enhancement measurements (HU), in detecting left atrial appendage (LAA) thrombi and differentiating thrombi from circulatory stasis in atrial fibrillation (AF) patients referred for catheter ablation. METHODS Consecutive patients were prospectively recruited and scanned using a third-generation dual-source CT system in dual-energy mode. Regions of interest were placed inside the filling defect in the LAA and ascending aorta (AA) of the same sections, to determine iodine concentration and the LAA/AA HU ratio. The diagnostic performance of iodine concentration and LAA/AA HU ratios were compared using transesophageal echocardiography (TEE) as the reference standard. RESULTS Among 302 patients, 10 thrombi and 27 cases with spontaneous echo contrast (SEC) were detected by TEE. Diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of iodine concentration were superior to those of LAA/AA HU ratios (iodine concentration: 99.7%, 100%, 99.7%, 90.9%, and 100% vs. LAA/AA HU ratios: 96.0%, 100%, 95.9%, 45.5%, and 100%) in detecting LAA thrombi. The area under the receiver operating characteristic curve of iodine concentration (0.996; 0.898-1.000) was significantly larger than that of the LAA/AA HU ratio (0.881; 0.733-0.964) in differentiating thrombi from circulatory stasis (p < 0.05). CONCLUSIONS DECT-derived iodine concentration was associated with improved diagnostic accuracy compared with conventional enhancement measurements in detecting LAA thrombi and differentiating thrombi from circulatory stasis in AF patients.
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18
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Li X, Kondray V, Tavri S, Ruhparwar A, Azeze S, Dey A, Partovi S, Rengier F. Role of imaging in diagnosis and management of left ventricular assist device complications. Int J Cardiovasc Imaging 2019; 35:1365-1377. [PMID: 30830527 DOI: 10.1007/s10554-019-01562-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 02/11/2019] [Indexed: 12/14/2022]
Abstract
Heart failure is a clinical condition that is associated with significant morbidity and mortality. With the advent of left ventricular assist device (LVAD), an increasing number of patients have received an artificial heart both as a bridge-to-therapy and as a destination therapy. Clinical trials have shown clear survival benefits of LVAD implantation. However, the increased survival benefits and improved quality of life come at the expense of an increased complication rate. Common complications include perioperative bleeding, infection, device thrombosis, gastrointestinal bleeding, right heart failure, and aortic hemodynamic changes. The LVAD-associated complications have unique pathophysiology. Multiple imaging modalities can be employed to investigate the complications, including computed tomography (CT), positron emission tomography-computed tomography (PET-CT), catheter angiography and echocardiography. Imaging studies not only help ascertain diagnosis and evaluate the severity of disease, but also help direct relevant clinical management and predict prognosis. In this article, we aim to review the common LVAD complications, present the associated imaging features and discuss the role of imaging in their management.
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Affiliation(s)
- Xin Li
- Department of Radiology, Section of Interventional Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Victor Kondray
- Department of Radiology, Section of Interventional Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sidhartha Tavri
- Department of Radiology, Section of Interventional Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Samuel Azeze
- Department of Radiology, Section of Interventional Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Aritra Dey
- Department of Radiology, Section of Interventional Radiology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sasan Partovi
- Department of Radiology, Section of Interventional Radiology, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Fabian Rengier
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
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Marques H, de Araújo Gonçalves P, Ferreira AM, Cruz R, Lopes J, Santos RD, Radu L, Costa F, Mesquita J, Carmo P, Cavaco D, Parreira L, Pisco J, Goyri O'Neill J, Adragão P. Cardiac computed tomography previous to atrial fibrillation ablation - effects of technological improvements and protocol optimization. Rev Port Cardiol 2018; 37:873-883. [PMID: 30466816 DOI: 10.1016/j.repc.2018.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 02/08/2018] [Accepted: 03/11/2018] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Cardiac computed tomography (CT) can provide a precise tridimentional anatomic map and exclude intra-cardiac thrombus. We aimed to access the impact of CT protocol optimization and technological evolution on the contrast and radiation dose as well as on image quality previous to atrial fibrillation (AF) ablation. METHODS From a prospective registry of consecutive patients who underwent cardiac CT in a single center, we selected 270 patients in whom the CT was done for evaluation prior to AF ablation and they were distributed in 3 groups: Group1: the first 150 patients included; Group2: the last 60 patients performed with the same CT scanner; Group3: the first 60 exams performed with the new CT scanner. Quality of the protocol was access based on radiation dose, contrast volume used, the use of a second (delayed) acquisition, and on quantitative image quality analisis (signal to noise and contrast to noise ratios; density homogeneity racio between LA and LAA). RESULTS We found a significant radiation dose as well as contrast dose reduction between the first and last subgroups (G1: 5,6mSv and 100ml; G2: 1,3mSv and 90ml; G3: 0,6mSv and 65ml). Even though group 3 had less radiation and contrast used it still had better quantitative image quality (signal/noise of 13,5; contrast/noise 14,8; density homogeneity racio of 0,92). CONCLUSION Protocol optimization and technology both contributed to significant lower radiation dose and contrast volume used on cardiac CTs prior to AF ablation, without compromising image quality.
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Affiliation(s)
- Hugo Marques
- Unidade de Imagem Cardiovascular por TC e RM (Unica), Centro de Imagiologia, Hospital da Luz, Lisboa, Portugal; Serviço de Radiologia, Hospital de Santa Marta, CHLC, Lisboa, Portugal; Nova Medical School, Lisboa, Portugal
| | - Pedro de Araújo Gonçalves
- Unidade de Imagem Cardiovascular por TC e RM (Unica), Centro de Imagiologia, Hospital da Luz, Lisboa, Portugal; Nova Medical School, Lisboa, Portugal; Serviço de Cardiologia, Hospital de Santa Cruz, CHLO, Lisboa, Portugal; Centro Cardiovascular, Hospital da Luz Lisboa, Portugal.
| | - António Miguel Ferreira
- Unidade de Imagem Cardiovascular por TC e RM (Unica), Centro de Imagiologia, Hospital da Luz, Lisboa, Portugal; Serviço de Cardiologia, Hospital de Santa Cruz, CHLO, Lisboa, Portugal
| | - Rita Cruz
- Serviço de Imagiologia, Hospital Beatriz Ângelo, Loures, Portugal
| | - João Lopes
- Serviço de Radiologia, Hospital de Santa Marta, CHLC, Lisboa, Portugal
| | - Rosana Dos Santos
- Unidade de Imagem Cardiovascular por TC e RM (Unica), Centro de Imagiologia, Hospital da Luz, Lisboa, Portugal; Serviço de Radiologia, Hospital de Santa Marta, CHLC, Lisboa, Portugal
| | - Lucian Radu
- Unidade de Imagem Cardiovascular por TC e RM (Unica), Centro de Imagiologia, Hospital da Luz, Lisboa, Portugal
| | - Francisco Costa
- Serviço de Cardiologia, Hospital de Santa Cruz, CHLO, Lisboa, Portugal; Centro Cardiovascular, Hospital da Luz Lisboa, Portugal
| | - João Mesquita
- Serviço de Cardiologia, Hospital de Santa Cruz, CHLO, Lisboa, Portugal; Centro Cardiovascular, Hospital da Luz Lisboa, Portugal
| | - Pedro Carmo
- Serviço de Cardiologia, Hospital de Santa Cruz, CHLO, Lisboa, Portugal; Centro Cardiovascular, Hospital da Luz Lisboa, Portugal
| | - Diogo Cavaco
- Serviço de Cardiologia, Hospital de Santa Cruz, CHLO, Lisboa, Portugal; Centro Cardiovascular, Hospital da Luz Lisboa, Portugal
| | | | | | | | - Pedro Adragão
- Serviço de Cardiologia, Hospital de Santa Cruz, CHLO, Lisboa, Portugal; Centro Cardiovascular, Hospital da Luz Lisboa, Portugal
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Cardiac computed tomography prior to atrial fibrillation ablation: Effects of technological advances and protocol optimization. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.repce.2018.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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21
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Kottmaier M, Jilek C, Berglar S, Reents T, Bourier F, Semmler V, Telishevska M, Koch-Büttner K, Lengauer S, Kornmayer M, Rousseva E, Brooks S, Hadamitzky M, Kolb C, Hessling G, Deisenhofer I. Exclusion of left atrial thrombus by dual-source cardiac computed tomography prior to catheter ablation for atrial fibrillation. Clin Res Cardiol 2018; 108:150-156. [PMID: 30051177 DOI: 10.1007/s00392-018-1333-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 07/16/2018] [Indexed: 11/26/2022]
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.
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Affiliation(s)
- Marc Kottmaier
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Lazarettstr. 36, 80636, Munich, Germany.
| | - Clemens Jilek
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Sophie Berglar
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Tilko Reents
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Felix Bourier
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Verena Semmler
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Martha Telishevska
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Katharina Koch-Büttner
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Sarah Lengauer
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Marielouise Kornmayer
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Elena Rousseva
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Stephanie Brooks
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Martin Hadamitzky
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Christoph Kolb
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Gabriele Hessling
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Lazarettstr. 36, 80636, Munich, Germany
| | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technische Universitaet Munich, Lazarettstr. 36, 80636, Munich, Germany
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22
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Deegan R, Ellis CR, Bennett JM. The Left Atrial Appendage, Including LAA Occlusion Devices Line Watchman, Amulet, and Lariat. Semin Cardiothorac Vasc Anesth 2018; 23:70-87. [PMID: 30020024 DOI: 10.1177/1089253218789159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Atrial fibrillation is a very common arrhythmia whose prevalence is expected to increase significantly as the population ages. The associated stroke risk is a major cause of morbidity and mortality. Stroke prevention by anticoagulation carries its own risks, leading to the search for alternative strategies. Multiple techniques have been developed to exclude the left atrial appendage (the main source of thromboembolism in atrial fibrillation) from the circulation. Such techniques offer the hope of stroke prevention without the risks of anticoagulation. This article describes the percutaneous approaches being currently performed in the United States. Particular emphasis is placed on the use of transesophageal echocardiography to guide these procedures.
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Affiliation(s)
- Robert Deegan
- 1 Vanderbilt University Medical Center, Nashville, TN, USA
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23
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Mosleh W, Sheikh A, Said Z, Ahmed MAA, Gadde S, Shah T, Wilson MF, Beck H, Kim C, Sharma UC. The use of cardiac-CT alone to exclude left atrial thrombus before atrial fibrillation ablation: Efficiency, safety, and cost analysis. Pacing Clin Electrophysiol 2018; 41:727-733. [PMID: 29667208 PMCID: PMC6192873 DOI: 10.1111/pace.13353] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 04/03/2018] [Accepted: 04/08/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a growing financial burden on the healthcare system. Cardiac computed tomographic angiography (CCTA) is needed for pulmonary vein mapping before AF ablation (AFA). CCTA has shown to be an alternative to transesophageal echocardiogram (TEE) to rule out left atrial appendage thrombus (LAAT) pre-AFA. We aim to examine the safety, cost-effectiveness, and time-efficiency of utilizing CCTA alone to rule out LAAT before AFA. METHODS We prospectively screened patients with paroxysmal AF undergoing cryoablation. CCTA with delayed enhancement was performed within 72 hours of AFA. Once LAAT was ruled out, patients were enrolled and planned TEE was cancelled. A retrospective control cohort that had both CCTA and TEE prior to AFA was identified. Direct cost data, electrophysiology laboratory utilization time, and 30-day stroke outcomes were collected from the EMR, follow-up phone calls, or clinic visits, and comparative analyses were performed. RESULTS Seventy patients met the inclusion criteria in the prospective CCTA-only cohort, and 71 for the retrospective CCTA+TEE cohort. Baseline characteristics were similar between the two groups. There was a nonsignificant reduction in overall cost ($15,870 ± 1,710 vs $16,557 ± 2,508, P = 0.06) in CCTA-only cohort, whereas the electrophysiology laboratory utilization time was significantly reduced (241.6 ± 41.7 vs 181.3 ±36.4 minutes, P < 0.001). There were no strokes reported on 30-day follow-up in the CCTA-only group. CONCLUSIONS In low-to-intermediate stroke risk patients with paroxysmal AF undergoing cryoablation, eliminating TEE and employing CCTA-only strategy to rule-out LAAT improves electrophysiology laboratory efficiency without influencing periprocedural cost or increasing postprocedural stroke risk.
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Affiliation(s)
- Wassim Mosleh
- Division of Cardiology, Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | - Ali Sheikh
- Division of Cardiology, Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | - Zaid Said
- Division of Cardiology, Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | | | - Siri Gadde
- Division of Cardiology, Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | - Tanvi Shah
- Division of Cardiology, Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | - Michael F Wilson
- Division of Cardiology, Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | - Hiroko Beck
- Division of Cardiology, Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | - Chee Kim
- Division of Cardiology, Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | - Umesh C Sharma
- Division of Cardiology, Department of Medicine, University at Buffalo, Buffalo, NY, USA
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24
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Kauw F, Dankbaar JW, Habets J, Cramer MJM, de Jong HWAM, Velthuis BK, Kappelle LJ. A Change of Heart: Yield of Cardiac Imaging in Acute Stroke Workup. Case Rep Neurol 2018; 10:118-123. [PMID: 29928217 PMCID: PMC6006656 DOI: 10.1159/000489254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 04/05/2018] [Indexed: 11/19/2022] Open
Abstract
This case report describes a patient who experienced a recurrent ischemic stroke within 24 h. Dual-energy computed tomography (DECT) angiography on admission showed 2 intracardiac thrombi, 1 in the left ventricle and 1 in the left atrial appendage. Following the second ischemic event, repeated DECT angiography showed that the ventricular thrombus had considerably diminished, suggesting that the recurrent brain infarction was caused by cardioembolism. This case emphasizes (1) the potential benefit of cardiac evaluation through CT angiography in the acute stroke setting, and (2) the use of DECT angiography for the detection of thrombus and the differentiation between thrombus, the myocardial wall, and a slow flow of contrast.
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Affiliation(s)
- Frans Kauw
- Department of Radiology, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Jan W Dankbaar
- Department of Radiology, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Jesse Habets
- Department of Radiology, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Maarten J M Cramer
- Department of Cardiology, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Hugo W A M de Jong
- Department of Radiology, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Birgitta K Velthuis
- Department of Radiology, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - L Jaap Kappelle
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
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25
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Korsholm K, Jensen JM, Nielsen-Kudsk JE. Cardiac Computed Tomography for Left Atrial Appendage Occlusion: Acquisition, Analysis, Advantages, and Limitations. Interv Cardiol Clin 2018. [PMID: 29526291 DOI: 10.1016/j.iccl.2017.12.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Transcatheter left atrial appendage occlusion is increasingly used for stroke prevention in atrial fibrillation. The technique has proven effective and safe in randomized trials and multiple observational studies. The procedure is challenging due to the complex anatomy of the left atrial appendage; accurate cardiac imaging is essential for procedural guidance. Transesophageal echocardiography is the gold standard, but cardiac computed tomography (CT) has gained increasing interest within recent years. Cardiac CT offers high-resolution imaging allowing for preprocedural anatomic evaluation and device sizing, but may also be useful for exclusion of left atrial appendage thrombus, and follow-up assessment of residual peri-device leaks.
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Affiliation(s)
- Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N DK-8200, Denmark
| | - Jesper Møller Jensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N DK-8200, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N DK-8200, Denmark.
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26
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Delgado V, Di Biase L, Leung M, Romero J, Tops LF, Casadei B, Marrouche N, Bax JJ. Structure and Function of the Left Atrium and Left Atrial Appendage. J Am Coll Cardiol 2017; 70:3157-3172. [DOI: 10.1016/j.jacc.2017.10.063] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 10/22/2017] [Indexed: 12/12/2022]
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27
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Incidence of Pulmonary Vein Stenosis After Radiofrequency Catheter Ablation of Atrial Fibrillation. JACC Clin Electrophysiol 2017; 3:589-598. [DOI: 10.1016/j.jacep.2017.02.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 02/09/2017] [Accepted: 02/10/2017] [Indexed: 11/20/2022]
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