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Heo J, Lee H, Lee IH, Nam HS, Kim YD. Impact of Left Atrial or Left Atrial Appendage Thrombus on Stroke Outcome: A Matched Control Analysis. J Stroke 2023; 25:111-118. [PMID: 36592972 PMCID: PMC9911853 DOI: 10.5853/jos.2022.02068] [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: 06/23/2022] [Accepted: 08/30/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND AND PURPOSE Left atrial or left atrial appendage (LA/LAA) thrombi are frequently observed during cardioembolic evaluation in patients with ischemic stroke. This study aimed to investigate stroke outcomes in patients with LA/LAA thrombus. METHODS This retrospective study included patients admitted to a single tertiary center in Korea between January 2012 and December 2020. Patients with nonvalvular atrial fibrillation who underwent transesophageal echocardiography or multi-detector coronary computed tomography were included in the study. Poor outcome was defined as modified Rankin Scale score >3 at 90 days. The inverse probability of treatment weighting analysis was performed. RESULTS Of the 631 patients included in this study, 68 (10.7%) had LA/LAA thrombi. Patients were likely to have a poor outcome when an LA/LAA thrombus was detected (42.6% vs. 17.4%, P<0.001). Inverse probability of treatment weighting analysis yielded a higher probability of poor outcomes in patients with LA/LAA thrombus than in those without LA/LAA thrombus (P<0.001). Patients with LA/LAA thrombus were more likely to have relevant arterial occlusion on angiography (36.3% vs. 22.4%, P=0.047) and a longer hospital stay (8 vs. 7 days, P<0.001) than those without LA/LAA thrombus. However, there was no difference in early neurological deterioration during hospitalization or major adverse cardiovascular events within 3 months between the two groups. CONCLUSIONS Patients with ischemic stroke who had an LA/LAA thrombus were at risk of a worse functional outcome after 3 months, which was associated with relevant arterial occlusion and prolonged hospital stay.
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Affiliation(s)
- JoonNyung Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyungwoo Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Il Hyung Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea,Correspondence: Young Dae Kim Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: +82-2-2228-1619 Fax: +82-2-393-0705 E-mail:
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Marques T, Darrieux F, Gouvêa F, Garambone L, Lindoso AP, Lage J, Sacilotto L, Coimbra AL, Pinheiro M, Olivetti N, Lara S, Hardy C, Athayde G, Hachul D, Pisani C, Wu TC, Scanavacca M. Trombo Atrial Esquerdo e Contraste Espontâneo Denso no Uso de Anticoagulante Oral de Ação Direta em Fibrilação Atrial: Visão de Centro Referenciado. Arq Bras Cardiol 2022; 119:514-519. [PMID: 36169450 PMCID: PMC9563890 DOI: 10.36660/abc.20210658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 04/06/2022] [Indexed: 11/18/2022] Open
Abstract
Fundamento Objetivo Métodos Resultados Conclusão
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Lurie A, Wang J, Hinnegan KJ, McIntyre WF, Belley-Côté EP, Amit G, Healey JS, Connolly SJ, Wong JA. Prevalence of Left Atrial Thrombus in Anticoagulated Patients With Atrial Fibrillation. J Am Coll Cardiol 2021; 77:2875-2886. [PMID: 34112315 DOI: 10.1016/j.jacc.2021.04.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The prevalence of left atrial (LA) thrombus in patients with atrial fibrillation (AF) or atrial flutter (AFL) on guideline-directed anticoagulation is not well known, yet this may inform transesophageal echocardiogram (TEE) use before cardioversion or catheter ablation. OBJECTIVES The purpose of this study was to quantify LA thrombus prevalence among patients with AF/AFL on guideline-directed anticoagulation and to identify high-risk subgroups. METHODS EMBASE, MEDLINE, and CENTRAL were systematically searched from inception to July 2020 for studies reporting on LA thrombus prevalence among patients with AF/AFL undergoing TEE following at least 3 weeks of continuous therapeutic oral anticoagulation with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). Meta-analysis was performed using random effects models. RESULTS Thirty-five studies describing 14,653 patients were identified. The mean-weighted LA thrombus prevalence was 2.73% (95% confidence interval [CI]: 1.95% to 3.80%). LA thrombus prevalence was similar for VKA- and DOAC-treated patients (2.80%; 95% CI: 1.86% to 4.21% vs. 3.12%; 95% CI: 1.92% to 5.03%; p = 0.674). Patients with nonparoxysmal AF/AFL had a 4-fold higher LA thrombus prevalence compared with paroxysmal patients (4.81%; 95% CI: 3.35% to 6.86% vs. 1.03%; 95% CI: 0.52% to 2.03%; p < 0.001). LA thrombus prevalence was higher among patients undergoing cardioversion versus ablation (5.55%; 95% CI: 3.15% to 9.58% vs. 1.65%; 95% CI: 1.07% to 2.53%; p < 0.001). Patients with CHA2DS2-VASc scores ≥3 had a higher LA thrombus prevalence compared with patients with scores ≤2 (6.31%; 95% CI: 3.72% to 10.49% vs. 1.06%; 95% CI: 0.45% to 2.49%; p < 0.001). CONCLUSIONS LA thrombus prevalence is high in subgroups of anticoagulated patients with AF/AFL, who may benefit from routine pre-procedural TEE use before cardioversion or catheter ablation.
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Affiliation(s)
- Antony Lurie
- Population Health Research Institute, Hamilton, Ontario, Canada; University of Western Ontario, London, Ontario, Canada
| | - Jia Wang
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada
| | | | - William F McIntyre
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada
| | - Emilie P Belley-Côté
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Guy Amit
- Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jorge A Wong
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
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Almorad A, Ohanyan A, Pintea Bentea G, Wielandts JY, El Haddad M, Lycke M, O'Neill L, Morissens M, De Keyzer E, Nguyen T, Anghel L, Samyn S, Berdaoui B, Tavernier R, Vandekerckhove Y, Duytschaever M, Verbeet T, Knecht S, Castro Rodriguez J. D-dimer blood concentrations to exclude left atrial thrombus in patients with atrial fibrillation. Heart 2020; 107:195-200. [PMID: 33087410 DOI: 10.1136/heartjnl-2020-317612] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/16/2020] [Accepted: 09/25/2020] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE Left atrial (LA) thrombus is routinely excluded by transoesophageal echocardiography (TOE) before cardioversion for non-valvular atrial fibrillation (AF). In the D-dimer blood concentrations to exclude LA thrombus in patients with AF study, two D-dimer cut-offs were compared to exclude LA thrombus prior to cardioversion. One was fixed to 500 ng/mL (DD500), based on clinical practice where such values are commonly accepted to exclude a thrombus. The other cut-off was adjusted to 10 times the patient's age (DDAge), based on the cut-off used to exclude pulmonary embolism. METHODS 142 consecutive patients with non-valvular AF aged 69.7±11.4 years (52% with paroxysmal AF) referred for precardioversion TOE to exclude LA thrombus were prospectively enrolled. D-dimers were measured at the time of TOE by an ELISA test. RESULTS LA thrombus was excluded with TOE in 129 (91%) and confirmed in 13 (9%) patients. D-dimers were significantly lower in patients without LA thrombus (729±611 vs 2376±1081 ng/L; p<0.05). DDAge indicated absence of LA thrombus with higher specificity than DD500 (66.4% vs 50.4%; p<0.05). Both cut-offs were able to identify all 13 patients with LA thrombus (false negative 0%). Patients with D-dimers <DDAge and without LA thrombus (true negative) represented 60.6% of the population and could have safely avoided TOE (flow chart). CONCLUSIONS This study demonstrates the efficacy of D-dimer cut-offs to exclude LA thrombus in patients with AF. Age adjustment greatly increases the proportion of patients in whom LA thrombus can be safely excluded and consequently avoid precardioversion TOE.
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Affiliation(s)
- Alexandre Almorad
- Cardiology, Brugmann University Hospital, Brussels, Belgium .,Cardiology, AZ Sint-Jan AV, Bruges, Belgium
| | - Anush Ohanyan
- Cardiology, Brugmann University Hospital, Brussels, Belgium
| | | | | | | | | | | | | | - Eva De Keyzer
- Cardiology, Brugmann University Hospital, Brussels, Belgium
| | - Thomas Nguyen
- Cardiology, Brugmann University Hospital, Brussels, Belgium
| | - Laura Anghel
- Cardiology, Brugmann University Hospital, Brussels, Belgium
| | - Sophie Samyn
- Cardiology, Brugmann University Hospital, Brussels, Belgium
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Al Rawahi M, Samuel M, Galatas C, Joza J, Lima PY, Barbosa R, Thanassoulis G, Bernier ML, Huynh T, Essebag V. Incidence and Predictors of Intracardiac Thrombus on Pre-electrophysiological Procedure Transesophageal Echocardiography. CJC Open 2019; 1:231-237. [PMID: 32159114 PMCID: PMC7063624 DOI: 10.1016/j.cjco.2019.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 06/17/2019] [Indexed: 01/19/2023] Open
Abstract
Background Cerebral thromboembolism is a potentially devastating complication of atrial fibrillation (AF) and atrial flutter (AFl). The use of transesophageal echocardiogram (TEE) before electrophysiological procedures in anticoagulated patients is variable. Our objective was to determine the incidence and identify predictors of intracardiac left atrial appendage (LAA) thrombus on TEE in patients with AF/AFl before electrical cardioversion or ablation. Methods We reviewed TEEs of 401 patients undergoing an electrical cardioversion, AF, or AFl ablation from April 2013 to September 2015 at the McGill University Health Center. Clinical and echocardiographic variables were collected at the time of the TEE and follow-up visits. Multivariate logistic regression was used to determine predictors of LAA thrombus. Results Of 401 patients, 11.2% had LAA thrombus on TEE. The majority (87%) of patients were anticoagulated for at least 3 weeks before the TEE. The incidence of LAA thrombus was 21% (23/110) in patients taking warfarin vs 6.4% (15/236) in patients taking direct oral anticoagulants. Multivariate analysis identified prior stroke (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.1-6.9) and heart failure (OR, 2.2; 95% CI, 1.0-4.7) as predictors of thrombus, whereas direct oral anticoagulant use (OR, 0.4; 95% CI, 0.2-0.8) was associated with reduced odds of thrombus. Conclusions LAA thrombus was identified in a significant proportion of patients undergoing TEE before cardioversion or ablation of AF/AFl despite preprocedural anticoagulation. Patients at increased risk of LAA thrombus (heart failure and prior stroke) may benefit from TEE before cardioversion, AF, or AFl ablation.
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Affiliation(s)
- Mohamed Al Rawahi
- McGill University Health Center, Division of Cardiology, Montreal, Quebec, Canada.,Sultan Qaboos University Hospital, Muscat, Oman
| | - Michelle Samuel
- McGill University Health Center, Division of Cardiology, Montreal, Quebec, Canada
| | - Christos Galatas
- McGill University Health Center, Division of Cardiology, Montreal, Quebec, Canada.,Hôpital Cité-de-la-Santé, Laval, Quebec, Canada
| | - Jacqueline Joza
- McGill University Health Center, Division of Cardiology, Montreal, Quebec, Canada
| | - Pedro Y Lima
- McGill University Health Center, Division of Cardiology, Montreal, Quebec, Canada
| | | | - George Thanassoulis
- McGill University Health Center, Division of Cardiology, Montreal, Quebec, Canada
| | - Martin L Bernier
- McGill University Health Center, Division of Cardiology, Montreal, Quebec, Canada
| | - Thao Huynh
- McGill University Health Center, Division of Cardiology, Montreal, Quebec, Canada
| | - Vidal Essebag
- McGill University Health Center, Division of Cardiology, Montreal, Quebec, Canada.,Hôpital Sacré-Coeur de Montréal, Montreal, Quebec, Canada
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Zhan Y, Joza J, Al Rawahi M, Barbosa RS, Samuel M, Bernier M, Huynh T, Thanassoulis G, Essebag V. Assessment and Management of the Left Atrial Appendage Thrombus in Patients With Nonvalvular Atrial Fibrillation. Can J Cardiol 2018; 34:252-261. [DOI: 10.1016/j.cjca.2017.12.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 12/04/2017] [Accepted: 12/11/2017] [Indexed: 01/14/2023] Open
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Atkinson C, Hinton J, Gaisie EB, Yue AM, Roberts PR, Rakhit DJ, Shah BN. Use of the CHA 2DS 2VASc score to reduce utilisation of transoesophageal echocardiography prior to ablation for atrial fibrillation. Echo Res Pract 2017; 4:45-52. [PMID: 28864464 PMCID: PMC5633057 DOI: 10.1530/erp-17-0042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 08/17/2017] [Indexed: 01/15/2023] Open
Abstract
Transoesophageal echocardiography (TOE) is frequently performed prior to atrial fibrillation (AF) ablation to exclude left atrial appendage (LAA) thrombus. However, patients undergoing AF ablation are usually anticoagulated, thus making the presence of thrombus unlikely in most cases. This study aimed to determine whether the CHA2DS2VASc scoring system can be used to identify patients that do not require TOE prior to AF ablation. In this single-centre retrospective study, local institutional and primary care databases and electronic patient records were searched to identify patients that had undergone TOE prior to AF ablation. Patient demographics, CHA2DS2VASc score, TOE findings and anticoagulation status were collected for analysis. Over a 7-year period (2008–2014), 332 patients (age 57 ± 10 years; 74% male) underwent TOE prior to proposed AF ablation. CHA2DS2VASc scores of 0, 1, 2 and >2 were found in 39, 34, 15 and 12% of patients, respectively. The prevalence of LAA thrombus was 0.6% (2 patients) and these 2 patients had risk scores of 2 and 4. No patients with a score of 0 or 1 had LAA thrombus. Patients that are classed as low risk by the CHA2DS2VASc score do not require a pre-ablation TOE to screen for LAA thrombus provided they are adequately anticoagulated. This would lead to a significant reduction in health care expenditures by reducing unnecessary TOE requests and thereby improve patient experience.
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Affiliation(s)
- Charlotte Atkinson
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Jonathan Hinton
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Edmund B Gaisie
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Arthur M Yue
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Paul R Roberts
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Dhrubo J Rakhit
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Benoy N Shah
- Department of Cardiology, University Hospital Southampton, Southampton, UK
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Laish-Farkash A, Suleiman M. Evaluation of left atrial thrombus prior to catheter ablation of atrial fibrillation: Is it time for an individualized approach? J Cardiovasc Electrophysiol 2017; 28:1137-1139. [DOI: 10.1111/jce.13303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 07/18/2017] [Accepted: 07/19/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Avishag Laish-Farkash
- Electrophysiology and Pacing Unit, Department of Cardiology; Rambam Health Care Campus; Haifa Israel
| | - Mahmoud Suleiman
- Electrophysiology and Pacing Unit, Department of Cardiology; Rambam Health Care Campus; Haifa Israel
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Bejinariu AG, Härtel DU, Brockmeier J, Oeckinghaus R, Herzer A, Tebbe U. Left atrial thrombi and spontaneous echo contrast in patients with atrial fibrillation : Systematic analysis of a single-center experience. Herz 2016; 41:706-714. [PMID: 27100878 DOI: 10.1007/s00059-016-4423-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 01/30/2016] [Accepted: 02/14/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Atrial fibrillation is associated with a high risk for thromboembolic events. Thrombi in the left atrial appendage and spontaneous echo contrast (SEC) correlate positively with this embolic risk. We studied the laboratory, echocardiographic, and epidemiologic parameters that could predict left atrial thrombi and the intensity of the SEC. PATIENTS AND METHODS Between September 2013 and June 2015 we included 372 patients with atrial fibrillation before planned electrical cardioversion (transesophageal-guided strategy) in this study. After assessing the risk of stroke and bleeding (CHA2DS2-VASc and HAS-BLED scores), we measured the concentration of the D-dimer and B-type natriuretic peptide at the time of the transesophageal echocardiography as well as the left atrial volume and the ejection fraction during transthoracic echocardiography. RESULTS The ejection fraction and the CHA2DS2-VASc score were identified as independent predictors of both left atrial thrombi and SEC, whereas the left atrial volume could only predict the intensity of SEC. In contrast to the results of other studies, the biomarkers in this study failed to predict the outcome. CONCLUSION Only the echocardiographic and epidemiologic parameters were predictors of left atrial thrombi and SEC intensity, while the studied biomarkers had no predictive power. Using clinical data and transthoracic echocardiography, we can change the therapeutic strategy in high-risk patients.
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Affiliation(s)
- A G Bejinariu
- Clinic for Cardiology, Angiology and Intensive Care, Klinikum Lippe Detmold, Röntgenstr. 18, 32756, Detmold, Germany.
| | - D U Härtel
- Clinic for Cardiology, Angiology and Intensive Care, Klinikum Lippe Detmold, Röntgenstr. 18, 32756, Detmold, Germany
| | - J Brockmeier
- Clinic for Cardiology, Angiology and Intensive Care, Klinikum Lippe Detmold, Röntgenstr. 18, 32756, Detmold, Germany
| | - R Oeckinghaus
- Clinic for Cardiology, Angiology and Intensive Care, Klinikum Lippe Detmold, Röntgenstr. 18, 32756, Detmold, Germany
| | - A Herzer
- Clinic for Cardiology, Angiology and Intensive Care, Klinikum Lippe Detmold, Röntgenstr. 18, 32756, Detmold, Germany
| | - U Tebbe
- Clinic for Cardiology, Angiology and Intensive Care, Klinikum Lippe Detmold, Röntgenstr. 18, 32756, Detmold, Germany
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Echocardiographic Predictors of Left Atrial Thrombus in Patients With Severe Rheumatismal Mitral Stenosis. RAZAVI INTERNATIONAL JOURNAL OF MEDICINE 2014. [DOI: 10.5812/rijm.15602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Providência R, Albenque JP, Combes N, Combes S, Boveda S. Excluding the presence of left atrial thrombus before pulmonary vein isolation: "primum non nocere"! J Cardiovasc Electrophysiol 2013; 24:E3-5. [PMID: 23437839 DOI: 10.1111/jce.12104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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