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Pieszko K, Hiczkiewicz J, Łojewska K, Uziębło-Życzkowska B, Krzesiński P, Gawałko M, Budnik M, Starzyk K, Wożakowska-Kapłon B, Daniłowicz-Szymanowicz L, Kaufmann D, Wójcik M, Błaszczyk R, Mizia-Stec K, Wybraniec M, Kosmalska K, Fijałkowski M, Szymańska A, Dłużniewski M, Kucio M, Haberka M, Kupczyńska K, Michalski B, Tomaszuk-Kazberuk A, Wilk-Śledziewska K, Wachnicka-Truty R, Koziński M, Kwieciński J, Wolny R, Kowalik E, Kolasa I, Jurek A, Budzianowski J, Burchardt P, Kapłon-Cieślicka A, Slomka PJ. Artificial intelligence in detecting left atrial appendage thrombus by transthoracic echocardiography and clinical features: the Left Atrial Thrombus on Transoesophageal Echocardiography (LATTEE) registry. Eur Heart J 2024; 45:32-41. [PMID: 37453044 PMCID: PMC10757867 DOI: 10.1093/eurheartj/ehad431] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 05/03/2023] [Accepted: 06/22/2023] [Indexed: 07/18/2023] Open
Abstract
AIMS Transoesophageal echocardiography (TOE) is often performed before catheter ablation or cardioversion to rule out the presence of left atrial appendage thrombus (LAT) in patients on chronic oral anticoagulation (OAC), despite associated discomfort. A machine learning model [LAT-artificial intelligence (AI)] was developed to predict the presence of LAT based on clinical and transthoracic echocardiography (TTE) features. METHODS AND RESULTS Data from a 13-site prospective registry of patients who underwent TOE before cardioversion or catheter ablation were used. LAT-AI was trained to predict LAT using data from 12 sites (n = 2827) and tested externally in patients on chronic OAC from two sites (n = 1284). Areas under the receiver operating characteristic curve (AUC) of LAT-AI were compared with that of left ventricular ejection fraction (LVEF) and CHA2DS2-VASc score. A decision threshold allowing for a 99% negative predictive value was defined in the development cohort. A protocol where TOE in patients on chronic OAC is performed depending on the LAT-AI score was validated in the external cohort. In the external testing cohort, LAT was found in 5.5% of patients. LAT-AI achieved an AUC of 0.85 [95% confidence interval (CI): 0.82-0.89], outperforming LVEF (0.81, 95% CI 0.76-0.86, P < .0001) and CHA2DS2-VASc score (0.69, 95% CI: 0.63-0.7, P < .0001) in the entire external cohort. Based on the proposed protocol, 40% of patients on chronic OAC from the external cohort would safely avoid TOE. CONCLUSION LAT-AI allows accurate prediction of LAT. A LAT-AI-based protocol could be used to guide the decision to perform TOE despite chronic OAC.
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Affiliation(s)
- Konrad Pieszko
- ‘Club 30’, Polish Cardiac Society, Poland
- Department of Interventional Cardiology and Cardiac Surgery, University of Zielona Gora, Collegium Medicum, Zielona Gora, Poland
- WSSP ZOZ Nowa Sol, Nowa Sol, Poland
| | - Jarosław Hiczkiewicz
- Department of Interventional Cardiology and Cardiac Surgery, University of Zielona Gora, Collegium Medicum, Zielona Gora, Poland
- WSSP ZOZ Nowa Sol, Nowa Sol, Poland
| | | | - Beata Uziębło-Życzkowska
- ‘Club 30’, Polish Cardiac Society, Poland
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Paweł Krzesiński
- ‘Club 30’, Polish Cardiac Society, Poland
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Monika Gawałko
- ‘Club 30’, Polish Cardiac Society, Poland
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
- Institute of Pharmacology, West German Heart and Vascular Centre, University Duisburg-Essen, Essen, Germany
| | - Monika Budnik
- ‘Club 30’, Polish Cardiac Society, Poland
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Starzyk
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, Kielce, Poland
| | - Beata Wożakowska-Kapłon
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, Kielce, Poland
| | | | - Damian Kaufmann
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Gdansk, Poland
| | - Maciej Wójcik
- Department of Cardiology, Medical University of Lublin, Lublin, Poland
| | - Robert Błaszczyk
- Department of Cardiology, Medical University of Lublin, Lublin, Poland
| | - Katarzyna Mizia-Stec
- 1st Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Maciej Wybraniec
- 1st Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | | | | | - Anna Szymańska
- Department of Heart Diseases, Postgraduate Medical School, Warsaw, Poland
| | | | - Michał Kucio
- Department of Cardiology, School of Health Sciences, Medical University of Silesia, Katowice, Poland
| | - Maciej Haberka
- Department of Cardiology, School of Health Sciences, Medical University of Silesia, Katowice, Poland
| | | | - Błażej Michalski
- Department of Cardiology, Medical University of Lodz, Lodz, Poland
| | | | | | - Renata Wachnicka-Truty
- Department of Cardiology and Internal Medicine, Medical University of Gdansk, Gdynia, Poland
| | - Marek Koziński
- ‘Club 30’, Polish Cardiac Society, Poland
- Department of Cardiology and Internal Medicine, Medical University of Gdansk, Gdynia, Poland
| | - Jacek Kwieciński
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Rafał Wolny
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Ewa Kowalik
- Department of Congenital Heart Diseases, National Institute of Cardiology, Warsaw, Poland
| | - Iga Kolasa
- Department of Interventional Cardiology and Cardiac Surgery, University of Zielona Gora, Collegium Medicum, Zielona Gora, Poland
| | - Agnieszka Jurek
- ‘Club 30’, Polish Cardiac Society, Poland
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Jan Budzianowski
- ‘Club 30’, Polish Cardiac Society, Poland
- Department of Interventional Cardiology and Cardiac Surgery, University of Zielona Gora, Collegium Medicum, Zielona Gora, Poland
- WSSP ZOZ Nowa Sol, Nowa Sol, Poland
| | - Paweł Burchardt
- ‘Club 30’, Polish Cardiac Society, Poland
- Department of Biology and Lipid Disorders, Poznan University of Medical Sciences, Poznan, Poland
| | - Agnieszka Kapłon-Cieślicka
- ‘Club 30’, Polish Cardiac Society, Poland
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr J Slomka
- Department of Medicine (Division of Artificial Intelligence in Medicine), Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite Metro 203, 90048, Los Angeles, CA, USA
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Chang P, Xiao J, Hu Z, Kwan AC, Fan Z. Imaging of left heart intracardiac thrombus: clinical needs, current imaging, and emerging cardiac magnetic resonance techniques. Ther Adv Cardiovasc Dis 2022; 16:17539447221107737. [PMID: 35762763 PMCID: PMC9243573 DOI: 10.1177/17539447221107737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Intracardiac thrombus in the left atrium and atrial appendage (LA/LAA) and left ventricle (LV) increases the risk of systemic thromboembolism and causes potentially devastating diseases such as ischemic stroke and acute ischemia in abdominal organs and lower extremities. Detecting the presence and monitoring the resolution of left heart intracardiac thrombus are of vital importance for stratifying patients and guiding treatment decisions. Currently, echocardiography is the most frequently used method for the above clinical needs, followed by computed tomography. An increasing number of studies have been performed to investigate the value of cardiac magnetic resonance (CMR) as an alternative imaging modality given its several unique strengths. This article provides an overview of the clinical relevance of the LA/LAA and LV thrombus as well as the diagnostic performance of the current imaging modalities and emerging CMR techniques.
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Affiliation(s)
- Peng Chang
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Department of Cardiovascular, Lanzhou University Second Hospital, Lanzhou, China
| | - Jiayu Xiao
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Zhehao Hu
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Department of Bioengineering, University of California, Los Angeles, Los Angeles, CA, USA
| | - Alan C Kwan
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Zhaoyang Fan
- Department of Radiology, Keck School of Medicine, University of Southern California, 2250 Alcazar Street, CSC Room 104, Los Angeles, CA 90033, USA.,Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Department of Biomedical Engineering, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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3
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Noubiap JJ, Agbaedeng TA, Ndoadoumgue AL, Nyaga UF, Kengne AP. Atrial thrombus detection on transoesophageal echocardiography in patients with atrial fibrillation undergoing cardioversion or catheter ablation: A pooled analysis of rates and predictors. J Cardiovasc Electrophysiol 2021; 32:2179-2188. [PMID: 33969568 DOI: 10.1111/jce.15082] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/27/2021] [Accepted: 05/03/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To summarize data on the rates and predictors of left atrial thrombus/left atrial appendage thrombus (LAT/LAAT) detection by transoesophageal echocardiography (TEE) before electrical cardioversion (ECV) or catheter ablation (CA) for atrial fibrillation (AF). METHODS EMBASE, MEDLINE, and Web of Science Core Collection were searched to identify all studies providing relevant data and published by October 7, 2020. A random-effects meta-analysis method was used to pool effect size estimates. RESULTS A total of 85 studies were included, reporting data from 56 660 patients with AF. In patients undergoing CA and ECV, the pooled prevalence of LAT/LAAT was 1.8% and 7.5% in those not on oral anticoagulation (OAC), 1.8% and 5.5% in those taking OAC, and 1.3% and 4.9% in case of adequate OAC, respectively. According to the type of OAC, the prevalence was 2.0% and 7.6% for vitamin K antagonist, 1.3% and 3.5% for direct oral anticoagulant. Predictors of LAT/LAAT detection were nonparoxysmal AF (odds ratio [OR]: 3.6, 95% confidence interval: 2.4-5.2), hypertension (OR: 2.9, 1.2-7.0), previous stroke (OR: 3.0, 1.6-5.63), heart failure (OR: 4.3, 2.7-6.8), and CHADS2 score ≥2 (OR: 3.3, 1.9-5.8) for patients undergoing CA; and heart failure (OR: 2.8, 1.3-6.2) and the CHA2 DS2 -VASc score (OR: 2.55, 1.5-4.5) for those undergoing ECV. CONCLUSION The prevalence of LAT/LAAT in AF patients undergoing ECV or CA varies widely, mainly due to differences in patient risk profiles and OAC types. Further research should determine whether the predictors of LAT/LAAT detection identified by this study could be used to select patients who require preprocedural TEE.
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Affiliation(s)
- Jean Jacques Noubiap
- Centre for Heart Rhythm Disorders, The University of Adelaide, Adelaide, Australia
| | - Thomas A Agbaedeng
- Centre for Heart Rhythm Disorders, The University of Adelaide, Adelaide, Australia
| | | | - Ulrich Flore Nyaga
- Department of Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - Andre Pascal Kengne
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
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4
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Efremidis M, Bazoukis G, Vlachos K, Prappa E, Megarisiotou A, Dragasis S, Ramirez FD, Bourier F, Mililis P, Saplaouras A, Tse G, Liu T, Efremidis T, Kitsoulis P, Thomopoulos C, Sideris A, Letsas KP. Safety of catheter ablation of atrial fibrillation without pre- or peri-procedural imaging for the detection of left atrial thrombus in the era of uninterrupted anticoagulation. J Arrhythm 2021; 37:28-32. [PMID: 33664883 PMCID: PMC7896446 DOI: 10.1002/joa3.12466] [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: 08/04/2020] [Revised: 10/18/2020] [Accepted: 11/04/2020] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The need for pre- or peri-procedural imaging to rule out the presence of left atrial thrombus in patients undergoing catheter ablation of atrial fibrillation (AF) is unclear in the era of uninterrupted direct oral anticoagulant (DOAC) regimen. We sought to examine the safety of catheter ablation in appropriately selected patients with paroxysmal AF without performing screening for left atrial thrombus. PATIENTS AND METHODS Consecutive patients planned for radiofrequency AF catheter ablation between January 2016 and June 2020 were enrolled, and prospectively studied. All subjects were receiving uninterrupted anticoagulation with DOACs for at least 4 weeks before the procedure. All subjects were in sinus rhythm the day of the procedure. The primary outcome of the study was ischemic stroke or transient ischemic attack (TIA) during at 30 days. RESULTS A total of 451 patients (age 59.7 ± 10.2 years, 289 males) with paroxysmal AF were included in the study. The mean CHA2DS2-VASc score was 1.4 ± 1.2. The mean left ventricular ejection fraction and left atrial diameter were 60 ± 5% and 39.3 ± 4 mm, respectively. Regarding the anticoagulation regimen, apixaban was used in 197 (43.6%) patients, rivaroxaban in 148 (32.8%) patients, and dabigatran in 106 (23.5%) patients. None of the patients developed clinical ischemic stroke or TIA during the 30-day post-discharged period. CONCLUSIONS Catheter ablation can be safely performed in low-risk patients with paroxysmal AF without imaging for the detection of left atrial thrombus in the era of uninterrupted DOAC anticoagulation.
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Affiliation(s)
- Michael Efremidis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - George Bazoukis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Konstantinos Vlachos
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Efstathia Prappa
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Athanasia Megarisiotou
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Stylianos Dragasis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - F. Daniel Ramirez
- Hôpital Cardiologique du Haut LévèqueCHU de Bordeaux and IHU‐LIRYCPessacFrance
| | - Felix Bourier
- Department of ElectrophysiologyGerman Heart CenterTechnical UniversityMunichGermany
| | - Panagiotis Mililis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Athanasios Saplaouras
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Gary Tse
- Xiamen Cardiovascular HospitalXiamen UniversityXiamenPeople's Republic of China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular DiseaseDepartment of CardiologyTianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinPeople's Republic of China
| | - Theodore Efremidis
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Panagiotis Kitsoulis
- Laboratory of Anatomy‐Histology‐EmbryologySchool of MedicineUniversity of IoanninaIoanninaGreece
| | | | - Antonios Sideris
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
| | - Konstantinos P. Letsas
- Second Department of CardiologyLaboratory of Cardiac Electrophysiology"Evangelismos" General Hospital of AthensAthensGreece
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5
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Patel K, Natale A, Yang R, Trivedi C, Romero J, Briceno D, Mohanty S, Alviz I, Natale V, Sanchez J, Della Rocca DG, Tarantino N, Zhang XD, Mohanty P, Horton R, Burkhardt D, Gopinathannair R, Joseph Gallinghouse G, Lakkireddy D, Di Biase L. Is transesophageal echocardiography necessary in patients undergoing ablation of atrial fibrillation on an uninterrupted direct oral anticoagulant regimen? Results from a prospective multicenter registry. Heart Rhythm 2020; 17:2093-2099. [PMID: 32681991 DOI: 10.1016/j.hrthm.2020.07.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/06/2020] [Accepted: 07/12/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Thromboembolic stroke is a rare but devastating consequence of atrial fibrillation (AF) ablation. Transesophageal echocardiography (TEE) is recommended to rule out left atrial appendage thrombus; however, its use is variable. OBJECTIVE The purpose of this study was to assess whether TEE is mandatory in patients undergoing AF ablation on uninterrupted direct oral anticoagulants (DOACs). METHODS Data from our prospective multicenter registry of patients with AF undergoing radiofrequency catheter ablation on uninterrupted DOACs were analyzed. All the included patients were on anticoagulation for at least 4 weeks before ablation. All AF ablation procedures were performed under intracardiac echocardiography guidance. Before transseptal puncture, heparin bolus was administered, followed by continuous infusion, with a target activated clotting time of >300 seconds. RESULTS A total of 6186 patients (3180 on apixaban [51.4%], 2528 on rivaroxaban [40.9%], 404 on dabigatran [6.5%], and 74 on edoxaban [1.2%]) were analyzed. The mean age of the study population was 69.4 ± 10.3 years; 4194 patients (67.8%) were male, and 5120 patients (82.8%) had persistent and long-standing persistent AF. The mean CHA2DS2-VASc score was 2.86 ± 1.58; the mean CHADS2 score was 1.65 ± 1.14. Intracardiac echocardiography ruled out left atrial appendage and left atrial thrombi in all patients and revealed "smoke" in 1672 patients (27.03%). Transient ischemic attack was noted in 1 patient with long-standing persistent AF in the setting of a missed dose of rivaroxaban before ablation. CONCLUSION Our study showed that performing AF ablation in patients on uninterrupted DOACs without TEE is safe and feasible in high stroke risk patients. Elimination of routine preablation TEE would have significant economic and clinical implications.
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Affiliation(s)
- Kavisha Patel
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Andrea Natale
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Ruike Yang
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; Department of Cardiology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Chintan Trivedi
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Jorge Romero
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - David Briceno
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Sanghamitra Mohanty
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Isabella Alviz
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Veronica Natale
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Javier Sanchez
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Domenico G Della Rocca
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Nicola Tarantino
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Xiao-Dong Zhang
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Prasant Mohanty
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Rodney Horton
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - David Burkhardt
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Rakesh Gopinathannair
- Department of Electrophysiology, Kansas City Heart Rhythm Institute, Overland Park, Kansas
| | - G Joseph Gallinghouse
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Dhanunjaya Lakkireddy
- Department of Electrophysiology, Kansas City Heart Rhythm Institute, Overland Park, Kansas
| | - Luigi Di Biase
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas.
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6
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Whiteside HL, Nagabandi A, Brown K, Ayyala DN, Sharma GK. Prevalence and clinical characteristics associated with left atrial thrombus detection: Apixaban. World J Cardiol 2019; 11:84-93. [PMID: 30820278 PMCID: PMC6391620 DOI: 10.4330/wjc.v11.i2.84] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/18/2018] [Accepted: 01/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The prevalence of left atrial appendage (LAA) thrombus detection by transesophageal echocardiogram (TEE) in patients with non-valvular atrial fibrillation (AF) anticoagulated with apixaban is not well defined and identification of additional risk factors may help guide the selection process for pre-procedural TEE. The purpose of our study was to retrospectively analyze the prevalence of LAA thrombus detection by TEE in patients continuously anticoagulated with apixaban for ≥ 4 wk and evaluate for any cardiac risk factors or echocardiographic characteristics which may serve as predictors of thrombus formation.
AIM To retrospectively analyze the prevalence of LAA thrombus detection by TEE in patients continuously anticoagulated with apixaban.
METHODS Clinical and echocardiographic data for 820 consecutive patients with AF undergoing TEE at Augusta University Medical Center over a four-year period were retrospectively analyzed. All patients (apixaban: 226) with non-valvular AF and documented compliance with apixaban for ≥ 4 wk prior to index TEE were included.
RESULTS Following ≥ 4 wk of continuous anticoagulation with apixaban, the prevalence of LAA thrombus and LAA thrombus/dense spontaneous echocardiographic contrast was 3.1% and 6.6%, respectively. Persistent AF, left ventricular ejection fraction < 30%, severe LA dilation, and reduced LAA velocity were associated with thrombus formation. Following multivariate logistic regression, persistent AF (OR: 7.427; 95%CI: 1.02 to 53.92; P = 0.0474), and reduced LAA velocity (OR: 1.086; 95%CI: 1.010 to 1.187; P = 0.0489) were identified as independent predictors of LAA thrombus. No Thrombi were detected in patients with a CHA2DS2-VASc score ≤ 1.
CONCLUSION Among patients with non-valvular AF and ≥ 4 wk of anticoagulation with apixaban, the prevalence of LAA thrombus detected by TEE was 3.1%. This suggests that continuous therapy with apixaban does not completely eliminate the risk of LAA thrombus and that TEE prior to cardioversion or catheter ablation may be of benefit in patients with multiple risk factors.
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Affiliation(s)
- Hoyle L Whiteside
- Division of Internal Medicine, Medical College of Georgia at Augusta University, Augusta, GA 30912, United States
| | - Arun Nagabandi
- Division of Cardiology, Medical College of Georgia at Augusta University, Augusta, GA 30912, United States
| | - Kristen Brown
- Division of Internal Medicine, Medical College of Georgia at Augusta University, Augusta, GA 30912, United States
| | - Deepak N Ayyala
- Division of Biostatistics and Data Science, Department of Population Health Sciences, Medical College of Georgia at Augusta University, Augusta, GA 30912, United States
| | - Gyanendra K Sharma
- Division of Cardiology, Medical College of Georgia at Augusta University, Augusta, GA 30912, United States
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7
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Alqarawi W, Birnie DH, Spence S, Ramirez FD, Redpath CJ, Lemery R, Nair GM, Nery PB, Davis DR, Green MS, Beauchesne L, Chan K, Ascah K, Burwash I, Sadek MM. Prevalence of left atrial appendage thrombus detected by transoesophageal echocardiography before catheter ablation of atrial fibrillation in patients anticoagulated with non-vitamin K antagonist oral anticoagulants. Europace 2018; 21:48-53. [DOI: 10.1093/europace/euy129] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/12/2018] [Indexed: 01/11/2023] Open
Affiliation(s)
- Wael Alqarawi
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, Canada
- Division of Cardiology, Department of Cardiac Sciences, King Saud University, Riyadh, Saudi Arabia
| | - David H Birnie
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, Canada
| | - Stewart Spence
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, Canada
| | - F Daniel Ramirez
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, Canada
| | - Calum J Redpath
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, Canada
| | - Robert Lemery
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, Canada
| | - Girish M Nair
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, Canada
| | - Pablo B Nery
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, Canada
| | - Darryl R Davis
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, Canada
| | - Martin S Green
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, Canada
| | - Luc Beauchesne
- Echocardiography Laboratory, Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, Canada
| | - Kwan Chan
- Echocardiography Laboratory, Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, Canada
| | - Kathryn Ascah
- Echocardiography Laboratory, Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, Canada
| | - Ian Burwash
- Echocardiography Laboratory, Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, Canada
| | - Mouhannad M Sadek
- Arrhythmia Service, Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON, Canada
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Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Cosedis Nielsen J, Curtis AB, Davies DW, Day JD, d’Avila A, (Natasja) de Groot NMS, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ, Yamane T. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2018; 20:e1-e160. [PMID: 29016840 PMCID: PMC5834122 DOI: 10.1093/europace/eux274] [Citation(s) in RCA: 715] [Impact Index Per Article: 119.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Hugh Calkins
- From the Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Riccardo Cappato
- Humanitas Research Hospital, Arrhythmias and Electrophysiology Research Center, Milan, Italy (Dr. Cappato is now with the Department of Biomedical Sciences, Humanitas University, Milan, Italy, and IRCCS, Humanitas Clinical and Research Center, Milan, Italy)
| | | | - Eduardo B Saad
- Hospital Pro-Cardiaco and Hospital Samaritano, Botafogo, Rio de Janeiro, Brazil
| | | | | | - Vinay Badhwar
- West Virginia University School of Medicine, Morgantown, WV
| | - Josep Brugada
- Cardiovascular Institute, Hospital Clínic, University of Barcelona, Catalonia, Spain
| | - John Camm
- St. George's University of London, London, United Kingdom
| | | | | | | | | | | | - D Wyn Davies
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - John D Day
- Intermountain Medical Center Heart Institute, Salt Lake City, UT
| | | | | | - Luigi Di Biase
- Albert Einstein College of Medicine, Montefiore-Einstein Center for Heart & Vascular Care, Bronx, NY
| | | | | | | | | | - Sabine Ernst
- Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Guilherme Fenelon
- Albert Einstein Jewish Hospital, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Elaine Hylek
- Boston University School of Medicine, Boston, MA
| | - Warren M Jackman
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jose Jalife
- University of Michigan, Ann Arbor, MI, the National Center for Cardiovascular Research Carlos III (CNIC) and CIBERCV, Madrid, Spain
| | - Jonathan M Kalman
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Hans Kottkamp
- Hirslanden Hospital, Department of Electrophysiology, Zurich, Switzerland
| | | | | | - Richard Lee
- Saint Louis University Medical School, St. Louis, MO
| | - Thorsten Lewalter
- Department of Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | | | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montréal, Canada
| | | | - Francis E Marchlinski
- Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | - Hiroshi Nakagawa
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX
| | - Stanley Nattel
- Montreal Heart Institute and Université de Montréal, Montreal, Canada, McGill University, Montreal, Canada, and University Duisburg-Essen, Essen, Germany
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Evgeny Pokushalov
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | | | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Claudio Tondo
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino, IRCCS, Department of Cardiovascular Sciences, University of Milan, Milan, Italy
| | | | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Canada
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Lan H, Zhou X, Xue J, Liu B, Chen G. The ability of left ventricular end-diastolic volume variations measured by TEE to monitor fluid responsiveness in high-risk surgical patients during craniotomy: a prospective cohort study. BMC Anesthesiol 2017; 17:165. [PMID: 29202703 PMCID: PMC5716247 DOI: 10.1186/s12871-017-0456-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 11/24/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND This study was aimed to evaluate the ability of left ventricular end-diastolic volume variations (LVEDVV) measured by transesophageal echocardiography (TEE) compared with stroke volume variation (SVV) obtained by the FloTrac/Vigileo monitor to predict fluid responsiveness, in patients undergoing craniotomy with goal direct therapy. METHODS We used SVV obtained by the FloTrac/Vigileo monitor to manage intraoperative hypotension in adult patients undergoing craniotomy (ASA III - IV) after obtaining IRB approval and informed consent. The LVEDVV were measured by TEE through the changes of left ventricular short diameter of axle simultaneously. When cardiac index (CI) ≤ 2.5 and SVV ≥ 15%, comparisons were made between the two devices before and after volume expansion. RESULTS We enrolled twenty-six patients referred for craniotomy in this study and 145 pairs of data were obtained. Mean Vigileo-SVV and TEE-LVEDVV were 17.8 ± 2.78% and 22.1 ± 7.25% before volume expansion respectively, and were 10.95 ± 2.8% and 13.58 ± 3.78% after volume expansion respectively (P < 0.001). The relationship between Vigileo-SVV and TEE-LVEDVV was significant (r2 = 0.55; p < 0.001). Agreement between Vigileo-SVV and TEE-LVEDVV was 3.3% ± 3.9% (mean bias ± SD, Bland-Altman). CONCLUSIONS For fluid responsiveness of patients during craniotomy in ASA III-IV, LVEDVV measured by left ventricular short diameter of axle using M type echocaidiographic measurement seems an acceptable monitoring indicator. This accessible method has promising clinical applications in situations where volume and cardiac function monitoring is of great importance during surgery. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR-TRC-13003583 , August 20, 2013.
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Affiliation(s)
- Haidan Lan
- Department of Anesthesiology, West China Hospital of Sichuan University, No.37, Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Xiaoshuang Zhou
- Department of Anesthesiology, West China Hospital of Sichuan University, No.37, Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Jing Xue
- Department of Anesthesiology, West China Hospital of Sichuan University, No.37, Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Bin Liu
- Department of Anesthesiology, West China Hospital of Sichuan University, No.37, Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Guo Chen
- Department of Anesthesiology, West China Hospital of Sichuan University, No.37, Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China.
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Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Nielsen JC, Curtis AB, Davies DW, Day JD, d’Avila A, de Groot N(N, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ, Yamane T. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2017; 14:e275-e444. [PMID: 28506916 PMCID: PMC6019327 DOI: 10.1016/j.hrthm.2017.05.012] [Citation(s) in RCA: 1391] [Impact Index Per Article: 198.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Hugh Calkins
- Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Riccardo Cappato
- Humanitas Research Hospital, Arrhythmias and Electrophysiology Research Center, Milan, Italy (Dr. Cappato is now with the Department of Biomedical Sciences, Humanitas University, Milan, Italy, and IRCCS, Humanitas Clinical and Research Center, Milan, Italy)
| | | | - Eduardo B. Saad
- Hospital Pro-Cardiaco and Hospital Samaritano, Botafogo, Rio de Janeiro, Brazil
| | | | | | - Vinay Badhwar
- West Virginia University School of Medicine, Morgantown, WV
| | - Josep Brugada
- Cardiovascular Institute, Hospital Clínic, University of Barcelona, Catalonia, Spain
| | - John Camm
- St. George’s University of London, London, United Kingdom
| | | | | | | | | | | | - D. Wyn Davies
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - John D. Day
- Intermountain Medical Center Heart Institute, Salt Lake City, UT
| | | | | | - Luigi Di Biase
- Albert Einstein College of Medicine, Montefiore-Einstein Center for Heart & Vascular Care, Bronx, NY
| | | | | | | | | | - Sabine Ernst
- Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Guilherme Fenelon
- Albert Einstein Jewish Hospital, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Elaine Hylek
- Boston University School of Medicine, Boston, MA
| | - Warren M. Jackman
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jose Jalife
- University of Michigan, Ann Arbor, MI, the National Center for Cardiovascular Research Carlos III (CNIC) and CIBERCV, Madrid, Spain
| | - Jonathan M. Kalman
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Hans Kottkamp
- Hirslanden Hospital, Department of Electrophysiology, Zurich, Switzerland
| | | | | | - Richard Lee
- Saint Louis University Medical School, St. Louis, MO
| | - Thorsten Lewalter
- Department of Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | | | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montréal, Canada
| | | | - Francis E. Marchlinski
- Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | - Hiroshi Nakagawa
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX
| | - Stanley Nattel
- Montreal Heart Institute and Université de Montréal, Montreal, Canada, McGill University, Montreal, Canada, and University Duisburg-Essen, Essen, Germany
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Evgeny Pokushalov
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | | | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Claudio Tondo
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino, IRCCS, Department of Cardiovascular Sciences, University of Milan, Milan, Italy
| | | | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Canada
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WITHDRAWN: 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Arrhythm 2017. [DOI: 10.1016/j.joa.2017.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Wyrembak J, Campbell KB, Steinberg BA, Bahnson TD, Daubert JP, Velazquez EJ, Samad Z, Atwater BD. Incidence and Predictors of Left Atrial Appendage Thrombus in Patients Treated With Nonvitamin K Oral Anticoagulants Versus Warfarin Before Catheter Ablation for Atrial Fibrillation. Am J Cardiol 2017; 119:1017-1022. [PMID: 28153350 DOI: 10.1016/j.amjcard.2016.12.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 12/08/2016] [Accepted: 12/08/2016] [Indexed: 12/13/2022]
Abstract
The utility of routine transesophageal echocardiography (TEE) to exclude left atrial appendage (LAA) thrombus before atrial fibrillation (AF) ablation in patients treated with nonvitamin K oral anticoagulant (NOAC) therapy is unclear. This single-center retrospective study sought to investigate the incidence of LAA thrombus in patients undergoing routine TEE before AF ablation treated with warfarin or NOAC therapy. We included 937 routine pre-AF ablation TEE procedures performed in patients treated with warfarin (n = 517) or NOAC (n = 420). Patients were anticoagulated without interruption for at least 4 consecutive weeks before the TEE. Patients treated with warfarin had lower LAA velocity and underwent TEE earlier in the study period than those treated with NOAC (p <0.05). The incidence of LAA thrombus was higher in patients treated with warfarin (1.55%, 8 of 517) compared with patients treated with NOAC (0.24%, 1 of 420, p = 0.0473 for difference). No LAA thrombus was identified in NOAC-treated patients with a CHA2DS2-VASC score <5 and in warfarin-treated patients with a CHA2DS2-VASC score <2. TEE-related complications occurred in 3 of 937 procedures (0.3%). In conclusion, LAA thrombus is detected rarely during pre-AF ablation TEE. Treatment with an NOAC is associated with a lower incidence of pre-AF ablation LAA thrombus compared with warfarin.
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Di Biase L, Briceno DF, Trivedi C, Mohanty S, Gianni C, Burkhardt JD, Mohanty P, Bai R, Gunda S, Horton R, Bailey S, Sanchez JE, Al-Ahmad A, Hranitzky P, Gallinghouse GJ, Reddy YM, Zagrodzky J, Hongo R, Beheiry S, Lakkireddy D, Natale A. Is transesophageal echocardiogram mandatory in patients undergoing ablation of atrial fibrillation with uninterrupted novel oral anticoagulants? Results from a prospective multicenter registry. Heart Rhythm 2016; 13:1197-202. [DOI: 10.1016/j.hrthm.2016.03.024] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Indexed: 01/09/2023]
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Pokorney SD, Hammill BG, Qualls LG, Steinberg BA, Curtis LH, Piccini JP. Cost analysis of periprocedural imaging in patients undergoing catheter ablation for atrial fibrillation. Am J Cardiol 2014; 114:266-71. [PMID: 24952929 PMCID: PMC4090097 DOI: 10.1016/j.amjcard.2014.04.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 04/14/2014] [Accepted: 04/14/2014] [Indexed: 10/25/2022]
Abstract
Cardiovascular imaging is an important part of procedural planning and safety for catheter ablation of atrial fibrillation (AF). However, the costs of imaging surrounding catheter ablation of AF have not been described. Medicare fee-for-service data were used to evaluate Medicare expenditures before, during, and after catheter ablation for AF from July 2007 to December 2009. Among 11,525 patients who underwent catheter ablation for AF, the mean overall expenditure on the day of the procedure was $14,455 (SD $7,441). The mean imaging expenditure in the periprocedural period, which included the 30 days before the catheter ablation and the day of the ablation itself, was $884 (SD $455). Periprocedural imaging expenditures varied by the imaging strategy used, ranging from a mean of $557 (SD $269) for patients with electroanatomic mapping only to $1,234 (SD $461) for patients with electroanatomic mapping, transesophageal echocardiogram, and computed tomography or magnetic resonance imaging. Mean patient-level imaging expenditures varied by provider (mean $872, SD $249). Periprocedural imaging expenditures also varied by patient risk, with mean expenditures of $862 (SD $444) for patients with a CHADS2 score of ≥2 compared with $907 (SD $466) for CHADS2 score<2 (p<0.001). In conclusion, periprocedural imaging accounts for approximately 6% of mean Medicare expenditures for catheter ablation of AF. The expenditures for periprocedural imaging vary both at the patient and at the provider level and they are inversely related to stroke risk by CHADS2 score.
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Affiliation(s)
- Sean D Pokorney
- Duke Center for Atrial Fibrillation, Division of Cardiology, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Bradley G Hammill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Laura G Qualls
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Benjamin A Steinberg
- Duke Center for Atrial Fibrillation, Division of Cardiology, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Lesley H Curtis
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Jonathan P Piccini
- Duke Center for Atrial Fibrillation, Division of Cardiology, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
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Anderson LH, Black EJ, Civello KC, Martinson MS, Kress DC. Cost-effectiveness of the convergent procedure and catheter ablation for non-paroxysmal atrial fibrillation. J Med Econ 2014; 17:481-91. [PMID: 24693987 DOI: 10.3111/13696998.2014.911185] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Patients with persistent or longstanding atrial fibrillation have modest success achieving sinus rhythm with catheter ablation or rhythm control medications. Their high risk of stroke, bleed, and heart failure leads to significant morbidity and health care costs. The convergent procedure has been shown to be successful in this population, with 80% of patients in sinus rhythm after 1 year. This study evaluated the cost-effectiveness of the convergent procedure, catheter ablation, and medical management for non-paroxysmal AF patients. METHODS A Markov micro-simulation model was used to estimate costs and effectiveness from a payer perspective. Parameter estimates were from the literature. Three patient cohorts were simulated, representing lower, medium, and higher risks of stroke, bleed, heart failure, and hospitalization. Effects were estimated by quality-adjusted life-years (QALYs). Single-variable sensitivity analysis was performed. RESULTS After 5 years, convergent procedure patients averaged 1.10 procedures, with 75% of survivors in sinus rhythm; catheter ablation patients had 1.65 procedures, with 49% in sinus rhythm. Compared to medical management, catheter ablation and the convergent procedure were cost-effective for the lower risk (ICER <$35,000) and medium risk (ICER <$15,000) cohorts. The procedures dominated medical management for the higher risk cohort (lower cost and higher QALYs). The convergent procedure dominated catheter ablation for all risk cohorts. RESULTS were subject to simplifying assumptions and limited by uncertain factors such as long-term maintenance of sinus rhythm after successful procedure and incremental AF-associated event rates for AF patients relative to patients in sinus rhythm. In the absence of clinical trial data, convergent procedure efficacy was estimated with observational evidence. Limitations were addressed with sensitivity analyses and a moderate 5 year time horizon. CONCLUSION The convergent procedure results in superior maintenance of post-ablation sinus rhythm with fewer repeat ablation procedures compared to catheter ablation, leading to lower cost and higher QALYs after 5 years.
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Bhave PD, Knight BP. Optimal Strategies Including Use of Newer Anticoagulants for Prevention of Stroke and Bleeding Complications Before, During, and After Catheter Ablation of Atrial Fibrillation and Atrial Flutter. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 15:450-66. [PMID: 23568665 DOI: 10.1007/s11936-013-0242-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Prashant D Bhave
- Cardiology Division/Electrophysiology Section, Northwestern University Feinberg School of Medicine, 676 North St. Claire, Suite 600, Chicago, IL, 60611, USA,
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Garg V, Shen X, Cheng Y, Nawarskas JJ, Raisch DW. Use of number needed to treat in cost-effectiveness analyses. Ann Pharmacother 2013; 47:380-7. [PMID: 23463742 DOI: 10.1345/aph.1r417] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review the use of number needed to treat (NNT) and/or number needed to harm (NNH) values to determine their relevance in helping clinicians evaluate cost-effectiveness analyses (CEAs). DATA SOURCES PubMed and EconLit were searched from 1966 to September 2012. STUDY SELECTION AND DATA EXTRACTION Reviews, editorials, non-English-language articles, and articles that did not report NNT/NNH or cost-effectiveness ratios were excluded. CEA studies reporting cost per life-year gained, per quality-adjusted life-year (QALY), or other cost per effectiveness measure were included. Full texts of all included articles were reviewed for study information, including type of journal, impact factor of the journal, focus of study, data source, publication year, how NNT/NNH values were reported, and outcome measures. DATA SYNTHESIS A total of 188 studies were initially identified, with 69 meeting our inclusion criteria. Most were published in clinician-practice-focused journals (78.3%) while 5.8% were in policy-focused journals, and 15.9% in health-economics-focused journals. The majority (72.4%) of the articles were published in high-impact journals (impact factor >3.0). Many articles focused on either disease treatment (40.5%) or disease prevention (40.5%). Forty-eight percent reported NNT as a part of the CEA ratio per event. Most (53.6%) articles used data from literature reviews, while 24.6% used data from randomized clinical trials, and 20.3% used data from observational studies. In addition, 10% of the studies implemented modeling to perform CEA. CONCLUSIONS CEA studies sometimes include NNT ratios. Although it has several limitations, clinicians often use NNT for decision-making, so including NNT information alongside CEA findings may help clinicians better understand and apply CEA results. Further research is needed to assess how NNT/NNH might meaningfully be incorporated into CEA publications.
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Affiliation(s)
- Vishvas Garg
- Pharmacoeconomics, Epidemiology, Pharmaceutical Policy, and Outcomes Research program, Department of Pharmacy Practice and Administrative Sciences, College of Pharmacy, University of New Mexico, Albuquerque, NM, USA.
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Verma A, Tsang B. The use of anticoagulation during the periprocedure period of atrial fibrillation ablation. Curr Opin Cardiol 2012; 27:55-61. [DOI: 10.1097/hco.0b013e32834dc34d] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Geller JC, Brunelli M. Catheter ablation of atrial fibrillation without prior transoesophageal echocardiography: are we there yet? Europace 2011; 13:453-4. [PMID: 21343240 DOI: 10.1093/europace/eur030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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Calvo N, Mont L, Vidal B, Nadal M, Montserrat S, Andreu D, Tamborero D, Pare C, Azqueta M, Berruezo A, Brugada J, Sitges M. Usefulness of transoesophageal echocardiography before circumferential pulmonary vein ablation in patients with atrial fibrillation: is it really mandatory? Europace 2010; 13:486-91. [PMID: 21186230 DOI: 10.1093/europace/euq456] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
AIMS Transoesophageal echocardiography (TEE) is recommended prior to circumferential pulmonary vein ablation (CPVA) in patients with atrial fibrillation (AF) to identify left atrial (LA) or left atrial appendage (LAA) wall thrombi. It is not clear whether all patients undergoing CPVA should receive pre-procedural TEE. We wanted to assess the incidence of LA thrombus in these patients and to identify factors associated with its presence. METHODS AND RESULTS Consecutive patients referred for CPVA from 2004 to 2009 underwent TEE within 48 h prior to the procedure. Of 408 patients included in the study, 6 patients (1.47%) had LA thrombi, persistent AF, and LA dilation. Compared with patients without thrombus, these six patients had larger LA diameter (P = 0.0001) and more frequently were women (P = 0.002), had persistent AF (P = 0.04), and had underlying structural cardiac disease (P = 0.014). The likelihood of presenting LA thrombus increased with the number of these four risk factors present (P < 0.001). None of the patients with paroxysmal AF and without LA dilation had LA thrombus. A cut-off value of 48.5 mm LA diameter yielded 83% sensitivity, 92% specificity, and a 10.1 likelihood ratio to predict LA thrombus appearance. CONCLUSION The incidence of LA thrombus prior to CPVA is low. Persistent AF, female sex, structural cardiopathy, and LA dilation were associated with the presence of LA thrombus. Our data suggest that the use of TEE prior to CPVA to detect LA thrombi might not be needed in patients with paroxysmal AF and no LA dilation or structural cardiopathy.
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Affiliation(s)
- N Calvo
- Cardiology Department, Thorax Clinic Institute, Hospital Clínic, IDIBAPS-Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Villarroel 170, Barcelona 08036, Catalonia, Spain
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Merino JL. Periprocedural stroke and atrial fibrillation ablation: to do transoesophageal echocardiography, or not to do transoesophageal echocardiography, that is the question. Europace 2010; 12:1514-5. [PMID: 20937717 DOI: 10.1093/europace/euq360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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