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Yu N, Hong Y, Lv X, Liu Q, Yan M. Preoperative diagnostic value of multimodal spectral CT for patients with atrial fibrillation undergoing radiofrequency ablation. Front Med (Lausanne) 2024; 11:1440020. [PMID: 39328316 PMCID: PMC11425045 DOI: 10.3389/fmed.2024.1440020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 08/23/2024] [Indexed: 09/28/2024] Open
Abstract
Objective Delayed enhancement cardiac computed tomography (CT) empowers the diagnosis of left atrial appendage thrombus while limited to scanning heterogeneity. We optimized the spectral CT scan and post-process protocols, incorporating delayed enhancement and spectral iodine analysis to discriminate left atrial appendage (LAA) thrombus with better morphological relationships between the left atrium, pulmonary vein, and esophagus. Methods A total of 278 consecutive patients were retrieved from January 2019 to June 2023. All patients underwent transesophageal echocardiography (TEE) and spectral CT scan of the left atrial and pulmonary vein, with a complete period including the pulmonary venous phase and three delay phases. TEE diagnosis was used as the standard reference. For patients exhibiting LAA filling defects during the pulmonary venous phase, a delayed scan of 30 s (phase I) was performed. If the filling defects persisted, a further delayed scan of 1 min (phase II) was conducted. In cases where the filling defects persisted, an additional delayed scan of 2 min (phase III) was carried out. Iodine concentration in the filled defect area of LAA and the left atrium was measured in phase III. Moreover, 30 patients were randomly selected for water-swallowing and the other 30 for calm breathing. The image quality and esophageal dilation of the two groups were assessed by two experienced surgeons specializing in radiofrequency ablation. Results In total, 14 patients were diagnosed with thrombi by TEE. The sensitivity, specificity, positive predictive values, negative predictive values, and AUC of phase III delayed combined with iodine quantification for thrombi diagnosis were all 100%. The water-swallowing group exhibited significantly greater esophageal filling and expansion than the calm-breathing group, contributing to a better morphology assessment with no significant difference in image quality. Conclusion Combined with iodine quantification, delayed enhancement of spectral CT imaging presents a promising diagnostic potency for LAA thrombus. Incorporating water swallowing into the CT scan process further enables anatomical visualization of the esophagus, left atrium, and pulmonary vein, thereby providing more objective and authentic imaging evidence to assess the esophageal morphology and positional relationships.
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Affiliation(s)
- Na Yu
- Department of Radiology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuqin Hong
- Department of Radiology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xue Lv
- Department of Radiology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qiao Liu
- Department of Radiology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Min Yan
- Department of Radiology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
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2
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Xu B, Du Y, Yu Z, Sun Y, Xiang M. Cardiac thrombus detected by cardiac computed tomography angiography in patients with acute ischemic stroke: a meta-analysis. Front Neurol 2024; 15:1453683. [PMID: 39318872 PMCID: PMC11420050 DOI: 10.3389/fneur.2024.1453683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2024] [Accepted: 08/14/2024] [Indexed: 09/26/2024] Open
Abstract
Background Detecting cardiac thrombus in patients with acute ischemic stroke is crucial in determine stroke etiology and predict prognosis. However, the prevalence of cardiac thrombus in patients with acute ischemic stroke is unclear. Object This study aimed to evaluate the prevalence of cardiac thrombus detected by cardiac computed tomography angiography (CCTA) in patients with acute ischemic stroke through a meta-analysis. Methods Embase, Web of Science, MEDLINE, and CENTRAL were searched from January 1, 2000, to May 1, 2024. We included observational studies enrolling patients who underwent CCTA within 1 month following acute ischemic stroke, and reporting the incidence of cardiac thrombi on CCTA. Meta-analysis was performed using random effects models. Results Twenty-six studies involving 4,516 patients were identified. The pooled prevalence of cardiac thrombus detected on CCTA in patients with acute ischemic stroke was 0.08 (95% confidence interval [CI]: 0.06-0.11). Inter-study heterogeneity was high (I2 = 88%). Among stroke type, the prevalence of atrial fibrillation, timing of CCTA and CCTA technology, the prevalence of atrial fibrillation was the only factor associated with cardiac thrombi prevalence detected by CCTA. However, atrial fibrillation was not documented in 41.5% of the patients with cardiac thrombi. Conclusion CCTA is a useful non-invasive imaging approach for detecting cardiac thrombus in patients with acute ischemic stroke, which might be helpful to determine the stroke etiology.
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Affiliation(s)
- Buyun Xu
- State Key Laboratory of Transvascular Implantation Devices, Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Cardiology, Shaoxing People’s Hospital (Shaoxing Hospital of Zhejiang University), Shaoxing, China
| | - Ye Du
- Department of Neurology, Shaoxing People’s Hospital (Shaoxing Hospital of Zhejiang University), Shaoxing, China
| | - Zhangjie Yu
- Department of Cardiology, Shaoxing People’s Hospital (Shaoxing Hospital of Zhejiang University), Shaoxing, China
| | - Yong Sun
- Department of Cardiology, Shaoxing People’s Hospital (Shaoxing Hospital of Zhejiang University), Shaoxing, China
| | - Meixiang Xiang
- State Key Laboratory of Transvascular Implantation Devices, Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Nio SS, Rinkel LA, Cramer ON, Özata ZB, Beemsterboer CFP, Guglielmi V, Bouma BJ, Boekholdt SM, Lobé NHJ, Beenen LFM, Marquering HA, Majoie CBLM, Roos YBWEM, van Randen A, Planken RN, Coutinho JM. Left Atrial Appendage Opacification on Cardiac Computed Tomography in Acute Ischemic Stroke: The Clinical Implications of Slow-Flow. J Am Heart Assoc 2024; 13:e034106. [PMID: 39190561 DOI: 10.1161/jaha.123.034106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/02/2024] [Indexed: 08/29/2024]
Abstract
BACKGROUND Left atrial appendage (LAA) slow-flow may increase the risk of ischemic stroke. We studied LAA attenuation on cardiac computed tomography in patients with acute ischemic stroke. METHODS AND RESULTS We used data from a prospective cohort of patients with acute ischemic stroke undergoing cardiac computed tomography during the acute stroke imaging protocol. We compared characteristics, functional outcome (modified Rankin scale: higher scores indicating worse outcome), stroke recurrence and major adverse cardiovascular events after 2-year follow-up between patients with LAA thrombus (filling defect<100 Hounsfield Unit (HU)), slow-flow (filling defect ≥100 HU) and normal filling. Of 421 patients, 31 (7%) had LAA thrombus, 69 (16%) slow-flow, and 321 (76%) normal filling. Patients with thrombus or slow-flow more often had known atrial fibrillation compared with normal filling (45%, 39%, and 9%, P<0.001). Patients with thrombus had higher National Institutes of Health Stroke Scale-scores compared with slow-flow and normal filling (18 [interquartile range, 9-22], 6 [interquartile range, 3-17], and 5 [interquartile range, 2-11], P<0.001). Compared with normal filling, there was no difference with slow-flow in functional outcome (median modified Rankin scale, 3 versus 2; acOR 0.8 [95% CI, 0.5-1.4]), stroke recurrence (adjusted hazard ratio, 0.8 [95% CI, 0.3-1.9]) or major adverse cardiovascular events (adjusted hazard ratio, 1.2 [95% CI, 0.7-2.1]), while patients with thrombus had worse functional outcome (median modified Rankin scale, 6, acOR, 3.3 [95% CI, 1.5-7.4]). In cryptogenic stroke patients (n=156) slow-flow was associated with stroke recurrence (27% versus 6%, aHR, 4.1 [95% CI, 1.1-15.7]). CONCLUSIONS Patients with slow-flow had similar characteristics to patients with thrombus, but had less severe strokes. Slow-flow was not significantly associated with functional outcome or major adverse cardiovascular events, but was associated with recurrent stroke in patients with cryptogenic stroke.
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Affiliation(s)
- Shan Sui Nio
- Department of Neurology Amsterdam UMC, Location University of Amsterdam Amsterdam The Netherlands
| | - Leon A Rinkel
- Department of Neurology Amsterdam UMC, Location University of Amsterdam Amsterdam The Netherlands
| | - Olivia N Cramer
- Department of Neurology Amsterdam UMC, Location University of Amsterdam Amsterdam The Netherlands
| | - Z Beyda Özata
- Department of Neurology Amsterdam UMC, Location University of Amsterdam Amsterdam The Netherlands
| | - Chiel F P Beemsterboer
- Department of Neurology Amsterdam UMC, Location University of Amsterdam Amsterdam The Netherlands
| | - Valeria Guglielmi
- Department of Neurology Amsterdam UMC, Location University of Amsterdam Amsterdam The Netherlands
| | - Berto J Bouma
- Department of Cardiology Amsterdam UMC, Location University of Amsterdam Amsterdam The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology Amsterdam UMC, Location University of Amsterdam Amsterdam The Netherlands
| | - Nick H J Lobé
- Department of Radiology and Nuclear Medicine Amsterdam UMC, Location University of Amsterdam Amsterdam The Netherlands
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine Amsterdam UMC, Location University of Amsterdam Amsterdam The Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine Amsterdam UMC, Location University of Amsterdam Amsterdam The Netherlands
- Department of Biomedical Engineering and Physics Amsterdam UMC, Location University of Amsterdam Amsterdam The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine Amsterdam UMC, Location University of Amsterdam Amsterdam The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology Amsterdam UMC, Location University of Amsterdam Amsterdam The Netherlands
| | - Adrienne van Randen
- Department of Radiology and Nuclear Medicine Amsterdam UMC, Location University of Amsterdam Amsterdam The Netherlands
| | - R Nils Planken
- Department of Radiology and Nuclear Medicine Amsterdam UMC, Location University of Amsterdam Amsterdam The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology Amsterdam UMC, Location University of Amsterdam Amsterdam The Netherlands
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Khalili E, Daversin-Catty C, Olivares AL, Mill J, Camara O, Valen-Sendstad K. On the importance of fundamental computational fluid dynamics toward a robust and reliable model of left atrial flows. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2024; 40:e3804. [PMID: 38286150 DOI: 10.1002/cnm.3804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 08/31/2023] [Accepted: 01/07/2024] [Indexed: 01/31/2024]
Abstract
Computational fluid dynamics (CFD) studies of left atrial flows have reached a sophisticated level, for example, revealing plausible relationships between hemodynamics and stresses with atrial fibrillation. However, little focus has been on fundamental fluid modeling of LA flows. The purpose of this study was to investigate the spatiotemporal convergence, along with the differences between high- (HR) versus normal-resolution/accuracy (NR) solution strategies, respectively. Rigid wall CFD simulations were conducted on 12 patient-specific left atrial geometries obtained from computed tomography scans, utilizing a second-order accurate and space/time-centered solver. The convergence studies showed an average variability of around 30% and 55% for time averaged wall shear stress (WSS), oscillatory shear index (OSI), relative residence time (RRT), and endothelial cell activation potential (ECAP), even between intermediate spatial and temporal resolutions, in the left atrium (LA) and left atrial appendage (LAA), respectively. The comparison between HR and NR simulations showed good correlation in the LA for WSS, RRT, and ECAP (R 2 > .9 ), but not for OSI (R 2 = .63 ). However, there were poor correlations in the LAA especially for OSI, RRT, and ECAP (R 2 = .55, .63, and .61, respectively), except for WSS (R 2 = .81 ). The errors are comparable to differences previously reported with disease correlations. To robustly predict atrial hemodynamics and stresses, numerical resolutions of 10 M elements (i.e., Δ x = ∼ .5 mm) and 10 k time-steps per cycle seem necessary (i.e., one order of magnitude higher than normally used in both space and time). In conclusion, attention to fundamental numerical aspects is essential toward establishing a plausible, robust, and reliable model of LA flows.
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Affiliation(s)
- Ehsan Khalili
- Department of Computational Physiology, Simula Research Laboratory, Oslo, Norway
| | - Cécile Daversin-Catty
- Department of Numerical Analysis and Scientific Computing, Simula Research Laboratory, Oslo, Norway
| | - Andy L Olivares
- Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
| | - Jordi Mill
- Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
| | - Oscar Camara
- Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
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Guo C, Jiang Z, He J, Ma H, Wang Y, Tan J, Ou Q, Tian Y, Tian L, Liu Q, Huang J, Yang L. Impact of left atrial appendage thrombus location on diagnostic accuracy of cardiac CT: a single-centre case-control study. BMJ Open 2024; 14:e079876. [PMID: 38296275 PMCID: PMC10831467 DOI: 10.1136/bmjopen-2023-079876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/15/2024] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVE Cardiac CT (CCT) is an emerging non-invasive modality for assessing left atrial appendage (LAA) thrombus, but the results were conflicting. Our study aims to evaluate the accuracy of CCT for detecting LAA thrombus in patients undergoing catheter ablation of atrial fibrillation, using trans-oesophageal echocardiography (TEE) as the reference standard. DESIGN Case-control study. SETTING Patient data were collected from a tertiary hospital in China between 2017 and 2022. PARTICIPANTS The study enrolled 726 patients (male: 60.2%, age: 61±11 years) who had both TEE and CCT before catheter ablation of atrial fibrillation. MEASURES The CCT protocol consisted of one angiographic phase and one delayed scan 30 s later. LAA thrombi were defined as solid masses on TEE or persistent defects on CCT. The thrombus dimension and location, the LAA filling and emptying flow velocity were assessed by TEE. RESULTS Of the 57 (7.9%) patients with LAA thrombi identified by TEE, 29 (50.9%) were located at the LAA ostium, and 28 (49.1%) were in the LAA. The former showed higher motility following blood flow and heartbeats than the latter. The CCT detected 14 (48.3%) of the LAA-ostium thrombi but 25 (89.3%) of those in the LAA (p=0.001). The LAA-ostium thrombi with the LAA mean flow velocity >0.35 m/s and maximum diameters <10 mm were more prone to have CCT false-negative results. CONCLUSION For patients undergoing catheter ablation for atrial fibrillation, CCT with a 30 s delay scan is less sensitive to LAA thrombi than TEE, especially for LAA-ostium thrombi with smaller sizes and higher LAA flow velocity.
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Affiliation(s)
- Chuxian Guo
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
- Guizhou Medical University, Guiyang, Guizhou, China
| | - Zhi Jiang
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Jionghong He
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
- Echocardiography Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Haiyan Ma
- Radiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Yuquan Wang
- Radiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Jing Tan
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
- Echocardiography Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Qiaoqiao Ou
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
- Guizhou Medical University, Guiyang, Guizhou, China
| | - Ye Tian
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Longhai Tian
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Qifang Liu
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Jing Huang
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Long Yang
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
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6
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Malhotra P. Use of Computed Tomography for Left Atrial Appendage Occlusion Procedure Planning and Post-Procedure Assessment. Interv Cardiol Clin 2024; 13:19-28. [PMID: 37980064 DOI: 10.1016/j.iccl.2023.08.006] [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] [Indexed: 11/20/2023]
Abstract
Transcatheter left atrial appendage occlusion (LAAO) is an alternative to systemic anticoagulation in patients with non-valvular atrial fibrillation with increased risk for thromboembolic events. Pre- and post-procedural imaging is essential for technical success, allowing practitioners to identify contraindications, select appropriate devices, and recognize procedural complications. Although transesophageal echocardiography has traditionally served as the preeminent imaging modality in LAAO, cardiac computed tomography imaging has emerged as a noninvasive surrogate given its excellent isotropic spatial resolution, multiplanar reconstruction capability, rapid temporal resolution, and large field of view.
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Affiliation(s)
- Pankaj Malhotra
- Department of Imaging, Mark Taper Imaging Center, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Taper M335, Los Angeles, CA 90048, USA; Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA.
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7
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Sulague RM, Whitham T, Danganan LML, Effiom V, Candelario K, Latif N, Hameed I. The Left Atrial Appendage and Atrial Fibrillation-A Contemporary Review. J Clin Med 2023; 12:6909. [PMID: 37959374 PMCID: PMC10650862 DOI: 10.3390/jcm12216909] [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: 10/02/2023] [Revised: 10/28/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023] Open
Abstract
In patients with atrial fibrillation, the left atrial appendage may serve as the site of thrombus formation due to stasis that occurs within the appendage because of its shape and trabeculations. Although thrombus formation can be reduced by using anticoagulants, this may be contraindicated in some patients. The need for a better alternative treatment prompted the study of left atrial appendage occlusion for thromboembolism prophylaxis. Due to this, procedures that excise or occlude the left atrial appendage have gained attention because of their ability to prevent thromboembolic events. This article provides a comprehensive review of the left atrial appendage and its associated procedures' clinical utility.
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Affiliation(s)
- Ralf Martz Sulague
- Graduate School of Arts and Sciences, Georgetown University, Washington, DC 20057, USA;
| | - Tarik Whitham
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH 44272, USA;
| | | | - Victory Effiom
- College of Medical Sciences, University of Calabar, Calabar 540271, Nigeria;
| | - Katherine Candelario
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, 330 Cedar Street, New Haven, CT 06510, USA; (K.C.); (N.L.)
| | - Nida Latif
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, 330 Cedar Street, New Haven, CT 06510, USA; (K.C.); (N.L.)
| | - Irbaz Hameed
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, 330 Cedar Street, New Haven, CT 06510, USA; (K.C.); (N.L.)
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8
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Honnekeri B, Fava AM, Reyaldeen R, Kanj M, Alvarez P, Xu B. Prominent para-cardiac fat mimicking left atrial appendage thrombus on echocardiography: Utility of cardiac computed tomography. Echocardiography 2023; 40:875-878. [PMID: 37199004 DOI: 10.1111/echo.15595] [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: 03/05/2023] [Accepted: 05/03/2023] [Indexed: 05/19/2023] Open
Abstract
Transesophageal echocardiography is the most frequently used imaging modality for exclusion of left atrial appendage thrombus prior to cardioversion. Echocardiographers should be aware of rare conditions that may mimic left atrial appendage thrombus. Here, we describe a rare case of prominent para-cardiac fat mimicking left atrial appendage thrombus on transesophageal echocardiographic imaging. Multimodality imaging with cardiac computed tomography was instrumental in providing further anatomical delineation and characterization of the echodensity as prominent para-cardiac fat in this case.
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Affiliation(s)
- Bianca Honnekeri
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Agostina M Fava
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Reza Reyaldeen
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mohamed Kanj
- Section of Electrophysiology, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Paulino Alvarez
- Section of Heart Failure and Cardiac Transplantation, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bo Xu
- Section of Cardiovascular Imaging, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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9
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Li X, Cai Y, Chen X, Ming Y, He W, Liu J, Pu H, Chen X, Peng L. Radiomics Based on Single-Phase CTA for Distinguishing Left Atrial Appendage Thrombus from Circulatory Stasis in Patients with Atrial Fibrillation before Ablation. Diagnostics (Basel) 2023; 13:2474. [PMID: 37568837 PMCID: PMC10417448 DOI: 10.3390/diagnostics13152474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/14/2023] [Accepted: 07/20/2023] [Indexed: 08/13/2023] Open
Abstract
Differentiation of left atrial appendage thrombus (LAAT) and left atrial appendage (LAA) circulatory stasis is difficult when based only on single-phase computed tomography angiography (CTA) in routine clinical practice. Radiomics provides a promising tool for their identification. We retrospectively enrolled 204 (training set: 144; test set: 60) atrial fibrillation patients before ablation, including 102 LAAT and 102 circulatory stasis patients. Radiomics software was used to segment whole LAA on single-phase CTA images and extract features. Models were built and compared via a multivariable logistic regression algorithm and area under of the receiver operating characteristic curves (AUCs), respectively. For the radiomics model, radiomics clinical model, radiomics radiological model, and combined model, the AUCs were 0.82, 0.86, 0.90, 0.93 and 0.82, 0.82, 0.84, 0.85 in the training set and the test set, respectively (p < 0.05). One clinical feature (rheumatic heart disease) and four radiological features (transverse diameter of left atrium, volume of left atrium, location of LAA, shape of LAA) were added to the combined model. The combined model exhibited excellent differential diagnostic performances between LAAT and circulatory stasis without increasing extra radiation exposure. The single-phase, CTA-based radiomics analysis shows potential as an effective tool for accurately detecting LAAT in patients with atrial fibrillation before ablation.
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Affiliation(s)
- Xue Li
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, China; (X.L.); (X.C.); (W.H.); (J.L.); (H.P.)
| | - Yuyan Cai
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China;
| | - Xiaoyi Chen
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, China; (X.L.); (X.C.); (W.H.); (J.L.); (H.P.)
| | - Yue Ming
- West China School of Medicine, Sichuan University, Chengdu 610041, China;
| | - Wenzhang He
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, China; (X.L.); (X.C.); (W.H.); (J.L.); (H.P.)
| | - Jing Liu
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, China; (X.L.); (X.C.); (W.H.); (J.L.); (H.P.)
| | - Huaxia Pu
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, China; (X.L.); (X.C.); (W.H.); (J.L.); (H.P.)
| | - Xinyue Chen
- CT Collaboration, Siemens Healthineers, Chengdu 610041, China;
| | - Liqing Peng
- Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, China; (X.L.); (X.C.); (W.H.); (J.L.); (H.P.)
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10
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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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11
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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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12
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Barnea R, Agmon IN, Shafir G, Peretz S, Mendel R, Naftali J, Shiyovich A, Kornowski R, Auriel E, Hamdan A. Cardiac CT for intra-cardiac thrombus detection in embolic stroke of undetermined source (ESUS). Eur Stroke J 2022; 7:212-220. [PMID: 36082249 PMCID: PMC9446335 DOI: 10.1177/23969873221099692] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/22/2022] [Indexed: 10/17/2023] Open
Abstract
Introduction Embolic stroke of undetermined source (ESUS) is a common medical challenge regarding secondary prevention strategy. Cardiac imaging is the cornerstone of embolic stroke workup, in an effort to diagnose high risk cardio-embolic sources. Cardiac computed tomography angiography (CCTA) is an emerging imaging modality with high diagnostic performance for intra-cardiac thrombus detection. The yield of CCTA implementation in addition to standard care in ESUS workup is unknown. Thus, the aim of this study was to assess the utility of CCTA in detecting intra-cardiac thrombi in the routine ESUS workup. Patients and methods This is a retrospective observational analysis of ESUS cases managed in vascular neurology unit between 2019 and 2021. Within this ESUS registry, consecutive patients undergoing CCTA were included and carefully analyzed. Results During the study period 1066 Ischemic stroke (IS) cases were treated and evaluated. 266/1066 (25%) met ESUS criteria and 129/266 (48%) underwent CCTA. Intra-cardiac thrombus was detected by CCTA in 22/129 (17%; 95% CI, 11.5%-23.5%) patients: left ventricular thrombus (LVT) in 13 (10.1%) patients, left atrial appendage (LAA) thrombus in 8 (6.2%) patients, and left atrial (LA) thrombus in 1 (0.8%) patient. Only 5/22 (23%) of these thrombi were suspected, but could not be confirmed, in trans-thoracic echocardiogram (TTE). Among CCTA-undergoing patients, 27/129 (21%; 95% CI, 14%-28%) were found to have an indication (including pulmonary embolism) for commencing anticoagulation (AC) treatment, rather than anti-platelets. In favor of CCTA implementation, 22/266 (8.2%; 95% CI, 4.9%-11.5%) patients within the entire ESUS cohort were diagnosed with intra-cardiac thrombus, otherwise missed. Conclusion CCTA improves the detection of intra-cardiac thrombi in addition to standard care in ESUS patients. The implementation of CCTA in routine ESUS workup can change secondary prevention strategy in a considerable proportion of patients.
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Affiliation(s)
- Rani Barnea
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Inbar Nardi Agmon
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Cardiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
| | - Gideon Shafir
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Radiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
| | - Shlomi Peretz
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Rom Mendel
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Jonathan Naftali
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Arthur Shiyovich
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Cardiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
| | - Ran Kornowski
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Cardiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
| | - Eitan Auriel
- Department of Neurology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
| | - Ashraf Hamdan
- Sackler School of Medicine, Tel-Aviv
university, Tel-Aviv, Israel
- Department of Cardiology, Rabin Medical
Center – Beilinson Hospital, Petach Tikva, Israel
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13
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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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14
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Li XN, Wang JX, Wei Q, Yu XB, Zhou YT, Ma XY, Zhao N, Lu B. Diagnostic Value of Delayed Contrast-Enhanced Cardiac Computed Tomography for Detecting Left Atrial Appendage Thrombus in Patients With Atrial Fibrillation. Front Cardiovasc Med 2022; 9:847163. [PMID: 35571218 PMCID: PMC9095922 DOI: 10.3389/fcvm.2022.847163] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 03/07/2022] [Indexed: 11/21/2022] Open
Abstract
Objective Delayed enhancement cardiac CT is a reliable tool for the diagnosis of left atrial appendage thrombus but limited for scanning heterogeneity. We aimed to explore the improvement of the 1 and 3-min delay phase at the diagnostic level to detect left atrial appendage thrombus, in order to set up a reasonable CT scanning scheme. Materials and Methods A total of 6,524 patients were continuously retrieved from January 2015 to September 2020 retrospectively. The patients had undergone Transesophageal echocardiography (TEE) and cardiac CT with complete period include the arterial enhancement phase, 1 and 3-min delay phase, TEE were used as the reference standard. The final study included 329 patients. Three experienced radiologists independently assessed each phase of the cardiac CT images for thrombus diagnosis. We explored the improvement of the diagnostic ability of different delayed contrast-enhanced phases for left atrial appendage thrombus detection. Multiple logistic regression analysis were used for further high-risk stratification to avoid an additional 1-min delayed scan. Results In total, 29 thrombosis were detected at TEE. For all cardiac CT phases, sensitivity and negative predictive were 100%. The specificity were 0.54, 0.93, and 1.00, respectively; The positive predictive values (PPV) were 0.17, 0.57, and 1.00, respectively; Area under curve (AUC) were 0.75, 0.95, and 0.98, respectively. High risk factors that cannot be clearly diagnosed with 1-min delay phase included reduced cardiac function, increased CHA2DS2-VAScscore and left atrial enlargement. Compared with the arterial enhanced phase, increased radiation doses in the 1 and 3-min delay phases were 1.7 ± 1.3 msv and 1.5 ± 0.8 msv (mean ± standard deviation). Conclusion Using TEE as the reference standard, early contrast-enhanced CT scanning with 1 and 3-min delay is necessary for the diagnosis of left appendage thrombus, which could significantly improve the diagnostic efficiency. Patients with high-risk stratification are suitable for direct 3-min delayed scanning.
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Affiliation(s)
- Xiang-Nan Li
- State Key Laboratory of Cardiovascular Disease, Department of Radiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing-Xi Wang
- State Key Laboratory of Cardiovascular Disease, Department of Radiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qing Wei
- State Key Laboratory of Cardiovascular Disease, Department of Ultrasonography, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xian-Bo Yu
- CT Collaboration, Siemens Healthineers Ltd., Beijing, China
| | - Yu-Tao Zhou
- State Key Laboratory of Cardiovascular Disease, Department of Radiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Yan Ma
- State Key Laboratory of Cardiovascular Disease, Department of Radiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Na Zhao
- State Key Laboratory of Cardiovascular Disease, Department of Radiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bin Lu
- State Key Laboratory of Cardiovascular Disease, Department of Radiology, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Bin Lu,
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15
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Thomas W, Werkmeister M, O'Rourke E, Ward S, Bentley L, Premaratne M. Use of computed tomography left atrial appendage as an alternative to trans-oesophageal echocardiography during the COVID-19 pandemic. J Med Imaging Radiat Oncol 2022; 66:809-811. [PMID: 35393775 PMCID: PMC9111323 DOI: 10.1111/1754-9485.13411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/17/2022] [Accepted: 03/30/2022] [Indexed: 11/29/2022]
Affiliation(s)
| | | | | | - Stephen Ward
- Radiology, Peninsula Health, Frankston, Victoria, Australia
| | - Louise Bentley
- Radiology, Peninsula Health, Frankston, Victoria, Australia
| | - Manuja Premaratne
- Cardiology, Peninsula Health, Frankston, Victoria, Australia.,Monash University, Clayton, Victoria, Australia.,Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
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16
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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: 24] [Impact Index Per Article: 8.0] [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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17
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Gilhofer TS, Abdellatif W, Nicolaou S, Jalal S, Powell J, Inohara T, Starovoytov A, Saw J. Cardiac CT angiography after percutaneous left atrial appendage closure: early versus delayed scanning after contrast administration. DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY (ANKARA, TURKEY) 2021; 27:703-709. [PMID: 34792023 DOI: 10.5152/dir.2021.20349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Cardiac computed tomography angiography (CCTA) is increasingly used for device surveillance after left atrial appendage closure (LAAC). While CT protocols with delayed scans are useful to diagnose thrombus in the LAA, an optimal protocol for post-procedural CCTA has not been established. Therefore, we assessed the role of delayed versus early scans for device surveillance. METHODS We retrospectively reviewed patients who underwent LAAC at Vancouver General Hospital who had follow-up CCTAs using standard (early) and delayed scans. Scans were performed on Toshiba 320-detector (Aquilion ONE). Image quality was interpreted by 2 independent observers for anatomy, LAA contrast patency, and device-related thrombus (DRT) using VitreaWorkstationTM. A Likert scale of 1-5 was used (1= poor quality, 5= excellent) for assessment. RESULTS We included 27 consecutive LAAC patients (9 Amplatzer, 18 WATCHMAN) with mean age 76.0±7.7 years, mean CHADS2 score 2.8±1.3, CHA2DS2-VASc score 4.4±1.6 and HAS-BLED score 3.4±1.0. Subjective quality assessments by both reviewers favored early scans for assessment of anatomy (reviewer 1: 4.63±0.63 [early] vs. 1.74±0.71 [delayed]; reviewer 2: 4.63±0.63 [early] vs. 1.89±0.64 [delayed]) and DRT (reviewer 1: 4.78±0.42 [early] vs. 3.11±1.16 [delayed]; reviewer 2: 4.70±0.47 [early] vs. 3.04±1.29 [delayed]). Inter-rater variability showed good correlation between reviewers (intraclass correlation 0.61-0.95). Mean LAA/LA attenuation ratios were significantly different between scans, with larger mean percent reduction of contrast opacification from LA to LAA in the early scans (57.0±36.6% reduction for early vs. 29.1±30.8% for delayed; p < 0.001) CONCLUSION: For CT device surveillance post-LAAC early phase imaging provides superior image quality objectively and subjectively compared with delayed scanning.
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Affiliation(s)
- Thomas S Gilhofer
- Department of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Waleed Abdellatif
- Department of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Savvas Nicolaou
- Deparment of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Sabeena Jalal
- Deparment of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Jennifer Powell
- Deparment of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Taku Inohara
- Department of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Andrew Starovoytov
- Department of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Jacqueline Saw
- Department of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
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18
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Aziz MU, Manapragada P, Singh SP. Non coronary applications of cardiac computed tomography: A review. J Med Imaging Radiat Sci 2021; 52:S51-S64. [PMID: 34483085 DOI: 10.1016/j.jmir.2021.07.003] [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: 05/17/2021] [Revised: 07/11/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
Acquired heart diseases including valvular pathologies and conduction abnormalities, along with coronary artery disease make cardiovascular disease one of the major causes of mortality and morbidity worldwide. Advances in cardiac computed tomography (CCT) have led to markedly improved image quality for assessment of several coronary and noncoronary cardiac abnormalities. With the latest versions of CT scanners, image acquisition can be completed within a few seconds, in a single breath hold and with much less radiation exposure, thus making CT an even more attractive diagnostic tool with its high temporal and excellent spatial resolution. Additional advantages are its noninvasive nature, wide availability, fast image acquisition and ability to provide additional data about the cardiac structure, function, valvular motion, and presence or absence of valvular vegetation, mass or intracardiac thrombus. These factors can result in change in management in many valvular pathologies pre- and post-intervention, and in electrophysiological procedures. The goal of this article is to review applications of cardiac CT in non-coronary indications including valvular assessment, pulmonary vein isolation procedure, and left atrial appendage evaluation for its transcatheter occlusion.
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Affiliation(s)
- Muhammad Usman Aziz
- The University of Alabama at Birmingham, Department of Diagnostic Radiology, Birmingham, AL, United States.
| | - Padma Manapragada
- The University of Alabama at Birmingham, Department of Diagnostic Radiology, Birmingham, AL, United States
| | - Satinder P Singh
- The University of Alabama at Birmingham, Department of Diagnostic Radiology, Birmingham, AL, United States
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19
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Okuno T, Lanz J, Stortecky S, Heg D, Bernhard B, Gräni C, Huber A, Praz F, Räber L, Valgimigli M, Siontis GCM, Windecker S, Pilgrim T. Clinical impact of left atrial appendage filling defects in patients undergoing transcatheter aortic valve implantation. Eur Heart J Cardiovasc Imaging 2021; 23:1354-1364. [PMID: 34463717 DOI: 10.1093/ehjci/jeab142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/07/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS Incidental detection of left atrial appendage (LAA) filling defects is a common finding on multi-detector computed tomography in aortic stenosis patients under evaluation for transcatheter aortic valve implantation (TAVI). We aimed to investigate the incidence of LAA filling defects before TAVI and its impact on clinical outcomes. METHODS AND RESULTS In a prospective registry, LAA filling defects were retrospectively evaluated and categorized into one of four sub-types: thrombus-like, heterogeneous, horizontal, and Hounsfield Unit (HU)-run-off. The primary endpoint was the composite of cardiovascular death or disabling stroke up to 1-year follow-up. Among 1621 patients undergoing TAVI between August 2007 and June 2018, LAA filling defects were present in 177 patients (11%), and categorized as thrombus-like in 22 (1.4%), heterogeneous in 37 (2.3%), horizontal in 80 (4.9%), and HU-run-off in 38 (2.4%). Compared to patients with normal LAA filling, patients with LAA filling defects had greater prevalence of atrial fibrillation (84.7% vs. 26.4%, P < 0.001) and history of cerebrovascular events (16.4% vs. 10.9%, P = 0.045). The primary endpoint occurred in 131 patients (9.2%) with normal LAA filling and in 36 patients (21.2%) with LAA filling defects (P < 0.001). Subgroup analysis suggested that the risk of disabling stroke was greatest in the thrombus-like pattern (23.0%), followed by the HU-run-off (8.0%), the heterogeneous (6.2%), and the horizontal pattern (1.2%). CONCLUSION LAA filling defects were observed in 11% of aortic stenosis patients undergoing TAVI and associated with an increased risk of cardiovascular death and disabling stroke up to 1 year following TAVI. TRIAL REGISTRATION https://www.clinicaltrials.gov. NCT01368250.
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Affiliation(s)
- Taishi Okuno
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Dik Heg
- Clinical Trials Unit Bern, University of Bern, Bern, Switzerland
| | - Benedikt Bernhard
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Adrian Huber
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - George C M Siontis
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
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20
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Molina-Fuentes MF, Neumann R, Behringer W, Franz M, Schulze PC, Witte OW, Günther A, Klingner C, Lehmkuhl L, Steiniger B, Teichgräber U, Rod JE, Mayer TE. Feasibility of the Big 5-Jena eCS Protocol : First Experience Implementing a New Extended CT Protocol in the Initial Diagnostics of Ischemic Stroke. Clin Neuroradiol 2021; 31:901-909. [PMID: 34379134 PMCID: PMC8356684 DOI: 10.1007/s00062-021-01058-6] [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: 12/09/2020] [Accepted: 06/18/2021] [Indexed: 10/25/2022]
Abstract
PURPOSE The most common protocols in the initial diagnostic of acute ischemic stroke do not assess cardiogenic or aortic causes of embolism. These are usually evaluated later by transthoracic (TTE) or transesophageal (TEE) echocardiography. This study aimed to evaluate the feasibility of a diagnostic tool for thoracic cardiovascular thrombi according to the first experience with a new extended cardio-stroke protocol (Big 5-Jena eCS protocol) in acute stroke patients. METHODS Retrospective analyses of the tomography scans database of the Jena University Hospital were performed. We included a total of 67 patients in the feasibility analyses, based on the evaluation of three outcomes. RESULTS Primary outcome: the Big 5-Jena eCS protocol was able to detect thoracic cardiovascular thrombi in a total of 20 patients in different locations including the arch of the aorta, the aortic valve, the left atrium, the left atrial appendage, the left ventricle, and the pulmonary arteries. Secondary outcome: implementating the protocol did not result in a significant elevation of the radiation exposure compared to traditional protocols. Tertiary outcome: the new protocol identified seven cases that were considered negative by echocardiography. CONCLUSION The implementation of an extended cardio-stroke protocol is feasible, no significantly time-consuming, acquiring assessable imaging, and maintaining radiation exposure acceptable. The Big 5-Jena eCS protocol was also able to detect some thrombi not reported by TTE or TEE; however, due to our data's explorative character, a conclusive comparison with cardiac ultrasound is not possible. A prospective pilot study and clinical trials should be conducted to assess the diagnostic accuracy of this protocol compared to echocardiography and determine the potential impact on diagnostic and treatment decisions.
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Affiliation(s)
- Moisés F Molina-Fuentes
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany. .,Department of Diagnostic and Interventional Radiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany. .,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.
| | - Rotraud Neumann
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Wilhelm Behringer
- Emergency Department, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Marcus Franz
- Department of Internal Medicine, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - P Christian Schulze
- Department of Internal Medicine, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Albrecht Günther
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Carsten Klingner
- Hans Berger Department of Neurology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Lukas Lehmkuhl
- Clinic for Radiology, Rhön-Klinikum Campus Bad Neustadt, Bad Neustadt a. d. Saale, Germany
| | - Beatrice Steiniger
- Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - Ulf Teichgräber
- Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
| | - J E Rod
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Thomas E Mayer
- Department of Neuroradiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany.,Institute for Diagnostic and Interventional Radiology, Jena University Hospital-Friedrich Schiller University, Jena, Germany
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21
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Szekely Y, Shmilovich H, Hochstadt A, Ghantous E, Topilsky Y, Aviram G, Hadad Y, Arbel Y, Konigstein M, Banai S, Finkelstein A, Halkin A. Long-term implications of left atrial appendage thrombus identified incidentally by pre-procedural cardiac computed tomography angiography in patients undergoing transcatheter aortic valve replacement. Eur Heart J Cardiovasc Imaging 2021; 22:563-571. [PMID: 32154881 DOI: 10.1093/ehjci/jeaa030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 01/18/2020] [Accepted: 02/12/2020] [Indexed: 11/12/2022] Open
Abstract
AIMS The prevalence and prognostic implications of left atrial appendage (LAA) thrombus (LAAT) in patients considered for transcatheter aortic valve replacement (TAVR) are incompletely defined. We, therefore, studied pre-procedural cardiac computed tomography angiography (CCTA) scans of TAVR candidates to determine the prevalence of LAAT and its association with late outcomes. METHODS AND RESULTS Baseline clinical variables and CCTA findings from a prospective TAVR registry were analysed for the prevalence of pre-procedural LAAT and its impact on in-hospital outcomes and late mortality. LAAT was differentiated from LAA filling defects (LAAFD) reflecting stasis without clot. Patients (n = 561) with complete in-hospital and late mortality data were included in the study (median follow-up 31.6 months). LAAT and LAAFD were evidenced on pre-procedural CCTA in 24 (4.3%) and 26 (4.6%) patients, respectively. One hundred fourteen (20.3%) patients died during the study period. Though in-hospital adverse event rates (including stroke) did not differ among groups, mortality at long-term follow-up was higher among LAAT patients compared with those with or without LAAFD (58.3% vs. 11.5% vs. 19.0%, respectively; P < 0.003). By multivariable analysis, LAAT (but not LAAFD) was independently associated with all-cause mortality [hazard ratio (HR) = 3.33 (1.83-6.00), P < 0.001]. In patients with LAAT, oral anticoagulation at discharge was associated with lower mortality risk, independently of atrial fibrillation status. CONCLUSIONS LAAT visualized by pre-procedural CCTA is an independent predictor of late mortality following TAVR, but not peri-procedural stroke. When reporting TAVR-CCTA, particular note should be made of LAA features and presence of LAAT which may have prognostic and management implications.
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Affiliation(s)
- Yishay Szekely
- Department of Cardiology, Tel Aviv Medical Center affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 64239, Israel
| | - Haim Shmilovich
- Department of Cardiology, Tel Aviv Medical Center affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 64239, Israel
| | - Aviram Hochstadt
- Department of Cardiology, Tel Aviv Medical Center affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 64239, Israel
| | - Eihab Ghantous
- Department of Cardiology, Tel Aviv Medical Center affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 64239, Israel
| | - Yan Topilsky
- Department of Cardiology, Tel Aviv Medical Center affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 64239, Israel
| | - Galit Aviram
- Department of Radiology, Tel Aviv Medical Center affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 64239, Israel
| | - Yitzhak Hadad
- Department of Radiology, Tel Aviv Medical Center affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 64239, Israel
| | - Yaron Arbel
- Department of Cardiology, Tel Aviv Medical Center affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 64239, Israel
| | - Maayan Konigstein
- Department of Cardiology, Tel Aviv Medical Center affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 64239, Israel
| | - Shmuel Banai
- Department of Cardiology, Tel Aviv Medical Center affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 64239, Israel
| | - Ariel Finkelstein
- Department of Cardiology, Tel Aviv Medical Center affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 64239, Israel
| | - Amir Halkin
- Department of Cardiology, Tel Aviv Medical Center affiliated with the Sackler Faculty of Medicine, Tel Aviv University, 6 Weizmann Street, Tel Aviv 64239, Israel
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22
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Austein F, Eden M, Both M, Salehi Ravesh M, Jansen O, Langguth P. In Reply: Practicability and Diagnostic Yield of One-Stop Stroke CT with Delayed-Phase Cardiac CT in Detecting Major Cardioembolic Sources of Acute Ischemic Stroke. Clin Neuroradiol 2021; 31:923-924. [PMID: 34228139 PMCID: PMC8648679 DOI: 10.1007/s00062-021-01045-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Friederike Austein
- Department of Neuroradiological Intervention and Diagnostics, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
| | - Matthias Eden
- Department of Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Marcus Both
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Mona Salehi Ravesh
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Olav Jansen
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Patrick Langguth
- Department for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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23
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Schnabel RB, Camen S, Knebel F, Hagendorff A, Bavendiek U, Böhm M, Doehner W, Endres M, Gröschel K, Goette A, Huttner HB, Jensen C, Kirchhof P, Korosoglou G, Laufs U, Liman J, Morbach C, Nabavi DG, Neumann-Haefelin T, Pfeilschifter W, Poli S, Rizos T, Rolf A, Röther J, Schäbitz WR, Steiner T, Thomalla G, Wachter R, Haeusler KG. Expert opinion paper on cardiac imaging after ischemic stroke. Clin Res Cardiol 2021; 110:938-958. [PMID: 34143285 PMCID: PMC8238761 DOI: 10.1007/s00392-021-01834-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 03/01/2021] [Indexed: 12/19/2022]
Abstract
This expert opinion paper on cardiac imaging after acute ischemic stroke or transient ischemic attack (TIA) includes a statement of the "Heart and Brain" consortium of the German Cardiac Society and the German Stroke Society. The Stroke Unit-Commission of the German Stroke Society and the German Atrial Fibrillation NETwork (AFNET) endorsed this paper. Cardiac imaging is a key component of etiological work-up after stroke. Enhanced echocardiographic tools, constantly improving cardiac computer tomography (CT) as well as cardiac magnetic resonance imaging (MRI) offer comprehensive non- or less-invasive cardiac evaluation at the expense of increased costs and/or radiation exposure. Certain imaging findings usually lead to a change in medical secondary stroke prevention or may influence medical treatment. However, there is no proof from a randomized controlled trial (RCT) that the choice of the imaging method influences the prognosis of stroke patients. Summarizing present knowledge, the German Heart and Brain consortium proposes an interdisciplinary, staged standard diagnostic scheme for the detection of risk factors of cardio-embolic stroke. This expert opinion paper aims to give practical advice to physicians who are involved in stroke care. In line with the nature of an expert opinion paper, labeling of classes of recommendations is not provided, since many statements are based on expert opinion, reported case series, and clinical experience.
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Affiliation(s)
- Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany
| | - Stephan Camen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Fabian Knebel
- Department of Cardiology and Angiology, University of Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Hagendorff
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
| | - Udo Bavendiek
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Michael Böhm
- Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital of Saarland, Saarland University, Homburg (Saar) , Germany
| | - Wolfram Doehner
- Berlin Institute of Health, Center for Regenerative Therapies, and Department of Cardiology (Virchow Klinikum), Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany
- Klinik Und Hochschulambulanz Für Neurologie Mit Abteilung Für Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
- ExcellenceCluster NeuroCure, Berlin, Germany
| | - Klaus Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Andreas Goette
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany
- Department of Cardiology & Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Gießen, Gießen, Germany
| | - Christoph Jensen
- B. Braun Ambulantes Herzzentrum Kassel MVZ GmbH, Kassel, Germany
- Ruhr University Bochum, Bochum, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Grigorios Korosoglou
- Department of Cardiology and Vascular Medicine, GRN Hospital Weinheim, Weinheim, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
| | - Jan Liman
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Caroline Morbach
- Comprehensive Heart Failure Center and Department for Medicine I, University Hospital Würzburg, Würzburg, Germany
| | | | - Tobias Neumann-Haefelin
- Department of Neurology, Klinikum Fulda, Universitätsmedizin Marburg - Campus Fulda, Fulda, Germany
| | - Waltraud Pfeilschifter
- Department of Neurology, Goethe-University Hospital Frankfurt, Frankfurt, Germany
- Department of Neurology and Clinical Neurophysiology, Klinikum Lüneburg, Lüneburg, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University, Heidelberg, Germany
| | - Andreas Rolf
- Department of Cardiology, Kerckhoff-Heart-Center, Bad Nauheim, Germany and Campus Kerckhoff Justus-Liebig-University, Gießen, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Klinik Hamburg Altona, Hamburg, Germany
| | - Wolf Rüdiger Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, Universitätsklinikum OWL der Universität Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Thorsten Steiner
- Department of Neurology, Heidelberg University, Heidelberg, Germany
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rolf Wachter
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
- University Medical Center Goettingen, Göttingen, Germany
| | - Karl Georg Haeusler
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany.
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
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24
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Brandes A, Crijns HJGM, Rienstra M, Kirchhof P, Grove EL, Pedersen KB, Van Gelder IC. Cardioversion of atrial fibrillation and atrial flutter revisited: current evidence and practical guidance for a common procedure. Europace 2021; 22:1149-1161. [PMID: 32337542 PMCID: PMC7399700 DOI: 10.1093/europace/euaa057] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/25/2020] [Indexed: 12/17/2022] Open
Abstract
Cardioversion is widely used in patients with atrial fibrillation (AF) and atrial flutter when a rhythm control strategy is pursued. We sought to summarize the current evidence on this important area of clinical management of patients with AF including electrical and pharmacological cardioversion, peri-procedural anticoagulation and thromboembolic complications, success rate, and risk factors for recurrence to give practical guidance.
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Affiliation(s)
- Axel Brandes
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Corresponding author. Tel: +45 30 43 36 50. E-mail address:
| | - Harry J G M Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Centre, Groningen, The Netherlands
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, UHB and Sandwell & West Birmingham Hospitals, NHS Trusts, Birmingham, UK
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Kenneth Bruun Pedersen
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark
| | - Isabelle C Van Gelder
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, University of Groningen, University Medical Centre, Groningen, The Netherlands
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25
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Predictive Value of Cardiac CTA, Cardiac MRI, and Transthoracic Echocardiography for Cardioembolic Stroke Recurrence. AJR Am J Roentgenol 2021; 217:336-346. [PMID: 32936016 DOI: 10.2214/ajr.20.23903] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND. Transthoracic echocardiography (TTE) is the standard of care for initial evaluation of patients with suspected cardioembolic stroke. Although TTE is useful for assessing certain sources of cardiac emboli, its diagnostic capability is limited in the detection of other sources, including left atrial thrombus and aortic plaques. OBJECTIVE. The purpose of this article was to investigate sensitivity, specificity, and predictive value of cardiac CTA (CCTA), cardiac MRI (CMRI), and TTE for recurrence in patients with suspected cardioembolic stroke. METHODS. We retrospectively included 151 patients with suspected cardioembolic stroke who underwent TTE and either CMRI (n = 75) or CCTA (n = 76) between January 2013 and May 2017. We evaluated for the presence of left atrial thrombus, left ventricular thrombus, vulnerable aortic plaque, cardiac tumors, and valvular vegetation as causes of cardioembolic stroke. The end point was stroke recurrence. Sensitivity, specificity, PPV, and NPV for recurrent stroke were calculated; the diagnostic accuracy of CMRI, CCTA, and TTE was compared between and within groups using AUC. RESULTS. Twelve and 14 recurrent strokes occurred in the CCTA and CMRI groups, respectively. Sensitivity, specificity, PPV, and NPV were 33.3%, 93.7%, 50.0%, and 88.2% for CCTA; 14.3%, 80.3%, 14.3%, and 80.3% for CMRI; 14.3%, 83.6%, 16.7%, and 80.9% for TTE in the CMRI group; and 8.3%, 93.7%, 20.0%, and 84.5% for TTE in the CCTA group. Accuracy was not different (p > .05) between CCTA (AUC = 0.63; 95% CI, 0.49-0.77), CMRI (0.53; 95% CI, 0.42-0.63), TTE in the CMRI group (0.51; 95% CI, 0.40-0.61), and TTE in the CCTA group (0.51; 95% CI, 0.42-0.59). In the CCTA group, atrial and ventricular thrombus were detected by CCTA in three patients and TTE in one patient; in the CMRI group, thrombus was detected by CMRI in one patient and TTE in two patients. CONCLUSION. CCTA, CMRI, and TTE showed comparably high specificity and NPV for cardioembolic stroke recurrence. CCTA and CMRI may be valid alternatives to TTE. CCTA may be preferred given potentially better detection of atrial and ventricular thrombus. CLINICAL IMPACT. CCTA and CMRI have similar clinical performance as TTE for predicting cardioembolic stroke recurrence. This observation may be especially important when TTE provides equivocal findings.
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Rajiah P, Alkhouli M, Thaden J, Foley T, Williamson E, Ranganath P. Pre- and Postprocedural CT of Transcatheter Left Atrial Appendage Closure Devices. Radiographics 2021; 41:680-698. [PMID: 33939541 DOI: 10.1148/rg.2021200136] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Transcatheter left atrial appendage (LAA) closure is an alternative to long-term anticoagulation therapy in selected patients with nonvalvular atrial fibrillation who have an increased risk for stroke. LAA closure devices can be implanted by means of either an endocardial or a combined endocardial and epicardial approach. Preprocedural imaging is key to identifying contraindications, accurately sizing the device, and minimizing complications. Transesophageal echocardiography (TEE) has been the reference standard imaging modality to assess the anatomy for LAA closure and to provide intraprocedural guidance. However, CT has emerged as a less-invasive alternative to TEE for pre- and postprocedural imaging. CT is comparable to TEE for exclusion of thrombus but is superior to TEE for the delineation of complex LAA anatomy, measurement for device sizing, and evaluation of pulmonary venous and extracardiac structures. CT provides accurate measurements of the LAA ostial diameter, landing zone diameter, and LAA length, which are vital for accurate sizing of the device. CT allows evaluation of the relationship with the pulmonary veins and other adjacent structures that can be injured during the procedure. CT also simulates procedural fluoroscopic angles and provides evaluation of the interatrial septum, which is punctured during LAA closure. CT also provides a more convenient method for the evaluation of postprocedural complications such as incomplete closure, peridevice leaking, device-related thrombus, and device dislodgement. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Prabhakar Rajiah
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Mohamad Alkhouli
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Jeremy Thaden
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Thomas Foley
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Eric Williamson
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Praveen Ranganath
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
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27
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Rodríguez-Granillo GA, Cirio JJ, Ciardi C, Caballero ML, Ceron M, Bleise C, Diluca P, Lylyk P. Early Triage of Cardioembolic Sources Using Chest Spectral Computed Tomography in Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2021; 30:105731. [PMID: 33751990 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/25/2021] [Accepted: 03/01/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The present study investigated the potential usefulness of delayed-phase, low-dose, non-gated, chest spectral CT scans (DSCT) for the early triage of cardioembolic (CE) sources in patients admitted with acute ischemic stroke (AIS), and for the simultaneous detection of myocardial disease and thrombotic complications. MATERIAL AND METHODS Since July 2020 and promoted by the COVID-19 pandemic, we implemented the use of DSCT after cerebrovascular CT angiography (CTA) among patients with AIS using a dual-layer spectral CT. We explored the presence of CE sources, as well as late myocardium iodine enhancement (LIE) and pulmonary thromboembolism. Among patients further undergoing transesophageal echocardiogram (TEE) or cardiac CTA, we explored the diagnostic performance. RESULTS Fifty consecutive patients with AIS who underwent DSCT after cerebrovascular CTA comprised the patient population. The confidence degree for excluding cardiac thrombi was significantly higher than for LIE (4.4±0.8 vs. 3.4±1.3, p<0.0001). DSCT identified a CE source in 4 (8%) and LIE in 24 (48%) patients. The iodine ratio of CE sources was significantly lower compared to the left atrial appendage of patients with no CE sources (0.25±0.1 mg/mL vs. 0.91±0.2 mg/mL, p<0.0001). TEE/cardiac CT, performed in 20 (40%) patients, identified a CE source in 5 (25%) cases, whereas DSCT identified 4 (20%), leading to a sensitivity and specificity of 80% (95% CI 28-99%) and 100% (95% CI 78-100%) respectively (kappa 0.86). CONCLUSIONS In this pilot study, we identified DSCT as a potential unsophisticated approach for the early triage of CE sources among patients with AIS undergoing CTA upon admission.
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Affiliation(s)
- Gaston A Rodríguez-Granillo
- Department of Cardiovascular Imaging, Instituto Medico ENERI, Clinica La Sagrada Familia, Av. Libertador 6647 (C1428ARJ), Buenos Aires, Argentina; Instituto Medico ENERI, Clinica La Sagrada Familia. Av. Libertador 6647 (C1428ARJ), Buenos Aires, Argentina.
| | - Juan J Cirio
- Stroke Unit, Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina; Instituto Medico ENERI, Clinica La Sagrada Familia. Av. Libertador 6647 (C1428ARJ), Buenos Aires, Argentina
| | - Celina Ciardi
- Stroke Unit, Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina; Instituto Medico ENERI, Clinica La Sagrada Familia. Av. Libertador 6647 (C1428ARJ), Buenos Aires, Argentina
| | - Maria Laura Caballero
- Stroke Unit, Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina; Instituto Medico ENERI, Clinica La Sagrada Familia. Av. Libertador 6647 (C1428ARJ), Buenos Aires, Argentina
| | - Marcos Ceron
- Department of Cardiovascular Imaging, Instituto Medico ENERI, Clinica La Sagrada Familia, Av. Libertador 6647 (C1428ARJ), Buenos Aires, Argentina; Instituto Medico ENERI, Clinica La Sagrada Familia. Av. Libertador 6647 (C1428ARJ), Buenos Aires, Argentina
| | - Carlos Bleise
- Department of Interventional Radiology, Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina; Instituto Medico ENERI, Clinica La Sagrada Familia. Av. Libertador 6647 (C1428ARJ), Buenos Aires, Argentina
| | - Pablo Diluca
- Department of Radiology, Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina; Instituto Medico ENERI, Clinica La Sagrada Familia. Av. Libertador 6647 (C1428ARJ), Buenos Aires, Argentina
| | - Pedro Lylyk
- Department of Interventional Radiology, Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina; Instituto Medico ENERI, Clinica La Sagrada Familia. Av. Libertador 6647 (C1428ARJ), Buenos Aires, Argentina
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Rodriguez-Granillo GA, Cirio JJ, Ciardi C, Caballero ML, Diluca P, Castrillon R, Ceron M, Scrivano E, Lylyk P. Cardiovascular thrombotic complications in acute ischemic stroke assessed by chest spectral computed tomography during COVID-19. Minerva Cardiol Angiol 2021; 69:606-618. [PMID: 33703860 DOI: 10.23736/s2724-5683.21.05547-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
During the pandemic context, diagnostic algorithms had to be adapted considering the decimated medical personnel, local technical resources, and the likelihood of contamination. Given the higher probability of thrombotic complications related to COVID-19 and the availability of a dual-layer spectral computed tomography (CT) scanner, we have recently adopted the use of low-dose, non-gated, chest CT scans performed five minutes after contrast administration among patients admitted with acute ischemic stroke (AIS) undergoing cerebrovascular CT angiography. Dual-layer spectral CT comprises a single X-ray source and two-layer detector with different photon-absorption capabilities. In addition to conventional images, the two distinct energy datasets obtained enable multiparametric spectral analysis without need to change the original scanning protocol. The two spectral features that emerge as most useful for patients with AIS are virtual monoenergetic imaging and iodine-based results. Aside from the evaluation of lung parenchyma, this novel strategy enables ruling out cardioembolic sources and simultaneously providing evidence of pulmonary and myocardial injury in a single session and immediately after CT cerebrovascular angiography. Furthermore, it involves a non-invasive, seemingly accurate, unsophisticated, safer (very low radiation dose and no contrast administration), and cheaper tool for ruling out cardioembolic sources compared to transesophageal echocardiogram and cardiac CT. Accordingly, we sought to standardize the technical aspects and overview the usefulness of delayed-phase, low-dose chest spectral CT in patients admitted with AIS.
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Affiliation(s)
- Gaston A Rodriguez-Granillo
- Department of Cardiovascular Imaging, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina - .,National Council of Scientific and Technical Investigations - Consejo Nacional de Investigaciones Cientificas y Tecnicas (CONICET), Buenos Aires, Argentina -
| | - Juan J Cirio
- Stroke Unit, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Celina Ciardi
- Stroke Unit, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Maria L Caballero
- Stroke Unit, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Pablo Diluca
- Department of Radiology, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Ricardo Castrillon
- Department of Radiology, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Marcos Ceron
- Department of Cardiovascular Imaging, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Esteban Scrivano
- Department of Interventional Radiology, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
| | - Pedro Lylyk
- Department of Interventional Radiology, ENERI Medical Institute, La Sagrada Familia Clinic, Buenos Aires, Argentina
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Use of radiomics to differentiate left atrial appendage thrombi and mixing artifacts on single-phase CT angiography. Int J Cardiovasc Imaging 2021; 37:2071-2078. [PMID: 33544242 PMCID: PMC7863854 DOI: 10.1007/s10554-021-02178-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/26/2021] [Indexed: 11/24/2022]
Abstract
To assess if radiomics can differentiate left atrial appendage (LAA) contrast-mixing artifacts and thrombi on early-phase CT angiography without the need for late-phase images. Our study included 111 patients who underwent early- and late-phase, contrast-enhanced cardiac CT. Of these, 79 patients had LAA filling defects from thrombus (n = 46, mean age: 72 ± 12 years, M:F 26:20) or contrast-mixing artifact (n = 33, mean age: 71 ± 13 years, M:F 21:12) on early-contrast-enhanced phase. The remaining 32 patients (mean age: 66 ± 10 years, M:F 19:13) had homogeneous LAA opacification without filling defects. The entire LAA volume on early-phase CT images was manually segmented to obtain radiomic features (Frontier, Siemens). A radiologist assessed for the presence of LAA filling defects and recorded the size and mean CT attenuation (HU) of filling defects and normal LAA. The data were analyzed using multiple logistic regression with receiver operating characteristics area under the curve (AUC) as an output. The radiologist correctly identified all 32 patients without LAA filling defects, 42/46 LAA with thrombi, and 23/33 contrast mixing artifacts. Although HU of LAA thrombi and contrast mixing artifacts was significantly different, with the lowest AUC (0.66), it was inferior to both radiologist assessment and radiomics (p = 0.05). Combination of radiologist assessment and radiomics (AUC 0.92) was superior to HU (0.66), radiomics (0.85), and radiologist (0.80) alone (p < 0.008). Radiomics can differentiate between LAA filling defects from thrombi and contrast mixing artifacts on early-phase contrast-enhanced CT images without the need for late-phase CT.
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Kharbanda RK, Newton JD. Smoke signals - do they help to predict TAVI-associated stroke risk? EUROINTERVENTION 2021; 16:1046-1047. [PMID: 33470218 PMCID: PMC9707432 DOI: 10.4244/eijv16i13a191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Rajesh K Kharbanda
- Oxford University NHS Trust and Oxford NIHR Biomedical Research Centre, Oxford, United Kingdom
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Senadeera SC, Palmer DG, Keenan R, Beharry J, Yuh Lim J, Hurrell MA, Mouthaan P, Fink JN, Wilson D, Lim A, Wu TY. Left Atrial Appendage Thrombus Detected During Hyperacute Stroke Imaging Is Associated With Atrial Fibrillation. Stroke 2020; 51:3760-3764. [PMID: 33161849 DOI: 10.1161/strokeaha.120.030258] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND PURPOSE Left atrial appendage (LAA) is the likely embolic source in atrial fibrillation (AF)-related cardioembolic strokes. We sought to determine the prevalence of LAA thrombus on hyperacute stroke imaging and its association with AF. METHODS We retrospectively examined the clinical and radiological features of patients assessed through the hyperacute stroke imaging pathway over a 12-month period at Christchurch Hospital. The LAA was included in the computed tomography angiogram scan-range as part of the multimodal imaging protocol. Two radiological readers blinded to clinical information independently assessed for the presence of LAA thrombus. The association between AF and LAA thrombus was determined by multivariable logistic regression analysis. RESULTS Of 303 patients included in the analysis, the overall prevalence of LAA thrombus was 6.6% and 14.9% in patients with known AF. Patients with LAA thrombus were older (85 versus 75 years, P<0.01), more commonly had known or newly diagnosed AF (75% versus 30%, P<0.01) and heart failure (30% versus 8%, P=0.01), and was associated with intracranial large vessel occlusion (65% versus 39%, P=0.02). In the multivariable model, AF (odds ratio, 3.71 [95% CI, 1.25-11.01] P=0.02) was independently associated with LAA thrombus after adjusting for age and congestive heart failure. Interrater reliability was moderate (kappa=0.56). CONCLUSIONS LAA thrombus is a potential radiological marker of AF and can be assessed as a part of hyperacute stroke imaging.
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Affiliation(s)
- Sajith C Senadeera
- Department of Radiology (S.C.S., R.K., M.A.H., P.M., A.L.), Christchurch Hospital, New Zealand
| | - David G Palmer
- Department of Neurology (D.G.P., J.B., J.Y.L., J.N.F., D.W., T.Y.W.), Christchurch Hospital, New Zealand
| | - Ross Keenan
- Department of Radiology (S.C.S., R.K., M.A.H., P.M., A.L.), Christchurch Hospital, New Zealand
| | - James Beharry
- Department of Neurology (D.G.P., J.B., J.Y.L., J.N.F., D.W., T.Y.W.), Christchurch Hospital, New Zealand
| | - Jen Yuh Lim
- Department of Neurology (D.G.P., J.B., J.Y.L., J.N.F., D.W., T.Y.W.), Christchurch Hospital, New Zealand
| | - Michael A Hurrell
- Department of Radiology (S.C.S., R.K., M.A.H., P.M., A.L.), Christchurch Hospital, New Zealand
| | - Paul Mouthaan
- Department of Radiology (S.C.S., R.K., M.A.H., P.M., A.L.), Christchurch Hospital, New Zealand
| | - John N Fink
- Department of Neurology (D.G.P., J.B., J.Y.L., J.N.F., D.W., T.Y.W.), Christchurch Hospital, New Zealand
| | - Duncan Wilson
- Department of Neurology (D.G.P., J.B., J.Y.L., J.N.F., D.W., T.Y.W.), Christchurch Hospital, New Zealand.,New Zealand Brain Research Institute, Christchurch (D.W., T.Y.W.)
| | - Anthony Lim
- Department of Radiology (S.C.S., R.K., M.A.H., P.M., A.L.), Christchurch Hospital, New Zealand
| | - Teddy Y Wu
- Department of Neurology (D.G.P., J.B., J.Y.L., J.N.F., D.W., T.Y.W.), Christchurch Hospital, New Zealand.,New Zealand Brain Research Institute, Christchurch (D.W., T.Y.W.)
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Holswilder G, Wermer MJ, Holman ER, Kruyt ND, Kroft LJ, van Walderveen MA. CT Angiography of the Heart and Aorta in TIA and Ischaemic Stroke: Cardioembolic Risk Sources and Clinical Implications. J Stroke Cerebrovasc Dis 2020; 29:105326. [PMID: 33010723 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 09/09/2020] [Accepted: 09/11/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Cardiac emboli are important causes of (recurrent) ischaemic stroke. Aorta atherosclerosis might also be associated with an increased risk of stroke recurrence. This study aimed to evaluate the yield and clinical implications of CT-angiography (CTA) of the heart and aorta in the diagnostic workup of transient ischaemic attack (TIA) or ischaemic stroke. METHODS CTA of the heart and aortic arch was performed in TIA/ischaemic stroke patients, in addition to routine diagnostic workup. Occurrence of cardioembolic (CE) risk sources and complex aortic plaques were assessed. Implications of cardiac CTA for therapeutic management were evaluated RESULTS: Sixty-seven patients were included (TIA n = 33, ischaemic stroke n = 34) with a mean age of 68 years (range 51-89) and median NIHSS of 0 (interquartile range 0-2). CE risk sources were detected in 29 (43%) patients. An intracardiac thrombus was present in 2 patients (3%; TIA 0%; ischaemic stroke 6%). Medium/low-risk CE sources included mitral annular calcification (9%), aortic valve calcification (18%) and patent foramen ovale (18%). Complex aortic plaque was identified in 16 patients (24%). In two patients with an intracardiac thrombus, therapeutic management changed from antiplatelet to oral anticoagulation. CONCLUSIONS CTA of the heart and aorta has a high yield for detection of embolic risk sources in TIA/ischaemic stroke, with clinical consequences for 6% of ischaemic stroke patients. Implementation of CTA of the heart and aorta in the acute stroke setting seems valuable, but cost-effectiveness of this approach remains to be determined.
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Affiliation(s)
- Ghislaine Holswilder
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, the Netherlands.
| | - Marieke Jh Wermer
- Department of Neurology, Leiden University Medical Center Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Eduard R Holman
- Department of Cardiology, Leiden University Medical Center Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Center Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Lucia Jm Kroft
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Marianne Aa van Walderveen
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300 RC, Leiden, the Netherlands
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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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Shi C, Xie H, Ma Y, Yang Z, Zhang J. Nanoscale Technologies in Highly Sensitive Diagnosis of Cardiovascular Diseases. Front Bioeng Biotechnol 2020; 8:531. [PMID: 32582663 PMCID: PMC7289988 DOI: 10.3389/fbioe.2020.00531] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 05/04/2020] [Indexed: 12/19/2022] Open
Abstract
Cardiovascular diseases (CVD) are the leading cause of death and morbidity in the world and are a major contributor to healthcare costs. Although enormous progress has been made in diagnosing CVD, there is an urgent need for more efficient early detection and the development of novel diagnostic tools. Currently, CVD diagnosis relies primarily on clinical symptoms based on molecular imaging (MOI) or biomarkers associated with CVDs. However, sensitivity, specificity, and accuracy of the assay are still challenging for early-stage CVDs. Nanomaterial platform has been identified as a promising candidate for improving the practical usage of diagnostic tools because of their unique physicochemical properties. In this review article, we introduced cardiac biomarkers and imaging techniques that are currently used for CVD diagnosis. We presented the applications of various nanotechnologies on diagnosis within cardiac immunoassays (CIAs) and molecular imaging. We also summarized and compared different cardiac immunoassays based on their sensitivities and working ranges of biomarkers.
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Affiliation(s)
- Chaohong Shi
- Department of Rehabilitation Medicine, The First People’s Hospital of Wenling, Wenzhou Medical University, Wenling, China
| | - Haotian Xie
- Department of Mathematics, The Ohio State University, Columbus, OH, United States
| | - Yifan Ma
- Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, OH, United States
| | - Zhaogang Yang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Jingjing Zhang
- Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, OH, United States
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Groeneveld NS, Guglielmi V, Leeflang MMG, Matthijs Boekholdt S, Nils Planken R, Roos YBWEM, Majoie CBLM, Coutinho JM. CT angiography vs echocardiography for detection of cardiac thrombi in ischemic stroke: a systematic review and meta-analysis. J Neurol 2020; 267:1793-1801. [PMID: 32140869 PMCID: PMC7293690 DOI: 10.1007/s00415-020-09766-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/16/2020] [Accepted: 02/18/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE Cardiac thrombi are an important cause of embolic stroke. We studied the diagnostic yield and diagnostic accuracy of cardiac CT angiography (CTA) compared to echocardiography for detection of cardiac thrombi in ischemic stroke patients. METHODS We performed a systematic review and meta-analysis of the literature on cardiac CTA versus echocardiography for detection of cardiac thrombi in ischemic stroke patients. We included studies (N ≥ 20) in which both cardiac CTA (index test) and echocardiography (reference test) were performed and data on cardiac thrombi were reported. Results were stratified for type of echocardiography: transesophageal (TEE) vs transthoracic (TTE). RESULTS Out of 1530 studies, 14 were included (all single center cohort studies), with data on 1568 patients. Mean age varied between 52 and 69 years per study and 66% were men. Reported time intervals ranged from 0 to 21 days between stroke and first test, and from 0 to 199 days between tests. In ten studies that compared CTA to TEE, CTA detected cardiac thrombi in 87/1385 (6.3%) patients versus 68/1385 (4.9%) on TEE (p < 0.001). In four studies comparing CTA to TTE, CTA detected thrombi in 23/183 (12.5%) patients versus 12/183 (6.6%) on TTE (p = 0.010). Pooled sensitivity and specificity of CTA versus TEE were 86.0% (95% CI 65.6-95.2) and 97.4% (95% CI 95.0-98.7), respectively. CONCLUSIONS CTA may be a promising alternative to echocardiography for detection of cardiac thrombi in patients with ischemic stroke, especially now that CTA is standard care for patient selection for endovascular treatment. However, studies were too heterogeneous and of insufficient methodological quality to draw firm conclusions. Large, prospective studies on this topic are warranted.
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Affiliation(s)
| | - Valeria Guglielmi
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mariska M G Leeflang
- Department of Clinical Epidemiology and Biostatistics and Bioinformatics Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R Nils Planken
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department 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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Gilhofer TS, Saw J. Periprocedural Imaging for Left Atrial Appendage Closure: Computed Tomography, Transesophageal Echocardiography, and Intracardiac Echocardiography. Card Electrophysiol Clin 2020; 12:55-65. [PMID: 32067648 DOI: 10.1016/j.ccep.2019.11.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Percutaneous left atrial appendage closure is increasingly performed for stroke prevention for patients with nonvalvular atrial fibrillation with contraindications to oral anticoagulation. The success and complication rates with left atrial appendage closure have dramatically improved with maturing experience, growing procedural familiarity, and preprocedural planning. Multimodality imaging involving cardiac computer tomography angiography, transesophageal echocardiography, or intracardiac echocardiography in conjunction with fluoroscopy has improved the efficacy, procedural success, and safety of left atrial appendage closure in recent years. Proceduralists need to familiarize themselves with the various modalities and understand their complimentary roles and their limitations.
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Affiliation(s)
- Thomas S Gilhofer
- Interventional Cardiology, Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jacqueline Saw
- Interventional Cardiology, Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, British Columbia V5Z1M9, Canada.
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Korsholm K, Berti S, Iriart X, Saw J, Wang DD, Cochet H, Chow D, Clemente A, De Backer O, Møller Jensen J, Nielsen-Kudsk JE. Expert Recommendations on Cardiac Computed Tomography for Planning Transcatheter Left Atrial Appendage Occlusion. JACC Cardiovasc Interv 2020; 13:277-292. [DOI: 10.1016/j.jcin.2019.08.054] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 08/05/2019] [Accepted: 08/14/2019] [Indexed: 12/13/2022]
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Yu Y, Yu M, Liu J, Ding N, Huang J, Wan D, Zhao Y, Ma Z. In vivo monitoring of thrombosis in mice by optical coherence tomography. JOURNAL OF BIOPHOTONICS 2019; 12:e201900105. [PMID: 31339664 DOI: 10.1002/jbio.201900105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/17/2019] [Accepted: 07/21/2019] [Indexed: 06/10/2023]
Abstract
The objective of this study is to establish a novel method for continuously monitoring thrombus progression with various outcome measures and to assess the efficacy of antithrombotic drugs in murine thrombosis model in mice. In the study, thrombus was induced in the femoral vein of mice by FeCl3 and monitored over time by spectral-domain optical coherence tomography (OCT). Three-dimensional images of thrombi with or without heparin as an antithrombotic agent were obtained from OCT angiography. In addition, several parameters of thrombi were analyzed and compared between control and anticoagulant groups. By using OCT, we were able to trace thrombus generation in the same mouse in real time. We found that in our model heparin reduced thrombus size by ~60% and thrombus cross-sectional area by 50%. OCT results also show that both time to thrombus size (>0.02mm3 ) and time to occlusion (>30%) were significantly reduced after heparin addition. This study demonstrates that OCT reliably monitors thrombus generation and progression from various aspects including thrombus size. This enables us to measure the kinetic of thrombosis more accurately, and effectively evaluate the efficacy and activities of antithrombotic drugs. This model may represent a useful tool in antithrombotic drug discoveries in preclinical studies.
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Affiliation(s)
- Yao Yu
- School of Control Engineering, Northeastern University at Qinhuangdao, Qinhuangdao, China
| | - Menghan Yu
- School of Control Engineering, Northeastern University at Qinhuangdao, Qinhuangdao, China
| | - Jian Liu
- School of Control Engineering, Northeastern University at Qinhuangdao, Qinhuangdao, China
| | - Ning Ding
- School of Sino-Dutch Biomedical and Information Engineering, Northeastern University, Shenyang, China
| | - Jiangmei Huang
- Department of Pathology, the First Hospital of Qinhuangdao, Qinhuangdao, China
| | - Dong Wan
- School of Life Sciences and Technology, Tongji University, Shanghai, China
| | - Yuliang Zhao
- School of Control Engineering, Northeastern University at Qinhuangdao, Qinhuangdao, China
| | - Zhenhe Ma
- School of Control Engineering, Northeastern University at Qinhuangdao, Qinhuangdao, China
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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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Nuffer Z, Baran TM, Krishnamoorthy V, Kaproth-Joslin K, Chaturvedi A. Accuracy of Non-Electrocardiographically Gated Thoracic CT Angiography for Right Atrial and Right Ventricular Enlargement. Radiol Cardiothorac Imaging 2019; 1:e190008. [PMID: 33778516 PMCID: PMC7977741 DOI: 10.1148/ryct.2019190008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 06/30/2019] [Accepted: 07/11/2019] [Indexed: 06/12/2023]
Abstract
PURPOSE To assess the role of long-axis (LA) and short-axis (SA) measurements of the right atrium (RA) and right ventricle (RV) at non-electrocardiographically (ECG) gated thoracic CT angiography for identification of RA enlargement and RV enlargement. MATERIALS AND METHODS This study was a retrospective case review of 138 patients who underwent both non-ECG-gated CT angiography and ECG-gated CT angiography concurrently from November 2016 through November 2018. The SA and LA of the RA and RV were measured by two observers blinded to the ECG-gated CT angiography data. ECG-gated CT angiography-derived RA end-systolic and RV end-diastolic volumes were used as standard of reference to derive cutoff values for diagnosis of RA and RV enlargement. RESULTS In this study, 138 patients were evaluated (70 men, 68 women; mean age, 70.0 years ± 18.4 [standard deviation]; mean body mass index, 29.3 kg/m2 ± 8.1). Of these patients, ECG-gated CT angiography revealed 36.2% had RA enhancement and 19.0% had RV enhancement. The best predictor of RA enhancement was the product of atrial LA and SA measurements, for which a threshold value of 3210 mm2 yielded a 94% sensitivity and 81.8% specificity (area under the curve [AUC], 0.92). A threshold of 55.5 mm for LA diameter had 86% sensitivity and 78.4% specificity in identifying RA enlargement. RV enlargement could be predicted if the SA diameter was greater than 48.5 mm (76.9% sensitivity and 64.9% specificity) and with a body surface area indexed value of 27.0 mm/m2 (92.3% sensitivity and 74.8% specificity [AUC, 0.87]). CONCLUSION RA and RV enlargement can be accurately diagnosed by using non-ECG-gated CT angiography.© RSNA, 2019Supplemental material is available for this article.
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Angulo Hervias E, Guillén Subirán ME, Yagüe Romeo D, Castán Senar A, Seral Moral P, Núñez Motilva ME. Multidetector computed tomography in planning the treatment of atrial fibrillation. RADIOLOGIA 2019; 62:148-159. [PMID: 31563419 DOI: 10.1016/j.rx.2019.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 06/23/2019] [Accepted: 07/02/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To know the anatomy of the pulmonary veins (PVs) by multidetector computed tomography (MDCT) in patients with atrial fibrillation (AF) prior to ablation. MATERIALS AND METHODS MDCT was performed in 89 patients with AF, analyzing the number of PVs, accessory variants and veins, diameter and ostial shape, distance to the first bifurcation and thrombus in the left atrial appendage. RESULTS The most frequent venous pattern was 4 PVs (two right and two. left) in 49 patients (55.1%). The superior veins had a statistically significant greater mean ostial diameter than the inferior veins (Right Superior Pulmonary Vein (RSPV)> Right Inferior Pulmonary Vein (RIPV); p=0.001 and Left Superior Pulmonary Vein (LSPV)> Left Inferior Pulmonary Vein (LIPV); p<0.001). The right pulmonary veins ostial diameters were significantly larger than the left pulmonary veins ostial diameters (RSPV> LSPV; p<0.001 and RIPV> LIPV; p<0.001). The most circular ostium was presented by the VPID (ratio: 0.885) compared to the LIPV (p<00.1) and LSPV (p<0.001). The superior veins had a statistically significant greater mean distance to first bifurcation than the inferior veins (RSPV> RIPV; p=0.008 and LSPV> LIPV; p=0.038). Mean distance to first bifurcation has been greater in left PVs respect to the right PVs (LSPV> RSPV; p<0.001and LIPV> RIPV; p<0.001). Other findings found in AI: diverticula (30), accessory auricular appendages (5), septal aneurysms (8), septal bags (6) and 1 thrombus in the left atrial appendage. CONCLUSION MDCT prior to ablation demonstrates the anatomy of the left atrium (LA) and pulmonary veins with significant differences between the diameters and morphology of the venous ostia.
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Affiliation(s)
- E Angulo Hervias
- Servicio de Radiodiagnóstico, Sección de Radiología Cardiotorácica, Hospital Universitario Miguel Servet, Zaragoza, España.
| | - M E Guillén Subirán
- Servicio de Radiodiagnóstico, Sección de Radiología Cardiotorácica, Hospital Universitario Miguel Servet, Zaragoza, España
| | - D Yagüe Romeo
- Servicio de Radiodiagnóstico, Sección de Radiología Cardiotorácica, Hospital Universitario Miguel Servet, Zaragoza, España
| | - A Castán Senar
- Servicio de Radiodiagnóstico, Sección de Radiología Cardiotorácica, Hospital Universitario Miguel Servet, Zaragoza, España
| | - P Seral Moral
- Servicio de Radiodiagnóstico, Sección de Radiología Cardiotorácica, Hospital Universitario Miguel Servet, Zaragoza, España
| | - M E Núñez Motilva
- Servicio de Radiodiagnóstico, Sección de Radiología Cardiotorácica, Hospital Universitario Miguel Servet, Zaragoza, España
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Liddy S, McQuade C, Walsh KP, Loo B, Buckley O. The Assessment of Cardiac Masses by Cardiac CT and CMR Including Pre-op 3D Reconstruction and Planning. Curr Cardiol Rep 2019; 21:103. [DOI: 10.1007/s11886-019-1196-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Kuronuma K, Matsumoto N, Suzuki Y, Makita A, Ashida T, Yokoyama K, Yoda S, Okumura Y. Usefulness of Dual-Phase Snapshot 320-Detector Computed Tomography for the Detection of a Left Atrial Appendage Thrombus. Int Heart J 2019; 60:849-853. [DOI: 10.1536/ihj.18-521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
| | | | | | - Ayano Makita
- Department of Cardiology, Nihon University Hospital
| | | | | | - Shunichi Yoda
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
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He YQ, Liu L, Zhang MC, Zeng H, Yang P. Dual-Energy Computed Tomography-Enabled Material Separation in Diagnosing Left Atrial Appendage Thrombus. Tex Heart Inst J 2019; 46:107-114. [PMID: 31236074 DOI: 10.14503/thij-16-5791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We explored the potential clinical value of material separation enabled by dual-energy spectral computed tomography in detecting left atrial appendage thrombi. The study enrolled 24 patients who were scheduled to undergo atrial fibrillation ablation (12 with and 12 without left atrial appendage thrombi). Computed tomograms were acquired in gemstone spectral imaging mode; the densities in the regions of the left atrial appendage cavities, pectinate muscles, and left atrial appendage thrombi were analyzed on monochromatic 70-keV images. Iodine and blood were chosen as the material basis pair; the iodine and blood densities were observed and quantitatively determined from the iodine- and blood-specific material decomposition images. On the 70-keV monochromatic and iodine-specific images, the left atrial appendage pectinate muscles and thrombi appeared as areas of hypodense attenuation. On the blood-specific images, similar areas of high attenuation were observed in the thrombi and cavities, whereas lower attenuation was noticed in the pectinate muscles. The quantitative iodine and blood densities in the pectinate muscles were lower than those in the cavities (P <0.001). The iodine densities in the thrombi were lower than those in the cavities (P <0.001); however, blood densities did not differ significantly between the thrombi and cavities (P=0.192). Compared with the pectinate muscles, the thrombi showed lower blood-density differences (P=0.003) and higher iodine-density differences (P=0.006) in relation to the cavities. Spectral computed tomography-enabled material separation is a novel method for differentiating left atrial appendage thrombi from pectinate muscles. The potential applications of this technology warrant further studies.
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Circulatory Stasis or Thrombus in Left Atrial Appendage, An Easy Diagnostic Solution. J Comput Assist Tomogr 2019; 43:406-409. [PMID: 30801566 DOI: 10.1097/rct.0000000000000853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the diagnostic performance of prone position cardiac multidetector computed tomography (MDCT) in the detection of left atrial appendage (LAA) thrombi and to make differentiate between thrombus and circulatory stasis using transesophageal echocardiography (TEE) as the criterion-standard imaging modality. METHODS From December 2014 to April 2016, 53 consecutive patients were admitted to the hospital because of circulatory stasis or/and thrombus. All patients underwent prone-position MDCT and TEE. Prone-position MDCT and TEE sensitivity, specificity, positive predictive value, and negative predictive value were calculated. RESULTS For the MDCT scan in the prone position, the sensitivity, specificity, positive predictive value, and negative predictive value results were 100%, 100%, 100%, and 100%, respectively. CONCLUSIONS Multidetector computed tomography scanning in the prone position differentiates circulatory stasis and LAA thrombus, is clinically useful for detecting and ruling out LAA thrombus, and may be an alternative to TEE as a diagnostic tool.
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Du X, Wang Y. The diagnostic efficacy of cardiac CTA combined with D-dimer assay for the detection of left atrial thrombus in patients with atrial fibrillation. Am J Emerg Med 2019; 37:1922-1926. [PMID: 30691863 DOI: 10.1016/j.ajem.2019.01.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 01/06/2019] [Accepted: 01/11/2019] [Indexed: 12/13/2022] Open
Abstract
PURPOSE We aimed to evaluate a combination diagnostic method of single-phased, single-contrast injection cardiac computed tomography angiography CTA combined with age-adjusted D-dimer assay for diagnosis of left atrial/left atrial appendage (LA/LAA) thrombus in comparison to transesophageal echocardiography (TEE) in patients with atrial fibrillation. The addition of D-dimer to the CTA is to increase specificity, since CTA is part of the combined method. MATERIALS AND METHODS Between October 2016 and December 2017, 113consective patients with non-valvular or valvular AF (male: 72.6%; mean age: 57.9 ± 11.5 y) underwent diagnostic work-up, included TEE, single-phased, single contrast injection cardiac CTA, and age-adjusted D-dimer assay, for the evaluation of LA/LAA thrombus formation. RESULTS Cardiac CTA identified 32 patients with filling defects in LA or LAA. Of these patients, 17 had an elevated D-dimer value according to age-adjusted cut-off. TEE detected definitive thrombus formation in 15 patients. Using TEE as the reference standard, the combination diagnostic method had a sensitivity of 100.0%, specificity of 97.9%, positive predictive value (PPV) of 88.2, and negative predictive value of 100.0%. Further, compared to cardiac CTA alone, the combination diagnostic method had significantly better specificity (82.7% vs. 97.9%, respectively; p < 0.01) and PPV (46.9% vs. 88.2%, respectively; p < 0.01). CONCLUSION The combination diagnostic method comprising single-phase, single-contrast injection cardiac CTA and age-adjusted D-dimer assay had good diagnostic efficacy for the detection of LA/LAA thrombus in patients with AF. The combination diagnostic method had significantly better specificity and PPV than cardiac CTA alone. The presented diagnostic approach could potentially facilitate rapid diagnosis or exclusion of left atrial thrombus under emergency situation or when TEE is un-available, with good diagnostic efficacy and no TEE related risks.
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Affiliation(s)
- Xin Du
- Chinese People's PLA General Hospital, China
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Yamaguchi J, Kinoshita K, Hirabayashi M, Hori S, Furukawa M, Sakurai A. Thromboembolic Complications Following Tissue Plasminogen Activator Therapy in Patients of Acute Ischemic Stroke - Case Report and Possibility for Detection of Cardiac Thrombi. Open Med (Wars) 2018; 13:551-555. [PMID: 30519632 PMCID: PMC6272048 DOI: 10.1515/med-2018-0081] [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: 08/01/2018] [Accepted: 09/23/2018] [Indexed: 01/20/2023] Open
Abstract
Many reports focus on the probability of intracranial hemorrhage as a complication after recombinant tissue plasminogen activator (rt-PA) therapy. However, thromboembolic complications are not well discussed. We experienced a case in which severe thromboembolic complications occurred in the right radial and right ulnar artery. Arterial fibrillation was observed in this case. If multiple thrombi exist in the atrium or ventricle, multiple small embolic particles may appear following thrombolytic therapy, and that may be a potential risk of secondary thromboembolic complications due to incomplete dissolution of thrombi. Transesophageal echocardiography is a standard method to detect intracardiac sources of emboli in the case of arterial fibrillation. Transesophageal echocardiography is, however, an invasive method for patients with ischemic stroke during rt-PA therapy. High resolution enhanced CT could be a useful tool and may be a reliable alternative to transthoracic echocardiography. Careful assessment of thromboembolic complications following rt-PA therapy in patients with arterial fibrillation is needed. In this case report and mini review, we would like to discuss about the accurate diagnostic methods to detect cardiac or undetermined embolic sources and provide expedited stroke care. These embolic sources may be more readily discovered during rt-PA therapy within the limited therapeutic time window.
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Affiliation(s)
- Junko Yamaguchi
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1 Oyaguchi Kamimachi, Itabashi-ku, Tokyo Japan
| | | | - Marina Hirabayashi
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1 Oyaguchi Kamimachi, Itabashi-ku, Tokyo Japan
| | - Satoshi Hori
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1 Oyaguchi Kamimachi, Itabashi-ku, Tokyo Japan
| | - Makoto Furukawa
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1 Oyaguchi Kamimachi, Itabashi-ku, Tokyo Japan
| | - Atsushi Sakurai
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1 Oyaguchi Kamimachi, Itabashi-ku, Tokyo Japan
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