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Pieszko K, Hiczkiewicz J, Łojewska K, Uziębło-Życzkowska B, Krzesiński P, Gawałko M, Budnik M, Starzyk K, Wożakowska-Kapłon B, Daniłowicz-Szymanowicz L, Kaufmann D, Wójcik M, Błaszczyk R, Mizia-Stec K, Wybraniec M, Kosmalska K, Fijałkowski M, Szymańska A, Dłużniewski M, Kucio M, Haberka M, Kupczyńska K, Michalski B, Tomaszuk-Kazberuk A, Wilk-Śledziewska K, Wachnicka-Truty R, Koziński M, Kwieciński J, Wolny R, Kowalik E, Kolasa I, Jurek A, Budzianowski J, Burchardt P, Kapłon-Cieślicka A, Slomka PJ. Artificial intelligence in detecting left atrial appendage thrombus by transthoracic echocardiography and clinical features: the Left Atrial Thrombus on Transoesophageal Echocardiography (LATTEE) registry. Eur Heart J 2024; 45:32-41. [PMID: 37453044 PMCID: PMC10757867 DOI: 10.1093/eurheartj/ehad431] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 05/03/2023] [Accepted: 06/22/2023] [Indexed: 07/18/2023] Open
Abstract
AIMS Transoesophageal echocardiography (TOE) is often performed before catheter ablation or cardioversion to rule out the presence of left atrial appendage thrombus (LAT) in patients on chronic oral anticoagulation (OAC), despite associated discomfort. A machine learning model [LAT-artificial intelligence (AI)] was developed to predict the presence of LAT based on clinical and transthoracic echocardiography (TTE) features. METHODS AND RESULTS Data from a 13-site prospective registry of patients who underwent TOE before cardioversion or catheter ablation were used. LAT-AI was trained to predict LAT using data from 12 sites (n = 2827) and tested externally in patients on chronic OAC from two sites (n = 1284). Areas under the receiver operating characteristic curve (AUC) of LAT-AI were compared with that of left ventricular ejection fraction (LVEF) and CHA2DS2-VASc score. A decision threshold allowing for a 99% negative predictive value was defined in the development cohort. A protocol where TOE in patients on chronic OAC is performed depending on the LAT-AI score was validated in the external cohort. In the external testing cohort, LAT was found in 5.5% of patients. LAT-AI achieved an AUC of 0.85 [95% confidence interval (CI): 0.82-0.89], outperforming LVEF (0.81, 95% CI 0.76-0.86, P < .0001) and CHA2DS2-VASc score (0.69, 95% CI: 0.63-0.7, P < .0001) in the entire external cohort. Based on the proposed protocol, 40% of patients on chronic OAC from the external cohort would safely avoid TOE. CONCLUSION LAT-AI allows accurate prediction of LAT. A LAT-AI-based protocol could be used to guide the decision to perform TOE despite chronic OAC.
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Affiliation(s)
- Konrad Pieszko
- ‘Club 30’, Polish Cardiac Society, Poland
- Department of Interventional Cardiology and Cardiac Surgery, University of Zielona Gora, Collegium Medicum, Zielona Gora, Poland
- WSSP ZOZ Nowa Sol, Nowa Sol, Poland
| | - Jarosław Hiczkiewicz
- Department of Interventional Cardiology and Cardiac Surgery, University of Zielona Gora, Collegium Medicum, Zielona Gora, Poland
- WSSP ZOZ Nowa Sol, Nowa Sol, Poland
| | | | - Beata Uziębło-Życzkowska
- ‘Club 30’, Polish Cardiac Society, Poland
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Paweł Krzesiński
- ‘Club 30’, Polish Cardiac Society, Poland
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Monika Gawałko
- ‘Club 30’, Polish Cardiac Society, Poland
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
- Institute of Pharmacology, West German Heart and Vascular Centre, University Duisburg-Essen, Essen, Germany
| | - Monika Budnik
- ‘Club 30’, Polish Cardiac Society, Poland
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Starzyk
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, Kielce, Poland
| | - Beata Wożakowska-Kapłon
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, Kielce, Poland
| | | | - Damian Kaufmann
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, Gdansk, Poland
| | - Maciej Wójcik
- Department of Cardiology, Medical University of Lublin, Lublin, Poland
| | - Robert Błaszczyk
- Department of Cardiology, Medical University of Lublin, Lublin, Poland
| | - Katarzyna Mizia-Stec
- 1st Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Maciej Wybraniec
- 1st Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | | | | | - Anna Szymańska
- Department of Heart Diseases, Postgraduate Medical School, Warsaw, Poland
| | | | - Michał Kucio
- Department of Cardiology, School of Health Sciences, Medical University of Silesia, Katowice, Poland
| | - Maciej Haberka
- Department of Cardiology, School of Health Sciences, Medical University of Silesia, Katowice, Poland
| | | | - Błażej Michalski
- Department of Cardiology, Medical University of Lodz, Lodz, Poland
| | | | | | - Renata Wachnicka-Truty
- Department of Cardiology and Internal Medicine, Medical University of Gdansk, Gdynia, Poland
| | - Marek Koziński
- ‘Club 30’, Polish Cardiac Society, Poland
- Department of Cardiology and Internal Medicine, Medical University of Gdansk, Gdynia, Poland
| | - Jacek Kwieciński
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Rafał Wolny
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Ewa Kowalik
- Department of Congenital Heart Diseases, National Institute of Cardiology, Warsaw, Poland
| | - Iga Kolasa
- Department of Interventional Cardiology and Cardiac Surgery, University of Zielona Gora, Collegium Medicum, Zielona Gora, Poland
| | - Agnieszka Jurek
- ‘Club 30’, Polish Cardiac Society, Poland
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland
| | - Jan Budzianowski
- ‘Club 30’, Polish Cardiac Society, Poland
- Department of Interventional Cardiology and Cardiac Surgery, University of Zielona Gora, Collegium Medicum, Zielona Gora, Poland
- WSSP ZOZ Nowa Sol, Nowa Sol, Poland
| | - Paweł Burchardt
- ‘Club 30’, Polish Cardiac Society, Poland
- Department of Biology and Lipid Disorders, Poznan University of Medical Sciences, Poznan, Poland
| | - Agnieszka Kapłon-Cieślicka
- ‘Club 30’, Polish Cardiac Society, Poland
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr J Slomka
- Department of Medicine (Division of Artificial Intelligence in Medicine), Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite Metro 203, 90048, Los Angeles, CA, USA
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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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López-Galvez R, Rivera-Caravaca JM, Roldán V, Orenes-Piñero E, Esteve-Pastor MA, López-García C, Saura D, González J, Lip GYH, Marín F. Imaging in atrial fibrillation: A way to assess atrial fibrosis and remodeling to assist decision-making. Am Heart J 2023; 258:1-16. [PMID: 36526006 DOI: 10.1016/j.ahj.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 11/22/2022] [Accepted: 12/10/2022] [Indexed: 05/11/2023]
Abstract
The 2020 ESC atrial fibrillation (AF) guidelines suggest the novel 4S-AF scheme for the characterization of AF. Imaging techniques could be helpful for this objective in everyday clinical practice, and information derived from these techniques reflects basic aspects of the pathophysiology of AF, which may facilitate treatment decision-making, and optimal management of AF patients. The aim of this review is to provide an overview of the mechanisms associated with atrial fibrosis and to describe imaging techniques that may help the management of AF patients in clinical practice. Transthoracic echocardiography is the most common procedure given its versatility, safety, and simplicity. Transesophageal echocardiography provides higher resolution exploration, and speckle tracking echocardiography can provide incremental functional and prognostic information over conventional echocardiographic parameters. In addition, LA deformation imaging, including LA strain and strain rate, are related to the extent of fibrosis. On the other hand, multidetector-row computed tomography and cardiac magnetic resonance provide higher resolution data and more accurate assessment of the dimensions, structure, and spatial relationships of the LA. Imaging is central when deciding on catheter ablation or cardioversion, and helps in selecting those patients who will really benefit from these procedures. Moreover, imaging enhances the understanding of the underlying mechanisms of atrial remodeling and might assists in refining the risk of stroke, which help to select the best medical therapies/interventions. In summary, evaluation of LA enlargement, LA remodeling and fibrosis with imaging techniques adds clinical and prognostic information and should be assessed as a part of routine comprehensive AF evaluation.
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Affiliation(s)
- Raquel López-Galvez
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain; School of Nursing, University of Murcia, Murcia, Spain; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Esteban Orenes-Piñero
- Department of Biochemistry and Molecular Biology, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Cecilia López-García
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Daniel Saura
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Josefa González
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
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Takumi K, Nagano H, Ueda K, Umehara T, Tokunaga T, Kamimura G, Sato M, Nakanosono R, Yoshiura T. Left atrial CT volume and CHA 2DS 2-VASc score predict early pulmonary vein stump thrombus after left upper lobectomy. Sci Rep 2023; 13:4965. [PMID: 36973354 PMCID: PMC10042883 DOI: 10.1038/s41598-023-32240-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
The purpose of this study is to clarify the feasibility of left atrial (LA) volume measurement and CHA2DS2-VASc score for predicting the development of pulmonary vein (PV) stump thrombus after left upper lobectomy (LUL). The study population comprised 50 patients who underwent LUL for pulmonary lesions. All patients were evaluated for the development of PV stump thrombus at 7 days after LUL. LA volume was measured using preoperative CT and the CHA2DS2-VASc score was evaluated. LA volume and CHA2DS2-VASc score were compared between patients with and without the development of PV stump thrombus using the Mann-Whitney U test. Receiver-operating characteristic (ROC) curve analysis was performed to evaluate the accuracy of prediction of PV stump thrombus development. PV stump thrombus was detected in 17 (33.4%) of the 50 patients. LA volume was significantly greater in patients who developed PV stump thrombus than in those without thrombus (79.7 ± 19.4 vs. 66.6 ± 17.0 mL, p = 0.040). CHA2DS2-VASc score was significantly higher in patients with PV stump thrombosis than in those without thrombus (3.4 ± 1.5 vs. 2.5 ± 1.5, p = 0.039). Area under the ROC curve values for predicting PV stump thrombus were 0.679, 0.676, and 0.714 for LA volume, CHA2DS2-VASc score, and their combination, respectively. In conclusion, LA volume measured using preoperative CT and CHA2DS2-VASc score may help predict the development of PV stump thrombus after LUL.
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Affiliation(s)
- Koji Takumi
- Departments of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, 890-8544, Japan.
| | - Hiroaki Nagano
- Departments of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, 890-8544, Japan
| | - Kazuhiro Ueda
- Departments of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, 890-8544, Japan
| | - Tadashi Umehara
- Departments of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, 890-8544, Japan
| | - Takuya Tokunaga
- Departments of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, 890-8544, Japan
| | - Go Kamimura
- Departments of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, 890-8544, Japan
| | - Masami Sato
- Departments of General Thoracic Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, 890-8544, Japan
| | - Ryota Nakanosono
- Departments of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, 890-8544, Japan
| | - Takashi Yoshiura
- Departments of Radiology, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima City, 890-8544, Japan
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Left Ventricular Ejection Fraction Can Predict Atrial Thrombosis Even in Non-High-Risk Individuals with Atrial Fibrillation. J Clin Med 2022; 11:jcm11143965. [PMID: 35887729 PMCID: PMC9317918 DOI: 10.3390/jcm11143965] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 06/29/2022] [Accepted: 07/05/2022] [Indexed: 02/04/2023] Open
Abstract
Background—Current guidelines do not recommend routine use of transesophageal echocardiography (TOE) in anticoagulated patients with atrial fibrillation (AF). The aim of our study was to identify predictors for left atrial thrombosis (LAT) in patients with AF that would require TOE despite anticoagulation therapy, using clinical, laboratory and echocardiographic data which are usually obtained in those patients in a real-world setting. Methods—We analyzed data from electronic medical records (EMR) of consecutive AF patients referred to two university hospitals between January 2014 and December 2017 for pulmonary vein isolation (PVI) or direct current cardioversion. The primary endpoint was the presence of left atrial thrombus on TOE. Multivariable and univariable logistic regression models were computed using variables that were significantly different between the LAT and the control groups. Results—A total of 838 patients were included, of whom 132 (15.8%) had LAT. After controlling for other variables, only the left ventricle ejection fraction (LVEF) remained statistically significant with an OR of 0.956 (95% CI 0.934−0.979), p < 0.01. Regression models including LVEF had significantly higher areas under the receiver operating characteristic (ROC) curves, including in subgroups with non-high thromboembolic risk (CHA2DS2-Vasc = 0 or 1), with an area under the curve (AUC) of 0.76 (95% CI 0.71−0.81), p < 0.0001. Conclusions—The LVEF is an independent predictor of LAT, and it might improve thromboembolic risk stratification in future models. LVEF significantly increased the predictive value of the CHA2DS2-Vasc model and was able to identify LAT in non-high-risk patients.
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