Prediction of spontaneous echocardiographic contrast within the left atrial appendage in cardiac computed tomography of patients with atrial fibrillation

This study aimed to assess the predictors of spontaneous echocardiographic contrast (SEC) using left atrial appendage (LAA) findings in cardiac computed tomography (CT) of patients with atrial fibrillation (AF). We retrospectively analyzed cardiac CT findings of the LAA, including morphology, volume, and filling defects, of 641 patients who underwent transesophageal echocardiography (TEE) prior to pulmonary vein isolation (PVI) from January 6, 2013 through December 16, 2019 at our institution. We investigated potential associated factors that might be predictors of SEC using cardiac CT findings and computed a receiver operator characteristic, choosing a threshold value at which the likelihood of SEC could be predicted based on the LAA volume indexed for body size. SEC correlated significantly with indexed LAA volume (P < 0.001; odds ratio [OR], 1.31; 95% confidence interval [CI], 1.17-1.48) of 7.75 cm3/m2 or greater (sensitivity, 76.0%; specificity, 57.7%), LAA early filling defect (P = 0.005; OR, 2.72; 95% CI, 1.35-5.48), a history of persistent AF (P < 0.001; OR, 3.81; 95% CI, 1.86-7.80), and LAA flow velocity (P < 0.001; OR, 0.97; 95% CI, 0.96-0.99). Findings of LAA in cardiac CT can allow for the noninvasive estimation of SEC to determine the need for additional TEE investigation and the need to obtain additional information for risk stratification and management of thromboembolic events in patients with AF.

Computed tomography findings associated with the reduction in left atrial appendage flow velocity in patients with atrial fibrillation

The reduction in flow velocity within the left atrial appendage (LAAFV) is associated with a high risk of thromboembolic events. There has been few reports using sufficient sample size about the relationship between LAAFV reduction and LAA features on cardiac computed tomography (CT), including LAA volume and filling defects, in patients with atrial fibrillation (AF). We evaluated the predictors of reduced flow velocity within the LAA using the findings of cardiac CT in patients with AF. We retrospectively analysed the cardiac CT findings of the LAA of 440 patients who underwent transoesophageal echocardiography prior to pulmonary vein isolation between 12 February, 2013 and 16 December, 2019 at our institution. We investigated the potential predictors of reduced LAAFV and the difference in LAAFV between the different morphological types of the LAA. The reduced flow velocity within the LAA was significantly correlated with higher CHADS₂ scores [P = 0.001; odds ratio (OR), 1.52; 95% confidence interval (CI), 1.18-1.95], early filling defect in the LAA (P = 0.001; OR, 3.36; 95% CI 1.63-6.93), and increased indexed LAA volume (P = 0.036; OR, 1.09; 95% CI 1.01-1.19). The LAA morphological type and AF type were not significant predictors of the LAAFV reduction. Increased LAA volume, early filling defects in the LAA, and higher CHADS₂ scores were independent predictors of LAAFV reduction in patients with AF. Our findings suggest that cardiac CT findings might allow non-invasive estimation of reduced LAAFV. These CT-derived parameters may provide additional information for the risk stratification and management of thromboembolic events in patients with AF.

Filling defects in the left atrial appendage restricted to the early phase of cardiac computed tomography as a potential risk of left atrial appendage dysfunction

BACKGROUND

Filling defects within the left atrial appendage (LAA) restricted to the early phase of computed tomography (CT) are not highly specific to the presence of thrombosis. The true significance of LAA early filling defects without thrombus remains uncertain. We evaluated the predictors of LAA early filling defects on echocardiography and cardiac CT findings in patients with atrial fibrillation (AF).

METHODS

Cardiac CT findings of 641 patients with AF who underwent transesophageal echocardiography prior to pulmonary vein isolation from 6 January 2013 to 16 December 2019 at our institution were retrospectively analyzed. We investigated potential predictors of LAA early filling defects and computed the receiver operator characteristics, choosing a threshold value at which the likelihood of LAA early filling defects could be predicted.

RESULTS

Early filling defects within the LAA correlated significantly with a history of persistent AF [p = 0.014; odds ratio (OR), 2.36; 95% confidence interval (CI), 1.19-4.66), low left ventricular ejection fraction (p = 0.009; OR, 2.62; 95% CI, 1.28-5.38), diminished LAA flow velocity (p < 0.001; OR, 0.97; 95% CI, 0.96-0.99) below 45.3 cm/s (sensitivity, 63.6%; specificity, 72.4%), and increased indexed LAA volume (p = 0.001; OR, 1.18; 95% CI, 1.07-1.30) ≥7.64 cm3/m2 (sensitivity, 70.5%; specificity, 69.0%).

CONCLUSION

Early filling defects within the LAA on cardiac CT were associated with LAA function including risk factors for thrombus development, which could lead to noninvasive estimation of LAA function and additional information for risk stratification of thromboembolic events in patients with AF.

Serious Complication of Anticoagulation in Vessel Thrombosis-associated Behçet Disease

Anticoagulation in venous thrombosis associated with Behçet disease (BD) is controversial. We herein report a 47-year-old woman with vessel thrombosis and pulmonary artery aneurysm (PAA) associated with BD who died of massive hemoptysis under oral anticoagulant. Although she was initially diagnosed with oral contraceptive-induced venous thromboembolism, a subsequent investigation led to a diagnosis of BD. Follow-up computed tomography (CT) showed persistent thrombus, so anticoagulant was continued for persistent thrombus. She died of massive hemoptysis after the development of PAA was identified on follow-up CT during the period of anticoagulation. Great care to prevent bleeding events is required when administering anticoagulants for BD with vessel thrombosis.

Repeated provocation of time- and ATP-induced early pulmonary vein reconnections after pulmonary vein isolation: eliminating paroxysmal atrial fibrillation in a single procedure

BACKGROUND

Recurrence of atrial fibrillation (AF) after successful pulmonary vein isolation (PVI) occurs mainly due to the reconnection of the once isolated PV. Although provocation and elimination of the early pulmonary vein reconnection (EPVR) soon after PVI has been widely performed to improve the outcome, AF recurrence due to subsequent PV reconnections still occurs. In this study, we repeatedly provoked and eliminated the EPVR to determine the appropriate procedural end point.

METHODS AND RESULTS

Seventy-five patients with paroxysmal AF underwent PVI. EPVR was provoked by both time and ATP induction every 30 minutes until 90 minutes after the individual isolation of all PVs. The number of reconnected atrio-PV gaps were evaluated and reablated at each provocation step. Although both time- and ATP-dependent EPVR was induced most frequently at 30 minutes after PVI (75 and 76 gaps, respectively), the prevalence of induced EPVR at 60 minutes was still high (64 and 36 gaps induced by time and ATP, respectively). Only a small number of EPVR appeared at 90 minutes after the elimination of all EPVR by 60 minutes (8 gaps, P<0.01). During the mean follow-up period of 370 days, 92% of cases were free from AF without antiarrhythmic drugs.

CONCLUSIONS

Provocation and elimination of time- and ATP-induced EPVR not only at 30 minutes but also at 60 minutes is recommended after PVI to improve its efficacy.