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Prevalence of LAA thrombus in patients undergoing percutaneous ablation of atrial fibrillation
Session:
Painel 3 - Imagiologia Cardiovascular 2
Speaker:
Cláudia Jesus Silva
Congress:
CPC 2020
Topic:
B. Imaging
Theme:
03. Imaging
Subtheme:
03.2 Computed Tomography
Session Type:
Posters
FP Number:
---
Authors:
Cláudia Jesus Silva; Pedro Freitas; António Ferreira; Francisco Albuquerque; Sara Guerreiro; João Abecasis; Catarina Brízido; Mariana Gonçalves; Gustavo Da Rocha Rodrigues; Ana Coutinho Santos; João Carmo; Maria Salomé Carvalho; Anai Durazzo; Francisco Moscoso Costa; Pedro Lopes Do Carmo; Carla Rodrigues Carvalho; Diogo Cavaco; Francisco Bello Morgado; Pedro Adragão; Miguel Mendes
Abstract
<p><strong>Introduction</strong>: Computed tomography (CT) is often performed before atrial fibrillation (AF) ablation to assess the anatomy of the pulmonary veins and exclude left atrial (LA) and left atrial appendage (LAA) thrombus. With the growing use of new oral anticoagulants (NOACs), a reassessment of the need for systematic thrombus exclusion in this context seems warranted.</p> <p><strong>Objective</strong>: To evaluate the prevalence of thrombus in LA/LAA in pre-ablation CT in a contemporary cohort of patients predominantly anticoagulated with NOACs.</p> <p><strong>Methods</strong>: We evaluated 789 consecutive patients (mean age 61±12 years; 38% female; 84% with paroxysmal AF) who underwent pre-ablation CT between Oct/2015 and Oct/2019. ECG-gated CT-angiography was performed using a dual-source 64-slice CT after iodinated contrast injection. Whenever necessary, a second dedicated acquisition was made 60 seconds after the first set of images. Presence of thrombus was defined as a persistent opacification defect. For each patient, thromboembolic risk was assessed with the CHA<sub>2</sub>DS<sub>2</sub>-VASc score.</p> <p><strong>Results</strong>: The median interval between CT and AF ablation was 1 day (IQR 1 – 2 days). The median CHA<sub>2</sub>DS<sub>2</sub>-VASc was 2 points (IQR 0 – 3 points), with 590 patients (75%) having CHA<sub>2</sub>DS<sub>2</sub>-VASc ≥ 1. Among the 199 patients (25%) with CHA<sub>2</sub>DS<sub>2</sub>-VASc = 0, 118 (59,3%) were anticoagulated with a NOAC and 14 (7%) with a vitamin K antagonist; 67 (34%) were not anticoagulated. Conversely, amongst the 590 patients with CHA<sub>2</sub>DS<sub>2</sub>-VASc ≥ 1, 84% were anticoagulated with a NOAC (n = 494), 11% used vitamin K antagonists (n = 62), and 34 patients were not anticoagulated (23 with CHA<sub>2</sub>DS<sub>2</sub>-VASc = 1).</p> <p>On cardiac CT, 521 (66%) patients were in sinus rhythm. Overall, only one LAA thrombus was found (0.12% [1/789]; 95%CI: 0.0 – 0,7%) – in a patient with CHA<sub>2</sub>DS<sub>2</sub>-VASc = 0, anticoagulated with a NOAC. The median effective radiation dose was 3.2 mSv (IQR 2.1 – 4.8 mSv). There were 5 minor allergic reactions to iodinated contrast. No strokes were documented within the first 24 hours after ablation.</p> <p><strong>Conclusion</strong>: In this contemporary cohort of patients with predominantly paroxysmal AF and anticoagulated with NOAC, the prevalence of intracavitary thrombus was extremely low (0.12%). While these findings do not compromise the multipurpose role of pre-ablation CT, they should nevertheless inform future discussions on the risk/benefit and cost/benefit of performing systematic exclusion of LA/LAA thrombi prior to AF ablation.</p>
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