1 Introduction
2 Methods
2.1 Study cohort
2.2 Definitions
2.3 Periprocedural anticoagulation
2.4 Scheduling for transesophageal echocardiography
2.5 Post-procedural follow-up
2.6 Statistical analysis
3 Results
3.1 Characteristics of the population
Characteristic | Total (n = 1155) | No TOE (n = 894) | TOE (n = 261) | p-value | |
---|---|---|---|---|---|
Demographics | |||||
Age, years | 70 (IQR, 62–76) | 70 (IQR, 62–76) | 69 (IQR, 60–77) | 0.31 | |
Male | 674 (58.4%) | 518 (57.9%) | 156 (59.8%) | 0.59 | |
Medical history | |||||
Persistent AF/AT | 555 (48.1%) | 420(46.9%) | 135 (51.7%) | 0.17 | |
Duration of AF, years | 3 (IQR, 1–5) | 3 (IQR1–5) | 2 (IQR, 1–5) | 0.24 | |
AF on presentation | 647 (56%) | 497 (55.6%) | 150 (57.4%) | 0.59 | |
Prior ablation in LA | 357 (31%) | 301 (33.7%) | 57 (21.8%) | 0.00027 | |
BMI, kg/m2 | 28.07 (IQR, 25–31.7) | 28 (IQR, 25–31) | 28 (IQR, 25–31) | 0.25 | |
Hypertension | 988 (85.6%) | 773 (86.5%) | 215 (82.3%) | 0.09 | |
Diabetes mellitus | 170 (14.7%) | 134 (15%) | 36 (13.8%) | 0.63 | |
Coronary artery disease | 275 (23.8%) | 227 (25.4%) | 48 (18.4%) | 0.019 | |
Obstructive sleep apnea | 148 (12.8%) | 117 (13.1%) | 31 (11.9%) | ||
Impaired kidney function (GFR < 60) | 207 (17.9%) | 146 (16.3%) | 61 (23.2%) | 0.009 | |
Previous CVE | 93 (8.1%) | 0 | 93 (35.6%) | < 0.00001 | |
History of LAAT | 24 (2.07%) | 0 | 24 (9.2%) | < 0.00001 | |
CHA2DS2-VASc score = 0 | 34 (2.94%) | 21 (2.3%) | 13 (5%) | 0.02 | |
CHA2DS2-VASc score = 1 | 183 (15.84%) | 136 (15.2%) | 47 (18%) | 0.27 | |
CHA2DS2-VASc score ≥ 2 | 938 (81.2%) | 737 (82.4%) | 201 (77%) | 0.48 | |
CHA2DS2-VASc score | 3 (IQR, 2–4) | 3 (IQR, 2–4) | 3 (IQR, 2–4) | 0.81 | |
Preprocedural echocardiographic parameters | |||||
Left ventricular EF, % | 59 (IQR, 50–60) | 60 (50–70) | 58 (48–70) | 0.09 | |
Left ventricular EF < 35% | 175 (15.2%) | 141 (15.7%) | 34 (13%) | 0.27 | |
Left atrium volume index (ml/m2) | 43.7 (IQR, 32.7–55) | 43 (IQR, 32–54) | 43 (IQR, 33–55) | 0.92 | |
Anticoagulation | |||||
NOACs | 1014 (87.8% | 827 (92.5%) | 177 (67.8%) | < 0.00001 | |
Apixaban | 530 (45.8%) | 443 (49.659) | 87 (33.3%) | < 0.00001 | |
Rivaroxaban | 359 (31.1%) | 294 (32.95) | 65 (22.3%) | 0.014 | |
Dabigatran | 22 (1.9%) | 14 (1.6%) | 8 (2.7%) | 0.119 | |
Edoxaban | 103 (8.92%) | 86 (9.6%) | 17 (5.8%) | 0.12 | |
VKAs | 94 (8.13%) | 62 (6.9%) | 32 (12.3%) | 0.005 | |
No or inappropriate intake/reduced dose of OAC 3 weeks before the procedure | 161 (13.9%) | 1 (0.1%) | 160 (61.3%) | < 0.00001 | |
LAA occluder | 6 (0.52%) | 4 (0.4%) | 2 (0.6%) | 0.52 | |
LAA resection | 1 (0.09%) | 1 (0.1%) | 0 | 1 |
3.1.1 Comparison between patients with and without TOE
Patient A | Patient B | |
---|---|---|
Age, years | 75 | 69 |
Gender | Female | Male |
BMI, kg/m2 | 28 | 28.9 |
CHA2DS2-VASc score | 3 | 3 |
OAK substance and regimen | Apixaban 5 mg twice daily | Rivaroxaban 15 mg |
LVEF, % | 55 | 25 |
LAVI, ml/m2 | 48.2 | 76.4 |
GFR | 90 | 52 |
AF type | Persistent | Persistent |
Presenting rhythm | AF | AF |
History of CVE | No | No |
Reason for TOE | Inappropriate NOAC regimen | Inappropriate NOAC regimen |
History of LAAT | No | No |
LAA occluder | No | No |
3.2 Cerebrovascular events
Patient #1 | Patient #2 | Patient #3 | Patient #4 | |
---|---|---|---|---|
Age, years | 69 | 80 | 71 | 66 |
Gender | Female | Female | Male | Female |
BMI, kg/m2 | 33.66 | 33.28 | 25.01 | 23.95 |
CHA2DS2-VASc score | 3 | 4 | 5 | 3 |
CHADS2 score | 1 | 2 | 4 | 1 |
LAA occluder | No | No | No | No |
OAK substance and regimen | Apixaban, 5 mg, twice daily | Apixaban, 2.5 mg, twice daily | Apixaban, 5 mg, twice daily | Rivaroxaban, 20 mg, once daily |
LVEF, % | 37 | 60 | 44 | 60 |
LAVI, ml/m2 | 53.8 | 66.8 | - | - |
AF type | Paroxysmal | Paroxysmal | Paroxysmal | Persistent |
Presenting rhythm | SR | SR | Afib | AFib |
TOE performed | No | No | Yes | Yes |
History of CVE | No | No | No | No |
Reason for TOE | - | - | Inappropriate OAK intake | Inappropriate OAK intake |
History of LAAT | No | No | No | No |
No or inappropriate intake/reduced dose of OAC 3 weeks before the procedure | Yes | No | Yes | Yes |
Procedure type | RF PVI | Cryo-PVI | RF PVI | Cryo-PVI |
Type of CVE | Thromboembolic | Thromboembolic | Thromboembolic | Thromboembolic |
Time of CVE diagnosis | Periprocedural | Periprocedural | Periprocedural | Periprocedural |
Post-procedure imaging | No LAA thrombus | Sludge in LAA | No LAA thrombus | No LAA thrombus |
No CVE (n = 1149) | CVE (n = 4) | p value | |
---|---|---|---|
Age, years | 70 (IQR, 62–76) | 70 (IQR, 68–73) | 0.58 |
Male sex | 673 (58.5%) | 1 (25%) | 0.31 |
BMI, kg/m2 | 28.06 (IQR, 25.01–31.70) | 29.1 (IQR, 24.7–33.4) | 0.85 |
Persistent AF | 554 (48.2%) | 1 (25%) | 0.63 |
Prior ablation | 355 (30.8%) | 0 | 0.32 |
AF on presentation | 645 (56.1%) | 2 (50%) | 1 |
Duration of AF, years | 3 (1–5) | 1.5 (1.25–1.75) | 0.31 |
CHA2DS2-VASc score | 3 (2–4) | 3 (2.5–3.5) | 0.1 |
CHA2DS2-VASc score ≥ 2 | 935 (81.3%%) | 3 (75%) | 0.57 |
Anticoagulation with DOAC | 985 (85.7%) | 4 (100%) | 1 |
No or inappropriate intake/reduced dose of OAC 3 weeks before the procedure | 232 (20.2%) | 2 (50%) | 0.18 |
History of LAAT | 24 (2.1%) | 0 | 1 |
Previous CVE | 93 (8.1%) | 0 | 1 |
Coronary artery disease | 274 (23.8%) | 1 (25%) | 1 |
Diabetes mellitus | 168 (14.6%) | 2 (50%) | 0.11 |
LAVI (ml/m2) | 43 (32–54) | Mean 60.3 | 0.45 |
LVEF < 45% | 269 (23.4%) | 2 (50%) | 0.24 |
LVEF, % | 59 (IQR, 50–60) | 52 (IQR, 42–61) | 0.79 |
4 Discussion
4.1 Mechanism of periprocedural thromboembolism
4.1.1 What speaks against performing TOE in every patient?
4.1.2 What is the likelihood of finding an LAA thrombus on TOE?
Number of patients | LAA-thrombus detected | Adherence | ||||||||
---|---|---|---|---|---|---|---|---|---|---|
Overall | No OAC | On VKA | On NOAC | Overall | No OAC | On VKA | On NOAC | To NOAC | To VKA | |
The ACUTE trial, 2002 [30] | 1152 | 549 (47.6%) | 603 (52.3%) | - | 76 (13.8%) TOE performed only in no OAC group! | 76 (13.8%) | No data | - | - | Not reported |
Puwanant et al. 2009 [31] | 1058 | 283 (26.7%) | 775 (73.3%) | - | 6 (0.6%) | 0 | 6 (0.8%) | - | - | Not reported |
Milhem et al. 2019 [9] | 2494 | 235 (9.4%) | 1059 (42.5%) | 1186 (47.6%) | 48 (1.92%) | 2 (0.8%) | 27 (2.5%) | 19 (1.6%) | Not reported | 18 of 27 patients with LAA thrombus |
Alqarawi et al. 2019 [32] | 942 | 0 | 496 (53%) | 447 (47%) | 3 (0.3%) | 0 | 3 (0.6%) | 0 | Not reported | Not reported |
Wegner et al. 2022 [33] | 512 | 82 (16%) | 138 (27%) | 292 (57%) | 19 (3.7%) | 3 (3.6%) | 7 (5.1%) | 9 (3.15) | < 3 weeks before or uncertain adherence | < 3 weeks before or uncertain adherence |