CT-criteria for left atrium appendage thrombus detection

Bauyrzhan Kaliyev 1 * , Raushan Rakhimzhanova 2, Tairkhan Dautov 1, Lyazzat Bastarbekova 1, Zhanar Moldakhanova 1, Azhar Kabdullina 3, Ayan Abdrakhmanov 4
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1 Department of Radiology, National Research Cardiac Surgery Center, Astana, Kazakhstan
2 Department of Radiology No1, Astana Medical University, Astana, Kazakhstan
3 Department of Nuclear Medicine, Medical Centre Hospital of President’s Affairs Administration of the Republic of Kazakhstan, Astana, Kazakhstan
4 Department of Interventional Arrhythmology, National Research Cardiac Surgery Center, Astana, Kazakhstan
* Corresponding Author
J CLIN MED KAZ, Volume 20, Issue 1, pp. 7-13. https://doi.org/10.23950/jcmk/12828
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ABSTRACT

Objective: Atrial fibrillation is strongly associated with stroke and accounts for 60% of cardioembolic stroke. Assessing thromboembolic risk is important for patients with atrial fibrillation. Approximately 90% of all thrombus are localized in the left atrium appendage (LAA). This study aimed to determine the efficacy of cardiac computed tomography (CT) for LAA thrombus detection.
Material and methods: This retrospective study included 292 patients. LAA thrombus was confirmed or excluded by cardiac CT with the reference to transesophageal echocardiography (TEE). We excluded patients with allergic reactions to iodide, increased creatinine levels, thyroid disease (hyperthyroidism), pregnancy, and age <18 years.
Results: According to the cardiac CT, 103 of 292 people had LAA thrombus, while according to TEE, only 48 of patients had LAA thrombus. The sensitivity and specificity of CT were 97.7% and 77%, respectively. The sensitivity and specificity of the CT was higher in 2016–2020, when the delayed phase was added to the standard protocol, compared to 2012–2015 years. Older age, higher BMI, higher CHA2DS2-VASc and HAS-BLED scores, and larger LA and LVESV were significantly associated with LAA thrombus detection on cardiac CT. Higher LVESV and LVEDV indexes (LVESVI and LVEDVI) and lower LV ejection fraction measured by TEE were also predictors of LAA thrombus detection by cardiac CT.
Conclusion: Our findings show that cardiac CT has high sensitivity and specificity for excluding or confirming LAA thrombus, and can also be exclusively used to determine the presence or absence of a thrombus.
Keywords: left atrium appendage thrombus, cardiac computed tomography, atrial fibrillation, cardioembolic stroke, transesophageal echocardiography

CITATION

Kaliyev B, Rakhimzhanova R, Dautov T, Bastarbekova L, Moldakhanova Z, Kabdullina A, et al. CT-criteria for left atrium appendage thrombus detection. J CLIN MED KAZ. 2023;20(1):7-13. https://doi.org/10.23950/jcmk/12828

REFERENCES

  • Murtagh B, Smalling RW. Cardioembolic stroke. Curr Atheroscler Rep. 2006;8:310-316. https://doi.org/10.1007/s11883-006-0009-9
  • Arboix A, Alió J. Cardioembolic stroke: clinical features, specific cardiac disorders and prognosis. Curr Cardiol Rev. 2010;6:150-161. https://doi.org/10.2174/157340310791658730
  • Ferro JM. Cardioembolic stroke: an update. Lancet Neurol. 2003;2:177-188 https://doi.org/10.1016/s1474-4422(03)00324-7
  • Kamel H, Okin PM, Elkind MS, Iadecola C. Atrial fibrillation and mechanisms of stroke: time for a new model. Stroke. 2016;47:895-900. https://doi.org/10.1161/STROKEAHA.115.0120044
  • Kong B, Liu Y, Huang H, Jiang H, Huang C. Left atrial appendage closure for thromboembolism prevention in patients with atrial fibrillation: advances and perspectives. J Thorac Dis. 2015;7:199-203. https://doi.org/10.3978/j.issn.2072-1439.2015.01.20
  • Syed FF, DeSimone CV, Friedman PA, Asirvatham SJ. Left atrial appendage exclusion for atrial fibrillation. Cardiol Clin. 2014;32:601-625. https://doi.org/10.1016/j.ccl.2014.07.006
  • Hart RG, Pearce LA, Miller VT, Anderson DC, Rothrock JF, Albers GW, et al. Cardioembolic vs. noncardioembolic strokes in atrial fibrillation: frequency and effect of antithrombotic agents in the stroke prevention in atrial fibrillation studies. Cerebrovasc Dis. 2000;10:39-43. https://doi.org/10.1016/0003-4975(95)00887-X
  • Mahajan R, Brooks AG, Sullivan T, Lim HS, Alasady M, Abed HS, et al. Importance of the underlying substrate in determining thrombus location in atrial fibrillation: implications for left atrial appendage closure. Heart. 2012;98:1120-1126. https://doi.org/10.1136/heartjnl-2012-301799
  • Xu J, Luc JG, Phan K. Atrial fibrillation: review of current treatment strategies. J Thorac Dis. 2016;8:E886-E900. https://doi.org/10.21037/jtd.2016.09.13
  • Bond R, Olshansky B, Kirchhof P. Recent advances in rhythm control for atrial fibrillation. F1000Res. 2017;6:1796. https://doi.org/10.12688/f1000research.11061.1
  • Brandes A, Crijns HJGM, Rienstra M, Kirchhof P, Grove EL, Pedersen KB, et al. Cardioversion of atrial fibrillation and atrial flutter revisited: current evidence and practical guidance for a common procedure. Europace. 2020;22:1149-1161. https://doi.org/10.1093/europace/euaa057
  • Kojodjojo P, O'Neill MD, Lim PB, Malcolm-Lawes L, Whinnett ZI, Salukhe TV, et al. Pulmonary venous isolation by antral ablation with a large cryoballoon for treatment of paroxysmal and persistent atrial fibrillation: medium-term outcomes and non-randomised comparison with pulmonary venous isolation by radiofrequency ablation. Heart. 2010;96:1379-1384. https://doi.org/10.1136/hrt.2009.192419
  • Squara F, Bres M, Scarlatti D, Moceri P, Ferrari E. Clinical outcomes after AF cardioversion in patients presenting left atrial sludge in trans-esophageal echocardiography. J Interv Card Electrophysiol. 2020;57:149-156. https://doi.org/10.1007/s10840-019-00561-8
  • Melillo E, Palmiero G, Ferro A, Mocavero PE, Monda V, Ascione L. Diagnosis and management of left atrium appendage thrombosis in atrial fibrillation patients undergoing cardioversion. Medicina. (Kaunas) 2019;55:E511. https://doi.org/10.3390/medicina55090511
  • Acar J, Cormier B, Grimberg D, Kawthekar G, Iung B, Scheuer B, et al. Diagnosis of left atrial thrombi in mitral stenosis-usefulness of ultrasound techniques compared with other methods. Eur Heart J. 1991;12 Suppl B:70-76. https://doi.org/10.1093/eurheartj/12.suppl_B.70
  • Manning WJ, Weintraub RM, Waksmonski CA, Haering JM, Rooney PS, Maslow AD, et al. Accuracy of transesophageal echocardiography for identifying left atrial thrombi. A prospective, intraoperative study. Ann Intern Med. 1995;123:817-822. https://doi.org/10.7326/0003-4819-123-11-199512010-00001
  • Purza R, Ghosh S, Walker C, Hiebert B, Koley L, Mackenzie GS, et al. Transesophageal echocardiography complications in adult cardiac surgery: a retrospective cohort study. Ann Thorac Surg. 2017;103:795-802. https://doi.org/10.1016/j.athoracsur.2016.06.073
  • Hur J, Kim YJ, Lee H-J, et al. Left atrial appendage thrombi in stroke patients: detection with two-phase cardiac CT angiography versus transesophageal echocardiography. Radiology. 2009;251:683–690. https://doi.org/10.1148/radiol.2513090794
  • Budoff MJ, Shittu A, Hacioglu Y, et al. Comparison of transesophageal echocardiography versus computed tomography for detection of left atrial appendage filling defect (thrombus) Am J Cardiol. 2014;113:173–177. https://doi.org/10.1016/j.amjcard.2013.09.037
  • Choi BH, Ko SM, Hwang HK, et al. Detection of left atrial thrombus in patients with mitral stenosis and atrial fibrillation: retrospective comparison of two-phase computed tomography, transoesophageal echocardiography and surgical findings. Eur Radiol. 2013;23:2944–2953. https://doi.org/10.1007/s00330-013-2944-5
  • Lazoura O, Ismail TF, Pavitt C et al (2015) A low-dose, dual-phase cardiovascular CT protocol to assess left atrial appendage anatomy and exclude thrombus prior to left atrial intervention. Int J Cardiovasc Imaging. https://doi.org/10.1007/s10554-015-0776-x
  • Shapiro MD, Neilan TG, Jassal DS, et al. Multidetector computed tomography for the detection of left atrial appendage thrombus: a comparative study with transesophageal echocardiography. J Comput Assist Tomogr. 2007;31(6):905-909. https://doi.org/10.1097/rct.0b013e31803c55e3
  • Kim YY, Klein AL, Halliburton SS, et al. Left atrial appendage filling defects identified by multidetector computed tomography in patients undergoing radiofrequency pulmonary vein antral isolation: a comparison with transesophageal echocardiography. Am Heart J. 2007;154(6):1199-1205. https://doi.org/10.1016/j.ahj.2007.08.004
  • Hur J, Kim YJ, Nam JE, et al. Thrombus in the left atrial appendage in stroke patients: detection with cardiac CT angiography--a preliminary report. Radiology. 2008;249(1):81-87. https://doi.org/10.1148/radiol.2491071544
  • Romero J, Husain SA, Kelesidis I, Sanz J, Medina HM, Garcia MJ. Detection of left atrial appendage thrombus by cardiac computed tomography in patients with atrial fibrillation: a meta-analysis. Circ Cardiovasc Imaging. 2013;6(2):185-194. https://doi.org/10.1161/CIRCIMAGING.112.000153
  • Osawa K, Nakanishi R, Ceponiene I, Nezarat N, French WJ, Budoff MJ. Predicting left atrial appendage thrombus from left atrial volume and confirmation by computed tomography with delayed enhancement. Tex Heart Inst J. 2020;47:78-85. https://doi.org/10.14503/THIJ-17-6290
  • Facchini E, Degiovanni A, Marino PN. Left atrium function in patients with coronary artery disease. Curr Opin Cardiol. 2014;29:423-429. https://doi.org/10.1097/HCO.0000000000000085
  • Xu Y, Zhao L, Zhang L, Han Y, Wang P, Yu S. Left atrial enlargement and the risk of stroke: a meta-analysis of prospective cohort studies. Front Neurol. 2020;11:26. https://doi.org/10.3389/fneur.2020.00026
  • Kim YG, Shim J, Oh SK, Park HS, Lee KN, Hwang SH, et al. Different responses of left atrium and left atrial appendage to radiofrequency catheter ablation of atrial fibrillation: A follow up MRI study. Sci Rep 2018;8:7871. https://doi.org/10.1038/s41598-018-26212-y
  • Vyas V, Lambiase P. Obesity and atrial fibrillation: epidemiology, pathophysiology and novel therapeutic opportunities. Arrhythm Electrophysiol Rev. 2019;8:28-36. https://doi.org/10.15420/aer.2018.76.2