Sriram Chenni S, Banchs Javier E, Moukabary Talal, Moradkhan Raman, Gonzalez Mario D
Heart & Vascular Institute, Penn State University, Hershey, PA, USA.
J Interv Card Electrophysiol. 2015 Sep;43(3):227-36. doi: 10.1007/s10840-015-0008-2. Epub 2015 May 3.
The role of intracardiac echocardiography (ICE) to detect thrombus within left atrium (LA) before atrial fibrillation (AF) ablation despite a recent transesophageal echocardiogram (TEE) is not well defined. We examined the prevalence of LA/left atrial appendage (LAA) thrombus using ICE immediately prior to AF ablation in patients in whom anticoagulation was not withheld.
We analyzed 122 consecutive patients (62.6 ± 10.8 years, 90 males, CHA(2)DS(2) -VASc score 2.4 ± 1.5, persistent AF 29.5 %) who underwent an ICE-guided AF ablation 1 day after a negative (n = 120) or inconclusive (n = 2) TEE for LA thrombus. LA was imaged with ICE from the right atrium, coronary sinus, and right ventricular inflow tract (RVIT). ICE and TEE images were compared for LAA area, thrombus, and spontaneous echo contrast (SEC).
LAA was adequately visualized in 99 and 100 % of patients with TEE and ICE, respectively. RVIT was the best ICE view for LAA visualization. The LAA 2-D-area measured by TEE was 4.9 ± 0.5 vs. 5 ± 0.5 cm(2) by ICE (P = NS). ICE identified a thrombus in seven patients with a previous negative TEE, leading to cancellation of ablation. It ruled out a thrombus in two patients with an inconclusive TEE. Thrombi were found in the LAA (n = 4), atrial septum (n = 2), and left superior pulmonary vein (n = 1). SEC during TEE was more frequent in patients with thrombus on ICE than those without (85.7 vs. 17.4 %; p = 0.03; positive predictive value 23.1 %, negative predictive value 98.9 %).
The results of our staged imaging approach suggest that ICE has a complimentary value in re-screening the LA/LAA for thrombus after a recent negative or equivocal TEE. The presence of SEC during TEE increases the probability of finding a thrombus with ICE, which could potentially be dislodged during catheter manipulation.
尽管近期进行了经食管超声心动图（TEE）检查，但心腔内超声心动图（ICE）在心房颤动（AF）消融术前检测左心房（LA）内血栓的作用尚不明确。我们在未停用抗凝药物的患者中，于AF消融术前立即使用ICE检查LA/左心耳（LAA）血栓的患病率。
我们分析了122例连续患者（年龄62.6±10.8岁，男性90例，CHA(2)DS(2)-VASc评分2.4±1.5，持续性AF占29.5%），这些患者在TEE检查LA血栓为阴性（n = 120）或不确定（n = 2）后1天接受了ICE引导下的AF消融。通过右心房、冠状窦和右心室流入道（RVIT）用ICE对LA进行成像。比较ICE和TEE图像的LAA面积、血栓和自发回声增强（SEC）情况。
TEE和ICE分别在99%和100%的患者中清晰显示了LAA。RVIT是ICE观察LAA的最佳视角。TEE测量的LAA二维面积为4.9±0.5 cm²，ICE测量的为5±0.5 cm²（P = 无显著性差异）。ICE在7例先前TEE检查为阴性的患者中发现了血栓，导致消融取消。它排除了2例TEE检查结果不确定患者的血栓。血栓见于LAA（n = 4）、房间隔（n = 2）和左上肺静脉（n = 1）。ICE检查发现有血栓的患者TEE检查时SEC更常见（85.7%对17.4%；p = 0.03；阳性预测值23.1%，阴性预测值98.9%）。
我们的分期成像方法结果表明，在近期TEE检查为阴性或不明确后，ICE在重新筛查LA/LAA血栓方面具有补充价值。TEE检查时SEC的存在增加了ICE发现血栓的可能性，而血栓在导管操作过程中可能会脱落。
