Volume 13, Issue 1, Pages (January 2016)

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Volume 13, Issue 1, Pages 12-19 (January 2016) Effectiveness of integrating delayed computed tomography angiography imaging for left atrial appendage thrombus exclusion into the care of patients undergoing ablation of atrial fibrillation Kenneth C. Bilchick, MD, MS, FACC, FHRS, Augustus Mealor, MD, Jorge Gonzalez, MD, Patrick Norton, MD, David Zhuo, MD, Pamela Mason, MD, FHRS, John D. Ferguson, MD, FHRS, Rohit Malhotra, MD, J. Michael Mangrum, MD, Andrew E. Darby, MD, John DiMarco, MD, PhD, FHRS, Klaus Hagspiel, MD, John Dent, MD, Christopher M. Kramer, MD, George J. Stukenborg, PhD, Michael Salerno, MD, PhD Heart Rhythm Volume 13, Issue 1, Pages 12-19 (January 2016) DOI: 10.1016/j.hrthm.2015.09.002 Copyright © 2016 Heart Rhythm Society Terms and Conditions

Heart Rhythm 2016 13, 12-19DOI: (10.1016/j.hrthm.2015.09.002) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 1 CTA protocol for patients undergoing catheter ablation of AF or LAFL. A flowchart demonstrating the clinical protocol for preprocedural imaging is shown. AF = atrial fibrillation; CTA = computed tomography angiography; ICE = intracardiac echocardiography; LAA = left atrial appendage; NPO = non per os; TEE = transesophageal echocardiography; TIA = transient ischemic attack. Heart Rhythm 2016 13, 12-19DOI: (10.1016/j.hrthm.2015.09.002) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 2 Examples of normal and abnormal CTA delayed left atrial appendage imaging. Filling defects in the LAA are seen on CTA (yellow arrows). For the case in which the filling defect was seen on both early and delayed imaging (panel C), the findings were confirmed by TEE (true positive). For the case in which the filling defect was seen on early but not delayed imaging (panel B), the finding was not confirmed by TEE (false positive). CTA = computed tomography angiography; TEE = transesophageal echocardiography. Heart Rhythm 2016 13, 12-19DOI: (10.1016/j.hrthm.2015.09.002) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 3 Performance of CTA with delayed LAA imaging relative to TEE as the reference standard. The sensitivity, specificity, positive predictive value, and negative predictive value for CTA with delayed LAA imaging relative to TEE as the reference standard are shown. In determining the specificity, the equivocal CTA results may be grouped with the positive CTA results or the negative CTA results. Specificity results obtained using both methods are shown in the example. CTA = computed tomography angiography; TEE = transesophageal echocardiography. Heart Rhythm 2016 13, 12-19DOI: (10.1016/j.hrthm.2015.09.002) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 4 CTA and TEE results by patient subgroup and time period. The number of patients with different CTA and TEE results is shown by patient subgroup and time period. CTA = computed tomography angiography; LAA = left atrial appendage; LAAT = left atrial appendage thrombus; Neg = negative; Pos = positive; SEC = spontaneous echo contrast; TEE = transesophageal echocardiography. Heart Rhythm 2016 13, 12-19DOI: (10.1016/j.hrthm.2015.09.002) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 5 Temporal trends in preprocedural TEE imaging before the catheter ablation of atrial fibrillation. The proportion of patients with TEE procedures after preprocedural CTA imaging has markedly decreased since the institution of the CTA protocol in June 2013. CTA = computed tomography angiography; TEE = transesophageal echocardiography. Heart Rhythm 2016 13, 12-19DOI: (10.1016/j.hrthm.2015.09.002) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 6 TEE procedures performed before catheter ablation by CHA2DS2-VASc score and year. The proportion of patients with preprocedural CTA imaging who also received TEE procedures is shown according to CHA2DS2-VASc score and time period (2014 vs 2013). CTA = computed tomography angiography; TEE = transesophageal echocardiography. Heart Rhythm 2016 13, 12-19DOI: (10.1016/j.hrthm.2015.09.002) Copyright © 2016 Heart Rhythm Society Terms and Conditions