Antoine Milhem1, Pierre Ingrand2, Frédéric Tréguer3, Olivier Cesari4, Antoine Da Costa5, Dominique Pavin6, Philippe Rivat7, Nicolas Badenco8, Sélim Abbey9, Noura Zannad10, Pierre François Winum11, Jacques Mansourati12, Philippe Maury13, Hugues Bader14, Arnaud Savouré15, Frédéric Sacher16, Marius Andronache17, Caroline Allix-Béguec18, Christian De Chillou19, Frédéric Anselme15. 1. Groupe Hospitalier de la Rochelle Ré Aunis, La Rochelle, France. Electronic address: antoine.milhem@ch-larochelle.fr. 2. Epidemiology and Biostatistics, INSERM CIC 1402 Université de Poitiers, CHU Poitiers, Poitiers, France. 3. Clinique St-Joseph, Trélazé, France. 4. Clinique Saint Gatien, Tours, France. 5. CHU Saint-Etienne, Saint-Etienne, France. 6. CHU Rennes, Rennes, France. 7. Polyclinique Vauban, Valenciennes, France. 8. APHP, Hôpital Pitié Salpêtrière, Paris, France. 9. Nouvelles Cliniques Nantaises, Groupe Confluent, Nantes, France. 10. CHR Metz-Thionville, Metz, France. 11. CHU Nîmes, Nîmes, France. 12. CHU Brest, Brest, France. 13. CHU Toulouse, Toulouse, France. 14. CH Pau, Pau, France. 15. CHU Rouen, Rouen, France. 16. CHU Bordeaux, Bordeaux, France. 17. CHU Nancy, Vandœuvre lès-Nancy, France. 18. Groupe Hospitalier de la Rochelle Ré Aunis, La Rochelle, France. 19. CHU Nancy, Vandœuvre lès-Nancy, France; INSERM-IADI U1254, Vandœuvre lès-Nancy, France.
Abstract
OBJECTIVES: This study hypothesized that the association of D-dimer blood level and several clinical items in a new risk score could predict the absence of atrial thrombus. BACKGROUND: Symptomatic and drug resistant atrial fibrillation (AF) can be treated by catheter ablation. The procedure-related risk of thromboembolism is limited by the pre-operative use of transesophageal echocardiography (TEE) to detect atrial thrombi. METHODS: Patients admitted for catheter ablation of AF (n = 2,494) were prospectively included in a multicenter study. TEE was systematically performed before the procedure to search for atrial thrombus (primary endpoint). D-dimer level, CHADS2 score, left ventricular ejection fraction, pre-operative anticoagulation regimen, and medical history were collected. A logistic regression model was used to identify factors associated with the presence of atrial thrombus (hypertension, history of stroke, heart failure, D-dimer level >270 ng/ml). These factors were aggregated in a new score called atrial thrombus exclusion (ATE). RESULTS: The incidence of atrial thrombus was 1.92%. CHADS2 score and D-dimer level were significantly associated with atrial thrombus (p < 0.0001 and p < 0.0001, respectively). A zero CHADS2 score failed to exclude all atrial thrombi (5 false negatives; sensitivity: 89.58%, specificity: 52.2%). No false negative was found with a zero ATE score, which had a specificity of 37% and a higher sensitivity (100%) than the CHADS2 score (p < 0.031) to predict the absence of intra-atrial thrombi on TEE. Conversely, the positive predictive value was poor, and the ATE score should not be used to conclude a positive diagnosis of thrombus. CONCLUSIONS: An ATE score of zero was strongly associated with the absence of atrial thrombus. This new score could be useful to rule out a diagnosis of atrial thrombus before catheter ablation of AF.
OBJECTIVES: This study hypothesized that the association of D-dimer blood level and several clinical items in a new risk score could predict the absence of atrial thrombus. BACKGROUND: Symptomatic and drug resistant atrial fibrillation (AF) can be treated by catheter ablation. The procedure-related risk of thromboembolism is limited by the pre-operative use of transesophageal echocardiography (TEE) to detect atrial thrombi. METHODS:Patients admitted for catheter ablation of AF (n = 2,494) were prospectively included in a multicenter study. TEE was systematically performed before the procedure to search for atrial thrombus (primary endpoint). D-dimer level, CHADS2 score, left ventricular ejection fraction, pre-operative anticoagulation regimen, and medical history were collected. A logistic regression model was used to identify factors associated with the presence of atrial thrombus (hypertension, history of stroke, heart failure, D-dimer level >270 ng/ml). These factors were aggregated in a new score called atrial thrombus exclusion (ATE). RESULTS: The incidence of atrial thrombus was 1.92%. CHADS2 score and D-dimer level were significantly associated with atrial thrombus (p < 0.0001 and p < 0.0001, respectively). A zero CHADS2 score failed to exclude all atrial thrombi (5 false negatives; sensitivity: 89.58%, specificity: 52.2%). No false negative was found with a zero ATE score, which had a specificity of 37% and a higher sensitivity (100%) than the CHADS2 score (p < 0.031) to predict the absence of intra-atrial thrombi on TEE. Conversely, the positive predictive value was poor, and the ATE score should not be used to conclude a positive diagnosis of thrombus. CONCLUSIONS: An ATE score of zero was strongly associated with the absence of atrial thrombus. This new score could be useful to rule out a diagnosis of atrial thrombus before catheter ablation of AF.