Utility of Nongated Multidetector Computed Tomography for Detection of Left Atrial Thrombus in Patients Undergoing Catheter Ablation of Atrial Fibrillation

OBJECTIVES The aim of this study was to determine whether multidetector computed tomography (MDCT) is able to exclude left atrial appendage (LAA) thrombus in patients referred for catheter ablation of atrial fibrillation (CAAF). BACKGROUND MDCT is commonly used to render pulmonary vein and left atrial anatomy before CAAF. Transesophageal echocardiography (TEE) is also often performed before the ablation to exclude LAA thrombus. Whether MDCT alone is sufficient to exclude LAA thrombus is unknown. METHODS Patients referred for CAAF at the Mayo Clinic between March 2004 and October 2006 were included. Clinical data, 64-slice MDCT (nonelectrocardiography-gated), and TEE were all analyzed. Image data were independently reviewed by 2 cardiac radiologists blinded to the TEE findings. The appearance of the LAA was defined as normal (fully opacified) or abnormal (underfilled). RESULTS Four hundred two patients (mean age 56 +/- 10 years; 76% male; ejection fraction 56 +/- 10%) were included. Three hundred sixty-two had no evidence of a filling defect by ungated MDCT or left atrial spontaneous echo contrast or thrombus by TEE. In 40 patients, the LAA was "underfilled" with 9 definite thrombi confirmed by TEE. Sensitivity and specificity was 100% and 92%, respectively, with a negative predictive value of 100% and positive predictive value of 23%. In patients with LAA underfilling, Doppler-derived LAA emptying velocities were substantially reduced (mean 19 cm/s; range 6 to 61 cm/s) below the normal range. A higher CHADS(2) (congestive heart failure, hypertension, age older than 75 years, and diabetes) score (1.6 vs. 1.1) was observed in patients with LAA filling defects. No cases of LAA thrombus were observed in patients age <52 years with CHADS(2) score <1. CONCLUSIONS In patients referred for CAAF, MDCT is a sensitive (100% sensitivity) imaging modality that could be used alone especially in patients age <52 years with a CHADS(2) score <1. Incorporation of these findings could decrease the need for multiple imaging modalities and thereby reduce cost of the procedure. (J Am Coll Cardiol Img 2009;2:69-76) (C) 2009 by the American College of Cardiology Foundation