Atrial thrombi detection prior to pulmonary vein isolation: Diagnostic accuracy of cardiac computed tomography versus transesophageal echocardiography

Background: Patients routinely undergo transesophageal echocardiography (TEE) prior to pulmonary vein isolation (PVI) in order to rule out the presence of intra-atrial thrombi. Cardiac computed tomography (CCT) is also routinely conducted prior to the procedure to determine cardiac anatomy. Although it has been demonstrated that CCT can also rule out intra-atrial thrombi, the use of CCT for thrombi detection is controversial. The primary objective was to determine the utility of CCT for detection of atrial thrombi as compared to TEE. Methods: Patients who underwent PVI between 2010 and 2011 with CTs and TEEs completed within 3 days of each other were retrospectively identified. TEE reports were analyzed, while CCTs were interpreted by a cardiologist specializing in CCTs. Severe spontaneous echo contrast or thrombus detected on TEE were considered positive, as were filling defects found on CCT. Results: A total of 51 patients undergoing PVI (mean age 59.4 +/- 9.5 years; 75% male; ejection fraction 60 +/- 12%) had both TEE and CCT in timely fashion. By TEE, 0 left atrial appendage (LAA) thrombi were identified with mild to moderate spontaneous echo contrast in 4 patients. By CCT, 2 definite LAA thrombi were identified and thrombi in 4 patients could not be ruled out. Specificity, positive predictive value, and negative predictive value for CCT were 88%, 0%, and 100%, respectively. Conclusions: CCT is an effective tool in ruling out atrial thrombi prior to PVI. TEE should be completed only if CCT is positive.