title: Role of the CHADS2 score in the evaluation of thromboembolic risk in patients with atrial fibrillation undergoing transesophageal echocardiography before pulmonary vein isolation.
abstract: OBJECTIVE
  The goals of this study were to determine: 1) if low-risk patients assessed by a CHADS(2) score, a clinical scoring system quantifying a risk of stroke in patients with atrial fibrillation (AF), require a routine screening transesophageal echocardiogram (TEE) before pulmonary vein isolation (PVI); and 2) the relationship of a CHADS(2) score with left atrial (LA)/left atrial appendage (LAA) spontaneous echo contrast, sludge, and thrombus.
  
  
  BACKGROUND
  There is no clear consensus of whether a screening TEE before catheter ablation of AF should be performed in every patient.
  
  
  METHODS
  Initial TEEs for pre-PVI of 1,058 AF patients (age 57 +/- 11 years, 80% men) were reviewed and compared with a CHADS(2) score.
  
  
  RESULTS
  CHADS(2) scores of 0, 1, 2, 3, 4, 5, and 6 were present in 47%, 33%, 14%, 5%, 1%, 0.3%, and 0% of patients, respectively. The prevalence of LA/LAA thrombus, sludge, and spontaneous echo contrast were present in 0.6%, 1.5%, and 35%. The prevalence of LA/LAA thrombus/sludge increased with ascending CHADS(2) score (scores 0 [0%], 1 [2%], 2 [5%], 3 [9%], and 4 to 6 [11%], p < 0.01). No patient with a CHADS(2) score of 0 had LA/LAA sludge/thrombus. In a multivariate model, history of congestive heart failure and left ventricular ejection fraction <35% were significantly associated with sludge/thrombus.
  
  
  CONCLUSIONS
  The prevalence of LA/LAA sludge/thrombus in patients with AF undergoing a pre-PVI screening TEE is very low (<2%) and increases significantly with higher CHADS(2) scores. This suggests that a screening TEE before PVI should be performed in patients with a CHADS(2) score of >or=1, and in patients with a CHADS(2) score of 0 when the AF is persistent and therapeutic anticoagulation has not been maintained for 4 weeks before the procedure.
authors.affiliation: Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA.
authors.forename: Sarinya
authors.initials: S
authors.lastname: Puwanant
authors.forename: Brandon C
authors.initials: BC
authors.lastname: Varr
authors.forename: Kevin
authors.initials: K
authors.lastname: Shrestha
authors.forename: Sarah K
authors.initials: SK
authors.lastname: Hussain
authors.forename: W H Wilson
authors.initials: WH
authors.lastname: Tang
authors.forename: Ruvin S
authors.initials: RS
authors.lastname: Gabriel
authors.forename: Oussama M
authors.initials: OM
authors.lastname: Wazni
authors.forename: Mandeep
authors.initials: M
authors.lastname: Bhargava
authors.forename: Walid I
authors.initials: WI
authors.lastname: Saliba
authors.forename: James D
authors.initials: JD
authors.lastname: Thomas
authors.forename: Bruce D
authors.initials: BD
authors.lastname: Lindsay
authors.forename: Allan L
authors.initials: AL
authors.lastname: Klein
mesh_terms: D000368:Aged; D020517:Atrial Appendage / Q000000981:diagnostic imaging; D001281:Atrial Fibrillation / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000601:surgery; D017115:Catheter Ablation; D017548:Echocardiography, Transesophageal; D022062:Electrophysiologic Techniques, Cardiac; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011667:Pulmonary Veins / Q000601:surgery; D012189:Retrospective Studies; D018570:Risk Assessment; D020521:Stroke / Q000453:epidemiology*; D013318:Stroke Volume; D013923:Thromboembolism / Q000453:epidemiology*; D018487:Ventricular Dysfunction, Left / Q000453:epidemiology