title: Usefulness of transoesophageal echocardiography before circumferential pulmonary vein ablation in patients with atrial fibrillation: is it really mandatory?
abstract: OBJECTIVE
  Transoesophageal echocardiography (TEE) is recommended prior to circumferential pulmonary vein ablation (CPVA) in patients with atrial fibrillation (AF) to identify left atrial (LA) or left atrial appendage (LAA) wall thrombi. It is not clear whether all patients undergoing CPVA should receive pre-procedural TEE. We wanted to assess the incidence of LA thrombus in these patients and to identify factors associated with its presence.
  
  
  RESULTS
  Consecutive patients referred for CPVA from 2004 to 2009 underwent TEE within 48 h prior to the procedure. Of 408 patients included in the study, 6 patients (1.47%) had LA thrombi, persistent AF, and LA dilation. Compared with patients without thrombus, these six patients had larger LA diameter (P = 0.0001) and more frequently were women (P = 0.002), had persistent AF (P = 0.04), and had underlying structural cardiac disease (P = 0.014). The likelihood of presenting LA thrombus increased with the number of these four risk factors present (P < 0.001). None of the patients with paroxysmal AF and without LA dilation had LA thrombus. A cut-off value of 48.5 mm LA diameter yielded 83% sensitivity, 92% specificity, and a 10.1 likelihood ratio to predict LA thrombus appearance.
  
  
  CONCLUSIONS
  The incidence of LA thrombus prior to CPVA is low. Persistent AF, female sex, structural cardiopathy, and LA dilation were associated with the presence of LA thrombus. Our data suggest that the use of TEE prior to CPVA to detect LA thrombi might not be needed in patients with paroxysmal AF and no LA dilation or structural cardiopathy.
authors.affiliation: Cardiology Department, Thorax Clinic Institute, Hospital Clínic, IDIBAPS-Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Villarroel 170, Barcelona 08036, Catalonia, Spain.
authors.forename: N
authors.initials: N
authors.lastname: Calvo
authors.forename: L
authors.initials: L
authors.lastname: Mont
authors.forename: B
authors.initials: B
authors.lastname: Vidal
authors.forename: M
authors.initials: M
authors.lastname: Nadal
authors.forename: S
authors.initials: S
authors.lastname: Montserrat
authors.forename: D
authors.initials: D
authors.lastname: Andreu
authors.forename: D
authors.initials: D
authors.lastname: Tamborero
authors.forename: C
authors.initials: C
authors.lastname: Pare
authors.forename: M
authors.initials: M
authors.lastname: Azqueta
authors.forename: A
authors.initials: A
authors.lastname: Berruezo
authors.forename: J
authors.initials: J
authors.lastname: Brugada
authors.forename: M
authors.initials: M
authors.lastname: Sitges
mesh_terms: D000328:Adult; D001281:Atrial Fibrillation / Q000000981:diagnostic imaging* / Q000601:surgery*; D017115:Catheter Ablation; D017548:Echocardiography, Transesophageal; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008403:Mass Screening / Q000379:methods; D008875:Middle Aged; D011667:Pulmonary Veins / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors; D012680:Sensitivity and Specificity; D013923:Thromboembolism / Q000000981:diagnostic imaging / Q000453:epidemiology