Background

Preprocedural transesophageal echocardiography (TEE) screening for LA or LAA thrombi is standard operating procedure (SOP) in most centers performing atrial fibrillation ablation. However, TEE is a procedure that imposes procedural risks for patients and is often challenging to include in daily clinical practice, besides causing patient discomfort.

At our center, we have implemented a novel SOP regarding preprocedural TEE screening for atrial thrombi. According to this, patients who present in sinus rhythm and suffer from a low stroke risk based on CHADS-VASC-Score (<2) or have sufficiently taken their anticoagulatory medication, are now exempt from preprocedural TEE screening. The aims of this novel SOP are a reduction of TEEs performed in course of ablation procedures. 

Aims

The aims of this study are to assess whether a novel SOP regarding preprocedural TEE screening for LA thrombi can effectively reduce the number of TEEs performed without imposing patients to a higher risk for strokes in course of catheter ablation of atrial arrhythmias.

Methods

We retrospectively analyzed data of 2335 consecutive patients who received catheter ablation of atrial arrhythmias at the University Hospital of Cologne between 2018 and 2022. All patients treated until March 2020  received preprocedural TEE before every ablation procedure, screening for atrial thrombi. In all following cases, a novel SOP was applied: Patients in sinus rhythm at the beginning of the procedure who were either sufficiently anticoagulated or had a CHADS-VASC-Score <2 did not receive TEE prior to the ablation procedure. We compared both groups regarding incidence of stroke and transient ischemic attack (TIA).

Results

Out of 2335 included patients, 961 (41%) were treated according to the old SOP and 1374 (59%) patients were treated according to the new SOP. Both groups did not differ significantly regarding their baseline parameters. Similar ablation procedures were performed in both groups (old SOP vs. new SOP): Performed ablation procedures consisted of  PVI (689, 68.8% vs. 921, 64.5%; p=0.04), re-PVI (179, 17.8% vs. 240, 16.8%; p=0.52), substrate-based ablation of persistent AF (70, 7% vs. 186, 13%; p<0.01), AT ablation (111, 11% vs. 276, 11.3%; p=0.69) and CTI ablation (95, 9.5% vs. 230, 9.5%; p=1.0).

No statistically significant difference between the groups was detected: A stroke was diagnosed in 2 patients in each group (old SOP: 0.2%, new SOP 0.1%; p=0.72). A TIA was diagnosed in 6 (0.6%) patients that were treated according to the old SOP and 3 (0.2%) patients that were treated according to the new SOP (p=0.12). In none of the included patients, a TEE-related complication could be observed.

Conclusion

We demonstrate outcomes of a novel SOP for pre-procedural TEE screening of atrial thrombi that limits TEEs to those patients who are at a high risk of stroke according to current guidelines and CHADS-VASC-Score. Those patients who present in sinus rhythm and have a CHADS-VASC-Score <2 or have sufficiently taken their anticoagulatory medication can be safely treated with catheter ablation without performing prior TEE.