Key result
Cardiac CT-guided direct current cardioversion was safe and feasible, with zero cardiac-related deaths and no episodes of TIA or embolic stroke over a median follow-up of 175 days.
Why the study?
TEE is the gold standard for LAA evaluation before DCCV, but the COVID-19 pandemic restricted TEE and anesthesia availability.
Does a novel cardiac CT protocol safely and effectively exclude left atrial appendage thrombus prior to direct current cardioversion in patients with atrial fibrillation or flutter?
Cohort (n=161)
No
Does a novel cardiac CT protocol safely and effectively exclude left atrial appendage thrombus prior to direct current cardioversion in patients with atrial fibrillation or flutter?
Cardiac CT with a delayed acquisition protocol is a safe and feasible alternative to TEE for excluding LAA thrombus prior to cardioversion, with no embolic events or renal injury observed.
Objective To assess left atrial appendage (LAA) thrombus detection using a novel cardiac computed tomography (CT) protocol specifically prior to direct current cardioversion (DCCV). Background Transesophageal echocardiography (TEE) is the gold standard in evaluating the LAA prior to DCCV for atrial fibrillation (AF) or flutter (AFL). The COVID-19 pandemic has restricted availability of TEE and anesthesia support. Methods Prospective cohort of consecutive patients with uncontrolled AF/AFL referred for DCCV from March 2020 to March 2021 were enrolled. CT evaluation of LAA was performed with an initial arterial and subsequent 30-second delayed acquisition to exclude thrombus prior to DCCV. Primary end points were to assess safety and outcomes. Results A total of 161 patients were included; mean age 69.8 ± 11.1 years; mean CHA 2 DS 2 -VASc 3.4 ± 1.7; and HAS-BLED 1.8 ± 0.9. Median follow-up 175 (105-267) days with zero cardiac-related deaths, and no episodes of TIA or embolic stroke. There was no statistically significant change in mean glomerular filtration rate (GFR) in the study population between the pre- and post-GFR measurements (73.9 ± 21.0 vs 72.7 ± 20.3; p=0.104). Overall mean total dose length product (DLP) was 1042.8 ± 447.5 mGy*cm. Modifying the CT protocol to a narrower 8-cm axial coverage had a statistically significant decrease in total DLP (from 1130.6 ± 464.1 mGy*cm to 802.1 ± 286.4 mGy*cm; P<0.0001). Conclusion Cardiac CT is both a safe and feasible alternative imaging to TEE for patients prior to DCCV. Perspectives Competency in Medical Knowledge Cardiac CT is a powerful tool for the evaluation of left atrial appendage and detection of thrombus prior to direct current cardioversion. Translational Outlook Our protocol was implemented with the restrictions during COVID-19 in mind, yet CT can be a viable tool beyond the pandemic; future randomized clinical trials can bridge the gap between CT and TEE in the setting of cardioversion and help elucidate its safety profile further.
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Veillet-Chowdhury et al. (2022) conducted a cohort in Atrial fibrillation or atrial flutter (n=161). Cardiac computed tomography (CT) guided direct current cardioversion was evaluated on Safety and outcomes (cardiac-related deaths, TIA, or embolic stroke). Cardiac CT-guided direct current cardioversion was safe and feasible, with zero cardiac-related deaths and no episodes of TIA or embolic stroke over a median follow-up of 175 days.
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