Transesophageal Echocardiography Following Left Atrial Appendage Electrical Isolation: Diagnostic Pitfalls and Clinical Implications

C. Gianni, Javier E. Sanchez, Qiong Chen, D. D. Della Rocca, S. Mohanty, C. Trivedi, A. Al‐Ahmad, M. Bassiouny, J. Burkhardt, G. Gallinghouse, R. Horton, P. Hranitzky, Jorge Romero, L. Di Biase, Mario J. Garcia, A. Natale
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引用次数: 1

Abstract

Background: Following left atrial appendage (LAA) electrical isolation, the decision on whether to continue oral anticoagulation after successful atrial fibrillation ablation is based on the study of its mechanical function on transesophageal echocardiography (TEE). In this cohort, LAA contraction is absent and the incorrect interpretation of emptying flow velocities can lead to unwanted clinical sequelae. Methods: One hundred and sixty consecutive TEE exams performed to evaluate the LAA mechanical function following its electrical isolation were reviewed by an experienced operator blinded to the original diagnosis of LAA dysfunction. The rate of diagnostic discrepancy in the assessment LAA dysfunction and its clinical implications were evaluated. Results: Diagnostic discrepancy with misclassification of the LAA mechanical function occurred 36% (58/160) of TEE exams. In most cases (57/58), such discrepancy was observed in the setting of an incorrect original diagnosis of a normal LAA mechanical function despite absent/reduced or inconsistent LAA contraction. This main source of this wrong diagnosis was the wrong interpretation of passive LAA flows (34/57; 60%), followed by failure to identify dissociated firing (15/57; 26%). In rare cases (8/57; 14%), velocities of surrounding structures were interpreted as LAA flow due to misplacement of the pulsed-wave Doppler sample volume. Following LAA isolation, the proportion of patients who experienced a cerebrovascular event while off oral anticoagulation due to the misclassification of their LAA mechanical function was 70% (7/10 [95% CI, 40%–89%]). Conclusions: Underdiagnosis of LAA mechanical dysfunction is common in TEEs performed following LAA electrical isolation, and it is associated with an increased risk of cerebrovascular events owing to oral anticoagulation discontinuation despite absent/reduced LAA contraction. Careful review of the TEE exam by an operator with specific expertise in LAA imaging and familiar with the functional implications of LAA isolation is necessary before interrupting oral anticoagulation in this cohort.
经食管超声心动图左心耳电隔离:诊断缺陷和临床意义
背景:经食管超声心动图(TEE)对左心耳(LAA)电隔离后房颤消融成功后是否继续口服抗凝的决定是基于对其力学功能的研究。在这个队列中,LAA没有收缩,对排空血流速度的错误解释可能导致不必要的临床后遗症。方法:由一名经验丰富的操作人员对LAA功能障碍的原始诊断进行盲法检查,对160例连续TEE检查进行评估,以评估其电隔离后的LAA机械功能。评估LAA功能障碍的诊断差异率及其临床意义。结果:TEE检查中有36%(58/160)存在LAA机械功能的误诊。在大多数病例(57/58)中,尽管LAA收缩缺失/减少或不一致,但这种差异是在LAA机械功能正常的原始诊断错误的情况下观察到的。这种错误诊断的主要来源是对被动LAA流的错误解释(34/57;60%),其次是无法识别游离放电(15/57;26%)。在极少数情况下(8/57;14%),由于脉冲波多普勒样本体积的错位,周围结构的速度被解释为LAA流。在LAA分离后,由于LAA机械功能分类错误而停止口服抗凝时发生脑血管事件的患者比例为70% (7/10 [95% CI, 40%-89%])。结论:LAA电隔离后tee患者中LAA机械功能障碍的漏诊是常见的,并且在LAA收缩缺失/减少的情况下,由于口服抗凝停药导致脑血管事件的风险增加。在中断口服抗凝治疗之前,有必要由具有LAA成像专业知识和熟悉LAA隔离功能含义的操作人员仔细检查TEE检查。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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