Effectiveness of integrating delayed computed tomography angiography imaging for left atrial appendage thrombus exclusion into the care of patients undergoing ablation of atrial fibrillation

Background Computed tomography angiography (CTA) can identify and rule out left atrial appendage (LAA) thrombus when delayed imaging is also performed. Objective In patients referred for CTA to evaluate pulmonary vein anatomy before the ablation of atrial fibrillation (AF) or left atrial flutter (LAFL), we sought to determine the effectiveness of a novel clinical protocol for integrating results of CTA delayed LAA imaging into preprocedure care. Methods After making delayed imaging of the LAA part of our routine preablation CTA protocol, we integrated early reporting of preablation CTA LAA imaging results into clinical practice as part of a formal protocol in June 2013. We then analyzed the effectiveness of this protocol by evaluating 320 AF/LAFL ablation patients with CTA imaging during the time period 2012–2014. Results In CTA patients with delayed LAA imaging, the sensitivity and negative predictive values for LAA thrombus using intracardiac echocardiography or transesophageal echocardiography (TEE) as the reference standard were both 100%. Intracardiac echocardiography during ablation confirmed the absence of thrombus in patients with negative CTA or negative TEE results. No patients with either negative CTA results or equivocal CTA results combined with negative TEE results had strokes or transient ischemic attacks. Overall, the need for TEE procedures decreased from 57.5% to 24.0% during the 3-year period because of the CTA protocol. Conclusion Clinical integration of CTA delayed LAA imaging into the care of patients having catheter ablation of AF or LAFL is feasible, safe, and effective. Such a protocol could be used broadly to improve patient care.