Use of the CHA2DS2VASc score to reduce utilisation of transoesophageal echocardiography prior to ablation for atrial fibrillation

Charlotte Atkinson,Paul R Roberts,Benoy N Shah,Edmund B Gaisie,Arthur M Yue,Dhrubo J Rakhit,Jonathan Hinton

doi:10.1530/erp-17-0042

Abstract

Transoesophageal echocardiography (TOE) is frequently performed prior to atrial fibrillation (AF) ablation to exclude left atrial appendage (LAA) thrombus. However, patients undergoing AF ablation are usually anticoagulated, thus making the presence of thrombus unlikely in most cases. This study aimed to determine whether the CHA2DS2VASc scoring system can be used to identify patients that do not require TOE prior to AF ablation. In this single-centre retrospective study, local institutional and primary care databases and electronic patient records were searched to identify patients that had undergone TOE prior to AF ablation. Patient demographics, CHA2DS2VASc score, TOE findings and anticoagulation status were collected for analysis. Over a 7-year period (2008–2014), 332 patients (age 57 ± 10 years; 74% male) underwent TOE prior to proposed AF ablation. CHA2DS2VASc scores of 0, 1, 2 and >2 were found in 39, 34, 15 and 12% of patients, respectively. The prevalence of LAA thrombus was 0.6% (2 patients) and these 2 patients had risk scores of 2 and 4. No patients with a score of 0 or 1 had LAA thrombus. Patients that are classed as low risk by the CHA2DS2VASc score do not require a pre-ablation TOE to screen for LAA thrombus provided they are adequately anticoagulated. This would lead to a significant reduction in health care expenditures by reducing unnecessary TOE requests and thereby improve patient experience.

Highlights

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in the Western world and is associated with significant morbidity and mortality [1]
One of the procedural risks of AF ablation is thromboembolic stroke [4] and one potential mechanism for this is dislodgement of thrombus present in the atria by catheters and wires used during the procedure
transoesophageal echocardiogram (TOE) is the gold standard for thrombus screening in the left atrium (LA) and the left atrial appendage (LAA); TOE has a 93–97% sensitivity and 100% specificity for imaging LA/LAA thrombus when compared to surgical findings [8]

Summary

Introduction

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in the Western world and is associated with significant morbidity and mortality [1]. The presence of AF portends a significant risk of thromboembolism, which can cause ischaemic stroke. Clinical risk scores such as the CHADS2 and the CHA2DS2VASc score have been validated for the use of thromboembolic risk stratification in patients with non-. Heart Rhythm Society (HRS)/European Heart Rhythm Association (EHRA)/European Cardiac Arrhythmia Society (ECAS) recommendations for AF ablation [7] state that patients who are in AF at the time of the ablation should undergo a pre-procedural transoesophageal echocardiogram (TOE) despite anticoagulation status. TOE is the gold standard for thrombus screening in the left atrium (LA) and the left atrial appendage (LAA); TOE has a 93–97% sensitivity and 100% specificity for imaging LA/LAA thrombus when compared to surgical findings [8]

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