Exclusion of Intra-Atrial Thrombus Diagnosis Using D-Dimer Assay Before Catheter Ablation of Atrial Fibrillation
Antoine Milhem, Pierre Ingrand, Frédéric Tréguer, Olivier Cesari, Antoine Da Costa, Dominique Pavin, Philippe Rivat, Nicolas Badenco, Sélim Abbey, Noura Zannad, Pierre François Winum, Jacques Mansourati, Philippe Maury, Hugues Bader, Arnaud Savouré, Frédéric Sacher, Marius Andronache, Caroline Allix-Béguec, Christian De Chillou, Frédéric Anselme, ATE Study Group, Alain Al Arnaout, Walid Amara, Mathieu Amelot, Clément Bars, Lucile Becoulet, Paul Bru, Philippe Chevalier, Jean-Philippe Darmon, Jean-Claude Deharo, Antoine Dompnier, Cécile Duplantier-Duchene, Fabrice Extramiana, Jean-Paul Faugier, Charles Guenancia, Jérôme Horvilleur, François Jourda, Gabriel Laurent, Nicolas Lellouche, Isabelle Magnin Poull, Olivier Piot, Antoine Roux, Yannick Saludas, Julien Seitz, Jérôme Taieb, Antoine Milhem, Pierre Ingrand, Frédéric Tréguer, Olivier Cesari, Antoine Da Costa, Dominique Pavin, Philippe Rivat, Nicolas Badenco, Sélim Abbey, Noura Zannad, Pierre François Winum, Jacques Mansourati, Philippe Maury, Hugues Bader, Arnaud Savouré, Frédéric Sacher, Marius Andronache, Caroline Allix-Béguec, Christian De Chillou, Frédéric Anselme, ATE Study Group, Alain Al Arnaout, Walid Amara, Mathieu Amelot, Clément Bars, Lucile Becoulet, Paul Bru, Philippe Chevalier, Jean-Philippe Darmon, Jean-Claude Deharo, Antoine Dompnier, Cécile Duplantier-Duchene, Fabrice Extramiana, Jean-Paul Faugier, Charles Guenancia, Jérôme Horvilleur, François Jourda, Gabriel Laurent, Nicolas Lellouche, Isabelle Magnin Poull, Olivier Piot, Antoine Roux, Yannick Saludas, Julien Seitz, Jérôme Taieb
Abstract
Objectives: This study hypothesized that the association of D-dimer blood level and several clinical items in a new risk score could predict the absence of atrial thrombus.
Background: Symptomatic and drug resistant atrial fibrillation (AF) can be treated by catheter ablation. The procedure-related risk of thromboembolism is limited by the pre-operative use of transesophageal echocardiography (TEE) to detect atrial thrombi.
Methods: Patients admitted for catheter ablation of AF (n = 2,494) were prospectively included in a multicenter study. TEE was systematically performed before the procedure to search for atrial thrombus (primary endpoint). D-dimer level, CHADS2 score, left ventricular ejection fraction, pre-operative anticoagulation regimen, and medical history were collected. A logistic regression model was used to identify factors associated with the presence of atrial thrombus (hypertension, history of stroke, heart failure, D-dimer level >270 ng/ml). These factors were aggregated in a new score called atrial thrombus exclusion (ATE).
Results: The incidence of atrial thrombus was 1.92%. CHADS2 score and D-dimer level were significantly associated with atrial thrombus (p < 0.0001 and p < 0.0001, respectively). A zero CHADS2 score failed to exclude all atrial thrombi (5 false negatives; sensitivity: 89.58%, specificity: 52.2%). No false negative was found with a zero ATE score, which had a specificity of 37% and a higher sensitivity (100%) than the CHADS2 score (p < 0.031) to predict the absence of intra-atrial thrombi on TEE. Conversely, the positive predictive value was poor, and the ATE score should not be used to conclude a positive diagnosis of thrombus.
Conclusions: An ATE score of zero was strongly associated with the absence of atrial thrombus. This new score could be useful to rule out a diagnosis of atrial thrombus before catheter ablation of AF.
Keywords: clinical biological score; diagnostic performance; preoperative transesophageal echocardiography.
Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
Source: PubMed