Transesophageal echo LAA thrombus

1
Transesophageal echo LAA thrombus
2
Conventional anticoagulation strategy limitations

• Prolonging treatment for 7 to 8 weeks (doubling
  duration) increases the risk of bleeding
• Relatively inconvenient for both patients and
  physicians
• Prolonged atrial fibrillation (AF) may decrease
  success in maintaining normal sinus rhythm (NSR)
• Results in repeat visits, repeat INRs, and
  increased costs
• Not routinely followed in clinical practice
• Patients with left atrial appendage (LAA) thrombi
  who should receive more prolonged or intensive
  anticoagulation (AC), are not identified before
  DC cardioversion (DCC)

3
Potential advantages of TEE guided DCC

• Decrease period of AC (by half) for 87 of the
  patients without thrombi
• Earlier DCC may be more successful in the
  restoration and maintenance of NSR
• Potentially lower stroke rate by detecting
  pre-existing thrombi which may embolize at DCC
• Cost savings by decreasing bleeds and strokes and
  allowing earlier DCC in patients without thrombi
• Functional status and quality of life may be
  better in patients who receive earlier DCC to NSR

4
TEE guided cardioversion of atrial fibrillation

• In 2000, this approach has demonstrated its
  effectiveness in almost eliminating the stroke
  risk of cardioverting over 1200 patients with
  atrial fibrillation.
• Manning WJ, et al. J Am Coll Cardiol
  1995251354-1361
• Klein A, et al. Ann Intern Med 1997126200-209
• Corrado G, et al. Chest 1999115140-143

5
Assessment of cardioversion using transesophageal
echocardiographyeight week clinical outcomes
The Cleveland Clinic Foundation

• Controlled, randomized, prospective trial
• Compares the TEE guided arm with short term
  anticoagulation versus the conventional approach

6
ACUTE multicenter study

• Primary endpoints stroke, TIA, or peripheral
  embolism
• Secondary endpoints all-cause mortality, major
  and minor bleeding, functional status, and
  success and maintenance of sinus rhythm
• Sample size 2900 pts for primary endpoint (90
  power)
• Intention to treat analysis
• Inclusions
• Patients gt18 years with AF gt2 days duration who
  were candidates for DCC
• Atrial flutter with documented history of AF
• Exclusions
• Chronic (gt7 days) anticoagulation
• Hemodynamic instability or contraindications to
  TEE or warfarin
• Anticipated need to discontinue anticoagulation

7
ACUTE multicenter study design
Atrial fibrillation gt 2 days duration to undergo
DCC
Random assignment (11)
TEE-guided strategytherapeutic anticoagulation
with heparin or warfarinTEE
Conventional strategy
Thrombus detectedNo DCC
No thrombus detectedDCC
3 weeks warfarin
3 weeks warfarin
Repeat TEE
DCC
4 weeks warfarin
No thrombus DCC
thrombus No DCC
4 weeks warfarin
4 weeks warfarin
4 weeks warfarin
Follow-up at 8 weeks after assignment
8
TEE Group(619)
ACUTE multicenter results
TEE (551)
No TEE (68)
DCC done (427)
DCC not done (124)
Spontan conv (31)Pt. refuse (4)Unable pass
probe (5)Medical (6)
Thrombi (79)Spontaneous conv (31)Chemical
(7)Pt. refuse (4)Surgery (1)Lost to follow-up
(2)
No success (83)
Lost to follow-up (22)
DCC done(8)
DCC not done(60)
Success (344)
Success (6)
No success (2)
9
Conventional Group(603)
ACUTE multicenter results
DCC done (367)
DCC not done (236)
Spontan Conver (124)Chemical (2)Pt. refuse
(23)Pt. expired (4)Surgery (4)Physician
decision (8)Not therapeutic (29)Bleeding
(10)Medical (8)Lost to follow-up (24)
No success (74)
Success (293)
10
Primary endpointsembolic events

• TEE Conventional
• n 619 n 603 p value
• CVA 4 (0.65) 2 (0.33) 0.432
• TIA 1 (0.16) 1 (0.17) 0.985
• Peripheral
• embolism 0 0 -
• Composite CVA,
• TIA, peripheral
• embolism 5 (0.81) 3 (0.50) 0.501

11
Secondary endpoints

• TEE Conventional
• n 619 n 603 p value
• Major Bleeding 5 (0.81) 9 (1.50) 0.261
• Minor Bleeding 14 (2.30) 24 (4.0) 0.084
• Composite major
• minor bleeding 19 (3.11) 33 (5.50) 0.025
• SR at 8 weeks 326 (52.7) 304 (50.4)
  0.431
• SR sinus rhythm

12
Limitations

• No major funding study supported, in part, by
  small GIAs and dedication of site investigators
• Rate of recruitment and patient enrollment over
  the 5-year period
• Under-powered study
• Longer post DCC follow-up in TEE arm

13
ACUTE multicenter studyconclusions

• This randomized study showed that embolic events
  were lower than expected (0.65) and total
  bleeding complications were higher than expected
  (4.2) in both the TEE guided and conventional
  anticoagulation arms.
• Compared to the conventional strategy, a TEE
  guided strategy with short term anticoagulation
  does not appear to lower embolic events over an 8
  week study period.
• The TEE guided anticoagulation strategy tended to
  decrease major and minor bleeding complications.

14
ACUTE multicenter studyconclusions

• The TEE-guided strategy allows for early
  cardioversion but no improvement in immediate or
  8 week sinus rhythm or functional capacity
  outcome.
• The TEE guided strategy showed no difference in
  cardiac deaths or cardioversion related deaths
  compared to the conventional anticoagulation
  strategy.

15
Is it TEE time?

• The bottom line is that TEE with short-term
  anticoagulation can be done safely and can be
  done to perform early cardioversion with less
  bleeding than conventional and as a good
  alternative to conventional therapy.
• Dr Allan Klein
• Director, Cardiovascular Imaging Research
  Cleveland Clinic Foundation
• Cleveland, OH

16
Cardioversion for atrial fibrillation

• Safety of conventional approach well documented.
• 1) Follow guidelines
• 2) Do not perform on patients who are not well
  anticoagulated
• 3) Success rates should be high (gt90)

Prystowsky EN, et al. Management of patients
with atrial fibrillation. Circulation
1996931262-1277
17
TEE vs conventional approach

• Both are safe and effective ways to guide CV when
  done correctly.
• Perhaps 10-20 of patients should undergo TEE
  (eg a hospitalized patient who needs to be
  cardioverted to sinus rhythm quickly).
• 80 of patients should undergo the conventional
  CV as the preferred approach.
• Many patients need to remain on longterm
  anticoagulation after cardioversion despite the
  use of either the conventional or TEE approach.

18
TEE vs conventional approach

• One argument for TEE is that people dont
  strictly follow conventional guidelines.
• A longer period of anticoagulation is required
  for conventional approach in some patients (and
  needs to be restarted in the face of a bleed).
• Over 20 of patients never make it to
  cardioversion while waiting 3 weeks.

19
Who should get TEE?

• 1) High risk patients requiring early
  cardioversion.
• 2) Low risk patients in whom you may wish to
  exclude longterm anticoagulation.

20
Use of TEE

• 1) Operator requires high level of expertise.
• 2) If a clot is found under TEE, and TEE
  guidelines are closely followed then up to 5-7
  will never be cardioverted because of persistence
  of clot.
• 3) Longterm anticoagulation is still required in
  high risk patients.

21
Is it TEE time?

• In the end run, 2 techniques are available for
  the clinician. They should both be used
  judiciously and TEE should not be used to avoid
  longterm anticoagulation in the high-risk
  patient.
• Dr Eric Prystowsky
• Director, Clinical Electrophysiology Laboratory
• St Vincent Hospital
• Indianapolis, IN