Implementation and first outcomes of a novel SOP for preprocedural transesophageal echocardiography screening in course of atrial arrhythmia ablation
Authors: Dittrich S , Scheurlen C , Van Den Bruck J H , Filipovic K , Woermann J , Erlhoefer S , Schipper J H , Lueker J , Sultan A , Steven D 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
Preprocedural transesophageal echocardiography (TEE) screening for LA or LAA thrombi is standard operating procedure (SOP) in most centers performing atrial fibrillation ablation. However, TEE is a procedure that imposes procedural risks for patients and is often challenging to include in daily clinical practice, besides causing patient discomfort. At our center, we have implemented a novel SOP regarding preprocedural TEE screening for atrial thrombi. Patients who present in sinus rhythm and suffer from a low stroke risk based on CHADS-VASC-Score (&lt;2) or have sufficiently taken their anticoagulatory medication, are exempt from preprocedural TEE screening. The aims of this novel SOP are a reduction of TEEs performed in course of ablation procedures.

Purpose
The purposes of this study are to assess whether a novel SOP regarding preprocedural TEE screening for LA thrombi can effectively reduce the number of TEEs performed without imposing patients to a higher risk for strokes in course of catheter ablation of atrial arrhythmias.

Methods
Data of 2335 consecutive patients who received catheter ablation of atrial arrhythmias at the University Hospital of Cologne between 2018 and 2022 was retrospectively analyzed. All patients treated until March 2020 received preprocedural TEE before every ablation procedure, screening for atrial thrombi. In all following cases, a novel SOP was applied: Patients in sinus rhythm at the beginning of the procedure who were either sufficiently anticoagulated or had a CHADS-VASC-Score &lt;2 did not receive TEE prior to the ablation procedure. We compared both groups regarding incidence of stroke and transient ischemic attack (TIA).

Results
Out of 2335 included patients, 961 (41%) were treated according to the old SOP and 1374 (59%) patients were treated according to the new SOP. Both groups did not differ significantly regarding their baseline parameters. Performed ablation procedures (old SOP vs. new SOP) consisted of PVI (689, 68.8% vs. 921, 64.5%; p=0.04), re-PVI (179, 17.8% vs. 240, 16.8%; p=0.52), substrate-based ablation of persistent AF (70, 7% vs. 186, 13%; p&lt;0.01), AT ablation (111, 11% vs. 276, 11.3%; p=0.69) and CTI ablation (95, 9.5% vs. 230, 9.5%; p=1.0). No significant difference between the groups was detected: A stroke was diagnosed in 2 patients in each group (old SOP: 0.2%, new SOP 0.1%; p=0.72). A TIA was diagnosed in 6 (0.6%) patients that were treated according to the old SOP and 3 (0.2%) patients that were treated according to the new SOP (p=0.12). No TEE-related complication occurred.

Conclusion
We demonstrate outcomes of a novel SOP for pre-procedural TEE screening of LA thrombi that limits TEEs to patients who are at high risk of stroke according to current guidelines and CHADS-VASC-Score. Patients who present in sinus rhythm and have a CHADS-VASC-Score &lt;2 or have sufficiently taken their anticoagulatory medication can be safely treated with catheter ablation without performing prior TEE.