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QUARTERLY FOCUS ISSUE: HEART RHYTHM DISORDERSS: CLINICAL RESEARCH

Role of the CHADS₂ Score in the Evaluation of Thromboembolic Risk in Patients With Atrial Fibrillation Undergoing Transesophageal Echocardiography Before Pulmonary Vein Isolation

Sarinya Puwanant, MD^_*,, Brandon C. Varr, BS^_*, Kevin Shrestha, AB^_*, Sarah K. Hussain, MD^_*, W.H. Wilson Tang, MD^_*, Ruvin S. Gabriel, MD^_*, Oussama M. Wazni, MD^_*, Mandeep Bhargava, MD^_*, Walid I. Saliba, MD^_*, James D. Thomas, MD^_*, Bruce D. Lindsay, MD^_* and Allan L. Klein, MD^_*,_*

^_* Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
Division of Cardiology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand

Manuscript received June 16, 2009; accepted July 8, 2009.

^_* Reprint requests and correspondence: Dr. Allan L. Klein, Heart & Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk F15, Cleveland, Ohio 44195 (Email: kleina{at}ccf.org).

Objectives: The goals of this study were to determine: 1) if low-risk patients assessed by a CHADS₂ score, a clinical scoring system quantifying a risk of stroke in patients with atrial fibrillation (AF), require a routine screening transesophageal echocardiogram (TEE) before pulmonary vein isolation (PVI); and 2) the relationship of a CHADS₂ score with left atrial (LA)/left atrial appendage (LAA) spontaneous echo contrast, sludge, and thrombus.

Background: There is no clear consensus of whether a screening TEE before catheter ablation of AF should be performed in every patient.

Methods: Initial TEEs for pre-PVI of 1,058 AF patients (age 57 ± 11 years, 80% men) were reviewed and compared with a CHADS₂ score.

Results: CHADS₂ scores of 0, 1, 2, 3, 4, 5, and 6 were present in 47%, 33%, 14%, 5%, 1%, 0.3%, and 0% of patients, respectively. The prevalence of LA/LAA thrombus, sludge, and spontaneous echo contrast were present in 0.6%, 1.5%, and 35%. The prevalence of LA/LAA thrombus/sludge increased with ascending CHADS₂ score (scores 0 [0%], 1 [2%], 2 [5%], 3 [9%], and 4 to 6 [11%], p < 0.01). No patient with a CHADS₂ score of 0 had LA/LAA sludge/thrombus. In a multivariate model, history of congestive heart failure and left ventricular ejection fraction <35% were significantly associated with sludge/thrombus.

Conclusions: The prevalence of LA/LAA sludge/thrombus in patients with AF undergoing a pre-PVI screening TEE is very low (<2%) and increases significantly with higher CHADS₂ scores. This suggests that a screening TEE before PVI should be performed in patients with a CHADS₂ score of 1, and in patients with a CHADS₂ score of 0 when the AF is persistent and therapeutic anticoagulation has not been maintained for 4 weeks before the procedure.

Key Words: atrial fibrillation • CHADS₂ score • left atrial appendage • pulmonary vein isolation • transesophageal echocardiography

Abbreviations and Acronyms   AF = atrial fibrillation   CHF = congestive heart failure   CT = computed tomography   DCC = direct current cardioversion   INR = international normalized ratio   LA = left atrial   LAA = left atrial appendage   LVEF = left ventricular ejection fraction   PAF = paroxysmal atrial fibrillation   PVI = pulmonary vein isolation   SEC = spontaneous echo contrast   TEE = transesophageal echocardiogram   TIA = transient ischemic attack

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