Safety and Feasibility of a CT-Based Pathway for Left Atrial Appendage Assessment Prior to Inpatient Cardioversion: A Single-Center Experience.

BACKGROUND

Transesophageal echocardiography (TEE) for left atrial appendage (LAA) thrombus exclusion before cardioversion faces logistical barriers including limited availability, patient intolerance, and procedural delays. We evaluated the feasibility and short-term safety of a cardiac CT-based alternative pathway in hospitalized patients with atrial fibrillation (AF).

METHODS

This retrospective single-center study included 408 consecutive AF inpatients planned for cardioversion. The primary endpoint was the composite of stroke/TIA or systemic embolism within 48 h post-cardioversion. Secondary endpoints included 30-day thromboembolic events, acute kidney injury, and all-cause mortality at 30 days and 1 year. Imaging modality selection was based on availability, clinical factors, and contraindications.

RESULTS

Among 74 patients undergoing CT-guided cardioversion and 206 undergoing TEE-guided cardioversion, no strokes or TIAs occurred within 48 h in either group (0/74 CT vs. 0/206 TEE, p = 1.0). By 30 days, one TIA occurred in the CT group (1.4%) and none in the TEE group (0%), representing an absolute risk difference of +1.4% (95% CI: -0.8% to +7.3%; p = 0.26). Acute kidney injury occurred in 8.1% of CT patients compared with 3.9% in the TEE group (absolute risk difference +4.2%, 95% CI: -1.4% to +12.9%; OR 2.18, 95% CI: 0.60-7.45; p = 0.21). No mortality was observed at 30 days or 1 year.

CONCLUSIONS

In this single-center feasibility analysis, a CT-based imaging pathway for LAA assessment prior to cardioversion was associated with no periprocedural thromboembolic events and acceptable short-term safety. Prospective randomized trials are needed to define the clinical role of CT as an alternative to TEE.