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

Objectives The goals of this study were to determine: 1) if low-risk patients assessed by a CHADS(2) 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 CHADS(2) 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 CHADS(2) score. Results CHADS(2) 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 CHADS(2) score (scores 0 [0%], 1 [2%], 2 [5%], 3 [9%], and 4 to 6 [11%], p < 0.01). No patient with a CHADS(2) 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 CHADS(2) scores. This suggests that a screening TEE before PVI should be performed in patients with a CHADS(2) score of >= 1, and in patients with a CHADS(2) score of 0 when the AF is persistent and therapeutic anticoagulation has not been maintained for 4 weeks before the procedure. (J Am Coll Cardiol 2009; 54: 2032-9) (C) 2009 by the American College of Cardiology Foundation