Original Article

Detection of Left Atrial Appendage Thrombus by Cardiac

Computed Tomography in Patients With Atrial Fibrillation
A Meta-Analysis
Jorge Romero, MD; Syed Arman Husain, MD; Iosif Kelesidis, MD; Javier Sanz, MD;
Hector M. Medina, MD; Mario J. Garcia, MD

Background—Transesophageal echocardiogram (TEE) is considered the gold standard modality in detecting left atrial/
LA appendage (LA/LAA) thrombi. However, this is a semi-invasive procedure with rare but potential life-threatening
complications. Cardiac computed tomography has been proposed as an alternative method. The purpose of this meta-
analysis was to evaluate the diagnostic accuracy of cardiac computed tomography assessing LA/LAA thrombi in
comparison with TEE.
Methods and Results—A systematic review of Medline, Cochrane, and Embase to look for clinical trials assessing detection
of LA/LAA thrombi by cardiac computed tomography when compared with TEE in patients with a history of atrial
fibrillation before electric cardioversion/pulmonary vein isolation or after cardioembolic cerebrovascular accident was
performed using standard approach and bivariate analysis. Nineteen studies with 2955 patients (men, 71%; mean age, 61±4
years) fulfilled the inclusion criteria. Most studies (85%, 16 studies) used 64-slide multidetector computed tomography
and 15 studies (79%) were electrocardiographic-gated. The incidence of LA/LAA thrombi was 8.9% (SD, ±7). The mean
sensitivity and specificity were 96% and 92%, whereas the positive predictive value and negative predictive value were
41% and 99%, respectively. The diagnostic accuracy was 94%. In a subanalysis of studies in which delayed imaging
was performed, the diagnostic accuracy significantly improved to a mean weighted sensitivity and specificity of 100%
and 99%, respectively, whereas the positive predictive value and negative predictive value increased to 92% and 100%,
respectively. The accuracy for this technique was 99%.
Conclusions—Cardiac computed tomography, particularly when delayed imaging is performed, is a reliable alternative to
Downloaded from http://ahajournals.org by on May 21, 2019

TEE for the detection of LA/LAA thrombi/clot, avoiding the discomfort and risks associated with TEE. (Circ Cardiovasc
Imaging. 2013;6:185-194.)

Key Words: cardiac computed tomography ◼ cardioembolic cerebrovascular accident ◼ electric cardioversion ◼

left atrial appendage thrombus ◼ left atrial thrombus ◼ pulmonary vein isolation ◼ transesophageal echocardiogram

A trial fibrillation (AF) and associated cardioembolic cere-

brovascular accidents (CVAs) are 2 well-known major
healthcare problems worldwide.1,2 It has been estimated that
(LA/LAA) thrombi in patients with ischemic CVA of sus-
pected cardioembolic pathogenesis or with AF undergoing
electric cardioversion (EC) or pulmonary vein isolation (PVI)
2.2 million people in America and 4.5 million in the European because it provides superior visualization of posterior struc-
Union have paroxysmal or persistent AF.3 Likewise, the tures, such as the LA and LAA, when compared with transtho-
annual incidence of new or recurrent stroke in the United racic echocardiography (TTE).9
States is ≈795 000 of which ≈87% are because of ischemia.4 TEE has been demonstrated to be an accurate modality based
AF is associated with an increased long-term risk of stroke.5
on 2 large prospective studies. The first one with a thrombi
The rate of ischemic stroke among patients with nonvalvular
prevalence of 5.2% showed a sensitivity of 100%, a specificity
AF averages 5% per year.6–8
of 99% with a positive predictive value (PPV) of 86% and a
Clinical Perspective on p 194 negative predictive value (NPV) of 100%.10 In the second study,
Transesophageal echocardiogram (TEE) is considered the with a LA/LAA thrombus prevalence of 15%, all thrombi were
gold standard modality in detecting left atrial/LA appendage confirmed at surgicopathologic studies (specificity 100%).
Received September 25, 2012; accepted January 9, 2013.
From the Division of Cardiology and Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of
Medicine, Bronx, NY (J.R., S.A.H., I.K., H.M.M., M.J.G.); and The Zena and Michael A. Wiener Cardiovascular Institute, Marie-Josée and Henry R.
Kravis Center for Cardiovascular Health, Mount Sinai School of Medicine, New York, NY (J.S.).
The online-only Data Supplement is available at http://circimaging.ahajournals.org/lookup/suppl/doi: 10.1161/CIRCIMAGING.112.000153/-/
DC1.
Correspondence to Mario J. Garcia, MD, Division of Cardiology, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of
Medicine, 111 E 210th St, Silver Zone, Bronx, NY 10467-2400. E-mail mariogar@montefiore.org
© 2013 American Heart Association, Inc.
Circ Cardiovasc Imaging is available at http://circimaging.ahajournals.org DOI: 10.1161/CIRCIMAGING.112.000153

185
 186  Circ Cardiovasc Imaging  March 2013
However, in 2 patients, LA thrombi were present but could not
be detected by TEE (sensitivity, 93.3%). Furthermore, the PPV
was 100%, the NPV was 98.9%, and the diagnostic accuracy
was 99.1%.11 Likewise, TEE findings indicative of atrial stasis
or thrombosis have been independently associated with high
thromboembolic risk in patients with AF.9
TEE is a semi-invasive procedure generally safe in expe-
rienced hands. Nevertheless, it is time-consuming, carries
physical discomfort, is not readily available at all times, and
it is associated, although rarely, with potential life-threatening
complications.12
During the past decade, cardiac computed tomography
(CCT) and cardiac MRI (CMR) have been tested for the detec-
tion of LA/LAA thrombi. Moreover, these imaging modalities
are commonly used in clinical practice for guidance of PVI
procedures. Of these, CCT has been more widely investigated,
showing high sensitivity, although variable specificity for the
detection of LA/LAA thrombus.
In the following meta-analysis, we scrutinize the accuracy
of CCT in the evaluation of LA/LAA thrombi in the available
literature when compared with TEE.
Methods
Search Strategy
The objective of the current analysis was to evaluate the available stud-
ies, in which CCT was compared with TTE for the detection of LA/
LAA thrombi in patients undergoing EC or PVI for persistent or par-
oxysmal AF and in subjects being evaluated for cardioembolic CVA.
We searched PubMed, Embase, and Cochrane Central Register
Downloaded from http://ahajournals.org by on May 21, 2019
of Clinical Trials (Cochrane Library, Issue 4, 2012) using the terms
(left atrial thrombus OR left atrial appendage OR left atrial appendage
thrombus OR left atrial clot OR left atrial appendage thrombi OR left
atrial appendage filling defects OR Left atrial thrombi or atrial throm-
bus) AND (64-Slice multidetector CT OR 64-Slice multidetector com-
puted tomography OR computed tomography OR cardiac CT OR CT
OR CCT). We limited our search to humans in peer-reviewed journals
from 1966 to May 2012. No language restriction was applied. The ref-
erence lists of bibliographies of identified articles were also reviewed.
Selection Criteria
To be included in the analysis, a trial had to fulfill the following cri-
teria: (1) the study was either prospective or retrospective (only if
both TEE and CCT were performed consecutively within 7 days) in-
volving patients who underwent both CCT and TEE evaluation to
rule out LA/LAA thrombi before PVI/EC for AF or as part of stroke
assessment; (2) the study allowed for sensitivity, specificity (NPV),
and (PPV) calculations.
Data Extraction
Two authors (J.R. and S.H.) extracted the data independently and
in duplicate. Data were extracted using standardized protocol and
reporting forms. Disagreements were resolved by arbitration (J.R.
or M.G.), and consensus was reached after discussion. We extracted
characteristics of each trial, interval between CCT and TEE, CCT
methodology (eg, ECG-gated versus non–ECG-gated), and baseline
patient demographics for our analysis. In instances where these
values were not readily available, the principal investigator of that
particular trial was approached to supply the relevant information.
Quality Assessment
To assess the quality and reporting of studies, we evaluated 14
items that were considered relevant to the review topic, based on the
Quality Assessment of Diagnostic Accuracy Studies (QUADAS) in-
strument.13 Two reviewers (J.R. and S.H.) independently assessed the
quality items, and discrepancies were resolved by consensus. These
items covered patient spectrum, reference standard, disease progres-
sion bias, verification bias, review bias, clinical review bias, incor-
poration bias, test execution, study withdrawals, and indeterminate
results among others.
Statistical Analysis
Sensitivities (number of thrombi detected by the index test [CCT]
divided by the total number of thrombi detected by the reference
Figure 1.  Selection of studies. CT indicates
computed tomography; LA, left atrium; TEE,
transesophageal echocardiogram; and TTE, trans-
thoracic echocardiogram.
 Romero et al   Computed Tomography Assessing LA/LAA Thrombus   187

Table 1.  Baseline Characteristics of Studies Included in the Meta-Analysis

Avg.
Heart Slice
Rate, β-Blocker Thickness, Diagnostic Incidence of
Reference Study Design N Men, % Age, y Indication CT Type bpm Used mm Criteria for TEE Thrombus, %
Achenbach et al34 Prospective 52 63 66 DCCV EKG-gated EBCTEarly 91 NR 1.5 LAT/LAAT 13
phase images
Dorenkamp et al35 Prospective 329 65 62 PVI EKG-gated 64-slice NR Yes 0.6 LAT/LAAT 2
MDCTEarly phase
imaging
Feuchtner et al39 Prospective 64 68 58 PVI/CT Sx EKG-gated 64-slice 68 Yes 0.6 LAT/LAAT 14
MDCTEarly phase
images
Hur et al40 Retrospective 101 62 67 CVA EKG-gated 64-section 62 Yes 0.6 LAAT 8
CCTAEarly phase
images
Hur et al33 Prospective 55 65 61 CVA EKG-gated 64-section 61 Yes 0.6 LAAT 25
CCTADelayed phase
images
Hur et al32 Prospective 137 69 61 CVA EKG-gated 64-slice 61 Yes 0.6 LAT/LAAT 9
CCTADelayed phase
images
Hur et al27 Prospective 83 67 67 CVA EKG-gated 64-slice 65 No 0.6 LAT/LAAT 15
DSCTDelayed phase
image
Hur et al25 Prospective 63 78 64 CVA 64-Slice MDCT (unclear 64 No 0.6 LAT/LAAT 21
if EKG gating used)
Delayed phase images
Jaber et al36 Prospective 31 77 54 PVI EKG-gated 4-slice NR No 1 LAT/LAAT 19
MDCT with 3D
Downloaded from http://ahajournals.org by on May 21, 2019

reconstructionDelayed
phase images
Kapa et al31 Prospective 255 78 58 PVI EKG-gated DSCTEarly NR No 0.6 LA/LAAT 2
phase images
Kim et al38 Retrospective 223 82 57 PVI EKG-gated 16, 40, and NR No 1.20.60.75 LAAT+SEC 7
64-slice MDCTEarly
phase images
Kim et al37 Prospective 314 59 65 CVA EKG-gated 64-slice NR Yes 0.625 LAT/LAAT 7
MDCTEarly phase
images
Kim et al37 Prospective 314 59 65 CVA EKG-gated 64-slice NR Yes 0.625 LAT/LAAT 7
MDCTDelayed phase
images
Maltagliati et al24 Prospective 171 83 60 PVI 64-Slice MDCT (EKG NR NR NR LAT/LAAT 2
gating not reported)
Early phase images
Martinez et al28 Prospective 402 77 56 PVI Ungated 64-slice NR No 0.6 LAAT 2
MDCTEarly phase
imaging
Sawit et al26 Retrospective 70 73 58 PVI EKG-gated (pt in sinus NR No NR LA/LAAT 3
rhythm) and nongated
(pts in AF) 256, 128,
and 64-slice CCTEarly
phase images
Sawit et al26 Retrospective 70 73 58 PVI EKG-gated (pt in NR No NR LA/LAAT 3
sinus rhythm) and
nongated (pts in AF)
256, 128, and 64-slice
CCTDelayed phase
images
(Continued)
 188  Circ Cardiovasc Imaging  March 2013
Table 1.  Continued
Reference Study Design N Men, % Age, y Indication
Singh et al 30
Retrospective 51 73 64 PVI
Tang et al29 Prospective 170 72 56 PVI
CT indicates computed tomography; CCT, cardiac computed tomography; CCTA, coronary computed tomography angiography; CVA, cerebrovascular accident; DCCV,
direct current cardioversion; EBCT, electron-beam computed tomography; LAT/LAAT, left atrial thrombi/left atrial appendage thrombi; MDCT, multidetector computed
tomography; PVI, pulmonary vein isolation; and TEE, transesophageal echocardiogram.
standard [TEE]), specificities (number of normal LA/LAA estimated
by the index test divided by the total number of normal LA/LAA
estimated by the reference test), PPV (number of thrombi that were
confirmed by the reference standard divided by the total number of
thrombi identified by the index test), and NPV (number of normal
LA/LAA that were confirmed by the reference standard divided by
the total number of normal LA/LAA identified by the index test) were
calculated for every study.
In this meta-analysis, we estimated summary sensitivity and
specificity using a more recently developed bivariate random effects
model instead.14,15 The bivariate approach assumed logit transforms
of sensitivity and specificity from individual studies are from a bivari-
ate normal distribution. The bivariate approach is considered to be
a better approach as compared with the standard summary receiver
operating characteristics (ROC) approach16 because first, it assesses
heterogeneity across studies in sensitivity and specificity and pro-
vides a summary estimate of sensitivity and specificity; second, it
Downloaded from http://ahajournals.org by on May 21, 2019
models sensitivity and specificity jointly so that a 95% confidence el-
lipse around the summary estimate can be calculated; third, it allows
one to directly compare sensitivity and specificity between methods;
furthermore, several choices are available to obtain a summary ROC
curve.14,15 In this article, the summary ROC curve was obtained by
transforming the regression line of logit sensitivity on logit specificity
into ROC space.14 A similar bivariate approached was used to model
PPV and NPV.17 Publication bias was assessed for each analysis using
Peter and Harbord methods.
We assessed between-study heterogeneity visually, by plotting sen-
sitivity and specificity in the ROC curves. We also drew summary
ROC curves and confidence regions for summary sensitivity and
specificity.15,18
The analyses were conducted using STATA 12 (Metandi Syntax),
and the figures were generated using STATA graph editor.
Sensitivity Analysis
We further evaluated whether the performance of each technique
depends on features of the technique (eg, ECG-gated versus non–
ECG-gated) and patient characteristics. We also performed a detailed
sensitivity analysis to identify whether inclusion of retrospective
studies had a significant impact on the overall results of this meta-
analysis. A logistic regression for each technique was used to model
the sensitivity on these factors.
Results
Study Selection
We identified 1800 abstracts, of which 29 articles were
retrieved and reviewed for possible inclusion (Figure 1).
Nineteen studies with a total of 2955 patients fulfilled the
inclusion criteria and were included in the meta-analysis.
Five studies were excluded from the final analysis because
they did not meet the inclusion criteria: 1 study had both a
Avg.
Heart Slice
Rate, β-Blocker Thickness, Diagnostic Incidence of
CT Type bpm Used mm Criteria for TEE Thrombus, %
EKG-gated 64-slice NR NR 0.6 LAAT 4
MDCTEarly phase
images
Non–EKG-gated NR NR NA LAT/LAAT 6
64-slice MDCTDelayed
images not used
prolonged time interval between CCT and TEE (ie, mean
30 days) and ≈50% of the patients enrolled underwent TTE
instead of TEE,19 another also had a prolonged time interval
between CTT and TEE (ie, mean time between multidetector
computed tomography [MDCT] and TEE 10.7±16.3 days),20
1 study assessed LA/LAA morphology (eg, multilobed
LAA, LA diameter, etc) instead of thrombus,21 and 2
studies did not provide enough data to calculate diagnostic
accuracies.22,23
Baseline Characteristics
A total of 19 studies24–40 with 2955 patients (mean age, 61
years [SD, ±4]; men, 71%) with AF undergoing PVI/EC or
patients with CVA being worked-up for cardioembolic source
were included (Table 1). The overall incidence for LA/LAA
thrombi was 8.9% (SD, ±7). Twelve studies (74%) were pro-
spective and 5 (26%) were designed retrospectively perform-
ing both tests in a consecutive fashion within 1 week. Eleven
studies were performed before PVI, 7 studies after CVAs,
and 1 study before EC. Most studies (85%, 16 studies) used
64-slide MDCT and only 1 study used electron-beam com-
puted tomography. Electrocardiographic-gated (ECG-gated)
CCT protocols were performed in 15 studies (79%) with
delayed phase images obtained only in 7 studies (37%). The
average slice thickness was 0.6 mm.
Sensitivity Analysis
We examined every variable included in the baseline charac-
teristics table (eg, study design, percentage of men, ECG-gated
versus non–ECG-gated, whether or not β-blockers were used,
average heart rate, type of CCT, and slice thickness; Table
1). No factor was identified that had a significant influence
on its sensitivity. However, when we performed a sensitivity
analysis for comparing studies that used delayed imaging ver-
sus those that did not, we found a significant impact on the
specificity of CCT showing that the former had a remarkably
higher PPV (Table I in the online-only Data Supplement).
More importantly, our sensitivity analysis on the impact of
including retrospective studies in our final results did not show
any statistical significance when compared with the overall
diagnostic accuracies if only prospective studies had been
included in this meta-analysis. We performed this analysis for
both (1) all CT studies and (2) delayed phase imaging studies
(Table II in the online-only Data Supplement).
 Romero et al   Computed Tomography Assessing LA/LAA Thrombus   189
Quality Assessment
Reporting was slightly poor on items 10 and 11 (Were the index
test results interpreted without knowledge of the results of the
reference standard?) and (Were the reference standard results
interpreted without knowledge of the results of the index
test?), respectively, on the study by Tang et al.29 This might
have led to overestimation of diagnostic accuracy (review
bias). Nevertheless, this trial had one of the lowest sensitivi-
ties and PPVs of all studies included in this meta-analysis.
Achenbach et al,34 did not report the time interval between
tests, which might have introduced disease progression bias.
Likewise, Maltagliati et al,24 failed to report a detailed expla-
nation of the execution of the index test to permit its repli-
cation in clinical practice. Otherwise, all the studies showed
high-quality scores in the remaining 13 items of QUADAS
(Figure I and II in the online-only Data Supplement).
Publication Bias
Using Peter’s method, there was no indication of publication
bias (P value of 0.78). Conversely, using Harbord’s test there
was indication of publication bias (P value of 0.004). This
might indicate that some studies reporting negative results for
this technique might not have been submitted for publication,
and if they were, they were never published.
Diagnostic Accuracy for All CCT Studies
The weighted mean sensitivity and specificity were 96% (95%
confidence interval [CI], 92%–100%) and 92% (95% CI,
91%–93%), whereas the PPV was 41% (95% CI, 37%–44%)
Downloaded from http://ahajournals.org by on May 21, 2019
and NPV was 99% (95% CI, 99%–100%), respectively (Table
2). CCT had a weighted overall accuracy of 94% (95% CI,
91%–96%). Figure 2A through 2D demonstrates the overall
weighted sensitivity, specificity, and predictive values (ran-
dom effects analysis).
Delayed Phase Images Studies
Baseline Characteristics
On sensitivity analysis (Table 1), the 7 studies enrolled a total
of 753 patients (mean age, 61±4 years; men, 70%) and had an
overall incidence for LA/LAA thrombi of 14±8%. Six studies
were prospective (86%). All studies were ECG-gated. Like-
wise, different parameters (ie, contrast volume, delayed time,
slice thickness, and kVp) used in delayed imaging protocols
are shown in Table III in the online-only Data Supplement.
Diagnostic Accuracy
In these studies, the mean weighted sensitivity and speci-
ficity were 100% (95% CI, 96%–100%) and 99% (95% CI,
98%–100%), whereas the PPV and NPV were 92% (95% CI,
86%–98%) and 100% (95% CI, 99%–100%), respectively
(Table 3). The weighted overall accuracy for this technique
was 99% (95% CI, 98%–100%). It was noticed that, using
delayed images improved the PPV from 41% (all studies
combined) or from 26% (early phase images studies) to 92%
(P<0.001) making CCT as accurate as TTE for the detection
of LA/LAA thrombus. Figure 2A through 2D demonstrates
the overall weighted sensitivity, specificity, and predictive
values comparing early versus delayed phase image studies
(random effects analysis).
PVI Studies
Baseline Characteristics
A total of 11 studies with a total of 1836 patients (mean age,
64 years [SD, ±3]; men, 75%) with AF undergoing PVI were
included. The overall incidence for LA/LAA thrombi was
5.8% (SD, ±5). Seven (64%) were prospective and 4 (36%)
were designed retrospectively performing both tests in a con-
secutive fashion within 1 week. Eight studies (73%) were
ECG-gated. Most studies were performed using 64-slice
MDCT, 1 study used 4-slice MDCT with 3-dimensional (3D)
reconstruction and another one used dual-source computed
tomography.
Diagnostic Accuracy
In these studies, the mean weighted sensitivity and speci-
ficity were 91% (95% CI, 85%–97%) and 95% (95% CI,
94%–96%), whereas the Upland NPV was 33% (95% CI,
28%–38%) and 100% (95% CI, 99%–100%), respectively.
The weighted overall accuracy for this technique was 95%
(95% CI, 94%–96%). Similarly, when delayed imaging proto-
cols were performed, the diagnostic accuracy of CCT signifi-
cantly improved. Sensitivity and specificity were 100% (95%
CI, 83%–100%) and 100% (95% CI, 98%–100%), whereas
the Upland NPV was 100% (95% CI, 98%–100%) and 100%
(95% CI, 99%–100%), respectively. The weighted overall
accuracy for this technique was 100% (95% CI, 98%–100%).
Finally, the bivariate model showing combined summary
diagnostic accuracies, 95% CI, and 95% predictive region in
summary ROC curves for all studies using only early phase
imaging and those adding delayed phase imaging is displayed
in Figure 3A through 3C. These ROCs clearly demonstrate
that the 95% confidence region and the 95% prediction region
are much smaller in the group with delayed phase images
studies than in the 2 other groups (overall and early phase
images studies) indicating that the former group has a much
lower heterogeneity.
Discussion
Our meta-analysis demonstrated overall high accuracy of
CCT compared with TEE for the detection of LA/LAA throm-
bus in patients with AF. When delayed CT imaging is used,
the accuracy of CT is even higher with sensitivity, specificity,
PPV, NPV, and accuracy >92%.
Despite the fact that TEE has a considerable number of
applications in clinical practice including but not limited
to evaluation of valvular disease and aortic pathology, it is
most commonly ordered to guide anticoagulation therapy in
patients with AF or atrial flutter in the setting of stroke, car-
dioversion, and radiofrequency ablation.
TEE has been validated as a fairly accurate tool for the
detection of LAA/LA thrombi/clot in studies comparing its
results with intraoperative findings,5 and this is the reason
why the 2011 American College of Cardiology Foundation/
American Heart Association/Heart Rhythm Society–focused
updates incorporated into the American College of Cardiology/
American Heart Association/European Society of Cardiology
2006 guidelines for the management of patients with AF rec-
ommend TEE as the only imaging modality for this purpose.41
 190  Circ Cardiovasc Imaging  March 2013

Table 2.  Sensitivities/Specificities and Predictive Values for All Cardiac Computed Tomography Studies
Reference Sensitivity, % Specificity, % PPV, % NPV, % Accuracy
Achenbach et al 34
100 (7/7) 87 (39/45) 54 (7/13) 100 (39/39) 88 (46/52)
Dorenkamp et al35 29 (2/7) 98 (314/322) 20 (2/10) 98 (314/319) 96 (316/329)
Feuchtner et al39 100 (4/4) 97 (58/60) 67 (4/6) 100 (58/58) 97 (62/64)
Hur et al40 100 (8/8) 96 (89/93) 67 (8/12) 100 (89/89) 96 (97/101)
Hur et al33 100 (14/14) 98 (40/41) 93 (14/15) 100 (40/40) 98 (54/55)
Hur et al32 100 (12/12) 100 (125/125) 100 (12/12) 100 (125/125) 100 (137/137)
Hur et al27 100 (13/13) 100 (70/70) 100 (13/13) 100 (70/70) 100 (83/83)
Hur et al25
100 (13/13) 100 (50/50) 100 (13/13) 100 (50/50) 100 (63/63)
Jaber et al36 100 (6/6) 100 (25/25) 100 (6/6) 100 (25/25) 100 (31/31)
Kapa et al31 100 (4/4) 88 (222/251) 12 (4/33) 100 (222/222) 89 (226/255)
Kim et al38 93 (14/15) 85 (177/208) 31 (14/45) 99 (177/178) 86 (191/223)
Kim et al37 100 (23/23) 67 (195/291) 19 (23/119) 100 (195/195) 69 (218/314)
Kim et al37 100 (23/23) 98 (285/291) 79 (23/29) 100 (285/285) 98 (308/314)
Maltagliati et al24 100 (4/4) 92 (153/167) 22 (4/18) 100 (153/153) 92 (157/171)
Martinez et al28 100 (9/9) 92 (362/393) 23 (9/40) 100 (362/362) 92 (371/402)
Sawit et al 26
100 (2/2) 84 (57/68) 15 (2/13) 100 (57/57) 84 (59/70)
Sawit et al26 100 (2/2) 100 (68/68) 100 (2/2) 100 (68/68) 100 (70/70)
Singh et al30 100 (2/2) 96 (47/49) 50 (2/4) 100 (47/47) 96 (49/51)
Tang et al29 36 (4/11) 94 (149/159) 29 (4/14) 96 (149/156) 90 (153/170)
Weighted mean 96 92 41 99 94
Segments are given as % (n/N). NPV indicates negative predictive value; and PPV, positive predictive value.

However, for some patients, TEE may be an uncomfort- This meta-analysis clearly demonstrates that CCT can play
able and a time-consuming procedure. Although extremely a critical role in the detection of LLA/LA thrombi/clot before
Downloaded from http://ahajournals.org by on May 21, 2019

unusual, life-threatening complications have been reported
in the literature.12 It also has a few absolute and some rela-
tive contraindications making reliable alternative imaging
modalities a growing need in contemporary clinical practice.
Consequently, newer imaging modalities, such as CCT, has
been tested and compared with TTE during the past decade for
the diagnosis of LA/LAA thrombi.
The diagnostic accuracy of CCT has been extensively stud-
ied indicating a high NPV. Nonetheless, there have been major
discrepancies between reported PPVs and accuracy estimates.
As a result CCT has not been included in practice guidelines
for evaluation of patients with AF. This is unfortunate because
many patients are more often being evaluated by this modality
for a variety of clinical indications, including 3D guidance of
PVI procedures.
ECCV, PVI and in the evaluation for cardiovascular source
of embolus in patients experiencing ischemic CVA with a
weighted sensitivity and a specificity of 96% and 92% and
PPV and NPV of 41% and 99%, respectively. Its overall diag-
nostic accuracy was 94%.
As expected, the low PPV was because, in part, of the low
prevalence of the disease (ie, 8.9% for all studies and 14%
delayed phase images studies), in this case the presence of
LAA/LA thrombi/clot in the studied population. Nevertheless,
this is an accurate estimate of the LAA/LA thrombi/clot in
clinical practice for nonvalvular AF (ie, 5%–15%).42–44 In addi-
tion, the criteria used to determine the presence of thrombus
relies in the detection of regions of low attenuation. Because
the CCT study is static and the images are captured a few sec-
onds after arrival of contrast to the left heart (LA/LAA), it

Table 3.  Sensitivities/Specificities and Predictive Values for Delayed Phase Images Studies
Reference Sensitivity, % Specificity, % PPV, % NPV, % Accuracy
Kim et al 37
100 (23/23) 98 (285/291) 79 (23/29) 100 (285/285) 98 (308/314)
Jaber et al36 100 (6/6) 100 (25/25) 100 (6/6) 100 (25/25) 100 (31/31)
Hur et al33 100 (14/14) 98 (40/41) 93 (14/15) 100 (40/40) 98 (54/55)
Hur et al32
100 (12/12) 100 (125/125) 100 (12/12) 100 (125/125) 100 (137/137)
Hur et al27 100 (13/13) 100 (70/70) 100 (13/13) 100 (70/70) 100 (83/83)
Hur et al25 100 (13/13) 100 (50/50) 100 (13/13) 100 (50/50) 100 (63/63)
Sawit et al26 100 (2/2) 100 (68/68) 100 (2/2) 100 (68/68) 100 (70/70)
Weighted mean 100 99 92 100 99
Segments are given as % (n/N). NPV indicates negative predictive value; and PPV: positive predictive value.
 Romero et al   Computed Tomography Assessing LA/LAA Thrombus   191
Downloaded from http://ahajournals.org by on May 21, 2019

Figure 2.  Forest plots of diagnostic accuracies for cardiac computed tomography (CCT; early phase images studies, delayed phase
images studies, and overall summary estimates for all the CCT studies). A, Forest plots of sensitivity. B, Forest plots of specificity. C,
Forest plots of positive predictive value (PPV). D, Forest plots of negative predictive value (NPV): the size of the square plotting symbol is
proportional to the same size for each study. Horizontal lines are the 95% confidence intervals (CI), and the summary sensitivity, specific-
ity, and predictive values are calculated based on a random effects model. ES indicates effect size.

is difficult to differentiate thrombus from sluggish flow. The
addition of delayed imaging allows a better distinction of
both conditions. Hence, a filling defect that persists 1 minute
after contrast injection is more likely to represent thrombus,
whereas sluggish flow is more likely to show contrast opaci-
fication in LA/LAA during delayed images. In the subanaly-
sis of those studies in which delayed images were obtained,
sensitivity and specificity were 100% and 99%, respectively.
Likewise, the PPV significantly increased to 92%, while
maintaining a high NPV (ie, 100%) and an overall diagnos-
tic accuracy of 99%. These findings demonstrate that CCT
using delayed imaging is a reasonable alternative to TEE for
evaluating this patient population. Even though ECG gating
definitely improves imaging quality, our sensitivity analysis
showed no impact of this technique in the final results.
With a prevalence of LA/LAA thrombi/clot ranging between
5% and 15% in patients with nonvalvular AF, the vast major-
ity of patients will have a negative test (ie, 85%–95%). CCT
provides a NPV of almost 100%, consequently, precluding the
need for further testing before cardioversion or PVI. On the
contrary, if a CCT is positive, CCT provides a PPV of 92%
(LA/LAA thrombi/clots prevalence 14%) if delayed images
are used. Although PPV is not as high as other diagnostic accu-
racy parameters, it is comparable with the PPV provided by
TEE (ie, 86% with LA/LAA thrombi/clot prevalence of 5.2%
and 100% with LA/LAA thrombi/clot prevalence of 15%).10,11
 192  Circ Cardiovasc Imaging  March 2013
Downloaded from http://ahajournals.org by on May 21, 2019
Figure 3.  Hierarchical summary receiver operating characteris-
tic (HSROC) curves. HSROC plots of computed tomography to
predict detection of thrombi across (A) all studies, (B) early phase
images studies, and (C) delay phase images studies (bivariate
estimate). On the basis of combined sensitivity and specificity
weighted for sample size of each data set reflected by the size of
the circles, showing average sensitivity and specificity estimate
of the study results (solid square) and 95% confidence region
around it.
Therefore, special consideration should be given to CCT
for this purpose in patients with persistent AF being evaluated
for PVI.
The 2012 Heart Rhythm Society and the European Heart
Rhythm Association expert consensus statement on catheter
and surgical ablation of AF45 recommends further character-
ization of left atrium and pulmonary vein with CCT, CMR,
or intracardiac echocardiography for integrated electroana-
tomic mapping either using the magnet and impedance-based
system (CARTO mapping system; CARTO-3) or the elec-
tric impedance mapping system (NavX, St. Jude Medical
Inc, Minneapolis, MN). Several studies have demonstrated
increased efficacy of radiofrequency catheter ablation for AF
using integrated electroanatomic mapping.46,47
On the basis of these facts, in most tertiary institutions it is
a routine practice to perform CCT in patients undergoing PVI
for AF. In this particular scenario, CCT may be used to rule
out the presence of LA/LAA thrombi/clot and thus avoid the
need of a second, unnecessary preprocedural TEE.
In all fairness, CCT has 2 major disadvantages compared
with TEE. First of all, CCT examinations required the admin-
istration of ≈60 to 120 mL of iodinated contrast agents, which
are associated with a risk for contrast-induced nephropathy in
patients with underlying kidney disease (ie, serum creatinine,
>1.5–2.0 mg/dL) and risk factor, such as diabetes mellitus vol-
ume depletion or advanced age. Similarly, in patients who are
allergic to iodinated agents, CCT might relatively be contra-
indicated although they can be premedicated with H1 antihis-
tamines and glucocorticoids. Second, the amount of ionizing
radiation to which these patients are exposed is considerably
high specially when using 64-slice MDCT and ECG-gating
protocols with or without tube current modulation (ie, 9 and
15 mSv, respectively).48
Likewise, the imaging acquisition with ECG-gated or non-
ECG CCT on patients with AF might be challenging some-
times. However, this issue is in part mitigated by the fact that
LAA does not move significantly in this rhythm.
Other Imaging Modalities
CMR is also an appealing technique that has gained popu-
larity to evaluate these patients. CMR imaging has also been
proposed for the detection of LA/LAA thrombi and compared
with TEE using different techniques (ie, 2D perfusion and
3D turbo fast low-angle shot). Only a few studies have been
published to date revealing ambiguous results with diagnos-
tic values ranging from sensitivities and specificities of 47%
and 50% to almost perfect concordance between CMR and
TEE. In addition, the longer time required for examination,
higher range of contraindications, and higher procedural costs
make CMR a less attractive modality. Similarly, intracardiac
echocardiography has been recently proposed and tested for
this purpose in patients scheduled for AF ablation showing
promising applications, particularly when preprocedural TEE
results are inconclusive.
Clinical Implications
In view of having TEE, as the main diagnostic tool for LA/LAA
thrombus which carries discomfort and risks, there is growing
need to find an alternative test to evaluate for the presence or
absence of LA/LAA thrombus in clinical practice. As we have
demonstrated in this meta-analysis, CCT with delayed imaging
provides very high comparable diagnostic accuracy compared
with TEE for detection of LA/LAA thrombus either in patients
with persistent or paroxysmal AF undergoing pharmacologi-
cal/EC or PVI or for the evaluation of cardioembolic source in
patients experiencing ischemic CVAs. Special attention should
be given in the setting of catheter ablation for AF (PVI), in
which preprocedural CCT is routinely ordered to optimize ana-
tomic characterization of the LA and the pulmonary veins (ie,
integrated electroanatomical mapping). In this scenario, CCT
may be used to rule out LA/LAA thrombi avoiding the need
of a second test (TEE), thereby decreasing costs and in-hos-
pital time. Likewise, CCT might also be used as an alternative
 Romero et al   Computed Tomography Assessing LA/LAA Thrombus   193
imaging modality when echocardiography laboratory person-
nel are not available to perform and interpret a TEE, especially
after hours and on weekends.
Study Limitations
Five studies included in this meta-analysis were designed ret-
rospectively. However, they had a high methodological quality
and they all met the inclusion criteria (ie, TEE and CCT per-
formed consecutively within 1 week). Furthermore, a detailed
sensitivity analysis, including only prospective studies, did not
reveal any statistical difference when compared with our results.
Although CCT provides diagnostic accuracy as high as TEE
for the detection of thrombus, it does not provide physiological
information, such as blood flow velocity of LAA, which might
be useful in some cases to guide clinical decision making.
Moreover, in patients with known or suspected valvular heart
disease, TEE remains the superior diagnostic imaging modality.
Finally, there was a discrepancy when assessing for publi-
cation bias using 2 different methods as stated earlier under
the publication bias section.
Conclusion
CCT is a reliable alternative imaging modality to TEE for the
detection of LA/LAA thrombi/clot in patients with AF before
pharmacological/EC, PVI or as an evaluation for cardioem-
bolic source in patients with ischemic CVA avoiding the dis-
comfort and risks associated with TEE.
Disclosures
Downloaded from http://ahajournals.org by on May 21, 2019
None.
References
1. Benjamin EJ, Wolf PA, D’Agostino RB, Silbershatz H, Kannel WB, Levy
D. Impact of atrial fibrillation on the risk of death: the Framingham Heart
Study. Circulation. 1998;98:946–952.
2. Chugh SS, Blackshear JL, Shen WK, Hammill SC, Gersh BJ. Epidemiol-
ogy and natural history of atrial fibrillation: clinical implications. J Am
Coll Cardiol. 2001;37:371–378.
3. Feinberg WM, Cornell ES, Nightingale SD, Pearce LA, Tracy RP, Hart RG,
Bovill EG. Relationship between prothrombin activation fragment F1.2
and international normalized ratio in patients with atrial fibrillation. Stroke
Prevention in Atrial Fibrillation Investigators. Stroke. 1997;28:1101–1106.
4. Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB,
Bravata DM, Dai S, Ford ES, Fox CS, Fullerton HJ, Gillespie C, Hailpern
SM, Heit JA, Howard VJ, Kissela BM, Kittner SJ, Lackland DT, Licht-
man JH, Lisabeth LD, Makuc DM, Marcus GM, Marelli A, Matchar DB,
Moy CS, Mozaffarian D, Mussolino ME, Nichol G, Paynter NP, Soliman
EZ, Sorlie PD, Sotoodehnia N, Turan TN, Virani SS, Wong ND, Woo D,
Turner MB; American Heart Association Statistics Committee and Stroke
Statistics Subcommittee. Executive summary: heart disease and stroke sta-
tistics–2012 update: a report from the American Heart Association. Circu-
lation. 2012;125:188–197.
5. Mügge A, Kühn H, Nikutta P, Grote J, Lopez JA, Daniel WG. Assessment of
left atrial appendage function by biplane transesophageal echocardiography
in patients with nonrheumatic atrial fibrillation: identification of a subgroup
of patients at increased embolic risk. J Am Coll Cardiol. 1994;23:599–607.
6. Wolf PA, Dawber TR, Thomas HE Jr, Kannel WB. Epidemiologic as-
sessment of chronic atrial fibrillation and risk of stroke: the Framingham
study. Neurology. 1978;28:973–977.
7. Lévy S, Maarek M, Coumel P, Guize L, Lekieffre J, Medvedowsky JL,
Sebaoun A. Characterization of different subsets of atrial fibrillation in
general practice in France: the ALFA study. The College of French Cardi-
ologists. Circulation. 1999;99:3028–3035.
8. Flegel KM, Shipley MJ, Rose G. Risk of stroke in non-rheumatic atrial
fibrillation. Lancet. 1987;1:526–529.
9. Zabalgoitia M, Halperin JL, Pearce LA, Blackshear JL, Asinger RW,
Hart RG. Transesophageal echocardiographic correlates of clinical risk of
thromboembolism in nonvalvular atrial fibrillation. Stroke Prevention in
Atrial Fibrillation III Investigators. J Am Coll Cardiol. 1998;31:1622–1626.
10. Manning WJ, Weintraub RM, Waksmonski CA, Haering JM, Rooney
PS, Maslow AD, Johnson RG, Douglas PS. Accuracy of transesophageal
echocardiography for identifying left atrial thrombi. A prospective, intra-
operative study. Ann Intern Med. 1995;123:817–822.
11. Hwang JJ, Chen JJ, Lin SC, Tseng YZ, Kuan P, Lien WP, Lin FY, Chu SH,
Hung CR, How SW. Diagnostic accuracy of transesophageal echocardiogra-
phy for detecting left atrial thrombi in patients with rheumatic heart disease
having undergone mitral valve operations. Am J Cardiol. 1993;72:677–681.
12. Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D’Ambra MN, Elt-
zschig HK. Safety of transesophageal echocardiography. J Am Soc Echo-
cardiogr. 2010;23:1115–27; quiz 1220.
13. Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J. The develop-
ment of QUADAS: a tool for the quality assessment of studies of diag-
nostic accuracy included in systematic reviews. BMC Med Res Methodol.
2003;3:25.
14. Arends LR, Hamza TH, van Houwelingen JC, Heijenbrok-Kal MH, Hun-
ink MG, Stijnen T. Bivariate random effects meta-analysis of ROC curves.
Med Decis Making. 2008;28:621–638.
15. Reitsma JB, Glas AS, Rutjes AW, Scholten RJ, Bossuyt PM, Zwinderman AH.
Bivariate analysis of sensitivity and specificity produces informative sum-
mary measures in diagnostic reviews. J Clin Epidemiol. 2005;58:982–990.
16. Littenberg B, Moses LE. Estimating diagnostic accuracy from mul-
tiple conflicting reports: a new meta-analytic method. Med Decis Mak.
1993;13:313–321.
17. Chu H, Nie L, Cole SR, Poole C. Meta-analysis of diagnostic accuracy
studies accounting for disease prevalence: alternative parameterizations
and model selection. Stat Med. 2009;28:2384–2399.
18. Harbord RM, Deeks JJ, Egger M, Whiting P, Sterne JA. A unification of
models for meta-analysis of diagnostic accuracy studies. Biostatistics.
2007;8:239–251.
19. Burke SJ, Aggarwala G, Stanford W, Mullan B, Thompson B, van Beek
EJ. Preablation assessment for the left atrium: comparison of ECG-gated
cardiac CT with echocardiography. Acad Radiol. 2008;15:835–843.
20. Shapiro MD, Neilan TG, Jassal DS, Samy B, Nasir K, Hoffmann U, Sarwar
A, Butler J, Brady TJ, Cury RC. Multidetector computed tomography for the
detection of left atrial appendage thrombus: a comparative study with trans-
esophageal echocardiography. J Comput Assist Tomogr. 2007;31:905–909.
21. Budge LP, Shaffer KM, Moorman JR, Lake DE, Ferguson JD, Mangrum
JM. Analysis of in vivo left atrial appendage morphology in patients with
atrial fibrillation: a direct comparison of transesophageal echocardiogra-
phy, planar cardiac CT, and segmented three-dimensional cardiac CT. J
Interv Card Electrophysiol. 2008;23:87–93.
22. Gottlieb I, Pinheiro A, Brinker JA, Corretti MC, Mayer SA, Bluemke DA,
Lima JA, Marine JE, Berger RD, Calkins H, Abraham TP, Henrikson CA.
Diagnostic accuracy of arterial phase 64-slice multidetector CT angiogra-
phy for left atrial appendage thrombus in patients undergoing atrial fibril-
lation ablation. J Cardiovasc Electrophysiol. 2008;19:247–251.
23. Patel A, Au E, Donegan K, Kim RJ, Lin FY, Stein KM, Markowitz SM, Iwai
S, Weinsaft JW, Min JK, Lerman BB. Multidetector row computed tomogra-
phy for identification of left atrial appendage filling defects in patients under-
going pulmonary vein isolation for treatment of atrial fibrillation: comparison
with transesophageal echocardiography. Heart Rhythm. 2008;5:253–260.
24. Maltagliati A, Pontone G, Annoni A, Formenti A, Galli CA, Tamborini
G, Alimento M, Andreini D, Tondo C, Pepi M. Multidetector computed
tomography vs multiplane transesophageal echocardiography in detecting
atrial thrombi in patients candidate to radiofrequency ablation of atrial
fibrillation. Int J Cardiol. 2011;152:251–254.
25. Hur J, Kim YJ, Lee HJ, Nam JE, Hong YJ, Kim HY, Lee JW, Choi
BW. Cardioembolic stroke: dual-energy cardiac CT for differentia-
tion of left atrial appendage thrombus and circulatory stasis. Radiology.
2012;263:688–695.
26. Sawit ST, Garcia-Alvarez A, Suri B, Gaztanaga J, Fernandez-Friera L,
Mirelis JG, D’Anca M, Fuster V, Sanz J, Garcia MJ. Usefulness of cardiac
computed tomographic delayed contrast enhancement of the left atrial ap-
pendage before pulmonary vein ablation. Am J Cardiol. 2012;109:677–684.
27. Hur J, Kim YJ, Lee HJ, Nam JE, Ha JW, Heo JH, Chang HJ, Kim HS, Hong YJ,
Kim HY, Choe KO, Choi BW. Dual-enhanced cardiac CT for detection of left
atrial appendage thrombus in patients with stroke: a prospective comparison
study with transesophageal echocardiography. Stroke. 2011;42:2471–2477.
28. Martinez MW, Kirsch J, Williamson EE, Syed IS, Feng D, Ommen S,
Packer DL, Brady PA. Utility of nongated multidetector computed tomog-
raphy for detection of left atrial thrombus in patients undergoing cath-
eter ablation of atrial fibrillation. J Am Coll Cardiol Cardiovasc Imaging.
2009;2:69–76.
 194  Circ Cardiovasc Imaging  March 2013

29. Tang RB, Dong JZ, Zhang ZQ, Li ZA, Liu XP, Kang JP, Yu RH, Long de Y,
Ma CS. Comparison of contrast enhanced 64-slice computed tomography and
transesophageal echocardiography in detection of left atrial thrombus in pa-
tients with atrial fibrillation. J Interv Card Electrophysiol. 2008;22:199–203.
30. Singh NK, Nallamothu N, Zuck VP, Issa ZF. Left atrial appendage filling
defects on 64-slice multidetector computed tomography in patients under-
going pulmonary vein isolation: predictors and comparison to transesoph-
ageal echocardiography. J Comput Assist Tomogr. 2009;33:946–951.
31. Kapa S, Martinez MW, Williamson EE, Ommen SR, Syed IS, Feng D,
Packer DL, Brady PA. ECG-gated dual-source CT for detection of left
atrial appendage thrombus in patients undergoing catheter ablation for
atrial fibrillation. J Interv Card Electrophysiol. 2010;29:75–81.
32. Hur J, Kim YJ, Lee HJ, Ha JW, Heo JH, Choi EY, Shim CY, Kim TH,
Nam JE, Choe KO, Choi BW. Cardiac computed tomographic angiogra-
phy for detection of cardiac sources of embolism in stroke patients. Stroke.
2009;40:2073–2078.
33. Hur J, Kim YJ, Lee HJ, Ha JW, Heo JH, Choi EY, Shim CY, Kim TH, Nam
JE, Choe KO, Choi BW. Left atrial appendage thrombi in stroke patients:
detection with two-phase cardiac CT angiography versus transesophageal
echocardiography. Radiology. 2009;251:683–690.
34. Achenbach S, Sacher D, Ropers D, Pohle K, Nixdorff U, Hoffmann U,
Muschiol G, Flachskampf FA, Daniel WG. Electron beam computed to-
mography for the detection of left atrial thrombi in patients with atrial
fibrillation. Heart. 2004;90:1477–1478.
35. Dorenkamp M, Sohns C, Vollmann D, Lüthje L, Seegers J, Wachter R,
Puls M, Staab W, Lotz J, Zabel M. Detection of left atrial thrombus dur-
ing routine diagnostic work-up prior to pulmonary vein isolation for atrial
fibrillation: Role of transesophageal echocardiography and multidetector
computed tomography. Int J Cardiol. 2013;163:26–33.
36. Jaber WA, White RD, Kuzmiak SA, Boyle JM, Natale A, Apperson-Hansen
C, Thomas JD, Asher CR. Comparison of ability to identify left atrial throm-
bus by three-dimensional tomography versus transesophageal echocardiog-
raphy in patients with atrial fibrillation. Am J Cardiol. 2004;93:486–489.
37. Kim SC, Chun EJ, Choi SI, Lee SJ, Chang HJ, Han MK, Bae HJ, Park JH. Dif-
ferentiation between spontaneous echocardiographic contrast and left atrial ap-
pendage thrombus in patients with suspected embolic stroke using two-phase
multidetector computed tomography. Am J Cardiol. 2010;106:1174–1181.
Downloaded from http://ahajournals.org by on May 21, 2019
Cardiology Foundation/American Heart Association Task Force on Prac-
tice Guidelines developed in partnership with the European Society of Car-
diology and in collaboration with the European Heart Rhythm Association
and the Heart Rhythm Society. J Am Coll Cardiol. 2011;57:e101–e198.
42. Manning WJ, Silverman DI, Gordon SP, Krumholz HM, Douglas PS. Car-
dioversion from atrial fibrillation without prolonged anticoagulation with
use of transesophageal echocardiography to exclude the presence of atrial
thrombi. N Engl J Med. 1993;328:750–755.
43. Leung DY, Black IW, Cranney GB, Hopkins AP, Walsh WF. Prognostic
implications of left atrial spontaneous echo contrast in nonvalvular atrial
fibrillation. J Am Coll Cardiol. 1994;24:755–762.
44. Manning WJ, Silverman DI, Keighley CS, Oettgen P, Douglas PS. Trans-
esophageal echocardiographically facilitated early cardioversion from
atrial fibrillation using short-term anticoagulation: final results of a pro-
spective 4.5-year study. J Am Coll Cardiol. 1995;25:1354–1361.
45. Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, Cri-
jns HJ, Damiano RJ Jr, Davies DW, DiMarco J, Edgerton J, Ellenbogen
K, Ezekowitz MD, Haines DE, Haissaguerre M, Hindricks G, Iesaka Y,
Jackman W, Jalife J, Jais P, Kalman J, Keane D, Kim YH, Kirchhof P,
Klein G, Kottkamp H, Kumagai K, Lindsay BD, Mansour M, March-
linski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Nak-
agawa H, Natale A, Nattel S, Packer DL, Pappone C, Prystowsky E,
Raviele A, Reddy V, Ruskin JN, Shemin RJ, Tsao HM, Wilber D; Heart
Rhythm Society Task Force on Catheter and Surgical Ablation of Atrial
Fibrillation. 2012 HRS/EHRA/ECAS expert consensus statement on
catheter and surgical ablation of atrial fibrillation: recommendations
for patient selection, procedural techniques, patient management and
follow-up, definitions, endpoints, and research trial design: a report of
the Heart Rhythm Society (HRS) Task Force on Catheter and Surgi-
cal Ablation of Atrial Fibrillation. Developed in partnership with the
European Heart Rhythm Association (EHRA), a registered branch of
the European Society of Cardiology (ESC) and the European Cardiac
Arrhythmia Society (ECAS); and in collaboration with the American
College of Cardiology (ACC), American Heart Association (AHA),
the Asia Pacific Heart Rhythm Society (APHRS), and the Society of
Thoracic Surgeons (STS). Endorsed by the governing bodies of the
American College of Cardiology Foundation, the American Heart As-

38. Kim YY, Klein AL, Halliburton SS, Popovic ZB, Kuzmiak SA, Sola S,
Garcia MJ, Schoenhagen P, Natale A, Desai MY. Left atrial appendage fill-
ing defects identified by multidetector computed tomography in patients
undergoing radiofrequency pulmonary vein antral isolation: a comparison
with transesophageal echocardiography. Am Heart J. 2007;154:1199–1205.
39. Feuchtner GM, Dichtl W, Bonatti JO, Jodocy D, Müller S, Hintringer F, Gra-
dl J, Klauser A, Cury RC. Diagnostic accuracy of cardiac 64-slice computed
tomography in detecting atrial thrombi. Comparative study with transesopha-
geal echocardiography and cardiac surgery. Invest Radiol. 2008;43:794–801.
40. Hur J, Kim YJ, Nam JE, Choe KO, Choi EY, Shim CY, Choi BW. Throm-
bus in the left atrial appendage in stroke patients: detection with cardiac
CT angiography—a preliminary report. Radiology. 2008;249:81–87.
41. Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA,
Halperin JL, Kay GN, Le Huezey JY, Lowe JE, Olsson SB, Prystowsky
EN, Tamargo JL, Wann LS. 2011 ACCF/AHA/HRS focused updates in-
corporated into the ACC/AHA/ESC 2006 Guidelines for the management
of patients with atrial fibrillation: a report of the American College of
sociation, the European Cardiac Arrhythmia Society, the European
Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia
Pacific Heart Rhythm Society, and the Heart Rhythm Society. Heart
Rhythm. 2012;9:632–696.e21.
46. Bertaglia E, Bella PD, Tondo C, Proclemer A, Bottoni N, De Ponti R,
Landolina M, Bongiorni MG, Corò L, Stabile G, Dello Russo A, Verlato
R, Mantica M, Zoppo F. Image integration increases efficacy of paroxys-
mal atrial fibrillation catheter ablation: results from the CartoMerge Italian
Registry. Europace. 2009;11:1004–1010.
47. Della Bella P, Fassini G, Cireddu M, Riva S, Carbucicchio C, Giraldi F, Mac-
cabelli G, Trevisi N, Moltrasio M, Pepi M, Galli CA, Andreini D, Ballerini G,
Pontone G. Image integration-guided catheter ablation of atrial fibrillation: a
prospective randomized study. J Cardiovasc Electrophysiol. 2009;20:258–265.
48. Jakobs TF, Becker CR, Ohnesorge B, Flohr T, Suess C, Schoepf UJ, Rei-
ser MF. Multislice helical CT of the heart with retrospective ECG gating:
reduction of radiation exposure by ECG-controlled tube current modula-
tion. Eur Radiol. 2002;12:1081–1086.

CLINICAL PERSPECTIVE
Transesophageal echocardiography is currently the gold standard and the only approved imaging modality to evaluate the
presence or absence of left atrial appendage thrombus. The present meta-analysis evaluated the diagnostic accuracy of car-
diac computed tomography (CCT) for this purpose in patients with (1) atrial fibrillation undergoing electric cardioversion/
pulmonary vein isolation or (2) with CVA in 19 studies with a total of 2955 patients. CCT demonstrated to be as accurate as
transesophageal echocardiography, especially when delayed images were acquired yielding weighted mean sensitivity and
specificity of 100% and 99% as well as PPV and NPV of 92% and 100%, respectively, with an overall diagnostic accuracy
of 99%. Of notice, ECG-gating had no impact on our final results. These findings indicate that CCT is a reliable alternative
imaging modality when TTE is contraindicated or not readily available. Moreover, special consideration should be given
to this modality in the setting of patients undergoing pulmonary vein isolation for persistent or paroxysmal atrial fibrilla-
tion, in whom CCT is routinely performed in most medical centers to optimize anatomic characterization of the left atrium/
pulmonary veins by integrating these images into the navigation mapping systems (ie, integrated electroanatomic mapping,
CARTO/ESI). As result, CCT should also be implemented with the objective to rule out left atrial appendage thrombus,
avoiding an unnecessary preprocedural transesophageal echocardiography, which will ultimately reduce costs and save time.