Introduction Transoesophageal echocardiography (TOE) is the modality of choice for diagnosing aortic atheroma. This is characterized by irregular intimal thickening of at least 2 mm, and has been shown to be associated with an increased risk of ischaemic stroke. Based on the association between aortic atheroma and ischaemic stroke, the 2016 European Society of Cardiology guidelines allocate of a CHA2DS2-VASc score of one for patients with documented evidence of aortic atheroma. During TOE guided direct current cardioversion (DCCV) for atrial fibrillation or atrial flutter, the primary goal is to assess for intra-cardiac thrombus, primarily in the left atrial appendage. Additional assessment of the aorta during this procedure provides valuable information in a patient group that require accurate assessment of their long-term stroke risk.
Methods This single centre retrospective analysis assessed all TOE guided cardioversions performed in a tertiary referral centre between 1st January 2017 and 31st December 2017. Images from the procedures were assessed by a Consultant cardiologist who was blinded from the patient’s clinical information. The degree of Aortic atheroma was assessed according to the five-point Katz grading criteria. A score of 2 or more on the Katz grading system was used to determine clinically significant atheroma.
Results A total of 97 TOE guided cardioversions were performed during the 15 month period. Full clinical information was available 90 patients. 28 studies (31%) had adequate visualisation of the aorta to allow atherosclerotic severity to be graded. 41 of 90 patients were low risk patients, with a CHA2DS2-VASc score of 0 or 1 (45%). The average CHA2DS2-VASc score of all patients was 1.8 (±1.6) prior to assessment of the aorta. 14 of 28 patients (50%) had aortic atheroma grade 2 or more (figure 1), the likelihood finding atheroma and the severity increased with age (figure 2). When aortic atheroma was assessed, the average CHA2DS2-VASc score increased to 2.25 (±1.8). Recalculation of the patient’s CHA2DS2-VASc score with this additional information increased the score in 11 of 14 cases.
Conclusions Assessment of aortic atheroma at time of TOE guided cardioversion provides important information that can enable a more accurate assessment of a patient’s long-term stroke risk. It is present in a significant proportion of patients undergoing TOE guided cardioversion and therefore should be routinely assessed and documented. We have shown that aortic atheroma can be present in low risk patients, and this can transition the patient from a low to medium risk group requiring long term anticoagulation.
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