Patients undergoing atrial fibrillation (AFib) ablation who were not properly anticoagulated and did not undergo preprocedural transesophageal echocardiogram (TEE) were significantly more likely to suffer from transient ischemic attack (TIA) or pulmonary embolism (PE), according to a recent study published in the Journal of Atrial Fibrillation & Electrophysiology.

Using data captured by ACC's AFib Ablation Registry from 2016 to 2020, Brent Klinkhammer, MD, PharmD, et al., included 34,309 patients, 17,730 of whom underwent preprocedural TEE. They employed a retrospective analysis to review trends in the use of TEE prior to an ablation procedure and corresponding patient outcomes.

Several patient factors were associated with pre-ablation TEE, including male sex, higher BMI, higher CHA₂DS₂-VASc score and left ventricular dysfunction. Meanwhile, patients with preprocedural CT, paroxysmal AFib, sleep apnea and the use of preprocedural anticoagulation were less likely to have pre-ablation TEE.

"This study also found other predictors of pre-ablation TEE which are more difficult to explain," add the authors. "We speculate that confounding factors may have impacted the results of this analysis in regard to the negative correlation between diabetes and pre-ablation TEE."

The authors note a significant decline in preprocedural TEE from 59.6% in 2016 to 47.7% in 2020 (p<0.0001), and patients who were not anticoagulated and did not undergo preprocedural TEE had a significantly higher risk of procedural or in-hospital TIA (odds ratio [OR] 1.31: 0.13-0.73, p=0.0041) and PE (OR 0.20: 0.07-0.58, p=0.0014).

"This largest-of-its-kind, real-world study underscores the importance of a systemic approach to preprocedural imaging and anticoagulation management and gives clarity to the safety of TEE in this clinical setting," the authors write. "Future [AFib] guidelines should define the standard of care practices for preprocedural imaging and anticoagulation prior to [AFib] ablation procedures."