Combined Pulmonary Vein and LA/LAA Thrombus Assessment: Can CMR Kill Two Birds With One Stone?

A trial fibrillation is the most common sustained arrhythmia worldwide (1), and catheter-based pulmonary vein isolation (PVI) is becoming a dominant approach to its management. Stroke and transient ischemic attack are known risks of PVI (2). To improve PVI safety, atrial thrombus needs to be excluded. Traditionally, patients undergo elective computed tomography angiography or magnetic resonance angiography (MRA) before PVI for characterization of pulmonary vein anatomy and transesophageal echocardiography (TEE) immediately before the PVI to exclude atrial thrombi. Despite being the gold standard for detection of atrial and atrial appendage thrombi (3), TEE is moderately invasive. Because TEE does not optimally image the pulmonary veins, patients routinely undergo both MRA (or computed tomography angiography) as well as TEE, increasing health care costs and patient inconvenience. It would be preferable to have a single noninvasive imaging modality that allowed for both pulmonary vein evaluation and exclusion of atrial and atrial appendage thrombi.