Safety and Feasibility of a CT‐Based Pathway for Left Atrial Appendage Assessment Prior to Inpatient Cardioversion: A Single‐Center Experience

BACKGROUND: Transesophageal echocardiography (TEE) for left atrial appendage (LAA) thrombus exclusion before cardioversion faces logistical barriers including limited availability, patient intolerance, and procedural delays. We evaluated the feasibility and short-term safety of a cardiac CT-based alternative pathway in hospitalized patients with atrial fibrillation (AF). METHODS: This retrospective single-center study included 408 consecutive AF inpatients planned for cardioversion. The primary endpoint was the composite of stroke/TIA or systemic embolism within 48 h post-cardioversion. Secondary endpoints included 30-day thromboembolic events, acute kidney injury, and all-cause mortality at 30 days and 1 year. Imaging modality selection was based on availability, clinical factors, and contraindications. RESULTS: Among 74 patients undergoing CT-guided cardioversion and 206 undergoing TEE-guided cardioversion, no strokes or TIAs occurred within 48 h in either group (0/74 CT vs. 0/206 TEE, p = 1.0). By 30 days, one TIA occurred in the CT group (1.4%) and none in the TEE group (0%), representing an absolute risk difference of +1.4% (95% CI: -0.8% to +7.3%; p = 0.26). Acute kidney injury occurred in 8.1% of CT patients compared with 3.9% in the TEE group (absolute risk difference +4.2%, 95% CI: -1.4% to +12.9%; OR 2.18, 95% CI: 0.60-7.45; p = 0.21). No mortality was observed at 30 days or 1 year. CONCLUSIONS: In this single-center feasibility analysis, a CT-based imaging pathway for LAA assessment prior to cardioversion was associated with no periprocedural thromboembolic events and acceptable short-term safety. Prospective randomized trials are needed to define the clinical role of CT as an alternative to TEE.