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Differentiation of left atrial appendage thrombus from circulatory stasis using cardiac CT radiomics in patients with valvular heart disease

  • Cardiac
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Abstract

Objectives

To determine whether quantitative radiomic features from cardiac CT could differentiate the left atrial appendage (LAA) thrombus from circulatory stasis in patients with valvular heart disease.

Methods

Ninety-five consecutive patients with valvular heart disease and filling defects in LAA on two-phase cardiac CT from March 2016 to August 2018 were retrospectively enrolled and classified as having thrombus or stasis by transesophageal echocardiography or cardiac surgery. The ratio of Hounsfield units in the filling defects to those in the ascending aorta (AA) was calculated on early- and late-phase CT (LAA/AAE and LAA/AAL, respectively). Radiomic features were extracted from semi-automated three-dimensional segmentation of the filling defect on early-phase CT. The diagnostic ability of radiomic features for differentiating thrombus from stasis was assessed and compared to LAA/AAE and LAA/AAL by comparing the AUC of ROC curves. Diagnostic performances of CT attenuation ratios and radiomic features were validated with an independent validation set.

Results

Thrombus was diagnosed in 25 cases and stasis in 70. Sixty-eight radiomic features were extracted. Values of 8 wavelet-transformed features were lower in thrombus than in stasis (p < 0.001). The AUC value of a radiomic feature, wavelet_LHL, for diagnosing thrombus was 0.78, which was higher than that of LAA/AAE (AUC = 0.54, p = 0.025) and similar to that of LAA/AAL (AUC = 0.76, p = 0.773). In the validation set, the AUC of wavelet_LHL was 0.71, which was higher than that of LAA/AAE (AUC = 0.57, p = 0.391) and similar to that of LAA/AAL (AUC = 0.75, p = 0.707).

Conclusions

Quantitative radiomic features from the early phase of cardiac CT may help diagnose LAA thrombus in patients with valvular heart disease.

Key Points

• Wavelet-transformed grey-level non-uniformity values from radiomic analysis are significantly lower for LAA thrombus than for circulatory stasis.

• Radiomic features may have an additional value for differentiating LAA thrombus from circulatory stasis when interpreting single-phase cardiac CT.

• Radiomic features extracted from single-phase images may show similar diagnostic ability as conventional quantitative analysis from two-phase images.

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Abbreviations

AA:

Ascending aorta

AF:

Atrial fibrillation

CI:

Confidence interval

GLCM:

Grey-level co-occurrence matrix

GLRLM:

Grey-level run-length matrix

H:

High-pass filter

ICC:

Intraclass correlation coefficient

L:

Low-pass filter

LAA:

Left atrial appendage

TEE:

Transesophageal echocardiography

References

  1. Al-Saady NM, Obel OA, Camm AJ (1999) Left atrial appendage: structure, function, and role in thromboembolism. Heart 82:547–554

    Article  CAS  Google Scholar 

  2. Beigel R, Wunderlich NC, Ho SY, Arsanjani R, Siegel RJ (2014) The left atrial appendage: anatomy, function, and noninvasive evaluation. JACC Cardiovasc Imaging 7:1251–1265

    Article  Google Scholar 

  3. (1994) Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med 154:1449-1457

  4. Ozkan M, Kaymaz C, Kirma C et al (1998) Predictors of left atrial thrombus and spontaneous echo contrast in rheumatic valve disease before and after mitral valve replacement. Am J Cardiol 82:1066–1070

    Article  CAS  Google Scholar 

  5. Fatkin D, Kelly RP, Feneley MP (1994) Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast and thromboembolic risk in vivo. J Am Coll Cardiol 23:961–969

    Article  CAS  Google Scholar 

  6. Doufekias E, Segal AZ, Kizer JR (2008) Cardiogenic and aortogenic brain embolism. J Am Coll Cardiol 51:1049–1059

    Article  Google Scholar 

  7. Mirdamadi A, Mirmohammadsadeghi M, Marashinia F, Nourbakhsh M (2013) Left atrial appendage occlusion. Int J Prev Med 4:102–104

    PubMed  PubMed Central  Google Scholar 

  8. Zhan Y, Joza J, Al Rawahi M et al (2018) Assessment and management of the left atrial appendage thrombus in patients with nonvalvular atrial fibrillation. Can J Cardiol 34:252–261

    Article  Google Scholar 

  9. Fuster V, Ryden LE, Cannom DS et al (2011) 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 123:e269–e367

    PubMed  Google Scholar 

  10. Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D’Ambra MN, Eltzschig HK (2010) Safety of transesophageal echocardiography. J Am Soc Echocardiogr 23:1115–1127 quiz 1220-1111

    Article  Google Scholar 

  11. Romero J, Husain SA, Kelesidis I, Sanz J, Medina HM, Garcia MJ (2013) Detection of left atrial appendage thrombus by cardiac computed tomography in patients with atrial fibrillation: a meta-analysis. Circ Cardiovasc Imaging 6:185–194

    Article  Google Scholar 

  12. Hur J, Kim YJ, Lee HJ et al (2011) Dual-enhanced cardiac CT for detection of left atrial appendage thrombus in patients with stroke: a prospective comparison study with transesophageal echocardiography. Stroke 42:2471–2477

    Article  Google Scholar 

  13. Teunissen C, Habets J, Velthuis BK, Cramer MJ, Loh P (2017) Double-contrast, single-phase computed tomography angiography for ruling out left atrial appendage thrombus prior to atrial fibrillation ablation. Int J Cardiovasc Imaging 33:121–128

    Article  Google Scholar 

  14. Hur J, Kim YJ, Lee HJ et al (2012) Cardioembolic stroke: dual-energy cardiac CT for differentiation of left atrial appendage thrombus and circulatory stasis. Radiology 263:688–695

    Article  Google Scholar 

  15. Nam K, Suh YJ, Han K, Park SJ, Kim YJ, Choi BW (2019) Value of computed tomography radiomic features for differentiation of periprosthetic mass in patients with suspected prosthetic valve obstruction. Circ Cardiovasc Imaging 12:e009496

    Article  Google Scholar 

  16. Kolossvary M, Karady J, Szilveszter B et al (2017) Radiomic features are superior to conventional quantitative computed tomographic metrics to identify coronary plaques with napkin-ring sign. Circ Cardiovasc Imaging:10

  17. Kolossvary M, Kellermayer M, Merkely B, Maurovich-Horvat P (2018) Cardiac computed tomography radiomics: a comprehensive review on radiomic techniques. J Thorac Imaging 33:26–34

    Article  Google Scholar 

  18. Daimee MA, Salama AL, Cherian G, Hayat NJ, Sugathan TN (1998) Left atrial appendage function in mitral stenosis: is a group in sinus rhythm at risk of thromboembolism? Int J Cardiol 66:45–54

    Article  CAS  Google Scholar 

  19. Chiang CW, Lo SK, Ko YS, Cheng NJ, Lin PJ, Chang CH (1998) Predictors of systemic embolism in patients with mitral stenosis. A prospective study. Ann Intern Med 128:885–889

    Article  CAS  Google Scholar 

  20. Vigna C, Russo A, De Rito V et al (1992) Frequency of left atrial thrombi by transesophageal echocardiography in idiopathic and in ischemic dilated cardiomyopathy. Am J Cardiol 70:1500–1501

    Article  CAS  Google Scholar 

  21. Hur J, Kim YJ, Lee HJ et al (2009) Left atrial appendage thrombi in stroke patients: detection with two-phase cardiac CT angiography versus transesophageal echocardiography. Radiology 251:683–690

    Article  Google Scholar 

  22. Kim SC, Chun EJ, Choi SI et al (2010) Differentiation between spontaneous echocardiographic contrast and left atrial appendage thrombus in patients with suspected embolic stroke using two-phase multidetector computed tomography. Am J Cardiol 106:1174–1181

    Article  Google Scholar 

  23. DeLong ER, DeLong DM, Clarke-Pearson DL (1988) Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 44:837–845

    Article  CAS  Google Scholar 

  24. Tani T, Yamakami S, Matsushita T et al (2003) Usefulness of electron beam tomography in the prone position for detecting atrial thrombi in chronic atrial fibrillation. J Comput Assist Tomogr 27:78–84

    Article  Google Scholar 

  25. Kawaji T, Numamoto H, Yamagami S et al (2019) Real-time surveillance of left atrial appendage thrombus during contrast computed tomography imaging for catheter ablation: THe Reliability of cOMputed tomography Beyond UltraSound in THROMBUS detection (THROMBUS) study. J Thromb Thrombolysis 47:42–50

    Article  Google Scholar 

  26. Sawit ST, Garcia-Alvarez A, Suri B et al (2012) Usefulness of cardiac computed tomographic delayed contrast enhancement of the left atrial appendage before pulmonary vein ablation. Am J Cardiol 109:677–684

    Article  Google Scholar 

  27. Li R, Xing L, Napel S, Rubin DL (2019) Radiomics and radiogenomics: technical basis and clinical applications (imaging in medical diagnosis and therapy), 1st edn. Chapman and Hall/CRC, USA

    Book  Google Scholar 

Download references

Acknowledgements

This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (2018R1C1B6007251) and a faculty research grant of Yonsei University College of Medicine (6-2018-0041).

Funding

This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (2018R1C1B6007251) and a faculty research grant of Yonsei University College of Medicine (6-2018-0041).

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Authors and Affiliations

  1. Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea

    Sei Hyun Chun, Young Joo Suh, Kyunghwa Han, Young Jin Kim & Byoung Wook Choi

  2. Department of Radiology, Seoul National University College of Medicine, Institute of Radiation Medicine, Seoul National University Medical Research Center, Cancer Research Institute, Seoul National University, Seoul, Republic of Korea

    Sang Joon Park

  3. Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea

    Chi Young Shim & Geu-Ru Hong

  4. Department of Cardiothoracic Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea

    Sak Lee & Seung-Hyun Lee

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  1. Sei Hyun Chun
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Correspondence to Young Joo Suh.

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The scientific guarantor of this publication is Byoung Wook Choi.

Conflict of interest

Dr. Sang Joon Park is CEO of MEDICAL IP.

Statistics and biometry

One of the authors, Dr. Kyunghwa Han, has significant statistical expertise.

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Written informed consent was waived by the institutional review board.

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Chun, S.H., Suh, Y.J., Han, K. et al. Differentiation of left atrial appendage thrombus from circulatory stasis using cardiac CT radiomics in patients with valvular heart disease. Eur Radiol 31, 1130–1139 (2021). https://doi.org/10.1007/s00330-020-07173-1

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  • DOI: https://doi.org/10.1007/s00330-020-07173-1

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