INTRODUCTION Atrial fibrillation (AF) increases the risk of thromboembolic events, including ischemic stroke, by promoting clot formation in the left atrial appendage (LAA). 1 The risk of stroke in patients with AF varies widely depending on age, clinical variables, and cardiac structure or function. Accordingly, several stroke risk stratification systems for AF patients have been developed, with the CHA 2 DS 2 VASc scale being the

Background: Paroxysmal atrial fibrillation (PAF) and paroxysmal supraventricular tachycardia (PSVT) leading to hemodynamic compromise are among the most common reasons for admission to the coronary care unit (CCU) and need prompt and efficient therapy. Direct current cardioversion is the therapy of choice, but if found contraindicated or unavailable some antiarrhythmie agents are usually given to restore sinus rhythm. Many of these drugs have obvious limitations, especially in patients with acute myocardial infarction and/or heart failure. Hypothesis: The aim of the present study was to assess the safety and efficacy of intravenous amiodarone in the acute termination of PAF or PSVT refractory to other antiarrhythmie agents in a large group of patients consecutively admitted to our CCU. Methods: In the present study, we evaluated the safety and efficacy of amiodarone given intravenously in 142 consecutive patients with PAF or PSVT lasting < 24 h. In 37% of patients no evidence of underlying heart disease which may have caused arrhythmias were defined. A median of two other antiarrhythmic agents given prior to the first amiodarone injection had been ineffective. Results: Sinus rhythm was restored in 91 patients (64%) (65% in the PAF group and 61% in the PSVT group). The mean time to rhythm conversion was 5.5 ± 6.1 h for patients with PAF and 1.2 ± 1.2 h for patients with PSVT. The mean dose of amiodarone administered up to conversion was 340 ± 220 mg for PAF and 220 ± 105 mg for PSVT. Except for transient first‐degree atrioventricular block in two patients, no adverse effects possibly related to amiodarone were observed (including proarrhythmia and incidence or aggravation of heart failure symptoms). Conclusion: Amiodarone given intravenously for acute termination of supraventricular tachyarrhythmias is completely safe and seems effective. The results of this study, which is the largest ever made, indicate a need of randomized, controlled trials for the ultimate assessment of the efficacy of amiodarone in this clinical setting.

In non-sedated patients undergoing AF ablation, the micro-TEE can be used for the assessment of the LA, LAA, and pulmonary veins anatomy as well as the guidance of transseptal puncture.

Background-Transesophageal echocardiography (TEE) is the gold standard for the exclusion of thrombi in the left atrial appendage (LAA) before ablation for atrial fibrillation. Intracardiac echocardiography (ICE) is used to assist atrial fibrillation ablation; however, it can also be used for LAA imaging. The aim of our study was to determine whether ICE could replace TEE and to identify the optimal ICE placement for LAA visualization. Methods and Results-Seventy-six consecutive patients (56 men; mean age, 55±9.6 years) scheduled for atrial fibrillation ablation underwent TEE before the procedure and LAA assessment by ICE. An 8F AcuNav probe was introduced into right atrium, pulmonary artery, and coronary sinus. LAA structure was analyzed by the echocardiographer and electrophysiologist who were blinded to the results of TEE. ICE probe was positioned in the right atrium in all patients, in the pulmonary artery in 64 of 74 (86%) patients, and in the coronary sinus in 49 of 74 (66%) patients. The LAA was properly visualized in 56 of 64 (87.5%) patients from the pulmonary artery versus 13 of 49 (26%) patients from the coronary sinus (P<0.001). From the right atrium, the whole LAA cavity could not be seen in any patient. In those patients in whom LAA was visualized properly by ICE, a perfect agreement between ICE and TEE was obtained (both techniques detected LAA thrombus in 2 patients and excluded LAA thrombus in the remaining patients). Conclusions-ICE

Background Transesophageal echocardiography (TEE) remains the gold standard for exclusion of left atrial appendage (LAA) thrombus in patients scheduled for direct electrical cardioversion (DEC) or atrial fibrillation (AF) ablation. Recently, intracardiac echocardiography (ICE) of the pulmonary artery (PA) has been shown to provide excellent LAA images and to be useful in verification of equivocal TEE findings. Hypothesis ICE of the PA may have a role in detecting false‐positive TEE results. Methods Twenty‐one patients (12 male, age 65 ± 8 years, CHADS2VASC2 score [congestive heart failure, hypertension, age ≥ 75, age 65‐74, diabetes mellitus, stroke/TIA/thrombo‐embolism, vascular disease, sex female] = 2.2; HAS‐BLED score [hypertension, abnormal renal and liver function, stroke, bleeding, labile International Normalized Ratio, elderly, drugs or alcohol] = 1.1), in whom a thrombus in the LAA was detected during TEE before DEC or AF ablation, underwent ICE of the PA. Results On TEE, in 7 (33%) patients, the LAA thrombus was described as “solid” and in the remaining 14 (67%) as “soft.” Disagreement between the TEE and ICE (thrombus in TEE and no thrombus in ICE) was found in 9 (43%) patients. In the solid thrombus group, ICE confirmed thrombi existence in 6 and excluded thrombi in 1 patient. In the soft thrombus group, ICE confirmed thrombi in 6 patients and excluded thrombi in the remaining 8 patients. Of the demographic and clinical variables, only the longstanding persistent type of AF was significantly associated with the presence of an LAA thrombus detected both by TEE and ICE. Conclusions With TEE, a false positive of an LAA thrombus may be indicated, especially when a thrombus is described as soft rather than solid. Our study suggests that ICE may be a valuable option for verification of a TEE‐based diagnosis of a thrombus.