Left Atrial Chamber and Appendage Function After Internal Atrial Defibrillation: A Prospective and Serial Transesophageal Echocardiographic Study

Omran, Heyder; Jung, Werner; Rabahieh, Rami; Schimpf, Rainer; Wolpert, Christian; Hagendorff, Andreas; Fehske, Wolfgang; Lüderitz, Berndt

doi:10.1016/s0735-1097(96)00439-1

Cited by 105 publications

(42 citation statements)

References 18 publications

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“…Top, patient with CBE;Bottom, control subject; Right, maximumLAAarea; Left, minimumLAAarea (transverse plane by transesophageal echocardiograms). It has been clearly shown that left atrial dysfunction due to atrial stunning can be recovered for dozens of minutes after the cessation of PAF, whereas, prolongation of the atrial stunning has been suggested to play a critical role in the thrombus formation in LAA by experimental studies (39)(40)(41)(42) Previous clinical reports demonstrate that the nature of altered coagulation and fibrinolysis are different in various subtypes of ischemic stroke (45). Especially, plasma levels of D-dimer and thrombin-antithrombin III complex are significantly higher in cases with cardioembolic stroke, compared with atherothrombotic or lacunar stroke (46).…”

Section: Resultsmentioning

confidence: 99%

Direct Evidence that Sustained Dysfunction of Left Atrial Appendage Contributes to the Occurrence of Cardiogenic Brain Embolism in Patients with Paroxysmal Atrial Fibrillation

et al. 2003

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Objective The goal of this study was to investigate transesophageal echocardiographic (TEE) findings after the termination of atrial fibrillation to clarify the direct evidence for occurrence of acute cardiogenic brain embolism (CBE) in patients with paroxysmal atrial fibrillation (PAF).Patients and Methods Among98 consecutive patients with CBE, we investigated TEE in 16 patients with PAF (Group CBE, 72±10 years) within 7 days of the onset and 2 weeks after the first study, in comparison with 15 agematched PAF patients without CBE(Group N). The duration from reversal to normal sinus rhythm to first TEE was 6±1 days in both groups. Results There were no significant differences in left atrial dimension and emptying flow velocity of the left atrial appendage (LAA-eV) between groups. Group CBE had significantly larger LAA area (4.3±1.3 cm2 vs. 3.1±1.0 cm2, p<0.05), smaller LAAfractional area change (LAA-FAC) (43±25% vs. 80±22%, p<0.001), and a higher incidence of left atrial spontaneous echo contrast (LAA-SEC) (25% vs. 7%, p<0.05) than group N, and those abnormalities in group CBEwere significantly improved at the second TEE (LAA area: to 3.2±0.9 cm2, p<0.05; LAA-FAC: to 84±26%, p<0.001; LAA-SEC: to 0%, p<0.05),respectively. Conclusion LAA-FAC is a more sensitive marker for LAAdysfunction than the widely used index, LAA-eV, and a sustained deterioration of LAA-FACmay be direct evidence for thrombus formation and occurrence of acute CBE in patients with PAF.

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Section: Resultsmentioning

confidence: 99%

Direct Evidence that Sustained Dysfunction of Left Atrial Appendage Contributes to the Occurrence of Cardiogenic Brain Embolism in Patients with Paroxysmal Atrial Fibrillation

et al. 2003

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“…The mechanism seems to be a 'stunning' of the left atrial appendage in cardioversion first reported during direct current conversion where patients developed a new spontaneous echo contrast and impaired velocities in the left atrial appendage, which could predispose to thrombus formation [12,34] . One embolic event has been described in a patient with a therapeutic anticoagulation level without thrombus formation but with a low velocity flow in the left atrial appendage and spontaneous echo contrast, after internal cardioversion with a lower energy than that needed for direct currentcardioversion [35] . A proposed mechanism has been administration of electrical energy.…”

Section: Thrombi and Velocities In The Left Atrial Appendagementioning

confidence: 99%

Transoesophageal echocardiography-guided cardioversion of atrial fibrillation or flutter. Selection of a low-risk group for immediate cardioversion

Roijer

Eskilsson

Olsson

2000

European Heart Journal

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Aims Despite exclusion of left atrial thrombi by transoesophageal echocardiography, cardioversion-related thromboembolism has been reported in atrial fibrillation or flutter. To define a low-risk group for cardioversion without previous anticoagulation, patients were selected for immediate cardioversion if there were no thrombi, no echo spontaneous contrast and the outflow velocity of the left atrial appendage was greater than 0·25 m . s 1 on transoesophageal echocardiography. Methods and ResultsTwo hundred and forty-two consecutive patients referred for cardioversion of atrial fibrillation or flutter with a duration of more than 2 days and no anticoagulation therapy were examined with transoesophageal echocardiography. After the transoesophageal echocardiography examination, patients who were eligible for immediate cardioversion were anticoagulated with low molecular weight heparin (dalteparin) subcutaneously, together with warfarin prior to cardioversion. Dalteparin treatment was continued until the patient had reached therapeutic prothrombin values.Based on the transoesophageal echocardiographic findings the patients were divided into two groups: immediate cardioversion, group A, with a mean age of 62 13 years (n=162); or conventional warfarin treatment before cardioversion, group B, with a mean age of 67 10 years (P<0·05) (n=80). In group A, lone atrial fibrillation or flutter was more common (53%; 95% CI: 45-61) compared to group B (34%; 95% CI: 23-44, P<0·05), while heart disease was more common in group B (45%; 95% CI: 34-56) compared to group A (31%; 95% CI: 24-39, P<0·05). Echocardiography revealed thrombi in 5% (95% CI: 2·6-8) of the patients, left atrial size was larger, fractional shortening lower, and a higher proportion had impaired left ventricular function in group B. No thromboembolic event occurred at or after cardioversion in any of the patients; however, before planned cardioversion one transitory ischaemic attack, one lethal stroke and one cardiac death occurred in three of the patients with thrombi despite warfarin therapy. One-month follow-up maintenance of sinus rhythm was 75% in group A compared to 45% in group B (P<0·01).Conclusion After using our transoesophageal echocardiographic exclusion criteria (no thrombi, no spontaneous echo contrast and left atrial appendage outflow velocity d0·25 m . s 1 ) cardioversion can safely be performed in 2/3 of patients with atrial fibrillation or flutter without previous anticoagulation therapy. These patients maintained sinus rhythm significantly better after 1 month compared to patients with prolonged warfarin therapy before cardioversion.

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“…It is known that LAA contractile dysfunction present immediately after cessation of AF by successful cardioversion recovers gradually to levels approximately equivalent to that in control groups within 1 week [11,12,13]. Few prior studies measured LAA flow after long-term maintenance of sinus rhythm.…”

Section: Discussionmentioning

confidence: 99%

Identification of Good Responders to Rhythm Control of Paroxysmal and Persistent Atrial Fibrillation by Transthoracic and Transesophageal Echocardiography

Wang

Lin

et al. 2005

Cardiology

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Background: Identification of good responders to rhythm control in the management of atrial fibrillation (AF) is worthwhile in terms of increasing hemodynamic benefit and decreasing the likelihood of unstable anticoagulation even after the Atrial Fibrillation Follow-Up Investigation of Rhythm Management. Methods: We tested the hypothesis that atrial substrate determines the risk of recurrence on rhythm control both in patients with paroxysmal AF (PAF) and in those with persistent or sustained AF (≧1 week, SAF). There were 90 consecutive patients (mean age 63 ± 12 years, 67 males and 23 females) with previous PAF (n = 66) or SAF (n = 24). They were maintained in sinus rhythm successfully for at least 1 month after conversion and then studied by transthoracic and transesophageal echocardiography. All of the patients were followed regularly by determination of symptoms, 12-lead ECG and intermittent Holter recording to determine recurrence of AF after echocardiographic study. Results: After 9.1 ± 3.8 (range 3–12) months of follow-up, 23 of the 90 (26%) patients had documented recurrence of AF (67 without recurrence). Univariate analysis of demographic characteristics, medications, ECG and echocardiographic parameters revealed that, compared with the group of patients without recurrent AF, the group of those with it included more members of the SAF group (11/27 vs. 13/67, p = 0.039), included more male subjects (22/23 vs. 45/67, p = 0.045), had a larger left atrial volume index (LAVI; 27 ± 9 vs. 22 ± 9 ml/m², p = 0.024) and had lower LA appendage peak emptying velocity (LAAPEV; 42 ± 15 vs. 55 ± 22 cm/s, p = 0.01). Multivariate Cox proportional hazards regression analysis adjusted for age, gender and AF group revealed that patients with LAVI <30 ml/m² and LAAPEV >46 cm/s had the least recurrence of AF (relative risk 0.18, 95% confidence interval 0.06–0.55, vs. with LAVI >30 ml/m² or LAAPEV <46 cm/s, p = 0.002). Kaplan-Meier probability of freedom from AF recurrence was significantly better when LAVI <30 ml/m² (log-rank p = 0.02), LAAPEV > 46 cm/s (p = 0.013) or both (p = 0.004). The superiority to predict the rate of sinus rhythm maintenance was the same in the PAF and SAF groups. Conclusions: Good responders to rhythm control in the PAF and SAF groups share the characteristics of smaller LA volume and better LAA contractile function, emphasizing the critical role of atrial substrate remodeling in recurrence of AF.

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Left Atrial Chamber and Appendage Function After Internal Atrial Defibrillation: A Prospective and Serial Transesophageal Echocardiographic Study

Cited by 105 publications

References 18 publications

Direct Evidence that Sustained Dysfunction of Left Atrial Appendage Contributes to the Occurrence of Cardiogenic Brain Embolism in Patients with Paroxysmal Atrial Fibrillation

Direct Evidence that Sustained Dysfunction of Left Atrial Appendage Contributes to the Occurrence of Cardiogenic Brain Embolism in Patients with Paroxysmal Atrial Fibrillation

Transoesophageal echocardiography-guided cardioversion of atrial fibrillation or flutter. Selection of a low-risk group for immediate cardioversion

Identification of Good Responders to Rhythm Control of Paroxysmal and Persistent Atrial Fibrillation by Transthoracic and Transesophageal Echocardiography

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