Transesophageal Echocardiographic Evidence of Atrial Fibrillation with Systolic Flow in the Right Atrial Appendage and Systolic Reversal Pulmonary Flow in a Patient with DDD Permanent Pacing

Abstract

We report the case of a patient with atrial fibrillation on standard electrocardiogram who underwent transesophageal echocardiography to rule out presence of thrombi in heart cavities. Pulsed-wave Doppler investigation revealed multiphasic waves consistent with atrial fibrillation in the left atrial appendage, while in the right atrial appendage, a biphasic flow was registered after QRS depolarization. Some hypotheses are made about the origin of this signal.

Systolic Pulmonary and Hepatic Vein Flow Reversal Due to Pacemaker‐Induced Retrograde Ventriculoatrial Conduction

“…Oneglia et al. described a single case of systolic pulmonary vein flow reversals related to VVI pacing, but the presence of concomitant AF confounded this case . Lee and colleagues demonstrated a significantly higher incidence of systolic flow reversals in the pulmonary veins among patients with retrograde VA conduction due to VVI pacing as compared with the DDDR mode, however 67% of their patients in VVI mode also had MR .…”

“…These patterns can be significantly affected by diastolic abnormalities of the heart affecting relaxation and compliance such as restrictive cardiomyopathy, constrictive cardiomyopathy, and diastolic heart failure. Reversal of flow into pulmonary veins from the left atrium during systole has been associated most commonly with severe MR and AF . Similarly, hepatic systolic flow reversal has been most commonly associated with hemodynamically significant tricuspid regurgitation and AF.…”

“…Reversal of flow into pulmonary veins from the left atrium during systole has been associated most commonly with severe MR and AF. [1][2][3] Similarly, hepatic systolic flow reversal has been most commonly associated with hemodynamically significant tricuspid regurgitation and AF. Oneglia et al described a single case of systolic pulmonary vein flow reversals related to VVI pacing, but the presence of concomitant AF confounded this case.…”

“…Similar to these left‐sided events, the hepatic venous flow can show tri‐ or quadriphasic patterns. Systolic pulmonary and hepatic vein flow reversals have been most often associated with significant AV valve regurgitation and atrial fibrillation (AF) . We report the case of profound systolic flow reversals occurring during VVI pacing with 1:1 retrograde ventriculoatrial (VA) conduction.…”

“…Systolic pulmonary and hepatic vein flow reversals have been most often associated with significant AV valve regurgitation and atrial fibrillation (AF). [1][2][3] We report the case of profound systolic flow reversals occurring during VVI pacing with 1:1 retrograde ventriculoatrial (VA) conduction. Symptoms, electrocardiogram (ECG) findings, and the spectral Doppler abnormalities resolved completely following resumption of DDDR pacing.…”