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Yamaguchi T. Atrial structural remodeling and atrial fibrillation substrate: A histopathological perspective. J Cardiol 2024:S0914-5087(24)00096-0. [PMID: 38810728 DOI: 10.1016/j.jjcc.2024.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/16/2024] [Accepted: 05/21/2024] [Indexed: 05/31/2024]
Abstract
Atrial fibrillation (AF) substrate progresses with the advancement of atrial structural remodeling, resulting in AF perpetuation and recurrence. Although fibrosis is considered a hallmark of atrial structural remodeling, the histological background has not been fully elucidated because obtaining atrial specimens is difficult, especially in patients not undergoing open-heart surgery. Bipolar voltage reduction evaluated using electroanatomic mapping during AF ablation is considered a surrogate marker for the progression of structural remodeling; however, histological validation is lacking. We developed an intracardiac echocardiography-guided endomyocardial atrial biopsy technique to evaluate atrial structural remodeling in patients undergoing catheter ablation for nonvalvular AF. The histological factors associated with a decrease in bipolar voltage were interstitial fibrosis, as well as an increase in myocardial intercellular space preceding fibrosis, myofibrillar loss, and a decrease in cardiomyocyte nuclear density, which is a surrogate marker for cardiomyocyte density. Cardiomyocyte hypertrophy is closely associated with a decrease in cardiomyocyte nuclear density, suggesting that hypertrophic changes compensate for cardiomyocyte loss. Electron microscopy also revealed that increased intercellular spaces indicated the leakage of plasma components owing to increased vascular permeability. Additionally, amyloid deposition was observed in 4 % of biopsy cases. Only increased intercellular space and interstitial fibrosis were significantly higher for long-standing persistent AF than for paroxysmal AF and associated with recurrence after AF ablation, suggesting that this interstitial remodeling is the AF substrate. An increase in intercellular space that occurs early in AF formation is a therapeutic target for the AF substrate, which prevents irreversible interstitial degeneration due to collagen accumulation. This endomyocardial atrial biopsy technique will allow the collection of atrial tissue from a wide variety of patients and significantly facilitate the elucidation of the mechanisms of atrial cardiomyopathy, structural remodeling, and AF substrates.
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Pozios I, Vouliotis AI, Dilaveris P, Tsioufis C. Electro-Mechanical Alterations in Atrial Fibrillation: Structural, Electrical, and Functional Correlates. J Cardiovasc Dev Dis 2023; 10:jcdd10040149. [PMID: 37103028 PMCID: PMC10141162 DOI: 10.3390/jcdd10040149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Atrial fibrillation is the most common arrhythmia encountered in clinical practice affecting both patients’ survival and well-being. Apart from aging, many cardiovascular risk factors may cause structural remodeling of the atrial myocardium leading to atrial fibrillation development. Structural remodelling refers to the development of atrial fibrosis, as well as to alterations in atrial size and cellular ultrastructure. The latter includes myolysis, the development of glycogen accumulation, altered Connexin expression, subcellular changes, and sinus rhythm alterations. The structural remodeling of the atrial myocardium is commonly associated with the presence of interatrial block. On the other hand, prolongation of the interatrial conduction time is encountered when atrial pressure is acutely increased. Electrical correlates of conduction disturbances include alterations in P wave parameters, such as partial or advanced interatrial block, alterations in P wave axis, voltage, area, morphology, or abnormal electrophysiological characteristics, such as alterations in bipolar or unipolar voltage mapping, electrogram fractionation, endo-epicardial asynchrony of the atrial wall, or slower cardiac conduction velocity. Functional correlates of conduction disturbances may incorporate alterations in left atrial diameter, volume, or strain. Echocardiography or cardiac magnetic resonance imaging (MRI) is commonly used to assess these parameters. Finally, the echocardiography-derived total atrial conduction time (PA-TDI duration) may reflect both atrial electrical and structural alterations.
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3
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Ito T, Suwa M. Assessment of left atrial appendage function by echocardiography. Heart Fail Rev 2023:10.1007/s10741-023-10298-2. [PMID: 36800057 DOI: 10.1007/s10741-023-10298-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2023] [Indexed: 02/18/2023]
Abstract
The left atrial appendage (LAA) is considered not only to be the most frequent site of thrombus formation, but also to play a pivotal role in maintaining normal cardiac function. Transesophageal echocardiography (TEE) is widely used to assess LAA function. The LAA flow velocity has been used as a surrogate for LAA function, and it varies with multiple interrelated factors including age, hemodynamics, type of arrhythmia, and antiarrhythmic interventions. Relatively great importance of LAA function is involved with intraatrial thrombus formation and subsequent thromboembolism, and thus, understanding of characteristics and behaviors of the LAA under various clinical conditions may help determine strategies against atrial thrombosis. Also, techniques other than TEE-derived Doppler to assess LAA function, such as tissue Doppler imaging, have been proposed. In this review, we introduce clinical and echocardiographic correlates of LAA function, the LAA flow velocity in particular, its significance, and how to interpret functional patterns of the LAA each relevant to specific clinical settings.
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Affiliation(s)
- Takahide Ito
- Department of Cardiology, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-Machi, Takatsuki, Osaka, 569-8686, Japan.
| | - Michihiro Suwa
- Cardiovascular Division, Hokusetsu General Hospital, Takatsuki, Japan
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Zhong XF, Liu DS, Zheng YQ, Peng GJ, Sheng YY, Chen LX, Liu YY. Left atrial reservoir and pump function after catheter ablation with persistent atrial fibrillation: a two-dimensional speckle tracking imaging study. Acta Cardiol 2022; 78:331-340. [PMID: 35904446 DOI: 10.1080/00015385.2022.2076308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE By using ultrasound strain rate (SR) imaging to evaluate the left atrial (LA) reservoir and pump function after catheter ablation (CA) with persistent atrial fibrillation (PAF). METHODS A total of 45 patients with PAF underwent echocardiography examination before and after ablation as well as during 6 months of follow-up. Peak SR was measured at each LA segment (septal, lateral, anterior, inferior and posterior) during systole (LAs) and late diastole (LAa). RESULTS During 6 months after CA, 30 patients were free of atrial fibrillation recurrence (AFR). left atrial area index (LAAI), left atrial maximum volume index (LAVImax), and E/Ea were obviously higher in patients with before CA, left atrial ejection fraction (LAEF), SR-LAs were lower than in normal cases, the SR-LAa was disappeared. Shortly after ablation, SR-LAa was recovered, and SR-LAs was reduced compared to those at baseline. At midterm follow-up, LAEF and SR-LAs were still lower than the control group, and LAAI and LAVImax were higher. SR-LAa was recovered slowly over time, but still lower. CONCLUSION LA reservoir function was seriously damaged and LA pump function disappeared in patients with PAF. LA reservoir function impairment appeared shortly after ablation, it showed improvement at midterm follow-up, but some degree of damage to the LA reservoir and pump function was still present. Speckle tracking imaging is a feasible technique for the assessment of LA function in patients with PAF, which is a potentially valuable clinical tool to assist in the early detection of atrial remodelling and reverse remodelling.
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Affiliation(s)
- Xiao-Fang Zhong
- Department of Ultrasound, Shenzhen Medical Ultrasound Engineering Center, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Dong-Sheng Liu
- Department of Pain Management, Peking University Shenzhen Hospital, Shenzhen, China
| | - Ying-Qi Zheng
- Department of Ultrasound, Shenzhen Medical Ultrasound Engineering Center, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Gui-Juan Peng
- Department of Ultrasound, Shenzhen Medical Ultrasound Engineering Center, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Yuan-Yuan Sheng
- Department of Ultrasound, Shenzhen Medical Ultrasound Engineering Center, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Li-Xin Chen
- Department of Ultrasound, Shenzhen Medical Ultrasound Engineering Center, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Ying-Ying Liu
- Department of Ultrasound, Shenzhen Medical Ultrasound Engineering Center, Shenzhen People's Hospital, Second Clinical Medical College of Jinan University, First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
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5
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Yokoseki O, Tsutsumi K, Obinata C, Toba Y. Transient atrial mechanical dysfunction assessed in acute phase of embolic stroke of undetermined source. J Stroke Cerebrovasc Dis 2020; 29:105032. [PMID: 32807444 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/01/2020] [Accepted: 06/04/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Paroxysmal atrial fibrillation (PAF) has been suggested as a major cause of embolic stroke of undetermined source (ESUS). Transient atrial mechanical dysfunction (stunning) frequently occurs after conversion of atrial fibrillation to sinus rhythm. The study aim was to determine if reversible atrial mechanical dysfunction in ESUS could help elucidate the mechanism of stroke. METHODS Eighty-five consecutive patients with acute ischemic stroke were enrolled according to the following inclusion criteria: [1] ≥55 years old; [2] normal sinus rhythm upon admission; [3] no apparent embolic source; and [4] transthoracic echocardiographic evaluation had been performed in both the early phase (<72 h) and late phase (>7 days) after stroke onset. There were 27 patients in the lacunar or atherothrombotic infarction group (controls), 22 in the PAF group, and 36 in the ESUS group. To determine atrial stunning, transmitral flow velocity profiles (Doppler peak E- [early diastolic] and A- [atrial systolic] waves) were obtained. RESULTS In the early phase, an E/A velocity ratio ≥ 1.0 was less common in the control group (1 patient, 3.7%) than in the PAF group (19 patients, 86.4%; p < 0.001) and ESUS group (10 patients, 27.8%; p < 0.05). In the late phase, the E/A ratio decreased to less than 1.0 in six patients (31.6%) who had PAF and in eight patients (80.0%) who had ESUS. CONCLUSION Transient atrial mechanical dysfunction could be a helpful finding for elucidating the stroke mechanism in patients with ESUS, and early echocardiographic assessment could improve its detection.
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Affiliation(s)
- Osamu Yokoseki
- Department of Cardiology, Ueda Hanazono Hospital, 1-15-25 Chuo Nishi, Ueda 386-0023, Japan.
| | - Keiji Tsutsumi
- Department of Neurosurgery, Kobayashi Neurosurgical Neurological Hospital, Ueda, Japan
| | - Chiharu Obinata
- Department of Neurosurgery, Kobayashi Neurosurgical Neurological Hospital, Ueda, Japan.
| | - Yasuyuki Toba
- Department of Neurosurgery, Kobayashi Neurosurgical Neurological Hospital, Ueda, Japan.
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6
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Nuqali A, Shafiq Q, Syed MM, Sheikh M. A Suspected Case of Acute Embolic Myocardial Infarction Following Direct-Current Cardioversion of Atrial Fibrillation. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:1306-1310. [PMID: 30385736 PMCID: PMC6699203 DOI: 10.12659/ajcr.911469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Patient: Male, 66 Final Diagnosis: A suspected case of acute embolic myocardial infarction following direct current cardioversion of atrial fibrillation Symptoms: Exertional shortness of breath Medication: — Clinical Procedure: Direct current cardioversion Specialty: Cardiology
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Affiliation(s)
- Abdulelah Nuqali
- Department of Internal Medicine, George Washington University, Washington, DC, USA
| | - Qaiser Shafiq
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Mubbasher M Syed
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Mujeeb Sheikh
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Toledo Medical Center, Toledo, OH, USA
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7
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Lip GY, Banerjee A, Boriani G, Chiang CE, Fargo R, Freedman B, Lane DA, Ruff CT, Turakhia M, Werring D, Patel S, Moores L. Antithrombotic Therapy for Atrial Fibrillation. Chest 2018; 154:1121-1201. [DOI: 10.1016/j.chest.2018.07.040] [Citation(s) in RCA: 481] [Impact Index Per Article: 80.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/11/2018] [Accepted: 07/24/2018] [Indexed: 02/08/2023] Open
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8
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Kimura D, Fukuda I, Tsushima T, Sakai T, Umetsu S, Ogasawara Y, Shimamura N, Ohkuma H. Management of acute ischemic stroke after pulmonary resection: incidence and efficacy of endovascular thrombus aspiration. Gen Thorac Cardiovasc Surg 2018; 67:306-311. [PMID: 30367330 DOI: 10.1007/s11748-018-1024-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 10/11/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We analyzed acute ischemic stroke by thromboembolism in the early period after lung cancer surgery. METHODS A retrospective review of the clinical records of patients who underwent lung resection for primary lung cancer was performed. Patients who underwent lobectomy, bilobectomy, and pneumonectomy were included. The clinical characteristics of the patients, the incidence of atrial fibrillation (Af) after surgery, and the incidence of acute ischemic stroke were analyzed. The clinical courses of patients having acute ischemic stroke were also reviewed. RESULTS In 4 (0.6%) of 696 patients, acute ischemic stroke occurred in the early period during hospitalization after lung cancer surgery. Acute ischemic stroke occurred within 4 days in three cases and after 4 days in one case. The resection site of the lung was the left side in all cases, and there were three cases of left upper lobectomy and one case of left lower lobectomy. As for the two recent patients, thrombus removal was performed by a neurosurgeon, and both cases achieved successful recanalization. The time between symptom detection and recanalization was 205 and 170 min, respectively. One patient was cured without any residual effect of disease, and the other patient's hemiplegia resolved and aphasia improved. CONCLUSION Since cerebral infarction impairs the patient's quality of life, thrombus removal should be considered if possible.
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Affiliation(s)
- Daisuke Kimura
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, Hirosaki University, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Ikuo Fukuda
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, Hirosaki University, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan.
| | - Takao Tsushima
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, Hirosaki University, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Takehiro Sakai
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, Hirosaki University, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Satoko Umetsu
- Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, Hirosaki University, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Yukari Ogasawara
- Department of Neurosurgery, Graduate School of Medicine, Hirosaki University, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Norihito Shimamura
- Department of Neurosurgery, Graduate School of Medicine, Hirosaki University, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
| | - Hiroki Ohkuma
- Department of Neurosurgery, Graduate School of Medicine, Hirosaki University, 5 Zaifu-cho, Hirosaki, Aomori, 036-8562, Japan
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9
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McBride DA, Markman TM, Liang JJ, Santangeli P. Left Atrial Appendage Closure Devices for Stroke Prevention in Patients with Non-Valvular AF. US CARDIOLOGY REVIEW 2018. [DOI: 10.15420/usc.2018.6.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The left atrial appendage (LAA) may be involved in offloading atrial pressure during left ventricular systole. As ventricular rate increases, LAA emptying decreases during early diastole causing increased risk of thrombus formation particularly in patients with non-valvular AF (NVAF). The LAA is the site of thrombus formation in more than 90 % of patients with NVAF, so is an important target for thromboembolic prophylaxis in these patients. Anticoagulation therapy is used to treat NVAF, but it has long-term complications and may be contraindicated in some patients. Therefore, alternative strategies to reduce embolic risk in patients with AF have been developed. These include percutaneous, thoracoscopic, and open closure strategies. This study reviews the safety and efficacy of these strategies, comparing these approaches and devices with pharmacological strategies. There is little data to endorse one strategy over another. Given the minimal evidence available, recommendations in support of LAA occlusion remain weak and guidelines have called for more research and coding of endpoints for this emerging technology.
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10
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Xie R, Yang Y, Cui W, Yin H, Zheng H, Zhang J, You L. Atorvastatin can ameliorate left atrial stunning induced by radiofrequency ablation for atrial fibrillation. Can J Physiol Pharmacol 2017; 95:985-992. [PMID: 28301729 DOI: 10.1139/cjpp-2016-0126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The objective of this study was to study the functional changes of the left atrium after radiofrequency ablation treatment for atrial fibrillation and the therapeutic effect of atorvastatin. Fifty-eight patients undergoing radiofrequency ablation for atrial fibrillation were randomly divided into non-atorvastatin group and atorvastatin group. Patients in the atorvastatin group were treated with atorvastatin 20 mg p.o. per night in addition to the conventional treatment of atrial fibrillation; patients in the non-atorvastatin group received conventional treatment of atrial fibrillation only. Echocardiography was performed before radiofrequency ablation operation and 1 week, 2 weeks, 3 weeks, and 4 weeks after operation. Two-dimensional ultrasound speckle tracking imaging system was used to measure the structural indexes of the left atrium. Results indicated that there was no significant change for indexes representing the structural status of the left atrium within a month after radiofrequency ablation (P > 0.05); however, there were significant changes for indexes representing the functional status of the left atrium. There were also significant changes in indexes reflecting left atrial strain status: the S and SRs of atorvastatin group were higher than those of non-atorvastatin group (P < 0.05). In summary, atorvastatin could improve left atrial function and shorten the duration of atrial stunning after radiofrequency ablation of atrial fibrillation.
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Affiliation(s)
- Ruiqin Xie
- Department of Cardiology, the Second Hospital of Hebei Medical University. No. 215, West Heping Road, Shijiazhuang, 050000, Hebei, China.,Department of Cardiology, the Second Hospital of Hebei Medical University. No. 215, West Heping Road, Shijiazhuang, 050000, Hebei, China
| | - Yingtao Yang
- Department of Cardiology, the Second Hospital of Hebei Medical University. No. 215, West Heping Road, Shijiazhuang, 050000, Hebei, China.,Department of Cardiology, the Second Hospital of Hebei Medical University. No. 215, West Heping Road, Shijiazhuang, 050000, Hebei, China
| | - Wei Cui
- Department of Cardiology, the Second Hospital of Hebei Medical University. No. 215, West Heping Road, Shijiazhuang, 050000, Hebei, China.,Department of Cardiology, the Second Hospital of Hebei Medical University. No. 215, West Heping Road, Shijiazhuang, 050000, Hebei, China
| | - Hongning Yin
- Department of Cardiology, the Second Hospital of Hebei Medical University. No. 215, West Heping Road, Shijiazhuang, 050000, Hebei, China.,Department of Cardiology, the Second Hospital of Hebei Medical University. No. 215, West Heping Road, Shijiazhuang, 050000, Hebei, China
| | - Hongmei Zheng
- Department of Cardiology, the Second Hospital of Hebei Medical University. No. 215, West Heping Road, Shijiazhuang, 050000, Hebei, China.,Department of Cardiology, the Second Hospital of Hebei Medical University. No. 215, West Heping Road, Shijiazhuang, 050000, Hebei, China
| | - Jidong Zhang
- Department of Cardiology, the Second Hospital of Hebei Medical University. No. 215, West Heping Road, Shijiazhuang, 050000, Hebei, China.,Department of Cardiology, the Second Hospital of Hebei Medical University. No. 215, West Heping Road, Shijiazhuang, 050000, Hebei, China
| | - Ling You
- Department of Cardiology, the Second Hospital of Hebei Medical University. No. 215, West Heping Road, Shijiazhuang, 050000, Hebei, China.,Department of Cardiology, the Second Hospital of Hebei Medical University. No. 215, West Heping Road, Shijiazhuang, 050000, Hebei, China
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11
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Athanassopoulos GD. 3D Printing for Left Atrial Appendage (LAA) Modeling Based on Transesophageal Echocardiography: A Step Forward in Closure with LAA Devices. Cardiology 2016; 135:249-254. [PMID: 27537688 DOI: 10.1159/000448024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 06/27/2016] [Indexed: 11/19/2022]
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12
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Yingchoncharoen T, Jha S, Burchill LJ, Klein AL. Transesophageal Echocardiography in Atrial Fibrillation. Card Electrophysiol Clin 2016; 6:43-59. [PMID: 27063820 DOI: 10.1016/j.ccep.2013.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Transesophageal echocardiography (TEE) plays an important role in atrial fibrillation (AF), mainly to detect the presence of left atrial appendage (LAA) thrombus. It is useful in direct current cardioversion (DCC) guidance and for AF ablation and LAA occlusion. With the increasing number of patients affected by AF, the use of TEE will grow and become an important screening modality for LAA thrombus. Future direction includes broader multi-institutional use; further tools to risk stratify patients; and the use of a new spectrum of oral anticoagulants and their cost-effectiveness in patients with AF undergoing DCC, AF ablation, and LAA occlusion.
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Affiliation(s)
- Teerapat Yingchoncharoen
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195, USA
| | - Saurabh Jha
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195, USA
| | - Luke J Burchill
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195, USA
| | - Allan L Klein
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195, USA.
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13
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Absence of left atrial stunning after cardioversion of recent-onset atrial fibrillation in patients at low-stroke risk. Eur J Emerg Med 2015; 24:217-223. [PMID: 26458205 DOI: 10.1097/mej.0000000000000333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The aim of the present study was to evaluate the presence and degree of spontaneous echo contrast (SEC) in the left atrium and of left atrial appendage (LAA) contractility before and after cardioversion (CV) in patients with recent-onset atrial fibrillation (AF). METHODS Our study included 56 patients divided into two groups: group 1, comprising 32 clinically stable patients who were admitted to the Emergency Department with less than or equal to 48 h duration AF, and who underwent transoesophageal echocardiography (TEE)-guided CV; and the control group (group 2), comprising 24 patients admitted to the Cardiological Department for elective TEE-guided CV of greater than 48 h AF. All patients underwent repeat TEE within 1 h after successful CV. RESULTS Patients with recent-onset AF (group 1) showed no thrombogenic milieu at baseline without any evidence of atrial stunning after successful CV. SEC mean grade (0-3 grading) was 0.09±0.3 versus 0.12±0.4 after CV (P=0.98), and LAA flow velocity was 60.7±19.4 versus 56.7±20.5 cm/s after CV (P=0.07). Group 2 patients showed a significantly higher degree of SEC compared with those in group 1 (0.09±0.3 vs. 0.66±0.7, P=0.0093) and significantly lower LAA flow velocities (60.7±19.4 vs. 32.5±12.4, P<0.0001), with significant worsening after successful CV (SEC degree: 0.66±0.9 vs. 1.37±0.9, P=0.0093; LAA flow velocity: 32.5±12.4 vs. 20.4±12.7 cm/s, P<0.0001). CONCLUSION The absence of thrombogenic milieu and of left atrial stunning after CV in patients with recent-onset AF favours early CV without anticoagulation, at least in patients with a low thromboembolic risk profile. These patients could be discharged earlier from urgent care.
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14
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Beigel R, Wunderlich NC, Ho SY, Arsanjani R, Siegel RJ. The left atrial appendage: anatomy, function, and noninvasive evaluation. JACC Cardiovasc Imaging 2015; 7:1251-65. [PMID: 25496544 DOI: 10.1016/j.jcmg.2014.08.009] [Citation(s) in RCA: 289] [Impact Index Per Article: 32.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 08/12/2014] [Accepted: 08/20/2014] [Indexed: 12/23/2022]
Abstract
The left atrial appendage (LAA) is a finger-like extension originating from the main body of the left atrium. Atrial fibrillation (AF) is the most common clinically important cardiac arrhythmia, occurring in approximately 0.4% to 1% of the general population and increasing with age to >8% in those >80 years of age. In the presence of AF thrombus, formation often occurs within the LAA because of reduced contractility and stasis; thus, attention should be given to the LAA when evaluating and assessing patients with AF to determine the risk for cardioembolic complications. It is clinically important to understand LAA anatomy and function. It is also critical to choose the optimal imaging techniques to identify or exclude LAA thrombi in the setting of AF, before cardioversion, and with current and emerging transcatheter therapies, which include mitral balloon valvuloplasty, pulmonary vein isolation, MitraClip (Abbott Laboratories, Abbott Park, Illinois) valve repair, and the implantation of LAA occlusion and exclusion devices. In this review, we present the current data regarding LAA anatomy, LAA function, and LAA imaging using the currently available noninvasive imaging modalities.
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Affiliation(s)
- Roy Beigel
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; The Heart Institute, Sheba Medical Center, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Siew Yen Ho
- Cardiac Morphology Unit, Royal Brompton Hospital, London, England
| | - Reza Arsanjani
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Robert J Siegel
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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15
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Hansen ML, Jepsen RMH, Olesen JB, Ruwald MH, Karasoy D, Gislason GH, Hansen J, Køber L, Husted S, Torp-Pedersen C. Thromboembolic risk in 16 274 atrial fibrillation patients undergoing direct current cardioversion with and without oral anticoagulant therapy. ACTA ACUST UNITED AC 2014; 17:18-23. [DOI: 10.1093/europace/euu189] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Tanaka K, Koga M, Sato K, Suzuki R, Minematsu K, Toyoda K. Three-Dimensional Analysis of the Left Atrial Appendage for Detecting Paroxysmal Atrial Fibrillation in Acute Ischemic Stroke. Int J Stroke 2014; 9:1045-51. [DOI: 10.1111/ijs.12268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 02/02/2014] [Indexed: 11/28/2022]
Abstract
Background Atrial fibrillation impairs left atrial appendage function and the thrombus formation in the left atrial appendage is a major cause of cardioembolic stroke. Aims To evaluate the association between the volume of the left atrial appendage measured by real-time three-dimensional transesophageal echocardiography and presence of paroxysmal atrial fibrillation in patients with cerebral infarction or transient ischemic attack. Methods Real-time three-dimensional transesophageal echocardiography was performed to measure left atrial appendage end-diastolic and end-systolic volumes to calculate left atrial appendage ejection fraction. Patients with normal sinus rhythm at the time of real-time three-dimensional transesophageal echocardiography were divided into groups with and without paroxysmal atrial fibrillation. Volumetric data were corrected with the body surface area. Results Of 146 patients registered, 102 (29 women, 72·2 ± 10·7 years) were normal sinus rhythm at the examination. In 23 patients with paroxysmal atrial fibrillation, left atrial appendage end-diastolic volume (4·78 ± 3·00 ml/m2 vs. 3·14 ± 2·04 ml/m2, P = 0·003) and end-systolic volume (3·10 ± 2·47 ml/m2 vs. 1·39 ± 1·56 ml/m2, P < 0·001) were larger and left atrial appendage ejection fraction (37·3 ±19·1% vs. 57·1 ± 17·5%, P < 0·001) was lower than in the other 79 patients without paroxysmal atrial fibrillation. The optimal cutoff for left atrial appendage peak flow velocity to predict paroxysmal atrial fibrillation was 39·0 cm/s (sensitivity, 54·6%; specificity, 89·7%; c-statistic, 0·762). The cutoffs for left atrial appendage end-diastolic volume, end-systolic volume, and ejection fraction were 4·52 ml/m2 (sensitivity, 47·8%; specificity, 82·3%; c-statistic, 0·694), 1·26 ml/m2 (sensitivity, 91·3%; specificity, 60·3%; c-statistic, 0·806), and 47·9% (sensitivity, 78·3%; specificity, 74·7%; c-statistic, 0·774), respectively. In multivariate analysis, all these parameters were independently associated with paroxysmal atrial fibrillation after adjusting for sex, age, diabetes mellitus, and previous stroke. Conclusions Left atrial appendage volumetric analysis by real-time three-dimensional transesophageal echocardiography is a promising method for detecting paroxysmal atrial fibrillation in acute cerebral infarction or transient ischemic attack.
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Affiliation(s)
- Koji Tanaka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masatoshi Koga
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazuaki Sato
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Rieko Suzuki
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazuo Minematsu
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
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Yashiro Y, Arimoto T, Hashimoto N, Tamura H, Iwayama T, Ishigaki D, Kumagai Y, Nishiyama S, Takahashi H, Shishido T, Miyamoto T, Watanabe T, Kubota I. Predictors of Left Atrial Coagulation Activity Among Paroxysmal Atrial Fibrillation Patients. Circ J 2014; 79:61-9. [DOI: 10.1253/circj.cj-14-0630] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yoshinori Yashiro
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Takanori Arimoto
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Naoaki Hashimoto
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Harutoshi Tamura
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Tadateru Iwayama
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Daisuke Ishigaki
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Yu Kumagai
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Satoshi Nishiyama
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Hiroki Takahashi
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Tetsuro Shishido
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Takuya Miyamoto
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Tetsu Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
| | - Isao Kubota
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine
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Tanaka K, Koga M, Ohyama S, Tokunaga K, Sato K, Suzuki R, Minematsu K, Toyoda K. Evaluation of the left atrial appendage by real-time three-dimensional transesophageal echocardiography for acute stroke patients. ACTA ACUST UNITED AC 2014. [DOI: 10.3995/jstroke.36.260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Philip I, Leblanc I, Berroëta C, Mouren S, Chterev V, Bourel P. Fibrillation atriale en anesthésie–réanimation : de la cardiologie médicale à la période périopératoire. ACTA ACUST UNITED AC 2012; 31:897-910. [DOI: 10.1016/j.annfar.2012.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 08/20/2012] [Indexed: 01/11/2023]
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Bansal M, Kasliwal RR. Echocardiography for left atrial appendage structure and function. Indian Heart J 2012; 64:469-75. [PMID: 23102384 DOI: 10.1016/j.ihj.2012.07.020] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 07/17/2012] [Indexed: 10/28/2022] Open
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21
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Atrial Fibrillation Management in Elderly. CURRENT CARDIOVASCULAR RISK REPORTS 2012. [DOI: 10.1007/s12170-012-0263-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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22
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Friedman PA, Holmes DR. Non-surgical left atrial appendage closure for stroke prevention in atrial fibrillation. J Cardiovasc Electrophysiol 2011; 22:1184-91. [PMID: 21914028 DOI: 10.1111/j.1540-8167.2011.02172.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Non-Surgical Left Atrial Appendage Closure for Stroke Prevention in Atrial Fibrillation. The most feared complication associated with atrial fibrillation (AF) is stroke, the risk of which increases with advanced age. Because of its complex anatomy and diminished blood flow during AF, the left atrial appendage (LAA) has been a common site of left atrial thrombi and presumed source of thromboembolism. Systemic anticoagulation to treat what may be largely a localized phenomenon is associated with significant complications. Newer anticoagulation agents hold great promise in facilitating dosing and eliminating drug and food interactions, but do not eliminate bleeding risk. These challenges have led to interest in mechanical exclusion of the LAA as a means of preventing thromboembolism in AF. Although surgery permits greater visualization and management of complications, the potential morbidity has limited adoption in often-frail elderly patients. In this paper, we review the current state of percutaneous left atrial exclusion for stroke prevention in AF, and the strengths and limitations of each of these strategies. The nonsurgical approaches to excluding the LAA from the central circulation can be divided into 3 broad categories: transseptally placed devices, percutaneous epicardial approach, and hybrid approaches. The availability of several approaches will allow physician selection of the optimal approach for a given patient based on clinical, physiological, and anatomical considerations. LAA exclusion stands to become an increasingly attractive option for patients with nonvalvular AF because it can be offered to elderly AF patients, and eliminates the long-term cumulative bleeding risks and adherence challenge of anticoagulants.
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Affiliation(s)
- Paul A Friedman
- Division of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Kay GN, Le Huezey JY, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann LS. 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation. Circulation 2011; 123:e269-367. [PMID: 21382897 DOI: 10.1161/cir.0b013e318214876d] [Citation(s) in RCA: 592] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Kay GN, Le Huezey JY, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann LS. 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol 2011; 57:e101-98. [PMID: 21392637 DOI: 10.1016/j.jacc.2010.09.013] [Citation(s) in RCA: 642] [Impact Index Per Article: 49.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Schotten U, Verheule S, Kirchhof P, Goette A. Pathophysiological mechanisms of atrial fibrillation: a translational appraisal. Physiol Rev 2011; 91:265-325. [PMID: 21248168 DOI: 10.1152/physrev.00031.2009] [Citation(s) in RCA: 852] [Impact Index Per Article: 65.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Atrial fibrillation (AF) is an arrhythmia that can occur as the result of numerous different pathophysiological processes in the atria. Some aspects of the morphological and electrophysiological alterations promoting AF have been studied extensively in animal models. Atrial tachycardia or AF itself shortens atrial refractoriness and causes loss of atrial contractility. Aging, neurohumoral activation, and chronic atrial stretch due to structural heart disease activate a variety of signaling pathways leading to histological changes in the atria including myocyte hypertrophy, fibroblast proliferation, and complex alterations of the extracellular matrix including tissue fibrosis. These changes in electrical, contractile, and structural properties of the atria have been called "atrial remodeling." The resulting electrophysiological substrate is characterized by shortening of atrial refractoriness and reentrant wavelength or by local conduction heterogeneities caused by disruption of electrical interconnections between muscle bundles. Under these conditions, ectopic activity originating from the pulmonary veins or other sites is more likely to occur and to trigger longer episodes of AF. Many of these alterations also occur in patients with or at risk for AF, although the direct demonstration of these mechanisms is sometimes challenging. The diversity of etiological factors and electrophysiological mechanisms promoting AF in humans hampers the development of more effective therapy of AF. This review aims to give a translational overview on the biological basis of atrial remodeling and the proarrhythmic mechanisms involved in the fibrillation process. We pay attention to translation of pathophysiological insights gained from in vitro experiments and animal models to patients. Also, suggestions for future research objectives and therapeutical implications are discussed.
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Affiliation(s)
- Ulrich Schotten
- Department of Physiology, University Maastricht, Maastricht, The Netherlands.
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Xavier Scheuermeyer F, Grafstein E, Stenstrom R, Innes G, Poureslami I, Sighary M. Thirty-day outcomes of emergency department patients undergoing electrical cardioversion for atrial fibrillation or flutter. Acad Emerg Med 2010; 17:408-15. [PMID: 20370780 DOI: 10.1111/j.1553-2712.2010.00697.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES While the short-term (<7-day) safety and efficiency of electrical cardioversion for emergency department (ED) patients with atrial fibrillation or flutter have been established, the 30-day outcomes with respect to stroke, thromboembolic events, or death have not been investigated. METHODS A two-center cohort of consecutive ED patients undergoing cardioversion for atrial fibrillation or flutter between January 1, 2000, and September 30, 2007, was retrospectively investigated. This cohort was probabilistically linked with both a regional ED database and the provincial health registry to determine which patients had a subsequent ED visit or hospital admission, stroke, or thromboembolic event or died within 30 days. In addition, trained reviewers performed a detailed chart abstraction on 150 randomly selected patients, with emphasis on demographics, vital signs, medical treatment, and predefined adverse events. Hemodynamically unstable patients or those whose condition was the result of an underlying acute medical diagnosis were excluded. Data were analyzed by descriptive methods. RESULTS During the study period, 1,233 patients made 1,820 visits for atrial fibrillation or flutter to the ED. Of the 400 eligible patients undergoing direct-current cardioversion (DCCV), no patients died, had a stroke, or had a thromboembolic event in the following 30 days (95% confidence interval [CI] = 0.0 to 0.8% for all outcomes). A total of 141 patients were included in the formal chart review, with five patients (3.5%, 95% CI = 0.5% to 6.6%) failing cardioversion, six patients (4.3%, 95% CI = 0.9% to 7.6%) having a minor adverse event that did not change disposition, and five patients (3.5%, 95% CI = 0.5% to 6.6%) admitted to hospital at the index visit. CONCLUSIONS Cardioversion of patients with atrial fibrillation or flutter in the ED appears to have a very low rate of long-term complications.
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Affiliation(s)
- Frank Xavier Scheuermeyer
- Department of Emergency Medicine, St Paul's Hospital and the University of British Columbia, Vancouver, BC, USA.
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Crandall MA, Bradley DJ, Packer DL, Asirvatham SJ. Contemporary management of atrial fibrillation: update on anticoagulation and invasive management strategies. Mayo Clin Proc 2009; 84:643-62. [PMID: 19567719 PMCID: PMC2704137 DOI: 10.1016/s0025-6196(11)60754-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice. Its increasing prevalence, particularly among the elderly, renders it one of the most serious current medical epidemics. Several management questions confront the clinician treating a patient with AF: Should the condition be treated? Is the patient at risk of death or serious morbidity as a result of this diagnosis? If treatment is necessary, is rate control or rhythm control superior? Which patients need anticoagulation therapy, and for how long? This review of articles obtained by a search of the PubMed and MEDLINE databases presents the available evidence that can guide the clinician in answering these questions. After discussing the merits of available therapy, including medications aimed at controlling rate, rhythm, or both, we focus on the present status of ablative therapy for AF. Catheter ablation, particularly targeting the pulmonary veins, is being increasingly performed, although the precise indications for this approach and its effectiveness and safety are being actively investigated. We briefly discuss other invasive options that are less frequently used, such as pacemakers, defibrillators, left atrial appendage closure devices, and the surgical maze procedure.
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Affiliation(s)
| | | | | | - Samuel J. Asirvatham
- Address correspondence to Samuel J. Asirvatham, MD, Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (). Individual reprints of this article and a bound reprint of the entire Symposium on Cardiovascular Diseases will be available for purchase from our Web site www.mayoclinicproceedings.com.
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Aronow WS, Banach M. Atrial Fibrillation: The New Epidemic of the Ageing World. J Atr Fibrillation 2009; 1:154. [PMID: 28496617 DOI: 10.4022/jafib.154] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2008] [Revised: 02/19/2009] [Accepted: 03/14/2009] [Indexed: 02/06/2023]
Abstract
The prevalence of atrial fibrillation (AF) increases with age. As the population ages, the burden of AF increases. AF is associated with an increased incidence of mortality, stroke, and coronary events compared to sinus rhythm. AF with a rapid ventricular rate may cause a tachycardia-related cardiomyopathy. Immediate direct-current (DC) cardioversion should be performed in patients with AF and acute myocardial infarction, chest pain due to myocardial ischemia, hypotension, severe heart failure, or syncope. Intravenous beta blockers, diltiazem, or verapamil may be administered to reduce immediately a very rapid ventricular rate in AF. An oral beta blocker, verapamil, or diltiazem should be used in persons with AF if a fast ventricular rate occurs at rest or during exercise despite digoxin. Amiodarone may be used in selected patients with symptomatic life-threatening AF refractory to other drugs. Digoxin should not be used to treat patients with paroxysmal AF. Nondrug therapies should be performed in patients with symptomatic AF in whom a rapid ventricular rate cannot be slowed by drugs. Paroxysmal AF associated with the tachycardia-bradycardia syndrome should be treated with a permanent pacemaker in combination with drugs. A permanent pacemaker should be implanted in patients with AF and symptoms such as dizziness or syncope associated with ventricular pauses greater than 3 seconds which are not drug-induced. Elective DC cardioversion has a higher success rate and a lower incidence of cardiac adverse effects than does medical cardioversion in converting AF to sinus rhythm. Unless transesophageal echocardiography has shown no thrombus in the left atrial appendage before cardioversion, oral warfarin should be given for 3 weeks before elective DC or drug cardioversion of AF and continued for at least 4 weeks after maintenance of sinus rhythm. Many cardiologists prefer, especially in elderly patients , ventricular rate control plus warfarin rather than maintaining sinus rhythm with antiarrhythmic drugs. Patients with chronic or paroxysmal AF at high risk for stroke should be treated with long-term warfarin to achieve an International Normalized Ratio of 2.0 to 3.0. Patients with AF at low risk for stroke or with contraindications to warfarin should be treated with aspirin 325 mg daily.
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Affiliation(s)
- Wilbert S Aronow
- Cardiology Division, Department of Medicine, New York Medical College, Valhalla, New York and the Department of Molecular Cardionephrology and Hypertension, Medical University of Lodz, Lodz, Poland
| | - Maciej Banach
- Cardiology Division, Department of Medicine, New York Medical College, Valhalla, New York and the Department of Molecular Cardionephrology and Hypertension, Medical University of Lodz, Lodz, Poland
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Mitral annular velocity by Doppler tissue imaging for the evaluation of atrial stunning after cardioversion of atrial fibrillation. Int J Cardiovasc Imaging 2008; 25:113-20. [PMID: 18758990 DOI: 10.1007/s10554-008-9360-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2007] [Accepted: 08/18/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Atrial and/or appendage stunning (AS) usually occur after successful cardioversion of atrial fibrillation (AF). Several parameters except mitral annular velocity were previously evaluated to determine AS. We investigated whether mitral annular velocity was useful for determining of AS. METHODS This study consisted of 52 consecutive patients with AF <3 months who converted to the sinus rhythm. Mitral inflow and annular velocities were measured before and after cardioversion. Left atrial appendage (LAA) size and flow were assessed. The average velocity of septal and lateral segments of mitral annulus was considered as the final annular velocity. Thrombus and/or spontaneous echo contrast (SEC) were also investigated. RESULTS Of 52 patients, 29 (56%) had AS but 23 did not. There was no significant difference in age, gender, and cardioversion type between two groups. Hypertension was more prevalent in patients without AS compared to those with AS (P = 0.02). Mitral annular systolic and E-wave velocities were comparable in both groups (P > 0.05). Mitral annular A-wave velocity (3.1 +/- 2.9 vs. 7.1 +/- 2.2 cm/s, P < 0.001), and its velocity-time integral (0.27 +/- 0.22 vs. 0.74 +/- 0.19 cm, P < 0.001) were significantly lower in patients with AS compared with those without AS. The annular A-wave velocity < or =3.3 cm/s predicted AS with a sensitivity of 59% and specificity of 76%. It was correlated with mitral inflow A velocity (r = 0.85, P < 0.001), LAA emptying velocity (r = 0.41, P = 0.003) and presence of SEC (r = -0.52, P < 0.001). CONCLUSION After cardioversion of AF, mitral annular A-wave velocity may be a new marker to determine AS.
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Melduni RM, Malouf JF, Chandrasekaran K, Bruce CJ, White RD, Law KK, Al Atawi FO, Somers VK, Gersh BJ, Hodge DO, Friedman PA, Seward JB, Ammash NM. New Insights Into the Predictors of Left Atrial Stunning After Successful Direct-Current Cardioversion of Atrial Fibrillation and Flutter. J Am Soc Echocardiogr 2008; 21:848-54. [DOI: 10.1016/j.echo.2007.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Indexed: 01/01/2023]
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Singer DE, Albers GW, Dalen JE, Fang MC, Go AS, Halperin JL, Lip GYH, Manning WJ. Antithrombotic Therapy in Atrial Fibrillation. Chest 2008; 133:546S-592S. [PMID: 18574273 DOI: 10.1378/chest.08-0678] [Citation(s) in RCA: 571] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Daniel E Singer
- From the Clinical Epidemiology Unit, General Medicine Division, Massachusetts General Hospital, Boston, MA.
| | | | | | | | - Alan S Go
- Division of Research, Kaiser Permanente of Northern California, Oakland, CA
| | | | - Gregory Y H Lip
- Department of Medicine, University of Birmingham, Birmingham, UK
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de Luca I, Colonna P, Sorino M, Del Salvatore B, De Luca L. New Monodimensional Transthoracic Echocardiographic Sign of Left Atrial Appendage Function. J Am Soc Echocardiogr 2007; 20:324-32. [PMID: 17336761 DOI: 10.1016/j.echo.2006.08.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2006] [Indexed: 11/29/2022]
Affiliation(s)
- Italo de Luca
- Department of Cardiology-Azienda Policlinico, Bari, Italy.
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Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation-executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation). Eur Heart J 2007; 27:1979-2030. [PMID: 16885201 DOI: 10.1093/eurheartj/ehl176] [Citation(s) in RCA: 362] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Transesophageal Echocardiography for Patients with Atrial Fibrillation. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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ACC/AHA/ESC: Guías de Práctica Clínica 2006 para el manejo de pacientes con fibrilación auricular. Versión resumida. Rev Esp Cardiol 2006. [DOI: 10.1157/13096583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006; 114:e257-354. [PMID: 16908781 DOI: 10.1161/circulationaha.106.177292] [Citation(s) in RCA: 1381] [Impact Index Per Article: 76.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Zamorano JL. ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation—Executive Summary. J Am Coll Cardiol 2006; 48:854-906. [PMID: 16904574 DOI: 10.1016/j.jacc.2006.07.009] [Citation(s) in RCA: 714] [Impact Index Per Article: 39.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
Atrial fibrillation is the most commonly encountered sustained arrhythmia. Echocardiography has augmented the knowledge about etiology and complications of atrial fibrillation. Transthoracic echocardiography allows rapid, safe and comprehensive assessment of cardiac structure and function, and is recommended for all subjects with atrial fibrillation. The use of transesophageal echocardiography has contributed to a better understanding of the thromboembolic risk in patients with atrial fibrillation, especially in the setting of electrical cardioversion. Several investigators have demonstrated the feasibility and safety profile of early cardioversion with short-term anticoagulation in patients with atrial fibrillation and a transesophageal echocardiography negative for atrial thrombi. More recently, transesophageal and intracardiac echocardiography have been employed in patients with atrial fibrillation to monitor percutaneous procedures such as pulmonary veins radiofrequency ablation or left atrial appendage obliteration. In this review the available echocardiographic imaging modalities and their specific role in the evaluation and management in atrial fibrillation are described.
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Coll-Vinent B, Monteagudo J, Miró O, Luis Marín J, Nava S, Scalise A, Sánchez M, Bragulat E, Sitges M, Brugada J, Mont L. Transient endothelial dysfunction is present shortly after cardioversion in patients with lone atrial fibrillation. Thromb Res 2006; 117:235-40. [PMID: 16378829 DOI: 10.1016/j.thromres.2005.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2004] [Revised: 02/08/2005] [Accepted: 02/22/2005] [Indexed: 10/25/2022]
Affiliation(s)
- Blanca Coll-Vinent
- Emergency Department, Hospital Clínic, Villarroel 170, 08036 Barcelona, Spain.
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Abstract
Atrial fibrillation (AF) is a significant cause of morbidity and health care expenditures. Patients with AF suffer a variety of symptoms including chest pain, palpitations, shortness of breath, and fatigue. Some patients have no symptoms, a condition referred to as asymptomatic or "silent" AF. Asymptomatic AF has significant clinical implications. Patients with unrecognized AF may present with devastating thromboembolic consequences or a tachycardia-mediated cardiomyopathy. The incidence of asymptomatic AF is greater than previously perceived. This manuscript provides an overview of the clinical entity of asymptomatic AF including the epidemiology, clinical significance, and the implications it has on the daily management of patients suffering from AF.
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Affiliation(s)
- Robert W Rho
- Department of Medicine (Division of Cardiology), University of Washington School of Medicine, Seattle, WA, 98195-6422, USA
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Spiecker M, Böhm S, Börgel J, Grote J, Görlitz S, Huesing A, Mügge A. Doppler echocardiographic prediction of recurrent atrial fibrillation following cardioversion. Int J Cardiol 2005; 113:161-6. [PMID: 16330115 DOI: 10.1016/j.ijcard.2005.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2005] [Revised: 09/05/2005] [Accepted: 11/05/2005] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cardioversion for atrial fibrillation (AF) is associated with impairment of left atrial mechanical function and increased risk of thrombus formation with subsequent embolisation. Measuring atrial mechanical function is of interest to determine the individual risk of thromboembolism and the risk of recurrent AF. METHODS We included 112 consecutive patients with AF and planned cardioversion. Serial echocardiographic measurements of left atrial size and Doppler measurement of mitral valve peak A wave velocities were obtained at days 0, 1, 2, 3, and 28 following cardioversion. These measurements and clinical parameters were related to clinical events and recurrent AF within 4 weeks following cardioversion. Cardioversion was achieved in 100 patients. RESULTS AF-recurrence within 4 weeks was 23.9% and 45.8% for patients with < or = and > 6 weeks AF-duration, respectively (p=0.04). Peak A wave velocities were significantly lower up to 2 days following cardioversion in patients with AF-recurrence. A peak A wave velocity < 52 cm/s at day 1 resulted in an odds ratio of 5.0 (95% CI: 1.4-18.6) for recurrence of AF. In multiple logistic regression analysis, peak A wave velocity at day 1 remained the only independent predictor of recurrent AF. Left atrial diameter did not correlate with recurrence of AF. CONCLUSIONS A single measurement of mitral peak A wave velocity 1 day following cardioversion is predictive of AF recurrence. This method is feasible for risk estimation with potential therapeutic implications.
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Affiliation(s)
- Martin Spiecker
- Heart and Vascular Center Bochum, Department of Medicine II/Cardiology, St. Josef-Hospital, University of Bochum, Gudrunstrasse 56, 44791 Bochum, Germany.
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de Luca I, Sorino M, De Luca L, Colonna P, Del Salvatore B, Corlianò L. Pre- and post-cardioversion transesophageal echocardiography for brief anticoagulation therapy with enoxaparin in atrial fibrillation patients: a prospective study with a 1-year follow-up. Int J Cardiol 2005; 102:447-54. [PMID: 16004890 DOI: 10.1016/j.ijcard.2004.05.052] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2004] [Accepted: 05/05/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND In patients with atrial fibrillation (AF) eligible for electrical cardioversion (C), the guided approach with transesophageal echocardiography (TEE) allows to avoid the 3 weeks of recommended precardioversion anticoagulation therapy. However, after sinus rhythm restoration, at least other 4 weeks of oral anticoagulation therapy are indicated, due to the postcardioversion thromboembolic risk related to left atrial (LA) and left atrial appendage (LAA) stunning. The aim of this study was to prospectively assess the effectiveness and the safety of anticoagulation therapy discontinuation 7 days after C using low-molecular-weight heparins (LMWH) in a selected group of patients who underwent a pre-C and 7 days post-C TEE evaluation. METHODS One hundred one patients (74 patients with nonvalvular AF and 27 patients with atrial flutter lasting >48 h and history of AF) were enrolled into the study. Two patients refused the TEE, therefore, in 99/101, we performed a first TEE and, within 24 h, a C if there were no LAA thrombi, complex aortic plaques or severe spontaneous echocontrast. After C and 7 days of home-administered enoxaparin, a second TEE was carried out. In the absence of any new thrombi, severe spontaneous echocontrast and/or low emptying velocity of LAA, the therapy with enoxaparin was stopped; otherwise, anticoagulation therapy with enoxaparin was overlapped with oral anticoagulation and continued for at least 3 weeks. All patients were clinically followed at 1, 6 and 12 months after C. RESULTS Sinus rhythm was restored in 68/99 patients after successful C. The second TEE was carried out in 53 patients. At 1 month follow-up, no thromboembolic events were recorded either in patients at risk who had continued the oral anticoagulant therapy for at least 3 weeks or in those who suspended LMWH after 7 days post-C TEE. Between the 2nd and 12th month, three ischemic strokes occurred, all in the group of patients who had anticoagulation therapy for at least 3 weeks and had shown LAA velocity <25 cm/s at first or second TEE. No thromboembolic events were recorded in patients with normal LAA velocity; conversely, among the patients who had shown low LAA velocity at either TEE, three suffered from ischemic stroke. In two of these three patients, low LAA velocity was detected only at post-C TEE. CONCLUSIONS A brief anticoagulation therapy using LMWH appears to be safe and feasible. The 7 days post-C TEE can well-define patients without LAA stunning at low thromboembolic risk, who may take advantage of an early interruption of enoxaparin as an alternative to long oral anticoagulation. The LAA stunning, even in the absence of other thromboembolic risk factors, could select a group of patients at high risk who should continue oral anticoagulation indefinitely or until signs of LAA dysfunction disappear.
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Affiliation(s)
- Italo de Luca
- Department of Cardiology, Azienda Policlinico, Bari, Italy.
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Takagi M, Doi A, Shirai N, Hirata K, Takemoto Y, Takeuchi K, Yoshikawa J. Acute improvement of atrial mechanical stunning after electrical cardioversion of persistent atrial fibrillation: comparison between biatrial and single atrial pacing. Heart 2005; 91:58-63. [PMID: 15604336 PMCID: PMC1768638 DOI: 10.1136/hrt.2003.032334] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the acute effects of atrial pacing at different pacing sites on mechanical stunning after cardioversion of atrial fibrillation (AF). SETTING Tertiary referral centre. PATIENTS 20 patients with persistent AF were studied. INTERVENTIONS Spontaneous echo contrast (SEC), left atrial appendage emptying velocity (LAAEV), and left atrial appendage emptying fraction (LAAEF) were assessed by transoesophageal echocardiography (TOE) during AF, after conversion to sinus rhythm, and during atrial pacing from the right atrial appendage, left lateral atrium, and both atria simultaneously. Transmitral inflow velocity of the atrial wave (TMIF-A) by TOE and the maximum P wave duration in 12 lead ECG were also measured during sinus rhythm and atrial pacing. MAIN OUTCOME MEASURES Comparison of atrial mechanical function and P wave duration in 12 lead ECG during atrial pacing from different sites after cardioversion of AF. RESULTS Compared with sinus rhythm, atrial pacing at 80 beats/min increased LAAEV from mean (SD) 14.6 (10.1) to 33.4 (19.8) cm/s (p = 0.001), LAAEF from 13.8 (8.5) to 32.1 (11.2)% (p < 0.001), and TMIF-A from 24.6 (11.9) to 45.6 (21.0) cm/s (p < 0.001) and reduced SEC grade from 2.6 (1.0) to 1.6 (0.9) (p < 0.001). These effects had a positive force-frequency relation. Biatrial pacing produced the shortest P wave duration and resulted in the most significant improvement in atrial function (LAAEV, 33.2 (19.3) v 53.7 (23.9) cm/s, p = 0.0001; LAAEF, 31.9 (11.1) v 46.2 (12.6)%, p < 0.0001; TMIF-A, 37.7 (18.3) v 54.1 (21.2) cm/s, p < 0.001; SEC grade, 1.4 (1.1) v 0.8 (0.9), p = 0.001, right atrial appendage versus biatrial pacing). CONCLUSIONS Atrial pacing at increased rates can improve atrial mechanical function after cardioversion of persistent AF. Biatrial pacing may be the most effective technique to reverse atrial mechanical stunning.
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Affiliation(s)
- M Takagi
- Department of Internal Medicine and Cardiology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 5458585, Japan.
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Oki T, Oishi Y, Tanaka H, Emi S, Mizuguchi Y, Ishimoto T, Nagase N, Ara N. Renewed Interest in Left Atrial Function: What do we Need to Evaluate Clinically? J Echocardiogr 2005. [DOI: 10.2303/jecho.3.60] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Stellbrink C, Schimpf T. Anticoagulation during cardioversion in patients with atrial fibrillation: current clinical practice. Am J Cardiovasc Drugs 2005; 5:155-62. [PMID: 15901203 DOI: 10.2165/00129784-200505030-00002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The role of anticoagulation in the long-term treatment of atrial fibrillation (AF) has been well established in prospective randomized trials. Less certainty exists on the optimal anticoagulation in the setting of AF cardioversion. Current guidelines advocate anticoagulation for 3-4 weeks before and after cardioversion of AF of >48 hours' duration. Alternatively, early cardioversion may be performed after exclusion of left atrial thrombi by transesophageal echocardiography. However, with conventional anticoagulation, the risk of bleeding has to be considered and, thus, anticoagulation is frequently underused in the clinical setting. Moreover, the role of cardioversion has been questioned by recent trials suggesting no benefit of sinus rhythm restoration over rate control in AF. This article aims to summarize the currently available data on anticoagulation in cardioversion of AF in the context of these new studies and points to some new drugs such as low-molecular weight heparins and oral thrombin inhibitors that may lead to safer anticoagulation for prevention of thromboembolic complications of AF in the future.
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Affiliation(s)
- Christoph Stellbrink
- Department of Medicine and Cardiology, University of Technology, Aachen, Germany.
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Yamada H, Donal E, Kim YJ, Agler DA, Zhang Y, Greenberg NL, Mazgalev TN, Thomas JD, Grimm RA. The pseudorestrictive pattern of transmitral Doppler flow pattern after conversion of atrial fibrillation to sinus rhythm: is atrial or ventricular dysfunction to blame? J Am Soc Echocardiogr 2004; 17:813-8. [PMID: 15282482 DOI: 10.1016/j.echo.2004.04.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patients with paroxysmal atrial fibrillation (AF) who have recently converted from AF to sinus rhythm often exhibit a restrictive Doppler pattern in the transmitral flow (TMF) velocity. However, the mechanism of this phenomenon has not been well defined. We evaluated the temporal change of TMF pattern and hemodynamics after conversion of AF to in sinus rhythm in an animal model. Eight open-chest dogs underwent 3 hours of pacing-induced AF. TMF velocities and pressure data were acquired at baseline (sinus rhythm), immediately after conversion of AF, and every 10 minutes thereafter. Early diastolic TMF velocity was increased immediately after conversion and recovered to the baseline value in 20 minutes. Atrial systolic TMF velocity was reduced after AF and recovered to baseline value in 20 to 30 minutes. Early diastolic/atrial systolic TMF velocity was increased after conversion, and recovered to baseline value in 20 to 30 minutes. The mean left atrial (LA) pressure increased immediately, 10 and 20 minutes after the conversion of AF to sinus rhythm. The left ventricular end-diastolic pressure was increased and positive left ventricular dP/dt and tau were decreased immediately after AF, whereas they recovered within 10 minutes. In conclusion, a pseudorestrictive pattern of TMF after AF occurred as a result of transient LA mechanical functional impairment and increased LA pressure caused by LA stunning. Transient left ventricular diastolic dysfunction also effected the TMF velocity immediately after the conversion from AF to sinus rhythm, although it recovered faster than LA mechanical dysfunction.
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Affiliation(s)
- Hirotsugu Yamada
- Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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