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Adedara VO, Sharma V, Nawaz H, Reyes-Rivera J, Afzal-Tohid S, Pareshbhai PT, Boyapati SP, Sharafshah A. Transesophageal Echocardiogram Before Cardioversion in Atrial Fibrillation Patients. Cureus 2023; 15:e39702. [PMID: 37398783 PMCID: PMC10309076 DOI: 10.7759/cureus.39702] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Transesophageal echocardiography (TEE) offers an invaluable, non-invasive avenue for diagnosing and managing various cardiac conditions, including atrial fibrillation (AF). As the most common cardiac arrhythmia, AF affects millions and can lead to severe complications. Cardioversion, a procedure to restore the heart's normal rhythm, is frequently conducted on AF patients resistant to medication. Due to inconclusive data, TEE's utility prior to cardioversion in AF patients remains ambiguous. Understanding TEE's potential benefits and limitations in this population could significantly influence clinical practice. This review aims to scrutinize the current literature on the use of TEE before cardioversion in AF patients. The principal objective is to understand TEE's potential benefits and limitations comprehensively. The study seeks to offer a clear understanding and practical recommendations for clinical practice, thereby improving the management of AF patients before cardioversion using TEE. A literature search of databases was conducted using the keywords "Atrial Fibrillation," "Cardioversion" and "Transesophageal echocardiography," resulting in 640 articles. These were narrowed to 103 following title and abstract reviews. After applying exclusion and inclusion criteria with a quality assessment, 20 papers were included: seven retrospective studies, 12 prospective observational studies, and one randomized controlled trial (RCT). Stroke risk associated with direct-current cardioversion (DCC) potentially results from post-cardioversion atrial stunning. Thromboembolic events occur post cardioversion, with or without prior atrial thrombus or cardioversion complications. Generally, cardiac thrombus localizes in the left atrial appendage (LAA), a clear contraindication to cardioversion. Atrial sludge without LAA thrombus in TEE is a relative contraindication. TEE before electrical cardioversion (ECV) in anticoagulated AF individuals is uncommon. In AF patients planned for cardioversion, contrast enhancement facilitates thrombus exclusion in TEE images, reducing embolic events. Left atrial thrombus (LAT) frequently occurs in AF patients, necessitating TEE examination. Despite the increased use of pre-cardioversion TEE, thromboembolic events persist. Notably, patients with post-DCC thromboembolic events had no LA thrombus or LAA sludge. The use of TEE-guided DCC has grown due to its ability to detect atrial thrombi pre-cardioversion, aiding risk stratification. Thrombus in the left atrium also signals an elevated risk of future thromboembolic events in AF patients. While atrial stunning post cardioversion detected by TEE is a significant risk factor for future thromboembolic events, further evidence is required. Therapeutic anticoagulation is essential during and post cardioversion, even if no atrial thrombus is detected. Current data recommends cardioversion guided by TEE, particularly in outpatient settings.
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Affiliation(s)
- Victor O Adedara
- Medicine, St. George's University School of Medicine, St. George's, GRD
| | - Vagisha Sharma
- Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IND
| | - Hassan Nawaz
- Medicine, Nishtar Medical University and Hospital, Multan, PAK
| | | | | | | | - Sri P Boyapati
- Medicine, Siddartha Medical College, Dr. YSR University of Health Sciences, Vijayawada, IND
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Yujing W, Congxin H, Shaning Y, Lijun J, Xiaojun H, Gang W, Qiang X. Digitalis does not improve left atrial mechanical dysfunction after successful electrical cardioversion of chronic atrial fibrillation. Cell Biochem Biophys 2010; 57:27-34. [PMID: 20352374 DOI: 10.1007/s12013-010-9080-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This study was designed to investigate whether administration of digitalis could improve mechanical function of left atrial appendage (LAA) and left atrium prospectively in patients with atrial stunning. Fifty-four consecutive patients in whom atrial stunning was observed immediately after cardioversion of chronic atrial fibrillation (AF) were randomized into digitalis or control group for 1 week following cardioversion. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were performed prior to, immediately following, 1 day after and 1 week after cardioversion to measure transmitral flow velocity and LAA flow velocity. Electrical cardioversion of AF elicited significantly slower left atrial appendage peak emptying velocity (LAA-PEV) and peak filling velocity (LAA-PFV) immediately following cardioversion in both groups. 1 day post cardioversion, there were no significant differences in transmitral E wave, A wave, E/A ratio, LAA-PEV, LAA-PFV or left atrial appendage ejection fraction (LAA-EF) between digitalis and control groups. 1 week post cardioversion, no significant differences were found in transmitral E wave, A wave, E/A ratio, LAA-PEV, LAA-PFV or LAA-EF between the two groups. The occurrence rates of spontaneous echo contrast were not significantly different between digitalis and control groups one day and one week post cardioversion. In conclusion, digitalis did not improve left atrial and appendage mechanical dysfunction following cardioversion of chronic AF. Digitalis did not prevent the development of spontaneous echo contrast in left atrial chamber and appendage. This may be due to the fact that digitalis aggravates intracellular calcium overload induced by chronic AF and has a negative effect on ventricular rate.
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Affiliation(s)
- Wang Yujing
- Division of Cardiology, Renmin's Hospital of Wuhan University, Ziyang Road, Wuchang District, Wuhan, 430060, Hubei Province, China
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McCrindle BW, Karamlou T, Wong H, Gangam N, Trivedi KR, Lee KJ, Benson LN. Presentation, management and outcomes of thrombosis for children with cardiomyopathy. Can J Cardiol 2006; 22:685-90. [PMID: 16801999 PMCID: PMC2560561 DOI: 10.1016/s0828-282x(06)70937-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Thrombosis in children with dilated and inflammatory cardiomyopathy is an unpredictable complication with potentially important morbidity. OBJECTIVE To determine the prevalence, associated factors, management and outcomes of thrombosis in this setting. METHODS Data were obtained from review of medical records. Factors associated with thrombosis and the impact on outcome were sought. RESULTS From 1990 to 1998, 66 patients that presented with dilated cardiomyopathy were followed for a median interval of 1.4 years (range 0 to 9.79 years) from first presentation. Thrombosis was diagnosed in four patients at presentation and in four patients during follow-up. Thrombosis was noted in one additional patient at examination after death. The overall nine-year period prevalence of thrombosis was 14%. Anticoagulation was started at presentation in 31% of patients. The mean left ventricular ejection fraction at presentation was significantly lower in those given anticoagulation (19+/-8%) versus those who were not (32+/-15%; P < 0.001). The mean ejection fraction at presentation was similar in those patients with (25+/-10%) versus those without thrombosis (28+/-15%; P = 0.44). During follow-up, 11 patients died and seven underwent cardiac transplantation. Kaplan-Meier estimates of freedom from death or transplantation were 88% at three months, 81% at one year and 70% at five years. Survival free of transplantation was not affected by thrombosis. CONCLUSIONS Thrombosis is common in children with cardiomyopathy, can occur at any time in the patients' clinical course and is not related to clinical features or survival free of transplantation. The relevance and prevention of thrombosis in this setting remains unclear.
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Affiliation(s)
- Brian W McCrindle
- Division of Cardiology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada.
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Gottdiener JS, Bednarz J, Devereux R, Gardin J, Klein A, Manning WJ, Morehead A, Kitzman D, Oh J, Quinones M, Schiller NB, Stein JH, Weissman NJ. American Society of Echocardiography recommendations for use of echocardiography in clinical trials. J Am Soc Echocardiogr 2005; 17:1086-119. [PMID: 15452478 DOI: 10.1016/j.echo.2004.07.013] [Citation(s) in RCA: 329] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Abstract
For over two decades, valuable insights have been accumulated from epidemiologic studies and randomized trials about the risks for and prevention of AF-related stroke. AF substantially raises the risk of stroke, most likely through an atrio-embolic mechanism. Warfarin and other members of its class of oral anticoagulants targeted at an INR of 2.5 can abrogate the risk of stroke attributable to AF effectively and fairly safely. High-quality management of anticoagulation can be achieved in usual clinical care. These insights have important implications for the care of individual patients and more generally for public health. Future research is needed to specify the risk of stroke and hemorrhage among patients with AF better, particularly among older individuals, to optimize use of antithrombotic agents, and to define the role of recently developed antithrombotic drugs and invasive nondrug approaches.
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Affiliation(s)
- Margaret C Fang
- University of California, San Francisco, 533 Parnassus Avenue, Box 0131, San Francisco, CA 94143, USA.
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Abstract
The most common cardiovascular arrhythmia is atrial fibrillation (AF), with an estimated prevalence of 2.5 million in 1994. The extent of this public health problem is enormous, particularly in its stroke sequelae. Routine management of this public health problem includes anticoagulation as the primary stroke-preventive measure. Echocardiography has been an important adjunctive tool in the evaluation of AF. More innovative and controversial is the putative role of transesophageal echocardiography in the treatment strategy of AF cardioversion to sinus rhythm. The standard of care for AF of less than 1-year duration is to attempt cardioversion to sinus rhythm. An alternative strategy is to utilize the assets of transesophageal echocardiography to visually screen the left atrium for thrombus, thereby playing an active role in the treatment strategy of AF. This review will discuss the role of echocardiography in AF as it was initially used as a diagnostic tool with weak prognostic features, and, more recently, as it can be used today as an adjunctive tool to guide therapy with excellent stroke risk-stratification features.
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Affiliation(s)
- A J Labovitz
- Division of Cardiology, Saint Louis University School of Medicine, Health Sciences Center, 3635 Vista Ave and Grand, FDT-14, St Louis, MO 63110, USA.
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Klein AL, Murray RD, Grimm RA. Role of transesophageal echocardiography-guided cardioversion of patients with atrial fibrillation. J Am Coll Cardiol 2001; 37:691-704. [PMID: 11693739 DOI: 10.1016/s0735-1097(00)01178-5] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Electrical cardioversion of patients with atrial fibrillation (AF) is frequently performed to relieve symptoms and improve cardiac performance. Patients undergoing cardioversion are treated conventionally with therapeutic anticoagulation for three weeks before and four weeks after cardioversion to decrease the risk of thromboembolism. A transesophageal echocardiography (TEE)-guided strategy has been proposed as an alternative that may lower stroke and bleeding events. Patients without atrial cavity thrombus or atrial appendage thrombus by TEE are cardioverted on achievement of therapeutic anticoagulation, whereas cardioversion is delayed in higher risk patients with thrombus. The aim of this review is to discuss the issues and controversies associated with the management of patients with AF undergoing cardioversion. We provide an overview of the TEE-guided and conventional anticoagulation strategies in light of the recently completed Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) clinical trial. The two management strategies comparably lower the patient's embolic risk when the guidelines are properly followed. The TEE-guided strategy with shorter term anticoagulation may lower the incidence of bleeding complications and safely expedite early cardioversion. The inherent advantages and disadvantages of both strategies are presented. The TEE-guided approach with short-term anticoagulation is considered to be a safe and clinically effective alternative to the conventional approach, and it is advocated in patients in whom earlier cardioversion would be clinically beneficial.
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Affiliation(s)
- A L Klein
- Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA.
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Cunningham R, Mikhail MG. Management of patients with syncope and cardiac arrhythmias in an emergency department observation unit. Emerg Med Clin North Am 2001; 19:105-21, vii. [PMID: 11214393 DOI: 10.1016/s0733-8627(05)70170-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Syncope is an ideal condition for the emergency observation setting because of its difficulty in diagnosis, many causes, high liability, and variable diagnostic approaches. Hospital admissions can be averted with appropriate patient selection for a short-term observation period. Atrial fibrillation is a common presenting condition in the emergency department. With aggressive management, the appropriately selected patient can have restoration of sinus rhythm and be safely discharged home.
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Affiliation(s)
- R Cunningham
- Department of Emergency Medicine, University of Michigan Hospital, Michigan, USA
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Jaber WA, Prior DL, Thamilarasan M, Grimm RA, Thomas JD, Klein AL, Asher CR. Efficacy of anticoagulation in resolving left atrial and left atrial appendage thrombi: A transesophageal echocardiographic study. Am Heart J 2000; 140:150-6. [PMID: 10874278 DOI: 10.1067/mhj.2000.106648] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Transesophageal echocardiography (TEE) is the gold standard for evaluation of the left atrium and the left atrial appendage (LAA) for the presence of thrombi. Anticoagulation is conventionally used for patients with atrial fibrillation to prevent embolization of atrial thrombi. The mechanism of benefit and effectiveness of thrombi resolution with anticoagulation is not well defined. METHODS AND RESULTS We used a TEE database of 9058 consecutive studies performed between January 1996 and November 1998 to identify all patients with thrombi reported in the left atrium and/or LAA. One hundred seventy-four patients with thrombi in the left atrial cavity (LAC) and LAA were identified (1.9% of transesophageal studies performed). The incidence of LAA thrombi was 6.6 times higher than LAC thrombi (151 vs 23, respectively). Almost all LAC thrombi were visualized on transthoracic echocardiography (90.5%). Mitral valve pathology was associated with LAC location of thrombi (P <.0001), whereas atrial fibrillation or flutter was present in most patients with LAA location of thrombi. Anticoagulation of 47 +/- 18 days was associated with thrombus resolution in 80.1% of the patients on follow-up TEE. Further anticoagulation resulted in limited additional benefit. CONCLUSIONS LAC thrombi are rare and are usually associated with mitral valve pathology. Transthoracic echocardiography is effective in identifying these thrombi. LAA thrombi occur predominantly in patients with atrial fibrillation or flutter. Short-term anticoagulation achieves a high rate of resolution of LAA and LAC thrombi but does not obviate the need for follow-up TEE.
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Affiliation(s)
- W A Jaber
- Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Letters to the Editor. J Am Soc Echocardiogr 1999. [DOI: 10.1016/s0894-7317(99)70115-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
In general, aspirin is indicated to prevent thrombosis in conditions associated with high shear rates (i.e., atherosclerosis) and warfarin is indicated to prevent thrombosis in conditions associated with stasis (i.e., atrial fibrillation). While aspirin and warfarin should generally not be used together, their combined use is beneficial in selected patients (e.g., some patients with mechanical valve prostheses). Aspirin in a dose of 75-150 mg per day is indicated to prevent vascular events in patients with ischaemic heart disease and also in patients at high risk of ischaemic heart disease. All patients with atrial fibrillation should be considered for oral anticoagulant therapy, with the decision for its use based on an assessment of the balance between the risk of thromboembolism and bleeding. The recommended therapeutic INR (international normalised ratio) range in non-valvular atrial fibrillation is 2.0-3.0. Warfarin is contraindicated in pregnancy, particularly during the first trimester; however, it may still need to be used in the second and third trimesters in patients with mechanical valve prostheses.
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Affiliation(s)
- R E Peverill
- Department of Medicine, Monash Medical Centre, and Monash University, Melbourne, VIC.
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Affiliation(s)
- B J Gersh
- Mayo Clinic, Cardiovascular Diseases, Rochester, MN 55905, USA
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Design of a Clinical Trial for the Assessment of Cardioversion Using Transesophageal Echocardiography (The ACUTE Multicenter Study) 11This study was supported in part by grants from the American Medical Association Education and Research Foundation, Chicago, Illinois; and American Society of Echocardiography Outcomes Research, Raleigh, North Carolina. Am J Cardiol 1998. [DOI: 10.1016/s0002-9149(98)00007-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Lee HT, Cozine K. Incidental conversion to sinus rhythm from atrial fibrillation during external jugular venous catheterization. J Clin Anesth 1997; 9:664-7. [PMID: 9438896 DOI: 10.1016/s0952-8180(97)00151-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
External jugular venous (EJV) catheterization is a frequent method of gaining central venous access because of its low complication rate. We describe a unique experience during EJV in which a patient with chronic atrial fibrillation converted suddenly to a sustained sinus rhythm without perioperative complication from this event. Our experience depicts a rare consequence of the central catheter placement and we, as anesthesiologists, should be aware of its potential occurrence in the operating room.
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Affiliation(s)
- H T Lee
- Department of Anesthesiology, College of Physicians & Surgeons of Columbia University, New York, NY. USA
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