1
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Ardashev A, Passman R, Zotova I, Efimov I, Rytkin E, Trachiotis G, Knight BP. Comprehensive Analysis of Anticoagulant Therapy in Patients with Isolated Atrial Flutter. Am J Cardiol 2024; 230:72-81. [PMID: 39089525 DOI: 10.1016/j.amjcard.2024.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/10/2024] [Accepted: 07/21/2024] [Indexed: 08/04/2024]
Abstract
Limited comparative data exist regarding the risk of cardiogenic emboli in patients with isolated atrial flutter (AFL). Some studies suggest a lower complication risk in AFL compared to atrial fibrillation (AFib), but methodological limitations and conflicting reports necessitate a comprehensive investigation. Our analysis proposes that isolated AFL carries a lower risk of ischemic events and left atrial thrombus formation than AFib. Importantly, we caution against applying stroke risk assessment approaches designed for AFib to AFL patients, as it may lead to harmful overestimations and unnecessary anticoagulant prescriptions. Furthermore, we highlight the current lack of sufficient data to determine the overall clinical benefit of prolonged anticoagulant therapy in patients with isolated AFL, especially when CHA2DS2-VASc index values are below 4. This review challenges existing perceptions, offering insights into the nuanced risk profiles of the transitional nature of isolated AFL due to the high incidence of AFib development within a year of AFL diagnosis. In conclusion, tailored risk assessments and further research are essential for precise clinical decision-making in this dynamic landscape.
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Affiliation(s)
- Andrey Ardashev
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago IL, USA.
| | - Rod Passman
- Division of Cardiology, Northwestern University, Chicago IL, USA
| | - Irina Zotova
- Healthcare Department, State Budget Healthcare Institution "City Hospital #17" of Moscow, Moscow, Russia
| | - Igor Efimov
- Department of Biomedical Engineering, Northwestern University, Chicago IL, USA
| | - Eric Rytkin
- Department of Biomedical Engineering, Northwestern University, Chicago IL, USA
| | - Gregory Trachiotis
- Department of Surgery, MedStar Georgetown University Hospital, Washington, DC, USA; Department of Surgery, The George Washington University Hospital, Washington, DC, USA; Department of Biomedical Engineering, The George Washington University, Washington, DC, USA
| | - Bradley P Knight
- Division of Cardiology, Northwestern University, Chicago IL, USA
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2
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Moady G, Rubinstein G, Mobarki L, Shturman A, Or T, Atar S. The Risk of Left Atrial Appendage Thrombus in Patients With Atrial Flutter Versus Atrial Fibrillation. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2024; 18:11795468231221404. [PMID: 38192356 PMCID: PMC10771748 DOI: 10.1177/11795468231221404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 11/18/2023] [Indexed: 01/10/2024]
Abstract
Objective Patients with atrial fibrillation (AF) are at increased risk of thromboembolic events originating mainly from left atrial appendage thrombus (LAAT). Patients with atrial flutter (AFL) are treated with anticoagulation based on the same criteria as patients with AF. However, whether patients with AFL have similar thromboembolic risk as AF is unclear. In the current study we aimed to estimate the prevalence of LAAT in patients with AFL undergoing trans-esophageal echocardiography (TEE). Methods/results We included 438 patients (404 with AF and 34 with AFL) scheduled for TEE to rule out LAAT before cardioversion (patients who reported no or inadequate anticoagulation before cardioversion). Demographic and echocardiographic data were compared between patients with and without LAAT. Despite a similar CHA2DS2-VASC score (3.8 ± 1.3 vs 3.4 ± 1.5 in the AF and AFL groups, respectively, P = .09), LAAT was documented in 12 (2.8%) in the AF group and in no patient in the AFL group (P < .0001). Conclusion Based on our results and previous studies, it seems reasonable to re-evaluate the need for oral anticoagulation in specific populations with AFL such as those with solitary AFL (without a history of AF episodes) undergoing successful ablation and in those with low CHA2DS2-VASC score.
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Affiliation(s)
- Gassan Moady
- Department of Cardiology, Galilee Medical Center, Nahariya, Israel
- Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Gal Rubinstein
- Department of Cardiology, Galilee Medical Center, Nahariya, Israel
| | - Loai Mobarki
- Department of Cardiology, Galilee Medical Center, Nahariya, Israel
| | | | - Tsafrir Or
- Department of Cardiology, Galilee Medical Center, Nahariya, Israel
| | - Shaul Atar
- Department of Cardiology, Galilee Medical Center, Nahariya, Israel
- Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
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3
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Ono K, Iwasaki Y, Akao M, Ikeda T, Ishii K, Inden Y, Kusano K, Kobayashi Y, Koretsune Y, Sasano T, Sumitomo N, Takahashi N, Niwano S, Hagiwara N, Hisatome I, Furukawa T, Honjo H, Maruyama T, Murakawa Y, Yasaka M, Watanabe E, Aiba T, Amino M, Itoh H, Ogawa H, Okumura Y, Aoki‐Kamiya C, Kishihara J, Kodani E, Komatsu T, Sakamoto Y, Satomi K, Shiga T, Shinohara T, Suzuki A, Suzuki S, Sekiguchi Y, Nagase S, Hayami N, Harada M, Fujino T, Makiyama T, Maruyama M, Miake J, Muraji S, Murata H, Morita N, Yokoshiki H, Yoshioka K, Yodogawa K, Inoue H, Okumura K, Kimura T, Tsutsui H, Shimizu W. JCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac Arrhythmias. J Arrhythm 2022; 38:833-973. [PMID: 36524037 PMCID: PMC9745564 DOI: 10.1002/joa3.12714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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4
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Ono K, Iwasaki YK, Akao M, Ikeda T, Ishii K, Inden Y, Kusano K, Kobayashi Y, Koretsune Y, Sasano T, Sumitomo N, Takahashi N, Niwano S, Hagiwara N, Hisatome I, Furukawa T, Honjo H, Maruyama T, Murakawa Y, Yasaka M, Watanabe E, Aiba T, Amino M, Itoh H, Ogawa H, Okumura Y, Aoki-Kamiya C, Kishihara J, Kodani E, Komatsu T, Sakamoto Y, Satomi K, Shiga T, Shinohara T, Suzuki A, Suzuki S, Sekiguchi Y, Nagase S, Hayami N, Harada M, Fujino T, Makiyama T, Maruyama M, Miake J, Muraji S, Murata H, Morita N, Yokoshiki H, Yoshioka K, Yodogawa K, Inoue H, Okumura K, Kimura T, Tsutsui H, Shimizu W. JCS/JHRS 2020 Guideline on Pharmacotherapy of Cardiac Arrhythmias. Circ J 2022; 86:1790-1924. [DOI: 10.1253/circj.cj-20-1212] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | - Yu-ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Masaharu Akao
- Department of Cardiovascular Medicine, National Hospital Organization Kyoto Medical Center
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School of Medicine
| | - Kuniaki Ishii
- Department of Pharmacology, Yamagata University Faculty of Medicine
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoshinori Kobayashi
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital
| | | | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | | | - Tetsushi Furukawa
- Department of Bio-information Pharmacology, Medical Research Institute, Tokyo Medical and Dental University
| | - Haruo Honjo
- Research Institute of Environmental Medicine, Nagoya University
| | - Toru Maruyama
- Department of Hematology, Oncology and Cardiovascular Medicine, Kyushu University Hospital
| | - Yuji Murakawa
- The 4th Department of Internal Medicine, Teikyo University School of Medicine, Mizonokuchi Hospital
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center
| | - Eiichi Watanabe
- Department of Cardiology, Fujita Health University School of Medicine
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Mari Amino
- Department of Cardiovascular Medicine, Tokai University School of Medicine
| | - Hideki Itoh
- Division of Patient Safety, Hiroshima University Hospital
| | - Hisashi Ogawa
- Department of Cardiology, National Hospital Organisation Kyoto Medical Center
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Chizuko Aoki-Kamiya
- Department of Obstetrics and Gynecology, National Cerebral and Cardiovascular Center
| | - Jun Kishihara
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Eitaro Kodani
- Department of Cardiovascular Medicine, Nippon Medical School Tama Nagayama Hospital
| | - Takashi Komatsu
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University School of Medicine
| | | | | | - Tsuyoshi Shiga
- Department of Clinical Pharmacology and Therapeutics, The Jikei University School of Medicine
| | - Tetsuji Shinohara
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University
| | - Atsushi Suzuki
- Department of Cardiology, Tokyo Women's Medical University
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute
| | - Yukio Sekiguchi
- Department of Cardiology, National Hospital Organization Kasumigaura Medical Center
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Noriyuki Hayami
- Department of Fourth Internal Medicine, Teikyo University Mizonokuchi Hospital
| | | | - Tadashi Fujino
- Department of Cardiovascular Medicine, Toho University, Faculty of Medicine
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Mitsunori Maruyama
- Department of Cardiovascular Medicine, Nippon Medical School Musashi Kosugi Hospital
| | - Junichiro Miake
- Department of Pharmacology, Tottori University Faculty of Medicine
| | - Shota Muraji
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | | | - Norishige Morita
- Division of Cardiology, Department of Medicine, Tokai University Hachioji Hospital
| | - Hisashi Yokoshiki
- Department of Cardiovascular Medicine, Sapporo City General Hospital
| | - Koichiro Yoshioka
- Division of Cardiology, Department of Internal Medicine, Tokai University School of Medicine
| | - Kenji Yodogawa
- Department of Cardiovascular Medicine, Nippon Medical School
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
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5
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Ashraf H, Agasthi P, Shanbhag A, Mehta RA, Rattanawong P, Allam M, Pujari SH, Mookadam F, Freeman WK, Srivathsan K, Sorajja D, Shen WK, Noseworthy PA, Yang EH, Masry HZE, Yao X, Mulpuru SK, Beohar N, Holmes DR, Arsanjani R. Long-Term Clinical Outcomes of Underdosed Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Atrial Flutter. Am J Med 2021; 134:788-796. [PMID: 33444586 DOI: 10.1016/j.amjmed.2020.12.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 12/12/2020] [Accepted: 12/14/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although direct oral anticoagulants (DOACs) have been shown to be effective at reducing the risk of stroke in patients with atrial fibrillation/flutter (AF), they are sometimes underdosed off-label to mitigate their associated higher bleeding risk. We sought to evaluate frequency and clinical outcomes of inappropriate underdosing of DOACS in patients with AF. METHODS We conducted a study of subjects with AF who had a clinical indication for stroke prophylaxis (with a congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65 to 47 years, sex category [CHA2DS2-VASc] of 2 or greater) and were prescribed 1 of the 4 clinically approved DOACs (apixaban, rivaroxaban, dabigatran, or edoxaban). We compared all-cause mortality, composite of stroke and systemic embolism, composite of myocardial infarction (MI), acute coronary syndromes (ACS), and coronary revascularization, and major bleeding between patients appropriately dosed and inappropriately underdosed. RESULTS A total of 8125 patients met inclusion criteria, with a mean follow up of 2.2 ± 2 years. Of those, 1724 patients (21.2%) were inappropriately dosed. After adjusting for baseline variables, there was no difference in all-cause mortality, risk of stroke or systemic embolism, International Society on Thrombosis and Haemostasis (ISTH) major bleeding, or composite of myocardial infarction, acute coronary syndromes, or coronary revascularization between patients appropriately dosed and inappropriately underdosed. In subgroup analysis, only apixaban demonstrated an increased incidence all-cause mortality (hazard ratio [HR] 1.24, 95% confidence interval [CI] 1.03-1.49) with inappropriate underdosing. There was no difference in the remaining clinical outcomes noted on subgroup analysis. CONCLUSION Underdosing of DOACs did not minimize risk of bleeding, systemic embolization or all-cause mortality in patients with AF. Inappropriate underdosing with apixaban in particular was associated with increased all-cause mortality.
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Affiliation(s)
- Hasan Ashraf
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix Ariz.
| | | | - Anusha Shanbhag
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix Ariz
| | - Ramila A Mehta
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minn
| | | | - Mohamed Allam
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix Ariz
| | | | - Farouk Mookadam
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix Ariz
| | | | | | - Dan Sorajja
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix Ariz
| | - Win-Kuang Shen
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix Ariz
| | | | - Eric H Yang
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix Ariz
| | | | - Xiaoxi Yao
- Department of Health Care Policy and Research, Mayo Clinic, Rochester, Minn
| | - Siva K Mulpuru
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
| | - Nirat Beohar
- Division of Cardiology, Mount Sinai Medical Center, Miami, Fla
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn
| | - Reza Arsanjani
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix Ariz
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6
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Reißmann B, Rottner L, Rillig A, Metzner A. [Cardiac arrhythmia]. MMW Fortschr Med 2021; 163:62-71. [PMID: 33783803 DOI: 10.1007/s15006-021-9651-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Bruno Reißmann
- Abteilung für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg--Eppendorf, Hamburg, Germany
| | - Laura Rottner
- Abteilung für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg--Eppendorf, Hamburg, Germany
| | - Andreas Rillig
- Abteilung für Kardiologie, Universitäres Herz- und Gefäßzentrum Hamburg--Eppendorf, Hamburg, Germany
| | - Andreas Metzner
- ASKLEPIOS Klinik St. Georg, Hanseat. Herzzentrum Hamburg\/Abt. Kardiologie, Lohmühlenstraße 5, 20099, Hamburg, Germany
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7
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Grüner-Hegge N, Kella DK, Padmanabhan D, Deshmukh AJ, Mehta R, Hodge D, Melduni RM, Greene EL, Friedman PA. Renal Dysfunction following Direct Current Cardioversion of Atrial Fibrillation: Incidence and Risk Factors. Cardiorenal Med 2020; 11:27-32. [PMID: 33296908 DOI: 10.1159/000507566] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 02/27/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Emerging data suggest that cardioversion for atrial fibrillation (AF) may be associated with acute kidney injury (AKI). However, limited data are available regarding the incidence and risk factors for AKI after direct current cardioversion (DCCV) of AF. METHODS All patients undergoing DCCV at Mayo Clinic between 2001 and 2012 for AF were prospectively enrolled in a database. All patients with serum creatinine (SCR) values pre- and post-cardioversion were reviewed for AKI, defined as a ≥25% decline in eGFR (estimated glomerular filtration rate) from baseline value within 7 days of the DCCV. RESULTS Of the 6,427 eligible patients, 1,256 (19.5%) patients had pre- and post-DCCV SCR available and formed the cohort under study. The mean age was 70.4 (SD 11.7) years, and 67.3% were male. During the study period, 131 (10.4%) patients suffered from AKI following DCCV. AKI was independently associated with inpatient status (OR 26.79; 95% CI 3.69-194.52), CHA2DS2-VASc score (OR 1.25; 95% CI 1.11-1.41), prior use of diuretics (OR 1.59; 95% CI 1.03-2.46), and absence of CKD (OR 1.61; 95% CI 1.04-2.49), and was independent of the success of the DCCV. None of the patients required acute dialysis during the study outcome period. CONCLUSION AKI following DCCV of AF is common, self-limited, and without the need for replacement therapies.
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Affiliation(s)
| | - Danesh K Kella
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Deepak Padmanabhan
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ramila Mehta
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida, USA
| | - David Hodge
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida, USA
| | - Rowlens M Melduni
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Eddie L Greene
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul A Friedman
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA,
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8
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Andrade JG, Aguilar M, Atzema C, Bell A, Cairns JA, Cheung CC, Cox JL, Dorian P, Gladstone DJ, Healey JS, Khairy P, Leblanc K, McMurtry MS, Mitchell LB, Nair GM, Nattel S, Parkash R, Pilote L, Sandhu RK, Sarrazin JF, Sharma M, Skanes AC, Talajic M, Tsang TSM, Verma A, Verma S, Whitlock R, Wyse DG, Macle L. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2020; 36:1847-1948. [PMID: 33191198 DOI: 10.1016/j.cjca.2020.09.001] [Citation(s) in RCA: 319] [Impact Index Per Article: 79.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/05/2020] [Accepted: 09/05/2020] [Indexed: 12/20/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Martin Aguilar
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jafna L Cox
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Paul Khairy
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stanley Nattel
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Jean-François Sarrazin
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Mukul Sharma
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Mario Talajic
- Montreal Heart Institute, University of Montreal, Montréal, Quebec, Canada
| | - Teresa S M Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
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9
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Andrade JG, Verma A, Mitchell LB, Parkash R, Leblanc K, Atzema C, Healey JS, Bell A, Cairns J, Connolly S, Cox J, Dorian P, Gladstone D, McMurtry MS, Nair GM, Pilote L, Sarrazin JF, Sharma M, Skanes A, Talajic M, Tsang T, Verma S, Wyse DG, Nattel S, Macle L. 2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2019; 34:1371-1392. [PMID: 30404743 DOI: 10.1016/j.cjca.2018.08.026] [Citation(s) in RCA: 173] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 08/14/2018] [Accepted: 08/15/2018] [Indexed: 11/19/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) Atrial Fibrillation Guidelines Committee provides periodic reviews of new data to produce focused updates that address clinically important advances in atrial fibrillation (AF) management. This 2018 Focused Update addresses: (1) anticoagulation in the context of cardioversion of AF; (2) the management of antithrombotic therapy for patients with AF in the context of coronary artery disease; (3) investigation and management of subclinical AF; (4) the use of antidotes for the reversal of non-vitamin K antagonist oral anticoagulants; (5) acute pharmacological cardioversion of AF; (6) catheter ablation for AF, including patients with concomitant AF and heart failure; and (7) an integrated approach to the patient with AF and modifiable cardiovascular risk factors. The recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) standards. Individual studies and literature were reviewed for quality and bias; the literature review process and evidence tables are included as Supplementary Material and are available on the CCS Web site. Details of the updated recommendations are presented, along with their background and rationale. This document is linked to an updated summary of all CCS AF guidelines recommendations, from 2010 to the present 2018 Focused Update, which is provided in the Supplementary Material.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - L Brent Mitchell
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Ratika Parkash
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kori Leblanc
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Clare Atzema
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Jeff S Healey
- McMaster University, Hamilton, Ontario, Canada; Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Stuart Connolly
- McMaster University, Hamilton, Ontario, Canada; Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Jafna Cox
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David Gladstone
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - M Sean McMurtry
- University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Louise Pilote
- McGill University Health Centre, Montréal, Quebec, Canada
| | | | - Mike Sharma
- McMaster University, Hamilton, Ontario, Canada; Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Allan Skanes
- London Heart Institute, Western University, London, Ontario, Canada
| | - Mario Talajic
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Teresa Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Subodh Verma
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - D George Wyse
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Stanley Nattel
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Laurent Macle
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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10
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Chen X, Liu H, Zhang Y, Wang C, Xu D, Yang B, Ju W, Zhang F, Chen H, Cao K, Chen M. Atrial electromechanical delay assessment in early phase after catheter ablation for patients with atrial fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:327-332. [PMID: 30632635 DOI: 10.1111/pace.13602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 01/02/2019] [Accepted: 01/06/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Variation of atrial electromechanical delay (AED) in early phase after catheter ablation in patients with atrial fibrillation (AF) is lacking. METHODS Fifty-five consecutive patients restored sinus rhythm after ablation was included. Echocardiography was performed at 4 h, 1 day, and 3 days after radiofrequency catheter ablation, and AED was measured simultaneously by echocardiography with pulse Doppler imaging and pulse wave tissue Doppler imaging. RESULTS AED parameters were significantly longer in the nonparoxysmal atrial fibrillation (NPAF) group than in the paroxysmal atrial fibrillation (PAF) group at each checking point after ablation (P < 0.05). Compared with other checking points, AED parameters were significantly longer 4 h postablation in the NPAF group, while no significant difference was found between different checking points in the PAF group. AED-leap, representing the variation of AED in NPAF patients, was significantly positively correlated with the duration of NPAF (r = 0.5291, P = 0.0113). CONCLUSIONS Compared with PAF, NPAF patients have a longer AED postablation, and an abrupt decrease in the initial-h postablation. Such phenomenon gives rise to the different clinical features of PAF and NPAF, and could guide different assessment and treatment strategies for different types of AF.
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Affiliation(s)
- Xiaodong Chen
- Department of Cardiology, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China.,Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing, China
| | - Hailei Liu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yi Zhang
- Department of Cardiology, Shanghai Tenth People's Hospital, Shanghai, China
| | - Chunru Wang
- Department of Cardiology, Affiliated Hospital of Integrated Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China.,Jiangsu Province Academy of Traditional Chinese Medicine, Nanjing, China
| | - Di Xu
- Department of Cardiology, Geriatrics, The First Affiliate Hospital of Nanjing Medical University, Nanjing, China
| | - Bing Yang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weizhu Ju
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fengxiang Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hongwu Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kejiang Cao
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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11
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Hwang J, Park HS, Jun SW, Choi SW, Lee CH, Kim IC, Cho YK, Yoon HJ, Kim H, Nam CW, Hur SH, Lee SH, Han S. The incidence of left atrial appendage thrombi on transesophageal echocardiography after pretreatment with apixaban for cardioversion in the real-world practice. PLoS One 2018; 13:e0208734. [PMID: 30532128 PMCID: PMC6285970 DOI: 10.1371/journal.pone.0208734] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 11/22/2018] [Indexed: 01/22/2023] Open
Abstract
The risk of thromboembolisms during the post-cardioversion period is high. For patients with persistent atrial fibrillation (AF), anticoagulation with warfarin (INR 2.0~3.0) is recommended for at least three weeks prior and four weeks after cardioversion. We aimed to evaluate the efficacy of apixaban in preventing thromboembolic events during post-cardioversion. We enrolled 127 consecutive persistent AF patients (83 persistent, 44 longstanding persistent AF), scheduled to undergo cardioversion and were pretreated with apixaban. All patients underwent transesophageal echocardiography (TEE) to rule out thrombi in the left atrium (LA) or LA appendage (LAA) after anticoagulation with apixaban. The median duration of anticoagulation before the TEE was 37 (interquartile range [IQR] 34, 50) days. There were 7 patients (5.5%) with visible thrombi in the LAA. A spontaneous echo contrast was noted in 24 (18.9%) patients. Cardioversion was attempted in 117 patients, and they were prescribed amiodarone before the elective DC cardioversion. Sinus rhythm was achieved in 37 patients (31.6%) by amiodarone itself. DC cardioversion was attempted in 80 patients and was successful in 73 (91.3%). None of the cardioverted patients had any thromboembolic events within one month. Transient ischemic attacks were observed in one patient during a median follow up period of 202 days (IQR 143, 294). In conclusion, apixaban could be used as an anticoagulant for patients scheduled for cardioversion. However, the incidence of thrombi was not negligible. TEE or other imaging modalities should be considered before cardioversion or other invasive procedures.
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Affiliation(s)
- Jongmin Hwang
- Department of internal medicine, Division of Cardiology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Hyoung-Seob Park
- Department of internal medicine, Division of Cardiology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Seung-Woon Jun
- Department of internal medicine, Division of Cardiology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Sang-Woong Choi
- Department of internal medicine, Division of Cardiology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Cheol Hyun Lee
- Department of internal medicine, Division of Cardiology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - In-Cheol Kim
- Department of internal medicine, Division of Cardiology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Yun-Kyeong Cho
- Department of internal medicine, Division of Cardiology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Hyuck-Jun Yoon
- Department of internal medicine, Division of Cardiology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Hyungseop Kim
- Department of internal medicine, Division of Cardiology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Chang-Wook Nam
- Department of internal medicine, Division of Cardiology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Seung-Ho Hur
- Department of internal medicine, Division of Cardiology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Sang Hoon Lee
- Department of internal medicine, Division of Cardiology, Department of Internal Medicine, SM Christianity Hospital, Pohang, Republic of Korea
| | - Seongwook Han
- Department of internal medicine, Division of Cardiology, Keimyung University Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
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12
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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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13
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Katritsis DG, Boriani G, Cosio FG, Hindricks G, Jaïs P, Josephson ME, Keegan R, Kim YH, Knight BP, Kuck KH, Lane DA, Lip GYH, Malmborg H, Oral H, Pappone C, Themistoclakis S, Wood KA, Blomström-Lundqvist C, Gorenek B, Dagres N, Dan GA, Vos MA, Kudaiberdieva G, Crijns H, Roberts-Thomson K, Lin YJ, Vanegas D, Caorsi WR, Cronin E, Rickard J. European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE). Europace 2018; 19:465-511. [PMID: 27856540 DOI: 10.1093/europace/euw301] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Demosthenes G Katritsis
- Athens Euroclinic, Athens, Greece; and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Giuseppe Boriani
- Cardiology Department, Modena University Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | | | | | - Pierre Jaïs
- University of Bordeaux, CHU Bordeaux, LIRYC, France
| | | | - Roberto Keegan
- Hospital Privado del Sur y Hospital Español, Bahia Blanca, Argentina
| | - Young-Hoon Kim
- Korea University Medical Center, Seoul, Republic of Korea
| | | | | | - Deirdre A Lane
- Asklepios Hospital St Georg, Hamburg, Germany.,University of Birmingham Institute of Cardiovascular Science, City Hospital, Birmingham, UK; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Science, City Hospital, Birmingham, UK; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Helena Malmborg
- Department of Cardiology and Medical Science, Uppsala University, Uppsala, Sweden
| | - Hakan Oral
- University of Michigan, Ann Arbor, MI, USA
| | - Carlo Pappone
- IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | | | | | | | - Bulent Gorenek
- Cardiology Department, Eskisehir Osmangazi University, Eskisehir, Turkey
| | | | - Gheorge-Andrei Dan
- Colentina University Hospital, 'Carol Davila' University of Medicine, Bucharest, Romania
| | - Marc A Vos
- Department of Medical Physiology, Division Heart and Lungs, Umc Utrecht, The Netherlands
| | | | - Harry Crijns
- Mastricht University Medical Centre, Cardiology & CARIM, The Netherlands
| | | | | | - Diego Vanegas
- Hospital Militar Central - Unidad de Electrofisiologìa - FUNDARRITMIA, Bogotà, Colombia
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14
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Atzema CL. Stroke Prevention for High-Risk Atrial Fibrillation in the Emergency Setting: The Emergency Physician Perspective. Can J Cardiol 2018; 34:125-131. [DOI: 10.1016/j.cjca.2017.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 11/07/2017] [Accepted: 11/08/2017] [Indexed: 12/23/2022] Open
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15
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Comparison of prevalence and management of left atrial appendage thrombi under old and new anticoagulants prior to left atrial catheter ablation. Am Heart J 2017; 193:8-15. [PMID: 29129259 DOI: 10.1016/j.ahj.2017.07.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 07/31/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The prevalence and management of left atrial appendage (LAA) thrombi associated with new anticoagulants remain to be elucidated, especially prior to atrial fibrillation (AFib) ablation. This study sought to (1) compare the prevalence of LAA thrombi and/or severe LAA contrast under vitamin K antagonist (VKA) agents and novel oral anticoagulants (NOACs), (2) evaluate the rate of LAA thrombus resolution after anticoagulation modification, and (3) determine the predictive factors of LAA thrombi and severe LAA contrast in patients prior to LA AFib ablation. METHODS Between January 2013 and March 2016, 576 consecutive patients referred for AFib ablation were included, and the prevalence of transesophageal echocardiography-detected thrombi was similar under NOACs (2.1%) and VKA agents (2.6%). RESULTS Thrombus resolution was obtained in 50% of cases following anticoagulation modification. Through multivariate exact logistic regression analysis with relevant clinical and echocardiographic features, age (P<.001), LAA hypocontractility (P<.001), and left ventricular ejection fraction (P=.007) were found to be independently associated with the occurrence of LAA thrombus. The relevant factors independently associated with LAA thrombus or severe contrast were LAA hypocontractility (P<.001) and age (P<.001). CONCLUSIONS The prevalence of transesophageal echocardiography-detected thrombi in patients referred for AFib ablation is similar under NOACs (2.1%) and VKA agents (2.6%). Under VKA therapy with 3-4 international normalized ratio, 50% of thrombi dissolved. Independent predictive factors of procedure contraindication included age, LAA hypocontractility, and left ventricular ejection fraction.
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16
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Abstract
Significant advances in our understanding of transient ischemic attack (TIA) have taken place since it was first recognized as a major risk factor for stroke during the late 1950's. Recently, numerous studies have consistently shown that patients who have experienced a TIA constitute a heterogeneous population, with multiple causative factors as well as an average 5–10% risk of suffering a stroke during the 30 days that follow the index event. These two attributes have driven the most important changes in the management of TIA patients over the last decade, with particular attention paid to effective stroke risk stratification, efficient and comprehensive diagnostic assessment, and a sound therapeutic approach, destined to reduce the risk of subsequent ischemic stroke. This review is an outline of these changes, including a discussion of their advantages and disadvantages, and references to how new trends are likely to influence the future care of these patients.
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Affiliation(s)
- Camilo R Gomez
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
| | - Michael J Schneck
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
| | - Jose Biller
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
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17
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Ţînţ D, Petriş AO, Pop I, Melnic R, Ignat AM, Rogozea LM. Vitamin K Antagonists Versus Novel Oral Anticoagulants for Elective Electrical Cardioversion of Atrial Fibrillation. Am J Ther 2017; 24:e553-e558. [DOI: 10.1097/mjt.0000000000000590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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Abstract
Clinical electrophysiology has made the traditional classification of rapid atrial rhythms into flutter and tachycardia of little clinical use. Electrophysiological studies have defined multiple mechanisms of tachycardia, both re-entrant and focal, with varying ECG morphologies and rates, authenticated by the results of catheter ablation of the focal triggers or critical isthmuses of re-entry circuits. In patients without a history of heart disease, cardiac surgery or catheter ablation, typical flutter ECG remains predictive of a right atrial re-entry circuit dependent on the inferior vena cava-tricuspid isthmus that can be very effectively treated by ablation, although late incidence of atrial fibrillation remains a problem. Secondary prevention, based on the treatment of associated atrial fibrillation risk factors, is emerging as a therapeutic option. In patients subjected to cardiac surgery or catheter ablation for the treatment of atrial fibrillation or showing atypical ECG patterns, macro-re-entrant and focal tachycardia mechanisms can be very complex and electrophysiological studies are necessary to guide ablation treatment in poorly tolerated cases.
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Affiliation(s)
- Francisco G Cosío
- Getafe University Hospital, European University of Madrid, Madrid, Spain
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19
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Evaluation of left atrial appendage function and thrombi in patients with atrial fibrillation: from transthoracic to real time 3D transesophageal echocardiography. Int J Cardiovasc Imaging 2016; 33:491-498. [PMID: 27853971 DOI: 10.1007/s10554-016-1026-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 11/14/2016] [Indexed: 10/20/2022]
Abstract
The detection of embolic sources in patients with atrial fibrillation (AF) is important to guide anticoagulant therapy. Two-dimensional transesophageal echocardiography (TEE) is the gold standard to study left atrial appendage (LAA) anatomy and morphology, despite some false-positive diagnosis. We hypothesized that real time 3D TEE (RT3DTEE) is superior to 2DTEE in detecting and/or excluding LAA thrombi. We studied 93 patients with non-valvular AF (60 males, age = 67.1 ± 14.2 years) referred for electric cardioversion with transthoracic, 2DTEE and RT3DTEE. Before cardioversion, TTE allowed a confident measurement of emptying velocity of LAA (LAAeV) only in 59/93 patients (63%). On the contrary a good quality TEE LAAeV was obtained in all patients with 49/93 (53%) dysfunctional LAA (LAAeV < 40 cm/s). A subgroup of 5 patients (7.2% of the 69 effective cardioversion) presented a persistent dysfunction after cardioversion (with LAAeV values of <40 cm/s on the TEE post-CV). TEE allowed to observe a bilobed shape in 45 patients (48.4%) and three lobes in 22 patients (23.7%). In addition, besides to several additional findings, 2DTEE managed to detect thrombi with certainty in 8/93 patients (8.6%). In other 5 cases with diagnostic doubts for thrombi with 2DTEE (5/93 patients: 5.4%), the addition of the RT3DTEE mode allowed to discriminate with certainty the presence of just pectinate muscles in 4 patients RT3DTEE in patients with AF at risk of embolism is feasible, accurate and showed an additional diagnostic capability in the differential diagnosis of selected cases with suspected LAA thrombi.
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20
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Demir AD, Soylu M, Ozdemir O, Topaloğlu S, Aras D, Saşmaz A, Korkmaz S. Do Different Atrial Flutter Types Carry the Same Thromboembolic Risk? Angiology 2016; 56:593-9. [PMID: 16193199 DOI: 10.1177/000331970505600511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Thromboembolic risk of atrial flutter (AFl) types has not been elucidated sufficiently in previous reports. The authors classified the patients according to surface electrocardiogram and electrophysiologic characteristics as those with typical AFl (37 patients, 78.4% male, mean age 59.8 ±9.5 years) and atypical AFl (13 patients, 69.2% male, mean age 60.9 ±6.9 years) and compared them regarding some clinical, echocardiographic, and hematologic parameters. An age- and gender-matched control group composed of 20 individuals without any organic heart disease in sinus rhythm was chosen (80% male, mean age 60.3 ±7.9 years). Clinical features such as age, gender, organic heart disease, hypertension, diabetes mellitus, AFl duration, and the prevalence of paroxysmal atrial fibrillation were similar in both AFl groups. Echocardiographic parameters such as left ventricular ejection fraction, left atrial (LA) diameter, LA spontaneous echo contrast, and LA appendage emptying velocities were similar in both AFl groups. Fibrinogen, fibrin D-dimer, and thrombin-antithrombin III levels reflecting coagulation system activity were found to be increased in the patients with atypical AFl when compared with those with typical AFl and the control group (p<0.001). In Pearson’s correlation analysis, significant correlation between these hematologic markers and clinical and echocardiographic parameters were not found (p>0.05). The coagulation system activity was found to be increased in patients with atypical AFl. Thus, anticoagulation due to the increased thromboembolic risk should be considered in patients with atypical AFl.
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Affiliation(s)
- Ahmet Duran Demir
- Department of Cardiology at Türkiye Yüksek Ihtisas Hospital, Ankara, Turkey.
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21
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Enomoto Y, Ito N, Fujino T, Noro M, Ikeda T, Sugi K. The Efficacy and Safety of Oral Rivaroxaban in Patients with Non-Valvular Atrial Fibrillation Scheduled for Electrical Cardioversion. Intern Med 2016; 55:1953-8. [PMID: 27477399 DOI: 10.2169/internalmedicine.55.5315] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective Electrical cardioversion (EC) is associated with an increased risk of thrombotic events in patients with non-valvular atrial fibrillation (NVAF). Patients who experience AF for a period of >48 hours therefore require adequate anticoagulation therapy for at least 3 weeks before and 4 weeks after EC. While the guidelines address the management of vitamin K antagonists (VKAs), there are limited data on the use of novel oral anticoagulants (NOAC). One NOAC, rivaroxaban, has a rapid onset of action and might therefore shorten the time for which anti-coagulant treatment is required before a patient undergoes EC. Methods This study included 91 patients with NVAF of >48 hours in duration or in whom the time of onset was unknown who were undergoing EC after pretreatment with rivaroxaban. All of the patients were pretreated with rivaroxaban for at least 2 hours before EC and the same dose of rivaroxaban was prescribed for 4 weeks after EC. The primary endpoint was a successful EC without any thrombotic events or bleeding complications within 30 days after EC. The secondary endpoint was the time to EC. Results The mean age was 63±12 years and 70 of the 91 patients were male. The CHADS2 and HAS-BLED scores were 1.0±1.0 and 1.7±1.3, respectively. Although there were no thrombotic events, minor bleeding (gingival hemorrhage) occurred 20 days after the initiation of rivaroxaban treatment in one patient. The average time to EC was 11.9±11.1 days. Conclusion Rivaroxaban is safe and effective drug for NVAF patients who are scheduled for an EC. Furthermore, since VKAs take a substantial amount of time to establish adequate anticoagulation, pretreatment with rivaroxaban could shorten the time to the EC.
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Affiliation(s)
- Yoshinari Enomoto
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Japan
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22
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Katritsis DG, Boriani G, Cosio FG, Jais P, Hindricks G, Josephson ME, Keegan R, Knight BP, Kuck KH, Lane DA, Lip GY, Malmborg H, Oral H, Pappone C, Themistoclakis S, Wood KA, Young-Hoon K, Lundqvist CB. Executive Summary: European Heart Rhythm Association Consensus Document on the Management of Supraventricular Arrhythmias: Endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE). Arrhythm Electrophysiol Rev 2016; 5:210-224. [PMID: 28116087 PMCID: PMC5248663 DOI: 10.15420/aer.2016:5.3.gl1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 10/20/2016] [Indexed: 12/26/2022] Open
Abstract
This paper is an executive summary of the full European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, published in Europace. It summarises developments in the field and provides recommendations for patient management, with particular emphasis on new advances since the previous European Society of Cardiology guidelines. The EHRA consensus document is available to read in full at http://europace.oxfordjournals.org.
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Affiliation(s)
- Demosthenes G Katritsis
- Athens Euroclinic, Athens, Greece; Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Giuseppe Boriani
- Cardiology Department, Modena University Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Pierre Jais
- University of Bordeaux, CHU Bordeaux, LIRYC, France
| | | | - Mark E Josephson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Roberto Keegan
- Hospital Privado del Sur y Hospital Espanol, Bahia Blanca, Argentina
| | | | | | - Deirdre A Lane
- University of Birmingham Institute of Cardiovascular Science, City Hospital, Birmingham, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregory Yh Lip
- University of Birmingham Institute of Cardiovascular Science, City Hospital, Birmingham, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Helena Malmborg
- Department of Cardiology and Medical Science, Uppsala University, Uppsala, Sweden
| | - Hakan Oral
- University of Michigan, Ann Arbor, MI, USA
| | - Carlo Pappone
- IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | | | | | - Kim Young-Hoon
- Korea University Medical Center, Seoul, Republic of Korea
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23
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Vadmann H, Nielsen PB, Hjortshøj SP, Riahi S, Rasmussen LH, Lip GYH, Larsen TB. Atrial flutter and thromboembolic risk: a systematic review. Heart 2015; 101:1446-55. [DOI: 10.1136/heartjnl-2015-307550] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 04/13/2015] [Indexed: 11/04/2022] Open
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24
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Cresti A, García-Fernández MA, De Sensi F, Miracapillo G, Picchi A, Scalese M, Severi S. Prevalence of auricular thrombosis before atrial flutter cardioversion: a 17-year transoesophageal echocardiographic study. Europace 2015; 18:450-6. [PMID: 26017468 DOI: 10.1093/europace/euv128] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 04/13/2015] [Indexed: 11/13/2022] Open
Abstract
AIMS Prevalence of left appendage thrombosis ranges from 6 to 18% in persistent atrial fibrillation (AF). Few and low sample size studies have assessed left and right atrial thrombosis in persistent atrial flutter (AFL) and a wide variety of frequencies, from 1 to 21%, has been reported. The aim of this study was to evaluate the prevalence of atrial appendage thrombosis in a large population of patients undergoing transoesophageal echocardiography (TEE)-guided cardioversion (CV) for recent AFL onset and compare it with AF. METHODS AND RESULTS From 1999 to September 2014, we collected data of 1081 patients to CV: 877 affected by AF (81.1%) and 204 by AFL (18.9%). The presence of auricular thrombosis was evaluated by TEE in AF or AFL persisting for more than 48 h. The presence of appendage thrombosis, Doppler emptying velocities, and severe spontaneous echo contrast (SEC) was studied. The overall prevalence of atrial thrombosis was 9.62% (104/1081). Frequency of atrial thrombosis in AFL patients was 6.4% (13/204) vs. 10.5% among AF (92/877), P = 0.074. Comparing the two appendages, frequency of left atrial appendage thrombosis was in AFL 5.9% (12/204) vs. 9.9% (87/877) in the AF group, P = 0.07. Right atrial appendage thrombosis was present in 0.5% (1/204) in the AFL group vs. 0.8% (7/877) in the AF group, P = 0.64. Moderate to severe SEC (3+/4+) was present in 28% of AFL patients (57/204) vs. 35% of AF patients (307/877), P = 0.05. CONCLUSION Auricular thrombosis is not an infrequent finding in AFL before CV. Our study suggests the use of TEE screening in AFL, as well as in AF, when patients arrive to clinical attention after more than 48 h from arrhythmia onset.
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Affiliation(s)
- Alberto Cresti
- Cardiological Department, Misericordia Hospital, via Senese, Grosseto 58100, Italy
| | - Miguel Angel García-Fernández
- Department of Medicine, San Carlos University Hospital, Universidad Complutense, Facultad de Medicina, Madrid, Spain
| | - Francesco De Sensi
- Cardiological Department, Misericordia Hospital, via Senese, Grosseto 58100, Italy
| | - Gennaro Miracapillo
- Cardiological Department, Misericordia Hospital, via Senese, Grosseto 58100, Italy
| | - Andrea Picchi
- Cardiological Department, Misericordia Hospital, via Senese, Grosseto 58100, Italy
| | - Marco Scalese
- Department of Epidemiology and Health Research, Institute of Clinical Physiology, National Council of Research, F. G. Monasterio, Pisa, Italy
| | - Silva Severi
- Cardiological Department, Misericordia Hospital, via Senese, Grosseto 58100, Italy
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Owais K, Mahmood F, Montealegre-Gallegos M, Khabbaz KR, Matyal R. Left Atrial Appendage, Intraoperative Echocardiography, and the Anesthesiologist. J Cardiothorac Vasc Anesth 2015; 29:1651-62. [PMID: 26321120 DOI: 10.1053/j.jvca.2015.04.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Indexed: 12/28/2022]
Affiliation(s)
- Khurram Owais
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Feroze Mahmood
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Mario Montealegre-Gallegos
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kamal R Khabbaz
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Robina Matyal
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Yoshida T, Fujii T, Uchino S, Takinami M. Epidemiology, prevention, and treatment of new-onset atrial fibrillation in critically ill: a systematic review. J Intensive Care 2015; 3:19. [PMID: 25914828 PMCID: PMC4410002 DOI: 10.1186/s40560-015-0085-4] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 03/31/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is a common arrhythmia in the ICU. The aim of this review is to summarize relevant information on new-onset AF in non-cardiac critical illness with respect to epidemiology, prevention, and treatment. METHODS We conducted a PubMed search in June 2014 and included studies describing the epidemiology, prevention, and treatment of new-onset AF and atrial flutter during ICU stay in non-cardiac adult patients. Selected studies were divided into the three categories according to the extracted information. The methodological quality of selected studies was described according to the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS We identified 1,132 citations, and after full-text-level selection, we included 10 studies on etiology/outcome and five studies on treatment. There was no study related to prevention. Overall quality of evidence was mostly low or very low due to their observational study designs, small sample sizes, flawed diagnosis of new-onset AF, and the absence of mortality evaluation. The incidence of new-onset AF varied from 4.5% to 15.0%, excluding exceptional cases (e.g., septic shock). Severity scores of patients with new-onset AF were higher than those without new-onset AF in eight studies, in four of which the difference was statistically significant. Five studies reported risk factors for new-onset AF, all of which used multivariate analyses to extract risk factors. Multiple risk factors are reported, e.g., advanced age, the white race, severity scores, organ failures, and sepsis. Hospital mortality in new-onset AF patients was higher than that of patients without AF in all studies, four of which found statistical significance. Among the five studies on treatment, only one study was randomized controlled, and various interventions were studied. CONCLUSIONS New-onset AF occurred in 5%-15% of the non-cardiac critically ill patients. Patients with new-onset AF had poor outcomes compared with those without AF. Despite the high incidence of new-onset AF in the general ICU population, currently available information for AF, especially for management (prevention, treatment, and anticoagulation), is quite limited. Further research is needed to improve our understanding of new-onset AF in critically ill patients.
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Affiliation(s)
- Takuo Yoshida
- Intensive Care Unit, Department of Anesthesiology, The Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo 105-8471 Japan
| | - Tomoko Fujii
- Intensive Care Unit, Department of Anesthesiology, The Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo 105-8471 Japan
| | - Shigehiko Uchino
- Intensive Care Unit, Department of Anesthesiology, The Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo 105-8471 Japan
| | - Masanori Takinami
- Intensive Care Unit, Department of Anesthesiology, The Jikei University School of Medicine, 3-19-18, Nishi-Shinbashi, Minato-ku, Tokyo 105-8471 Japan
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Alyeshmerni D, Pirmohamed A, Barac A, Smirniotopoulos J, Xue E, Goldstein S, Mazel J, Lindsay J. Transesophageal Echocardiographic Screening before Atrial Flutter Ablation: Is It Necessary for Patient Safety? J Am Soc Echocardiogr 2013; 26:1099-105. [DOI: 10.1016/j.echo.2013.05.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Indexed: 10/26/2022]
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Mahajan R, Pathak R, Lim HS, Willoughby SR, Sanders P. Does catheter ablation of atrial fibrillation eliminate the need for anticoagulation? Interv Cardiol 2013. [DOI: 10.2217/ica.13.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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García-Seara J, Gude F, Cabanas-Grandío P, Martínez-Sande JL, Fernández-López X, Elices-Teja J, Raposeiras Roubin S, González-Juanatey JR. Structural and functional inverse cardiac remodeling after cavotricuspid isthmus ablation in patients with typical atrial flutter. Rev Esp Cardiol 2012; 65:1003-9. [PMID: 22841435 DOI: 10.1016/j.recesp.2012.03.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 03/30/2012] [Indexed: 10/28/2022]
Abstract
INTRODUCTION AND OBJECTIVES The purpose of the present study is to determine the structural and functional cardiac changes that occur in patients at 1-year follow-up after ablation of typical atrial flutter. METHODS We enrolled 95 consecutive patients referred for cavotricuspid isthmus ablation. Echocardiography was performed at ≤6h post-procedure and 1-year follow-up. RESULTS Of 95 patients initially included, 89 completed 1-year follow-up. Hypertensive cardiopathy was the most frequently associated condition (39%); 24% of patients presented low baseline left ventricular systolic dysfunction. We observed a significant reduction in right and left atrial areas, end-diastolic and end-systolic left ventricular diameters, and interventricular septum. We observed substantial improvement in right atrium contraction fraction and left ventricular ejection fraction, and a reduction in pulmonary hypertension. Changes in diastolic dysfunction pattern were observed: 60% of patients progressed from baseline grade III to grade I; at 1-year follow-up, this improvement was found in 81%. We found no structural differences between paroxysmal and persistent atrial flutter at baseline and 1-year follow-up, exception for basal diastolic function. CONCLUSIONS In patients with typical atrial flutter undergoing cavotricuspid isthmus catheter ablation, we found inverse structural and functional cardiac remodeling at 1-year follow-up with much improved left ventricular ejection fraction, right atrium contraction fraction, and diastolic dysfunction pattern. Full English text available from:www.revespcardiol.org.
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Affiliation(s)
- Javier García-Seara
- Servicio de Cardiología, Hospital Clínico de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain.
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Parikh MG, Aziz Z, Krishnan K, Madias C, Trohman RG. Usefulness of transesophageal echocardiography to confirm clinical utility of CHA2DS2-VASc and CHADS2 scores in atrial flutter. Am J Cardiol 2012; 109:550-5. [PMID: 22133753 DOI: 10.1016/j.amjcard.2011.10.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 10/04/2011] [Accepted: 10/04/2011] [Indexed: 11/15/2022]
Abstract
The CHA(2)DS(2)-VASc and CHADS(2) risk stratification schemes are used to predict thromboembolism and ischemic stroke in patients with atrial fibrillation. However, limited data are available regarding the utility of these risk stratification schemes for stroke in patients with atrial flutter. A retrospective analysis of 455 transesophageal echocardiographic studies in patients with atrial flutter was performed to identify left atrial (LA) thrombi and/or spontaneous echocardiographic contrast (SEC). The CHA(2)DS(2)-VASc (Congestive heart failure, Hypertension, Age ≥75 years [doubled risk weight], Diabetes mellitus, previous Stroke/transient ischemic attack [doubled risk weight], Vascular disease, Age 65 to 74 years, Sex) and CHADS(2) (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, previous Stroke/transient ischemic attack [double risk weight]) scores were calculated to stratify the risk of stroke or transient cerebrovascular ischemic events. Transesophageal echocardiography revealed LA thrombi in 5.3% and SEC in 25.9% of patients. Using CHADS(2), LA thrombus was found in 2.2% of the low-intermediate-risk group and 8.3% of the high-risk group (p = 0.005). SEC was found in 19.8% of the low-intermediate-risk group and 32% of the high-risk group (p = 0.004). Using CHA(2)DS(2)-VASc, LA thrombus was found in 1.7% of the low-intermediate-risk group and 6.5% of the high-risk group (p = 0.053). SEC was found in 11.8% of the low-intermediate-risk group versus 30.9% of the high-risk group (p = 0.004). The sensitivity for LA thrombus/SEC with a high CHADS(2) and CHA(2)DS(2)-VASc score was 64.8% and 88.7%, respectively (p = 0.0001). The specificity for LA thrombus/SEC with high CHADS(2) and CHA(2)DS(2)-VASc scores was 52.6% and 28.9%, respectively (p = 0.0001). In conclusion, both CHA(2)DS(2)-VASc and CHADS(2) scores are useful for stroke risk stratification in patients with atrial flutter. CHA(2)DS(2)-VASc had greater sensitivity for LA thrombus and SEC detection at the cost of reduced specificity.
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Affiliation(s)
- Milind G Parikh
- Department of Internal Medicine, Section of Cardiology, Electrophysiology, Arrhythmia, Pacemaker Services, Rush University Medical Center, Chicago, Illinois, 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. 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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Multidetector CT of left atrium. Eur J Radiol 2010; 81:e37-46. [PMID: 21123014 DOI: 10.1016/j.ejrad.2010.11.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Revised: 10/23/2010] [Accepted: 11/09/2010] [Indexed: 11/20/2022]
Abstract
MDCT angiography has enabled visualization of left atrium in addition to coronary arteries. CT images can be utilized to demonstrate normal anatomy and pathologies. Left atrium variations and pathologies include atrial septal pouch, patent foramen ovale, atrial septal defect, atrial band, lipomatous hypertrophy, cor triatriatum, diverticulum, accessory appendages, atrial thrombus and masses. Left atrium should be carefully evaluated in patients undergoing coronary CT angiography. MDCT is becoming an alternative modality for the evaluation of left atrium.
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[Relation between cavo-tricuspid isthmus anatomy studied by transesophageal echocardiography and the immediate outcome of radiofrequency ablation of common atrial flutter]. Ann Cardiol Angeiol (Paris) 2010; 59:125-30. [PMID: 20605136 DOI: 10.1016/j.ancard.2010.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Accepted: 04/06/2010] [Indexed: 11/22/2022]
Abstract
Radiofrequency ablation is the only curative treatment of common atrial flutter. The aim of the treatment is to create a line of bidirectional block at the level of the cavo-tricuspid isthmus. This objective can be achieved in the vast majority of the patients. However, it may difficult or even not possible to create an isthmus block. The anatomy of the right atrium is subject to important variations, especially at the isthmus level. We therefore tested the hypothesis that these anatomic variations might influence the immediate outcome of cavo-tricuspid isthmus ablation. The anatomy of cavo-tricuspid isthmus was studied by trans-oesophageal echocardiography. The shape of the isthmus (concave or not), the presence of diverticula and the degree of development of the Eustachian ridge were analysed. From these data, the cavo-tricuspid anatomy was classified as simple or complex. The immediate outcome of radiofrequency ablation was reviewed in 94 patients (mean age of 63 years) according to the anatomy, simple or complex. When the anatomy was classified as simple, the success rate of radiofrequency ablation was 95.6%; when the anatomy was complex, the success rate was 76.9% (overall success rate for the entire population equal to 90.4%). The length of the cavo-tricuspid isthmus did not influence the outcome of radiofrequency ablation. In summary, it appears that the anatomy of cavo-tricuspid isthmus seems to play a role in the immediate outcome of radiofrequency ablation of cavo-tricuspid isthmus.
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FINLAY MALCOLM, SAWHNEY VINIT, SCHILLING RICHARD, THOMAS GLYN, DUNCAN EDWARD, HUNTER ROSS, VIRDI GURPREET, ABRAMS DOMINIC, SPORTON SIMON, DHINOJA MEHUL, EARLEY MARK. Uninterrupted Warfarin for Periprocedural Anticoagulation in Catheter Ablation of Typical Atrial Flutter: A Safe and Cost-Effective Strategy. J Cardiovasc Electrophysiol 2010; 21:150-4. [DOI: 10.1111/j.1540-8167.2009.01603.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Risius T, Mortensen K, Schwemer TF, Aydin MA, Klemm HU, Ventura R, Barmeyer A, Hoffmann B, Rostock T, Meinertz T, Willems S. Comparison of antero-lateral versus antero-posterior electrode position for biphasic external cardioversion of atrial flutter. Am J Cardiol 2009; 104:1547-50. [PMID: 19932790 DOI: 10.1016/j.amjcard.2009.07.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Revised: 07/02/2009] [Accepted: 07/02/2009] [Indexed: 12/01/2022]
Abstract
External cardioversion is an established and very important tool to terminate symptomatic atrial flutter. The superiority of the biphasic waveform has been demonstrated for atrial flutter, but whether electrode position affects the efficacy of cardioversion in this population is not known. The aim of this trial was to evaluate whether anterior-lateral (A-L) compared with anterior-posterior (A-P) electrode position improves cardioversion results. Of 130 screened patients, 96 (72 men, mean age 62 +/- 12 years) were included and randomly assigned to a cardioversion protocol with either A-L or A-P electrode position. In each group, 48 patients received sequential biphasic waveform shocks using a step-up protocol consisting of 50, 75, 100, 150, or 200 J. The mean energy (65 +/- 13 J for A-L vs 77 +/- 13 J for A-P, p = 0.001) and mean number of shocks (1.48 +/- 1.01 for A-L vs 1.96 +/- 1.00 for A-P, p = 0.001) required for successful cardioversion were significantly lower in the A-L group. The efficacy of the first shock with 50 J in the A-L electrode position (35 of 48 patients [73%]) was also highly significantly greater than the first shock with 50 J in the A-P electrode position (18 of 48 patients [36%]) (p = 0.001). In conclusion, the A-L electrode position increases efficacy and requires fewer energy and shocks in external electrical cardioversion of common atrial flutter. Therefore, A-L electrode positioning should be recommended for the external cardioversion of common atrial flutter.
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Affiliation(s)
- Tim Risius
- University Hospital Hamburg-Eppendorf, Heart Center, Department of Cardiology, Hamburg, Germany.
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Bronzetti G, D'Angelo C, Angelini A, Picchio FM, Boriani G. Resolution of atrial thrombosis with heparin in a newborn with atrial flutter. Acta Paediatr 2009; 98:1211-4. [PMID: 19243349 DOI: 10.1111/j.1651-2227.2009.01235.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
UNLABELLED Atrial thrombosis is a relatively rare event in children. We report a case of a newborn with AFI who after restoration of sinus rhythm, developed atrial thrombus on a prominent Chiari network floating between the right and left atrium through the patent foramen ovale. The thrombus was resolved following treatment with heparin without events. CONCLUSION Atrial stunning was proposed as a key mechanistic phenomenon because the thrombus occurred after the cardioversion of AFI to sinus rhythm. Heparin may be effective in the resolution of atrial thrombus within a few days.
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Affiliation(s)
- Gabriele Bronzetti
- Pediatric Cardiology and Adult Congenital Unit, University of Bologna, Bologna (BO), Italy.
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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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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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Olshansky B, Guo H. Acute anticoagulation adjustment in patients with atrial fibrillation at risk for stroke: approaches, strategies, risks and benefits. Expert Rev Cardiovasc Ther 2006; 3:571-90. [PMID: 16076269 DOI: 10.1586/14779072.3.4.571] [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: 11/08/2022]
Abstract
The acute management of anticoagulation in patients with atrial fibrillation to prevent stroke and other thromboembolic complications includes the use of individualized strategies tailored to the patient and based on the situation (cardioversion, surgeries, dental procedures, cardiac interventions, other invasive procedures and initiation of, or adjustment to, warfarin dosing). The vast range of choices can cause confusion and few randomized controlled clinical trials in this area provide adequate guidance. Chronic anticoagulation management is more straightforward since clinical evidence is ample, randomized clinical trial data provides cogent informaiton and guidelines have been established. Acute management of anticoagulation in patients with atrial fibrillation to prevent thromboembolic complications is often unrecognized but is emerging as a crucial, but challenging, and increasingly complex aspect of the care of patients with atrial fibrillation. This review addresses issues regarding such patients who may be at risk for stroke and require acute adjustments of anticoagulation (in light of, or in lieu of, chronic anticoagulation). Several promising new strategies are considered in light of established medical care. This analysis provides practical recommendations based on available data and presents results from recent investigations that may provide insight into future strategies.
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Affiliation(s)
- Brian Olshansky
- Cardiac Electrophysiology, University of Iowa Hospitals, 4426A JCP, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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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: 717] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Mohrs OK, Nowak B, Petersen SE, Welsner M, Rubel C, Magedanz A, Kauczor HU, Voigtlaender T. Thrombus Detection in the Left Atrial Appendage Using Contrast-Enhanced MRI: A Pilot Study. AJR Am J Roentgenol 2006; 186:198-205. [PMID: 16357402 DOI: 10.2214/ajr.04.1504] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Left atrial thrombi are an important cause for embolism-related morbidity and mortality. Transesophageal echocardiography (TEE), the clinical reference, is semiinvasive; thus, we aimed to assess the value of contrast-enhanced cardiovascular MRI for the detection of thrombus in the left atrial appendage. CONCLUSION The image quality was good for both 2D perfusion (grade 4 +/- 1) and 3D turbo fast low-angle shot (FLASH) (grade 4 +/- 1, n.s.). Compared with TEE, 2D perfusion, 3D turboFLASH, and the combination of both techniques yielded sensitivities of 47/35/44%, specificities of 50/67/67%, positive predictive values of 73/75/80%, and negative predictive values of 25/27/29%, respectively. The size of the thrombus was overestimated by 2D perfusion (66%) and by 3D turboFLASH (25%) and agreement for location and shape of thrombus was 50% and 75% for 2D perfusion and 75% and 50% for 3D turboFLASH, respectively. The TEE thrombus size was significantly larger in patients with true-positive diagnoses by 2D perfusion (148%) and by 3D turboFLASH (151%) when compared with patients with false-negative diagnoses (p < 0.05 for both). No such difference was found for image quality, time delay between TEE and MRI examination, and location and shape of thrombi. Contrast-enhanced MRI lacks diagnostic accuracy for the detection of thrombi in the left atrial appendage. Future technical improvements are essential to establish this technique as a noninvasive alternative to TEE.
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Affiliation(s)
- Oliver K Mohrs
- Cardiovascular Center Bethanien (CCB), Im Pruefling 23, D-60389 Frankfurt/Main, 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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Shindo S, Matsumoto H, Kubota K, Kojima A, Matsumoto M, Satoh K, Ozaki Y. Is the Size of an Abdominal Aortic Aneurysm Associated with Coagulopathy? World J Surg 2005; 29:925-9; discussion 929. [PMID: 15951938 DOI: 10.1007/s00268-005-7718-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abdominal aortic aneurysm (AAA) volume and intraluminal thrombi were analyzed with respect to the number and function of platelets, blood cells, and coagulation factors. A group of 43 patients who underwent repair of an AAA were enrolled in this study. The maximum diameter and volume of the AAA, and the volume of intraluminal thrombi and lumen were measured by computed tomography with planimetry. The platelet count and platelet function, prothrombin time, activated partial thromboplastin time, fibrinogen, plasminogen, antithrombin 3, fibrin degradation products (FDP), D-dimer, and blood cell counts were measured. Spontaneous platelet aggregation and the FDP, and D-dimer levels were elevated; all other factors remained within the normal range. Intraluminal thrombus volume was strongly correlated with the volume and diameter of the AAA. However, no correlation was observed between the size of the AAA and coagulating factors, including the number and aggregation value of platelets. AAAs are frequently associated with a coagulating disorder. However, its size and thrombus volume are not correlated with coagulation changes. Although an intraluminal thrombus increases along with fee enlargement of the AAA, the clinical manifestation of bleeding is rarely associated with an AAA. Therefore coagulopathy in patients with an AAA is not fully explained by its morphology.
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Affiliation(s)
- Shunya Shindo
- Second Department of Surgery, Faculty of Medicine, University of Yamanashi, Tamaho-cho, Nakakoma-gun, Yamanashi, Japan.
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