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Bansal M, Kasliwal RR. Echocardiography for left atrial appendage structure and function. Indian Heart J 2012; 64:469-75. [PMID: 23102384 DOI: 10.1016/j.ihj.2012.07.020] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 07/17/2012] [Indexed: 10/28/2022] Open
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Fukuda Y, Fukuda N, Sakabe K, Morishita S, Shinohara H, Tamura Y. Clinical significance of anterior mitral leaflet fibrillation in patients with nonvalvular atrial fibrillation: comparison with blood flow and wall motion of the left atrial appendage. J Echocardiogr 2009; 7:19-24. [PMID: 27278226 DOI: 10.1007/s12574-009-0005-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2008] [Revised: 01/28/2009] [Accepted: 02/04/2009] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Diastolic fibrillation of the anterior mitral leaflet (AML) is seen in patients with atrial fibrillation (AF). However, its clinical significance has been unclear. On the other hand, reduced blood flow velocity in the left atrial appendage (LAA) may be associated with LA thrombus formation. In this study, we investigate the relationship between the flow velocity and the wall motion velocity of the LAA and diastolic fibrillation of the AML in patients with nonvalvular AF. METHODS We performed transthoracic echocardiography (TTE) in 45 consecutive patients with chronic nonvalvular AF. The LAA flow velocity was measured by pulsed Doppler echocardiography with the sample volume positioned at the center of the LAA. The LAA wall motion velocity was measured by pulsed Doppler tissue imaging (DTI) with the sample volume at the medial wall of the LAA. The AML fibrillation velocity was measured by pulsed DTI with the sample volume at the AML tip. RESULTS The AML fibrillation velocity could be measured in 44 patients (97.8%), and the LAA flow and wall motion velocities were measurable in 35 (77.8%) and 42 (93.3%) patients, respectively. The AML fibrillation velocity had a range from 4 to 21 cm/s and showed significant positive correlation with the LAA flow velocity (r = 0.82, P < 0.001) and the wall motion velocity (r = 0.80, P < 0.001) of the LAA. An AML fibrillation velocity of ≤7 cm/s predicted patients having a tendency to LA thrombus formation (LAA flow velocity ≤20 cm/s) with high sensitivity (87.5%) and specificity (88.9%). CONCLUSION The AML fibrillation velocity seems to be a viable substitute for the LAA flow velocity in the detection of flow stagnation in the LA.
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Affiliation(s)
- Yamato Fukuda
- Department of Cardiology and Clinical Research, National Hospital Organization Zentsuji Hospital, 2-1-1 Senyu-cho, Zentsuji, Kagawa, 765-0001, Japan
| | - Nobuo Fukuda
- Department of Cardiology and Clinical Research, National Hospital Organization Zentsuji Hospital, 2-1-1 Senyu-cho, Zentsuji, Kagawa, 765-0001, Japan.
| | - Koichi Sakabe
- Department of Cardiology and Clinical Research, National Hospital Organization Zentsuji Hospital, 2-1-1 Senyu-cho, Zentsuji, Kagawa, 765-0001, Japan
| | - Satofumi Morishita
- Department of Cardiology and Clinical Research, National Hospital Organization Zentsuji Hospital, 2-1-1 Senyu-cho, Zentsuji, Kagawa, 765-0001, Japan
| | - Hisanori Shinohara
- Department of Cardiology and Clinical Research, National Hospital Organization Zentsuji Hospital, 2-1-1 Senyu-cho, Zentsuji, Kagawa, 765-0001, Japan
| | - Yoshiyuki Tamura
- Department of Cardiology and Clinical Research, National Hospital Organization Zentsuji Hospital, 2-1-1 Senyu-cho, Zentsuji, Kagawa, 765-0001, Japan
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Wang T, Wang M, Fung JWH, Yip GWK, Zhang Y, Ho PPY, Tse DMK, Yu CM, Sanderson JE. Atrial strain rate echocardiography can predict success or failure of cardioversion for atrial fibrillation: A combined transthoracic tissue Doppler and transoesophageal imaging study. Int J Cardiol 2007; 114:202-9. [PMID: 16822565 DOI: 10.1016/j.ijcard.2006.01.051] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2005] [Revised: 11/22/2005] [Accepted: 01/27/2006] [Indexed: 11/20/2022]
Abstract
AIMS The purpose of this study was to assess the feasibility of measuring left atrial dysfunction with tissue Doppler imaging derived strain rate and to explore its role in predicting the maintenance of sinus rhythm after cardioversion for atrial fibrillation. METHODS AND RESULTS Strain rate (SR) and tissue Doppler imaging (TDI) were performed with offline analysis of the basal left atrial wall (LA). SR detected a systolic (Ssr) and early diastolic (Esr) deformation induced by ventricular motion. LA dimensions and volume were measured. Left atrial appendage emptying (LAA_EV) and filling (LAA_FV) velocities were also obtained by transesophageal echocardiography. 27 healthy age-matched controls and 42 patients with AF before cardioversion were studied. Patients were grouped into (1): those who remained in sinus rhythm (group S, n=12) and (2) those who either failed cardioversion or reverted to AF within 4 weeks (group F, n=30). LA dimensions were significantly larger and atrial Esr was significantly lower in group F than group S (all p<0.01). LAA_EV and LAA_FV were not different between groups S and F. Multivariate regression analysis showed that a lower Esr and larger transverse LA diameter (LADtr) were independent predictors of failure of cardioversion (HR, 95% CI: 0.36, 0.14-0.88 and 2.85, 1.33-6.10, respectively). Esr combined with LADtr improved the sensitivity and specificity for predicting successful cardioversion. CONCLUSIONS SR can be measured in the basal LA wall in atrial fibrillation and the magnitude of the early diastolic SR could predict the success of cardioversion and the likelihood of maintenance of sinus rhythm.
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Affiliation(s)
- Tian Wang
- Division of Cardiology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, SAR, China
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Hennig T, Maass P, Hayano J, Heinrichs S. Exponential distribution of long heart beat intervals during atrial fibrillation and their relevance for white noise behaviour in power spectrum. J Biol Phys 2006; 32:383-92. [PMID: 19669444 DOI: 10.1007/s10867-006-9022-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2006] [Accepted: 07/30/2006] [Indexed: 10/23/2022] Open
Abstract
The statistical properties of heart beat intervals of 130 long-term surface electrocardiogram recordings during atrial fibrillation (AF) are investigated. We find that the distribution of interbeat intervals exhibits a characteristic exponential tail, which is absent during sinus rhythm, as tested in a corresponding control study with 72 healthy persons. The rate gamma of the exponential decay lies in the range 3-12 Hz and shows diurnal variations. It equals, up to statistical uncertainties, the level of the previously uncovered white noise part of the power spectrum, which is also characteristic for AF. The overall statistical features can be described by decomposing the intervals into two statistically independent times, where the first one is associated with a correlated process with 1/f noise characteristics, while the second one belongs to an uncorrelated process and is responsible for the exponential tail. It is suggested to use gamma as a further parameter for a better classification of AF and for the medical diagnosis. The relevance of the findings with respect to a general understanding of AF is discussed.
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Affiliation(s)
- Thomas Hennig
- Institut für Physik, Technische Universität Ilmenau, 98684 Ilmenau, Germany.
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Paraskevaidis IA, Dodouras T, Tsiapras D, Kremastinos DT. Prediction of Successful Cardioversion and Maintenance of Sinus Rhythm in Patients With Lone Atrial Fibrillation. Chest 2005; 127:488-94. [PMID: 15705986 DOI: 10.1378/chest.127.2.488] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE We aimed to prospectively investigate the predictive value of echocardiographic parameters for the prediction of successful cardioversion and long-term sinus rhythm (SR) maintenance in patients who have experienced a lone episode of atrial fibrillation (AF). MEASUREMENTS AND RESULTS Clinical and echocardiographic data, including mean left atrial appendage (LAA) peak flow velocity and mitral annulus motion, were analyzed in 78 consecutive patients (mean [+/- SD] age, 59.3 +/- 9.3 years) with AF lasting > 48 h and < 6 months. Sixty-one patients (78%) underwent successful external electrical cardioversion, while the remaining remained in AF. At the 1-year follow-up, of the 61 patients who had successfully been converted to SR, 24 (39.3%) remained in SR. For predicting the success of the cardioversion, we used a model consisting of two variables. LAA flow velocity (> 20 cm/s) and left ventricular (LV) fractional shortening (> 30%) appear to be quite strong, yielding 83.3% correct results. For predicting the maintenance of SR, we used a model consisting of two variables. The absence of the early systolic abnormal mitral annulus motion and LAA flow velocity (> 20 cm/s) appears to be quite strong, yielding 84.6% correct results. LAA flow velocity only marginally enters the model, and, if removed, little predictive value is lost (dropping to 83.3%). Removing the early systolic abnormal mitral annulus motion variable, the prediction value drops significantly to 70.5%. CONCLUSION LAA flow velocity combined with LV fractional shortening can predict the success of the conversion of AF to SR. Additionally, LAA flow velocity, combined with the analysis of mitral annulus motion before cardioversion, can predict the long-term maintenance of SR.
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Oki T, Oishi Y, Tanaka H, Emi S, Mizuguchi Y, Ishimoto T, Nagase N, Ara N. Renewed Interest in Left Atrial Function: What do we Need to Evaluate Clinically? J Echocardiogr 2005. [DOI: 10.2303/jecho.3.60] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Verma A, Marrouche NF, Yamada H, Grimm RA, Cummings J, Burkhardt JD, Kilicaslan F, Bhargava M, Karim AA, Thomas JD, Natale A. Usefulness of intracardiac Doppler assessment of left atrial function immediately post-pulmonary vein antrum isolation to predict short-term recurrence of atrial fibrillation. Am J Cardiol 2004; 94:951-4. [PMID: 15464687 DOI: 10.1016/j.amjcard.2004.06.039] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2004] [Revised: 06/08/2004] [Accepted: 06/08/2004] [Indexed: 10/26/2022]
Abstract
Doppler assessments of pulmonary venous (PV) and left atrial appendage flows are useful surrogates of left atrial (LA) function, but it is unknown if these can predict atrial fibrillation (AF) recurrence after pulmonary vein antrum isolation. We compared Doppler surrogates of LA function immediately after pulmonary vein antrum isolation in patients with AF recurrence versus matched patients without recurrence. Patients with a 6-month recurrence had significantly lower LA appendage peak emptying velocity (19 +/- 10 vs 29 +/- 11 cm/s) and lower peak PV systolic wave velocity (36 +/- 17 vs 46 +/- 22 cm/s) compared with those without, suggesting that intracardiac Doppler assessment of LA function after AF ablation predicts AF recurrence.
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Affiliation(s)
- Atul Verma
- Department of Cardiology, Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Bollmann A, Husser D, Steinert R, Stridh M, Soernmo L, Olsson SB, Polywka D, Molling J, Geller C, Klein HU. Echocardiographic and electrocardiographic predictors for atrial fibrillation recurrence following cardioversion. J Cardiovasc Electrophysiol 2004; 14:S162-5. [PMID: 14760919 DOI: 10.1046/j.1540.8167.90306.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Identification of suitable candidates for cardioversion currently is not based on individual electrical and mechanical atrial remodeling. Therefore, this study analyzed the meaning of atrial fibrillatory rate obtained from the surface ECG (as a measure of electrical remodeling) and left atrial size (as measure of mechanical remodeling) for prediction of early atrial fibrillation (AF) recurrence following cardioversion. METHODS AND RESULTS Forty-four consecutive patients (26 men and 18 women, mean age 62 +/- 11 years, no antiarrhythmic medication at baseline) with persistent AF were studied. Fibrillatory rate was obtained from high-gain, high-resolution surface ECG using digital signal processing (filtering, QRST subtraction, Fourier analysis) before electrical cardioversion. Univariate and multivariate regression analysis revealed larger systolic left atrial area (Beta = 0.176, P = 0.031) obtained by precardioversion echocardiogram from the apical four-chamber view and higher atrial fibrillatory rate (Beta = 0.029, P = 0.021) to be independent predictors for AF recurrence (n = 13). Stratification based on the regression equation (electromechanical index [EMI] = 0.176 systolic left atrial area + 0.029 fibrillatory rate - 17.674) allowed identification of groups at low, intermediate, or high risk. No patient with an EMI < -1.85 had early AF recurrence, as opposed to 78% with an EMI > -0.25. Intermediate results (40% recurrence rate) were obtained when the calculated EMI ranged between -1.85 and -0.25 (P < 0.001). CONCLUSION Fibrillatory rate obtained from the surface ECG and systolic left atrial area obtained by echocardiography may predict early AF recurrence in patients with persistent AF. These parameters might be useful in identifying candidates with a high likelihood of remaining in sinus rhythm after cardioversion.
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Affiliation(s)
- Andreas Bollmann
- Department of Cardiology, University Hospital Magdeburg, Magdeburg, Germany.
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Klein AL, Murray RD, Grimm RA. Role of transesophageal echocardiography-guided cardioversion of patients with atrial fibrillation. J Am Coll Cardiol 2001; 37:691-704. [PMID: 11693739 DOI: 10.1016/s0735-1097(00)01178-5] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Electrical cardioversion of patients with atrial fibrillation (AF) is frequently performed to relieve symptoms and improve cardiac performance. Patients undergoing cardioversion are treated conventionally with therapeutic anticoagulation for three weeks before and four weeks after cardioversion to decrease the risk of thromboembolism. A transesophageal echocardiography (TEE)-guided strategy has been proposed as an alternative that may lower stroke and bleeding events. Patients without atrial cavity thrombus or atrial appendage thrombus by TEE are cardioverted on achievement of therapeutic anticoagulation, whereas cardioversion is delayed in higher risk patients with thrombus. The aim of this review is to discuss the issues and controversies associated with the management of patients with AF undergoing cardioversion. We provide an overview of the TEE-guided and conventional anticoagulation strategies in light of the recently completed Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) clinical trial. The two management strategies comparably lower the patient's embolic risk when the guidelines are properly followed. The TEE-guided strategy with shorter term anticoagulation may lower the incidence of bleeding complications and safely expedite early cardioversion. The inherent advantages and disadvantages of both strategies are presented. The TEE-guided approach with short-term anticoagulation is considered to be a safe and clinically effective alternative to the conventional approach, and it is advocated in patients in whom earlier cardioversion would be clinically beneficial.
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Affiliation(s)
- A L Klein
- Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA.
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Bollmann A, Binias K, Grothues F, Sonne K, Esperer H, Nikutta P, Klein H. Left atrial appendage flow in nonrheumatic atrial fibrillation : relationship with pulmonary venous flow and ECG fibrillatory wave amplitude. Chest 2001; 119:485-92. [PMID: 11171727 DOI: 10.1378/chest.119.2.485] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE This study was conducted (1) to examine the relationship between left atrial appendage (LAA) flow velocity and pulmonary venous flow (PVF) variables during nonrheumatic atrial fibrillation (AF), and (2) to determine whether a reduction in LAA flow is reflected by the fibrillatory wave amplitude on the surface ECG. BACKGROUND Although LAA Doppler echocardiographic signals provide information regarding the velocity and direction of flow only for a localized narrow sample, systolic PVF represents in part the global left atrial function, mainly relaxation. Controversy exists about whether the amplitude of fibrillatory waves recorded on the surface ECG correlates with LAA flow velocity during AF. MEASUREMENTS AND RESULTS Thirty-three patients (20 men, 13 women; mean [+/- SD] age, 61 +/- 11 years) with nonrheumatic AF undergoing transthoracic and transesophageal echocardiography were studied. A correlation between LAA flow velocity and systolic PVF variables (peak systolic velocity, R: = 0.450, p = 0.009; velocity-time integral of systolic flow, R = 0.491, p = 0.004; systolic fraction of PVF, R: = 0.627, p < 0.0001) was observed. Patients with a low LAA flow profile (< 25 cm/s) had a reduced systolic PVF. Longer AF duration and the occurrence of moderate mitral regurgitation were related to reduced LAA flow. AF was subdivided into coarse (peak-to-peak fibrillatory amplitude > or = 1 mm) or fine (< 1 mm) in standard ECG lead V1. There was no association between the coarseness of AF and the LAA flow profile. CONCLUSION In patients with nonrheumatic AF, a reduction in LAA flow velocity correlates with a reduction in systolic PVF. These hemodynamic changes are not reflected by the ECG fibrillatory wave amplitude.
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Affiliation(s)
- A Bollmann
- Department of Cardiology, University Hospital Magdeburg, Otto-von-Guericke University, Magdeburg, Germany.
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Abstract
Transesophageal echocardiography has given new insight into the pathogenesis of the thromboembolic sequelae of AF and expanded the available therapeutic options. Studies to date indicate that TEE-guided cardioversion is a safe and reasonable approach when the clinical situation warrants prompt restoration of sinus rhythm. Whether widespread use of this strategy offers further benefit remains to be established, although there are theoretical advantages to such an approach. The potential for earlier cardioversion using a TEE-guided approach may facilitate the achievement and maintenance of sinus rhythm. In the long term, earlier restoration of sinus rhythm prevents adverse atrial remodeling, lowers embolic risk, and may improve cardiac performance and functional status. Thromboembolic sequelae (either cardioversion-related or as a result of chronic AF) remain the most devastating complications of AF. Every attempt to minimize this risk should be pursued aggressively. Information gathered from TEE has helped to elucidate the mechanisms responsible for postcardioversion embolism and has emphasized the importance of anticoagulation during and after the restoration of sinus rhythm. TEE also has the potential to further risk stratify patients with AF. Ultimately, a subset of patients may be identified who require more intense anticoagulation (i.e., those with dense SEC or thrombus, or persistent thrombus after prolonged anticoagulation) or in whom cardioversion may be deferred entirely. Likewise, TEE also may prove to be useful in identifying patients with a low-clinical risk profile who may be treated with aspirin alone and patients in whom warfarin may be superior. The results of the ACUTE study should help to further define the role of TEE in the management of patients with AF. Additional clinical studies are needed to address some of the issues that have been raised and to allow for optimal use of TEE in this patient population.
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Affiliation(s)
- M Thamilarasan
- Department of Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Abstract
The left atrial (LA) appendage is a common source of cardiac thrombus formation associated with systemic embolism. Transesophageal echocardiography allows a detailed evaluation of the structure and function of the appendage by two-dimensional imaging and Doppler interrogation of appendage flow. Specific flow patterns, reflecting appendage function, have been characterized for normal sinus rhythm and various abnormal cardiac rhythms. Appendage dysfunction has been associated with LA appendage spontaneous echocardiographic contrast, thrombus formation and thromboembolism. These associations have been studied extensively in patients with atrial fibrillation or atrial flutter, in patients undergoing cardioversion of atrial arrhythmias and in patients with mitral valve disease. The present review summarizes the literature on the echocardiographic assessment of LA appendage structure, function and dysfunction, which has become an integral part of the routine clinical transesophageal echocardiographic examination.
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Affiliation(s)
- Y Agmon
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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