Clinical value of left atrial appendage flow for prediction of long-term sinus rhythm maintenance in patients with nonvalvular atrial fibrillation (original) (raw)
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American Heart Journal, 1997
Accurate echocardiographic parameters for predicting the success of cardioversion or maintenance of sinus rhythm are poorly defined. This prospective transthoracic and transesophageal echocardiographic study was conducted to test the hypothesis that the left atrial appendage flow pattern could be a predictive parameter of the success of cardioversion and maintenance of sinus rhythm in patients with nonvalvular atrial fibrillation. Eighty-two consecutive patients with nonvalvular atrial fibrillation of ~6 months' duration underwent transesophageal examination after transthoracic echocardiography. After exclusion of left atrial thrombus, pharmacologic (n = 18) or electrical (n = 64) cardioversion was successful in 75 of 82 patients. In the group that underwent successful cardioversion, maintenance of sinus rhythm (n = 35) or recurrence of arrhythmia (n = 40) was assessed during a 1-year follow-up. During transesophageal examination, five left atrial appendage thrombi were found, spontaneous echo contrast was present in 26 (32%) patients, and mean peak left atrial appendage emptying velocity was 35 + 18 cm/sec. Peak left atrial appendage emptying velocity was found to be statistically related to parameters of left ventricular and left atrial function but not to Iong-term maintenance of sinus rhythm. No other echocardiographic parameter was identified as a predictor for either the success of cardioversion or the maintenance of sinus rhythm at follow-up. In patients with nonvalvular atrial fibrillation of recent onset, peak left atrial appendage emptying velocity appears to be a complex parameter depending on left atrial and left ventricular function but that does not predict either the success rate of cardioversion or Iong-term maintenance of sinus rhythm after successful cardioversion. (Am HeartJ 1997;134:745-51.)
CHEST Journal, 2005
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.
Left Atrial Appendage-Flow Velocity Predicts Cardioversion Success in Atrial Fibrillation
The Tohoku Journal of Experimental Medicine, 2006
Restoration of sinus rhythm by electrical cardioversion is a therapeutic option in appropriately selected patients with atrial fibrillation. It is important to determine predictors of electrical cardioversion outcome in patients with atrial fibrillation. Predictive value of clinical and conventional echocardiographic parameters for predicting cardioversion outcome is limited. The role of left atrial appendage (LAA) function, which may reflect left atrial contractile function, for prediction of cardioversion outcome remains unclear. We conducted a single center prospective study to evaluate the role of LAA function for prediction of cardioversion success in patients with atrial fibrillation. One hundred sixty three patients with atrial fibrillation underwent transthoracic and transesophageal echocardiography (TEE) before electrical cardioversion. LAA functions, including LAA peak flow velocity, LAA area and LAA ejection fraction, were examined. Cardioversion was successful in 133 patients and unsuccessful in 30 patients. Mean LAA peak emptying flow velocity was significantly higher in the patients with successful cardioversion than in those with unsuccessful cardioversion (0.34 ± 0.14 vs 0.27 ± 0.1 m/sec; p = 0.013). At multivariate logistic regression analysis, only LAA flow velocity (> 0.28 m/sec, odds ratio = 2.8 ; p = 0.03) proved to be an independent predictor of cardioversion success. LAA area ( p = 0.18) and LAA ejection fraction ( p = 0.52) were not different between successful and unsuccessful cardioversion groups. Therefore, measurement of LAA flow velocity provides valuable information for prediction of cardioversion outcome in patients with atrial fibrillation before TEE guided cardioversion.
Echocardiography, 2005
A-wave velocity, performed at 24 hours after CV in estimation of AF recurrence. The study group consisted of 187 consecutive patients with nonvalvular atrial fibrillation, who had been cardioverted to SR from 1998 to 2000. Transthoracic echocardiography was performed in all cases recruited for the study 24 hours after CV. Left atrial (LA) diameter, left ventricular ejection fraction, and mitral inflow A-wave velocity were measured. The patients were evaluated in five groups according to their recurrence time (<30 days, 31-90 days, 91-180 days, 181-365 days, and >365 days). Maintenance of SR was determined to have a negative linear correlation with age (r = −0.97, P = 0.006), LA diameter (r = −0.93, P = 0.02), and AF duration (r = −0.93, P = 0.02), while having a positive linear correlation with mitral inflow A-wave velocity (r = 0.96, P = 0.008). In the maintenance of sinus rhythm, age, LA diameter, and AF duration were not affected from the method of CV, while mitral inflow A-wave velocity was found to be affected with the method of CV. No relationship was determined between mitral inflow A-wave velocity and the maintenance of sinus rhythm in those performed electrical cardioversion, while frequency of recurrence was found to be higher in those with slow mitral inflow A-wave velocity who were performed pharmacological cardioversion (r = 0.89, P = 0.004). In conclusion, age, duration of AF, LA diameter, and the mitral inflow A-wave velocity can be used to predict the maintenance of SR after CV. (ECHOCARDIOGRAPHY, Volume 22, May 2005) atrial fibrillation, cardioversion, echocardiography, mitral inflow A-wave velocity Cardioversion (CV) of atrial fibrillation (AF) either by pharmacological or electrical approaches is the preferred treatment of patients with persistent AF. 1,2 However, both the treatment modalities carry a risk of recurrence in approximately 50%-60% of patients in the first year. 1,2 Recurrence of AF after CV is found to be associated with various clinical (etiology, duration of AF, age, functional capacity), transthoracic echocardiography (TTE) [left atrial (LA) diameter, left ventricular function, mitral inflow A-wave velocity], and transesophageal echocardiographic (TEE) parameters (left atrial appendage peak velocity). 3-9
International Journal of Cardiology, 2004
Internal cardioversion can restore sinus rhythm with energies below 6-10 J, often without anaesthesia/sedation. We investigated its safety and short-/medium-term efficacy in patients with persistent atrial fibrillation (AF) with left ventricular dysfunction (defined as ejection fraction &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; or = 40%). Among 34 patients with persistent AF who agreed to receive internal cardioversion, 16 had left ventricular dysfunction and 18 did not (the groups were similar as regards age, duration of AF and pretreatment with amiodarone). Internal CV was performed delivering 3.0/3.0-ms biphasic shocks between coil catheters using a step-up protocol. Sinus rhythm was always restored. General anaesthesia (administered only when discomfort was not tolerated) was required only in 2 of the 16 (12.5%) patients with left ventricular dysfunction. The defibrillation threshold was similar in patients with and without left ventricular dysfunction (10.2+/-6.9 vs. 8.4+/-4.9 J; p=0.37). Short-term (within 72 h) AF recurrence rates in the presence and absence of left ventricular dysfunction were 19% (3/16) and 6% (1/18), respectively (p=0.51). After cardioversion, all patients received antiarrhythmic drugs (mostly amiodarone in patients with left ventricular dysfunction and class IC agents in the remainder). With mean follow-up periods of about 220 days, AF recurrence rates among patients with and without left ventricular dysfunction were 50% (8/16) and 28% (5/18), respectively (p=0.328). We conclude that even in patients with left ventricular dysfunction, internal CV is safe and effective, minimizing risks from anaesthesia. Although these patients may have a higher risk of short- or medium-term AF recurrence, 6-month maintenance of sinus rhythm is possible in about 50% of cases.
European journal of arrhythmia & electrophysiology, 2022
ackground: Electrical cardioversion (ECV) is frequently performed to treat persistent atrial fibrillation (AF). Although several large trials have suggested that rate control in AF may be non-inferior to rhythm-based strategies, individual patients may have better outcomes in terms of quality of life if sinus rhythm (SR) is achieved and maintained. This real-world, retrospective, observational study aimed to define the success rate and role of ECV in the management of persistent AF in the era of catheter ablation. Methods: All patients who underwent ECV for symptomatic persistent AF at our institution between January 2014 and August 2019 were analysed. Clinical and echocardiographic baseline characteristics were used to identify independent predictors for AF recurrence at 12 and 24 months using a Cox multivariate model. Results: We identified 1,028 consecutive patients with symptomatic persistent AF, 319 of whom were subsequently excluded from the study because they either spontaneously reverted to SR prior to ECV or declined ECV. We evaluated 701 patients (mean age 71 ± 10.8 years, male 70.2%). Acute success was achieved in 96.8% of patients. SR at 12 and 24 months was seen in 26.6% and 14.3% of patients (p<0.0001), respectively. SR at 12 months was seen in 20.4% of patients with a left atrium (LA) diameter of ≤4 cm and in 6.2% of patients with an LA diameter of >4 cm (p<0.0001). At 24 months, SR was seen in 11.5% of patients with a LA diameter of ≤4 cm and in 2.8% with a diameter of >4 cm (p<0.0001). Predictors of SR at 12 months on univariate analysis were normal left ventricular systolic function and mild left ventricular systolic impairment (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.08-2.45, p=0.021 and OR 0.5, 95% CI 0.24-0.94, p=0.043, respectively). In addition, flecainide and sotalol therapy improved the chances of SR at 12 months (OR 2.87, 95% CI 1.16-7.12, p=0.021 and OR 2.25, 95% CI 0.98-5.05, p=0.049, respectively). Multivariate analysis revealed no further positive predictors for SR maintenance in 24 months. Conclusion: ECV was not an effective long-term strategy for the maintenance of SR.
Cardioversion safety in patients with nonvalvular atrial fibrillation
Blood Coagulation & Fibrinolysis, 2012
The objective of this study was to derive and test a score that can accurately predict the presence of left atrial or left atrial appendage thrombus (LAAT) in order to identify patients with nonvalvular atrial fibrillation who can be spared transesophageal echocardiogram (TEE) and safely cardioverted. This cross-sectional observational study including 180 individuals (37.2% women) undergoing clinical, echocardiographic and laboratory evaluation (including cardiac troponin I and C reactive protein; CRP) during an atrial fibrillation episode. LAAT was sought on TEE and predictors of this transesophageal echocardiographic finding were assessed. Based on predictors of LAAT (CRP, atrial volume, troponin, episode duration and stroke or embolism) we derived the CATES score and tested its accuracy through receiver operating curve analysis. LAAT was found in 9.4%. CHADS 2 and CHA 2 DS 2-VASc had a modest performance in predicting these changes displaying a 0.620 (c-statistic) in average. Using CATES score displayed a higher area under the curve value 0.816 for LAAT. No patients with LAAT were observed in patients with CATES scores ranging from '0' to '2', which corresponded to 49.4% (n U 89) of the sample. We developed a score that presented a very good accuracy for the detection of LAAT in our sample. Further studies in other populations, such as with bigger dimensions, are needed to validate this score and confirm its capability of selecting a very low risk group of patients that can be spared transesophageal echocardiography. Blood Coagul Fibrinolysis 23:597-602 ß 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins.