Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation. A multicenter study.

Black, Ian W.; Fatkin, Diane; Sagar, Kiran B.; Khandheria, Bijoy K.; Leung, Dominic Y.; Galloway, J. M. D.; Feneley, Michael P.; Walsh, Warren F.; Grimm, Richard A.; Stöllberger, Claudia

doi:10.1161/01.cir.89.6.2509

Cited by 277 publications

(115 citation statements)

References 31 publications

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“…Restoration of sinus rhythm provides numerous physiological benefits, 12) but as with most new therapies, direct-current CV also has adverse outcomes, including catastropic thromboembolism in up to 6.3 percent of patients who were not receiving anticoagulant therapy. 13) Nonrandomized studies where warfarin therapy was given for 3 to 4 weeks before CV led to an 80 percent reduction in CV-related thromboembolism, 14) providing the rationale for the use of this strategy for nearly three decades.…”

Section: Discussionmentioning

confidence: 99%

The Safety of Low-Molecular Weight Heparins for the Prevention of Thromboembolic Events after Cardioversion of Atrial Fibrillation

et al. 2003

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SUMMARYTransesophageal echocardiography (TEE) guided early cardioversion (CV) in conjunction with short-term anticoagulation has been shown to be safe, and an alternative to prolonged conventional anticoagulation therapy. Recently, low molecular weight heparins (LMWHs) have been used successfully as an alternative to standard heparin therapy obviating the need for hospitalization and APTT monitoring. The aim of this study was to determine the feasibility and safety of TEE guided early cardioversion in conjunction with short-term LMWH use in patients with nonvalvular atrial fibrillation (NVAF).The study group consisted of 172 consecutive patients with NVAF. Before TEE, 90 patients received LMWH (Dalteparin 2 × 5,000U) and 82 patients received standard heparin (UFH) (5,000U bolus followed by infusion to raise APTT to 1.5 times control). TEE was performed and the left atrium and left atrial appendage were examined thoroughly for the presence of thrombus. One patient from each group was excluded due to detection of a left atrial thrombus by TEE. Immediately after TEE, CV was attempted and warfarin was initiated. All patients received warfarin for one month after CV. In the LMWH group, 89 of 90 patients (98.9%) were successfully cardioverted. CV was successful in 97.5% of the patients in the UFH group. None of the patients experienced thromboembolic events during the four weeks after CV.TEE guided early CV in conjunction with short-term LMWH treatment is as safe as UFH for the prevention of thromboembolic events after CV. (Jpn Heart J 2003; 44: 369-377)

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Section: Discussionmentioning

confidence: 99%

The Safety of Low-Molecular Weight Heparins for the Prevention of Thromboembolic Events after Cardioversion of Atrial Fibrillation

et al. 2003

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“…Despite the utility of TOE for thrombus detection in the LAA [13], a small number of thromboembolic events continue to occur even when no thrombus is detected in a pre-cardioversion [8] or LAA-occlusion setting (1-2%) [5,6]. Possible causes include absent or sub-therapeutic anticoagulation [14] and air embolism due to insufficient venting during LAA occlusion [5].…”

Section: Toe-guided Thrombus Detectionmentioning

confidence: 99%

“…Thrombus located in accessory or retroverted lobes might escape recognition in the usual TOE views, which may partially explain the small incidence of stroke despite TOE interrogation of the LAA prior to cardioversion [8]. Hence, a good understanding of LAA anatomy and orientation is important.…”

Section: Introductionmentioning

confidence: 99%

Left Atrial Appendage Morphology in Patients with Non-Valvular Atrial Fibrillation

Joy¹,

Bertog²,

Betts³

et al. 2017

jshd

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Aims: Percutaneous left atrial appendage (LAA) occlusion has now become a suitable alternative to oral anticoagulation for stroke prevention in selected patients with atrial fibrillation (AF). However, LAA closure can be technically challenging and results suboptimal, in part due to variable left atrial anatomy.We aimed to characterize LAA morphology and identify potential anatomical pitfalls during LAA closure or LAA thrombus detection during transoesophageal echocardiography (TOE). Methods and Results: 103 patients with AF underwent cardiac magnetic resonance angiography to assess pulmonary venous anatomy. Adequate imaging quality was present in 76 in whom LAA morphology was assessed. The majority of LAAs (71%) were anterolaterally directed and 82% were 'claw'-shaped. However, there was significant variation in anatomy and course in the remainder: 11% were anteverted, 9% laterally directed and 9% retroverted. The shape was cone-like in 8%, fan-like in 5% and s-configured in 5% and there was significant variation in the curvature of the LAA body. While 66% had a single lobe, 30% were bilobed and 4% trilobed; 90% also had additional lobules. Conclusion: Our results demonstrate the significant variability of LAA geometry in AF patients. This may have implications for future device design for percutaneous LAA occlusion. The variable anatomy may affect LAA thrombus detection with TOE emphasizing the importance of multiple views to ensure complete assessment.

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“…Using the two-dimensional beam of TEE in visualizing the three-dimensional anatomy of the LAA is analogous to using a searchlight to visualize the entire roof of a cave, which is technically difficult to achieve completely. Studies have shown that embolism may presumably occur after cardioversion of AF, despite apparent exclusion of a pre-existing atrial thrombus by TEE (6). Plasma D-dimer constitutes an antigen-antibody reaction to the dimeric final degradation product of a mature clot.…”

mentioning

confidence: 99%

The D-dimer assay: A possible tool in the evaluation of atrial thrombosis

Ibebuogu

Salah

Malhotra

et al. 2008

Canadian Journal of Cardiology

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A trial fibrillation (AF) is the most common sustained arrhythmia seen in clinical practice, and affects more than 4% of the population older than 60 years of age (1,2). Peripheral thromboembolism and ischemic stroke contribute significantly to the observed mortality and morbidity rates. AF contributes to 15% to 20% of all strokes (1,3), and emboli arise predominantly from the left atrial appendage (LAA) (4). Hence, there is a need to exclude atrial thrombi before cardioversion in symptomatic AF. A recent large, randomized controlled trial has shown that negative transesophageal echocardiography (TEE) results may obviate the need for prolonged anticoagulation before cardioversion, with no significant difference in embolic events compared with conventional therapy (5). Because of the complex multilobed configuration of the LAA and the minute size of clinically significant thrombi, there are inherent limitations in using a nontomographic technique for visualization of the LAA. Using the two-dimensional beam of TEE in visualizing the three-dimensional anatomy of the LAA is analogous to using a searchlight to visualize the entire roof of a cave, which is technically difficult to achieve completely. Studies have shown that embolism may presumably occur after cardioversion of AF, despite apparent exclusion of a pre-existing atrial thrombus by TEE (6). Plasma D-dimer constitutes an antigen-antibody reaction to the dimeric final degradation product of a mature clot. An elevated fibrin D-dimer has a high sensitivity for intravascular thrombus (7) and may improve the evaluation of a patient with AF before cardioversion. CASE PRESENTATIONA 56-year-old man eight years post-renal transplant and four years post-coronary artery bypass surgery, as well as a history of adequately treated, methicillin-resistant Staphylococcus epidermidis bacteremia, CASE REPORT ©2008 Pulsus Group Inc. All rights reserved Atrial fibrillation (AF) is a common arrhythmia seen in clinical practice, and affects more than 4% of the population older than 60 years of age. Peripheral thromboembolism contributes significantly to the observed morbidity and mortality. Symptomatic AF, before cardioversion to normal sinus rhythm, requires either exclusion of atrial thrombi using transesophageal echocardiography (TEE) or the conventional use of three weeks of adequate anticoagulation. The exclusion of atrial thrombi by TEE, a nontomographic technique but comparable with conventional treatment of AF in outcomes, has inherent limitations due to the complex three-dimensional multilobed anatomy of the left atrial appendage, where the majority of atrial thrombi arise. Also, the conventional treatment of three weeks of therapeutic anticoagulation before cardioversion reportedly does not always eliminate atrial thrombi. Plasma D-dimer constitutes an antigen-antibody reaction to the dimeric final degradation product of a mature clot. An elevated fibrin D-dimer has a high sensitivity for intravascular thrombosis and, hence, may improve the evaluation of a patient with A...

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Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation. A multicenter study.

Cited by 277 publications

References 31 publications

The Safety of Low-Molecular Weight Heparins for the Prevention of Thromboembolic Events after Cardioversion of Atrial Fibrillation

The Safety of Low-Molecular Weight Heparins for the Prevention of Thromboembolic Events after Cardioversion of Atrial Fibrillation

Left Atrial Appendage Morphology in Patients with Non-Valvular Atrial Fibrillation

The D-dimer assay: A possible tool in the evaluation of atrial thrombosis

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