Effect of radiofrequency ablation on atrial mechanical function in patients with atrial flutter.

Atrial stunning, as assessed by left atrial appendage emptying and increased spontaneous echo contrast, is known to occur following direct-current cardioversion of atrial fibrillation (AF) and atrial flutter (AFI). Little is known on atrial mechanical function and the time course of atrial recovery following radiofrequency ablation of AFI. Fourteen patients undergoing radiofrequency ablation of persistent typical counterclockwise AFI were enrolled. Two-dimensional and pulse Doppler transesophageal echocardiography (TEE) were performed before ablation and immediately following restoration of sinus rhythm. Left atrial spontaneous echo contrast grades, left atrial appendage emptying fractions, and peak left atrial appendage emptying velocities were measured. Transthoracic echocardiography (TTE) was performed immediately after ablation, then repeated after 1 day, 1 week, and 6 weeks to measure peak transmitral velocities and percent atrial contribution to ventricular filling. Left atrial appendage emptying velocities decreased significantly following AFI termination (44 +/- 23 cm/s before ablation vs 25 +/- 14 cm/s after ablation, p = 0.01). Left atrial appendage emptying fractions also decreased significantly (0.48 +/- 0.1 preablation vs 0.34 +/- 0.17 postablation, p = 0.02). New spontaneous echo contrast developed in 4 patients (29%) after ablation. Four patients had complete atrial standstill after ablation, and 1 patient developed a new left atrial appendage thrombus. The percent atrial contribution to ventricular filling recovered progressively over 6 weeks with significant improvement in peak transmitral velocities at day 7. Thus, atrial stunning occurs after catheter ablation of AFI and may lead to rapid formation of thrombus in the left atrial appendage. Significant improvement in left atrial function occurs in 7 days.     

Transthoracic echocardiographic predictors of left atrial appendage thrombus

Transesophageal echocardiography (TEE) is commonly performed to detect the presence of a left atrial appendage (LAA) thrombus in the setting of an embolic event or before an anticipated electrical cardioversion for atrial fibrillation. The predictive value of transthoracic echocardiographic (TTE) findings in these patients has not been well defined. This study evaluated whether TTE findings can predict LAA thrombi using TEE as the gold standard for the identification of LAA thrombi. From November 1995 to March 2003, 10,753 patients underwent TEE to exclude LAA thrombi after embolic events or before cardioversion. Of these, 3,768 patients had complete TTE examinations performed <2 weeks before undergoing TEE. Demographics, TTE, and cardiac rhythm variables were analyzed using univariate and multivariate logistic regression to identify predictors of LAA thrombi diagnosed on subsequent TEE. LAA thrombi were identified by TEE in 199 patients (5.3%). Several TTE variables predicted LAA thrombi by TEE, including mitral stenosis, atrial fibrillation, tricuspid regurgitation, valvular prosthesis, left ventricular dysfunction, and right ventricular dysfunction. Mitral regurgitation was associated with a reduced risk for LAA thrombi (odds ratio 0.61, p = 0.003). A structurally normal heart in sinus rhythm (n = 247, 6.9%) had a 100% negative predictive value for LAA thrombi. In conclusion, several TTE variables were found to be predictive of LAA thrombi. The likelihood of LAA thrombi being found on TEE was infinitely small in the absence of these variables and the presence of sinus rhythm.     

房颤患者左心耳功能评估和血栓识别超声学进展

左心耳（LAA）是房颤患者最常见心源性血栓来源。持续性房颤（AF）患者左心房血栓可能会因为形态变异而导致诊断困难,由多普勒超声衍生而来的新型成像模式,如组织多普勒成像（TDI）和斑点跟踪超声心动图（STE）,以及由组织速度显像(TVI)得出的新技术-应变成像（SI）和应变速率成像（SRI）分析可能会对识别这些血栓有帮助。LAA游离壁较薄,现有的技术很难从视觉上评估它的机械功能,而LAA基底部的肌小梁如左脊（LLR）和基底内侧二尖瓣前庭BMAS,在某种程度上能反应LAA的机械活动,从而通过TEE进行LAA功能评估。本文综述了这方面的进展。     

Transthoracic Tissue Doppler Assessment of Left Atrial Appendage Contraction and Relaxation: Their Changes with Aging

Aim: We assessed left atrial appendage (LAA) function using transthoracic tissue Doppler echocardiography (TDE), and examined the influence of aging on LAA contraction and relaxation. Methods: The subjects were 45 consecutive patients with heart disease and 110 healthy individuals. LAA wall motion velocity (LAAWV) at the tip of the LAA was measured using transthoracic echocardiography (TTE) and/or transesophageal echocardiography (TEE). Results: We successfully recorded and measured LAAWV using TTE in 105 (95%) of the 110 healthy subjects. When angle correction was applied for the Doppler beam in TTE, LAAWV during contraction (LAAWVc) measured by TTE closely correlated with that measured by TEE (r = 0.97), and LAAWV during relaxation (LAAWVr) measured by TTE closely correlated with that measured by TEE (r = 0.95). LAAWVc and LAAWVr measured by TTE correlated significantly with the LAA flow velocities during LAA contraction and LAA relaxation measured by TEE (r = 0.64, P < 0.001; r = 0.53, P = 0.001). In healthy subjects, although LAAWVc remained unchanged with aging, LAAWVr significantly declined with aging (r =?0.48, P < 0.001) and had a significant negative correlation with left atrial dimension and a significant positive correlation with transmitral flow and annulus velocity during early diastole. Conclusion: Transthoracic TDE can provide information on LAA function. LAA relaxation may be impaired with aging and may be accompanied by early diastolic left ventricular dysfunction and chronic overload to the left atrium. (Echocardiography 2010;27:839‐846)     

房颤时左心耳结构和功能改变与肺静脉血流的关系研究

目的评价房颤时左心耳结构和功能改变与肺静脉血流变化的关系。方法74例房颤患者和16例正常人接受经胸超声心动图(TTE)和经食道超声心动图(TEE)检查,检测左心耳血栓形成、结构、功能和肺静脉血流频谱指标。结果18例房颤患者存在左心耳血栓,血栓组、非血栓组和正常组间左心耳结构、功能和肺静脉血流频谱有显著差异,其中血栓组左心耳扩大,血流速度下降最严重,左心耳结构、功能和肺静脉血流密切相关。结论房颤时左心耳结构改变,功能减退,肺静脉血流和左心耳结构、功能关系密切,能准确反应左心耳功能,在血栓评价中具有重要意义。     

Efficacy of anticoagulation in resolving left atrial and left atrial appendage thrombi: A transesophageal echocardiographic study

BACKGROUND: Transesophageal echocardiography (TEE) is the gold standard for evaluation of the left atrium and the left atrial appendage (LAA) for the presence of thrombi. Anticoagulation is conventionally used for patients with atrial fibrillation to prevent embolization of atrial thrombi. The mechanism of benefit and effectiveness of thrombi resolution with anticoagulation is not well defined. METHODS AND RESULTS: We used a TEE database of 9058 consecutive studies performed between January 1996 and November 1998 to identify all patients with thrombi reported in the left atrium and/or LAA. One hundred seventy-four patients with thrombi in the left atrial cavity (LAC) and LAA were identified (1.9% of transesophageal studies performed). The incidence of LAA thrombi was 6.6 times higher than LAC thrombi (151 vs 23, respectively). Almost all LAC thrombi were visualized on transthoracic echocardiography (90.5%). Mitral valve pathology was associated with LAC location of thrombi (P <.0001), whereas atrial fibrillation or flutter was present in most patients with LAA location of thrombi. Anticoagulation of 47 +/- 18 days was associated with thrombus resolution in 80.1% of the patients on follow-up TEE. Further anticoagulation resulted in limited additional benefit. CONCLUSIONS: LAC thrombi are rare and are usually associated with mitral valve pathology. Transthoracic echocardiography is effective in identifying these thrombi. LAA thrombi occur predominantly in patients with atrial fibrillation or flutter. Short-term anticoagulation achieves a high rate of resolution of LAA and LAC thrombi but does not obviate the need for follow-up TEE.     

阵发性心房颤动患者左心耳血栓形成的相关因素

目的 应用经胸和经食管超声探讨阵发性心房颤动(paroxysmal atrial fibrillation,PAF)患者左心耳血栓形成的相关因素。方法 PAF患者212例,以左心耳内有无血栓将患者分为血栓组（44例）和无血栓组（168例）,详细记录两组患者的一般资料,经胸超声(TTE)参数:左房内径（LAD）、左房舒张末期容积(LAEDV)、左房收缩末期容积(LAESV)、左房射血分数(LAEF),经食管超声(TEE)参数:左心耳内血流速度(LAA-v)、 45°,90°,135°切面左心耳横径(LAA-W)、左心耳深度(LAA-D)。比较两组患者的各项指标差别并进行多因素Logistic回归分析。结果 两组患者中性别、年龄、并发高血压病、糖尿病、高脂血症、 LAA-W及LAA-D差异均无统计学意义;患者的冠心病比例、LAD、LAEDV和LAESV血栓组大于无血栓组,LAEF及LAA-v血栓组小于无血栓组,差异均有统计学意义(均P<0.05);多因素Logistic回归分析显示,LAEF(OR=1.163, 95%CI:1.043~1.296,P<0.01)及LAA-v(OR=29.82,95%CI:7.97~29.82,P<0.05)是血栓形成的独立危险因素。结论 PAF患者左心耳内血栓形成与LAEF及LAA-v密切相关。     

Stunning of the left atrium after pharmacological cardioversion of atrial fibrillation

INTRODUCTION: Stunning of the left atrium and atrial appendage is a well known but not fully clarified phenomenon observed during the cardioversion of atrial fibrillation regardless of the cardioversion method attempted. AIM: To assess the effects of propafenone and amiodarone on left atrium and left atrial appendage contractility. METHODS: Forty patients with paroxysmal atrial fibrillation (20 females, 20 males), aged 60-83 (mean 72.0+/-10.1) years, were enrolled into the study. Half of these patients had sinus rhythm restored by the administration of oral propafenone (150-300 mg) and the remaining 20 patients were treated with intravenous amiodarone (150-450 mg). The control group consisted of 20 patients (10 females, 10 males) aged 52-78 (mean 61.2+/-9.3) years with sinus rhythm and no history of atrial fibrillation. All the patients had a transthoracic (TTE) and transesophageal (TEE) echocardiography performed while still in the AF, before drug administration and 1 hour after sinus rhythm restoration. RESULTS: All haemodynamic parameters of the left atrium measured after the sinus rhythm restoration were significantly worse when compared with the control group. Left atrial fractional shortening and total atrial fraction were significantly lower after propafenone than amiodarone (8.6+/-3.6% vs 11.7+/-5.5%, p<0.05; and LA FC 16.2+/-5.3% vs 23.3 (+/-6.3)% respectively, p<0.05). Doppler echocardiographic parameters included in the analysis such as mitral flow and superior left pulmonary vein flow were significantly lower in the sinus rhythm restoration group than in the control group. Among them the end-diastolic mitral flow velocity amplitude and flow velocity integral as well as the maximum pulmonary retrograde velocity were significantly worse in the group treated with propafenone than in patients receiving amiodarone. All the atrial appendage Doppler velocity parameters were significantly reduced after the sinus rhythm restoration in both groups. In the patients treated with propafenone, values of these parameters were significantly decreased compared with the patients receiving amiodarone. CONCLUSIONS: Successful pharmacological cardioversion of atrial fibrillation causes the left atrium and left atrial appendage contractility impairment similar to that observed with other methods of the sinus rhythm restoration. Following the AF cardioversion the level of left atrial stunning is higher in the patients treated with propafenone than in subjects receiving amiodarone.     

Transthoracic and Transesophageal Echocardiographic Indices Predictive of Sinus Rhythm Maintenance After Cardioversion of Atrial Fibrillation: An Echocardiographic Study During Direct Current Shock

BACKGROUND: Up to 57% of atrial fibrillation (AF) recurrences after cardioversion take place during the first 30 days following direct current shock (DCS) delivery. Previous echocardiographic studies on sinus rhythm (SR) maintenance after cardioversion have focused mainly on parameters recorded before DCS, while other studies have reported on the indices recorded soon after delivery of the shock. METHODS: Therefore, we investigated 18 patients with nonrheumatic AF, selected to undergo DCS, by both transthoracic (TTE) and transesophageal (TEE) echocardiography performed within 10 minutes before and after the electrical shock delivery. TTE was utilized for the evaluation of left atrium and left ventricle shape as well as for mitral Doppler flow sampling, while TEE was used to evaluate left atrial appendage (LAA) morphology and function, to score the LAA spontaneous echo contrast, and to evaluate the flow of left superior pulmonary vein; the transesophageal probe was left in situ during the electrical procedure. Thirty days after cardioversion, 10 (55%) patients maintained SR (Group 1) while 8 (45%) reverted to AF (Group 2). We compared the mean values of the parameters recorded in the two groups both before and after DCS. RESULTS: Although many parameters of pre- and postcardioversion analysis proved to be significantly different between the two groups, the most marked differences were exhibited by the following postcardioversion indices: Peak Doppler flow velocity of the end-diastolic mitral flow (30.10 +/- 5.24 vs. 20.50 +/- 6.32 cm/sec, P = 0.003); sum of peak velocities of the end-diastolic contraction (A) and relaxation (A(1)) of LAA (A + A(1) = 58.20 +/- 17.02 vs. 31.25 +/- 9.27 cm/sec, P = 0.001); duration of A + A(1) (162.70 +/- 27.01 vs. 133.75 +/- 5.31 msec, P = 0.002); and sum of durations of the early diastolic forward (E) and reverse (E(1)) flow of LAA (101.90 +/- 35.15 vs. 53.33 +/- 16.33 msec, P = 0.006). CONCLUSIONS: Using a single echocardiographic examination during DCS and after induction of anesthesia, without further discomfort to patients, we were able to identify useful parameters for the prediction of future electrical activity of the heart before as well as soon after DCS. Postcardioversion indices, derived by both TTE and TEE, were even more predictive of SR maintenance after 1 month than precardioversion parameters.     

经胸超声心动图多切面扫查法对左心耳及左心耳血栓的显示效果

目的探讨经胸超声心动图多切面扫查法对左心耳的显示及左心耳血栓检出的效果。方法入选32例心房颤动(房颤)患者,分别采用经胸二维超声心动图多切面扫查法及常规扫查法显示左心耳,并记录左心耳血栓的发生情况。常规扫查法采用调整的大动脉短轴切面进行观察,多切面扫查法在调整的大动脉短轴及其临近切面基础上同时进行调整的左心两腔切面及其邻近切面进行观察。以经食管超声心动图检查作为左心耳血栓检出的"金标准",比较多切面扫查法和常规扫查法对左耳血栓检出的敏感性、特异性。结果经胸超声心动图对左心耳的显示率:常规扫查法为50.0%,多切面扫查法为81.2%,两种方法左心耳的显示率有统计学差异(P0.05)。常规扫查法检出左心耳血栓的敏感性为27.3%、特异性90.5%;多切面扫查法检出左心耳血栓的敏感性为63.6%,特异性为95.2%。对于左心耳血栓的检出,多切面扫查法与经食管超声心动图一致性更好,优于常规扫查法。结论多切面扫查法能提高经胸超声心动图对左心耳的显示效果及左心耳血栓的检出,具有一定的临床实用价值。     

Comparative assessment of left atrial appendage by transesophageal and combined two- and three-dimensional transthoracic echocardiography

Objective: Our objective was to compare the utility of combined two‐dimensional (2D) transthoracic echocardiography (TTE) and three‐dimensional (3D) TTE versus 2D transesophageal echocardiography (TEE) in evaluation of the left atrium (LA) and LA appendage (LAA) for clot. Background: 2DTEE, usually performed to visualize the LAA, is semi‐invasive and not without risks. With improved technology the LAA has been increasingly visualized by 2DTTE and 3DTTE in many patients. Methods: We compared combined 2DTTE and 3DTTE with 2DTEE in evaluating the LA/LAA for a thrombus. Ninety‐two patients underwent 2DTTE, 3DTTE, and 2DTEE. An additional 20 patients, in whom TEE could not be performed, underwent 2DTTE and 3DTTE. Results: LA and LAA could be visualized in all patients. Of 92 patients studied, 74 had no thrombus and 7 had thrombus in the LAA by all modalities. Eleven patients, 9 with atrial fibrillation (AF), had a suspected thrombus by 2DTEE, but 3DTTE cropping clearly showed these to be prominent pectinate muscles which were seen in short axis on 2DTEE as rounded echo dense masses and therefore mimicked thrombi. These 9 patients with AF underwent successful cardioversion without any complications. Of the 20 patients in whom TEE could not be performed, 19 had no thrombus in the LA/LAA and 1 had a clot in the LAA. These 19 patients underwent successful cardioversion without complications. Conclusions: Our preliminary study suggests that combined 2DTTE and 3DTTE has comparable accuracy to TEE in evaluating the LA and LAA for thrombus. In some patients TEE, but not 3DTTE, may misdiagnose pectinate musculature as thrombus.     

Carvedilol therapy is associated with an improvement in left atrial appendage function in patients with congestive heart failure

Heart failure is one of the leading death reasons in the world. Left atrial appendage (LAA) is of great importance in maintaining cardiac function. We examined the effect of carvedilol therapy on left atrial appendage functions in patients with symptomatic congestive heart failure. Twenty patients with symptomatic congestive heart failure and resting ejection fraction < or = 40% were included in this study. LAA was visualized by transesophageal echocardiography. LAA area change (LAAAC), LAA empty velocity (LAAEV) and LAA empty velocity time integral (LAAEVTI) were calculated as the average of five cardiac cycles. A minimum dose of carvedilol administered to each patient, was titrated up to maximal dose that the patients could tolerate, during an 8-week period. After the third month of completing treatment, a second transthoracic and transesophageal echocardiographic study was performed. Heart rate (P < 0.001), systolic (P = 0.002) blood pressures were reduced by carvedilol therapy at the end of the third month. LAAEV (P < 0.001), LAAEVTI (P < 0.001), and LAAAC (P < 0.001) were significantly increased at the end of the third month of carvedilol therapy. This study indicates that in patients with symptomatic congestive heart failure, carvedilol therapy is associated with an improvement in left atrial appendage function.     

Transthoracic echocardiography for precardioversion screening during atrial flutter/fibrillation in young patients

BACKGROUND: Transthoracic echocardiography (TTE) is reliable for detection of thrombi in the left ventricle and right atrium, but not in the left atrial appendage. Therefore, transesophageal echocardiography (TEE) is routinely performed in adults prior to electric cardioversion for atrial flutter/fibrillation (AFF). Whether young survivors of congenital heart disease repair with AFF need routine TEE prior to electric cardioversion is unknown. HYPOTHESIS: Electric cardioversion for AFF is safe in survivors of congenital heart disease repair/palliation if an intracardiac thrombus is not suspected on TTE imaging. METHODS: This study reports the outcome of patients in a pediatric tertiary care cardiac unit where electric cardioversion was performed if no intracardiac thrombus was suspected on TTE. We performed a retrospective chart review of all patients treated with electric cardioversion for AFF at Children's Hospital of Michigan during 1997-2002. RESULTS: Of 35 patients who presented with 110 episodes of AFF requiring electric cardioversion during the study duration, 32 (age 3 months-49 years, median age 20.5 years, 104 AFF episodes) had previously undergone palliative surgery or repair of their congenital heart disease. Of these 32 patients, 18 were survivors of a Fontan palliation (for a single-ventricle variant) and the remaining 14 were survivors of other defects and repairs (septal defects, valve replacements, and tetralogy of Fallot). During 81% of the episodes, patients were receiving aspirin, warfarin, or heparin for anticoagulation at presentation. Transthoracic echocardiography was performed in 74 AFF episodes; of these, 10 TTE studies were suspicious for atrial thrombi. Transesophageal echocardiography confirmed the presence of a thrombus in 3 of these 10 patients. These patients received warfarin for 2 weeks and then underwent electric cardioversion. No thromboembolic events occurred immediately after or on follow-up in any patient. CONCLUSIONS: These findings suggest that TTE may be an effective imaging tool for precardioversion screening in young patients with AFF.     

非瓣膜病心房颤动患者电转复前后左心耳功能的经食管超声心动图研究

目的阐明左心耳功能对非瓣膜病心房颤动（ＮＶＡＦ）患者电转复成功率的预测价值,且对电转复后左心耳收缩功能恢复过程进行观察。方法应用经食管超声心动图对６０例ＮＶＡＦ患者电转复前及转复后２４小时、３天和１周左心耳血流频谱模式、峰值血流速度（ＬＡＡＰＥＶ）及左房自发显影的检测。结果（１）电转复前左心耳ＬＡＡＰＥＶ≥２０ｃｍ／ｓ者,转复成功率为７５％;反之,ＬＡＡＰＥＶ＜２０ｃｍ／ｓ,成功率为３０％;（２）电转复后左心耳血流频谱变成规则收缩与舒张的频谱模式,ＬＡＡＰＥＶ为２３±１０ｃｍ／ｓ,低于转复前３０±１２ｃｍ／ｓ（Ｐ＜０００１）;转复后左房新出现自发显影者８例,自发显影密度增加者１１例。结论ＮＶＡＦ患者电转复前左心耳收缩功能与窦性心律的维持高度相关;转复后左心耳“顿抑”,出现了血栓易于形成的条件,故对此类患者电转复后应给予足够的抗凝治疗,预防左房与左心耳血栓形成。     

Strain and strain rate imaging in evaluating left atrial appendage function by transesophageal echocardiography

BACKGROUND: This study was planned to assess whether strain rate (Sr) and strain (S) echocardiography is a useful method for functional assessment of the left atrial appendage (LAA). MATERIAL AND METHODS: Fifty-seven consecutive patients underwent a clinically indicated study. LAA late empty velocity (LAAEV) was calculated as a gold standard for left atrial appendage function. Real-time 2-dimensional color Doppler myocardial imaging data were recorded from the LAA at a high frame rate. Analysis was performed for LAA longitudinal strain rate and strain from midsegment of lateral wall of LAA. LAA strain determines regional lengthening expressed as a positive value or shortening expressed as a negative value. Peak systolic values were calculated from the extracted curve. RESULTS: Spearman correlation test results showed a statistically significant positive correlation was between the S, Sr variables and LAAEV (LAAEV vs S; r = 0.886, P < 0.001; LAAEV vs Sr: r = 0.897, P < 0.001, respectively). Strain and strain rate values were also significantly lower in patients with spontaneous echocardiographic contrast when compared with those without (strain; 2.42 +/- 0.98 vs 13.1 +/- 5.9, P < 0.001 and strain rate: 0.97 +/- 0.54 vs 3.34 +/- 1.15, P < 0.001, respectively). In addition, LAA strain and strain rate values were significantly lower in the patients with LAA thrombus (strain; 2.15 +/- 0.96 vs 8.35 +/- 6.9, P < 0.001, strain rate; 0.79 +/- 0.46 vs 2.30 +/- 1.48, P < 0.001, respectively). CONCLUSION: S and Sr imaging can be considered a robust technique for the assessment of the LAA systolic deformation.     

Effect of inotropic stimulation on left atrial appendage function in atrial myopathy of chronic atrial fibrillation

Atrial fibrillation (AF) leads to remodeling of the left atrium (LA) and left atrial appendage (LAA), resulting in atrial myopathy. Reduced LA and LAA function in chronic AF leads to thrombus formation and spontaneous echo contrast (SEC). The effect of inotropic stimulation on LAA function in patients with chronic AF is unknown. LAA emptying velocity (LAAEV) and maximal LAA area at baseline and after dobutamine were measured by transesophageal echocardiography in 14 subjects in normal sinus rhythm (NSR) and 6 subjects in AF. SEC in the LA was assessed before and after dobutamine. LAAEV increased significantly in both groups. However, the LAAEV at peak dobutamine in patients with AF remained significantly lower than the baseline LAAEV in patients who were in NSR (P = 0.009). Maximal LAA area decreased significantly with dobutamine in both groups, but LAA area at peak dose of dobutamine in patients with AF remained greater than baseline area in those in NSR (P = 0.01). Despite the increase in LAAEV, SEC improved in only two of five patients. We conclude that during AF, the LAA responds to inotropic stimulation with only a modest improvement in function.     

房间隔缺损并发心房纤颤患者应用Amplatzer伞封堵房缺后心房纤颤的电复律治疗

目的 :初步评价房间隔缺损并发心房纤颤患者应用 Am platzer伞封堵房间隔缺损后心房纤颤的电复律疗效。方法 :2例患者 （5 1～ 5 3岁 ）。在透视及食管超声心动图监视下经导管置入 Amplatzer伞封堵房间隔缺损。术后即时行超声心动图 ,术后 2 4h,和 1,3,6月 ,分别行经胸超声心动图评价房间隔缺损治疗效果。术后 6月行电复律。结果 :2例患者疗效均佳 ,房间隔未见残余分流 ,电复律成功 ,患者转为窦性心律 ,复律后无并发症及 Amplatzer伞移位。结论 :应用 Am platzer伞封堵房间隔缺损并发心房纤颤患者 ,电复律易成功 ,是一种安全有效的复律方法。     

Clinical value of left atrial appendage flow for prediction of long-term sinus rhythm maintenance in patients with nonvalvular atrial fibrillation

OBJECTIVES: This study evaluated the role of various clinical and echocardiographic parameters, including the left atrial appendage (LAA) anterograde flow velocity, for prediction of the long-term preservation of sinus rhythm (SR) in patients with successful cardioversion (CV) of nonvalvular atrial fibrillation (AF). BACKGROUND: Echocardiographic parameters for assessing long-term SR maintenance after successful CV of nonvalvular AF are not accurately defined. METHODS: Clinical, transthoracic echocardiographic and transesophageal echocardiographic (TEE) data--measured in AF lasting >48 h--of 186 consecutive patients (116 men, mean age: 65 +/- 9 years) with successful CV (electrical or pharmacologic) were analyzed for assessment of one-year maintenance of SR. RESULTS: At one-year follow-up, 91 of 186 (49%) patients who underwent successful CV continued to have SR. Mean LAA peak emptying flow velocity was higher in patients remaining in SR for one year than in those with AF relapse (41.7 +/- 20.2 cm/s vs. 27.7 +/- 17.0 cm/s; p < 0.001). On multivariate logistic regression analysis, only the mean LAA peak emptying velocity >40 cm/s (p = 0.0001; chi(2): 23.9, odds ratio [OR] = 5.2, confidence interval [CI] 95% = 2.7 to 10.1) and the use of preventive antiarrhythmic drug treatment (p = 0.0398; chi(2): 4.2; OR = 2.0, CI 95% = 1.0 to 3.8) predicted the continuous preservation of SR during one year, outperforming other univariate predictors such as absence of left atrial spontaneous echocardiographic contrast during TEE, the left atrial parasternal diameter <44 mm, left ventricular ejection fraction >46% and AF duration <1 week before CV. The negative and positive predictive values of the mean LAA peak emptying velocity >40 cm/s for assessing preservation of SR were 66% (CI 95% = 56.9 to 74.2) and 73% (CI 95% = 62.4 to 83.3), respectively. CONCLUSIONS: In TEE-guided management of nonvalvular AF, high LAA flow velocity identifies patients with greater likelihood to remain in SR for one year after successful CV. Low LAA velocity is of limited value in identifying patients who will relapse into AF.     

Stratification of thromboembolic risk of atrial fibrillation by transthoracic echocardiography and transesophageal echocardiography: The relative role of left atrial appendage function, mitral valve disease, and spontaneous echocardiographic contrast

The role of transesophageal echocardiography (TEE) in thromboembolic risk stratification in atrial fibrillation (AF) has not been established. Left atrial appendage contractile dysfunction in patients with AF predisposes to thrombus formation. The extent of blood stasis and propensity for thrombus can be assessed during TEE by measurement of the peak Doppler velocity of blood outflow from the appendage. Spontaneous echocardiographic contrast (SEC) is a swirling pattern of blood echogenicity that may be detected by TEE in the left atrium in patients with AF. The presence of SEC reflects left atrial blood stasis and a prothrombotic state. SEC is associated with an increased risk of systemic thromboembolic events. Parameters derived from TEE may provide additional prognostic data to clinical history and transthoracic echocardiography in thromboembolic risk stratification in AF.