© 2000 by European Society of Cardiology
Early cardioversion of atrial fibrillation and atrial flutter guided by transoesophageal echocardiography
A single centre 8·5-year experience
Unità Operativa di Cardiologia, Ospedale Valduce Como, Italy; 1Unità di Statistica e Biometria, Ospedale Valduce Como, Italy
AIMS: To analyse the safety and impact on maintenance of sinus rhythm of transoesophageal echocardiographically guided early cardioversion associated with short-term anticoagulation in a large series of patients with atrial fibrillation and atrial flutter.
METHODS AND RESULTS: Patients who were candidates for cardioversion were eligible for inclusion if they had atrial fibrillation or atrial flutter lasting longer than 2 days or of unknown duration. Patients received short-term anticoagulation with warfarin or heparin and underwent transthoracic echocardiography followed by transoesophageal echocardiography. Early cardioversion was performed if no thrombus was seen on the transoesophageal study. Warfarin was maintained for 1 month after cardioversion. In patients with atrial thrombi, cardioversion was deferred and prolonged anticoagulation was prescribed. The study population included 183 patients. One hundred and sixty nine patients without atrial thrombi underwent early cardioversion. Fourteen patients with atrial thrombi (7·6%) underwent a second transoesophageal echocardiogram after a median of 4 weeks of oral warfarin, and cardioversion was performed if clot regression was documented. No patient in our study population had a clinical thromboembolic event at 1 month follow-up (95% C.I. 0–0·016). The immediate success rate of cardioversion was better among patients with atrial fibrillation <4 weeks duration compared with patients with atrial fibrillation of longer or of unknown duration: 96·6% vs 85%, respectively (P=0·014). At 1 month follow-up, the percentage of arrhythmia relapses in patients with initially successful cardioversion was similar in the two groups (29% vs 26%, P=ns); thus the initial better outcome in patients with recent-onset arrhythmia was not lost.
CONCLUSION: Transoesophageal echocardiography-guided early cardioversion in concert with short-term anticoagulation is safe. This approach permits abbreviation of the overall duration of atrial fibrillation and has a better impact on the maintenance of sinus rhythm for patients in whom the duration of atrial fibrillation is <4 weeks.
Key Words: Atrial fibrillation, echocardiography, anticoagulation
Correspondence: Dr Giovanni Corrado, Unità Operativa di Cardiologia. Ospedale Generale Valduce Via Dante 11 22100 Como Italy. e-mail: cardiologia{at}valduce.it
[1] Prystowsky EN, Benson DW Jr, Fuster V. Management of patients with atrial fibrillation. A statement for healthcare professionals from the Subcommittee on Electrocardiography and Electrophysiology, American Heart Association. Circulation 1996; 93: 1262–1277.[Medline]
[2] McBride R. Stroke Prevention in Atrial Fibrillation study. Final Results. Circulation 1991; 84: 527–539.
[3] Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation: a major contributor to stroke in the elderly. The Framingham study. Arch Intern Med 1987; 147: 1561–1564.
[4] Pritchett ELC. Drug therapy. Management of atrial fibrillation. N Engl J Med 1992; 326: 1264–1271.[Web of Science][Medline]
[5] Benjamin EJ, Wolf PA, D'Agostino RB, Silbershatz H, Kannel WB, Levy D. Impact of atrial fibrillation on the risk of death. The Framingham heart study. Circulation 1998; 98: 946–952.
[6] Petersen P and Godtfredsen J. Embolic complications in paroxysmal atrial fibrillation. Stroke 1986; 17: 622–625.
[7] Morris JJ Jr, Entman M, North WC, Kong Y, McIntosh H. The changes in cardiac output with reversion of atrial fibrillation to sinus rhythm. Circulation 1965; 31: 670–678.
[8] Grogan M, Smith HC, Gersh BJ, Wood DL. Left ventricular dysfunction due to atrial fibrillation in patients initially believed to have idiopathic dilated cardiomyopathy. Am J Cardiol 1992; 69: 1570–1573.[CrossRef][Web of Science][Medline]
[9] Kieny JR, Sacrez A, Facello A. Increase in radionuclide left ventricular ejection fraction after cardioversion of chronic atrial fibrillation in idiopathic dilated cardiomyopathy. Eur Heart J 1992; 13: 1290–1295.
[10] Shapiro W and Klein G. Alterations in cardiac function immediately following electrical cardioversion of atrial fibrillation to normal sinus rhythm. Circulation 1968; 38: 1074–1084.
[11] Morris JJ, Kong Y, North WC, McIntosh HD. Experience with cardioversion of atrial fibrillation and flutter. Am J Cardiol 1964; 14: 94–100.[CrossRef][Web of Science][Medline]
[12] Bjerkelund C and Orning OM. The efficacy of anticoagulant therapy in preventing embolism related to D.C. electrical conversion of atrial fibrillation. Am J Cardiol 1969; 23: 208–216.[CrossRef][Web of Science][Medline]
[13] Weinberg DM and Mancini GBJ. Anticoagulation for cardioversion of atrial fibrillation. Am J Cardiol 1989; 63: 745–746.[CrossRef][Web of Science][Medline]
[14] Arnold AZ, Mick MJ, Mazurek RP, Loop FD, Trohman RG. Role of prophylactic anticoagulation for direct current cardioversion in patients with atrial fibrillation or atrial flutter. J Am Coll Cardiol 1992; 19: 851–855.[Abstract]
[15] Klein AL, Grimm RA, Black IW. Cardioversion guided by transesophageal echocardiography: the ACUTE pilot study. A randomized controlled trial. Ann Intern Med 1997; 126: 200–209.
[16] Laupacis A, Albers G, Dalen J, Dunn MI, Jacobson AK, Singer DE. Antithrombotic therapy in atrial fibrillation. Chest 1998; 114: 579S–589S.
[17] Aschenberg W, Schluter M, Kremer P, Schroder E, Siglov V, Bleifeld W. Transesophageal two-dimensional echocardiography for the detection of left atrial appendage thrombus. J Am Coll Cardiol 1986; 7: 163–166.[Abstract]
[18] Mügge A, Daniel WG, Haussmann D, Gödke J, Wagenbreth I, Lichtlen PR. Diagnosis of left atrial appendage thrombi by transesophageal echocardiography: clinical implications and follow-up. Am J Card Imaging 1990; 4: 173–179.
[19] Lin SL, Hsu TL, Liou JY. Usefulness of transesophageal echocardiography for the detection of left atrial thrombi in patients with rheumatic heart disease. Echocardiography 1992; 9: 161–168.[Web of Science][Medline]
[20] Manning WJ, Weintraub RM, Waksmonski CA. Accuracy of transesophageal echocardiography for identifying left atrial thrombi. A prospective, intraoperative study. Ann Intern Med 1995; 123: 817–822.
[21] Fatkin D, Scalia G, Jacobs N. Accuracy of biplane transesophageal echocardiography in detecting left atrial thrombus. Am J Cardiol 1996; 77: 321–324.[CrossRef][Web of Science][Medline]
[22] Manning WJ, Silverman DI, Gordon SPF, Krumholz HM, Douglas PS. Cardioversion from atrial fibrillation without prolonged anticoagulation with use of transesophageal echocardiography to exclude the presence of atrial thrombi. N Engl J Med 1993; 328: 750–755.
[23] Stoddard MF, Dawkins PR, Prince CR, Longaker RA. Transesophageal echocardiographic guidance of cardioversion in patients with atrial fibrillation. Am Heart J 1995; 129: 1204–1215.[CrossRef][Web of Science][Medline]
[24] Manning WJ, Silverman DI, Keighley CS, Oettgen P, Douglas PS. Transesophageal echocardiographically facilitated early cardioversion from atrial fibrillation using short-term anticoagulation: final results of a prospective 4·5-year study. J Am Coll Cardiol 1995; 25: 1354–1361.[Abstract]
[25] Sahan DJ, DeMaria A, Kisslo J, Weyman A. Recommendations regarding quantitation in M-Mode echocardiography: results of a survey of echocardiographic measurements. Circulation 1978; 58: 1072–1083.
[26] Seward JB, Khandheria BK, Oh JK, Freeman WK, Tajik AJ. Critical appraisal of transesophageal echocardiography: limitations, pitfalls, and complications. J Am Soc Echocardiogr 1992; 5: 288–305.[Medline]
[27] Orsinelli DA and Pearson AC. Usefulness of multiplane transesophageal echocardiography in differentiating left atrial appendage thrombus from pectinate muscles. Am Heart J 1996; 131: 622–623.[CrossRef][Web of Science][Medline]
[28] Castello R, Pearson AC, Labovitz AJ. Prevalence and clinical implications of atrial spontaneous contrast in patients undergoing transesophageal echocardiography. Am J Cardiol 1990; 65: 1149–1153.[CrossRef][Web of Science][Medline]
[29] Black IW, Hopkins AP, Lee LCL, Walsh WF. Evaluation of transesophageal echocardiography before cardioversion of atrial fibrillation and flutter in nonanticoagulated patients. Am Heart J 1993; 126: 375–381.[CrossRef][Web of Science][Medline]
[30] Black IW, Fatkin D, Sagar KB. Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation. A multicenter study. Circulation 1994; 89: 2509–2513.
[31] Moreyra E, Finkelhor RS, Cebul RD. Limitations of transesophageal echocardiography in the risk assessment of patients before nonanticoagulated cardioversion from atrial fibrillation and flutter: an analysis of pooled trials. Am Heart J 1995; 129: 71–75.[CrossRef][Web of Science][Medline]
[32] Antonielli E, Pizzuti A, Gandolfo N. Transesophageal echocardiography before cardioversion in patients with atrial fibrillation: usefulness and limits. G Ital Cardiol 1995; 25: 543–552.[Medline]
[33] Mehta D and Baruch L. Thromboembolism following cardioversion of ‘common’ atrial flutter. Risk factors and limitations of transesophageal echocardiography. Chest 1996; 110: 1001–1003.
[34] Grimm RA, Leung DY, Black IW, Stewart WJ, Thomas JD, Klein AL. Left atrial appendage ‘stunning’ after spontaneous conversion of atrial fibrillation demonstrated by transesophageal Doppler echocardiography. Am Heart J 1995; 130: 174–176.[CrossRef][Web of Science][Medline]
[35] Manning WJ, Silverman DI, Katz SE. Temporal dependence of the return of atrial mechanical function on the mode of cardioversion of atrial fibrillation to sinus rhythm. Am J Cardiol 1995; 75: 624–626.[CrossRef][Web of Science][Medline]
[36] Harjai KJ, Mobarek SK, Cheirif J, Boulos LM, Murgo JP, Abi-Samra F. Clinical variables affecting recovery of left atrial mechanical function after cardioversion from atrial fibrillation. J Am Coll Cardiol 1997; 30: 481–486.[Abstract]
[37] Grimm RA, Stewart WJ, Maloney JD. Impact of electrical cardioversion of atrial fibrillation on left atrial appendage function and spontaneous echo contrast: characterization by simultaneous transesophageal echocardiography. J Am Coll Cardiol 1993; 22: 1359–1366.[Abstract]
[38] Botto GL, Molteni S, Lombardi R. Atrial mechanical function after conversion of recent onset atrial fibrillation to sinus rhythm (Abstr). Pace 1998; 21: 813.
[39] Grimm RA, Klein AL, Black IW, Stewart WJ, Pacheco TR, Kidwell GA. Can patients with atrial arrhythmia susceptible to postcardioversion thromboembolism be identified precardioversion by clinical or echocardiographic parameters? (Abstr). Circulation 1993; 88: 1–313.
[40] Silverman DI and Manning WJ. Role of echocardiography in patients undergoing elective cardioversion of atrial fibrillation. Circulation 1998; 98: 479–486.
[41] Dittrich HC, Erickson JS, Schneiderman T, Blacky AR, Savides T, Nicod PH. Echocardiographic and clinical predictors for outcome of elective cardioversion of atrial fibrillation. Am J Cardiol 1989; 63: 193–197.[CrossRef][Web of Science][Medline]
[42] Wijffels MCEF, Kirchhof CJHJ, Dorland R, Alessie MA. Atrial fibrillation begets atrial fibrillation. Circulation 1995; 92: 1954–1968.
[43] Rubin DN, Katz SE, Riley MF, Douglas PS, Manning WJ. Evaluation of left atrial appendage anatomy and function in recent-onset atrial fibrillation by transesophageal echocardiography. Am J Cardiol 1996; 78: 774–778.[CrossRef][Web of Science][Medline]
[44] Mitusch R, Garbe M, Schmücker G, Schwabe K, Stierle U, Sheikhzadeh A. Relation of left atrial appendage function to the duration and reversibility of nonvalvular atrial fibrillation. Am J Cardiol 1995; 75: 944–947.[CrossRef][Web of Science][Medline]
[45] Manning WJ, Silverman DI, Katz SE. Impaired left atrial mechanical function after cardioversion: relationship to the duration of atrial fibrillation. J Am Coll Cardiol 1994; 23: 1535–1540.[Abstract]
[46] Collins LJ, Silverman DI, Douglas PS, Manning WJ. Cardioversion of nonrheumatic atrial fibrillation. Reduced thromboembolic complications with 4 weeks of precardioversion anticoagulation are related to atrial thrombus resolution. Circulation 1995; 92: 160–163.
[47] Corrado G, Tadeo G, Beretta S. Atrial thrombi resolution after prolonged anticoagulation in patients with atrial fibrillation: a transesophageal echocardiographic study. Chest 1999; 115: 140–143.
[48] Seto TB, Taira DA, Tsevat J, Manning WJ. Cost-effectiveness of trasesophageal echocardiography-guided cardioversion: a decision analytic model for patients admitted to the hospital with atrial fibrillation. J Am Coll Cardiol 1997; 29: 122–130.[Abstract]
[49] Seto TB, Taira DA, Manning WJ. Cardioversion in patients with atrial fibrillation and left atrial thrombi on initial transesophageal echocardiography: should transesophageal echocardiography be repeated before cardioversion? A cost-effectiveness analysis. J Am Soc Echocardiogr 1999; 12: 508–516.[CrossRef][Web of Science][Medline]
[50] Kinch JW and Davidoff R. Prevention of embolic events after cardioversion of atrial fibrillation: current and evolving strategies. Arch Intern Med 1995; 155: 1353–1360.
[51] Bikkina M, Alpert MA, Mulekar M, Shakoor A, Massey CV, Covin FA. Prevalence of intraatrial thrombus in patients with atrial flutter. Am J Cardiol 1995; 76: 186–189.[CrossRef][Web of Science][Medline]
[52] Irani WN, Grayburn PA, Afridi I. Prevalence of thrombus, spontaneous echocontrast, and atrial stunning in patients undergoing cardioversion of atrial flutter. A prospective study using transesophageal echocardiography. Circulation 1997; 95: 962–966.
[53] Corrado G, Sgalambro A, Mantero A. Thromboembolic risk in atrial flutter: preliminary results of the Italian multicenter FLASIEC study (Abstr). Circulation 1998; Suppl_1 1–703.
[54] Mayet J, More RS, Sutton GC. Anticoagulation for cardioversion of atrial arrhythmias. Eur Heart J 1998; 19: 548–552.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  M. Strandberg, M.J. P. Raatikainen, M. Niemela, M. Luotolahti, J. Hartiala, and K.E. J. Airaksinen Clinical practicality and predictive value of transoesophageal echocardiography in early cardioversion of atrial fibrillation Europace, June 1, 2006; 8(6): 408 - 412. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G Corrado, S Beretta, L Sormani, G Tadeo, G Foglia-Manzillo, L.M Tagliagambe, and M Santarone Prevalence of atrial thrombi in patients with atrial fibrillation/flutter and subtherapeutic anticoagulation prior to cardioversion Eur J Echocardiogr, August 1, 2004; 5(4): 257 - 261. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||