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Research paper
Published online: 2019-06-17
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Usefulness of transesophageal echocardiography before cardioversion in atrial arrhythmias

Katarzyna Kosmalska, Małgorzata Rzyman, Paweł Miękus, Natasza Gilis-Malinowska, Radosław Nowak, Marcin Fijałkowski
DOI: 10.5603/CJ.a2019.0056
·
Pubmed: 31225630

open access

Ahead of print
Original articles
Published online: 2019-06-17

Abstract

Background: Although many thromboembolism risk factors are well defined, formation of thrombus or dense spontaneous contrast (sludge) in the left atrium remains enigmatic and confounding. Exclusion of the thrombus is extremely important with respect to planned reversal of sinus rhythm. Data regarding the routine transesophagal echocardiography (TEE) before cardioversion are inconclusive. The authors focused on analyzing the usefulness of TEE before cardioversion by assessment of factors influencing the risk of thrombus and/or dense spontaneous echo contrast with the intention of extendingindications for TEE in the group with a high risk of thrombus or to forgo TEE in the low risk group.

Methods: Two hundred sixty-nine consecutive patients with persistent (> 48 h) atrial fibrillation or atrial flutter, in whom a direct current cardioversion was planned, were undergoing TEE for the detection of the left atrial thrombus or dense spontaneous echocontrast. Additional clinical and echocardiographic data were collected. The relationship between both thrombus and dense spontaneous echocontrast and covariates was analyzed with the use of binary logistic regression.

Results: Left atrium (LA) appendage (LAA) thrombus and/or sludge were detected in 79 (29%) patients. Signs of dementia in mini mental state examination (hazard ratio: 1.16; p = 0.005), low velocities in LAA (hazard ratio [HR]: 3.38; p = 0.032); presence of spontaneous echo contrast in LA (HR: 3.38; p = 0,003) consecutive episode of AF (HR: 2.27; p = 0,046); longer duration of atrial fibrillation (HR: 1.009; p = 0.022); were significant predictors of thrombus and/or dense spontaneous echo contrast. None of the patients with a CHA2DS2VASc score ≤ 1 had thrombus or sludge in the LAA. Among patients with a CHA2DS2VASc score > 1, the prevalence of thrombus or sludge in LAA was independent of the CHA2DS2VASc score value.

Conclusions: Amongst many factors, including an established as risk for thromboembolism only a few of them increased the risk for the presence of thrombus in LAA: low velocities in LAA, presence of spontaneous echocontrast, longer duration of arrhythmia, consecutive (not first) arrhythmia episode and signs of dementia from a mini-mental state examination questionnaire. It was believed that there could be a need for an extension of indications of TEE in vast majority of the patients with atrial arrhythmias, due most often to an unpredictable occurrence of thrombus and potentially disastrous thromboembolism. The only exception could have been the group of the patients with a CHA2DS2VASc score ≤ 1.

Abstract

Background: Although many thromboembolism risk factors are well defined, formation of thrombus or dense spontaneous contrast (sludge) in the left atrium remains enigmatic and confounding. Exclusion of the thrombus is extremely important with respect to planned reversal of sinus rhythm. Data regarding the routine transesophagal echocardiography (TEE) before cardioversion are inconclusive. The authors focused on analyzing the usefulness of TEE before cardioversion by assessment of factors influencing the risk of thrombus and/or dense spontaneous echo contrast with the intention of extendingindications for TEE in the group with a high risk of thrombus or to forgo TEE in the low risk group.

Methods: Two hundred sixty-nine consecutive patients with persistent (> 48 h) atrial fibrillation or atrial flutter, in whom a direct current cardioversion was planned, were undergoing TEE for the detection of the left atrial thrombus or dense spontaneous echocontrast. Additional clinical and echocardiographic data were collected. The relationship between both thrombus and dense spontaneous echocontrast and covariates was analyzed with the use of binary logistic regression.

Results: Left atrium (LA) appendage (LAA) thrombus and/or sludge were detected in 79 (29%) patients. Signs of dementia in mini mental state examination (hazard ratio: 1.16; p = 0.005), low velocities in LAA (hazard ratio [HR]: 3.38; p = 0.032); presence of spontaneous echo contrast in LA (HR: 3.38; p = 0,003) consecutive episode of AF (HR: 2.27; p = 0,046); longer duration of atrial fibrillation (HR: 1.009; p = 0.022); were significant predictors of thrombus and/or dense spontaneous echo contrast. None of the patients with a CHA2DS2VASc score ≤ 1 had thrombus or sludge in the LAA. Among patients with a CHA2DS2VASc score > 1, the prevalence of thrombus or sludge in LAA was independent of the CHA2DS2VASc score value.

Conclusions: Amongst many factors, including an established as risk for thromboembolism only a few of them increased the risk for the presence of thrombus in LAA: low velocities in LAA, presence of spontaneous echocontrast, longer duration of arrhythmia, consecutive (not first) arrhythmia episode and signs of dementia from a mini-mental state examination questionnaire. It was believed that there could be a need for an extension of indications of TEE in vast majority of the patients with atrial arrhythmias, due most often to an unpredictable occurrence of thrombus and potentially disastrous thromboembolism. The only exception could have been the group of the patients with a CHA2DS2VASc score ≤ 1.

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Keywords

left atrial appendage thrombus, sludge, atrial fibrillation; atrial flutter; cardioversion, transesophagal echocardiography

About this article
Title

Usefulness of transesophageal echocardiography before cardioversion in atrial arrhythmias

Journal

Cardiology Journal

Issue

Ahead of print

Article type

Research paper

Published online

2019-06-17

DOI

10.5603/CJ.a2019.0056

Pubmed

31225630

Keywords

left atrial appendage thrombus
sludge
atrial fibrillation
atrial flutter
cardioversion
transesophagal echocardiography

Authors

Katarzyna Kosmalska
Małgorzata Rzyman
Paweł Miękus
Natasza Gilis-Malinowska
Radosław Nowak
Marcin Fijałkowski

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