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Evaluation of left atrial appendage function and thrombi in patients with atrial fibrillation: from transthoracic to real time 3D transesophageal echocardiography

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Abstract

The detection of embolic sources in patients with atrial fibrillation (AF) is important to guide anticoagulant therapy. Two-dimensional transesophageal echocardiography (TEE) is the gold standard to study left atrial appendage (LAA) anatomy and morphology, despite some false-positive diagnosis. We hypothesized that real time 3D TEE (RT3DTEE) is superior to 2DTEE in detecting and/or excluding LAA thrombi. We studied 93 patients with non-valvular AF (60 males, age = 67.1 ± 14.2 years) referred for electric cardioversion with transthoracic, 2DTEE and RT3DTEE. Before cardioversion, TTE allowed a confident measurement of emptying velocity of LAA (LAAeV) only in 59/93 patients (63%). On the contrary a good quality TEE LAAeV was obtained in all patients with 49/93 (53%) dysfunctional LAA (LAAeV < 40 cm/s). A subgroup of 5 patients (7.2% of the 69 effective cardioversion) presented a persistent dysfunction after cardioversion (with LAAeV values of <40 cm/s on the TEE post-CV). TEE allowed to observe a bilobed shape in 45 patients (48.4%) and three lobes in 22 patients (23.7%). In addition, besides to several additional findings, 2DTEE managed to detect thrombi with certainty in 8/93 patients (8.6%). In other 5 cases with diagnostic doubts for thrombi with 2DTEE (5/93 patients: 5.4%), the addition of the RT3DTEE mode allowed to discriminate with certainty the presence of just pectinate muscles in 4 patients RT3DTEE in patients with AF at risk of embolism is feasible, accurate and showed an additional diagnostic capability in the differential diagnosis of selected cases with suspected LAA thrombi.

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References

  1. Bouzas-Mosquera A, Broullón FJ, Álvarez-García N, Méndez E, Peteiro J et al (2011) Left atrial size and risk for all-cause mortality and ischemic stroke. CMAJ 183:657–664

    Article  Google Scholar 

  2. Sorino M, Colonna P, De Luca L et al (2007) Post cardioversion transesophageal echocardiography (POSTEC) strategy with the use of Enoxaparin for brief anticoagulation in atrial fibrillation patients: the multicenter POSTEC trial (a pilot study). J Cardiovasc Med 8(12):1034–42

    Article  Google Scholar 

  3. Manning WJ, Weintraub RM, Waksmonski CA, Haering JM, Rooney PS, Maslow AD, Johnson RG, Douglas PS (1995) Accuracy of transesophageal echocardiography for identifying left atrial thrombi. A prospective, intraoperative study. Ann Intern Med 123(11):817–22

    Article  CAS  PubMed  Google Scholar 

  4. Klein AL, Murray RD, Grimm RA (2001) Role of transesophageal echocardiography-guided cardioversion of patients with atrial fibrillation. J Am Coll Cardiol 37(3):691–704

    Article  CAS  PubMed  Google Scholar 

  5. Willens HJ, Qin JX, Keith K, Torres S (2010) Diagnosis of a bilobed left atrial appendage and pectinate muscles mimicking thrombi on real-time 3-dimensional transesophageal echocardiography. J Ultrasound Med 29(6):975–980

    Article  PubMed  Google Scholar 

  6. Latcu DG, Rinaldi JP, Saoudi N (2009) Real-time three-dimensional transesophageal echocardiography for diagnosis of left atrial appendage thrombus. Eur J Echocardiogr 10:711–712

    Article  PubMed  Google Scholar 

  7. Lacomis JM, Goitein O, Deible C, Moran PL, Mamone G, Madan S, Schwartzman D (2007) Dynamic multidimensional imaging of the human left atrial appendage. Europace 9:1134–1140

    Article  PubMed  Google Scholar 

  8. Healey JS, Crystal E, Lamy A et al (2005) Left atrial appendage occlusion study (LAAOS): results of a randomized controlled pilot study of left atrial appendage occlusion during coronary bypass surgery in patients at risk for stroke. Am Heart J 150:288–293

    Article  PubMed  Google Scholar 

  9. Irani WN, Grayburn PA, Afridi I (1997) Prevalence of thrombus, spontaneous echo contrast, and atrial stunning in patients undergoing cardioversion of atrial flutter: a prospective study using transesophageal echocardiography. Circulation 95(4):962–966

    Article  CAS  PubMed  Google Scholar 

  10. Omran H, Jung W, Rabahieh R, Wirtz P, Becher H, Illien S, Schimpf R, Lüderitz B (1999) Imaging of thrombi and assessment of left atrial appendage function: a prospective study comparing transthoracic and transoesophageal echocardiography. Heart 81:192–198

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. de Luca I, Colonna P, Sorino M, Del Salvatore B, De Luca L (2007) New monodimensional transthoracic echocardiographic sign of left atrial appendage function. J Am Soc Echocardiogr 20(3):324–332

    Article  PubMed  Google Scholar 

  12. Di Biase L, Santangeli P, Anselmino M et al (2012) Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation? Results from a multicenter study. J Am Coll Cardiol 60(6):531–538

    Article  PubMed  Google Scholar 

  13. Veinot JP, Harrity PJ, Gentile F, Khandheria BK, Bailey KR, Eickholt JT, Seward JB, Tajik AJ, Edwards WD (1997) Anatomy of the normal left atrial appendage: a quantitative study of age-related changes in 500 autopsy hearts: implications for echocardiographic examination. Circulation 96(9):3112–3115.

    Article  CAS  PubMed  Google Scholar 

  14. Vestito D, De Santis D, Colonna P (2016) Threedimensional transesophageal echocardiography demonstration of left atrial appendage echocontrast regression after 6 months therapy with dabigatran and not with warfarin. J Cardiovasc Echography 26:52–55

    Article  Google Scholar 

  15. De Luca I, Sorino M, De Luca L, Colonna P, Del Salvatore B, Corlianò, L (2005) Pre- and post-cardioversion transesophageal echocardiography for brief anticoagulation therapy with enoxaparin in atrial fibrillation patients: a prospective study with a 1-year follow-up. Int J Cardiol 102:447–454

    Article  PubMed  Google Scholar 

  16. Takada T, Yasaka M, Nagatsuka K, Minematsu K, Yamaguchi T (2001) Blood flowin the left atrial appendage and embolicstroke in nonvalvular atrial fibrillation. Eur Neurol 46(3):148–152

    Article  CAS  PubMed  Google Scholar 

  17. Valocik G, Kamp O, Mihciokur M, Mannaerts HFJ, Li Y, Ripa S, Visser CA (2002) Assessment of the left atrial appendage mechanical function by three-dimensional echocardiography. Eur J Echocardiogr 3:207–213

    Article  CAS  PubMed  Google Scholar 

  18. Schneider B, Stöllberger C, Schneider B (2007) Diagnosis of left atrial appendage thrombi by multiplane transesophageal echocardiography: interlaboratory comparative study. Circ J 71:122–125

    Article  PubMed  Google Scholar 

  19. Agoston I, Xie T, Tiller FL, Rahman AM, Ahmad M (2006) Assessment of left atrial appendage by live three-dimensional echocardiography: early experience and comparison with transesophageal echocardiography. Echocardiography 23(2):127–132

    Article  PubMed  Google Scholar 

  20. Karakus G, Kodali V, Inamdar V, Nanda NC, Suwanjutah T, Pothineni KR (2008) Comparative assessment of left atrial appendage by transesophageal and combined two- and three-dimensional transthoracic echocardiography. Echocardiography 25(8):918–924

    Article  PubMed  Google Scholar 

  21. Hung J, Lang R, Flachskampf F, Shernan SK, McCulloch ML, Adams DB, Thomas J, Vannan M, Ryan T; ASE (2007) 3D echocardiography: a review of the current status and future directions. J Am Soc Echocardiogr 20(3):213–233

    Article  PubMed  Google Scholar 

  22. Nakajima H, Seo Y, Ishizu T, Yamamoto M, Machino T, Harimura Y, Kawamura R, Sekiguchi Y, Tada H, Aonuma K (2010) Analysis of the left atrial appendage by three-dimensional transesophageal echocardiography. Am J Cardiol 106(6):885–892. doi:10.1016/j.amjcard.2010.05.014

    Article  PubMed  Google Scholar 

  23. Matyal R, Mahmood F, Chaudhry H, Cummisford K, Hagberg R, Mahmood F (2010) Left atrial appendage thrombus and real-time 3-dimensional transesophageal echocardiography. J Cardiothorac Vasc Anesth 24(6):977–979

    Article  PubMed  Google Scholar 

  24. Cummisford K, Sundar S, Hagberg R, Mahmood F (2010) Real-time three-dimensional transesophageal echocardiography and a congenital bilobar left atrial appendage. J Cardiothorac Vasc Anesth 24(3):475–477

    Article  PubMed  Google Scholar 

  25. Yamamoto M, Seo Y, Kawamatsu N et al (2014) Complex left atrial appendage morphology and left atrial appendage thrombus formation in patients with atrial fibrillation. Circ Cardiovasc Imaging 7:337–343

    Article  PubMed  Google Scholar 

  26. Shah SJ, Bardo DM, Sugeng L, Weinert L, Lodato JA, Knight BP, Lopez JJ, Lang RM (2008) Real-time three-dimensional transesophageal echocardiography of the left atrial appendage: initial experience in the clinical setting. J Am Soc Echocardiogr 21(12):1362–1368

    Article  PubMed  Google Scholar 

  27. Nucifora G, Faletra FF, Regoli F, Pasotti E, Pedrazzini G, Moccetti T, Auricchio A (2011) Evaluation of the left atrial appendage with real-time 3-dimensional transesophageal echocardiography: implications for catheter-based left atrial appendage closure. Circ Cardiovasc Imaging 4(5):514–523

    Article  PubMed  Google Scholar 

  28. Martinez MW, Kirsch J, Williamson EE, Syed IS, Feng D, Ommen S, Packer DL, Brady PA (2009) Utility of nongated multidetector computed tomography for detection of left atrial thrombus in patients undergoing catheter ablation of atrial fibrillation. JACC Cardiovasc Imaging 2(1):69–76. doi:10.1016/j.jcmg.2008.09.011

    Article  PubMed  Google Scholar 

  29. Fumagalli S, Gabbai D, Francini S et al (2014) External cardioversion of atrial fibrillation uses an early improvement of cardiac performance: a longitudinal strain analysis study. J Cardiovasc Echogr 24:10–17

    Article  Google Scholar 

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Authors and Affiliations

  1. Cardiology Department, Hospital Policlinico of Bari, Piazza G. Cesare, 70124, Bari, Italy

    Ilaria Dentamaro, Domenico Vestito, Ennio Michelotto, Delia De Santis, Vittoria Ostuni & Paolo Colonna

  2. Department of Medical Sciences “M Aresu”, University of Cagliari, Cagliari, Italy

    Christian Cadeddu

Authors
  1. Ilaria Dentamaro
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  2. Domenico Vestito
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  3. Ennio Michelotto
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  4. Delia De Santis
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  5. Vittoria Ostuni
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  6. Christian Cadeddu
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  7. Paolo Colonna
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Correspondence to Paolo Colonna.

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Disclosures

This study was co-financed by a grant from Cassa di Risparmio di Puglia foundation. Paolo Colonna MD is Co-author of ESC guidelines on AF (version 2010 and 2012) and received institutional research grants from Bayer, Boehringer and Daichii-Sankyo and speaker honoraria from: Bayer, Boehringer, Pfizer-BMS and Daichii-Sankyo.

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The authors declare that they have no conflicts of interest.

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Dentamaro, I., Vestito, D., Michelotto, E. et al. Evaluation of left atrial appendage function and thrombi in patients with atrial fibrillation: from transthoracic to real time 3D transesophageal echocardiography. Int J Cardiovasc Imaging 33, 491–498 (2017). https://doi.org/10.1007/s10554-016-1026-6

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  • DOI: https://doi.org/10.1007/s10554-016-1026-6

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