Transesophageal echocardiography before and during direct ... · underwent c~diover~i~n twice, 70 tr di s were performed. Sixty-f0 irect current cardio- versions were subsequently

JAW Vol. 24, No. 2 February B 16

Co~se~~e~t~y, transesop

el P. Feneley, Cardiology Depart- ment, St. Vincent’s Hospital, Victoria Street, Darlinghurst, New South Wales 2010, Australia.

Q1994 by the American College cP Cardiology

3oa FATKIN ET AL. THROMBOEMBOLIC COMPLICATIONS OF DC CARDIOVEBSION

JACC Vol. 23, No. 2 February 199437-16

tion WAS ~24 h to 12 months (mean duration 57 days). Eight patients had mitral valve disease (rheumatic stenosis in 6, valve replacement in 1, valve repair in I), and 58 patients (gg$%) had nonvalvular atrial fibrillation. underwent c~diover~i~n twice, 70 tr di s were performed. Sixty-f0 irect current cardio- versions were subsequently performed in 60 patients; in others, sinus rhythm was restored in the 24 h before cardio- version, and in 1 patient the cardioversion ~r~ednre was

d independently by two observers ac

r sparsely distributed in the main c

tern titan I-t- but with ut increased gain set-

rate) = dense swu with somewhat lesser tuate in intensity but ardiac cycle; 4-t= (se-

and very sbw swirling battens usually with similar density in

rver differences in grading oc- curred in seven cases but did not exceed one grade and were resolved by I third observer.

these echocardiographic studies and ersion was ~24 h for 37 procedures 7 procedures, 72 h to I week for 10 eek for 10 procedures. In the /latter

p, the duration of atrial fibrillatio months, and no changes in the he tion status were obse~e~ in the interval between

y and cardioversion. In a subgroup of

raphic assessment of left at&l and ventricular function was made before, during and after cwdioversion. Transthoracic echocardiography per- formed before the procedure included measurement of or-

trunsver5e ventricniar censured at a positio

tracheal intubation. Follow-up transthoracic echocar

formed 24 h and 72 h after cardioversion. Transes echocardiography was avowed 72 h after car Patients with recurrent atrial Bbrillati vals were not restudied.

For comparison of indexes of atrial and vent~cn~ar func- tion with normal values, a cohort of 16 age- and gender- matched control subjects with no cardiac structural abnor- malities was select unde~ent transes of a cardio~enic sou en

sedation with intrave (1 to 3 mgkg body weight). Incremental direct current discharges were delivered through cutaneous electrode patches. A procedure was defined as successful if sinus

ioversiom procedure, add~t~o~a~ and approval from the institutio

cardioversion: long-term cou~ad~~ therapy (1 I ~atje~ts~ or short-term anticoagMlat~o~ (1 to 12 days) with i~t~ave~o~s heparin (30 patie~ts~~ subcutaneous heparin (8 patients) or coumadin (3 patients). On the day of cardioversion, antico-

ts) or subcutaneous (4 pa- twenty-five patients were

The significance of changes within groups was determined

310 FATKINETAL. JACC Vol. 23. No. 2 February 1 :3w=-16

current episode (days) LA-M (llun~ 43 58 43 33

LVFS< No NO NQ No

LAthrombus NO No NQ I) No; 2) N/A

LA SECt Befa CV 0 1-k 0

N/A N/A 2+

The from TEE to CV 24 k 3wk 6 days

Time cv to event h 7 days 6 days

Even WA SW3k~ Stroke

Rhythm at event AC therapy AC status

At CV

male; N/A = not applicable; SK = subcutaneous; SEC = s~~~aeous echo coat~st;

al function was dete~ined by using than

to f~~~tate corn~~~o~~ between i~dividu~ patients. A p value < 0.05 was considered signiticant.

nce of lefi atrial theom-

version are shown in Table 2.

Sia, the precardioversion grade of left atrial spontaneous e&o contrast was 0 in nine patients, 1+ in three patients and

Yes (a = 4)

Duration of AF (days) Mitral valve disease

MS+MR MVR MR only

LA diameter (mm) LV FS ~28% LA thrombus LA SEC Went fora-nen ovale ASWASA Atrial tumor

37119 6O+ 13 59 + 75 21 (35)

6

1; 45 -1: 6 20 (33) 0 (0)

23 (38) 3 0) 0 (0) Q (0)

Values presented are mean value + SD or number (%) of patients. ASDIASA = atrial septal defect or aneurysm; MR = mitral rqwgitation; MS = mitral stenosis; MVR = mitral valve replacement or repair; other abbreviations as in Table I.

Pre PreUA 05 10 30 5 0 10Om~~ 24hr ’ 72hr

%

0.5 1.0 3 0 5.0 10 Ofnin ’ 92hr

echo contrast. s of the restora-

spontaneous echo contrast was maximal within 1 min: I+ in three patients, 2t in one patient and 3+ in one patient. One

Pre PreUA 10 10 0~’ 24hr ’ 72hr

cba~ges were observ neous ecb contrast

echo contrast, there was a longe tion (51 I 32 vs. 8 2 9 days, number of shocks ( + 0.8 vs. 1.4 + 0.7, p = 0.02) and higher mean energ livered (516 t 204 vs. 272 f 319 9,

312 FATWN ET THBOIUBOE

JACC Vol. 23. No. 2

immediate postcardioversion pe Atr~~l~~~~t~~n~~ shortening.

in the

appendage coflt~ctiQn, was noted af- ter ca~iove~io~.

JACC Vol. 23, No. 2

lant therapy and only a 0.8% prevalence in long-term anticoagulant therapy. Although

rmined w~et~er these

etecteed by tr~~~§e§~~

tent of injury has been rel 1vered (22), consistent wit

sm for a variable

ow (29). The new a ous echo contrast

evidence of increased atrial blood stasis induced by the procedure. In the present series, patients with new or increased spontaneous echo contrast had a slower initial mean heart rate and a lower atria1 fractional shortening than

known, but theoretic eo~s~de~tio~s s until restitution of atrial contraction sufficient to prevent blood stasis.

ment for their anesthetic services; Associ the rn~~sc~~~; and Ms. Sue BradEey, 13 for ~ec~~ic~ assisIaace witi tram+

cureent countershock complications. Acta

e%cacy of aa~~c~a~la~~ therapy in electrical conversion of atria! fibtiBIa-

ion fQor c~~~ov~rs~o~ of atrial

eration

esophageal ec$~ocardio~rapby in detecting source of embolism patiernts with cerebral ischemia of uncertain etiology. J Am CoU Caxdiol

quantitation in A&mode ecboc~d~o~ra~hy: result5 of a survey ofeclnocar~ ic measurements. Circulation 1978;%:lD72-83. , Aiexander J, de Silva R, tidner F. A~lil~rorn~t~c t

atria! fibriilation. Chest 39@$94:118%278.

Grimm R,4, Klein AL, Cohen 61, Maloney JD. ~~~~sesopb~e~ echo- cardiography in patients with atrial ~hyt~~as undergoing e!eCWkX!

316 FATKIN ET AL. THROMBOEMBOLlC COMPLKATIONS OF DC CARDkOVERSION

JAW Vol. 23. No. 2 Fe~~~~y 1 :307-16

cardiovenion: identification of sources of emboli [abstract]. PACE 1992; 15587.

19. Manning WJ, Silverman DI. Gordon SPF, K.rumholz HM, Douglas PS. Cardiovefsion :soni atriat fibrillation without prolonged anticoagulation

phy to exclude the presence of

44. Clinical implication5 of kfl atrial spootaneous echo contrast in nourheumatic atrial fibrillation. Am J Cardiol 1992;70:327-31.

21. Da&l WG, Freedberg RS, Gxote J, et al. Incidence of left atriai thrombi

Lawn B. Cardioversion and

25. Lechleitner P. Genser N, direct current cardioversio 813-7.

tion of atrial mecbal~~c~ function fib~~atioR. J Am Co iol ~~9.13:~17-23.

3-9, 28. Silverman Dl, Katz SE, et very of atria! mecba~ic~

wing c~~iove~~i~~ to sinus r related to the ~umt~o~ of atd fib~ilatio~ [abstract). Circulation Suppl I:1397.