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Left atrial thrombus formation immediately after cardioversion of atrial fibrillation despite adequate anticoagulant therapy
CASE REPORTS
Left Atrial Thrombus Formation Immediately After Cardioversion of Atrial Fibrillation Despite Adequate Anticoagulant Therapy Kazuaki Tanabe, MD, Hiroyuki Yoshitomi, MD, Toshihiko Asanuma, MD, Toshio Shimada, MD, and Shigefumi Morioka, MD, Izumo, Japan
We observed a patient w h o exhibited de novo left atrial thrombus formation after cardioversion, despite administration o f adequate anticoagulant therapy. Preexisting atrial thrombus was excluded by transesophageal echocardiography. Preexisting severe left atrial
mechanical dysfimction may be considered as a risk factor for de n o v o thrombus formation after cardioversion, as well as the poor outcome o f cardioversion.
T h e potential benefits and limitations o f transesophageal echocardiography (TEE) in preventing t h r o m b o e m b o l i s m associated with cardioversion o f atrial fibrillation are controversial. 1.2 I m m e d i a t e l y after successful cardioversion, left atrial or left atrial appendage stunning m a y be present, potentially carrying a risk for de n o v o t h r o m b u s formation, a'~ We describe a patient with de n o v o left atrial t h r o m b u s f o r m a t i o n after cardioversion. T h e patient had received adequate anticoagulant therapy, and preexisting atrial t h r o m b u s was carefully excluded by TEE.
TEE (biplane, 5 M H z transducer; Aloka, Tokyo, japan) study did not show any thrombus in the left atrium and left atrial appendage (Figure 1, A). Spontaneous echo contrast was observed in the left atrium. On Doppler examination, the left atrial appendage flow signal did not reveal discernible emptying or filling fibrillatory waves (Figure 2). Mild mitral regurgitation was detected by color Doppler imaging. We planned direct current electrical cardioversion of atrial fibrillation to improve cardiac function. Before the procedure, the patient was sedated with intravenous thiopental sodium. In addition to anticoagulant therapy with warfarin, heparin (10,000 units) was given intravenously during the procedure. Normal sinus rhythm was restored with shock energy of 100 joules. Intravenous infusion of heparin was continued after cardioversion. A follow-up TEE study, performed 4 hours after restoration of sinus rhythm, revealed a de novo thrombus in the left atrial appendage (Figure 1, B). There was no significant change in the intensity of spontaneous echo contrast in the left atrium. Atrial fibrillation recurred 24 hours after cardioversion. There were no embolic complications during the follow-up period.
CASE R E P O R T A 43-year-old Japanese man with dilated cardiomyopathy was admitted to the hospital for treatment of congestive heart failure. He had had atrial fibrillation for 20 months and had been treated with a regimen of adequate anticoagulation (one and a half times control). He was taking digoxin, diuretics, an angiotensin-converting enzyme inhibitor, a [3-blocker, disopyramide, and warfarin. Physical examination showed a prominent S s gallop. His blood pressure was 98/74 mm Hg. Cardiomegaly was seen on the chest radiograph. The electrocardiogram showed complete right bundle branch block and atrial fibrillation, with an average ventricular rate of 80 beats/rain. A two-dimensional echocardiogram revealed marked global left ventricular systolic dysfunction (ejection fraction of 20%) with dilation of the left atrium (60 ram). The From the Fourth Department of Internal Medicine, Shimane Medical University. Reprint requests: Kazuaki Tanabe, MD, Fourth Department of Internal Medicine, Shimane Medical University, Ewa-eho 89-I, Izumo 693, Japan. Copyright @ 1995 by the American Society of Echocardiography. 0894-7317/95 $5.00 + 0 27/1/63311
(] AM Soe ECHOCaWIOGV,1995;8:747-9.)
DISCUSSION
In this case, use o f an angiotensin-converting enzyme inhibitor, a [3-blocker, and other therapies for heart failure could not i m p r o v e cardiac function and symptoms. Previous investigators r e p o r t e d that imp r o v e m e n t o f systolic left ventricular function m a y be expected in patients with atrial fibrillation after cardioversion, s'6 T h u s we a t t e m p t e d electrical cardioversion o f atrial fibrillation in spite o f the patient with severe atrial dilation, reduced left ventricular func747
748
T a n a b e et al.
Journal of the American Society of Echocardiography September October 1995
Figure 1 TEE before (A) and after (B) successful electrical cardioversion. No thrombus is seen in left atrial appendage (LAA) before cardioversion. De novo thrombus appears in left atrial appendage (arrow) after cardioversion. (LA, Left atrium; LV, left ventricle.)
Figure 2 Pulsed-wave Doppler flow signals in left atrial appendage before cardioversion during atrial fibrillation. Blood flow velocity is very low.
tion, and long duration o f atrial fibrillation while tolerating anticoagulant treatment. Several investigators have recently proposed that use o f T E E to screen patients for atrial thrombi before cardioversion might reduce the risk o f t h r o m boembolism and the requirement for anticoagulat i o n . 1"7 Other studies have suggcsted that persistent or increased left atrial stasis after cardioversion may result in a thrombogenic milieu. 3'4 Grimm et al. 3 performed T E E immediately before and after suc-
cessful electrical cardioversion. Left atrial spontaneous echo contrast developed de novo or increased after cardioversion in 35% o f the patients and was associated with a decrease in blood flow velocity in the left atrial appendage. In this case, adequate anticoagulant therapy did not prevent fresh thrombus formation immediately after cardioversion. In addition to the transient atrial mechanical dysfunction caused by cardioversion, severe reduction in left ventricular function and dilated
Journal of the AmericanSocietyof Echocardiography Volume 8 Number 5, Part 1
left a t r i u m m a y be c o n s i d e r e d i m p o r t a n t d e t e r m i nants o f l o w b l o o d flow velocity in the left a t r i u m a n d s u b s e q u e n t t h r o m b u s f o r m a t i o n in the left atrial a p p e n d a g e . This case suggests that preexisting severe left atrial mechanical dysfunction is associated w i t h an increased risk o f de n o v o t h r o m b u s f o r m a t i o n in t h e left a t r i u m after cardioversion despite a d e q u a t e a n t i c o a g u l a n t therapy, as well as w i t h a p o o r o u t c o m e o f cardioversion. REFERENCES
1. 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;328:750-5. 2. Black IW, Fatkin D, Sagar KB, et al. Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation: a multicenter study. Circulation 1994;89:2509-13.
Tanabe et al.
3. Grimm RA, Stewart WJ, Maloney JD, et al. Impact of electrical cardioversion for atrial fibrillation on left atrial appendage function and spontaneous echo contrast: characterization by simultaneous transesophageal echocardiography. J Am Coil Cardiol 1993;22:1359-66. 4. Fatldn D, Kuchar DL, Thorburn CW, Feneley MP. Transesophageal echocardiography before and during direct current cardioversion of atrial fibrillation: evidence for "atrial stunning" as a mechanism ofthromboembolic complications. J Am Coil Cardiol 1994;23:307-16. 5. 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;69:1570-3. 6. Shite J, Yokota Y, Yokoyama M. Heterogeneity and time course of improvement in cardiac function after cardioversion of chronic atrial fibrillation: assessment of serial echocardiographic indices. Br Heart J 1993;70:154-9. 7. Black IW, Hopkins AP, Lee LCL, Jacobson BM, Walsh WF. Role of transesophageal echocardiography in evaluation of cardiogenic embolism. Br Heart J 1991;66:302-7.
Congenital Sinus of Valsalva Aneurysm Dissecting into the Interventricular Septum With Left Ventricular Communication Yelda Basaran, MD, Muzaffer Degertekin, MD, Mehmet Balkanay, MD, Ismet Dindar, MD, Fikret Turan, MD, mad Cevat Yakut, MD, Istanbul, Turkey
I n this r e p o r t we describe a case o f a right coronary sinus ofValsalva aneurysm dissecting into the interventricular septum with spontaneous r u p t u r e into the left ventricle. Sufficient information was provided by echocardiography, cardiac catheterization, and a o r t o g r a p h y
to confirm the diagnosis. Surgical findings were in complete accordance with cross-sectional and color flow D o p p l e r imaging by transthoracic and transesophageal approaches. (J AM S o c ECHOCARDIOGR 1995;8: 749-53.)
S i n u s ofValsalva a n e u r y s m s are rare cardiac a n o m a lies t h a t m a y be c o n g e n i t a l o r a c q u i r e d a n d caused by s e p a r a t i o n o f the aortic wall m e d i a f r o m the valve r i n g t i s s u e ) A c q u i r e d a n e u r y s m m a y result f r o m t r a u m a , e n d o c a r d i t i s , syphilis, M a r f a n ' s s y n d r o m e , a n d senile type o f dilation. 2 C o n g e n i t a l a n e u r y s m s are m o r e c o m m o n . 2'3 A n a n e u r y s m m a y originate
from o n e o r m o r e sinuses o f Valsalva, b u t dissection i n t o the i n t e r v e n t r i c u l a r s e p t u m almost always originates f r o m the r i g h t c o r o n a r y sinus o f Valsalva. A n a n e u r y s m m a y r e m a i n clinically silent o r p r o d u c e various manifestations d e p e n d i n g o n the structure it c o m m u n i c a t e s w i t h o r o n w h i c h it m a y i m p i n g e . T h e presence o f atrioventricular c o n d u c t i o n disturbance in y o u n g patients s h o u l d raise a suspicion o f a sinus o f Valsalva a n e u r y s m dissecting into the interventricular s e p t u m .
From the Kosuyolu Heart and Research Hospital. Reprint requests: Yelda Basaran, MD, Kosuyolu Heart and Research Hospital, Istanbul, Kadyk6y-Istanbul, Turkey. Copyright 9 1995 by the American Society of Echocardiography. 0894-7317/95 $5.00 + 0 2 7 / 1 / 6 4 1 5 4
CASE R E P O R T A 25-year-old man was admitted to a local hospital with complaints ofexertional dyspnea and fatigue with exercise. 749
Left Atrial Thrombus Formation Immediately After Cardioversion of Atrial Fibrillation Despite Adequate Anticoagulant Therapy Kazuaki Tanabe, MD, Hiroyuki Yoshitomi, MD, Toshihiko Asanuma, MD, Toshio Shimada, MD, and Shigefumi Morioka, MD, Izumo, Japan
We observed a patient w h o exhibited de novo left atrial thrombus formation after cardioversion, despite administration o f adequate anticoagulant therapy. Preexisting atrial thrombus was excluded by transesophageal echocardiography. Preexisting severe left atrial
mechanical dysfimction may be considered as a risk factor for de n o v o thrombus formation after cardioversion, as well as the poor outcome o f cardioversion.
T h e potential benefits and limitations o f transesophageal echocardiography (TEE) in preventing t h r o m b o e m b o l i s m associated with cardioversion o f atrial fibrillation are controversial. 1.2 I m m e d i a t e l y after successful cardioversion, left atrial or left atrial appendage stunning m a y be present, potentially carrying a risk for de n o v o t h r o m b u s formation, a'~ We describe a patient with de n o v o left atrial t h r o m b u s f o r m a t i o n after cardioversion. T h e patient had received adequate anticoagulant therapy, and preexisting atrial t h r o m b u s was carefully excluded by TEE.
TEE (biplane, 5 M H z transducer; Aloka, Tokyo, japan) study did not show any thrombus in the left atrium and left atrial appendage (Figure 1, A). Spontaneous echo contrast was observed in the left atrium. On Doppler examination, the left atrial appendage flow signal did not reveal discernible emptying or filling fibrillatory waves (Figure 2). Mild mitral regurgitation was detected by color Doppler imaging. We planned direct current electrical cardioversion of atrial fibrillation to improve cardiac function. Before the procedure, the patient was sedated with intravenous thiopental sodium. In addition to anticoagulant therapy with warfarin, heparin (10,000 units) was given intravenously during the procedure. Normal sinus rhythm was restored with shock energy of 100 joules. Intravenous infusion of heparin was continued after cardioversion. A follow-up TEE study, performed 4 hours after restoration of sinus rhythm, revealed a de novo thrombus in the left atrial appendage (Figure 1, B). There was no significant change in the intensity of spontaneous echo contrast in the left atrium. Atrial fibrillation recurred 24 hours after cardioversion. There were no embolic complications during the follow-up period.
CASE R E P O R T A 43-year-old Japanese man with dilated cardiomyopathy was admitted to the hospital for treatment of congestive heart failure. He had had atrial fibrillation for 20 months and had been treated with a regimen of adequate anticoagulation (one and a half times control). He was taking digoxin, diuretics, an angiotensin-converting enzyme inhibitor, a [3-blocker, disopyramide, and warfarin. Physical examination showed a prominent S s gallop. His blood pressure was 98/74 mm Hg. Cardiomegaly was seen on the chest radiograph. The electrocardiogram showed complete right bundle branch block and atrial fibrillation, with an average ventricular rate of 80 beats/rain. A two-dimensional echocardiogram revealed marked global left ventricular systolic dysfunction (ejection fraction of 20%) with dilation of the left atrium (60 ram). The From the Fourth Department of Internal Medicine, Shimane Medical University. Reprint requests: Kazuaki Tanabe, MD, Fourth Department of Internal Medicine, Shimane Medical University, Ewa-eho 89-I, Izumo 693, Japan. Copyright @ 1995 by the American Society of Echocardiography. 0894-7317/95 $5.00 + 0 27/1/63311
(] AM Soe ECHOCaWIOGV,1995;8:747-9.)
DISCUSSION
In this case, use o f an angiotensin-converting enzyme inhibitor, a [3-blocker, and other therapies for heart failure could not i m p r o v e cardiac function and symptoms. Previous investigators r e p o r t e d that imp r o v e m e n t o f systolic left ventricular function m a y be expected in patients with atrial fibrillation after cardioversion, s'6 T h u s we a t t e m p t e d electrical cardioversion o f atrial fibrillation in spite o f the patient with severe atrial dilation, reduced left ventricular func747
748
T a n a b e et al.
Journal of the American Society of Echocardiography September October 1995
Figure 1 TEE before (A) and after (B) successful electrical cardioversion. No thrombus is seen in left atrial appendage (LAA) before cardioversion. De novo thrombus appears in left atrial appendage (arrow) after cardioversion. (LA, Left atrium; LV, left ventricle.)
Figure 2 Pulsed-wave Doppler flow signals in left atrial appendage before cardioversion during atrial fibrillation. Blood flow velocity is very low.
tion, and long duration o f atrial fibrillation while tolerating anticoagulant treatment. Several investigators have recently proposed that use o f T E E to screen patients for atrial thrombi before cardioversion might reduce the risk o f t h r o m boembolism and the requirement for anticoagulat i o n . 1"7 Other studies have suggcsted that persistent or increased left atrial stasis after cardioversion may result in a thrombogenic milieu. 3'4 Grimm et al. 3 performed T E E immediately before and after suc-
cessful electrical cardioversion. Left atrial spontaneous echo contrast developed de novo or increased after cardioversion in 35% o f the patients and was associated with a decrease in blood flow velocity in the left atrial appendage. In this case, adequate anticoagulant therapy did not prevent fresh thrombus formation immediately after cardioversion. In addition to the transient atrial mechanical dysfunction caused by cardioversion, severe reduction in left ventricular function and dilated
Journal of the AmericanSocietyof Echocardiography Volume 8 Number 5, Part 1
left a t r i u m m a y be c o n s i d e r e d i m p o r t a n t d e t e r m i nants o f l o w b l o o d flow velocity in the left a t r i u m a n d s u b s e q u e n t t h r o m b u s f o r m a t i o n in the left atrial a p p e n d a g e . This case suggests that preexisting severe left atrial mechanical dysfunction is associated w i t h an increased risk o f de n o v o t h r o m b u s f o r m a t i o n in t h e left a t r i u m after cardioversion despite a d e q u a t e a n t i c o a g u l a n t therapy, as well as w i t h a p o o r o u t c o m e o f cardioversion. REFERENCES
1. 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;328:750-5. 2. Black IW, Fatkin D, Sagar KB, et al. Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation: a multicenter study. Circulation 1994;89:2509-13.
Tanabe et al.
3. Grimm RA, Stewart WJ, Maloney JD, et al. Impact of electrical cardioversion for atrial fibrillation on left atrial appendage function and spontaneous echo contrast: characterization by simultaneous transesophageal echocardiography. J Am Coil Cardiol 1993;22:1359-66. 4. Fatldn D, Kuchar DL, Thorburn CW, Feneley MP. Transesophageal echocardiography before and during direct current cardioversion of atrial fibrillation: evidence for "atrial stunning" as a mechanism ofthromboembolic complications. J Am Coil Cardiol 1994;23:307-16. 5. 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;69:1570-3. 6. Shite J, Yokota Y, Yokoyama M. Heterogeneity and time course of improvement in cardiac function after cardioversion of chronic atrial fibrillation: assessment of serial echocardiographic indices. Br Heart J 1993;70:154-9. 7. Black IW, Hopkins AP, Lee LCL, Jacobson BM, Walsh WF. Role of transesophageal echocardiography in evaluation of cardiogenic embolism. Br Heart J 1991;66:302-7.
Congenital Sinus of Valsalva Aneurysm Dissecting into the Interventricular Septum With Left Ventricular Communication Yelda Basaran, MD, Muzaffer Degertekin, MD, Mehmet Balkanay, MD, Ismet Dindar, MD, Fikret Turan, MD, mad Cevat Yakut, MD, Istanbul, Turkey
I n this r e p o r t we describe a case o f a right coronary sinus ofValsalva aneurysm dissecting into the interventricular septum with spontaneous r u p t u r e into the left ventricle. Sufficient information was provided by echocardiography, cardiac catheterization, and a o r t o g r a p h y
to confirm the diagnosis. Surgical findings were in complete accordance with cross-sectional and color flow D o p p l e r imaging by transthoracic and transesophageal approaches. (J AM S o c ECHOCARDIOGR 1995;8: 749-53.)
S i n u s ofValsalva a n e u r y s m s are rare cardiac a n o m a lies t h a t m a y be c o n g e n i t a l o r a c q u i r e d a n d caused by s e p a r a t i o n o f the aortic wall m e d i a f r o m the valve r i n g t i s s u e ) A c q u i r e d a n e u r y s m m a y result f r o m t r a u m a , e n d o c a r d i t i s , syphilis, M a r f a n ' s s y n d r o m e , a n d senile type o f dilation. 2 C o n g e n i t a l a n e u r y s m s are m o r e c o m m o n . 2'3 A n a n e u r y s m m a y originate
from o n e o r m o r e sinuses o f Valsalva, b u t dissection i n t o the i n t e r v e n t r i c u l a r s e p t u m almost always originates f r o m the r i g h t c o r o n a r y sinus o f Valsalva. A n a n e u r y s m m a y r e m a i n clinically silent o r p r o d u c e various manifestations d e p e n d i n g o n the structure it c o m m u n i c a t e s w i t h o r o n w h i c h it m a y i m p i n g e . T h e presence o f atrioventricular c o n d u c t i o n disturbance in y o u n g patients s h o u l d raise a suspicion o f a sinus o f Valsalva a n e u r y s m dissecting into the interventricular s e p t u m .
From the Kosuyolu Heart and Research Hospital. Reprint requests: Yelda Basaran, MD, Kosuyolu Heart and Research Hospital, Istanbul, Kadyk6y-Istanbul, Turkey. Copyright 9 1995 by the American Society of Echocardiography. 0894-7317/95 $5.00 + 0 2 7 / 1 / 6 4 1 5 4
CASE R E P O R T A 25-year-old man was admitted to a local hospital with complaints ofexertional dyspnea and fatigue with exercise. 749