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Transient Ischemic Attacks—No Atrial Septal Defect and Sinus Rhythm
Journal of Cardiothoracic and Vascular Anesthesia ] (]]]]) ]]]–]]]
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Diagnostic Dilemma
Transient Ischemic Attacks—No Atrial Septal Defect and Sinus Rhythm †
n
Kimberly Hollander, MD , Eitezaz Mahmood, BA , n,1 Feroze Mahmood, MD *
Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA † Northwestern University Feinberg School of Medicine, Chicago, IL
Key Words: transient ischemic attack; atrial septal defect; patient foreman ovale; Doppler study; left atrial appendage; atrial fibrillation; transesophageal echocardiography
A 62-YEAR-OLD man with a history of multiple transient ischemic attacks manifested by dysarthria and right hand weakness presented to the authors’ institution for percutaneous patent foramen ovale closure. His preoperative transesophageal echocardiogram demonstrated a mobile interatrial septum and a patent foramen ovale with a small
left-to-right shunt without any other abnormalities. Additional evaluation, including long-term Holter monitoring and hypercoagulability studies, was noncontributory. The patient remained in sinus rhythm throughout the procedure. Two-dimensional and color-flow Doppler interrogation of the interatrial septum confirmed the finding of a mobile
Fig 1. (A) Continuous-wave Doppler across the mitral valve with E and A waves, indicating early diastole and atrial contraction. (B) Pulmonary vein pulse-wave Doppler showing atrial systolic reversal.
1 Address reprint requests to: Feroze Mahmood, MD, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1 Deaconess Road, CC470, Boston, MA, 02215. E-mail address: [email protected] (F. Mahmood).
http://dx.doi.org/10.1053/j.jvca.2017.02.050 1053-0770/& 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Hollander K, et al. (2017), http://dx.doi.org/10.1053/j.jvca.2017.02.050
2
K. Hollander et al. / Journal of Cardiothoracic and Vascular Anesthesia ] (]]]]) ]]]–]]]
Fig 2. (A) Left atrial appendage pulse-wave Doppler showing electromechanical dissociation with electrocardiogram in sinus rhythm. (B) Left atrial appendage pulse-wave Doppler showing normal sinus flow pattern, transitioning into waves suggestive of a mechanical discordant pattern.
interatrial septum, but a left-to-right shunt could not be confirmed (bubble study). Pulse-wave Doppler interrogation of the mitral inflow and the pulmonary veins demonstrated normal atrial contraction (Fig 1A and B). However, pulsewave Doppler interrogation of the left atrial appendage
demonstrated a mechanical discordant pattern that was inconsistent with the sinus rhythm (Fig 2A). The discordant pattern in the left atrial appendage was intermittent, with transient phases of normal left atrial appendage ejection (Fig 2B). What is the diagnosis?
Fig 3. Representation of left atrial appendage flow in normal sinus rhythm, showing positive contraction wave in early systole, negative filling wave, positive and negative systolic reflection waves, and positive early diastolic left atrial appendage outflow wave.
Please cite this article as: Hollander K, et al. (2017), http://dx.doi.org/10.1053/j.jvca.2017.02.050
K. Hollander et al. / Journal of Cardiothoracic and Vascular Anesthesia ] (]]]]) ]]]–]]]
Diagnosis: Electromechanical Discordance Between the Left Atrium and Appendage Isolated left atrial appendage fibrillation in patients with paroxysmal atrial fibrillation during periods of sustained sinus rhythm has been reported.1 However, the current case suggested the possibility of isolated left atrial appendage fibrillation in patients without sustained or paroxysmal atrial fibrillation. It also suggested that transient episodic fibrillation of the left atrial appendage might be a thrombogenic state with likely embolic risk. Although a left atrial appendage thrombus was not identified, the patient had an extensive evaluation that excluded paroxysmal atrial fibrillation and patent foramen ovale as the sources of repetitive emboli. Thus, it was quite likely that the left atrial appendage was the source of these emboli. The current findings suggested that the left atrium and left atrial appendage should be interrogated as two distinct chambers. The left atrial appendage has a characteristic ejection pattern (Fig 3). In a normal sinus rhythm, the left atrial appendage flow is characterized by a positive contraction wave in early systole, negative filling wave, positive and negative systolic reflection waves, and positive early diastolic outflow wave. The fibrillation pattern consists of low-velocity saw-toothed-like waves that imply flow stagnation and inadequate emptying.2 Left atrial appendage mechanical discordance with the left atrium that does not reflect the surface electrocardiogram previously has been described.3,4 Most of these cases were reported after the maze procedure and after electrical or spontaneous cardioversion.4–6 To date, there is only one retrospective study evaluating the concordance of surface electrocardiogram and left atrial appendage mechanical function.1 This study of more than 200 patients showed
3
discordance between the electrocardiogram and left atrial appendage in 7.5% of patients. Within this group, 3.5% demonstrated sinus rhythm on electrocardiogram and fibrillation of the left atrial appendage, as was the case with the current patient.1 The fibrillating left atrial appendage likely resulted in a prothrombotic phenotype, which may explain the risk of thromboembolism and mechanism of transient ischemic attacks despite the apparent sinus rhythm on electrocardiogram. The current case emphasized transesophageal echocardiogram evaluation of the left atrium and specifically the left atrial appendage, even in the absence of a history of atrial fibrillation, to evaluate rhythm and risk of thrombus.
References 1 Warraich HJ, Gandhavadi M, Manning WJ. Mechanical discordance of the left atrium and appendage: A novel mechanism of stroke in paroxysmal atrial fibrillation. Stroke 2014;45:1481–4. 2 Agmon Y, Khandheria BK, Gentile F, et al. Echocardiographic assessment of the left atrial appendage. J Am Coll Cardiol 1999;34:1867–77. 3 Naqvi TZ, Zaky J. Electric dissociation within left atrial appendage diagnosed by Doppler echocardiography. J Am Soc Echocardiogr 2004;17: 1077–9. 4 Seto TB, Buchholz WA, Douglas PS, et al. When the body and appendage of the left atrium disagree: “Focal” atrial fibrillation—Implications for atrial thrombus formation and risk of thromboembolism. J Am Soc Echocardiogr 1999;12:1097–100. 5 Naqvi TZ, Rafie R, Cesario D. Electrical dissociation within the left atrium and left atrial appendage diagnosed with transesophageal echocardiography. J Am Soc Echocardiogr 2010;23:e1–4. 6 Matsumoto Y, Watanabe G, Endo M, et al. Coexistence of sinus rhythm and segmental atrial fibrillation after maze procedure. Ann Thorac Surg 2002;74: 249–51.
Please cite this article as: Hollander K, et al. (2017), http://dx.doi.org/10.1053/j.jvca.2017.02.050
Contents lists available at ScienceDirect
HOSTED BY
journal homepage: www.jcvaonline.com/locate/yjcan
Diagnostic Dilemma
Transient Ischemic Attacks—No Atrial Septal Defect and Sinus Rhythm †
n
Kimberly Hollander, MD , Eitezaz Mahmood, BA , n,1 Feroze Mahmood, MD *
Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA † Northwestern University Feinberg School of Medicine, Chicago, IL
Key Words: transient ischemic attack; atrial septal defect; patient foreman ovale; Doppler study; left atrial appendage; atrial fibrillation; transesophageal echocardiography
A 62-YEAR-OLD man with a history of multiple transient ischemic attacks manifested by dysarthria and right hand weakness presented to the authors’ institution for percutaneous patent foramen ovale closure. His preoperative transesophageal echocardiogram demonstrated a mobile interatrial septum and a patent foramen ovale with a small
left-to-right shunt without any other abnormalities. Additional evaluation, including long-term Holter monitoring and hypercoagulability studies, was noncontributory. The patient remained in sinus rhythm throughout the procedure. Two-dimensional and color-flow Doppler interrogation of the interatrial septum confirmed the finding of a mobile
Fig 1. (A) Continuous-wave Doppler across the mitral valve with E and A waves, indicating early diastole and atrial contraction. (B) Pulmonary vein pulse-wave Doppler showing atrial systolic reversal.
1 Address reprint requests to: Feroze Mahmood, MD, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1 Deaconess Road, CC470, Boston, MA, 02215. E-mail address: [email protected] (F. Mahmood).
http://dx.doi.org/10.1053/j.jvca.2017.02.050 1053-0770/& 2017 Elsevier Inc. All rights reserved.
Please cite this article as: Hollander K, et al. (2017), http://dx.doi.org/10.1053/j.jvca.2017.02.050
2
K. Hollander et al. / Journal of Cardiothoracic and Vascular Anesthesia ] (]]]]) ]]]–]]]
Fig 2. (A) Left atrial appendage pulse-wave Doppler showing electromechanical dissociation with electrocardiogram in sinus rhythm. (B) Left atrial appendage pulse-wave Doppler showing normal sinus flow pattern, transitioning into waves suggestive of a mechanical discordant pattern.
interatrial septum, but a left-to-right shunt could not be confirmed (bubble study). Pulse-wave Doppler interrogation of the mitral inflow and the pulmonary veins demonstrated normal atrial contraction (Fig 1A and B). However, pulsewave Doppler interrogation of the left atrial appendage
demonstrated a mechanical discordant pattern that was inconsistent with the sinus rhythm (Fig 2A). The discordant pattern in the left atrial appendage was intermittent, with transient phases of normal left atrial appendage ejection (Fig 2B). What is the diagnosis?
Fig 3. Representation of left atrial appendage flow in normal sinus rhythm, showing positive contraction wave in early systole, negative filling wave, positive and negative systolic reflection waves, and positive early diastolic left atrial appendage outflow wave.
Please cite this article as: Hollander K, et al. (2017), http://dx.doi.org/10.1053/j.jvca.2017.02.050
K. Hollander et al. / Journal of Cardiothoracic and Vascular Anesthesia ] (]]]]) ]]]–]]]
Diagnosis: Electromechanical Discordance Between the Left Atrium and Appendage Isolated left atrial appendage fibrillation in patients with paroxysmal atrial fibrillation during periods of sustained sinus rhythm has been reported.1 However, the current case suggested the possibility of isolated left atrial appendage fibrillation in patients without sustained or paroxysmal atrial fibrillation. It also suggested that transient episodic fibrillation of the left atrial appendage might be a thrombogenic state with likely embolic risk. Although a left atrial appendage thrombus was not identified, the patient had an extensive evaluation that excluded paroxysmal atrial fibrillation and patent foramen ovale as the sources of repetitive emboli. Thus, it was quite likely that the left atrial appendage was the source of these emboli. The current findings suggested that the left atrium and left atrial appendage should be interrogated as two distinct chambers. The left atrial appendage has a characteristic ejection pattern (Fig 3). In a normal sinus rhythm, the left atrial appendage flow is characterized by a positive contraction wave in early systole, negative filling wave, positive and negative systolic reflection waves, and positive early diastolic outflow wave. The fibrillation pattern consists of low-velocity saw-toothed-like waves that imply flow stagnation and inadequate emptying.2 Left atrial appendage mechanical discordance with the left atrium that does not reflect the surface electrocardiogram previously has been described.3,4 Most of these cases were reported after the maze procedure and after electrical or spontaneous cardioversion.4–6 To date, there is only one retrospective study evaluating the concordance of surface electrocardiogram and left atrial appendage mechanical function.1 This study of more than 200 patients showed
3
discordance between the electrocardiogram and left atrial appendage in 7.5% of patients. Within this group, 3.5% demonstrated sinus rhythm on electrocardiogram and fibrillation of the left atrial appendage, as was the case with the current patient.1 The fibrillating left atrial appendage likely resulted in a prothrombotic phenotype, which may explain the risk of thromboembolism and mechanism of transient ischemic attacks despite the apparent sinus rhythm on electrocardiogram. The current case emphasized transesophageal echocardiogram evaluation of the left atrium and specifically the left atrial appendage, even in the absence of a history of atrial fibrillation, to evaluate rhythm and risk of thrombus.
References 1 Warraich HJ, Gandhavadi M, Manning WJ. Mechanical discordance of the left atrium and appendage: A novel mechanism of stroke in paroxysmal atrial fibrillation. Stroke 2014;45:1481–4. 2 Agmon Y, Khandheria BK, Gentile F, et al. Echocardiographic assessment of the left atrial appendage. J Am Coll Cardiol 1999;34:1867–77. 3 Naqvi TZ, Zaky J. Electric dissociation within left atrial appendage diagnosed by Doppler echocardiography. J Am Soc Echocardiogr 2004;17: 1077–9. 4 Seto TB, Buchholz WA, Douglas PS, et al. When the body and appendage of the left atrium disagree: “Focal” atrial fibrillation—Implications for atrial thrombus formation and risk of thromboembolism. J Am Soc Echocardiogr 1999;12:1097–100. 5 Naqvi TZ, Rafie R, Cesario D. Electrical dissociation within the left atrium and left atrial appendage diagnosed with transesophageal echocardiography. J Am Soc Echocardiogr 2010;23:e1–4. 6 Matsumoto Y, Watanabe G, Endo M, et al. Coexistence of sinus rhythm and segmental atrial fibrillation after maze procedure. Ann Thorac Surg 2002;74: 249–51.
Please cite this article as: Hollander K, et al. (2017), http://dx.doi.org/10.1053/j.jvca.2017.02.050