This Article Full Text Full Text (PDF) Data Supplement Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Google Scholar Articles by Melduni, R. M. Articles by Gersh, B. J. PubMed PubMed Citation Articles by Melduni, R. M. Articles by Gersh, B. J. Related Collections Contractile function Coumarins Thrombosis risk factors Echocardiography Arrhythmias, clinical electrophysiology, drugs Embolic stroke Anticoagulants

(Circulation. 2008;118:e699-e700.)
© 2008 American Heart Association, Inc.

Images in Cardiovascular Medicine

Severe Left Atrial Appendage Stunning After Electrical Cardioversion of Atrial Fibrillation

Rowlens M. Melduni, MD; Naser M. Ammash, MD; Mark J. Callahan, MD; Joseph F. Malouf, MD; Krishnaswamy Chandrasekaran, MD; Bernard J. Gersh, MBChB, DPhil

From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn.

Reprint requests to Rowlens M. Melduni, MD, Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail melduni.rowlens@mayo.edu

An extract of the first 100% of the full text is provided, because this article has no abstract.

A 77-year-old man with a history of ischemic cardiomyopathy presented with 3 days of progressively worsening dyspnea. An ECG revealed atrial fibrillation at a rate of 97 bpm. An echocardiogram showed severe left atrial enlargement, severely elevated left ventricular filling pressure, and an ejection fraction of 30%. Thyroid function studies were normal. His symptoms of dyspnea improved modestly with intravenous diuresis. A transesophageal-guided cardioversion was performed to restore atrial systole. The patient was concurrently enrolled in a research study designed to assess left atrial appendage (LAA) stunning after electric cardioversion of atrial fibrillation. After electrical cardioversion, LAA velocities were markedly reduced, and a de novo 1.14x1.17-cm mobile thrombus was detected in the LAA consistent with severe LAA stunning (Figure and online-only Data Supplement movies). The phenomenon of atrial stunning is thought to occur in most patients after cardioversion of atrial fibrillation,^1,2 underscoring the importance of anticoagulation in the immediate postcardioversion period to reduce the risk of thromboembolic events.³

View larger version (111K):   Figure. Doppler flow velocity profiles in left atrial appendage (upper panels) and 2-dimensional images of the LAA before (A and B) and immediately after (C and D) direct-current cardioversion of patient with atrial fibrillation, illustrating severe atrial stunning. Note the marked reduction in late (post-A wave) LAA diastolic emptying velocity (C) and the newly formed LAA thrombus (D) after restoration of in sinus rhythm.

We acknowledge Mark Zangs for his expert technical assistance.

Disclosures

None.

The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/118/21/e699/DC1.

1. Melduni RM, Malouf JF, Chandrasekaran K, Bruce CJ, White RD, Law KK, Al Atawi FO, Somers VK, Gersh BJ, Hodge DO, Friedman PA, Seward JB, Ammash NM. New insights into the predictors of left atrial stunning after successful direct-current cardioversion of atrial fibrillation and flutter. J Am Soc Echocardiogr. 2008; 21: 848–854.[CrossRef][Medline] [Order article via Infotrieve]
   
2. Fatkin D, Kuchar DL, Thornburn CW, Feneley MP. Transesophageal echocardiography before and during direct current cardioversion of atrial fibrillation: evidence for "atrial stunning" as a mechanism of thromboembolic complications. J Am Coll Cardiol. 1994; 23: 307–316.[Abstract]
   
3. Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation: Analysis of pooled data from five randomized controlled trials. Arch Intern Med. 1994; 154: 1449–1457.[CrossRef][Medline] [Order article via Infotrieve]