Role of echocardiography in atrial fibrillation
- Warren J Manning, MD
Warren J Manning, MD
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine and Radiology
- Harvard Medical School
The role of echocardiographic imaging among patients with atrial fibrillation (AF) can be divided into several categories:
●Assessment of cardiac chamber sizes and function, the atrial contribution to left ventricular filling, the pericardium, and valvular function. This information may be helpful in determining the conditions associated with AF, the risk for recurrent AF following cardioversion, and the hemodynamic benefit of maintaining sinus rhythm. (See "Epidemiology of and risk factors for atrial fibrillation" and "Antiarrhythmic drugs to maintain sinus rhythm in patients with atrial fibrillation: Recommendations".)
●Identification of patients at increased risk for thromboembolic complications of AF before cardioversion and in patients with chronic AF. (See "Prevention of embolization prior to and after restoration of sinus rhythm in atrial fibrillation" and "Atrial fibrillation: Risk of embolization".)
Nearly all patients presenting with their first episode of AF will benefit from transthoracic (surface) echocardiographic (TTE) evaluation of left atrial size, left ventricular systolic function, and mitral valve morphology and function. A more selected subgroup may benefit from the additional information obtained from transesophageal echocardiographic (TEE) evaluation for left atrial thrombi to allow for early cardioversion if no thrombi are identified. Comparison with a prior TTE (if available) may allow for assessment of the atrial contribution to left ventricular filling when the patient is in sinus rhythm. (See "Management of new onset atrial fibrillation".)
Studies from the Stroke Prevention in Atrial Fibrillation (SPAF) investigators confirmed the usefulness of transesophageal echocardiography (TEE) for predicting thromboembolism [1,2]. This study involved 786 patients with nonrheumatic AF, 382 of whom were at high clinical risk for a thromboembolism (eg, women >75 years of age and patients with systolic blood pressure >160 mmHg or a history of previous thromboembolism, impaired left ventricular function, or recent congestive heart failure). The rate of stroke was increased over threefold when TEE evidence of dense spontaneous echocontrast was present, increased by threefold for reduced (<20 cm/second) left atrial appendage peak ejection flow velocity and for left atrial appendage thrombus, and increased by fourfold by complex aortic plaque.
- Transesophageal echocardiographic correlates of thromboembolism in high-risk patients with nonvalvular atrial fibrillation. The Stroke Prevention in Atrial Fibrillation Investigators Committee on Echocardiography. Ann Intern Med 1998; 128:639.
- Zabalgoitia M, Halperin JL, Pearce LA, et al. Transesophageal echocardiographic correlates of clinical risk of thromboembolism in nonvalvular atrial fibrillation. Stroke Prevention in Atrial Fibrillation III Investigators. J Am Coll Cardiol 1998; 31:1622.
- Dittrich HC, Pearce LA, Asinger RW, et al. Left atrial diameter in nonvalvular atrial fibrillation: An echocardiographic study. Stroke Prevention in Atrial Fibrillation Investigators. Am Heart J 1999; 137:494.
- Sanfilippo AJ, Abascal VM, Sheehan M, et al. Atrial enlargement as a consequence of atrial fibrillation. A prospective echocardiographic study. Circulation 1990; 82:792.
- Manning WJ, Leeman DE, Gotch PJ, Come PC. Pulsed Doppler evaluation of atrial mechanical function after electrical cardioversion of atrial fibrillation. J Am Coll Cardiol 1989; 13:617.
- Manning WJ, Silverman DI, Katz SE, et al. Impaired left atrial mechanical function after cardioversion: relation to the duration of atrial fibrillation. J Am Coll Cardiol 1994; 23:1535.
- Höglund C, Rosenhamer G. Echocardiographic left atrial dimension as a predictor of maintaining sinus rhythm after conversion of atrial fibrillation. Acta Med Scand 1985; 217:411.
- Dittrich HC, Erickson JS, Schneiderman T, et al. Echocardiographic and clinical predictors for outcome of elective cardioversion of atrial fibrillation. Am J Cardiol 1989; 63:193.
- Brodsky MA, Allen BJ, Capparelli EV, et al. Factors determining maintenance of sinus rhythm after chronic atrial fibrillation with left atrial dilatation. Am J Cardiol 1989; 63:1065.
- Blackshear JL, Pearce LA, Asinger RW, et al. Mitral regurgitation associated with reduced thromboembolic events in high-risk patients with nonrheumatic atrial fibrillation. Stroke Prevention in Atrial Fibrillation Investigators. Am J Cardiol 1993; 72:840.
- Ozkan M, Kaymaz C, Kirma C, et al. Predictors of left atrial thrombus and spontaneous echo contrast in rheumatic valve disease before and after mitral valve replacement. Am J Cardiol 1998; 82:1066.
- Nakagami H, Yamamoto K, Ikeda U, et al. Mitral regurgitation reduces the risk of stroke in patients with nonrheumatic atrial fibrillation. Am Heart J 1998; 136:528.
- Goldsmith IR, Blann AD, Patel RL, Lip GY. Reduced indexes of left atrial hypercoagulability in patients with severe mitral regurgitation. Am J Cardiol 2000; 86:234.
- Echocardiographic predictors of stroke in patients with atrial fibrillation: a prospective study of 1066 patients from 3 clinical trials. Arch Intern Med 1998; 158:1316.
- Manning WJ, Weintraub RM, Waksmonski CA, et al. Accuracy of transesophageal echocardiography for identifying left atrial thrombi. A prospective, intraoperative study. Ann Intern Med 1995; 123:817.
- Hwang JJ, Chen JJ, Lin SC, et al. Diagnostic accuracy of transesophageal echocardiography for detecting left atrial thrombi in patients with rheumatic heart disease having undergone mitral valve operations. Am J Cardiol 1993; 72:677.
- Manning WJ, Silverman DI, Keighley CS, et al. Transesophageal echocardiographically facilitated early cardioversion from atrial fibrillation using short-term anticoagulation: final results of a prospective 4.5-year study. J Am Coll Cardiol 1995; 25:1354.
- Weigner MJ, Thomas LR, Patel U, et al. Early cardioversion of atrial fibrillation facilitated by transesophageal echocardiography: short-term safety and impact on maintenance of sinus rhythm at 1 year. Am J Med 2001; 110:694.
- Klein AL, Grimm RA, Murray RD, et al. Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med 2001; 344:1411.
- Srimannarayana J, Varma RS, Satheesh S, et al. Prevalence of left atrial thrombus in rheumatic mitral stenosis with atrial fibrillation and its response to anticoagulation: a transesophageal echocardiographic study. Indian Heart J 2003; 55:358.
- Manning WJ, Silverman DI, Waksmonski CA, et al. Prevalence of residual left atrial thrombi among patients with acute thromboembolism and newly recognized atrial fibrillation. Arch Intern Med 1995; 155:2193.
- Ayirala S, Kumar S, O'Sullivan DM, Silverman DI. Echocardiographic predictors of left atrial appendage thrombus formation. J Am Soc Echocardiogr 2011; 24:499.
- Anter E, Silverstein J, Tschabrunn CM, et al. Comparison of intracardiac echocardiography and transesophageal echocardiography for imaging of the right and left atrial appendages. Heart Rhythm 2014; 11:1890.
- Tardif JC, Schwartz SL, Vannan MA, et al. Clinical usefulness of multiplane transesophageal echocardiography: comparison to biplanar imaging. Am Heart J 1994; 128:156.
- Collins LJ, Silverman DI, Douglas PS, Manning WJ. Cardioversion of nonrheumatic atrial fibrillation. Reduced thromboembolic complications with 4 weeks of precardioversion anticoagulation are related to atrial thrombus resolution. Circulation 1995; 92:160.
- Jaber WA, Prior DL, Thamilarasan M, et al. Efficacy of anticoagulation in resolving left atrial and left atrial appendage thrombi: A transesophageal echocardiographic study. Am Heart J 2000; 140:150.
- Seidl K, Rameken M, Drögemüller A, et al. Embolic events in patients with atrial fibrillation and effective anticoagulation: value of transesophageal echocardiography to guide direct-current cardioversion. Final results of the Ludwigshafen Observational Cardioversion Study. J Am Coll Cardiol 2002; 39:1436.
- Larsen JA, McPherson DD, Kadish AH, Goldberger JJ. Course of intraatrial thrombi resolution using transesophageal echocardiography. Echocardiography 2003; 20:121.
- Flaker G, Lopes RD, Al-Khatib SM, et al. Efficacy and safety of apixaban in patients after cardioversion for atrial fibrillation: insights from the ARISTOTLE Trial (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation). J Am Coll Cardiol 2014; 63:1082.
- Dunn M, Alexander J, de Silva R, Hildner F. Antithrombotic therapy in atrial fibrillation. Chest 1989; 95:118S.
- Pritchett EL. Management of atrial fibrillation. N Engl J Med 1992; 326:1264.
- Weigner MJ, Caulfield TA, Danias PG, et al. Risk for clinical thromboembolism associated with conversion to sinus rhythm in patients with atrial fibrillation lasting less than 48 hours. Ann Intern Med 1997; 126:615.
- Gallagher MM, Hennessy BJ, Edvardsson N, et al. Embolic complications of direct current cardioversion of atrial arrhythmias: association with low intensity of anticoagulation at the time of cardioversion. J Am Coll Cardiol 2002; 40:926.
- Airaksinen KE, Grönberg T, Nuotio I, et al. Thromboembolic complications after cardioversion of acute atrial fibrillation: the FinCV (Finnish CardioVersion) study. J Am Coll Cardiol 2013; 62:1187.
- de Divitiis M, Omran H, Rabahieh R, et al. Right atrial appendage thrombosis in atrial fibrillation: its frequency and its clinical predictors. Am J Cardiol 1999; 84:1023.
- Black IW, Chesterman CN, Hopkins AP, et al. Hematologic correlates of left atrial spontaneous echo contrast and thromboembolism in nonvalvular atrial fibrillation. J Am Coll Cardiol 1993; 21:451.
- Fatkin D, Herbert E, Feneley MP. Hematologic correlates of spontaneous echo contrast in patients with atrial fibrillation and implications for thromboembolic risk. Am J Cardiol 1994; 73:672.
- Fatkin D, Loupas T, Low J, Feneley M. Inhibition of red cell aggregation prevents spontaneous echocardiographic contrast formation in human blood. Circulation 1997; 96:889.
- Fatkin D, Kelly RP, Feneley MP. Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast and thromboembolic risk in vivo. J Am Coll Cardiol 1994; 23:961.
- Black IW, Hopkins AP, Lee LC, Walsh WF. Left atrial spontaneous echo contrast: a clinical and echocardiographic analysis. J Am Coll Cardiol 1991; 18:398.
- Puwanant S, Varr BC, Shrestha K, et al. Role of the CHADS2 score in the evaluation of thromboembolic risk in patients with atrial fibrillation undergoing transesophageal echocardiography before pulmonary vein isolation. J Am Coll Cardiol 2009; 54:2032.
- Tsai LM, Chen JH, Lin LJ, Teng JK. Natural history of left atrial spontaneous echo contrast in nonrheumatic atrial fibrillation. Am J Cardiol 1997; 80:897.
- Santiago D, Warshofsky M, Li Mandri G, et al. Left atrial appendage function and thrombus formation in atrial fibrillation-flutter: a transesophageal echocardiographic study. J Am Coll Cardiol 1994; 24:159.
- Shively BK, Gelgand EA, Crawford MH. Regional left atrial stasis during atrial fibrillation and flutter: determinants and relation to stroke. J Am Coll Cardiol 1996; 27:1722.
- Antonielli E, Pizzuti A, Pálinkás A, et al. Clinical value of left atrial appendage flow for prediction of long-term sinus rhythm maintenance in patients with nonvalvular atrial fibrillation. J Am Coll Cardiol 2002; 39:1443.
- Verhorst PM, Kamp O, Welling RC, et al. Transesophageal echocardiographic predictors for maintenance of sinus rhythm after electrical cardioversion of atrial fibrillation. Am J Cardiol 1997; 79:1355.
- Pérez Y, Duval AM, Carville C, et al. Is left atrial appendage flow a predictor for outcome of cardioversion of nonvalvular atrial fibrillation? A transthroacic and transesophageal echocardiographic study. Am Heart J 1997; 134:745.
- Fuster V, Rydén LE, Cannom DS, et al. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2011; 123:e269.
- Klein AL, Murray RD, Grimm RA. Role of transesophageal echocardiography-guided cardioversion of patients with atrial fibrillation. J Am Coll Cardiol 2001; 37:691.
- Nagarakanti R, Ezekowitz MD, Oldgren J, et al. Dabigatran versus warfarin in patients with atrial fibrillation: an analysis of patients undergoing cardioversion. Circulation 2011; 123:131.
- Cappato R, Ezekowitz MD, Klein AL, et al. Rivaroxaban vs. vitamin K antagonists for cardioversion in atrial fibrillation. Eur Heart J 2014; 35:3346.