Hemodynamic consequences of atrial fibrillation and cardioversion to sinus rhythm
- Gregory YH Lip, MD, FRCPE, FESC, FACC
Gregory YH Lip, MD, FRCPE, FESC, FACC
- Professor of Cardiovascular Medicine
- The University of Birmingham, UK
- Jordan M Prutkin, MD, MHS, FHRS
Jordan M Prutkin, MD, MHS, FHRS
- Associate Professor of Medicine, Division of Cardiology, Electrophysiology Section
- University of Washington
Atrial fibrillation (AF) can lead to a fall in cardiac output that is often clinically significant. Potential consequences include a fall in blood pressure, decreased exercise capacity, and pulmonary congestion, all of which are manifestations of heart failure (HF) (table 1). In addition, AF and HF often occur together, and each may predispose to the other .
The hemodynamic effects of AF and of cardioversion will be reviewed here. The clinical aspects and treatment of AF in patients with HF and cardiomyopathy are discussed separately. (See "The management of atrial fibrillation in patients with heart failure".)
ADVERSE HEMODYNAMICS IN AF
Many patients with atrial fibrillation (AF) develop a modest decline in left ventricular performance that typically returns to the previous baseline following reversion to sinus rhythm [2-5]. The magnitude of this effect and its reversibility were illustrated in a report of 15 patients with AF who were successfully cardioverted and maintained sinus rhythm for one month; 11 of these patients maintained sinus rhythm for three months . The mean duration of AF was three months (range 5 to 254 days). The following findings were noted after cardioversion:
●The mean left ventricular ejection fraction (LVEF) increased from 47 percent at baseline to 55 percent immediately after cardioversion to 61 percent at one month; there was no further increase at three months. The improvement in LVEF occurred in all but one patient. The maximum improvement in LVEF by one month coincides with the time to full recovery of left atrial contractile function . (See 'Atrial stunning' below.)
●The increase in LVEF was primarily due to enhanced diastolic filling resulting from two factors: (1) an increase in cycle length, which may involve both regularization of the heart rate and avoidance of short cycle lengths that impair ventricular contractility; and (2) the return of left atrial contractile function, as determined by peak A wave velocity, which increases the atrial contribution to ventricular filling [3,4].
- Wang TJ, Larson MG, Levy D, et al. Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study. Circulation 2003; 107:2920.
- Rodman T, Pastor BH, Figueroa W. Effect on cardiac output of conversion from atrial fibrillation to normal sinus mechanism. Am J Med 1966; 41:249.
- Raymond RJ, Lee AJ, Messineo FC, et al. Cardiac performance early after cardioversion from atrial fibrillation. Am Heart J 1998; 136:435.
- Viswanathan K, Daniak SM, Salomone K, et al. Effect of cardioversion of atrial fibrillation on improvement in left ventricular performance. Am J Cardiol 2001; 88:439.
- Van Gelder IC, Crijns HJ, Blanksma PK, et al. Time course of hemodynamic changes and improvement of exercise tolerance after cardioversion of chronic atrial fibrillation unassociated with cardiac valve disease. Am J Cardiol 1993; 72:560.
- 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.
- Pozzoli M, Cioffi G, Traversi E, et al. Predictors of primary atrial fibrillation and concomitant clinical and hemodynamic changes in patients with chronic heart failure: a prospective study in 344 patients with baseline sinus rhythm. J Am Coll Cardiol 1998; 32:197.
- Wijffels MC, Kirchhof CJ, Dorland R, Allessie MA. Atrial fibrillation begets atrial fibrillation. A study in awake chronically instrumented goats. Circulation 1995; 92:1954.
- Wijffels MC, Kirchhof CJ, Dorland R, et al. Electrical remodeling due to atrial fibrillation in chronically instrumented conscious goats: roles of neurohumoral changes, ischemia, atrial stretch, and high rate of electrical activation. Circulation 1997; 96:3710.
- Shillingford J, Thomas M. Hemodynamic effects of acute myocardial infarction in man. Prog Cardiovasc Dis 1967; 9:571.
- Nicod P, Hillis LD, Winniford MD, Firth BG. Importance of the "atrial kick" in determining the effective mitral valve orifice area in mitral stenosis. Am J Cardiol 1986; 57:403.
- 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.
- Kieny JR, Sacrez A, Facello A, et al. Increase in radionuclide left ventricular ejection fraction after cardioversion of chronic atrial fibrillation in idiopathic dilated cardiomyopathy. Eur Heart J 1992; 13:1290.
- Redfield MM, Kay GN, Jenkins LS, et al. Tachycardia-related cardiomyopathy: a common cause of ventricular dysfunction in patients with atrial fibrillation referred for atrioventricular ablation. Mayo Clin Proc 2000; 75:790.
- Stulak JM, Dearani JA, Daly RC, et al. Left ventricular dysfunction in atrial fibrillation: restoration of sinus rhythm by the Cox-maze procedure significantly improves systolic function and functional status. Ann Thorac Surg 2006; 82:494.
- Daoud EG, Weiss R, Bahu M, et al. Effect of an irregular ventricular rhythm on cardiac output. Am J Cardiol 1996; 78:1433.
- Wasmund SL, Li JM, Page RL, et al. Effect of atrial fibrillation and an irregular ventricular response on sympathetic nerve activity in human subjects. Circulation 2003; 107:2011.
- Natale A, Zimerman L, Tomassoni G, et al. Impact on ventricular function and quality of life of transcatheter ablation of the atrioventricular junction in chronic atrial fibrillation with a normal ventricular response. Am J Cardiol 1996; 78:1431.
- Muntinga HJ, Gosselink AT, Blanksma PK, et al. Left ventricular beat to beat performance in atrial fibrillation: dependence on contractility, preload, and afterload. Heart 1999; 82:575.
- Gosselink AT, Blanksma PK, Crijns HJ, et al. Left ventricular beat-to-beat performance in atrial fibrillation: contribution of Frank-Starling mechanism after short rather than long RR intervals. J Am Coll Cardiol 1995; 26:1516.
- Brookes CI, White PA, Staples M, et al. Myocardial contractility is not constant during spontaneous atrial fibrillation in patients. Circulation 1998; 98:1762.
- Schneider F, Martin DT, Schick EC, Gaasch WH. Interval-dependent changes in left ventricular contractile state in lone atrial fibrillation and in atrial fibrillation associated with coronary artery disease. Am J Cardiol 1997; 80:586.
- Hardman SM, Noble MI, Seed WA. Postextrasystolic potentiation and its contribution to the beat-to-beat variation of the pulse during atrial fibrillation. Circulation 1992; 86:1223.
- Rahimtoola SH, Ehsani A, Sinno MZ, et al. Left atrial transport function in myocardial infarction. Importance of its booster pump function. Am J Med 1975; 59:686.
- Linderer T, Chatterjee K, Parmley WW, et al. Influence of atrial systole on the Frank-Starling relation and the end-diastolic pressure-diameter relation of the left ventricle. Circulation 1983; 67:1045.
- Bonow RO, Frederick TM, Bacharach SL, et al. Atrial systole and left ventricular filling in hypertrophic cardiomyopathy: effect of verapamil. Am J Cardiol 1983; 51:1386.
- Robinson K, Frenneaux MP, Stockins B, et al. Atrial fibrillation in hypertrophic cardiomyopathy: a longitudinal study. J Am Coll Cardiol 1990; 15:1279.
- Khan MN, Jaïs P, Cummings J, et al. Pulmonary-vein isolation for atrial fibrillation in patients with heart failure. N Engl J Med 2008; 359:1778.
- Roy D, Paillard F, Cassidy D, et al. Atrial natriuretic factor during atrial fibrillation and supraventricular tachycardia. J Am Coll Cardiol 1987; 9:509.
- Hornestam B, Hall C, Held P, et al. N-terminal proANF in acute atrial fibrillation: a biochemical marker of atrial pressures but not a predictor for conversion to sinus rhythm. Digitalis in Acute Atrial Fibrillation (DAAF) Trial group. Am Heart J 1998; 135:1040.
- Rossi A, Enriquez-Sarano M, Burnett JC Jr, et al. Natriuretic peptide levels in atrial fibrillation: a prospective hormonal and Doppler-echocardiographic study. J Am Coll Cardiol 2000; 35:1256.
- Jourdain P, Bellorini M, Funck F, et al. Short-term effects of sinus rhythm restoration in patients with lone atrial fibrillation: a hormonal study. Eur J Heart Fail 2002; 4:263.
- Silvet H, Young-Xu Y, Walleigh D, Ravid S. Brain natriuretic peptide is elevated in outpatients with atrial fibrillation. Am J Cardiol 2003; 92:1124.
- Kihara T, Gillinov AM, Takasaki K, et al. Mitral regurgitation associated with mitral annular dilation in patients with lone atrial fibrillation: an echocardiographic study. Echocardiography 2009; 26:885.
- Gertz ZM, Raina A, Saghy L, et al. Evidence of atrial functional mitral regurgitation due to atrial fibrillation: reversal with arrhythmia control. J Am Coll Cardiol 2011; 58:1474.
- Tanimoto M, Pai RG. Effect of isolated left atrial enlargement on mitral annular size and valve competence. Am J Cardiol 1996; 77:769.
- Otsuji Y, Kumanohoso T, Yoshifuku S, et al. Isolated annular dilation does not usually cause important functional mitral regurgitation: comparison between patients with lone atrial fibrillation and those with idiopathic or ischemic cardiomyopathy. J Am Coll Cardiol 2002; 39:1651.
- Zhou X, Otsuji Y, Yoshifuku S, et al. Impact of atrial fibrillation on tricuspid and mitral annular dilatation and valvular regurgitation. Circ J 2002; 66:913.
- Hsu LF, Jaïs P, Sanders P, et al. Catheter ablation for atrial fibrillation in congestive heart failure. N Engl J Med 2004; 351:2373.
- Sun H, Gaspo R, Leblanc N, Nattel S. Cellular mechanisms of atrial contractile dysfunction caused by sustained atrial tachycardia. Circulation 1998; 98:719.
- Schotten U, Ausma J, Stellbrink C, et al. Cellular mechanisms of depressed atrial contractility in patients with chronic atrial fibrillation. Circulation 2001; 103:691.
- Sanders P, Morton JB, Morgan JG, et al. Reversal of atrial mechanical stunning after cardioversion of atrial arrhythmias: implications for the mechanisms of tachycardia-mediated atrial cardiomyopathy. Circulation 2002; 106:1806.
- Louie EK, Liu D, Reynertson SI, et al. "Stunning" of the left atrium after spontaneous conversion of atrial fibrillation to sinus rhythm: demonstration by transesophageal Doppler techniques in a canine model. J Am Coll Cardiol 1998; 32:2081.
- 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 Coll Cardiol 1993; 22:1359.
- Mattioli AV, Castelli A, Andria A, Mattioli G. Clinical and echocardiographic features influencing recovery of atrial function after cardioversion of atrial fibrillation. Am J Cardiol 1998; 82:1368.
- Harjai K, Mobarek S, Abi-Samra F, et al. Mechanical dysfunction of the left atrium and the left atrial appendage following cardioversion of atrial fibrillation and its relation to total electrical energy used for cardioversion. Am J Cardiol 1998; 81:1125.
- Omran H, Jung W, Rabahieh R, et al. Left atrial chamber and appendage function after internal atrial defibrillation: a prospective and serial transesophageal echocardiographic study. J Am Coll Cardiol 1997; 29:131.
- Fatkin 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 of thromboembolic complications. J Am Coll Cardiol 1994; 23:307.
- Falcone RA, Morady F, Armstrong WF. Transesophageal echocardiographic evaluation of left atrial appendage function and spontaneous contrast formation after chemical or electrical cardioversion of atrial fibrillation. Am J Cardiol 1996; 78:435.
- Shapiro EP, Effron MB, Lima S, et al. Transient atrial dysfunction after conversion of chronic atrial fibrillation to sinus rhythm. Am J Cardiol 1988; 62:1202.
- Stoddard MF, Dawkins PR, Prince CR, Longaker RA. Transesophageal echocardiographic guidance of cardioversion in patients with atrial fibrillation. Am Heart J 1995; 129:1204.
- 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.
- Moreyra E, Finkelhor RS, Cebul RD. Limitations of transesophageal echocardiography in the risk assessment of patients before nonanticoagulated cardioversion from atrial fibrillation and flutter: an analysis of pooled trials. Am Heart J 1995; 129:71.
- Gentile F, Elhendy A, Khandheria BK, et al. Safety of electrical cardioversion in patients with atrial fibrillation. Mayo Clin Proc 2002; 77:897.
- Berger M, Schweitzer P. Timing of thromboembolic events after electrical cardioversion of atrial fibrillation or flutter: a retrospective analysis. Am J Cardiol 1998; 82:1545.
- Oltrona L, Broccolino M, Merlini PA, et al. Activation of the hemostatic mechanism after pharmacological cardioversion of acute nonvalvular atrial fibrillation. Circulation 1997; 95:2003.
- Lip GY, Rumley A, Dunn FG, Lowe GD. Plasma fibrinogen and fibrin D-dimer in patients with atrial fibrillation: effects of cardioversion to sinus rhythm. Int J Cardiol 1995; 51:245.
- Abe, Y, Kim, et al. Evidence for the intravascular hyperclotting state induced by atrial fibrillation itself (abstract). J Am Coll Cardiol 1996; 27(Suppl A):35A.
- Upshaw CB Jr. Hemodynamic changes after cardioversion of chronic atrial fibrillation. Arch Intern Med 1997; 157:1070.
- Botkin SB, Dhanekula LS, Olshansky B. Outpatient cardioversion of atrial arrhythmias: efficacy, safety, and costs. Am Heart J 2003; 145:233.
- Fung KC, Tan HC, Kritharides L. Acute reductions in ventricular myocardial tissue velocities after direct current cardioversion of atrial fibrillation. J Am Soc Echocardiogr 2003; 16:656.
- Trouton TG, Allen JD, Young IS, et al. Altered cardiac oxygen extraction, lactate production and coronary blood flow after large dose transthoracic DC countershocks. Pacing Clin Electrophysiol 1993; 16:1304.
- Mayosi BM, Commerford PJ. Pulmonary edema following electrical cardioversion of atrial fibrillation. Chest 1996; 109:278.
- Atwood JE, Myers J, Sullivan M, et al. The effect of cardioversion on maximal exercise capacity in patients with chronic atrial fibrillation. Am Heart J 1989; 118:913.
- Gosselink AT, Crijns HJ, van den Berg MP, et al. Functional capacity before and after cardioversion of atrial fibrillation: a controlled study. Br Heart J 1994; 72:161.
- Gosselink AT, Bijlsma EB, Landsman ML, et al. Long-term effect of cardioversion on peak oxygen consumption in chronic atrial fibrillation. A 2-year follow-up. Eur Heart J 1994; 15:1368.
- ADVERSE HEMODYNAMICS IN AF
- Contributing factors
- - Rapid ventricular response
- Tachycardia-mediated cardiomyopathy
- - Irregular heart rate
- - Atrial systole
- - Neurohumoral activation
- - Mitral regurgitation
- HEMODYNAMICS AFTER CONVERSION OF CHRONIC AF TO SINUS RHYTHM
- Atrial stunning
- Pulmonary edema
- Improved exercise capacity
- - Mitral regurgitation