title: Left atrial chamber and appendage function after internal atrial defibrillation: a prospective and serial transesophageal echocardiographic study.
abstract: OBJECTIVE
  The purpose of this prospective study was to assess left atrial chamber and appendage function after internal atrial defibrillation of atrial fibrillation and to evaluate the time course of recovery.
  
  
  BACKGROUND
  External cardioversion of atrial fibrillation may result in left atrial appendage dysfunction ("stunning") and may promote thrombus formation. In contrast to external cardioversion, internal atrial defibrillation utilizes lower energies; however, it is unknown whether the use of lower energies may avoid stunning of the left atrial appendage.
  
  
  METHODS
  Transesophageal and transthoracic echocardiography were performed in 20 patients 24 h before and 1 and 7 days after internal atrial defibrillation to assess both left atrial chamber and appendage function. Transthoracic echocardiography was again performed 28 days after internal atrial defibrillation to assess left atrial function. The incidence and degree of spontaneous echo contrast accumulation (range 1+ to 4+) was noted, and peak emptying velocities of the left atrial appendage were measured before and after internal atrial defibrillation. To determine left atrial mechanical function, peak A wave velocities were obtained from transmitral flow velocity profiles.
  
  
  RESULTS
  Sinus rhythm was restored in all patients. The mean +/- SD peak A wave velocities increased gradually after cardioversion, from 0.47 +/- 0.16 m/s at 24 h to 0.61 +/- 0.13 m/s after 7 days (p < 0.05) and 0.63 +/- 0.13 m/s after 4 weeks. Peak emptying velocities of the left atrial appendage were 0.37 +/- 0.16 m/s before internal atrial defibrillation, decreased significantly after internal atrial defibrillation to 0.23 +/- 0.1 m/s at 24 h (p < 0.01) and then recovered to 0.49 +/- 0.23 m/s (p < 0.01) after 7 days. The corresponding values for the degree of spontaneous echo contrast were 1.2 +/- 1.2 before internal atrial defibrillation versus 2.0 +/- 1.0 (p < 0.01) and 1.1 +/- 1.3 (p < 0.01) 1 and 7 days after cardioversion, respectively. One patient developed a new thrombus in the left atrial appendage, and another had a thromboembolic event after internal atrial defibrillation.
  
  
  CONCLUSIONS
  Internal atrial defibrillation causes depressed left atrial chamber and appendage function and may result in the subacute accumulation of spontaneous echo contrast and development of new thrombi after cardioversion. These findings have important clinical implications for anticoagulation therapy before and after low energy internal atrial defibrillation in patients with atrial fibrillation.
authors.affiliation: Department of Medicine (Cardiology), University of Bonn, Germany.
authors.forename: H
authors.initials: H
authors.lastname: Omran
authors.forename: W
authors.initials: W
authors.lastname: Jung
authors.forename: R
authors.initials: R
authors.lastname: Rabahieh
authors.forename: R
authors.initials: R
authors.lastname: Schimpf
authors.forename: C
authors.initials: C
authors.lastname: Wolpert
authors.forename: A
authors.initials: A
authors.lastname: Hagendorff
authors.forename: W
authors.initials: W
authors.lastname: Fehske
authors.forename: B
authors.initials: B
authors.lastname: Lüderitz
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D016279:Atrial Function, Left / Q000502:physiology*; D001783:Blood Flow Velocity / Q000502:physiology; D004452:Echocardiography; D017548:Echocardiography, Transesophageal; D004554:Electric Countershock / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D013923:Thromboembolism / Q000453:epidemiology; D013997:Time Factors
chemical_list: D000925:Anticoagulants