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Circulation. 2008;118:e699-e700
doi: 10.1161/CIRCULATIONAHA.108.787374
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(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{at}mayo.edu

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


Figure 1191342
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  		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.


*    Acknowledgment
 
We acknowledge Mark Zangs for his expert technical assistance.

Disclosures

None.


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


*    References
up arrowTop
 *References
 
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.[Abstract/Free Full Text]





This Article
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Google Scholar
Right arrow Articles by Melduni, R. M.
Right arrow Articles by Gersh, B. J.
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PubMed
Right arrow PubMed Citation
Right arrow Articles by Melduni, R. M.
Right arrow Articles by Gersh, B. J.
Related Collections
Right arrow Contractile function
Right arrow Coumarins
Right arrow Thrombosis risk factors
Right arrow Echocardiography
Right arrow Arrhythmias, clinical electrophysiology, drugs
Right arrow Embolic stroke
Right arrow Anticoagulants

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