(Circulation. 1999;99:975-978.)
© 1999 American Heart Association, Inc.
Correspondence |
Spontaneous Echo Contrast and Atrial Fibrillation
Abteilung Innere Medizin St. Carolus-Krankenhaus, Görlitz, Germany
To the Editor:
The article by Silverman and Manning1 provides a lot of important data concerning the common problem of dealing with atrial fibrillation. Yet, there is 1 point that is not considered sufficiently. What is to be done with patients who show spontaneous echo contrast in the atria in spite of sufficient long-term (at least 1 month) anticoagulation? In our experience, these patients are not rare, and at present we are quite reluctant to perform any kind of cardioversion under these conditions. We would be very pleased if the authors could comment on this relevant clinical problem.
References
1.
Silverman DI, Manning WJ. Role of
echocardiography in patients undergoing elective
cardioversion of atrial fibrillation. Circulation. 1998;98:479–486.
Response
Beth Israel Deaconess Medical Center Boston, Mass
University of Connecticut Health Center Farmington, CT
Dr Breuer raises an important clinical issue regarding the management of patients with left atrial spontaneous echocardiographic contrast (SEC). SEC is an echocardiographic "visual" phenomenon believed to be related to blood stasis and likely reflects alterations in blood components. The incidence of SEC is not diminished by aspirin, heparin, or warfarin.1 2 Among patients with atrial fibrillation, SEC may be seen in almost 60% of subjects and >80% of those with atrial fibrillation and left atrial appendage thrombi.3 4 In the majority of patients, the "intensity" of SEC is mild, whereas a small minority of patients will have "dense" or "severe" SEC. Dense SEC is most commonly seen among patients with atrial fibrillation and coexistent mitral stenosis or markedly depressed cardiac output. In the absence of atrial thrombus, we do not consider SEC ("mild" or "severe") as a criterion to defer early cardioversion of atrial fibrillation. For those patients with "dense" SEC, however, it may sometimes be difficult to fully exclude a thrombus. We recommend conservative therapy with 4 weeks of warfarin before cardioversion if thrombus cannot be excluded on transesophageal echocardiography (TEE). In our experience, such patients represent a very small minority of subjects (<1%) of those referred for TEE-guided early cardioversion.
References
1. Black IW, Hopkins AP, Lee LC, Walsh WF. Left atrial spontaneous echo contrast: a clinical and echocardiographic analysis. J Am Coll Cardiol. 1991;18:398–404.[Abstract]
2. Daniel WG, Nellessen U, Schroder E, Nonnast-Daniel B, Bednarski PK, Nikutta P, Lichtlen PR. Left atrial spontaneous echo contrast in mitral valve disease: an indicator for an increased thromboembolic risk. J Am Coll Cardiol. 1988;11:1204–1211.[Abstract]
3. Manning WJ, Silverman DI, Keighley CS, Oettgen P, Douglas PS. Transesophageal echocardiographically facilitated cardioversion from atrial fibrillation using short-term anticoagulation: final results of a prospective 4.5 year study. J Am Coll Cardiol. 1995;25:1354–1361.[Abstract]
4.
Klein AL, Grimm RA, Black IW, Leung DY, Chung MK,
Vaughn SE, Murray RD, Miller DP, Arheart KL. Cardioversion guided by
transesophageal echocardiography:
the ACUTE pilot study: a randomized controlled trial. Ann Intern
Med. 1997;126:200–209.
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