Shen Xuedong, Li Huagui, Rovang Karen, Hee Tom, Holmberg Mark J, Mooss Aryan N, Mohiuddin Syed M
Cardiac Center of Creighton University, Omaha, Neb 68131-2044, USA.
Am Heart J. 2003 Oct;146(4):741-5. doi: 10.1016/S0002-8703(03)00390-9.
Atrial fibrillation (AF) is a recurrent problem that frequently requires repeat cardioversion. Transesophageal echocardiography (TEE) is indicated before cardioversion in patients who are underanticoagulated (warfarin therapy <3 weeks or international normalized ratio [INR] <2.0). It remains uncertain if TEE should be repeated in underanticoagulated patients who had no atrial thrombi detected by previous TEE. Methods and results From January 1996 to June 2001, 76 patients (43 men, 33 women; mean age, 68.8 +/- 10.4 years) who were underanticoagulated and had no atrial thrombi in previous TEE underwent repeat TEE before cardioversion of recurrent AF. The duration of recurrent AF at the time of the second TEE was 5.1 +/- 9.3 months (1 day to 4 years). The underlying diseases included coronary artery disease (n = 30), hypertension (n = 22), valvular heart diseases (n = 8), dilated cardiomyopathy (n = 4), hypertrophic cardiomyopathy (n = 2), and others (n = 10). Eight (10.5%) patients (2 men, 6 women; mean age, 68.6 +/- 6.6 years) were found to have intra-atrial thrombi on the second TEE. Of these 8 patients, 3 had coronary artery disease, 1 had hypertension, 2 had dilated cardiomyopathy, 1 had hypertrophic cardiomyopathy, and 1 had AF of unknown cause. The duration of recurrent AF in patients with and without thrombi was not significantly different (3.6 +/- 4.7 versus 5.3 +/- 9.7 months, P =.22). Of the 8 patients with intra-atrial thrombi on the second TEE, 5 had been taking warfarin for 3 to 4 weeks but had subtherapeutic INR and 3 were taking aspirin only. Compared with patients without intra-atrial thrombi, patients with intra-atrial thrombi had lower ejection fraction (32.5% +/- 18.1% versus 49.9% +/- 14.1%, P =.015), slower left atrial appendage empty velocity (0.22 +/- 0.08 versus 0.41 +/- 0.17 m/s, P <.01), and higher prevalence of spontaneous echo contrast (87.5%) than in patients without intra-atrial thrombi (19.1%, P <.05) but similar left atrial size (49.5 +/- 5.3 versus 47.3 +/- 7.1 mm, P =.15). Cardioversion was cancelled in all patients with atrial thrombi.
In underanticoagulated patients, repeat TEE is necessary before cardioversion of recurrent AF even if the previous TEE showed no atrial thrombi.
心房颤动（AF）是一个反复出现的问题，常常需要重复进行心脏复律。对于抗凝不足的患者（华法林治疗<3周或国际标准化比值[INR]<2.0），在心脏复律前需进行经食管超声心动图（TEE）检查。对于先前TEE未检测到心房血栓的抗凝不足患者，是否应重复进行TEE检查仍不确定。方法与结果 1996年1月至2001年6月，76例抗凝不足且先前TEE未发现心房血栓的患者（43例男性，33例女性；平均年龄68.8±10.4岁）在复发性AF心脏复律前接受了重复TEE检查。第二次TEE检查时复发性AF的持续时间为5.1±9.3个月（1天至4年）。基础疾病包括冠状动脉疾病（n = 30）、高血压（n = 22）、瓣膜性心脏病（n = 8）、扩张型心肌病（n = 4）、肥厚型心肌病（n = 2）及其他（n = 10）。8例（10.5%）患者（2例男性，6例女性；平均年龄68.6±6.6岁）在第二次TEE检查时发现有心房内血栓。在这8例患者中，3例患有冠状动脉疾病，1例患有高血压，2例患有扩张型心肌病，1例患有肥厚型心肌病，1例病因不明的AF。有血栓和无血栓患者的复发性AF持续时间无显著差异（3.6±4.7个月与5.3±9.7个月，P = 0.22）。在第二次TEE检查发现有心房内血栓的8例患者中，5例服用华法林3至4周但INR未达治疗水平，3例仅服用阿司匹林。与无心房内血栓的患者相比，有心房内血栓的患者射血分数较低（32.5%±18.1%与49.9%±14.1%，P = 0.015），左心耳排空速度较慢（0.22±0.08与0.41±0.17 m/s，P <0.01），自发回声增强的发生率较高（87.5%），高于无心房内血栓的患者（19.1%，P <0.05），但左心房大小相似（49.5±5.3与47. ???±7.1 mm，P = 0.15）。所有有心房血栓的患者均取消了心脏复律。
对于抗凝不足的患者，即使先前TEE未显示心房血栓，在复发性AF心脏复律前重复进行TEE检查也是必要的。
