Left atrial appendage ‘stunning’ after electrical cardioversion of atrial flutter: an attenuated response compared with atrial fibrillation as the mechanism for lower susceptibility to thromboembolic events
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Objectives This study sought to determine whether left atrial appendage stunning occurs in patients with atrial flutter and to compare left atrial appendage function in the pericardioversion period with that in patients with atrial fibrillation.Background Left atrial appendage stunning has recently been proposed as a key mechanistic phenomenon in the etiology of postcardioversion thromboembolic events in atrial fibrillation. Atrial flutter is thought to be associated with a negligible risk of thromboembolic events; therefore, anticoagulation is commonly withheld before and after cardioversion in these patients.Methods Sixty-three patients with atrial flutter (n = 19) or atrial fibrillation (n = 44) underwent transesophageal echocardiography immediately before and after electrical cardioversion. In addition to assessing the presence of thrombus and spontaneous echo contrast, we measured left atrial appendage emptying velocity and calculated shear rates by pulsed wave Doppler and two-dimensional echocardiography.Results Patients with atrial flutter exhibited greater left atrial appendage flow velocities before cardioversion than those with atrial fibrillation (42 +/- 19 vs. 28 +/- 15 cm/s [mean +/- SD], p < 0.001). Left atrial appendage shear rates were also higher in patients with atrial flutter (103 +/- 82 vs. 59 +/- 37 s-1, p < 0.001). After cardioversion, left atrial appendage flow velocities decreased compared with precardioversion values in patients with atrial fibrillation (28 +/- 15 before to 15 +/- 14 cm/s after cardioversion, p < 0.001) and atrial flutter (42 +/- 19 to 27 +/- 18 cm/s, respectively, p < 0.001). Shear rates decreased from 59 +/- 37 before cardioversion to 30 +/- 31 s-1 after cardioversion in atrial fibrillation (p < 0.001), and from 103 +/- 82 s to 65 +/- 52 s-1, respectively (p < 0.001), in atrial flutter. This decrease in flow velocity from before to after cardioversion occurred in 36 (82%) of 44 patients with atrial fibrillation and 14 (74%) of 19 with atrial flutter. The impaired left atrial appendage function after cardioversion was less pronounced in the group with atrial flutter (27 +/- 18 cm/s for atrial flutter vs. 15 +/- 14 cm/s for atrial fibrillation, p < 0.001). New or increased spontaneous echo contrast occurred in 22 (50%) of 44 patients with atrial fibrillation versus 4 (21%) of 19 with atrial flutter (p < 0.05).Conclusions Left atrial appendage stunning also occurs in patients with atrial flutter, although to a lesser degree than in those with atrial fibrillation. These data suggest that patients with atrial flutter are at risk for thromboembolic events after cardioversion, although this risk is most likely lower than that in patients with atrial fibrillation because of better preserved left atrial appendage function.
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Spontaneous echo contrast and LA appendage stunning have been reported in patients undergoing cardioversion of AFL, suggesting high embolic risk.
“Spontaneous echo contrast and LA appendage stunning have been reported in patients undergoing cardioversion of AFL, suggesting a high embolic risk in this situation.133,134”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [133]
In AFL lasting >48h, risk of thromboembolism appears high at the time of cardioversion to sinus rhythm by DC shock, atrial stimulation, or CTI ablation, and anticoagulation is recommended as in AF.
“In patients with AFL lasting .48h the risk of thromboembolism would appear high at the time of cardioversion to sinus rhythm, either by DC shock, atrial stimulation or CTI ablation, 133,134 and anticoagulation is recommended as in AF.”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [133]
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- Authors
- Grimm, R. A., Stewart, W. J., Arheart, K. L., Thomas, J. D., & Klein, A. L.
- Affiliations
- Cleveland Clinic (US)
- Corresponding author
- Grimm, Richard A
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 1997-03
- Volume
- 29
- Issue
- 3
- Pages
- 582-589
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W2073015884
- Cited by
- 150
- References
- 26
- Citations by year
- 2025: 1 · 2024: 4 · 2023: 2 · 2021: 5 · 2020: 1 · 2019: 8 · 2018: 2 · 2017: 2 · 2016: 3 · 2015: 3 · 2014: 3 · 2013: 7 · 2012: 6
- FWCI
- 6.57
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac tumors and thrombi
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Keywords
- atrial flutter, atrial fibrillation, electrical cardioversion, thromboembolism, left atrial appendage emptying velocity, shear rate, spontaneous echo contrast, transesophageal echocardiography, anticoagulation, left atrial appendage function, thromboembolic risk
- MeSH terms
- Aged, Atrial Fibrillation, Atrial Flutter, Coronary Thrombosis, Electric Countershock, Female, Humans, Male, Middle Aged, Echocardiography, Doppler, Atrial Function, Left, Echocardiography, Transesophageal
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