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CLINICAL STUDY: ATRIAL FIBRILLATION

Clinical value of left atrial appendage flow for prediction of long-term sinus rhythm maintenance in patients with nonvalvular atrial fibrillation

Emanuele Antonielli, MD^*, Alfredo Pizzuti, MD, Attila Pálinkás, MD, Mattia Tanga, MD^*, N. oèmi Gruber, MD, Claudio Michelassi, BSc, Albert Varga, MD, Alessandro Bonzano, MD, Nicola Gandolfo, MD, L.ászló Halmai, MD, Antonia Bassignana, MD^*, Muhammad Babar Imran, MD, Fabrizio Delnevo, MD, Miklós Csanády, MD and Eugenio Picano, MD, PhD^,*

^* Divisione di Cardiologia, Ospedale SS. Annunziata, Savigliano, Italy
Divisione di Cardiologia, Ospedale Mauriziano, Umberto I, Torino, Italy
Second Department of Medicine and Cardiology Center, Albert Szent-Györgyi Medical Faculty, University of Sciences, Szeged, Hungary
National Research Council, Consiglio Nazionale delle Ricerche, Institute of Clinical Physiology, Pisa, Italy

Manuscript received June 6, 2001; revised manuscript received January 31, 2002, accepted February 8, 2002.

^* Reprint requests and correspondence: Dr. Eugenio Picano, Institute of Clinical Physiology, Pisa, CNR, Via Moruzzi, 1, 56100 Pisa, Italy.
picano{at}ifc.cnr.it

OBJECTIVES: This study evaluated the role of various clinical and echocardiographic parameters, including the left atrial appendage (LAA) anterograde flow velocity, for prediction of the long-term preservation of sinus rhythm (SR) in patients with successful cardioversion (CV) of nonvalvular atrial fibrillation (AF).

BACKGROUND: Echocardiographic parameters for assessing long-term SR maintenance after successful CV of nonvalvular AF are not accurately defined.

METHODS: Clinical, transthoracic echocardiographic and transesophageal echocardiographic (TEE) data—measured in AF lasting >48 h—of 186 consecutive patients (116 men, mean age: 65 ± 9 years) with successful CV (electrical or pharmacologic) were analyzed for assessment of one-year maintenance of SR.

RESULTS: At one-year follow-up, 91 of 186 (49%) patients who underwent successful CV continued to have SR. Mean LAA peak emptying flow velocity was higher in patients remaining in SR for one year than in those with AF relapse (41.7 ± 20.2 cm/s vs. 27.7 ± 17.0 cm/s; p < 0.001). On multivariate logistic regression analysis, only the mean LAA peak emptying velocity >40 cm/s (p = 0.0001; ²: 23.9, odds ratio [OR] = 5.2, confidence interval [CI] 95% = 2.7 to 10.1) and the use of preventive antiarrhythmic drug treatment (p = 0.0398; ²: 4.2; OR = 2.0, CI 95% = 1.0 to 3.8) predicted the continuous preservation of SR during one year, outperforming other univariate predictors such as absence of left atrial spontaneous echocardiographic contrast during TEE, the left atrial parasternal diameter <44 mm, left ventricular ejection fraction >46% and AF duration <1 week before CV. The negative and positive predictive values of the mean LAA peak emptying velocity >40 cm/s for assessing preservation of SR were 66% (CI 95% = 56.9 to 74.2) and 73% (CI 95% = 62.4 to 83.3), respectively.

CONCLUSIONS: In TEE-guided management of nonvalvular AF, high LAA flow velocity identifies patients with greater likelihood to remain in SR for one year after successful CV. Low LAA velocity is of limited value in identifying patients who will relapse into AF.

Abbreviations and Acronyms   AF   atrial fibrillation   CI   confidence interval   CV   cardioversion   ECG   electrocardiogram   LA   left atrial   LAA   left atrial appendage   LV   left ventricular   OR   odds ratio   ROC   receiver-operating characteristic   SR   sinus rhythm   TEE   transesophageal echocardiography/echocardiographic   TTE   transthoracic echocardiography/echocardiographic

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