Frequency and Significance of Right Atrial Appendage Thrombi in Patients with Persistent Atrial Fibrillation or Atrial Flutter

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Increasing prevalence of atrial fibrillation and flutter in the United States.

Gerald Naccarelli, Helen Varker, Jay Lin … (2009)

The prevalence data for atrial fibrillation (AF) are dated. The present retrospective study estimated the current and projected prevalence of AF and atrial flutter (AFL) in the United States using a large national database. Claims data drawn from July 2004 to December 2005 from the MarketScan research databases from Thomson Reuters were used to identify patients aged >or=20 years with nontransient AF and/or AFL and age- and gender-matched controls without these conditions. Of the 21,648,681 patients in the databases, 242,903 (1.12%) had nontransient AF and/or AFL (222,605 AF only, 5,376 AFL only, and 14,922 AF and AFL). Patients with AF only, AFL only, and AF and AFL had a greater (p <0.001) prevalence of co-morbidities, including hypertension (62.0%, 61.3%, and 57.0%, respectively) and coronary artery disease (43.0%, 44.7%, and 44.5%, respectively), than matched controls (45.1% hypertension and 19.4% coronary artery disease). Applying the US Census Bureau population estimates to the prevalence rates for AF and/or AFL in the databases, it was estimated that 3.03 million persons in the United States had AF only, 0.07 million had AFL only, and 0.19 million had AF and AFL in 2005. The projected prevalence for 2050 was 7.56 million for AF only, 0.15 million for AFL only, and 0.44 million for AF and AFL. In conclusion, the current prevalence of AF and AFL is high and is projected to increase considerably by 2050. The current and projected increases in the prevalence of AF are greater than predicted by a previous sentinel study and might reflect more than the aging of the population.

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Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation.

Charles Murray, R Davidoff, … (2001)

The conventional treatment strategy for patients with atrial fibrillation who are to undergo electrical cardioversion is to prescribe warfarin for anticoagulation for three weeks before cardioversion. It has been proposed that if transesophageal echocardiography reveals no atrial thrombus, cardioversion may be performed safely after only a short period of anticoagulant therapy. In a multicenter, randomized, prospective clinical trial, we enrolled 1222 patients with atrial fibrillation of more than two days' duration and assigned them to either treatment guided by the findings on transesophageal echocardiography or conventional treatment. The composite primary end point was cerebrovascular accident, transient ischemic attack, and peripheral embolism within eight weeks. Secondary end points were functional status, successful restoration and maintenance of sinus rhythm, hemorrhage, and death. There was no significant difference between the two treatment groups in the rate of embolic events (five embolic events among 619 patients in the transesophageal-echocardiography group [0.8 percent]) vs. three among 603 patients in the conventional-treatment group [0.5 percent], P=0.50). However, the rate of hemorrhagic events was significantly lower in the transesophageal-echocardiography group (18 events [2.9 percent] vs. 33 events [5.5 percent], P=0.03). Patients in the transesophageal-echocardiography group also had a shorter time to cardioversion (mean [+/-SD], 3.0+/-5.6 vs. 30.6+/-10.6 days, P<0.001) and a greater rate of successful restoration of sinus rhythm (440 patients [71.1 percent] vs. 393 patients [65.2 percent], P=0.03). At eight weeks, there were no significant differences between the two groups in the rates of death or maintenance of sinus rhythm or in functional status. The use of transesophageal echocardiography to guide the management of atrial fibrillation may be considered a clinically effective alternative strategy to conventional therapy for patients in whom elective cardioversion is planned.

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Anatomy of the normal left atrial appendage: a quantitative study of age-related changes in 500 autopsy hearts: implications for echocardiographic examination.

Thomas W D Edwards, Joseph Harrity, John P Veinot … (1997)

Transesophageal echocardiography (TEE) is the diagnostic modality of choice for visualizing the left atrial appendage (LAA). This study defined the morphology of the LAA in normal autopsy specimen hearts and considered the implications of these findings for TEE studies. Five hundred normal autopsy hearts were reviewed (25 male and 25 female subjects from each decade for 10 decades). LAA length, width, orifice size, and number of lobes were recorded. Number of lobes was compared between sexes with the rank sum test and regressed against age. Mean length, width, and orifice size increased with age, up to age 20 years, in both sexes. Rates were significantly different between sexes for LAA size (P=.011) and width (P=.006). After age 20, statistically significant but clinically insignificant age-related changes were observed. Fifty-four percent of LAAs had two lobes (range, 1 to 4), with no age or sex differences. Lobes exist in different planes of the heart. Most pectinate muscles were > or = 1 mm in width. Pectinate muscles < 1 mm (2.6% of cases) were seen in only the first and last decades. Age- and sex-related differences in LAA dimensions exist. These differences and the existence of multilobed appendages are important in the accurate TEE evaluation of LAA. Because lobes exist in different planes, imaging must be done in multiple planes to visualize the entire LAA.