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European Heart Journal 2001 22(12):1042-1051; doi:10.1053/euhj.2000.2427
Copyright © 2001 by the European Society of Cardiology.
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Thromboembolic risk in atrial flutter. The FLASIEC (FLutterAtrialeSocietàIaliana diEcografiaCardiovascolare) multicentre study

G Corradoa,f1, A Sgalambrob, A Manteroc, F Gentiled, M Gasparinie, R Bufalinoe, A Morabitof, G Trocinog, R Schiavinag, S Mandorlah, R Mangiai, D Tovenaj, K Savinok, F Jacopil, E.M Pellegrinom, F Agostinin, G Centonzeo, F Bovenzip, E Caprinoq, G Tadeoa and M Santarone for the FLASIEC investigatorsa

a Unità Operativa di Cardiologia, Ospedale Generale Valduce, Como, Italy
b Servizio di Diagnostica Policardiografica con Unità Coronarica, Ospedale Civico, Codogno, Italy
c Servizio Centrale di Cardiologia, Ospedale Niguarda, Milano, Italy
d Divisione di Cardiologia, Ospedale Bassini, Cinisello Balsamo, Italy
e Dipartimento di Cardiologia, Istituto Clinico Humanitas, Rozzano, Italy
f Istituto di Statistica Medica e Biometria, Università degli Studi di Milano, Italy
g Divisione di Cardiologia, Ospedale San Gerardo dei Tintori, Monza, Italy
h Divisione di Cardiologia, Ospedale Silvestrini, Perugia, Italy
i Divisione di Cardiologia, Ospedale Cardinale Panico, Tricase, Italy
j Divisione di Cardiologia, Ospedale Maggiore, Crema, Italy
k Cattedra di Cardiologia, Università degli Studi di Perugia, Italy
l Dipartimento di Cardiologia, Ravenna-Faenza-Lugo, Sede di Faenza, Italy
m Divisione di Cardiologia, Ospedale Sacro Cuore di Gesù, Gallipoli, Italy
n Ospedale Carlo Poma, Mantova, Italy
o Servizio Autonomo di Cardiologia, Ospedale di Matera, Italy
p Divisione di Cardiologia, Policlinico di Bari, Italy
q Divisione di Cardiologia, Ospedale Civile, Vigevano, Italy

revised August 20, 2000; accepted August 23, 2000

Abstract

Aims Patients with atrial flutter are believed to be at lower risk of thromboembolism than patients with atrial fibrillation. However, the incidence of atrial thrombi and the need for anticoagulation in patients with atrial flutter is not well established.

Methods and Results A prospective observational multicentre study was undertaken to assess the frequency of atrial thrombi and spontaneous echocontrast and the prevalence for aortic complex atherosclerotic lesions in a cohort of unselected patients with atrial flutter. We evaluated 134 patients (102 male, aged 70±9 years); exclusion criteria were history of atrial fibrillation, rheumatic mitral valve disease and mitral mechanical prosthesis. The median of atrial flutter duration was 33 days. Twelve patients had been taking warfarin for more than 7 days. One hundred and twenty-four patients (94%) underwent a transoesophageal echocardiogram, which revealed left atrial appendage thrombi in two patients (1·6%) and right atrial thrombi in one patient (1%). At least moderate left atrial echocontrast was found in 16/124 patients (13%). Complex atherosclerotic aortic plaques were detected in 10 patients (8%). Atrial flutter conversion was attempted in 93/134 patients (69%). At the 1-month follow-up, two patients experienced a thromboembolic event following restoration of sinus rhythm.

Conclusions Atrial thrombi and echocontrast, and complex aortic atherosclerotic plaques are relatively uncommon in patients with atrial flutter. Post-cardioversion embolism was observed in two patients in our study population.

Key Words: Atrial flutter, echocardiography, thromboembolism

f1 Correspondence: Dr Giovanni Corrado, Unità Operativa di Cardiologia, Ospedale Generale Valduce, Via Dante 11, 22100 Como, Italy.

References

  1. Wolf PA, Dawber TR, Thomas HE, Kannel WB. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: the Framingham Study. Neurol. 1978;28:973–977[Abstract/Free Full Text]
  2. Petersen P, Boysen G, Godtfredsen J, Anderson ED, Andersen B. Placebo-controlled, randomized trial of warfarin and aspirin for prevention of thromboembolic complications in chronic atrial fibrillation: the Copenhagen AFA-SAK study. Lancet. 1989;1:175–179[ISI][Medline]
  3. N Engl J Med. 1990;322:863–868[Abstract]
  4. N Engl J Med. 1990;323:1505–1511[Abstract]
  5. Arch Int Med. 1994;154:1449–1457[Abstract]
  6. Leung DYC, Black IW, Cranney GB, Hopkins AP, Walsh WF. Prognostic implication of left atrial spontaneous echo contrast in nonvalvular atrial fibrillation. J Am Coll Cardiol. 1994;24:755–762[Abstract]
  7. Jones EF, Calafiore P, McNeil JJ, Tonkin AM, Donnan GA. Atrial fibrillation with left atrial spontaneous contrast detected by transesophageal echocardiography is a potent risk factor for stroke. Am J Cardiol. 1996;78:425–429[CrossRef][ISI][Medline]
  8. Leung DY, Davidson PM, Cranney GB, Walsh WF. Thromboembolic risk of left atrial thrombus detected by transesophageal echocardiogram. Am J Cardiol. 1997;79:626–629[CrossRef][ISI][Medline]
  9. Zabalgoitia M, Halperin JL, Pearce LA, Blackshear JL, Asinger RW, Hart RG. Transesophageal echocardiographic correlates of clinical risk of thromboembolism in nonvalvular atrial fibrillation. J Am Coll Cardiol. 1998;31:1622–1626[Abstract/Free Full Text]
  10. Laupacis A, Albers G, Dalen J, Dunn MI, Jacobson AK, Singer DE. Antithrombotic therapy in atrial fibrillation. Chest. 1998;114:579S–589S[ISI][Medline]
  11. Arnold AZ, Mick MJ, Mazurek RP, Loop FD, Trohman RG. Role of prophylactic anticoagulation for direct current cardioversion in patients with atrial fibrillation or atrial flutter. J Am Coll Cardiol. 1992;19:851–855[Abstract]
  12. Santiago D, Warshofsky M, Li Mandri G. Left atrial appendage function and thrombus formation in atrial fibrillation-flutter: a transesophageal echocardiographic study. J Am Coll Cardiol. 1994;24:159–164[Abstract]
  13. Omran H, Jung W, Rabahieh R. Left atrial appendage function in patients with atrial flutter. Heart. 1997;78:250–254[Abstract/Free Full Text]
  14. Kinch JW, Davidoff R. Prevention of embolic events after cardioversion of atrial fibrillation: current and evolving strategies. Arch Intern Med. 1995;155:1353–1360[Abstract]
  15. Black IW, Hopkins AP, Lee LCL, Walsh WF. Thromboembolic risk of atrial flutter (Abstr). J Am Coll Cardiol. 1992;19:314A
  16. Bikkina M, Alpert MA, Mulekar M, Shakoor A, Massey CV, Covin A. Prevalence of intraatrial thrombus in patients with atrial flutter. Am J Cardiol. 1995;76:186–189[CrossRef][ISI][Medline]
  17. Irani WN, Grayburn PA, Afridi I. Prevalence of thrombus, spontaneous echocontrast, and atrial stunning in patients undergoing cardioversion of atrial flutter. A prospective study using transesophageal echocardiography. Circulation. 1997;95:962–966[Abstract/Free Full Text]
  18. Grimm RA, Tsui KL, Vaughn SE. TEE-guided early cardioversion of atrial flutter: results from the Acute Trial registry (Abstr). Circulation. 1997;96:I-25
  19. Mehta D, Ip JH, Mann N. Incidence of atrial thrombi in patients with first presentation of atrial flutter undergoing electrical cardioversion. A prospective study (Abstr). Circulation. 1997;96:I-453
  20. Seidl K, Hauer B, Schwick NG, Zellner D, Zahn R, Senges J. Risk of thromboembolic events in patients with atrial flutter. Am J Cardiol. 1998;82:580–583[CrossRef][ISI][Medline]
  21. Weiss R, Marcovitz P, Knight BP. Acute changes in spontaneous echocontrast and atrial function after cardioversion of persistent atrial flutter. Am J Cardiol. 1998;82:1052–1055[CrossRef][ISI][Medline]
  22. Pech P, Latour H, Grolleau R. Le Flutter et ses limites. Arch Mal Couer. 1970;63:114–116
  23. Waldo AL, McLean WAH, Karp RB, Kouchoukos NT, James TN. Entrainment and interruption of atrial flutter with atrial pacing: studies in man following open heart surgery. Circulation. 1977;56:737–745[Abstract/Free Full Text]
  24. Triulzi M, Gillam LD, Gentile F, Newell JB, Weyman AE. Normal adult cross sectional echocardiographic values: linear dimensions and chamber areas. Echocardiography. 1984;1:403–426[CrossRef]
  25. Loperfido F, Pennestrl F, Digaetano A. Assessment of left atrial dimensions by cross sectional echocardiography in patients with mitral valve disease. Br Heart J. 1983;50:570–578[Abstract/Free Full Text]
  26. Sahan DJ, DeMaria A, Kisslo J, Weyman A. Reccomendations regarding quantitation in M-Mode echocardiography: results of a survey of echocardiogtraphic masurements. Circulation. 1978;58:1072–1083[Abstract/Free Full Text]
  27. Helmcke F, Nanda NC, Hsiung MC. Color Doppler assessment of mitral regurgitation with orthogonal planes. Circulation. 1987;75:175–183[Abstract/Free Full Text]
  28. Seward JB, Khandheria BK, Oh JK, Freeman WK, Tajik AJ. Critical appraisal of transesophageal echocardiography: limitations, pitfalls, and complications. J Am Soc Echocardiogr. 1992;5:288–305[Medline]
  29. Orsinelli DA, Pearson AC. Usefulness of multiplane transesophageal echocardiography in differentiating left atrial appendage thrombus from pectinate muscles. Am Heart J. 1996;131:622–623[CrossRef][ISI][Medline]
  30. Castello R, Pearson AC, Labovitz AJ. Prevalence and clinical implications of atrial spontaneous contrast in patients undergoing transesophageal echocardiography. Am J Cardiol. 1990;65:1149–1153[CrossRef][ISI][Medline]
  31. Fatkin D, Kelly RP, Feneley MP. Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast and thromboembolic risk in vivo. J Am Coll Cardiol. 1994;23:961–969[Abstract]
  32. Errichetti A, Weyman AE. Cardiac tumors and masses. Weyman AE. Principles and practice of echocardiography, 2nd edn. Philadelphia: Lea & Febiger; 1994. p. 1169–1170
  33. Kronzon I, Tunick PA. Transesophageal echocardiography in thoracic aortic atherosclerosis. Echocardiography. 1996;13:233–245[ISI][Medline]
  34. Gilligan DM, Burch M, Fuller IA. High prevalence of left atrial thrombi in patients with typical atrial flutter and left ventricular systolic dysfunction (Abstr). J Am Coll Cardiol. 1998;33:117A
  35. Klein AL, Grimm RA, Black IW. Cardioversion guided by transesophageal echocardiography: the ACUTE pilot study. A randomized, controlled trial. Ann Intern Med. 1997;126:200–209[Abstract/Free Full Text]
  36. Fatkin D, Scalia G, Jacobs N. Accuracy of biplane transesophageal echocardiography in detecting left atrial thrombus. Am J Cardiol. 1996;77:321–324[CrossRef][ISI][Medline]
  37. Pollick C, Taylor D. Assessment of left atrial appendage function by transesophageal echocardiography. Implications for the development of thrombus. Circulation. 1991;84:223–231[Abstract/Free Full Text]
  38. Stoddard MF, Dawkins PR, Prince CR, Longaker RA. Transesophageal echocardiographic guidance of cardioversion in patients with atrial fibrillation. Am Heart J. 1995;129:1204–1215[CrossRef][ISI][Medline]
  39. Manning WJ, Silverman DI, Keighley CS, Oettgen P, Douglas PS. Transesophageal echocardiographically facilitated early 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]
  40. Corrado G, Tadeo G, Beretta S. Atrial thrombi resolution after prolonged anticoagulation in patients with atrial fibrillation. A transesophageal echocardiographic study. Chest. 1999;115:140–143[Abstract/Free Full Text]
  41. Pagadala P, Gummadi SS, Olshansky B. Thromboembolic risk of atrial flutter: is the risk underestimated? (Abstr). Circulation. 1994;90:I-398
  42. Lanzerotti CJ, Olshansky B. Thromboembolism in chronic atrial flutter: is the risk underestimated? J Am Coll Cardiol. 1997;30:1506–1511[Abstract]
  43. Mehta D, Baruch L. Thromboembolism following cardioversion of "common" atrial flutter. Risk factors and limitations of transesophageal echocardiography. Chest. 1996;110:1001–1003[Abstract/Free Full Text]
  44. Black IW, Fatkin D, Sagar KB. Exclusion of atrial thrombus by transesophageal echocardiography does not preclude embolism after cardioversion of atrial fibrillation. A multicenter study. Circulation. 1994;89:2509–2513[Abstract/Free Full Text]
  45. Grimm RA, Stewart WJ, Maloney JD. Impact of electrical cardioversion of atrial fibrillation on left atrial appendage function and spontaneous echo contrast: characterization by simultaneous transesophageal echocardiography. J Am Coll Cardiol. 1993;22:1359–1366[Abstract]
  46. Fatkin D, Kuchar DL, Thorburn CW, Feneley MP. Transesophageal echocardiography before and during direct current cardioversion of atrial fibrillation: evidence for "atrial stunning" as a mechanism of thromboembolic complications. J Am Coll Cardiol. 1994;23:307–316[Abstract]
  47. Grimm RA, Leung DY, Black IW, Stewart WJ, Thomas JD, Klein AL. Left atrial appendage "stunning" after spontaneous conversion of atrial fibrillation demonstrated by transesophageal Doppler echocardiography. Am Heart J. 1995;130:174–176[CrossRef][ISI][Medline]
  48. Jordanes L, Germonprè E, Vandenbogaerde J. Atrial stunning lasts more than one week after cardioversion of atrial flutter (Abstr). J Am Coll Cardiol. 1991;17:325A
  49. Grimm RA, Stewart WJ, Arheart KL, Thomas JD, Klein AL. Left atrial appendage "stunning" after electrical cardioversion: an attenuated response compared with atrial fibrillation as the mechanism for lower susceptibility to thromboembolic events. J Am Coll Cardiol. 1997;29:582–589[Abstract]
  50. Sparks PB, Jayaprakash S, Vohra JK. Left atrial "stunning" following radiofrequency catheter ablation of chronic atrial flutter. J Am Coll Cardiol. 1998;32:468–475[Abstract/Free Full Text]
  51. Kontos MC, Paulsen WH. Impairment of left atrial appendage function after spontaneous conversion of atrial flutter. Clin Cardiol. 1988;21:769–771
  52. Tunick PA, McElhinney L, Mitchell T, Kronzon I. The alternation between atrial flutter and atrial fibrillation. Chest. 1992;101:34–36[Abstract/Free Full Text]

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