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1 From the Hunter Holmes McGuire Veterans Affairs Medical Center, Medical College of Virginia/Virginia Commonwealth University, Richmond
Background: A high incidence of embolic phenomena is associated with atrial fibrillation (AF) and the left atrial appendage (LAA) is frequently the source of the emboli. Thrombus formation may be due to stasis within the fibrillating and inadequately emptying LAA. Because LAA emptying in AF may be the result of mechanical compression by the adjacent left ventricle, it is possible that left ventricular diastolic filling duration will importantly influence passive emptying of the LAA. We hypothesized that the magnitude of emptying of the LAA in AF is related to the duration of left ventricular diastolic filling which is determined by the ventricular response rate in AF.
Objective: The objective of our study was to determine the relationship of ventricular response rate in AF to LAA emptying and to assess the influence of sinus rhythm and heart rate on LAA emptying immediately after direct current cardioversion to sinus rhythm.
Methods: To study this, we used transesophageal echocardiography to measure LAA ejection fraction ([LAAmax-LAAmin]/LAAmaxx100%) and evaluated its relationship to left ventricular response rate (VRR) in 26 patients with AF (mean age, 65±7 [1 SD] years).
Results: There was a strong inverse relationship between LAA ejection fraction and VRR in AF (r= 
0.73; p<0.001). LAA ejection fraction during AF was 26±10%, and immediately after successful cardioversion, it increased to 46±12% (p<0.001). However, during sinus rhythm there was no relationship between LAA ejection fraction and VRR (r=0.06; p=NS) in the subgroup of patients who were successfully converted to sinus rhythm. There were poor relationships between LAA ejection fraction and peak transmitral flow velocity (r=0.41; p=NS) or pulmonary venous flow velocity (r=0.03; p=NS) in AF.
Conclusion: These results indicate that the magnitude of LAA emptying in AF is strongly and inversely influenced by ventricular rate. Direct current cardioversion to sinus rhythm is associated with an increase in the magnitude of LAA emptying that is not influenced by heart rate. The magnitude of LAA emptying may be an important factor in the formation of thromboemboli in AF. The extent to which controlling the VRR in chronic AF will prevent stasis and LAA thrombus formation remains to be determined.
Key Words: atrial fibrillation • cardioversion • left atrial appendage • left atrium • thrombus
Submitted on April 5, 1994
Accepted on May 26, 2007
This article has been cited by other articles:
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  O A Obel, L Luddington, N Maarouf, K Aytemir, C Ekwall, M Malik, and A J Camm Effects of ventricular rate and regularity on the velocity and magnitude of left atrial appendage flow in atrial fibrillation Heart, June 1, 2005; 91(6): 764 - 768. [Abstract] [Full Text] [PDF]
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 J. L. Halperin and M. Gomberg-Maitland Obliteration of the leftatrial appendage forprevention of thromboembolism J. Am. Coll. Cardiol., October 1, 2003; 42(7): 1259 - 1261. [Full Text] [PDF]
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Y. Agmon, B. K. Khandheria, F. Gentile, and J. B. Seward Echocardiographic assessment of the left atrial appendage J. Am. Coll. Cardiol., December 1, 1999; 34(7): 1867 - 1877. [Abstract] [Full Text] [PDF]
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N M Al-Saady, O A Obel, and A J Camm Left atrial appendage: structure, function, and role in thromboembolism Heart, November 1, 1999; 82(5): 547 - 554. [Abstract] [Full Text]
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