Assessment of left atrial appendage wall velocities by transesophageal tissue Doppler echocardiography: a clinical study in patients with sinus rhythm.

To assess left atrial appendage (LAA) wall velocities, 42 patients in sinus rhythm underwent tissue Doppler interrogation during a clinically indicated transesophageal echocardiography. Color Doppler (B-mode and M-mode) and pulsed Doppler of LAA walls were obtained and analyzed in all patients. Color-coded tissue Doppler rendered a qualitative assessment of LAA wall, depicting both the timing and the sequence of LAA contraction. With pulsed Doppler interrogation, a triphasic signal was recorded in all patients, consisting of a positive wave (D1), followed by a biphasic wave (positive D2 and negative D3). Peak velocities of D1, D2, and D3 were 6.1 +/- 2, 20.1 +/- 7, and 16.1 +/- 5 cm/s, respectively. Mean coefficient of variation of LAA wall velocities was 6%, significantly lower than that of LAA percentage area change (29%). Compared with patients with abnormal relaxation, patients with normal mitral inflow had higher D1 peak velocities (7.3 +/- 1.2 vs 4.3 +/- 1 cm/s, respectively; P <.0001). Time sequence of ECG, LAA flow, and mitral inflow indicates that D1 component of LAA wall occurs in early diastole and is likely due to the upward movement of the mitral ring toward the base of the LAA wall. In conclusion, evaluation of LAA wall using tissue Doppler is feasible and reproducible. Although color tissue Doppler analysis allows a qualitative assessment, pulsed Doppler gives new quantitative insights for the comprehensive assessment of LAA wall dynamics, which complements the information obtained with flow interrogation.

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

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; chi(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; chi(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.