Citations

Mechanical cardiac alternans is usually associated with left ventricular dysfunction. Atrial alternans has been described on invasive assessment of atrial action potentials, however cannot be detected clinically. Herein we report a patient who had transthyretin type cardiac amyloidosis with prior history of recurrent atrial fibrillation requiring ablations as well as ablation for atrial flutter and a recent history of cardioversion for atrial flutter. The patient presented with diastolic heart failure and recurrent atrial flutter and was referred for a TEE guided cardioversion. Mechanical left and right atrial alternans was seen on Doppler interrogation of both atrial appendages with velocities corresponding to the flutter P wave on the ultrasound ECG monitor. The patient was successfully cardioverted with the TEE probe in situ. Post cardioversion TEE showed resumption of normal albeit reduced mechanical atrial function in the left atrium and preserved right atrial function in tissue Doppler imaging. Our case demonstrates the mechanical phenomenon of atrial alternans in both atria on TEE with disappearance of atrial alternans during sinus rhythm suggesting rate related atrial alternans likely related to atrial stiffness from amyloid infiltration and as well as possibly scar formation from prior ablations.

AbstractWe present a case of a 60‐year‐old male who was found to be in atrial fibrillation during routine evaluation. Anticoagulation was initiated for 36 h and he was referred for TEE‐guided electrical cardioversion. There was no thrombus identified in the left atrial appendage, however, the appendage was large and had a tongue‐like accessory lobe along with spontaneous contrast in the left atrium and its appendage. TEE probe was not withdrawn, patient underwent successful cardioversion with 200 joules and developed a marked increase in left atrial and left atrial appendage spontaneous contrast along with the development of tear drop shaped thrombus in the left atrial appendage immediately after cardioversion, which rapidly became more dense. There was an associated marked decrease in appendage velocities. Patient was hospitalized to initiate low molecular weight heparin. This case highlights the need for vigilance in patients with an unknown duration of atrial fibrillation, who have received a short duration of anticoagulant therapy and who have adverse appendage anatomy as thrombus may develop immediately after cardioversion despite anticoagulation.

We present a case of a 60 year old male who found to be in atrial fibrillation during routine evaluation. Anticoagulation was initiated for 36 hours and he was referred for TEE guided electrical cardioversion. There was no thrombus identified in the left atrial appendage, however the appendage was large and had a tongue like accessory lobe along with spontanous contrast on the left atrium and its appendage. TEE probe was not withdrawn, patient underwent successful cardioversion with 200 joules and developed a thrombus in the left atrial appendage immediately after cardioversion, which rapidly became more dense. There was an associated marked decrease in appendage velocities. Patient was hospitalized to initiate low molecular weight heparin. This case highlights the need for vigilance in patients with unknown duration of atrial fibrillation, who have received a short duration of anticoagulant therapy and who have adverse appendage anatomy as thrombus may develop immediately after cardioversion despite anticoagulation.