Echocardiography guided management of atrial fibrillation

Figures

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  Fig. 1. Measurement of both the left atrial volume indexed to body surface area and left atrial ejection fraction 4 h after a successful cardioversion. The end-systolic volume in the apical four-chamber view (91 mL, left upper panel) is averaged with the end-systolic volume in the apical two-chamber view (90 mL, right upper panel) and divided by the body surface area of 2 m2 to produce an indexed left atrial volume of 45 mL/m2. Left atrial volumes at end-diastole (66 mL in the apical four chamber view, left lower panel; 71 mL in the apical two chamber view, right lower panel) allow computing a left atrial emptying fraction of 24%

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  Fig. 2. Suggested algorithm for management of NOAF or AF of unknown duration, based on available intensive care medicine and cardiology data. Current evidence prefers a rhythm control for all with non-dilated LA (i.e. LAVI < 40 ml/m2). Further steps may be facilitated according to more detailed evaluation of pre and post cardioversion parameters gathered in Table 1. Indicated lists in the boxes on pharmacotherapy start with the most preferred agents. *At the initial phase in the ICU, the short-acting beta-blockers like landiolol or esmolol are recommended. **Vernakalant may be a primary treatment if available. Abbreviations: TTE transthoracic echocardiography, TOE trans-oesophageal echocardiography, AVP arginine vasopressin, LVEF left ventricular ejection fraction, AS aortic stenosis, MR mitral regurgitation, LAVI indexed end-systolic left atrial volume, HR heart rate, SR sinus rhythm, DC direct current, LA_EF left atrial emptying fraction, Avti velocity–time integral of mitral A wave

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  Fig. 3. Mitral Doppler pattern recorded 1 h after cardioversion (left panel) depicting a grade I left ventricular diastolic dysfunction with an E wave maximal velocity of 0.68 m/s, an E wave deceleration time of 302 ms, and an A wave maximal velocity of 0.92 m/s. Mean A wave velocity–time integral (middle panel) is 9 cm and indicates an increased contribution of LA contraction to LV filling. The right panel shows the mitral Doppler profile recorded in another patient with sinus tachycardia, resulting in partial fusion of the E and A waves. In this patient, A wave velocity–time integral reaches 10.3 cm using the trapezoid method (see also Fig. 2 ESM)

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  Fig. 4. Haemodynamic parameters recorded at the onset of arrhythmia, at 1 h after cardioversion, and at 4 h after cardioversion in 187 patients with septic shock and associated AF [25]. The standardised values of each parameter were obtained by subtracting the mean value at the onset from each value of that parameter (at arrhythmia onset, 1 h and 4 h after cardioversion) and dividing by the standard deviation at the onset of that parameter (median, IQR, p-values for differences at 1 h vs arrhythmia, linear mixed effect model). Abbreviations: HR heart rate, MAP mean arterial pressure, SV stroke volume, CO cardiac output, PAPs pulmonary artery systolic pressure, NAD dosage of norepinephrine