Atrial fibrillation echocardiography or ultrasound

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Atrial fibrillation

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] Anahita Deylamsalehi, M.D.[3]

Overview

Performing an echocardiogram in the setting of atrial fibrillation is essential to identify certain characteristics of the heart, including valvular heart disease, hypertrophy, presence of thrombus, the size and function of the left ventricle, the size of the atria, and the possible presence of pericardial disease.

Echocardiography

Echocardiography is essential to identify the following characteristics in the setting of atrial fibrillation:

• Valvular heart disease
• Left and right atrial size
• Left ventricle (LV) size and function
• Peak right ventricle pressure (pulmonary hypertension)
• Left ventricular hypertrophy
• Left atrium thrombus (low sensitivity)
• Pericardial disease

Transesophageal Echocardiography (TEE)

• A normal echocardiography (transthoracic or TTE) has a low sensitivity for identifying thrombi (blood clots) in the heart. If atrial fibrillation is suspected and urgent electrical cardioversion is planned a transesophageal echocardiogram (TEE) is preferred.

• The TEE has much better visualization of the left atrial appendage than transthoracic echocardiography. This structure, located in the left atrium, is the place where thrombus most commonly is formed in the setting of atrial fibrillation or atrial flutter. TEE has a very high sensitivity for locating thrombus in this area and can also detect sluggish blood flow in this area that is suggestive of thrombus formation.

• If no thrombus is seen on TEE, the incidence of stroke immediately after cardioversion is very low.
• The following are indications of transesophageal echocardiography (TEE) in atrial fibrillation patients, based on NICE guideline:
  • When an abnormal condition, such as valvular heart disease has been detected on transthoracic echocardiography and further investigation is required
  • When performing transthoracic echocardiography is not possible or when the findings of it is not absolutely clear
  • When TOE-guided cardioversion is considered

Transthoracic Echocardiography (TTE)

• A transthoracic echocardiogram is generally performed in newly diagnosed atrial fibrillation (AF), as well as if there is a major change in patient's clinical state. This ultrasound-based scan of the heart may help identify valvular heart disease (which may increase the risk of stroke), left and right atrial size (which indicates likelihood of atrial fibrillation changing into the permanent type), left ventricular size and dysfunction, peak right ventricular pressure (pulmonary hypertension), presence of left ventricular hypertrophy and pericardial disease.
• Significant enlargement of both the left and right atria is associated with long-standing atrial fibrillation and, if noted at the initial presentation of atrial fibrillation, suggests that the atrial fibrillation is likely of a longer duration than the individual's symptoms.
• Indications of transthoracic echocardiogram in atrial fibrillation patients, based on NICE guideline:
  • As a baseline echocardiogram for prolonged management
  • If treatment strategies such as cardioversion (both electrical and pharmacological) has been considered
  • When conditions such as structural heart disease or functional heart disease (which may present with heart failure or heart murmur is suspected
  • When clarification of clinical risk stratification is required for antithrombotic therapy