© 2015, Wiley Periodicals, Inc. DOI: 10.1111/echo.12956
Echocardiography
Isolated Left Atrial Mechanical Standstill after Catheter Ablation of Atrial Fibrillation Edmund Kenneth Kerut, M.D.,* James McKinnie, M.D.,† and Curtis Hanawalt, R.D.C.S.† *Heart Clinic of Louisiana, Marrero, Louisiana; and †West Jefferson Medical Center, Marrero, Louisiana
(Echocardiography 2015;32:1311–1313) Key words: Doppler, tissue, echo, standstill, P-wave, catheter, ablation A 84-year-old male practicing physician with exertional shortness of breath and chronic atrial fibrillation (AF) underwent catheter mapping and radiofrequency (RF) energy ablation of the left atrium (LA). The procedure involved isolation of the pulmonary veins at the antrum using RF energy. Also, a roof line and infero-posterior line were created to isolate the posterior wall of the LA. The coronary sinus and left atrial appendage were RF-ablated, and then, external synchronized cardioversion restored normal sinus rhythm (NSR). Postoperatively, the patient’s electrocardiogram (ECG) remained NSR (Fig. 1).
History included that of placement of a dual chamber pacemaker years prior for tachy-brady syndrome. Follow-up ECGs and transthoracic echocardiograms (TTE) were performed after the procedure and 4 months later. Each ECG revealed NSR. Both postoperative TTEs were unchanged in that LA mechanical function was not detectable, but right atrial (RA) mechanical function was intact. Mitral Doppler inflow (Fig. 2) failed to demonstrate late diastolic filling (A-wave), and mitral annulus (lateral, septal) tissue Doppler showed no late diastolic velocity (a0 ) (Fig. 3).
Figure 1. Electrocardiogram obtained 4 months after surgery. The patient’s rhythm is NSR with ventricular paced beats tracking P-waves (arrow). Address for correspondence and reprint requests: Edmund Kenneth Kerut, M.D., Heart Clinic of Louisiana, 1111 Medical Center Blvd, Suite N613, Marrero, LA 70072. Fax: +504-349-6621; E-mail: [email protected]
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Figure 2. Mitral pulsed-wave Doppler inflow demonstrates an early diastolic E-wave (arrow), but no late diastolic A-wave.
A
B
Figure 3. Mitral annulus tissue Doppler demonstrates an early diastolic velocity (e0 )(arrows), but no late diastolic velocity (a0 ) is found. These images are from the A. lateral mitral annulus and B. medial mitral annulus.
In contrast, however, an A-wave was noted with tricuspid Doppler inflow, and the lateral tricuspid annulus demonstrated an a0 -wave (Fig. 4). 1312
Figure 4. Lateral tricuspid annulus tissue Doppler demonstrates both an early diastolic velocity (e0 ) (arrow) and late diastolic velocity (a0 ) (vertical arrow).
These Doppler findings are consistent with preserved RA but lack of LA mechanical contraction (LA standstill). The mechanism for this finding may be a result of electrical disarticulation of the LA from the RA. Presumptively, the P-waves noted on the surface ECG are from within the RA only (no electrical activity within the LA).1 We have previously reported similar Doppler findings in a patient who had undergone a biatrial surgical CryoMaze procedure. There are several reports of LA mechanical standstill occurring as a consequence of the surgical MAZE procedure.1,2 However, reports of a surgical-based AF ablation with LA mechanical standstill isolated from a mechanically functional RA are rare.1 This case is that of a catheter-based AF ablation procedure with the development of LA mechanical standstill and preserved RA function. We have found only two other reports such as this. One involves a case with severe mitral stenosis3 and another that of a patient that had undergone two catheter ablation procedures for AF (pulmonary vein isolation, linear ablation, and ablation of fractionated LA electrograms).4 How prevalent loss of LA mechanical function is in patients with a surgical or catheter based AF ablation is unknown. Clinical ramifications of this finding are not well described. However, when LA mechanical standstill has been found, our group has recommended lifelong chronic anticoagulation. In addition, it appears that a “stiff left atrium syndrome” may develop, manifested as progressive exertional dyspnea and evidence of pulmonary hypertension.2 In fact, our patient previously reported to manifest these Doppler findings,1 1 year later did subsequently develop progressive exertional dyspnea and pulmonary hypertension. When performing a post-LA ablative procedure, either surgical or catheter based, one
Doppler of Isolated Left Atrial Standstill
should particularly evaluate both RA and LA mechanical functions, as a P-wave noted by surface ECG may not be indicative of both RA and LA contractile function. References 1. Kerut EK, McKinnie J, Reilly JP, et al: Doppler evidence of persistent left atrial mechanical standstill with normal P-waves by electrocardiogram after biatrial CryoMaze procedure for atrial fibrillation. Echocardiography 2011;28: 686–693.
2. Welch TD, Coylewright M, Powell BD, et al: Symptomatic pulmonary hypertension with giant left atrial v waves after surgical maze procedures: evaluation by comprehensive hemodynamic catheterization. Heart Rhythm 2013;10: 1839–1842. 3. Shaw TR, Northridge DB, Francis CM: Left atrial standstill in a patient with mitral stenosis and sinus rhythm: a risk of thrombus hidden by left and right atrial electrical dissociation. Heart 2003;89:1173. 4. Duncan E, Schilling RJ, Earley M: Isolated left atrial standstill identified during catheter ablation. Pacing Clin Electrophysiol 2010;11:1–5.
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Echocardiography
Isolated Left Atrial Mechanical Standstill after Catheter Ablation of Atrial Fibrillation Edmund Kenneth Kerut, M.D.,* James McKinnie, M.D.,† and Curtis Hanawalt, R.D.C.S.† *Heart Clinic of Louisiana, Marrero, Louisiana; and †West Jefferson Medical Center, Marrero, Louisiana
(Echocardiography 2015;32:1311–1313) Key words: Doppler, tissue, echo, standstill, P-wave, catheter, ablation A 84-year-old male practicing physician with exertional shortness of breath and chronic atrial fibrillation (AF) underwent catheter mapping and radiofrequency (RF) energy ablation of the left atrium (LA). The procedure involved isolation of the pulmonary veins at the antrum using RF energy. Also, a roof line and infero-posterior line were created to isolate the posterior wall of the LA. The coronary sinus and left atrial appendage were RF-ablated, and then, external synchronized cardioversion restored normal sinus rhythm (NSR). Postoperatively, the patient’s electrocardiogram (ECG) remained NSR (Fig. 1).
History included that of placement of a dual chamber pacemaker years prior for tachy-brady syndrome. Follow-up ECGs and transthoracic echocardiograms (TTE) were performed after the procedure and 4 months later. Each ECG revealed NSR. Both postoperative TTEs were unchanged in that LA mechanical function was not detectable, but right atrial (RA) mechanical function was intact. Mitral Doppler inflow (Fig. 2) failed to demonstrate late diastolic filling (A-wave), and mitral annulus (lateral, septal) tissue Doppler showed no late diastolic velocity (a0 ) (Fig. 3).
Figure 1. Electrocardiogram obtained 4 months after surgery. The patient’s rhythm is NSR with ventricular paced beats tracking P-waves (arrow). Address for correspondence and reprint requests: Edmund Kenneth Kerut, M.D., Heart Clinic of Louisiana, 1111 Medical Center Blvd, Suite N613, Marrero, LA 70072. Fax: +504-349-6621; E-mail: [email protected]
1311
Kerut, et al.
Figure 2. Mitral pulsed-wave Doppler inflow demonstrates an early diastolic E-wave (arrow), but no late diastolic A-wave.
A
B
Figure 3. Mitral annulus tissue Doppler demonstrates an early diastolic velocity (e0 )(arrows), but no late diastolic velocity (a0 ) is found. These images are from the A. lateral mitral annulus and B. medial mitral annulus.
In contrast, however, an A-wave was noted with tricuspid Doppler inflow, and the lateral tricuspid annulus demonstrated an a0 -wave (Fig. 4). 1312
Figure 4. Lateral tricuspid annulus tissue Doppler demonstrates both an early diastolic velocity (e0 ) (arrow) and late diastolic velocity (a0 ) (vertical arrow).
These Doppler findings are consistent with preserved RA but lack of LA mechanical contraction (LA standstill). The mechanism for this finding may be a result of electrical disarticulation of the LA from the RA. Presumptively, the P-waves noted on the surface ECG are from within the RA only (no electrical activity within the LA).1 We have previously reported similar Doppler findings in a patient who had undergone a biatrial surgical CryoMaze procedure. There are several reports of LA mechanical standstill occurring as a consequence of the surgical MAZE procedure.1,2 However, reports of a surgical-based AF ablation with LA mechanical standstill isolated from a mechanically functional RA are rare.1 This case is that of a catheter-based AF ablation procedure with the development of LA mechanical standstill and preserved RA function. We have found only two other reports such as this. One involves a case with severe mitral stenosis3 and another that of a patient that had undergone two catheter ablation procedures for AF (pulmonary vein isolation, linear ablation, and ablation of fractionated LA electrograms).4 How prevalent loss of LA mechanical function is in patients with a surgical or catheter based AF ablation is unknown. Clinical ramifications of this finding are not well described. However, when LA mechanical standstill has been found, our group has recommended lifelong chronic anticoagulation. In addition, it appears that a “stiff left atrium syndrome” may develop, manifested as progressive exertional dyspnea and evidence of pulmonary hypertension.2 In fact, our patient previously reported to manifest these Doppler findings,1 1 year later did subsequently develop progressive exertional dyspnea and pulmonary hypertension. When performing a post-LA ablative procedure, either surgical or catheter based, one
Doppler of Isolated Left Atrial Standstill
should particularly evaluate both RA and LA mechanical functions, as a P-wave noted by surface ECG may not be indicative of both RA and LA contractile function. References 1. Kerut EK, McKinnie J, Reilly JP, et al: Doppler evidence of persistent left atrial mechanical standstill with normal P-waves by electrocardiogram after biatrial CryoMaze procedure for atrial fibrillation. Echocardiography 2011;28: 686–693.
2. Welch TD, Coylewright M, Powell BD, et al: Symptomatic pulmonary hypertension with giant left atrial v waves after surgical maze procedures: evaluation by comprehensive hemodynamic catheterization. Heart Rhythm 2013;10: 1839–1842. 3. Shaw TR, Northridge DB, Francis CM: Left atrial standstill in a patient with mitral stenosis and sinus rhythm: a risk of thrombus hidden by left and right atrial electrical dissociation. Heart 2003;89:1173. 4. Duncan E, Schilling RJ, Earley M: Isolated left atrial standstill identified during catheter ablation. Pacing Clin Electrophysiol 2010;11:1–5.
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