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ECG and Atrial Appendage Doppler Discordance Is Common in Patients Undergoing Cardiac Surgery: Prospective Study
Akiva Nachshon1, Qizhe Cai2,3, Jason D Matos2
1Department of Anesthesia, Harvard Medical School, Boston, Massachusetts, USA.
Insights
A significant number of cardiac surgery patients without a history of atrial fibrillation (AF) exhibit discordance between ECG and atrial appendage rhythms. This discordance may increase thromboembolism risk in non-anticoagulated patients.
Area of Science:
- Cardiology
- Cardiac Surgery
- Electrophysiology
Background:
- Patients with atrial fibrillation (AF) face elevated thromboembolism risk, even with apparent sinus rhythm, due to potential asymptomatic AF episodes.
- Atrial mechanical discordance, where the left atrium (LA) is in sinus rhythm and the left atrial appendage (LAA) is in AF, may contribute to this risk.
Purpose of the Study:
- To determine the frequency of discordance between electrocardiogram (ECG) rhythm and LAA/right atrial appendage (RAA) Doppler ejection phenotype (transesophageal echocardiography [TEE]).
- To assess this discordance in patients undergoing cardiac surgery.
Main Methods:
- 124 patients undergoing coronary artery bypass graft (CABG) or valve surgery were prospectively studied.
- Intraoperative ECG and TEE were performed before cardiopulmonary bypass.
- ECG and TEE LAA/RAA Doppler spectra were independently classified as sinus rhythm or AF.
Main Results:
- Of 107 patients without a prior AF history, 39 (36%) showed ECG/atrial appendage Doppler discordance.
- Specifically, 12% had ECG/LAA discordance and 33% had ECG/RAA discordance.
- No significant differences in age, gender, or comorbidities were found between concordant and discordant groups.
Conclusions:
- A substantial minority of cardiac surgery patients without a history of AF exhibit ECG/atrial appendage Doppler discordance.
- This discordance may heighten the risk of thromboembolism in patients not on anticoagulation.
- Clinical parameters do not reliably identify patients at increased risk for this discordance.
Background:
Patients with atrial fibrillation (AF) remain at increased risk of thromboembolism despite apparent maintenance of sinus rhythm with the cause often attributed to periods of asymptomatic AF. Atrial mechanical discordance, with the body of the left atrium (LA) in sinus rhythm and the left atrial appendage (LAA) in AF may also be a contributor.
Objectives:
The purpose of this study was to assess the frequency of electrocardiogram (ECG) rhythm and LAA and/right atrial appendage (RAA) Doppler ejection phenotype (transesophageal echocardiography [TEE]) discordance in patients undergoing cardiac surgery.
Methods:
A total of 124 patients undergoing coronary artery bypass graft (CABG), CABG and valve surgery, or isolated valve repair or replacement (valve ± CABG) were prospectively studied. Intraoperative surface ECG rhythm strip and TEE were performed before cardiopulmonary bypass. The ECG and TEE LAA/RAA Doppler spectrum were independently classified as sinus or AF.
Results:
Of 107 patients (age 65 ± 12 years; 31% female; 65% CABG, 31% valve ± CABG) without a history of AF, 39 (36%) had ECG and LAA and/or RAA discordance (ECG/LAA Doppler discordance, n = 12 [11%]; ECG/RAA Doppler discordance, n = 35 [33%]). There was no significant difference between concordant and discordant groups with regard to age, gender, history of hypertension, diabetes, heart failure, or stroke (all P > 0.05).
Conclusions:
A large minority of patients without a history of AF undergoing cardiac surgery have ECG/atrial appendage Doppler discordance, a setting that may promote thromboembolism in non-anticoagulated patients. Clinical parameters do not identify patients at increased risk for discordance.
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