NAO, ecocardiografia e timing della cardioversione elettrica nella fibrillazione atriale Paolo Colonna MD FESC Cardiologia, Policlinico di Bari Presidente nazionale SIEC DOI: Research fundings (Institutional) from Bayer, Boehringer, BMS / Pfizer, Daiichi
2010 + revision 2012
NAO, ecocardiografia della cardioversione elettrica nella fibrillazione atriale 1. Indicazione alla cardioversione (sì / no) 2. Indicazione ai farmaci da utilizzare 3. Cardioversione guidata con eco TE 4. Indicazioni terapia anticoagulante (insieme a criteri clinici) Diagnosi eziologica Funzione VS Dimensioni / stato AS Funzione auricola sinistra Altre fonti emboligene
AF embolic risk stratification: From CHADS2 (2001) to CHA2DS2VASc (2010) to modified CHA2DS2VASc (2016)
Naif: NOAC in preferenza (Ia) Exper: cambiare? quando? LG ESC 2016 No more woman risk factor
TTE is recommended in all AF patients to guide treatment decisions. Class I, LOE C TTE should be used to identify structural disease (e.g. valvular disease) and assess LV size and function (systolic and diastolic), atrial size, and right heart function.
TOE is useful to further assess valvular heart disease and to exclude intracardiac thrombi, especially in the LAA, to facilitate early cardioversion or catheter ablation. Delayed-enhancement MRI of the left atrium using gadolinium contrast, T1 mapping using cardiac MRI, and intracardiac echo may help to guide treatment decisions in AF, but require external validation in multicentre studies
Disfunzione VSin da FA 63 aa, iperteso, FA da 48 ore (150/min) con disfunzione VS (FE 38%) e Extra Ventr coronarie: ateromasia diffusa senza stenosi significative Carvedilolo 6.25 bid + digossina 0,125mg fvm da 150 a 90/min e FE da 38 a 45%; Warfarin + cardioversione tra 4 sett
Scarso controllo con warfarin Dopo 4 settimane di warfarin con scarso controllo PT-INR (2 valori sotto 2) TEE
Come alternativa alle 3 sett di TAO, la cardioversione guidata dal TEE è raccomandata per escludere trombi in AS o auricola sin. Classe I, LOE B
Cosa fare? A. Subito cardioversione (no trombi, solo SEC denso) B. Ritarda cardioversione (warfarin non in range) C. Lasciare pz in FA definitivam + warfarin (disfunzione VS persistente) D. Risonanza o ecocontrasto
Stroke / embolism at 30 days D110 mg D150 mg Warfarin D110 mg D150 mg Warfarin Analysis of pts undergoing cardioversion (in ReLY trial) Nagarakanti, Circ 2011 10 9 8 7 6 5 4 3 2 1 0 TOE prior cardioversion p = n.s. NO TOE prior cardioversion
Rationale and design of the X-Vert trial in pts scheduled for cardioversion
X-VeRT: primary efficacy endpoints Cappato R Eur Heart J 2014 Rivaroxaban VKA (N=978) (N=492) % n* % n* Primary efficacy endpoint 0.51 5 1.02 5 Stroke 0.20 2 0.41 2 Haemorrhagic stroke 0.20 2 0 Ischaemic stroke 0 0.41 2 TIA 0 0 Non-CNS SE 0 0.20 1 MI 0.10 1 0.20 1 Cardiovascular death 0.41 4 0.41 2 Risk ratio (95% CI) 0.50 (0.15 1.73)
X-VeRT: primary safety endpoints Cappato R Eur Heart J 2014 Rivaroxaban VKA (N=988) (N=499) % n* % n* Risk ratio (95% CI) Major bleeding 0.61 6 0.80 4 0.76 (0.21 2.67) Fatal 0.1 1 0.4 2 Critical-site bleeding 0.2 2 0.6 3 Intracranial haemorrhage 0.2 2 0.2 1 Hb decrease 2 g/dl 0.4 4 0.2 1 Transfusion of 2 units of packed RBCs or whole blood 0.3 3 0.2 1
Days Patients (%) X-VeRT: time to cardioversion by cardioversion strategy Cappato R Eur Heart J 2014 100 80 60 Median time to cardioversion Rivaroxaban VKA p=0.628 p<0.001 Patients cardioverted as scheduled* p<0.001 1 patient with inadequate anticoagulation 40 20 22 days 30 days 95 patients with inadequate anticoagulation 0 Early Delayed Delayed cardioversion
1016 pts 188 pts Gotte et al EnsureAF Lancet 2016
Cardioversione ritardata Per INR instabile passaggio a dabigatran 150 mg 2 cp/die + nuovo TEE
TEE dopo dabigatran Sludge in Au Sin, pre-terapia
TEE dopo dabigatran
Cardioversione efficace (100 j); Carvedilolo 6.25 bid, ramipril 5, amiodarone 5d/w, dabigatran 150 bid; Dopo 15 gg, quasi completo recupero della funzione VS (FE 55%)
Echocardiography in atrial fib: information for clinical decisions EAE recommendations, EJE 10 Thrombi Spontaneous echocontrast LA appendage velocities Atrio auricular function LV function and thrombi Patent foramen ovale Only with TOE Complex aortic plaques
Left atrial appendage dysfunction
Evaluation of left atrial appendage function and thrombi in patients with AF: from transthoracic to real time 3D TEE Dentamaro, Colonna P. J CV Imag 2017
Resolution of giant left atrial appendage thrombus with rivaroxaban Hammerstingl, Thrombosis and Haemost 13 Rivaroxaban 4 weeks 6 weeks No AC baseline
Percentage of patients (95% CI) LA thrombus resolution in AF or A Flutter: prospective study with rivaroxaban (X-TRA) Lip G et al, AmHeartJ 16 (46.0 73.6) (28.1 55.9)
Cardiovascular death in AF pts with or without TEE abnormalities Down, JASE 2005. left atrial / appendage thrombus (LAT) left atrial spontaneous EchoContrast (LASEC)
Prevalence and clinical impact of LA thrombi /echocontrast in AF and low (0-1) CHADS2 score Kleeman et al. EJE 08
NAO, ecocardiografia della cardioversione elettrica nella fibrillazione atriale Eco TE: nessun rischio o incertezza nel... Conoscere meglio anatomia e funzione dell auricola sinistra (max con NAO) Accorciare i tempi della cardioversione Utile se buona esperienza di cardiac imaging anche tridimensionale per evitare falsi positivi