Author + information
- Ibolya Csecs, MD,
- Bela Merkely, MD, PhD and
- Brent D. Wilson, MD, PhD∗ ()
- ↵∗Division of Cardiovascular Medicine, University of Utah School of Medicine, 50 North Medical Drive, Salt Lake City, Utah 84132
We read with great interest the paper by El-Am et al. (1) that evaluated the outcomes of direct-current cardioversion (DCCV) for atrial arrhythmias in patients with cardiac amyloidosis (CA). The authors should be commended for conducting this elegant study. However, a few interesting, pertinent points arise from the analysis that we believe merit further discussion.
The investigators observed that the main reason for DCCV cancellation was intracardiac thrombus identified on transesophageal echocardiogram (TEE). CA patients were more frequently found to have left atrium (LA)/left atrial appendage (LAA) thrombus (28% vs. 2.5%) compared with control patients. Previous studies have shown that contrast agent use renders TEE images more interpretable, facilitates exclusion of atrial thrombi, and reduces the rate of embolic adverse events (2). Did patients receive intravenous contrast agent during TEE for thrombus identification?
The clinical importance of LAA spontaneous echo contrast in patients undergoing cardioversion is not well understood. What was the outcome of DCCV in CA patients with TEE evidence of spontaneous echo contrast? This current study reports that CA patients had significantly lower LAA emptying velocities. Differing LA anatomy might be an explanation for increased LA thrombus in CA patients. Are magnetic resonance imaging/computed tomography data available to better define LA structure for amyloidosis patients?
Antiarrhythmic drugs were used in 33% of CA and 56% of control patients. Widespread conduction system disease in CA patients may worsen in the presence of antiarrhythmic drugs (3). It would be useful to know the details of antiarrhythmic drug use in patients undergoing DCCV. The risk of arrhythmia recurrence during 1-year follow-up was 48% in CA patients. What treatments did CA patients receive for recurrence?
We thank the investigators again for an elegant and enlightening article.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2019 American College of Cardiology Foundation
- El-Am E.A.,
- Dispenzieri A.,
- Melduni R.M.,
- et al.
- Jung P.H.,
- Mueller M.,
- Schuhmann C.,
- et al.
- Falk R.H.