1
|
Słaboszewski M, Kolec R, Paszek E, Baran M, Undas A. Prothrombotic plasma fibrin clot phenotype is associated with spontaneous echo contrast in atrial fibrillation: The role of protein carbonylation. Thromb Res 2024; 240:109065. [PMID: 38908317 DOI: 10.1016/j.thromres.2024.109065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 06/04/2024] [Accepted: 06/14/2024] [Indexed: 06/24/2024]
Abstract
INTRODUCTION Spontaneous echo contrast (SEC) and left atrial appendage thrombus (LAAT) increase the risk of stroke and its severity in patients with atrial fibrillation (AF). Formation of denser fibrin networks and impaired fibrinolysis are associated with stroke risk in AF. This study investigated whether the prothrombotic fibrin clot phenotype characterizes patients with SEC/LAAT. METHODS We studied 139 anticoagulated patients with AF (median age, 70 years), who underwent transesophageal echocardiography (TEE). SEC and LAAT were recorded. We assessed plasma fibrin clot properties, i.e. permeability (Ks) and clot lysis time (CLT), von Willebrand Factor (vWF) antigen, endogenous thrombin potential (ETP), proteins involved in thrombosis and fibrinolysis, as well as plasma carbonylated protein content (PC). RESULTS SEC/LAAT was identified in 36 subjects (25.9 %) and was associated with heart failure (HF), AF duration, higher CHA2DS2VASc score, N-terminal prohormone of brain natriuretic peptide, and growth differentiation factor 15. Patients with SEC/LAAT had lower Ks (-15 %) and prolonged CLT (+19 %), along with higher fibrinogen (+24 %), ETP (+3 %), and plasminogen activator inhibitor-1 antigen (+16 %) compared with the remainder. Thrombin-activatable fibrinolysis inhibitor antigen, plasminogen, α2 - antiplasmin, and tissue plasminogen activator antigen were similar between the two groups. PC content was 50 % higher in SEC/LAAT and correlated with Ks (r = -0.47, p < 0.001) and CLT (r = 0.40, p < 0.001). On multivariate analysis, Ks, CLT, and PC levels, along with HF, remained independently associated with SEC/LAAT. CONCLUSIONS We demonstrated a formation of denser and poorly lysable fibrin networks in AF patients with SEC/LAAT despite anticoagulation. We suggest that this phenomenon is in part related to enhanced oxidative stress.
Collapse
Affiliation(s)
| | - Rafał Kolec
- Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Elżbieta Paszek
- Clinical Department of Interventional Cardiology, St. John Paul II Hospital, 31-202 Krakow, Poland; Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, 31-202 Krakow, Poland
| | | | - Anetta Undas
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, 31-202 Krakow, Poland; Krakow Center for Medical Research and Technologies, St. John Paul II Hospital, 31-202 Krakow, Poland.
| |
Collapse
|
2
|
Marongiu F, Barcellona D. Why Does Rivaroxaban Not Work in Severe Mitral Stenosis? Semin Thromb Hemost 2024; 50:303-306. [PMID: 37160162 DOI: 10.1055/s-0043-1768938] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Affiliation(s)
- Francesco Marongiu
- Haemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- Fondazione Arianna Anticoagulazione, Bologna, Italy
| | - Doris Barcellona
- Haemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| |
Collapse
|
3
|
Bloch-Isenberg N, Zukermann R, Massalha S, Qasum M, Reiner Benaim A, Marcusohn E. Transesophageal echocardiography and computerized tomography angiography mismatch in left atrial appendage thrombus evaluation. J Cardiovasc Med (Hagerstown) 2024; 25:63-67. [PMID: 38051642 DOI: 10.2459/jcm.0000000000001538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Transesophageal echocardiography (TEE) is the gold standard test for the diagnosis of left atrial appendage (LAA) thrombus. Nonetheless, computerized tomography angiography (CTA) is readily used to exclude LAA thrombus before pulmonary vein isolation (PVI) and LAA closure procedures. We aimed to assess the comparability of LAA thrombus diagnosis using chest CTA scans in patients with atrial fibrillation who underwent TEE. METHODS Retrospective collection of consecutive patients with atrial fibrillation who underwent TEE and chest CTA within 30 days and had evidence of spontaneous echo contrast (SEC) or LAA thrombus on TEE. Clinical, demographic, and echo data were collected. Prospective analysis of the CTA for evidence of LAA thrombus in the same group of patients was performed. We compared the findings of the two modalities. RESULTS Out of 1550 patients with atrial fibrillation who underwent TEE examinations in the study period, 63 patients underwent TEE within 30 days of a chest CTA scan. Twenty-three patients had LAA thrombus and 40 had some degree of SEC according to TEE. On CTA, 11 were interpreted as positive with a high level of suspicion for the presence of an LAA thrombus. Six patients (26.1%) had LAA thrombus according to both CT and TEE. Therefore, low concordance was found between test results (chi-squared continuity correction = 5.5, df = 1, and P -value = 0.01902). CONCLUSION The discrepancy between CTA and TEE results suggests these examinations might be more suitable as complementary examinations to exclude LAA thrombus.
Collapse
Affiliation(s)
| | | | | | - Majd Qasum
- Cardiology Department, Rambam Healthcare Campus, Haifa
| | - Anat Reiner Benaim
- Department of Epidemiology, Biostatistics, and Community Health Sciences, School of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | | |
Collapse
|
4
|
Ouchi K, Sakuma T, Higuchi T, Yoshida J, Narui R, Nojiri A, Yamane T, Ojiri H. Prediction of spontaneous echocardiographic contrast within the left atrial appendage in cardiac computed tomography of patients with atrial fibrillation. Heart Vessels 2023; 38:1138-1148. [PMID: 37029248 DOI: 10.1007/s00380-023-02263-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 03/23/2023] [Indexed: 04/09/2023]
Abstract
This study aimed to assess the predictors of spontaneous echocardiographic contrast (SEC) using left atrial appendage (LAA) findings in cardiac computed tomography (CT) of patients with atrial fibrillation (AF). We retrospectively analyzed cardiac CT findings of the LAA, including morphology, volume, and filling defects, of 641 patients who underwent transesophageal echocardiography (TEE) prior to pulmonary vein isolation (PVI) from January 6, 2013 through December 16, 2019 at our institution. We investigated potential associated factors that might be predictors of SEC using cardiac CT findings and computed a receiver operator characteristic, choosing a threshold value at which the likelihood of SEC could be predicted based on the LAA volume indexed for body size. SEC correlated significantly with indexed LAA volume (P < 0.001; odds ratio [OR], 1.31; 95% confidence interval [CI], 1.17-1.48) of 7.75 cm3/m2 or greater (sensitivity, 76.0%; specificity, 57.7%), LAA early filling defect (P = 0.005; OR, 2.72; 95% CI, 1.35-5.48), a history of persistent AF (P < 0.001; OR, 3.81; 95% CI, 1.86-7.80), and LAA flow velocity (P < 0.001; OR, 0.97; 95% CI, 0.96-0.99). Findings of LAA in cardiac CT can allow for the noninvasive estimation of SEC to determine the need for additional TEE investigation and the need to obtain additional information for risk stratification and management of thromboembolic events in patients with AF.
Collapse
Affiliation(s)
- Kotaro Ouchi
- Department of Radiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan.
| | - Toru Sakuma
- Department of Radiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Takahiro Higuchi
- Department of Radiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Jun Yoshida
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Ryosuke Narui
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Ayumi Nojiri
- Department of Laboratory Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Teiichi Yamane
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Hiroya Ojiri
- Department of Radiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| |
Collapse
|
5
|
Kelesoglu S, Elcık D, Zengin I, Ozan R, Inanc MT, Dogan A, Oguzhan A, Kalay N. Association of spontaneous echo contrast with Systemic Immune Inflammation Index in patients with mitral stenosis. Rev Port Cardiol 2022; 41:1001-1008. [PMID: 36137911 DOI: 10.1016/j.repc.2021.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE Spontaneous echo contrast (SEC) is the appearance of swirling, smoke-like echoes in the left atrium (LA) and is accepted as an independent predictor of thromboembolic risk. There is an established relationship between the inflammatory state and the prothrombotic state. Therefore, we investigated the relationship between the Systemic Immune Inflammation Index (SII), a new inflammation parameter introduced recently, and SEC in patients with mitral stenosis (MS). MATERIAL AND METHODS A total of 262 patients who underwent percutaneous mitral valvuloplasty (PMBV) for MS were included in this study. The patients were divided into two groups: patients with MS complicated by SEC and patients with MS without SEC, based on whether SEC occurred in the LA. RESULTS There were 79 patients (mean age 47.1 ± 6.6, 30.3% male gender) in the SEC (+) group, while there were 183 patients (mean age 46.4 ± 8.6, 29.5% male gender) in the SEC (-) group. In multivariate analysis, high levels of SII were an independent risk factor for SEC in patients with MS (OR: 1.001, 95% confidence interval (CI): 1.000-1.001, p<0.001) together with high levels of C-reactive protein (OR: 1.145, 95% CI: 1.027-1.277, p=0.014). The receiver operating characteristics (ROC) curve analysis showed that at a cutoff value of 547.6 for SII to predict SEC with 74.6% sensitivity and 77.6% specificity (area under ROC curve=0.736 (95% CI: 0.668-0.805), p<0.001). CONCLUSION Our study showed that the SII levels were independently associated with SEC in patients with MS.
Collapse
Affiliation(s)
- Saban Kelesoglu
- Department of Cardiology, Erciyes University Faculty of Medicine, Kayseri, Turkey.
| | - Deniz Elcık
- Department of Cardiology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Iskan Zengin
- Department of Cardiology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Ramazan Ozan
- Department of Cardiology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Mehmet Tugrul Inanc
- Department of Cardiology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Ali Dogan
- Department of Cardiology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Abdurrahman Oguzhan
- Department of Cardiology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Nihat Kalay
- Department of Cardiology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| |
Collapse
|
6
|
Wang Z, Wang B, Fu G, He B, Chu H, Zhang S. The Prognostic Nutritional Index May Predict Left Atrial Appendage Thrombus or Dense Spontaneous Echo Contrast in Patients With Atrial Fibrillation. Front Cardiovasc Med 2022; 9:860624. [PMID: 35571156 PMCID: PMC9098831 DOI: 10.3389/fcvm.2022.860624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 04/12/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesThe prognostic nutritional index (PNI) is an independent predictor of adverse outcomes in patients with cardiovascular diseases. The presence of left atrial appendage thrombus (LAAT) or spontaneous echo contrast (SEC) is associated with ischemic stroke. The present study aimed to investigate the relationship between the PNI and LAAT/dense SEC in patients with non-valvular atrial fibrillation (AF).MethodsIn patients with non-valvular AF, we compared demographics, clinical characteristics, and prevalence of LAAT/dense SEC according to the levels of the PNI. The relationship between the PNI and LAAT/dense SEC was observed.ResultsA total of 406 patients with non-valvular AF were consecutively included from March 2015 to February 2019. Of the study population, 53 patients had LAAT/dense SEC. The percentages of LAAT/dense SEC were 20.4, 14.1, and 4.5% in subjects from the lowest to the highest tertile of the PNI, respectively. Multivariate logistic analysis demonstrated that the PNI was an independent predictor for LAAT/dense SEC (OR 0.89; 95% CI, 0.82–0.97; P = 0.007). Receiver operating characteristic curve analysis revealed that the optimal cutoff value of the PNI for predicting LAAT/dense SEC was 48.0 (area under the curve: 0.68; 95% CI, 0.61–0.75; P < 0.001). The sensitivity and specificity were 83.0 and 47.6%, respectively. The risk of LAAT/dense SEC in patients with a PNI ≤ 48.0 was 2.57-fold higher than that in those with a PNI > 48.0.ConclusionThe PNI, calculated based on serum albumin and lymphocyte count, was inversely correlated with LAAT/dense SEC in patients with non-valvular AF. Therefore, it may be considered a predictor for LAAT/dense SEC.
Collapse
Affiliation(s)
- Zhao Wang
- Department of Ultrasonography, Ningbo First Hospital, Ningbo, China
| | - Binhao Wang
- Arrhythmia Center, Ningbo First Hospital, Ningbo, China
| | - Guohua Fu
- Arrhythmia Center, Ningbo First Hospital, Ningbo, China
| | - Bin He
- Arrhythmia Center, Ningbo First Hospital, Ningbo, China
| | - Huimin Chu
- Arrhythmia Center, Ningbo First Hospital, Ningbo, China
- *Correspondence: Huimin Chu,
| | - Shengmin Zhang
- Department of Ultrasonography, Ningbo First Hospital, Ningbo, China
- Shengmin Zhang,
| |
Collapse
|
7
|
Ito T, Akamatsu K, Hasegawa H, Sakatani Y, Miyamura M, Hoshiga M. Relationship of warfarin versus DOACs with thrombogenic milieu in the left atrium among patients with nonvalvular atrial fibrillation. Echocardiography 2022; 39:483-489. [PMID: 35137446 DOI: 10.1111/echo.15319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/25/2022] [Accepted: 01/30/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Thrombogenic milieu (TM) within the left atrium plays a pivotal role in the pathogenesis of thromboembolic events, for which anticoagulation treatment is indicated typically on the mandatory basis. Little is known, however, about which regimen of anticoagulation, warfarin or direct oral anticoagulants (DOACs), is more likely associated with TM. We evaluated relative relationship of the two treatment options with concurrently-observed TM in patients with nonvalvular atrial fibrillation (AF) who underwent transesophageal echocardiography. METHODS TM was defined as the presence of either left atrial spontaneous echo contrast (SEC) or thrombus, or both. To determine which regimen was more likely related to TM, we firstly compared the prevalence of TM in 208 patients taking warfarin (Warfarin group) versus 486 patients taking DOACs (DOAC group); and secondly, did the same analysis after propensity score matching. RESULTS Warfarin group was more likely associated with TM compared with DOAC group (46% vs 29%, p < 0.001). Similar findings were observed for dense SEC (18% vs 7%, p < 0.001) and thrombus (4% vs 1%, p = 0.057). The propensity score matching (198 patients for each group), where several baseline parameters were matched including age, gender, chronicity of AF, estimated glomerular filtration rate and B-type natriuretic peptide as well as the left ventricular ejection fraction, resulted in similar findings to the original groups (TM, 47% vs 32%, p = 0.002; dense SEC, 18% vs 7%, p = 0.001; thrombus, 4% vs 1%, p = 0.047). CONCLUSIONS This study may strengthen the data on randomized trials that DOACs are superior to warfarin in preventing thromboembolic events in nonvalvular AF patients. Further studies are required to elucidate the details behind this difference.
Collapse
Affiliation(s)
- Takahide Ito
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Kanako Akamatsu
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Hitomi Hasegawa
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Yuka Sakatani
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Masatoshi Miyamura
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Masaaki Hoshiga
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| |
Collapse
|
8
|
Abstract
A 17-year-old adolescent with severe multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease-2019 developed reduced left ventricular function and left ventricular thrombus. With treatment, his condition improved and the thrombus was dissolved. This case illustrates the risk of severe intra-cardiac thrombotic complications in patients with MIS-C.
Collapse
|
9
|
Wang B, Wang Z, Fu G, He B, Wang H, Zhuo W, Zhang S, Chu H. Left Atrial Spontaneous Echo Contrast and Ischemic Stroke in Patients Undergoing Percutaneous Left Atrial Appendage Closure. Front Cardiovasc Med 2021; 8:723280. [PMID: 34631825 PMCID: PMC8495018 DOI: 10.3389/fcvm.2021.723280] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/30/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: Spontaneous echo contrast (SEC) in the left atrium (LA) is frequently observed in atrial fibrillation (AF) patients and may lead to thromboembolic events. We aimed to investigate both periprocedural and long-term stroke risks associated with LA SEC in AF patients undergoing percutaneous left atrial appendage closure (LAAC). Methods: A total of 408 consecutive AF patients treated with LAAC between March 2015 and February 2019 were divided into two groups based on preprocedural transesophageal echocardiography: the study group (moderate/severe LA SEC; n = 41) and the control group (none, mild, or mild to moderate LA SEC; n = 367). To attenuate the observed imbalance in baseline covariates, a propensity score matching technique was used. Results: No periprocedural stroke/transient ischemic attack (TIA) was documented. The incidence of device-related thrombus was higher in the study group than in the control group (8.8 vs. 1.3%; P = 0.025). The mean follow-up period was 3.2 ± 1.1 years, during which 8 patients (2.2%) in the control group and 4 (9.8%) in the study group experienced stroke/TIA (P = 0.024). Moderate/severe LA SEC was identified as an independent predictor of stroke/TIA in both the original population (HR = 5.71, 95% CI 1.47-22.19, P = 0.012) and the matched population (HR = 9.79, 95% CI 1.44-66.86, P = 0.020). Conclusions: LA SEC did not show a relationship with periprocedural stroke events in patients undergoing percutaneous LAAC. However, moderate/severe LA SEC increased the incidence of device-related thrombus and the risk of late stroke/TIA.
Collapse
Affiliation(s)
- Binhao Wang
- Arrhythmia Center, Ningbo First Hospital, Ningbo, China
| | - Zhao Wang
- Department of Ultrasonography, Ningbo First Hospital, Ningbo, China
| | - Guohua Fu
- Arrhythmia Center, Ningbo First Hospital, Ningbo, China
| | - Bin He
- Arrhythmia Center, Ningbo First Hospital, Ningbo, China
| | - Hangxuan Wang
- Arrhythmia Center, Ningbo First Hospital, Ningbo, China
| | - Weidong Zhuo
- Arrhythmia Center, Ningbo First Hospital, Ningbo, China
| | - Shengmin Zhang
- Department of Ultrasonography, Ningbo First Hospital, Ningbo, China
| | - Huimin Chu
- Arrhythmia Center, Ningbo First Hospital, Ningbo, China
| |
Collapse
|
10
|
Clinical characteristics and outcomes in patients with echocardiographic left ventricular spontaneous echo contrast. Int J Cardiol 2021; 330:245-250. [PMID: 33577908 DOI: 10.1016/j.ijcard.2021.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 01/03/2021] [Accepted: 02/03/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Spontaneous echo contrast (SEC) is a known precursor to thrombus formation and thromboembolic events. This study aims to demonstrate the clinical characteristics and outcomes of patients with left ventricular spontaneous echo contrast (LV-SEC). METHODS Patients with consecutive echocardiogram performed from October 2009 to September 2019 were enrolled in this retrospective, single-center study. Those with LV-SEC were included, while patients complicated by left ventricular thrombus, with history of infective endocarditis, prosthetic valves, or lost to follow-up were excluded. The clinical endpoint was 1-year thromboembolic events (i.e. stroke and peripheral embolism). RESULTS Among 417 patients (mean age 63.5 ± 14.7 years; 86.8% men) with LV-SEC, the incidence of 1-year embolism was 12.9%. In multivariate Cox proportional hazard model, significant risk factors for thromboembolic event were age [hazard ratio (HR) = 1.022, 95% confidence interval (CI): 1.000-1.045], atrial fibrillation (AF) (HR = 2.292, 95% CI: 1.237-4.244), hemoglobin (HR = 1.032, 95% CI: 1.017-1.047), left ventricular ejection fraction (LVEF) (HR = 1.021, 95% CI: 1.002-1.041), and anticoagulant therapy (HR = 0.310, 95% CI: 0.168-0.572). For patients with repeated measurements for echocardiography, D-dimer (HR = 1.137, 95% CI: 1.051-1.231), and △LVEF (HR = 0.961, 95% CI: 0.928-0.996) were independently associated with the persistent LV-SEC. CONCLUSION The present study reported a high incidence of 1-year thromboembolic event in patients with LV-SEC. Age, AF, hemoglobin, LVEF were independent risk factors for 1-year embolism and a reduced risk of embolism was observed among patients with anticoagulation therapy. Additionally, D-dimer and △LVEF are independently associated with the persistent LV-SEC.
Collapse
|
11
|
Akamatsu K, Ito T, Ozeki M, Miyamura M, Sohmiya K, Hoshiga M. Left atrial spontaneous echo contrast occurring in patients with low CHADS 2 or CHA 2DS 2-VASc scores. Cardiovasc Ultrasound 2020; 18:31. [PMID: 32738924 PMCID: PMC7395968 DOI: 10.1186/s12947-020-00213-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 07/28/2020] [Indexed: 11/10/2022] Open
Abstract
Background Left atrial spontaneous echo contrast (LASEC) is common in patients with atrial fibrillation (AF), although scarce information exists on LASEC occurring in nonvalvular AF patients who have low thromboembolic risk scores. We therefore examined prevalence and determinants of LASEC under low CHADS2 or CHA2DS2-VASc scores in these patients. Methods Among 713 patients who underwent transesophageal echocardiography, 349 with a CHADS2 score < 2 (CHADS2 group) (93 women, mean age 65 years) and 221 with a CHA2DS2-VASc score < 2 (CHA2DS2-VASc group) (39 women, mean age 62 years) were separately examined for clinical and echocardiographic findings. Results LASEC was found in 77 patients of CHADS2 group (22%) and in 41 of CHA2DS2-VASc group (19%). Multivariate logistic regression analysis, adjusted for several parameters including non-paroxysmal AF, LA enlargement (LA diameter ≥ 50 mm), left ventricular (LV) hypertrophy, and an elevated B-type natriuretic peptide (BNP) (BNP ≥200 pg/mL) revealed that for CHADS2 group, non-paroxysmal AF (Odds ratio 5.65, 95%CI 3.08–10.5, P < 0.001), BNP elevation (Odds ratio 3.42, 95%CI 1.29–9.06, P = 0.013), and LV hypertrophy (Odds ratio 2.26, 95%CI 1.19–4.28, P = 0.013) were significant independent determinants of LASEC, and that for CHA2DS2-VASc group, non-paroxysmal AF (Odds ratio 3.38, 95%CI 1.51–7.54, P = 0.003) and LV hypertrophy (Odds ratio 2.53, 95%CI 1.13–5.70, P = 0.025) were significant independent determinants of LASEC. Conclusions LASEC was present in a considerable proportion of patients with nonvalvular AF under low thromboembolic risk scores. Information on AF chronicity, BNP, and LV hypertrophy might help identify patients at risk for thromboembolism, although large-scale studies are necessary to confirm our observations.
Collapse
Affiliation(s)
- Kanako Akamatsu
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, 569-8686, Japan
| | - Takahide Ito
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, 569-8686, Japan.
| | - Michishige Ozeki
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, 569-8686, Japan
| | - Masatoshi Miyamura
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, 569-8686, Japan
| | - Koichi Sohmiya
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, 569-8686, Japan
| | - Masaaki Hoshiga
- Department of Cardiology, Osaka Medical College, Takatsuki, Osaka, 569-8686, Japan
| |
Collapse
|
12
|
Ding WY, Gupta D, Lip GYH. Atrial fibrillation and the prothrombotic state: revisiting Virchow’s triad in 2020. Heart 2020; 106:1463-1468. [DOI: 10.1136/heartjnl-2020-316977] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 02/05/2023] Open
Abstract
Atrial fibrillation (AF) is characterised by an increased risk of pathological thrombus formation due to a disruption of physiological haemostatic mechanisms that are better understood by reference to Virchow’s triad of ‘abnormal blood constituents’, ‘vessel wall abnormalities’ and ‘abnormal blood flow’. First, there is increased activation of the coagulation cascade, platelet reactivity and impaired fibrinolysis as a result of AF per se, and these processes are amplified with pre-existing comorbidities. Several prothrombotic biomarkers including platelet factor 4, von Willebrand factor, fibrinogen, β-thromboglobulin and D-dimer have been implicated in this process. Second, structural changes such as atrial fibrosis and endothelial dysfunction are linked to the development of AF which promote further atrial remodelling, thereby providing a suitable platform for clot formation and subsequent embolisation. Third, these factors are compounded by the presence of reduced blood flow secondary to dilatation of cardiac chambers and loss of atrial systole which have been confirmed using various imaging techniques. Overall, an improved understanding of the various factors involved in thrombus formation will allow better clinical risk stratification and targeted therapies in AF.
Collapse
|
13
|
Sukulal K, Mohanan Nair KK, Sasidharan B, Valaparambil A, Ganapathi S, Sivasubramanian S, Sivadasanpillai H. Implication of d-dimer in rheumatic severe mitral stenosis – A tertiary centre study. Indian Heart J 2020; 72:101-106. [PMID: 32534681 PMCID: PMC7296235 DOI: 10.1016/j.ihj.2020.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 11/28/2019] [Accepted: 04/07/2020] [Indexed: 11/21/2022] Open
Abstract
Background In rheumatic mitral stenosis (MS), left atrial (LA) thrombus and LA spontaneous echo contrast (LA SEC) reflect hypercoagulability. The study focuses on whether D-dimer levels predict the existence of LA thrombus and SEC in patients with severe MS. Methods 95 consecutive patients with severe MS referred for transesophageal echocardiogram (TEE) between July 2011 and March 2012 to evaluate LA thrombus prior to balloon mitral valvotomy (BMV) were included in the study. D-Dimer levels in these patients were observed. Results Out of the 95 patients, 15 (15.8%) had LA thrombus and 52 patients had LA SEC (54.7%). Any correlation between D-Dimer levels and existence (or non-existence) of LA thrombus was not noticed from the receiver operating characteristics (ROC) curve with an area of .535. For patients with LA SEC, the D-Dimer levels were found to be considerably higher (776 ± 866 μg/L vs. 294 ± 331 μg/L, p = .001). An ideal cut-off level of 393 μg/L for diagnosing LA SEC was illustrated by the ROC curve with a sensitivity of 63.4%, specificity of 83.72%, positive predictive value of 82.5% and a negative predictive value of 65.45%. Conclusions D-dimer levels were not representative of the presence or absence of LA thrombus in patients with severe MS. Nonetheless, this study demonstrated the substantial link between D-Dimer level and LA SEC. If a D-Dimer level of 400 μg/L or higher is taken as positive, it has high specificity and positive predictive value for diagnosing LA SEC.
Collapse
|
14
|
Packer M. Potential Role of Atrial Myopathy in the Pathogenesis of Stroke in Rheumatoid Arthritis and Psoriasis: A Conceptual Framework and Implications for Prophylaxis. J Am Heart Assoc 2020; 9:e014764. [PMID: 31973602 PMCID: PMC7033881 DOI: 10.1161/jaha.119.014764] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute Baylor University Medical Center Dallas TX.,Imperial College London United Kingdom
| |
Collapse
|
15
|
Packer M. HFpEF Is the Substrate for Stroke in Obesity and Diabetes Independent of Atrial Fibrillation. JACC-HEART FAILURE 2020; 8:35-42. [DOI: 10.1016/j.jchf.2019.09.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 01/01/2023]
|
16
|
Ibebuogu UN, Schafer JH, Schwade MJ, Waller JL, Sharma GK, Robinson VJB. Useful indices of thrombogenesis in the exclusion of intra-cardiac thrombus. Echocardiography 2019; 37:86-95. [PMID: 31854027 PMCID: PMC7027915 DOI: 10.1111/echo.14562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 10/31/2019] [Accepted: 11/22/2019] [Indexed: 02/03/2023] Open
Abstract
Background Cardioversion in patients with atrial fibrillation (AF) can cause cardioembolic stroke, and effective clinical management is necessary to reduce morbidity and mortality. Currently, transesophageal echocardiography (TEE) is the accepted standard to diagnose cardiogenic thromboemboli; however, a negative TEE does not eliminate the possibility of left atrial thrombus. The objective of this study was to evaluate the diagnostic value of supplementing the TEE with additional noninvasive markers to ensure thrombus absence. Methods A prospective study was conducted on 59 patients who underwent TEE for suspected intra‐cardiac thrombi. The TEE indications included acute ischemic stroke (45.7%) and AF or flutter (59.3%). D‐dimer level and white blood cell counts were assessed. Results A negative D‐dimer level (<200 ng/mL) excluded the presence of intra‐cardiac thrombi. Groups with either negative (n = 14) or positive (n = 45) D‐dimer levels had comparable clinical characteristics. Comparing positive D‐dimer–level patients with thrombus (n = 7) and without thrombus (n = 33), patients with thrombus had reduced left atrial appendage (LAA) velocity (P = .0024), reduced left ventricular ejection fraction (LVEF) (P = .0263), increased neutrophil percent (P = .0261), decreased lymphocyte percent (P = .0216), and increased monocyte counts (P = .0220). The area under the receiver operating characteristic (ROC) curve for thrombus diagnostics was larger for combinations of clinical and biochemical data than for each parameter individually. Conclusions Supplementing the gold standard TEE with the analysis of LAA velocity, noninvasive LVEF, D‐dimer, and hemostatic markers provided additional useful diagnostic information. Larger studies are needed to further validate the efficacy of supplementing the TEE to better assess patients for intra‐cardiac thrombi.
Collapse
Affiliation(s)
- Uzoma N Ibebuogu
- Division of Cardiology, Department of Medicine, Augusta University Medical Center, Augusta, GA, USA.,Department of Medicine, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Joseph H Schafer
- Division of Cardiology, Department of Medicine, Augusta University Medical Center, Augusta, GA, USA
| | - Mark J Schwade
- Division of Cardiology, Department of Medicine, Augusta University Medical Center, Augusta, GA, USA
| | - Jennifer L Waller
- Division of Biostatistics and Data Science, Department of Population Health Sciences, Augusta University Medical Center, Augusta, GA, USA
| | - Gyanendra K Sharma
- Division of Cardiology, Department of Medicine, Augusta University Medical Center, Augusta, GA, USA
| | - Vincent J B Robinson
- Division of Cardiology, Department of Medicine, Augusta University Medical Center, Augusta, GA, USA
| |
Collapse
|
17
|
A Compelling Case for Less Aggressive Arrhythmia Management in Patients With Chronic Heart Failure and Long-Standing Atrial Fibrillation. J Card Fail 2019; 26:85-92. [PMID: 31465842 DOI: 10.1016/j.cardfail.2019.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/06/2019] [Accepted: 08/20/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND METHODS Atrial fibrillation (AF) is common in chronic heart failure, and some have advocated intensive rate and/or rhythm control strategies for these patients. However, the loss of atrial systole and irregularity of the ventricular response has not been shown to contribute to the progression of heart failure, and the presence or rate of long-standing AF in patients with chronic heart failure does not have prognostic significance. RESULTS In randomized clinical trials, pharmacological rhythm control has not been shown to be superior to rate-control in influencing long-term outcomes, but the use of membrane-active antiarrhythmic drugs can increase the risk of both pump failure and arrhythmic deaths in patients with heart failure. Additionally, intensive efforts to slow the ventricular rate in AF can potentially cause clinically inapparent bradyarrhythmias, which can trigger rate-dependent lethal rhythm disturbances or hemodynamic abnormalities. In patients with AF, a more stringent approach to rate control (target rate <80/min) is not superior to a more lenient strategy (target rate <110/min) on the risk of major events. Little is known about the effects of catheter ablation of long-standing AF in established heart failure, particularly in patients with a preserved or a meaningfully reduced ejection fraction, but ablation can add to the fibrotic burden of the left atrium and impair its capacitance functions. CONCLUSIONS For all of these reasons, the management of heart failure and long-standing AF should be primarily directed to slowing of the progression of their underlying cardiomyopathic process rather than the treatment of the arrhythmia. In addition, patients should receive long-term oral anticoagulation with non-vitamin K-antagonist oral anticoagulants to reduce the risk of thromboembolic events. The utility of intensive rate and rhythm control interventions for long-standing AF in patients with established heart failure requires further study.
Collapse
|
18
|
Ito T, Suwa M. Left atrial spontaneous echo contrast: relationship with clinical and echocardiographic parameters. Echo Res Pract 2019; 6:R65-R73. [PMID: 30959476 PMCID: PMC6499934 DOI: 10.1530/erp-18-0083] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/03/2019] [Indexed: 12/19/2022] Open
Abstract
Spontaneous echo contrast (SEC) indicates blood stasis in cardiac chambers and major vessels, and is a known precursor of thrombus formation. Transesophageal echocardiography plays a pivotal role in detecting and grading SEC in the left atrial (LA) cavity. Assessing LA SEC can identify patients at increased risk for thromboembolic events. LA SEC also develops in patients who have sinus rhythm, especially in those with heart failure. Detection of LA SEC is not uncommon in subjects who have multiple cardiovascular comorbidities, although mechanisms behind this association are not fully understood. In patients with atrial fibrillation, the role of mitral regurgitation in counteracting LA SEC and subsequent thromboembolism is controversial. Moreover, alterations of blood coagulability and elevated levels of certain biological markers in the blood contribute to occurrence of LA SEC. This review describes the pathogenesis and assessment of SEC, in addition to the relationship between LA SEC and clinical, biological and echocardiographic parameters.
Collapse
Affiliation(s)
- Takahide Ito
- Department of Cardiology, Osaka Medical College, Takatsuki, Japan
| | - Michihiro Suwa
- Department of Cardiovascular Medicine, Hokusetsu General Hospital, Takatsuki, Japan
| |
Collapse
|
19
|
Kim YG, Shim J, Boo KY, Kim DY, Oh SK, Lee KN, Choi JI, Kim YH. Different influence of cardiac hemodynamics on thromboembolic events in patients with paroxysmal and non-paroxysmal atrial fibrillation. PLoS One 2019; 14:e0214743. [PMID: 30925176 PMCID: PMC6440630 DOI: 10.1371/journal.pone.0214743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 03/19/2019] [Indexed: 11/19/2022] Open
Abstract
Blood stasis in left atrium (LA) or LA appendage (LAA) is thought to be the main cause of thrombus formation and systemic embolism in atrial fibrillation (AF) patients. Paroxysmal and non-paroxysmal AF differ significantly in various aspects. Impact of cardiac hemodynamics on systemic embolism might also differ between the 2 distinct AF entities. This study was performed to evaluate the influence of cardiac hemodynamics on systemic embolism in both paroxysmal and non-paroxysmal AF. Consecutive AF patients undergoing radiofrequency catheter ablation (RFCA) in Korea University Medical Center Anam Hospital between June 1998 and February 2018 were analyzed. Among 2,801 patients who underwent first-time RFCA, a total of 231 patients had either previous ischemic stroke, transient ischemic attack, or arterial embolism. In paroxysmal AF, LA diameter, LA volume (measured with magnetic resonance imaging), left ventricular (LV) ejection fraction, E/e’, LAA flow velocity, and prevalence of spontaneous echocontrast (SEC) and dense SEC were significantly different between patients with and without thromboembolic events. However, only E/e’ was different between patients with and without thromboembolic events in non-paroxysmal AF. The influence of LA diameter, LA volume, LV EF, LAA flow velocity, and dense SEC on thromboembolic events was significantly moderated by the type of AF. In conclusion, paroxysmal and non-paroxysmal AF might have a different mechanism responsible for thrombus formation and consequent embolic events. Relative contribution of hemodynamic parameters and other factors such as atrial myopathy to thromboembolic events in paroxysmal versus non-paroxysmal AF needs further evaluation.
Collapse
Affiliation(s)
- Yun Gi Kim
- Arrhythmia Center, Korea University Medical Center Anam Hospital, Seoul, Republic of Korea
| | - Jaemin Shim
- Arrhythmia Center, Korea University Medical Center Anam Hospital, Seoul, Republic of Korea
- * E-mail: (JS); (YHK)
| | - Ki Yung Boo
- Arrhythmia Center, Korea University Medical Center Anam Hospital, Seoul, Republic of Korea
| | - Do Young Kim
- Arrhythmia Center, Korea University Medical Center Anam Hospital, Seoul, Republic of Korea
| | - Suk-Kyu Oh
- Arrhythmia Center, Korea University Medical Center Anam Hospital, Seoul, Republic of Korea
| | - Kwang-No Lee
- Arrhythmia Center, Korea University Medical Center Anam Hospital, Seoul, Republic of Korea
| | - Jong-Il Choi
- Arrhythmia Center, Korea University Medical Center Anam Hospital, Seoul, Republic of Korea
| | - Young-Hoon Kim
- Arrhythmia Center, Korea University Medical Center Anam Hospital, Seoul, Republic of Korea
- * E-mail: (JS); (YHK)
| |
Collapse
|
20
|
Khan AA, Lip GYH. The prothrombotic state in atrial fibrillation: pathophysiological and management implications. Cardiovasc Res 2018; 115:31-45. [DOI: 10.1093/cvr/cvy272] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 10/30/2018] [Indexed: 02/06/2023] Open
Abstract
AbstractAtrial fibrillation (AF) is the commonest sustained cardiac arrhythmia and is associated with significant morbidity and mortality. There is plenty of evidence available to support the presence of a prothrombotic or hypercoagulable state in AF, but the contributory factors are multifactorial and cannot simply be explained by blood stasis. Abnormal changes in atrial wall (anatomical and structural, as ‘vessel wall abnormalities’), the presence of spontaneous echo contrast to signify abnormal changes in flow and stasis (‘flow abnormalities’), and abnormal changes in coagulation, platelet, and other pathophysiologic pathways (‘abnormalities of blood constituents’) are well documented in AF. The presence of these components therefore fulfils Virchow’s triad for thrombogenesis. In this review, we present an overview of the established and professed pathophysiological mechanisms for thrombogenesis in AF and its management implications.
Collapse
Affiliation(s)
- Ahsan A Khan
- Institute of Cardiovascular Sciences, University of Birmingham, City Hospital, Dudley Road, Birmingham, UK
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, City Hospital, Dudley Road, Birmingham, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| |
Collapse
|
21
|
Gedikli Ö, Mohanty S, Trivedi C, Gianni C, Chen Q, Della Rocca DG, Burkhardt JD, Sanchez JE, Hranitzky P, Gallinghouse GJ, Al-Ahmad A, Horton R, Di Biase L, Natale A. Impact of dense "smoke" detected on transesophageal echocardiography on stroke risk in patients with atrial fibrillation undergoing catheter ablation. Heart Rhythm 2018; 16:351-357. [PMID: 30312757 DOI: 10.1016/j.hrthm.2018.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Spontaneous echocardiographic contrast ("smoke") within the left atrial cavity on transesophageal echocardiography (TEE) suggests low blood flow velocities in the heart that may lead to thromboembolic (TE) events. OBJECTIVE The purpose of this study was to evaluate the risk of TE events in the periprocedural period and at long-term follow-up in atrial fibrillation (AF) patients having dense smoke on preprocedural TEE. METHODS A total of 2511 patients undergoing AF ablation were included in this analysis. They were classified as group 1 (dense smoke detected on TEE at baseline; n = 234) and group 2 (no smoke on baseline TEE; n = 2277). Patients were followed up for TE events, which included both stroke and transient ischemic attacks (TIAs). In order to attenuate the observed imbalance in baseline covariates between the study groups, a propensity score matching technique was used (covariates were age, sex, AF type, diabetes, and CHADS2VASc score). RESULTS In the periprocedural period, no TE events were reported in group 1 and 3 events (0.13%) were reported in group 2. At follow-up of 6.62 ± 2.01 years, 6 (2.6%) TE complications (2 TIA, 4 stroke) occurred in group 1 and 16 (0.70%) TE complications (6 TIA, 10 stroke) in group 2 (P = .004). In the propensity-matched population, 6 (2.56%) TE complications occurred in group 1 and 1 (0.2%) in group 2 (P = .007). CONCLUSION In our study population, the presence of dense left atrial smoke did not show any correlation with periprocedural TE events in patients undergoing catheter ablation with uninterrupted anticoagulation. However, significant association was observed with late stroke/TIA, irrespective of CHA2DS2-VASc score.
Collapse
Affiliation(s)
- Ömer Gedikli
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Department of Cardiology, Ondokuz Mayis University Medicine School, Samsun, Turkey
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Dell Medical School, Austin, Texas
| | - Chintan Trivedi
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Qiong Chen
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Henan Provincial People's Hospital, Zhengzhou, China
| | | | - J David Burkhardt
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Javier E Sanchez
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Patrick Hranitzky
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | | | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Rodney Horton
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Albert Einstein College of Medicine at Montefiore Hospital, New York, New York
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Dell Medical School, Austin, Texas; Interventional Electrophysiology, Scripps Clinic, San Diego, California; Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Cardiology, Stanford University, Stanford, California.
| |
Collapse
|
22
|
Zhan Y, Joza J, Al Rawahi M, Barbosa RS, Samuel M, Bernier M, Huynh T, Thanassoulis G, Essebag V. Assessment and Management of the Left Atrial Appendage Thrombus in Patients With Nonvalvular Atrial Fibrillation. Can J Cardiol 2018; 34:252-261. [DOI: 10.1016/j.cjca.2017.12.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 12/04/2017] [Accepted: 12/11/2017] [Indexed: 01/14/2023] Open
|
23
|
Kim YG, Choi JI, Kim MN, Cho DH, Oh SK, Kook H, Park HS, Lee KN, Baek YS, Roh SY, Shim J, Park SM, Shim WJ, Kim YH. Non-vitamin K antagonist oral anticoagulants versus warfarin for the prevention of spontaneous echo-contrast and thrombus in patients with atrial fibrillation or flutter undergoing cardioversion: A trans-esophageal echocardiography study. PLoS One 2018; 13:e0191648. [PMID: 29360845 PMCID: PMC5779688 DOI: 10.1371/journal.pone.0191648] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 01/09/2018] [Indexed: 11/19/2022] Open
Abstract
Spontaneous echo-contrast (SEC) and thrombus observed in trans-esophageal echocardiography (TEE) is known as a strong surrogate marker for future risk of ischemic stroke in patients with atrial fibrillation (AF) or atrial flutter (AFL). The efficacy of non-vitamin K antagonist oral anticoagulants (NOAC) compared to warfarin to prevent SEC or thrombus in patients with AF or AFL is currently unknown. AF or AFL patients who underwent direct current cardioversion (DCCV) and pre-DCCV TEE evaluation from January 2014 to October 2016 in a single center were analyzed. The prevalence of SEC and thrombus were compared between patients who received NOAC and those who took warfarin. NOAC included direct thrombin inhibitor and factor Xa inhibitors. Among 1,050 patients who were considered for DCCV, 424 patients anticoagulated with warfarin or NOAC underwent TEE prior to DCCV. Eighty patients who were anticoagulated for less than 21 days were excluded. Finally, 344 patients were included for the analysis (180 warfarin users vs. 164 NOAC users). No significant difference in the prevalence of SEC (44.4% vs. 43.9%; p = 0.919), dense SEC (13.9% vs. 15.2%; p = 0.722), or thrombus (2.2% vs. 4.3%; p = 0.281) was observed between the warfarin group and the NOAC group. In multivariate analysis, there was no association between NOAC and risk of SEC (odds ratio [OR]: 1.4, 95% CI: 0.796–2.297, p = 0.265) or thrombus (OR: 3.4, 95% CI: 0.726–16.039, p = 0.120). In conclusion, effectiveness of NOAC is comparable to warfarin in preventing SEC and thrombus in patients with AF or AFL undergoing DCCV. However, numerical increase in the prevalence of thrombus in NOAC group warrants further evaluation.
Collapse
Affiliation(s)
- Yun Gi Kim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Jong-Il Choi
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
- * E-mail:
| | - Mi-Na Kim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Dong-Hyuk Cho
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Suk-Kyu Oh
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Hyungdon Kook
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Hee-Soon Park
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Kwang No Lee
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Yong-Soo Baek
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Seung-Young Roh
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Jaemin Shim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Seong-Mi Park
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Wan Joo Shim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Young-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| |
Collapse
|
24
|
Weymann A, Sabashnikov A, Ali-Hasan-Al-Saegh S, Popov AF, Jalil Mirhosseini S, Baker WL, Lotfaliani M, Liu T, Dehghan H, Yavuz S, de Oliveira Sá MPB, Jang JS, Zeriouh M, Meng L, D'Ascenzo F, Deshmukh AJ, Biondi-Zoccai G, Dohmen PM, Calkins H, Cardiac Surgery And Cardiology-Group Imcsc-Group IMAOC. Predictive Role of Coagulation, Fibrinolytic, and Endothelial Markers in Patients with Atrial Fibrillation, Stroke, and Thromboembolism: A Meta-Analysis, Meta-Regression, and Systematic Review. Med Sci Monit Basic Res 2017; 23:97-140. [PMID: 28360407 PMCID: PMC5452871 DOI: 10.12659/msmbr.902558] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background The pathophysiological mechanism associated with the higher prothrombotic tendency in atrial fibrillation (AF) is complex and multifactorial. However, the role of prothrombotic markers in AF remains inconclusive. Material/Methods We conducted a meta-analysis of observational studies evaluating the association of coagulation activation, fibrinolytic, and endothelial function with occurrence of AF and clinical adverse events. A comprehensive subgroup analysis and meta-regression was performed to explore potential sources of heterogeneity. Results A literature search of major databases retrieved 1703 studies. After screening, a total of 71 studies were identified. Pooled analysis showed the association of coagulation markers (D-dimer (weighted mean difference (WMD)=197.67 and p<0.001), fibrinogen (WMD=0.43 and p<0.001), prothrombin fragment 1–2 (WMD=0.53 and p<0.001), antithrombin III (WMD=23.90 and p=0.004), thrombin-antithrombin (WMD=5.47 and p=0.004)); fibrinolytic markers (tissue-type plasminogen activator (t-PA) (WMD=2.13 and p<0.001), plasminogen activator inhibitor (WMD=11.44 and p<0.001), fibrinopeptide-A (WMD=4.13 and p=0.01)); and endothelial markers (von Willebrand factor (WMD=27.01 and p<0.001) and soluble thrombomodulin (WMD=3.92 and p<0.001)) with AF. Conclusions The levels of coagulation, fibrinolytic, and endothelial markers have been reported to be significantly higher in AF patients than in SR patients.
Collapse
Affiliation(s)
- Alexander Weymann
- Department of Cardiac Surgery, University Hospital Oldenburg, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield Middlesex, United Kingdom.,Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | | | - Aron-Frederik Popov
- Department of Cardiac Surgery, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | | | - William L Baker
- , University of Connecticut/Hartford Hospital Evidence-Based Practice Center, Hartford, CT, USA
| | | | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, 2nd Hospital of Tianjin Medical University, Tianjin, China (mainland)
| | - Hamidreza Dehghan
- Department of Health Technology Assessment, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran
| | - Senol Yavuz
- Department of Cardiovascular Surgery, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey
| | - Michel Pompeu Barros de Oliveira Sá
- Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Brazil.,, University of Pernambuco - UPE, Recife, Brazil.,, Nucleus of Postgraduate and Research in Health Sciences of Faculty of Medical Sciences and Biological Sciences Institute (FCM/ICB), Recife, Brazil
| | - Jae-Sik Jang
- Department of Cardiology, Busan Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Mohamed Zeriouh
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield Middlesex, United Kingdom.,Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
| | - Lei Meng
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, 2nd Hospital of Tianjin Medical University, Tianjing, China (mainland)
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Abhishek J Deshmukh
- Mayo Clinic Heart Rhythm Section, Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Guiseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy.,Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy
| | - Pascal M Dohmen
- Department of Cardiac Surgery, University Hospital Oldenburg, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Hugh Calkins
- Department of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | |
Collapse
|
25
|
Wan H, Wu S, Yang Y, Zhu J, Zhang A, Liang Y. Plasma fibrin D-dimer and the risk of left atrial thrombus: A systematic review and meta-analysis. PLoS One 2017; 12:e0172272. [PMID: 28207839 PMCID: PMC5313133 DOI: 10.1371/journal.pone.0172272] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 02/02/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Plasma fibrin d-dimer has been taken as a marker for thrombus. The aim of this study was to evaluate the relationship between d-dimer (DD) levels and left atrial spontaneous echo contrast (SEC)/left atrial thrombus (LAT). METHODS We identified clinical studies by systematic search of MEDLINE and EMBASE databases up to Feb 2016. All observational studies that considered DD as a study factor and trans-esophageal echocardiography (TEE) identified SEC/LAT as an outcome were included. Two reviewers independently selected the studies and extracted the data. RESULTS Of the 21 included studies, 16 studies (2652 patients) have compared the mean DD differences between patients with and without an evidence of the presence of SEC/LAT, 9 studies (1667 patients) have estimated the diagnostic value of DD in the presence of LAT, and 11 studies (1856 patients) have available information to calculate a ratio of the presence of LAT among individuals in the top and the bottom third of DD levels. The pooled standardized mean difference (SMD) of DD between patients with and without left atrial SEC and/or LAT was 1.29 [95%CI: 0.51, 2.08], with SMDs of 0.42 [95% CI: 0.08, 0.77] and 2.34 [95% CI: 1.01, 3.68] in SEC/LAT and LAT subgroups, respectively. The combined risk ratio of the presence of LAT among individuals between the top of the distribution of DD levels and that in the bottom third was 3.84 [95% CI: 2.35, 6.28], associating with a mean difference of 0.78 ug/ml (1.10 vs 0.32 ug/ml). The pooled sensitivity, specificity and positive likelihood ratio of DD for LAT were 0.75 [95% CI: 0.65, 0.83], 0.81 [95% CI: 0.59, 0.93] and 4.0 [95% CI: 1.7, 9.9], respectively. CONCLUSIONS High plasma fibrin DD was associated with left atrial SEC/LAT, particularly among patients with LAT. DD levels have moderate sensitivity and specificity for diagnosing LAT.
Collapse
Affiliation(s)
- Huaibin Wan
- Department of Cardiology, the First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Shuang Wu
- Emergency and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yanmin Yang
- Emergency and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jun Zhu
- Emergency and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Aidong Zhang
- Department of Cardiology, the First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Yan Liang
- Emergency and Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| |
Collapse
|
26
|
Sharma G, Shetkar S, Bhasin A, Ramakrishnan L, Juneja R, Naik N, Roy A, Ramakrishnan S, Bhargava B, Bahl VK. High sensitive C-reactive protein and interleukin 6 in atrial fibrillation with rheumatic mitral stenosis from Indian cohort. Indian Heart J 2016; 69:505-511. [PMID: 28822519 PMCID: PMC5560862 DOI: 10.1016/j.ihj.2016.12.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 11/26/2016] [Accepted: 12/12/2016] [Indexed: 11/28/2022] Open
Abstract
Introduction Presence of chronic low grade inflammation has often been implicated in the etiology of atrial fibrillation (AF). Whether pre-existing inflammatory state promotes AF or initiation of AF activates inflammation is a dilemma among clinicians. This study investigates the role of high sensitive C reactive protein (hs-CRP) and interleukin 6 (IL-6) in AF with rheumatic mitral stenosis (Rh-MS) as markers of chronic inflammation. Methods This case control cohort included sixty five (n = 65) Rh-MS patients having other valve lesions as trivial to mild. Out of them twenty nine (n = 29; group C) had baseline AF and rest were normal sinus rhythm (NSR). A 24 h holter recording was done in NSR patients to diagnose paroxysmal AF/tachyarrhythmia forming group B (n = 12) and not having any tachyarrhythmia were designated as NSR; group A (n = 24). Results hs-CRP and IL6 showed statistically significant increase in group C (permanent AF) compared to group A (95% CI: 4.2–0.9, p = 0.007; 95% CI: 1.2–0.89; p = 0.05 respectively), while it was non significant between group A and group B (p > 0.05). A weak positive correlation was observed with hs-CRP and left atrial volume index (LAVi) (r = 0.45, p = 0.06) in AF group as compared to NSR group. 68.2% of patients in AF group (27/41) had moderate to severe spontaneous echo contrast (SEC) as compared to 37.5% (10/24) in NSR group. Conclusion Increased hs-CRP and IL-6 levels in the paroxysmal and permanent AF group may favour the hypothesis that low grade chronic inflammation could be the cause of atrial fibrillation than a consequence.
Collapse
Affiliation(s)
- Gautam Sharma
- Department of Cardiology, Room No 12, 8th floor, All India Institute of Medical Sciences, New Delhi, India.
| | - Sudhir Shetkar
- Department of Cardiology, Apollo Group of Hospitals, Nashik, India.
| | - Ashu Bhasin
- Department of Neurology, All India Institute of Medical Sciences, Room No 708, New Delhi, India.
| | - Lakshmy Ramakrishnan
- Department of Cardiac Biochemistry, All India Institute of Medical Sciences, Room No 61 Ground Floor, New Delhi, India.
| | - Rajnish Juneja
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.
| | - Nitish Naik
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.
| | - Ambuj Roy
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.
| | | | - Balram Bhargava
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.
| | - Vinay Kumar Bahl
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India.
| |
Collapse
|
27
|
Left Atrial Enlargement on Transthoracic Echocardiography Predicts Left Atrial Thrombus on Transesophageal Echocardiography in Ischemic Stroke Patients. BIOMED RESEARCH INTERNATIONAL 2016; 2016:7194676. [PMID: 27822477 PMCID: PMC5086361 DOI: 10.1155/2016/7194676] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 09/25/2016] [Indexed: 12/26/2022]
Abstract
Background. Transesophageal echocardiogram (TEE) is superior to transthoracic echocardiogram (TTE) in detecting left atrial thrombus (LAT), a risk factor for stroke, but is costly and invasive, carrying a higher risk for complications. Aims. To determine the utility of using left atrial enlargement (LAE) on TTE to predict LAT on TEE. Methods. AIS patients who presented in 06/2008–7/2013 and underwent both TTE and TEE were identified from our prospective stroke registry. Analysis consisted of multivariate logistic regression with propensity score adjustment and receiver operating characteristic (ROC) area under the curve (AUC) analyses. Results. 219 AIS patients underwent both TTE and TEE. LAE on TTE was detected in 113 (51.6%) of AIS patients. Patients with LAE on TTE had higher proportion of LAT on TEE (8.4% versus 1.0%, p = 0.018). LAE on TTE predicted increased odds of LAT on TEE (OR = 8.83, 95% CI 1.04–74.83, p = 0.046). The sensitivity and specificity for LAT on TEE by LAE on TEE were 88.89% and 52.20%, respectively (AUC = 0.7054, 95% CI 0.5906–0.8202). Conclusions. LAE on TTE can predict LAT detected on TEE in nearly 90% of patients. This demonstrates the utility of LAE on TTE as a potential screening tool for LAT, potentially limiting unneeded costs and complications associated with TEE.
Collapse
|
28
|
Topaloglu S, Boyaci A, Ayaz S, Yilmaz S, Yanik O, Ozdemir O, Soylu M, Demir AD, Aras D, Kisacik HL, Korkmaz S. Coagulation, Fibrinolytic System Activation and Endothelial Dysfunction in Patients With Mitral Stenosis and Sinus Rhythm. Angiology 2016; 58:85-91. [PMID: 17351162 DOI: 10.1177/0003319706297917] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Anticoagulation treatment can prevent systemic embolism in patients with mitral stenosis (MS) and atrial fibrillation (AF), but this treatment is under debate if patients are in sinus rhythm. The authors aimed to determine the hemostatic changes in patients with MS and sinus rhythm. Forty-six patients (28 in sinus rhythm and 18 in AF) with mitral stenosis were enrolled in this study. They studied systemic venous fibrinogen, D-dimer, antithrombin-III, tissue plasminogen activator (tPA), plasminogen activator inhibitor-I (PAI-I), von Willebrand factor (vWF), and platelet factor 4 (PF 4) in these patients. The patients were first classified according to their rhythm as sinusal and AF, and then according to the presence of left atrial spontaneous echo contrast (LASEC). Fibrinogen, D-dimer, antithrombin-III, vWF, and PF 4 levels were significantly greater in patients with MS and sinus rhythm or atrial fibrillation compared to the control group (p<0.05). Whether the rhythm was sinus or AF, fibrinogen, D-dimer, antithrombin-III, vWF, and PF 4 levels were significantly higher in patients with LASEC than in the control group (p<0.05). Only PF 4 was higher in the AF group than in those with sinus rhythm (p<0.05). As to plasminogen activator and PAI-I levels, only tissue plasminogen activator levels were found to be higher in the AF group than in those with sinus rhythm and the control group (p<0.05). In patients with mitral stenosis and sinus rhythm, if LASEC is present, coagulation activation, platelet activation, and endothelial dysfunction are similar in patients with AF, and anticoagulation should be considered in these patients.
Collapse
Affiliation(s)
- Serkan Topaloglu
- Department of Cardiology, Ankara Turkiye Yuksek Ihtisas Hospital, 06100 Sihhiye, Ankara, Turkey.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Watanabe T, Shinoda Y, Ikeoka K, Inui H, Fukuoka H, Sunaga A, Kanda T, Uematsu M, Hoshida S. Dabigatran exhibits low intensity of left atrial spontaneous echo contrast in patients with nonvalvular atrial fibrillation as compared with warfarin. Heart Vessels 2016; 32:326-332. [PMID: 27406344 PMCID: PMC5334411 DOI: 10.1007/s00380-016-0871-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 07/01/2016] [Indexed: 11/29/2022]
Abstract
The presence of spontaneous echo contrast (SEC) in the left atrium has been reported to be an independent predictor of thromboembolic risk in patients with atrial fibrillation (AF). Dabigatran was associated with lower rates of stroke and systemic embolism as compared with warfarin when administered at a higher dose. Between July 2011 and October 2015, nonvalvular AF patients treated with warfarin or dabigatran who had transesophageal echocardiography prior to ablation therapy for AF were enrolled. The intensity of SEC was classified into four grades, from 0 to 3. Univariate and multivariate analysis was performed to analyze factors associated with SEC. Sixty-five patients were on dabigatran and 65 were on warfarin, with the prothrombin time in therapeutic range. There were no significant differences in the age, CHADS2 score, left atrial dimension, and left atrial appendage flow between the two groups. However, there were more grade 2 or higher patients with left atrial SEC in the warfarin group (n = 20) than in the dabigatran group (n = 2) (p < 0.001). When multivariate regression analysis was performed, grade 2 or higher left atrial SEC was independently associated with no dabigatran usage in addition to high brain natriuretic peptide level and high incidence of diabetes mellitus or persistent AF. Thus, dabigatran exhibited low intensity of left atrial SEC in nonvalvular AF patients as compared with warfarin.
Collapse
Affiliation(s)
- Tetsuya Watanabe
- Department of Cardiovascular Medicine, Yao Municipal Hospital, 1-3-1 Ryuge-cho, Yao, Osaka, 581-0069, Japan.
| | - Yukinori Shinoda
- Department of Cardiovascular Medicine, Yao Municipal Hospital, 1-3-1 Ryuge-cho, Yao, Osaka, 581-0069, Japan
| | - Kuniyasu Ikeoka
- Department of Cardiovascular Medicine, Yao Municipal Hospital, 1-3-1 Ryuge-cho, Yao, Osaka, 581-0069, Japan
| | - Hirooki Inui
- Department of Cardiovascular Medicine, Yao Municipal Hospital, 1-3-1 Ryuge-cho, Yao, Osaka, 581-0069, Japan
| | - Hidetada Fukuoka
- Department of Cardiovascular Medicine, Yao Municipal Hospital, 1-3-1 Ryuge-cho, Yao, Osaka, 581-0069, Japan
| | - Akihiro Sunaga
- Cardiovascular Center, Kansai Rosai Hospital, 3-1-69 Inabaso, Amagasaki, Hyogo, 660-8511, Japan
| | - Takashi Kanda
- Cardiovascular Center, Kansai Rosai Hospital, 3-1-69 Inabaso, Amagasaki, Hyogo, 660-8511, Japan
| | - Masaaki Uematsu
- Cardiovascular Center, Kansai Rosai Hospital, 3-1-69 Inabaso, Amagasaki, Hyogo, 660-8511, Japan
| | - Shiro Hoshida
- Department of Cardiovascular Medicine, Yao Municipal Hospital, 1-3-1 Ryuge-cho, Yao, Osaka, 581-0069, Japan
| |
Collapse
|
30
|
Turgut N, Akdemir O, Turgut B, Demir M, Ekuklu G, Vural O, Ozbay G, Utku U. Hypercoagulopathy in Stroke Patients with Nonvalvular Atrial Fibrillation: Hematologic and Cardiologic Investigations. Clin Appl Thromb Hemost 2016; 12:15-20. [PMID: 16444430 DOI: 10.1177/107602960601200104] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The coagulation system is activated and coagulation activation markers are elevated in acute ischemic stroke with nonvalvular atrial fibrillation (NVAF). The etiology, severity, and prognosis of the ischemic stroke might be estimated with the level of the activation of the coagulation system. In this study, prothrombin F1+2 (F1+2), D-dimer, and fibrinogen levels were measured in patients with acute ischemic stroke with and without NVAF, and stroke severity was compared with these hemostatic parameters. Of 55 patients, 29 had sinus rhythm (group I), 26 had NVAF (group II); 20 healthy subjects (group III) were included in the study. Subtypes of cerebral infarction were classified. The patients underwent stroke severity, electrocardiography, echocardiography, cranial computed tomography, cervical duplex ultrasonography, and hemostatic parameter studies. In group II, F1+2 level (2.83±0.89) was significantly higher than in group I (2.33±0.80) and III (1.94±0.64) (p values: group I-II, 0.036; groups II-III, 0.001; groups I-III, 0.104). In group III, fibrinogen level (251.64±60.96) was significantly lower than that in groups I (347.97±111.49) and II (364.04±86.20) (p=0.001). D-dimer was not significantly different between groups. In group I, lacunar syndrome (LACS), and in group II, partial and total anterior circulation syndrome (PACS+TACS) were more common (p=0.013, p=0.001, respectively). In group II, Scandinavian Stroke Scale scores were lower than those in group I (group I=45.2±14, group II=35.4±18.9, p=0.02). In conclusion, activation of coagulation, demonstrated by increment F1+2, is more abundant in the stroke patients with NVAF than in the stroke patients with sinus rhythm. Our results also showed that activation of the hemostatic system might be related to stroke subtype and stroke severity. It is suggested that the oral anticoagulation treatment as prophylaxis is important in the prevention of stroke in patients with NVAF.
Collapse
Affiliation(s)
- Nilda Turgut
- Department of Neurology, Trakya University School of Medicine, Edirne, Turkey.
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Zhao Y, Ji L, Liu J, Wu J, Wang Y, Shen S, Guo S, Jian R, Chen G, Wei X, Liao W, Kutty S, Liao Y, Bin J. Intensity of Left Atrial Spontaneous Echo Contrast as a Correlate for Stroke Risk Stratification in Patients with Nonvalvular Atrial Fibrillation. Sci Rep 2016; 6:27650. [PMID: 27277939 PMCID: PMC4899705 DOI: 10.1038/srep27650] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 05/24/2016] [Indexed: 11/21/2022] Open
Abstract
The intensity of left atrial spontaneous echo contrast (LASEC) by transesophageal echocardiography (TEE) has been proposed as an important variable in the stratification of thromboembolic risk, particularly in patients with nonvalvular atrial fibrillation (NVAF). We hypothesized that the quantification of LASEC by ultrasound will improve its utility in predicting subsequent stroke events in patients with NVAF. Patients (n = 206) with definite NVAF receiving TEE were included for this prospective cohort study. Baseline clinical risk factors of stroke, CHADS2 score and CHA2DS2-Vasc, left atrial thrombus (LAT), the five-grades of LASEC and video intensity (VI) value of LASEC were measured. During 2 years follow-up, 20 patients (9.7%) developed stroke. VI value of LASEC in the patients with stroke was higher compared to patients without stroke (25.30 ± 3.61 vs. 8.65 ± 0.81, p < 0.001). On logistic regression analysis, LAT, qualitative LASEC, graded LASEC, VI value of LASEC and CHADS2 and CHA2DS2-Vasc score were independent predictors of stroke. Among them, the highest area under the curve of receiver operating characteristic (ROC) in predicting stroke was VI value of LASEC (p < 0.05). These results show that quantification of LASEC by VI value is the most favorable predictor of stroke in patients with NVAF, and calls for improving the utility of LASEC in predicting subsequent stroke events.
Collapse
Affiliation(s)
- Yuanping Zhao
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.,Department of Gerontology, Cangzhou Central Hospital, Cangzhou, china
| | - Lijing Ji
- Department of Ultrasonography, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Jian Liu
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Juefei Wu
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Yan Wang
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Shuxin Shen
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Shengcun Guo
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Rong Jian
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Gangbin Chen
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Xuan Wei
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Wangjun Liao
- Department of Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Shelby Kutty
- University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, NE, United States
| | - Yulin Liao
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Jianping Bin
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| |
Collapse
|
32
|
Ali S, Ugwu J, Kanjwal Y. A Stunning Left Atrial Appendage Thrombus. Cardiology 2016; 134:394-7. [PMID: 27111448 DOI: 10.1159/000444166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 01/20/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Left atrial appendage thrombus formation is a known major complication of atrial fibrillation and atrial flutter which increases the risk of embolism and stroke. This risk of thrombosis is greatly increased with a lack of anticoagulation. After conversion to a normal sinus rhythm in these arrhythmias, the risk of thrombus formation in the left atrium persists through a phenomenon termed atrial myocardial stunning. CASE We present the case of a patient who previously underwent successful pulmonary vein isolation and was found to be in typical isthmus-dependent atrial flutter with a questionable recurrence of atrial fibrillation. The decision was made to return for atrial flutter ablation and for evaluation of prior pulmonary vein isolation. Initially, a transesophageal echocardiogram showed a normal ejection fraction, biatrial enlargement and no left atrial appendage thrombus. Ablation of the cavotricuspid isthmus was successfully accomplished with documented bidirectional block. A transesophageal echocardiogram probe was still in place prior to planned transseptal puncture for the evaluation of pulmonary veins. A large thrombus was now observed filling the left atrial appendage. Conclusion and Objective: Atrial stunning is a transient atrial contractile dysfunction that occurs whether sinus rhythm is restored spontaneously, electrically, pharmacologically or by ablation. We know after conversion that there is higher propensity to increased spontaneous echogenic contrast and decreased velocities; however, we do not have documented knowledge of exactly how soon after the conversion to a sinus rhythm a thrombus may be seen. We demonstrate a case of acute left atrial appendage thrombus formation immediately following the successful ablation of isthmus-dependent atrial flutter. Our report validates the belief that strategies of not interrupting anticoagulation prior to the conversion of these arrhythmias should be implemented.
Collapse
Affiliation(s)
- Sajid Ali
- Mercy St. Vincent Hospital and Medical Center, Toledo, Ohio, USA
| | | | | |
Collapse
|
33
|
Labbé V, Ederhy S. Faut-il anticoaguler les patients présentant une fibrillation atriale de novo en réanimation ? MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1178-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
34
|
A hypothesis about how to achieve anticoagulation without bleeding. Med Hypotheses 2015; 85:720-2. [DOI: 10.1016/j.mehy.2015.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 10/22/2015] [Indexed: 11/17/2022]
|
35
|
Choi JC, Oh YH, Kim JG, Kim HJ, Kong MH, Paeng DG, Ko NU, Easton JD. Spontaneous echo-contrast in the internal jugular veins of patients with ischemic stroke. JOURNAL OF CLINICAL ULTRASOUND : JCU 2015; 43:431-437. [PMID: 25346199 DOI: 10.1002/jcu.22249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 10/07/2014] [Indexed: 06/04/2023]
Abstract
PURPOSE Spontaneous echo-contrast (SEC) appears on B-mode images as moving curls of smoke in the lumen of veins. The aims of this study were to investigate the prevalence and characteristics of internal jugular vein SEC among patients with stroke, in comparison with control subjects. METHODS We enrolled 97 Korean patients with acute ischemic stroke and 50 controls. Both internal jugular veins were examined for the presence and severity of SEC and measurement of flow velocity. Venous samples were obtained for laboratory evaluation of hematologic factors. RESULTS In 294 internal jugular veins, the prevalence of SEC was 81% in stroke patients and 68% in controls (odds ratio, 2.0; 95% confidence interval, 1.1-3.6; p = 0.013). Stroke patients were more likely to have SEC on the left (p = 0.025) than on the right (p = 0.184) internal jugular vein. Overall, the association between stroke and SEC remained significant after adjustment for other variables (odds ratio, 4.3; 95% confidence interval, 1.7-10.8; p = 0.002). CONCLUSIONS Internal jugular vein SEC was found more frequently in stroke patients than in controls. However, local as well as systemic factors must be considered in the interpretation of this finding.
Collapse
Affiliation(s)
- Jay Chol Choi
- Department of Neurology, Jeju National University, Jeju, Korea
| | - Yun-Hee Oh
- Department of Neurology, Jeju National University, Jeju, Korea
| | - Joong Goo Kim
- Department of Neurology, Jeju National University, Jeju, Korea
| | - Hyeon-Ju Kim
- Department of Family Medicine, Jeju National University, Jeju, Korea
| | - Mi-Hee Kong
- Department of Family Medicine, Jeju National University, Jeju, Korea
| | - Dong-Guk Paeng
- Department of Ocean System Engineering, Jeju National University, Jeju, Korea
| | - Nerissa U Ko
- Department of Neurology, University of California-San Francisco, San Francisco, California
| | - J Donald Easton
- Department of Neurology, University of California-San Francisco, San Francisco, California
| |
Collapse
|
36
|
Lim HS, Willoughby SR, Schultz C, Alasady M, Rangnekar G, Dang J, Gan C, Lau DH, Roberts-Thomson KC, Young GD, Worthley MI, Sanders P. Thrombogenic Risk in Patients With Atrial Fibrillation. JACC Clin Electrophysiol 2015; 1:210-217. [DOI: 10.1016/j.jacep.2015.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 02/17/2015] [Accepted: 03/26/2015] [Indexed: 10/23/2022]
|
37
|
Detection of left atrial thrombus by intracardiac echocardiography in patients undergoing ablation of atrial fibrillation. J Interv Card Electrophysiol 2015; 43:227-36. [DOI: 10.1007/s10840-015-0008-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 04/06/2015] [Indexed: 01/30/2023]
|
38
|
Wu N, Chen X, Cai T, Wu L, Xiang Y, Zhang M, Li Y, Song Z, Zhong L. Association of inflammatory and hemostatic markers with stroke and thromboembolic events in atrial fibrillation: a systematic review and meta-analysis. Can J Cardiol 2014; 31:278-86. [PMID: 25746020 DOI: 10.1016/j.cjca.2014.12.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 12/05/2014] [Accepted: 12/05/2014] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) increases the risk of stroke and thromboembolic events. Recently, biomarkers have been proposed as a practical tool to predict adverse outcomes in patients with AF. The prognostic value of inflammatory and hemostatic markers in AF has been widely studied; however, the results of previous studies have been inconclusive. METHODS We conducted a systematic review and meta-analysis to evaluate the association of inflammatory and hemostatic markers with stroke and thromboembolic events in patients with AF. RESULTS A total of 27 studies including 22,176 participants met our inclusion criteria for the systematic review. Our meta-analysis determined that elevated circulating plasminogen activator inhibitor-1 (PAI-1) and thrombin-antithrombin (TAT) were significantly associated with increased risk of stroke in patients with AF (standardized mean difference [SMD], 0.89; 95% confidence interval [CI], 0.20-1.59 and 1.43; 95% CI, 0.40-2.47, respectively). Higher levels of D-dimer were associated with increased subsequent thromboembolic event risk with a pooled hazard ratio of 2.90 (95% CI, 1.22-6.90) for cohort studies and an SMD of 0.93 (95% CI, 0.36-1.50) for case-control studies. There was also very limited evidence indicating that other biomarkers-such as interleukin-6, von Willebrand factor, P-selectin, and mean platelet volume-could predict adverse outcomes in AF. CONCLUSIONS In conclusion, increased circulating PAI-1 and TAT levels were significantly associated with subsequent stroke in patients with AF, and high levels of D-dimer were associated with thromboembolic events in AF. Further epidemiologic studies are needed to accumulate more evidence on the prognostic role of inflammatory and hemostatic markers in AF.
Collapse
Affiliation(s)
- Na Wu
- Department of Epidemiology, College of Preventive Medicine, Third Military Medical University, Chongqing, People's Republic of China; Evidence-based Medicine and Clinical Epidemiology Center, Third Military Medical University, Chongqing, People's Republic of China
| | - Xinghua Chen
- Department of Cardiology, Southwest Hospital, Third Military Medical University, Chongqing, People's Republic of China
| | - Tongjian Cai
- Department of Epidemiology, College of Preventive Medicine, Third Military Medical University, Chongqing, People's Republic of China; Evidence-based Medicine and Clinical Epidemiology Center, Third Military Medical University, Chongqing, People's Republic of China
| | - Long Wu
- Department of Epidemiology, College of Preventive Medicine, Third Military Medical University, Chongqing, People's Republic of China; Evidence-based Medicine and Clinical Epidemiology Center, Third Military Medical University, Chongqing, People's Republic of China
| | - Ying Xiang
- Department of Epidemiology, College of Preventive Medicine, Third Military Medical University, Chongqing, People's Republic of China; Evidence-based Medicine and Clinical Epidemiology Center, Third Military Medical University, Chongqing, People's Republic of China
| | - Mengxuan Zhang
- Department of Epidemiology, College of Preventive Medicine, Third Military Medical University, Chongqing, People's Republic of China; Evidence-based Medicine and Clinical Epidemiology Center, Third Military Medical University, Chongqing, People's Republic of China
| | - Yafei Li
- Department of Epidemiology, College of Preventive Medicine, Third Military Medical University, Chongqing, People's Republic of China; Evidence-based Medicine and Clinical Epidemiology Center, Third Military Medical University, Chongqing, People's Republic of China
| | - Zhiyuan Song
- Department of Cardiology, Southwest Hospital, Third Military Medical University, Chongqing, People's Republic of China
| | - Li Zhong
- Department of Cardiology, Southwest Hospital, Third Military Medical University, Chongqing, People's Republic of China.
| |
Collapse
|
39
|
Jørgensen PG, Arnemo J, Swenson JE, Jensen JS, Galatius S, Frøbert O. Low cardiac output as physiological phenomenon in hibernating, free-ranging Scandinavian brown bears (Ursus arctos) - an observational study. Cardiovasc Ultrasound 2014; 12:36. [PMID: 25224464 PMCID: PMC4245199 DOI: 10.1186/1476-7120-12-36] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 09/09/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite 5-7 months of physical inactivity during hibernation, brown bears (Ursus arctos) are able to cope with physiological conditions that would be detrimental to humans. During hibernation, the tissue metabolic demands fall to 25% of the active state. Our objective was to assess cardiac function associated with metabolic depression in the hibernating vs. active states in free-ranging Scandinavian brown bears. METHODS We performed echocardiography on seven free-ranging brown bears in Dalarna, Sweden, anesthetized with medetomidine-zolazepam-tiletamine-ketamine during winter hibernation in February 2013 and with medetomidine-zolazepam-tiletamine during active state in June 2013. We measured cardiac output noninvasively using estimates of hemodynamics obtained by pulsed wave Doppler echocardiography and 2D imaging. Comparisons were made using paired T-tests. RESULTS During hibernation, all hemodynamic indices were significantly decreased (hibernating vs. active state): mean heart rate was 26.0 (standard deviation (SD): 5.6) beats per min vs. 75.0 (SD: 17.1) per min (P=0.002), mean stroke volume 32.3 (SD: 5.2) ml vs. 47.1 (SD: 7.9) ml (P=0.008), mean cardiac output 0.86 (SD: 0.31) l/min vs. 3.54 (SD: 1.04) l/min (P=0.003), and mean cardiac index 0.63 (SD: 0.21) l/min/kg vs. 2.45 (SD: 0.52) l/min/ m2 (P<0.001). Spontaneous echo contrast was present in all cardiac chambers in all seven bears during hibernation, despite the absence of atrial arrhythmias and valvular disease. CONCLUSION Free-ranging brown bears demonstrate hemodynamics comparable to humans during active state, whereas during hibernation, we documented extremely low-flow hemodynamics. Understanding these physiological changes in bears may help to gain insight into the mechanisms of cardiogenic shock and heart failure in humans.
Collapse
Affiliation(s)
- Peter Godsk Jørgensen
- Department of Cardiology, University of Copenhagen, Gentofte Hospital, Copenhagen, Denmark.
| | | | | | | | | | | |
Collapse
|
40
|
Hsu HY, Lee YS, Ou MC, Chung CP, Chen SY, Ho YP, Hu HH. Severity of spontaneous echo contrast in the jugular vein associated with ischemic stroke. ULTRASOUND IN MEDICINE & BIOLOGY 2014; 40:1427-1433. [PMID: 24768488 DOI: 10.1016/j.ultrasmedbio.2014.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 02/05/2014] [Accepted: 02/06/2014] [Indexed: 06/03/2023]
Abstract
This study evaluated the relationship between spontaneous echo contrast (SEC) in the internal jugular vein (JV), atherosclerotic markers and ischemic stroke. One hundred twenty patients with acute ischemic stroke and 120 controls were recruited. SEC score correlated with plasma level of fibrinogen (coefficient: 0.105, p = 0.022), hemoglobin (coefficient: 0.122, p = 0.008) and presence of JV reflux (coefficient: 0.314, p < 0.001) and peak flow velocity (coefficient: -0.244, p < 0.001) in the corresponding JV, but did not correlate with carotid plaque score (coefficient: 0.042, p = 0.358) or intima-media thickness (coefficient: 0.067, p = 0.303). Multivariate regression analysis revealed that fibrinogen level, SEC score, intima-media thickness, plaque score and history of coronary artery disease were associated with acute ischemic stroke. In conclusion, the severity of SEC in the JV might represent the tendency toward thrombogenesis in diseased cerebral circulation possibly through mechanisms other than arterial atherosclerosis.
Collapse
Affiliation(s)
- Hung-Yi Hsu
- Department of Neurology, Tungs' Taichung Metro Harbor Hospital, Taichung, Taiwan, Republic of China; School of Medicine, Chung Shan Medical University, Taichung, Taiwan, Republic of China; Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China.
| | - Yu-Shan Lee
- Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Ming-Che Ou
- Department of Hematology, Tungs' Taichung Metro Harbor Hospital, Taichung, Taiwan, Republic of China
| | - Chih-Ping Chung
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China; Neurologic Institute, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - Su-Yi Chen
- Department of Neurology, Tungs' Taichung Metro Harbor Hospital, Taichung, Taiwan, Republic of China; School of Medicine, Chung Shan Medical University, Taichung, Taiwan, Republic of China
| | - Yu-Ping Ho
- Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Han-Hwa Hu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China; Neurologic Institute, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| |
Collapse
|
41
|
|
42
|
Comparison of transesophageal echocardiography versus computed tomography for detection of left atrial appendage filling defect (thrombus). Am J Cardiol 2014; 113:173-7. [PMID: 24216123 DOI: 10.1016/j.amjcard.2013.09.037] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Revised: 09/03/2013] [Accepted: 09/03/2013] [Indexed: 02/02/2023]
Abstract
Patients with atrial fibrillation, who are referred for radiofrequency pulmonary vein antral isolation, frequently undergo transesophageal echocardiography (TEE) to detect and/or exclude left atrial or left atrial appendage (LAA) thrombus and cardiac computed tomographic angiography (CCTA) to define and/or evaluate left atrial and pulmonary venous anatomy. Previous studies have reported CCTA to have high sensitivity and negative predictive value (NPV) for detecting thrombus in the LAA. Previous studies determining an optimal LAA/ascending aorta (AA) Hounsfield unit (HU) density ratio for detection of LAA thrombus have been small, with limited numbers of thrombi. We thus sought to determine both the optimal cutoff for LAA HU density and LAA/AA HU density ratio in detecting LAA thrombus compared with TEE in a multicenter population. We included 84 patients who had undergone CCTA and TEE. LAA was evaluated by 64-row CCTA qualitatively (visual filling defect) and quantitatively (measurement of LAA HU density and LAA/AA HU density ratio), using a 1-cm area of interest in the same axial plane. Results were compared with TEE visualization of thrombus or spontaneous echo contrast. Qualitative identification of thrombus in LAA by CCTA compared with TEE detection of thrombus had a sensitivity of 100%, a specificity of 77.9%, a positive predictive value (PPV) of 51.6%, an NPV of 100%, and a total accuracy of 82.1%. The optimal LAA HU density cutoff for thrombus detection was 119 with a sensitivity of 88%, a specificity of 86%, PPV 56%, and an area under the curve of 0.923 (p = 0.0004). The optimal LAA/aorta HU ratio was 0.242 with a sensitivity of 87%, a specificity of 88%, a PPV of 64%, and an area under the curve of 0.921 (p = 0.0011). There is no significant difference (p = 0.72) between both areas under the curve, and both measurements improved the specificity and PPV compared with qualitative measures. Multidetector computed tomography is an imaging technique that can exclude LAA thrombus with very high NPV. Quantitative measurement of LAA HU density (cutoff 119) or LAA/aorta HU density ratio (cutoff 0.242) improves accuracy of positively detecting LAA thrombus. This technique is especially useful when delayed scanning is not performed and LAA is found incidentally after the patient scanning is complete.
Collapse
|
43
|
Kawabori M, Yoshimoto T, Ito M, Fujimoto S, Mikami T, Muraki M, Kaneko S, Nakayama N, Kuroda S, Houkin K. Spontaneous echo contrast and thrombus formation at the carotid bifurcation after carotid endarterectomy. Neurol Med Chir (Tokyo) 2013; 52:885-91. [PMID: 23269043 DOI: 10.2176/nmc.52.885] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Spontaneous echo contrast (SEC) consists of numerous microechoes swirling in the cardiovascular lumen and is usually seen during blood stasis in dysfunctional left atrium. However, SEC and consecutive local thrombus formation at the carotid artery early after carotid endarterectomy (CEA) have not been reported. This study retrospectively investigated the clinical importance and therapeutic strategy of postoperative SEC and thrombus formation in 113 consecutive patients who underwent CEA between 2001 and 2009. Ultrasonography was routinely performed preoperatively, intraoperatively, and 1 day and 1 week after the operation. If SEC and/or thrombus was detected at any time after the operation, follow-up ultrasonography was performed at short intervals, once a week for inpatients and once every 1-2 months for outpatients. Eight of the 113 patients (7%) had SEC after the operation from Day 1 to 12 (mean 7.2 days), and 6 of these 8 patients developed local de novo thrombus formation at the site of SEC from Day 6 to 33 (mean 14.7 days). The maximum luminal narrowing by the thrombi were 26-62% (mean 37%). After administering anticoagulant therapy, all thrombi disappeared from Day 13 to 190 (mean 57 days) from CEA. SEC seen after CEA is highly associated with consecutive local thrombus formation. Postoperative geometric blood stasis with the absence of intima may be the causative factor for its development.
Collapse
Affiliation(s)
- Masahito Kawabori
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Kupczyńska K, Kasprzak JD, Michalski B, Lipiec P. Prognostic significance of spontaneous echocardiographic contrast detected by transthoracic and transesophageal echocardiography in the era of harmonic imaging. Arch Med Sci 2013; 9:808-14. [PMID: 24273561 PMCID: PMC3832826 DOI: 10.5114/aoms.2013.38674] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 01/22/2011] [Accepted: 03/23/2011] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Echocardiographic diagnosis of spontaneous intracardiac contrast is the reflection of interactions between erythrocytes and plasma proteins. Underlying conditions are associated with low blood flow velocities in the heart. We sought to determine whether spontaneous echo contrast (SEC) detected in the era of widespread use of harmonic imaging still reflects poor prognosis and risk of thromboembolism. MATERIAL AND METHODS We retrospectively analyzed the database of a tertiary cardiology centre echocardiographic laboratory and identified 60 patients with SEC, but without solid intracardiac structures, and subsequently selected 60 sex- and age-matched controls without SEC. Data regarding baseline characteristics, treatment and clinical course during follow-up (median: 33.5 months; 95% CI: 24.79-40) were gained based on hospital and out-patient clinic documentation and telephone interviews. The clinical end-points included: all-cause death, cardiovascular death, stroke or transient ischemic attack (TIA), pulmonary embolism, peripheral embolism and composite thromboembolic end-point. RESULTS We observed that in the whole study group (p = 0.0016) and in the subgroup evaluated by TTE (p = 0.005) SEC predicted higher mortality. In the group assessed by TEE, SEC correlated with higher probability of stroke or TIA (p = 0.04). By multivariate analysis, in all patients SEC was a predictor of cardiovascular death (OR = 7.63; p = 0.008) and its localization in the left atrium independently predisposed to thromboembolism (OR = 10.15; p = 0.012). Furthermore, left ventricular SEC detected by TTE also emerged as an independent determinant of higher mortality (OR = 5.26; p = 0.015). CONCLUSIONS Despite a lower threshold of detection using harmonic imaging SEC is still a risk factor of poor prognosis, especially when observed on transthoracic examination.
Collapse
|
45
|
Odashiro K, Maruyama T, Yokoyama T, Nakamura H, Fukata M, Yasuda S, Saito K, Fujino T, Akashi K. Impaired Erythrocyte Deformability in Patients with Coronary Risk Factors: Significance of Nonvalvular Atrial Fibrillation. J Atr Fibrillation 2013; 6:939. [PMID: 28496902 DOI: 10.4022/jafib.939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 10/30/2013] [Accepted: 10/30/2013] [Indexed: 11/10/2022]
Abstract
Although coronary risk factors promote the formation of atherosclerotic plaque containing activated platelets and inflammatory leukocytes, and play a pivotal role in the development of coronary artery diseases (CAD), the hemorheological effects of these risk factors on circulating intact erythrocytes, a major component of whole blood cells, are poorly understood. Therefore, this study aimed to quantify erythrocyte deformability in patients with coronary risk factors, and enrolled 320 consecutive cardiac outpatients including 33 patients with nonvalvular atrial fibrillation (AF). Patients with acute coronary syndrome or valvular AF were excluded. Demographic variables obtained by medical records were correlated with erythrocyte deformability investigated by our highly sensitive and reproducible filtration technique. Among demographic variables, triglyceride (p = 0.004), HbA1c (p = 0.014) and body weight (p = 0.020) showed significant inverse correlation to the erythrocyte deformability. This deformability was not associated with types of CAD (old myocardial infarction vs. stable angina) or modality of treatment (percutaneous intervention vs. coronary artery bypass grafting). Unexpectedly, stepwise multiple regression analysis demonstrated that nonvalvular AF was the most significant contributor to the impaired erythrocyte deformability (p = 0.002). Hypertension and dyslipidemia are more prevalent in the AF patients (p < 0.001), and the erythrocyte deformability was found to be impaired synergistically and significantly (p < 0.001) during the stepwise accumulation of the coronary risk factors in addition to AF. In conclusion coronary risk factors synergistically impair the erythrocyte deformability, which may play an important role in critically stenotic coronary arteries. Since the impairment of intact erythrocyte deformability is mostly associated with nonvalvular AF, this common arrhythmia may reflect the coronary risk accumulation.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Takehiko Fujino
- Institute of Rheological Function of Foods Co. Ltd., Fukuoka, Japan
| | | |
Collapse
|
46
|
Lappegård KT, Hovland A, Pop GAM, Mollnes TE. Atrial fibrillation: inflammation in disguise? Scand J Immunol 2013; 78:112-9. [PMID: 23672430 DOI: 10.1111/sji.12061] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 05/03/2013] [Indexed: 02/03/2023]
Abstract
Atrial fibrillation is highly prevalent, and affected patients are at an increased risk of a number of complications, including heart failure and thrombo-embolism. Over the past years, there has been increasing interest in the role of inflammatory processes in atrial fibrillation, from the first occurrence of the arrhythmia to dreaded complications such as strokes or peripheral emboli. As the standard drug combination which aims at rate control and anticoagulation only offers partial protection against complications, newer agents are needed to optimize treatment. In this paper, we review recent knowledge regarding the impact of inflammation on the occurrence, recurrence, perpetuation and complications of the arrhythmia, as well as the role of anti-inflammatory therapies in the treatment for the disease.
Collapse
Affiliation(s)
- K T Lappegård
- Coronary Care Unit, Division of Internal Medicine, Nordland Hospital, Bodø, Norway.
| | | | | | | |
Collapse
|
47
|
Cox JL. Mechanical closure of the left atrial appendage: is it time to be more aggressive? J Thorac Cardiovasc Surg 2013; 146:1018-1027.e2. [PMID: 23993272 DOI: 10.1016/j.jtcvs.2013.07.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 07/09/2013] [Indexed: 10/26/2022]
Affiliation(s)
- James L Cox
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Mo.
| |
Collapse
|
48
|
Godai K, Hasegawa-Moriyama M, Unoki K, Uchida Y, Kuniyoshi T, Matsunaga A, Kanmura Y. Suspected intraoperative formation of left atrial thrombus in a patient with atrial fibrillation receiving bridging anticoagulation therapy. J Anesth 2013; 28:112-5. [PMID: 23812542 DOI: 10.1007/s00540-013-1664-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Accepted: 06/14/2013] [Indexed: 10/26/2022]
Abstract
We present a patient with atrial fibrillation (AF) in whom a left atrial (LA) thrombus might have formed during laparotomy despite bridging anticoagulation therapy. No evidence of thrombus was detected by transesophageal echocardiography (TEE) at the start of surgery; however, a thrombus measuring 13 × 10 mm was found in the LA appendage by the end of the procedure, suggesting that thrombus might develop intraoperatively in patients with AF even when bridging anticoagulation is properly established. Intraoperative TEE can assist in detecting intracardiac thrombus in patients with AF regardless of their anticoagulation status and provides a tool for intervention to prevent systemic embolization.
Collapse
Affiliation(s)
- Kohei Godai
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan,
| | | | | | | | | | | | | |
Collapse
|
49
|
Lim HS, Willoughby SR, Schultz C, Gan C, Alasady M, Lau DH, Leong DP, Brooks AG, Young GD, Kistler PM, Kalman JM, Worthley MI, Sanders P. Effect of atrial fibrillation on atrial thrombogenesis in humans: impact of rate and rhythm. J Am Coll Cardiol 2013; 61:852-60. [PMID: 23333141 DOI: 10.1016/j.jacc.2012.11.046] [Citation(s) in RCA: 149] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 11/18/2012] [Accepted: 11/20/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVES We sought to assess the effect of atrial fibrillation (AF) on atrial thrombogenesis in humans by determining the impact of rate and rhythm. BACKGROUND Although AF is known to increase the risk of thromboembolic stroke from the left atrium (LA), the exact mechanisms remain poorly understood. METHODS We studied 55 patients with AF who underwent catheter ablation while in sinus rhythm; 20 patients were induced into AF, 20 patients were atrial paced at 150 beats/min, and 15 were control patients. Blood samples were taken from the LA, right atrium, and femoral vein at baseline and at 15 min in all 3 groups. Platelet activation (P-selectin) was measured by flow cytometry. Thrombin generation (thrombin-antithrombin [TAT] complex), endothelial dysfunction (asymmetric dimethylarginine [ADMA]), and platelet-derived inflammation (soluble CD40 ligand [sCD40L]) were measured using enzyme-linked immunosorbent assay. RESULTS Platelet activation increased significantly in both the AF (p < 0.001) and pacing (p < 0.05) groups, but decreased in control patients (p < 0.001). Thrombin generation increased specifically in the LA compared with the periphery in both the AF (p < 0.01) and pacing (p < 0.01) groups, but decreased in control patients (p < 0.001). With AF, ADMA (p < 0.01) and sCD40L (p < 0.001) levels increased significantly at all sites, but were unchanged with pacing (ADMA, p = 0.5; sCD40L, p = 0.8) or in control patients (ADMA, p = 0.6; sCD40L, p = 0.9). CONCLUSIONS Rapid atrial rates and AF in humans both result in increased platelet activation and thrombin generation. Prothrombotic activation occurs to a greater extent in the human LA compared with systemic circulation. AF additionally induces endothelial dysfunction and inflammation. These findings suggest that although rapid atrial rates increase the thrombogenic risk, AF may further potentiate this risk.
Collapse
Affiliation(s)
- Han S Lim
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Hsu HY, Chung CP, Chen SY, Chiang YY, Hu HH. Spontaneous echo contrast in internal jugular veins: a probable indicator for systemic inflammation and a prothrombotic state. ULTRASOUND IN MEDICINE & BIOLOGY 2012; 38:926-932. [PMID: 22475693 DOI: 10.1016/j.ultrasmedbio.2012.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2011] [Revised: 01/29/2012] [Accepted: 02/05/2012] [Indexed: 05/31/2023]
Abstract
The hypothesis that spontaneous echo contrast (SEC) in the internal jugular vein (IJV) is a clinical indicator for systemic inflammation and thrombogenesis is investigated in this study. Fifty-two patients with cardiovascular diseases and 25 nondiseased subjects were evaluated. SEC was observed in 96 of 154 IJVs. The visual grading of SEC showed good interobserver agreement on SEC grades (κ value: 0.846, p < 0.001). Generalized estimating equations analysis was used for univariate and multivariate analysis. Univariate analysis showed that peak flow velocity in corresponding IJV (coefficient -0.001 [95% CI -0.019, -0.001], p = 0.031), jugular venous reflux (JVR, -0.010 [-0.019, -0.001], p = 0.002), plasma levels of fibrinogen (0.464 [0.208, 0.719], p < 0.001) and hs-C-reactive protein (hs-CRP) (0.479 [0.184, 0.774], p = 0.001) and previous history of ischemic stroke (0.779 [0.139, 1.417]; p = 0.017) correlated with the grades of SEC in IJV. Increased plasma levels of fibrinogen and hs-CRP, previous ischemic stroke, lower peak velocity in corresponding IJV and JVR were also independent predictors for the higher grades of SEC in IJV in multivariate regression analysis. SEC in IJV could be evaluated easily and semiquantitatively. SEC in IJVs could be a putative marker of cerebral circulation disturbance and an indicator of systemic inflammatory or prothrombotic state.
Collapse
Affiliation(s)
- Hung-Yi Hsu
- Department of Neurology, Tungs' Taichung Metro Harbor Hospital, Wuci Township, Taichung County, Taiwan.
| | | | | | | | | |
Collapse
|