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Takaishi Y, Kawasaki K, Uematsu K, Yoshioka S. Spontaneous echo contrast and decreased umbilical vein blood flow may predict thrombus formation in fetal intra-abdominal umbilical vein varix. J Med Ultrason (2001) 2024; 51:477-481. [PMID: 38530506 DOI: 10.1007/s10396-024-01428-w] [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: 01/06/2023] [Accepted: 02/09/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE Fetal intra-abdominal umbilical vein varix (FIUVV) can cause thrombosis, fetal growth restriction (FGR), and intrauterine fetal death (IUFD). However, its management and evaluation to avoid fetal risks have not been elucidated. The aim of this study was to develop a novel method to evaluate fetal risks, including FGR and fetal dysfunction via frequent ultrasound examinations. METHODS A 28-year-old pregnant woman was diagnosed with FIUVV via ultrasound at 26 weeks of gestation and admitted to our hospital. Ultrasound examinations were performed two to three times weekly to evaluate size and shape of the FIUVV and umbilical vein blood flow at the inflow and outflow sites of the FIUVV. RESULTS The outflow site of the FIUVV was constricted and collapsed, and the blood flow velocity at the inflow site of the FIUVV was decreased. At 32 weeks of gestation, spontaneous echo contrast (SEC), which indicates increased echogenicity, appeared. At 35 weeks of gestation, the patient noticed decreased fetal movement, and CTG showed non-reassuring fetal status. SEC in the FIUVV was remarkable. Fetal movement could not be confirmed at ultrasound. Cesarean section was performed and a 1,854-g healthy infant was delivered with an umbilical cord arterial pH of 7.266. CONCLUSION The echographic changes, such as decreased umbilical vein blood flow and SEC, in FIUVV observed in this case could indicate thrombus formation, which can lead to fetal dysfunction. Frequent ultrasound examinations can help determine the timing of delivery and improve the neonatal prognosis.
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Affiliation(s)
- Yu Takaishi
- Department of Obstetrics and Gynaecology, Kobe City Medical Center General Hospital, Kobe, Japan
- Department of Obstetrics and Gynaecology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Kaoru Kawasaki
- Department of Obstetrics and Gynaecology, Kobe City Medical Center General Hospital, Kobe, Japan.
- Department of Obstetrics and Gynaecology, Kindai University Faculty of Medicine, 377-2 Ohno-Higashi, Osaka-Sayama, Osaka, 589-8511, Japan.
| | - Kazuhiko Uematsu
- Department of Obstetrics and Gynaecology, Kobe City Medical Center General Hospital, Kobe, Japan
- Kosaka Womens Hospital, Higashi-Osaka, Japan
| | - Shinya Yoshioka
- Department of Obstetrics and Gynaecology, Kobe City Medical Center General Hospital, Kobe, Japan
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Huang O, Shi Z, Garg N, Jensen C, Palmeri ML. Automated Spontaneous Echo Contrast Detection Using a Multisequence Attention Convolutional Neural Network. ULTRASOUND IN MEDICINE & BIOLOGY 2024; 50:788-796. [PMID: 38461036 PMCID: PMC11060922 DOI: 10.1016/j.ultrasmedbio.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 03/11/2024]
Abstract
OBJECTIVE Spontaneous echo contrast (SEC) is a vascular ultrasound finding associated with increased thromboembolism risk. However, identification requires expert determination and clinician time to report. We developed a deep learning model that can automatically identify SEC. Our model can be applied retrospectively without deviating from routine clinical practice. The retrospective nature of our model means future works could scan archival data to opportunistically correlate SEC findings with documented clinical outcomes. METHODS We curated a data set of 801 archival acquisitions along the femoral vein from 201 patients. We used a multisequence convolutional neural network (CNN) with ResNetv2 backbone and visualized keyframe importance using soft attention. We evaluated SEC prediction performance using an 80/20 train/test split. We report receiver operating characteristic area under the curve (ROC-AUC), along with the Youden threshold-associated sensitivity, specificity, F1 score, true negative, false negative, false positive and true positive. RESULTS Using soft attention, we can identify SEC with an AUC of 0.74, sensitivity of 0.73 and specificity of 0.68. Without soft attention, our model achieves an AUC of 0.69, sensitivity of 0.71 and specificity of 0.60. Additionally, we provide attention visualizations and note that our model assigns higher attention score to ultrasound frames containing more vessel lumen. CONCLUSION Our multisequence CNN model can identify the presence of SEC from ultrasound keyframes with an AUC of 0.74, which could enable screening applications and enable more SEC data discovery. The model does not require the expert intervention or additional clinician reporting time that are currently significant barriers to SEC adoption. Model and processed data sets are publicly available at https://github.com/Ouwen/automatic-spontaneous-echo-contrast.
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Affiliation(s)
- Ouwen Huang
- Department of Biomedical Engineering, Duke University, Durham, NC, USA.
| | - Zewei Shi
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Naveen Garg
- Department of Abdominal Imaging, MD Anderson Cancer Center, Houston, TX, USA
| | - Corey Jensen
- Department of Abdominal Imaging, MD Anderson Cancer Center, Houston, TX, USA
| | - Mark L Palmeri
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
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Mannewald C, Roijer A, Platonov PG, Holmqvist F. Prevalence of left atrial appendage thrombus and spontaneous echo contrast on transesophageal echocardiography in patients scheduled for pulmonary vein isolation. Ann Noninvasive Electrocardiol 2024; 29:e13119. [PMID: 38682420 PMCID: PMC11056845 DOI: 10.1111/anec.13119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/19/2024] [Accepted: 04/11/2024] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND To avoid causing a thromboembolic event in patients undergoing catheter ablation for atrial fibrillation (AF), patients are treated with oral anticoagulants (OAC) prior to the procedure. Despite being on anticoagulants, some patients develop a left atrial appendage thrombus (LAAT). To exclude the presence of LAAT, transesophageal ultrasound (TEE) is performed in all patients prior to the procedure. We hypothesized continuous treatment with anticoagulants would result in a low prevalence of LAAT, in patients with low CHA2DS2-VASc score. METHOD Medical records of consecutive patients planned to undergo AF ablation at Lund University Hospital during the years 2018-2020 were reviewed retrospectively. Examination protocols from transesophageal and transthoracic echocardiography were examined for LAAT and spontaneous echo contrast (SEC). Patients with LAAT and SEC were compared to patients without using Mann-Whitney U-test and Pearson Chi-squared analysis to test for correlation. RESULTS Of 553 patients, three patients (0.54%) had LAAT, and 18 (3.25%) had spontaneous contrast (SEC). Patients with LAAT or SEC had a higher CHA2DS2-VASc score, more often presented in AF at TEE and less often had a normal sized left atrium. CONCLUSION There is a low prevalence of LAAT and SEC in patients with AF scheduled for pulmonary vein isolation. Patients with SEC or LAAT tend to have paroxysmal AF less often and more often presented in AF at admission. No patients with CHA2DS2-VASc 0, paroxysmal AF, normal sized left atrium and sinus rhythm at TEE were found to have LAAT or SEC.
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Affiliation(s)
| | - Anders Roijer
- Department of Cardiology, Clinical SciencesLund UniversityLundSweden
| | - Pyotr G. Platonov
- Department of Cardiology, Clinical SciencesLund UniversityLundSweden
| | - Fredrik Holmqvist
- Department of Cardiology, Clinical SciencesLund UniversityLundSweden
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Liu X, Li X, Xiong S, Zhang H, Suo R, Zhang X, Liu D, Fu H, Liu T, Li G. Neutrophil Extracellular Traps: Potential Prothrombotic State Markers and Therapeutic Targets for Atrial Fibrillation. Thromb Haemost 2024; 124:441-454. [PMID: 37734390 DOI: 10.1055/s-0043-1774310] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
BACKGROUND Recently, the mechanism of thrombogenesis has taken a new direction with the involvement of neutrophil extracellular traps (NETs). However, little is known about the relationship between NETs and thrombogenesis in atrial fibrillation (AF). OBJECTIVE Our study aimed to evaluate NETs in AF patients and their potential association with thrombogenesis. In addition, we studied the effect of NETs on thrombogenesis in rat models. METHODS A total of 125 AF patients and 172 controls were studied. Spontaneous echo contrast (SEC) was examined using transesophageal echocardiography to assess the prothrombotic state. We used rapid atrial pacing (RAP) rat models to study NETs' formation and their effects on thrombogenesis. The levels of NETs were analyzed by flow cytometry. To deeply understand the regulatory mechanism of NET formation, the transcriptional characteristics of the left atrial appendage (LAA) tissue from RAP rats were analyzed. RESULTS We found that NETs were increased significantly in AF patients and positively correlated with SEC grades. And inserting the NET level could significantly enhance the predictivity of CHA2DS2-VASc scores for the AF prothrombotic state. In the RAP models, we observed that NET levels increased significantly in the LAA and promoted thrombosis. Meanwhile, we found that these changes could be suppressed by the NET formation inhibitor. Transcriptomic analysis of the LAA tissue from RAP rats suggested that RAP might stimulate the NET formation by promoting the expression of inflammatory cytokine and adhesion genes. CONCLUSION NETs may constitute useful thrombogenesis risk markers in AF patients and provide a potential therapeutic strategy for AF management.
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Affiliation(s)
- Xing Liu
- Department of Cardiology, Tianjin key laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xinjian Li
- Department of Cardiology, Tianjin key laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Shenglin Xiong
- Department of Cardiology, You Country People's Hospital, Zhuzhou, Hunan, China
| | - Haipeng Zhang
- Department of Clinical Laboratory, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Rong Suo
- Department of Cardiology, Tianjin Hospital, Tianjin, China
| | - Xu Zhang
- Department of Cardiology, Tianjin key laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Daiqi Liu
- Department of Cardiology, Tianjin key laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Huaying Fu
- Department of Cardiology, Tianjin key laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Tong Liu
- Department of Cardiology, Tianjin key laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Guangping Li
- Department of Cardiology, Tianjin key laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
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Noubiap JJ, Nyaga UF, Middeldorp ME, Stokes MB, Sanders P. Cardiac imaging correlates and predictors of stroke in patients with atrial fibrillation: a meta-analysis. J Cardiovasc Med (Hagerstown) 2024; 25:280-293. [PMID: 38407860 DOI: 10.2459/jcm.0000000000001608] [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: 02/27/2024]
Abstract
BACKGROUND New nonclinical parameters are needed to improve the current stroke risk stratification schemes for patients with atrial fibrillation. This study aimed to summarize data on potential cardiac imaging correlates and predictors of stroke or systemic embolism in patients with atrial fibrillation. METHODS MEDLINE, EMBASE, and Web of Science were searched to identify all published studies providing relevant data through 16 November 2022. Random effects meta-analysis method was used to pool estimates. RESULTS We included 64 studies reporting data from a pooled population of 56 639 patients. Left atrial spontaneous echo-contrast [adjusted odds ratio (aOR) 3.32, 95% confidence interval (CI) 1.98-5.49], nonchicken wing left atrial appendage (LAA) morphology (aOR 2.15, 95% CI 1.11-4.18), left atrial enlargement (aOR 2.12, 95% CI 1.45-3.08), and higher LAA orifice diameter (aOR 1.56, 95% CI 1.18-2.05) were highly associated with stroke. Other parameters associated with stroke included higher left atrial sphericity (aOR 1.14, 95% CI 1.01-1.29), higher left atrial volume (aOR 1.03, 95% CI 1.01-1.04), higher left atrial volume index (aOR 1.014, 95% CI 1.004-1.023), lower left atrial reservoir strain [adjusted hazard ratio (aHR) 0.86, 95% CI 0.76-0.98], higher left ventricular mass index (aOR 1.010, 95% CI 1.005-1.015) and E / e' ratio (aOR 1.12, 95% CI 1.07-1.16). There was no association between LAA volume (aOR 1.37, 95% CI 0.85-2.21) and stroke. CONCLUSION These cardiac imaging parameters identified as potential predictors of thromboembolism may improve the accuracy of stroke risk stratification schemes in patients with atrial fibrillation. Further studies should evaluate the performance of holistic risk scores including clinical factors, biomarkers, and cardiac imaging.
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Affiliation(s)
- Jean Jacques Noubiap
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
| | | | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Smidt Heart Institute, Cedar-Sinai Medical Centre, Los Angeles, California, USA
| | - Michael B Stokes
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
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Smith EE, Yaghi S, Sposato LA, Fisher M. Atrial Fibrillation Detection and Load: Knowledge Gaps Related to Stroke Prevention. Stroke 2024; 55:205-213. [PMID: 38134250 DOI: 10.1161/strokeaha.123.043665] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Atrial fibrillation is a major cause of ischemic stroke. Technological advances now support prolonged cardiac rhythm monitoring using either surface electrodes or insertable cardiac monitors. Four major randomized controlled trials show that prolonged cardiac monitoring detects subclinical paroxysmal atrial fibrillation in 9% to 16% of patients with ischemic stroke, including in patients with potential alternative causes such as large artery disease or small vessel occlusion; however, the optimal monitoring strategy, including the target patient population and the monitoring device (whether to use an event monitor, insertable cardiac monitor, or stepped approach) has not been well defined. Furthermore, the clinical significance of very short duration paroxysmal atrial fibrillation remains controversial. The relevance of the duration of monitoring, burden of device-detected atrial fibrillation, and its proximity to the acute ischemic stroke will require more research to define the most effective methods for stroke prevention in this patient population.
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Affiliation(s)
| | | | | | - Marc Fisher
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.)
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Jiang L, Hao Z, Xie X, Xu K, Shen L, Pan X, Wang C, Ma L, Shen L, Fan Y, He B. Left atrial appendage angiography for stroke risk prediction in patients with atrial fibrillation. EUROINTERVENTION 2023; 19:695-702. [PMID: 37594402 PMCID: PMC10591194 DOI: 10.4244/eij-d-23-00325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 06/23/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND The current risk stratification schemes for stroke in patients with atrial fibrillation (AF) are insufficient for an accurate assessment of stroke risk. AIMS This study evaluates the association between the mechanical function of the left atrial appendage (LAA), as assessed by angiography, and the risk of stroke. METHODS We conducted a cross-sectional study to assess the mechanical function of the LAA by measuring the left atrial appendage ejection fraction (LAAEF) and grading the contrast retention (CR) using angiography. RESULTS A total of 746 patients referred for a left atrial appendage occlusion (LAAO) procedure with (n=151; stroke group) or without (n=595; control group) a history of stroke were included in the analysis. LAAEF was significantly lower (14% [9-19] vs 20% [12-33]; p<0.001) and grade 3 CR was more common (66.9% vs 33.9%; p<0.001) in patients with a history of stroke. Multivariable analysis showed that CR was independently associated with stroke in patients with AF (grade 2 vs grade 1=7.29; 95% confidence interval [CI]: 2.84-21.65; p<0.001; grade 3 vs grade 1=16.45; 95% CI: 6.16-51.02; p<0.001). The receiver operating characteristics curve demonstrated that CR identified patients with stroke more accurately than the CHA2D-VASc score (C-statistic 0.712 vs 0.512; p<0.001), and the combination of CR and the CHA2DS2-VASc score provided the best performance (C-statistic 0.871 vs 0.829 [CHA2DS2-VASc score alone]; p=0.048) Conclusions: Impaired mechanical function of the LAA, indicated by a low LAAEF and CR, is associated with a history of stroke in patients with AF. Assessment of CR using LAA angiography helps improve the stratification scheme for stroke risk prediction.
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Affiliation(s)
- Lisheng Jiang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Ziyong Hao
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Xiaoyi Xie
- Department of Ultrasound Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Ke Xu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Lan Shen
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Xin Pan
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Cheng Wang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Lan Ma
- Department of Ultrasound Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Linghong Shen
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Yiting Fan
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Ben He
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
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Spartera M, Stracquadanio A, Pessoa-Amorim G, Harston G, Mazzucco S, Young V, Von Ende A, Hess AT, Ferreira VM, Kennedy J, Neubauer S, Casadei B, Wijesurendra RS. Reduced Left Atrial Rotational Flow Is Independently Associated With Embolic Brain Infarcts. JACC Cardiovasc Imaging 2023; 16:1149-1159. [PMID: 37204381 DOI: 10.1016/j.jcmg.2023.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/22/2023] [Accepted: 03/10/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Up to 25% of embolic strokes occur in individuals without atrial fibrillation (AF) or other identifiable mechanisms. OBJECTIVES This study aims to assess whether left atrial (LA) blood flow characteristics are associated with embolic brain infarcts, independently of AF. METHODS The authors recruited 134 patients: 44 with a history of ischemic stroke and 90 with no history of stroke but CHA2DS2VASc score ≥1. Cardiac magnetic resonance (CMR) evaluated cardiac function and LA 4-dimensional flow parameters, including velocity and vorticity (a measure of rotational flow), and brain magnetic resonance imaging (MRI) was performed to detect large noncortical or cortical infarcts (LNCCIs) (likely embolic), or nonembolic lacunar infarcts. RESULTS Patients (41% female; age 70 ± 9 years) had moderate stroke risk (median CHA2DS2VASc = 3, Q1-Q3: 2-4). Sixty-eight (51%) had diagnosed AF, of whom 58 (43%) were in AF during CMR. Thirty-nine (29%) had ≥1 LNCCI, 20 (15%) had ≥1 lacunar infarct without LNCCI, and 75 (56%) had no infarct. Lower LA vorticity was significantly associated with prevalent LNCCIs after adjustment for AF during CMR, history of AF, CHA2DS2VASc score, LA emptying fraction, LA indexed maximum volume, left ventricular ejection fraction, and indexed left ventricular mass (OR: 2.06 [95% CI: 1.08-3.92 per SD]; P = 0.027). By contrast, LA flow peak velocity was not significantly associated with LNCCIs (P = 0.21). No LA parameter was associated with lacunar infarcts (all P > 0.05). CONCLUSIONS Reduced LA flow vorticity is significantly and independently associated with embolic brain infarcts. Imaging LA flow characteristics may aid identification of individuals who would benefit from anticoagulation for embolic stroke prevention, regardless of heart rhythm.
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Affiliation(s)
- Marco Spartera
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom; Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom.
| | - Antonio Stracquadanio
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom; Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom
| | - Guilherme Pessoa-Amorim
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom; Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom; CTSU Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - George Harston
- Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom
| | - Sara Mazzucco
- Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom; Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neuroscience, Oxford, United Kingdom
| | - Victoria Young
- Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom
| | - Adam Von Ende
- CTSU Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Aaron T Hess
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom
| | - Vanessa M Ferreira
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom; Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom
| | - James Kennedy
- Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom
| | - Stefan Neubauer
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom; Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom
| | - Barbara Casadei
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom
| | - Rohan S Wijesurendra
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom; University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom; Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom; CTSU Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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9
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Molnár AÁ, Sánta A, Pásztor DT, Merkely B. Atrial Cardiomyopathy in Valvular Heart Disease: From Molecular Biology to Clinical Perspectives. Cells 2023; 12:1796. [PMID: 37443830 PMCID: PMC10340254 DOI: 10.3390/cells12131796] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/01/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
This review discusses the evolving topic of atrial cardiomyopathy concerning valvular heart disease. The pathogenesis of atrial cardiomyopathy involves multiple factors, such as valvular disease leading to atrial structural and functional remodeling due to pressure and volume overload. Atrial enlargement and dysfunction can trigger atrial tachyarrhythmia. The complex interaction between valvular disease and atrial cardiomyopathy creates a vicious cycle of aggravating atrial enlargement, dysfunction, and valvular disease severity. Furthermore, atrial remodeling and arrhythmia can predispose to atrial thrombus formation and stroke. The underlying pathomechanism of atrial myopathy involves molecular, cellular, and subcellular alterations resulting in chronic inflammation, atrial fibrosis, and electrophysiological changes. Atrial dysfunction has emerged as an essential determinant of outcomes in valvular disease and heart failure. Despite its predictive value, the detection of atrial fibrosis and dysfunction is challenging and is not included in the clinical routine. Transthoracic echocardiography and cardiac magnetic resonance imaging are the main diagnostic tools for atrial cardiomyopathy. Recently published data have revealed that both left atrial volumes and functional parameters are independent predictors of cardiovascular events in valvular disease. The integration of atrial function assessment in clinical practice might help in early cardiovascular risk estimation, promoting early therapeutic intervention in valvular disease.
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10
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Bhuta S, Cao C, Pieper JA, Tong MS, Varghese J, Han Y, Harfi TT, Simonetti OP, Augostini RS, Kalbfleisch SJ, Savona SJ, Okabe T, Afzal MR, Hummel JD, Daoud EG, Houmsse M. Cardiac magnetic resonance imaging for left atrial appendage closure planning. Pacing Clin Electrophysiol 2023; 46:745-751. [PMID: 37221927 DOI: 10.1111/pace.14713] [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: 03/18/2023] [Revised: 04/25/2023] [Accepted: 05/02/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Transesophageal echocardiography (TEE) and cardiac computed tomography angiography (CCTA) are currently utilized for left atrial appendage closure (LAAC) planning. During the recent global iodine contrast media shortage in 2022, cardiac magnetic resonance imaging (CMR) was utilized for the first time for LAAC planning. This study sought to assess the utility of CMR versus TEE for LAAC planning. METHODS This single center retrospective study consisted of all patients who underwent preoperative CMR for LAAC with Watchman FLX or Amplatzer Amulet. Key measures were accuracy of LAA thrombus exclusion, ostial diameter, depth, lobe count, morphology, accuracy of predicted device size, and devices deployed per case. Bland-Altman Analysis was used to compare CMR versus TEE measurements of LAA ostial diameter and depth. RESULTS 25 patients underwent preoperative CMR for LAAC planning. A total of 24 (96%) cases were successfully completed with 1.2 ± 0.5 devices deployed per case. Among the 18 patients who underwent intraoperative TEE, there was no significant difference between CMR versus TEE in LAA thrombus exclusion (CMR 83% vs. TEE 100% cases, p = .229), lobe count (CMR 1.7 ± 0.8 vs. TEE 1.4 ± 0.6, p = .177), morphology (p = .422), and accuracy of predicted device size (CMR 67% vs. TEE 72% cases, p = 1.000). When comparing the difference between CMR and TEE measurements, Bland-Altman analysis demonstrated no significant difference in LAA ostial diameter (CMR-TEE bias 0.7 mm, 95% CI [-1.1, 2.4], p = .420), but LAA depth was significantly larger with CMR versus TEE (CMR-TEE bias 7.4 mm, 95% CI [1.6, 13.2], p = .015). CONCLUSIONS CMR is a promising alternative for LAAC planning in cases where TEE or CCTA are contraindicated or unavailable.
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Affiliation(s)
- Sapan Bhuta
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Carolyn Cao
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Justin A Pieper
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Matthew S Tong
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Juliet Varghese
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Yuchi Han
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Thura T Harfi
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Orlando P Simonetti
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ralph S Augostini
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Steven J Kalbfleisch
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Salvatore J Savona
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Toshimasa Okabe
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Muhammad R Afzal
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - John D Hummel
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Emile G Daoud
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mahmoud Houmsse
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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11
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Segan L, Nanayakkara S, Spear E, Shirwaiker A, Chieng D, Prabhu S, Sugumar H, Ling L, Kaye DM, Kalman JM, Voskoboinik A, Kistler PM. Identifying Patients at High Risk of Left Atrial Appendage Thrombus Before Cardioversion: The CLOTS-AF Score. J Am Heart Assoc 2023; 12:e029259. [PMID: 37301743 PMCID: PMC10356043 DOI: 10.1161/jaha.122.029259] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/13/2023] [Indexed: 06/12/2023]
Abstract
Background Transesophageal echocardiography-guided direct cardioversion is recommended in patients who are inadequately anticoagulated due to perceived risk of left atrial appendage thrombus (LAAT); however, LAAT risk factors remain poorly defined. Methods and Results We evaluated clinical and transthoracic echocardiographic parameters to predict LAAT risk in consecutive patients with atrial fibrillation (AF)/atrial flutter undergoing transesophageal echocardiography before cardioversion between 2002 and 2022. Regression analysis identified predictors of LAAT, combined to create the novel CLOTS-AF risk score (comprising clinical and echocardiographic LAAT predictors), which was developed in the derivation cohort (70%) and validated in the remaining 30%. A total of 1001 patients (mean age, 62±13 years; 25% women; left ventricular ejection fraction, 49.8±14%) underwent transesophageal echocardiography, with LAAT identified in 140 of 1001 patients (14%) and dense spontaneous echo contrast precluding cardioversion in a further 75 patients (7.5%). AF duration, AF rhythm, creatinine, stroke, diabetes, and echocardiographic parameters were univariate LAAT predictors; age, female sex, body mass index, anticoagulant type, and duration were not (all P>0.05). CHADS2VASc, though significant on univariate analysis (P<0.001), was not significant after adjustment (P=0.12). The novel CLOTS-AF risk model comprised significant multivariable predictors categorized and weighted according to clinically relevant thresholds (Creatinine >1.5 mg/dL, Left ventricular ejection fraction <50%, Overload (left atrial volume index >34 mL/m2), Tricuspid Annular Plane Systolic Excursion (TAPSE) <17 mm, Stroke, and AF rhythm). The unweighted risk model had excellent predictive performance with an area under the curve of 0.820 (95% CI, 0.752-0.887). The weighted CLOTS-AF risk score maintained good predictive performance (AUC, 0.780) with an accuracy of 72%. Conclusions The incidence of LAAT or dense spontaneous echo contrast precluding cardioversion in patients with AF who are inadequately anticoagulated is 21%. Clinical and noninvasive echocardiographic parameters may identify patients at increased risk of LAAT better managed with a suitable period of anticoagulation before undertaking cardioversion.
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Affiliation(s)
- Louise Segan
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Shane Nanayakkara
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- Monash UniversityMelbourneAustralia
| | | | | | - David Chieng
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Sandeep Prabhu
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Hariharan Sugumar
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Liang‐Han Ling
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - David M. Kaye
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- Monash UniversityMelbourneAustralia
| | - Jonathan M. Kalman
- University of MelbourneMelbourneAustralia
- Royal Melbourne HospitalMelbourneAustralia
| | - Aleksandr Voskoboinik
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- Monash UniversityMelbourneAustralia
| | - Peter M. Kistler
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
- Monash UniversityMelbourneAustralia
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12
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Adedara VO, Sharma V, Nawaz H, Reyes-Rivera J, Afzal-Tohid S, Pareshbhai PT, Boyapati SP, Sharafshah A. Transesophageal Echocardiogram Before Cardioversion in Atrial Fibrillation Patients. Cureus 2023; 15:e39702. [PMID: 37398783 PMCID: PMC10309076 DOI: 10.7759/cureus.39702] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Transesophageal echocardiography (TEE) offers an invaluable, non-invasive avenue for diagnosing and managing various cardiac conditions, including atrial fibrillation (AF). As the most common cardiac arrhythmia, AF affects millions and can lead to severe complications. Cardioversion, a procedure to restore the heart's normal rhythm, is frequently conducted on AF patients resistant to medication. Due to inconclusive data, TEE's utility prior to cardioversion in AF patients remains ambiguous. Understanding TEE's potential benefits and limitations in this population could significantly influence clinical practice. This review aims to scrutinize the current literature on the use of TEE before cardioversion in AF patients. The principal objective is to understand TEE's potential benefits and limitations comprehensively. The study seeks to offer a clear understanding and practical recommendations for clinical practice, thereby improving the management of AF patients before cardioversion using TEE. A literature search of databases was conducted using the keywords "Atrial Fibrillation," "Cardioversion" and "Transesophageal echocardiography," resulting in 640 articles. These were narrowed to 103 following title and abstract reviews. After applying exclusion and inclusion criteria with a quality assessment, 20 papers were included: seven retrospective studies, 12 prospective observational studies, and one randomized controlled trial (RCT). Stroke risk associated with direct-current cardioversion (DCC) potentially results from post-cardioversion atrial stunning. Thromboembolic events occur post cardioversion, with or without prior atrial thrombus or cardioversion complications. Generally, cardiac thrombus localizes in the left atrial appendage (LAA), a clear contraindication to cardioversion. Atrial sludge without LAA thrombus in TEE is a relative contraindication. TEE before electrical cardioversion (ECV) in anticoagulated AF individuals is uncommon. In AF patients planned for cardioversion, contrast enhancement facilitates thrombus exclusion in TEE images, reducing embolic events. Left atrial thrombus (LAT) frequently occurs in AF patients, necessitating TEE examination. Despite the increased use of pre-cardioversion TEE, thromboembolic events persist. Notably, patients with post-DCC thromboembolic events had no LA thrombus or LAA sludge. The use of TEE-guided DCC has grown due to its ability to detect atrial thrombi pre-cardioversion, aiding risk stratification. Thrombus in the left atrium also signals an elevated risk of future thromboembolic events in AF patients. While atrial stunning post cardioversion detected by TEE is a significant risk factor for future thromboembolic events, further evidence is required. Therapeutic anticoagulation is essential during and post cardioversion, even if no atrial thrombus is detected. Current data recommends cardioversion guided by TEE, particularly in outpatient settings.
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Affiliation(s)
- Victor O Adedara
- Medicine, St. George's University School of Medicine, St. George's, GRD
| | - Vagisha Sharma
- Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IND
| | - Hassan Nawaz
- Medicine, Nishtar Medical University and Hospital, Multan, PAK
| | | | | | | | - Sri P Boyapati
- Medicine, Siddartha Medical College, Dr. YSR University of Health Sciences, Vijayawada, IND
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13
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Ito T, Suwa M. Assessment of left atrial appendage function by echocardiography. Heart Fail Rev 2023:10.1007/s10741-023-10298-2. [PMID: 36800057 DOI: 10.1007/s10741-023-10298-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2023] [Indexed: 02/18/2023]
Abstract
The left atrial appendage (LAA) is considered not only to be the most frequent site of thrombus formation, but also to play a pivotal role in maintaining normal cardiac function. Transesophageal echocardiography (TEE) is widely used to assess LAA function. The LAA flow velocity has been used as a surrogate for LAA function, and it varies with multiple interrelated factors including age, hemodynamics, type of arrhythmia, and antiarrhythmic interventions. Relatively great importance of LAA function is involved with intraatrial thrombus formation and subsequent thromboembolism, and thus, understanding of characteristics and behaviors of the LAA under various clinical conditions may help determine strategies against atrial thrombosis. Also, techniques other than TEE-derived Doppler to assess LAA function, such as tissue Doppler imaging, have been proposed. In this review, we introduce clinical and echocardiographic correlates of LAA function, the LAA flow velocity in particular, its significance, and how to interpret functional patterns of the LAA each relevant to specific clinical settings.
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Affiliation(s)
- Takahide Ito
- Department of Cardiology, Osaka Medical and Pharmaceutical University, 2-7, Daigaku-Machi, Takatsuki, Osaka, 569-8686, Japan.
| | - Michihiro Suwa
- Cardiovascular Division, Hokusetsu General Hospital, Takatsuki, Japan
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14
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Kreimer F, Backhaus JF, Krogias C, Pflaumbaum A, Mügge A, Gotzmann M. P-wave parameters and their association with thrombi and spontaneous echo contrast in the left atrial appendage. Clin Cardiol 2023; 46:397-406. [PMID: 36808747 PMCID: PMC10106666 DOI: 10.1002/clc.23980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 01/07/2023] [Accepted: 01/12/2023] [Indexed: 02/20/2023] Open
Abstract
BACKGROUND The aim of this study was to examine the prevalence of abnormal P-wave parameters in patients with thrombus and/or spontaneous echo contrast (SEC) in the left atrial appendage (LAA), and to identify P-wave parameters particularly associated with thrombus and SEC formation. HYPOTHESIS We presume a significant relationship of P-wave parameters with thrombi and SEC. METHODS All patients in whom a thrombus or SEC was detected in the LAA on transoesophageal echocardiography were included in this study. Patients at risk (CHA2DS2-VASc Score ≥3) and routine transoesophageal echocardiography to exclude thrombi served as the control group. A detailed ECG analysis was performed. RESULTS Of a total of 4062 transoesophageal echocardiographies, thrombi and SEC were detected in 302 patients (7.4%). Of these patients, 27 (8.9%) presented with sinus rhythm. The control group included 79 patients. There was no difference in mean CHA2DS2-VASc score in the two groups (p = .182). A high prevalence of abnormal P-wave parameters was detected in patients with thrombus/SEC. Indicators for the presence of thrombi or SEC in the LAA were P-wave duration >118 ms (Odds ratio (OR) 3.418, Confidence interval (CI) 1.522-7.674, p < .001), P-wave dispersion >40 ms (OR 2.521, CI 1.390-4.571, p < .001) and advanced interatrial block (OR 1.431, CI 1.033-1.984, p = .005). CONCLUSION Our study revealed that several P-wave parameters are associated with thrombi and SEC in the LAA. The results may help identify patients who are at particularly high risk for thromboembolic events (e.g., in patients with embolic stroke of undetermined source).
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Affiliation(s)
- Fabienne Kreimer
- Cardiology and Rhythmology, St Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Julian Felix Backhaus
- Cardiology and Rhythmology, St Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Christos Krogias
- Neurology, St Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Andreas Pflaumbaum
- Cardiology and Rhythmology, St Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Andreas Mügge
- Cardiology and Rhythmology, St Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Michael Gotzmann
- Cardiology and Rhythmology, St Josef-Hospital, Ruhr University Bochum, Bochum, Germany
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15
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Abstract
INTRODUCTION Stroke is one of the leading causes of mortality and morbidity globally. Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. It is set to reach epidemic proportions. AF is associated with a five-fold increase in risk of stroke. Strokes caused by AF more often are fatal or result in severe disability. Even though the incidence of stroke has been significantly reduced by oral anticoagulation, AF is thought to account for a significant proportion of cryptogenic strokes where no etiology is identified. AREAS COVERED This article reviews the literature related to AF and stroke, pathophysiological insights, diagnosis of AF in stroke patients, and its management (Graphical Abstract). EXPERT OPINION The pathophysiology of thrombogenesis that links AF and stroke is not well understood and is an area of active research to identify new therapeutic targets to prevent AF and stroke. As the nature of AF and stroke is multifaceted, an integrated care approach to managing AF and stroke is increasingly essential.
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Affiliation(s)
- Sylvia E Choi
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Dimitrios Sagris
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Andrew Hill
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Stroke Division, Department of Medicine for Older People, Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Azmil H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Stroke Division, Department of Medicine for Older People, Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, UK
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16
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Wang H, Xi S, Chen J, Zhao L, Gan T, He B. Severe Left Atrial Spontaneous Echo Contrast in Nonvalvular Atrial Fibrillation: Clinical Characteristics and Impact on Ischemic Risk Postablation. Thromb Haemost 2022; 123:522-534. [PMID: 36402133 DOI: 10.1055/a-1983-0516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Spontaneous echo contrast (SEC) is an important precursor for intracardiac thrombus and stroke. There are very limited data on characteristics of severe SEC and its impact on ischemic risk of nonvalvular atrial fibrillation (NVAF) patients after radiofrequency catheter ablation. METHODS Transesophageal echocardiography files were reviewed between March 2009 and March 2021 in this monocentric retrospective study. SEC was classified into four levels. The primary endpoint was thromboembolic event (stroke, myocardial infarction, systemic embolism, and ensuing death), and the secondary endpoint included nonischemic mortality and recurrent atrial arrhythmia. RESULTS Six hundred SEC cases were enrolled and classified into mild SEC group (Grade 1-2, n = 515) and severe SEC group (Grade 3-4, n = 85). Independent risk factors for severe SEC included higher brain natriuretic peptide (BNP), erythrocyte sedimentation rate (ESR), and LAd/∆LVED (LAd = left atrial diameter; ∆LVED = left ventricular end-diastolic diameter - left ventricular end-systolic diameter). The severe SEC group had a higher peri-procedural ischemic event occurrence (7.1 vs. 1.9%, p = 0.007). At a median follow-up of 55 months, the severe SEC group had a lower freedom rate from ischemic events (90.1 vs. 75.3%, p < 0.001); older age and severe SEC were independent risk factors for ischemic events. In patients undergoing redo-procedure (n = 100), a remarkably reduced ESR (17.8 ± 12.0 vs. 28.2 ± 19.0 mm/h, p < 0.001) was observed in patients whose SEC disappeared. CONCLUSIONS Higher BNP, ESR, and LAd/∆LVED were the independent predictors for severe SEC. Severe SEC was associated with higher peri-procedural and long-term ischemic risks. ESR and LAd/∆LVED, as indicators of hematological and hemodynamic change, seemed helpful in identifying NVAF patients prone to developing severe SEC.
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Affiliation(s)
- Hao Wang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Siqi Xi
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jindong Chen
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Liang Zhao
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Tian Gan
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ben He
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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17
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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.
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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
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18
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Quintana RA, Dong T, Vajapey R, Reyaldeen R, Kwon DH, Harb S, Wang TKM, Klein AL. Preprocedural Multimodality Imaging in Atrial Fibrillation. Circ Cardiovasc Imaging 2022; 15:e014386. [PMID: 36256725 DOI: 10.1161/circimaging.122.014386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia worldwide and is associated with increased risk of heart failure, stroke, and death. In current medical practice, multimodality imaging is routinely used in the management of AF. Twenty-one years ago, the ACUTE trial (Assessment of Cardioversion Using Transesophageal Echocardiography) results were published, and the management of AF changed forever by incorporating transesophageal echocardiography guided cardioversion of patients in AF for the first time. Current applications of multimodality imaging in AF in 2022 include the use of transesophageal echocardiography and computed tomography before cardioversion to exclude left atrial thrombus and in left atrial appendage occlusion device implantation. Transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance are clinically used for AF ablation planning. The decision to use a particular imaging modality in AF is based on patient's characteristics, guideline recommendation, institutional preferences, expertise, and cost. In this first of 2-part review series, we discuss the preprocedural role of echocardiography, computed tomography, and cardiac magnetic resonance in the AF, with regard to their clinical applications, relevant outcomes data and unmet needs, and highlights future directions in this rapidly evolving field.
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Affiliation(s)
- Raymundo A Quintana
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO (R.A.Q.)
| | - Tiffany Dong
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
| | - Ramya Vajapey
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
| | - Reza Reyaldeen
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
| | - Deborah H Kwon
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
| | - Serge Harb
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
| | - Tom Kai Ming Wang
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH (T.D., R.V., R.R., D.H.K., S.H., T.K.M.W., A.L.K.)
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19
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Myers SJ, Jiménez-Ruiz A, Sposato LA, Whitehead SN. Atrial cardiopathy and cognitive impairment. Front Aging Neurosci 2022; 14:914360. [PMID: 35942230 PMCID: PMC9355976 DOI: 10.3389/fnagi.2022.914360] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/06/2022] [Indexed: 11/13/2022] Open
Abstract
Cognitive impairment involves complex interactions between multiple pathways and mechanisms, one of which being cardiac disorders. Atrial cardiopathy (AC) is a structural and functional disorder of the left atrium that may be a substrate for other cardiac disorders such as atrial fibrillation (AF) and heart failure (HF). The association between AF and HF and cognitive decline is clear; however, the relationship between AC and cognition requires further investigation. Studies have shown that several markers of AC, such as increased brain natriuretic peptide and left atrial enlargement, are associated with an increased risk for cognitive impairment. The pathophysiology of cognitive decline in patients with AC is not yet well understood. Advancing our understanding of the relationship between AC and cognition may point to important treatable targets and inform future therapeutic advancements. This review presents our current understanding of the diagnosis of AC, as well as clinical characteristics and potential pathways involved in the association between AC and cognitive impairment.
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Affiliation(s)
- Sarah J. Myers
- Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Amado Jiménez-Ruiz
- Department of Clinical Neurological Sciences, University Hospital, Western University, London, ON, Canada
| | - Luciano A. Sposato
- Department of Clinical Neurological Sciences, University Hospital, Western University, London, ON, Canada
| | - Shawn N. Whitehead
- Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- *Correspondence: Shawn N. Whitehead,
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20
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Sun S, Su B, Lin J, Zhao C, Ma C. A nomogram to predict left atrial appendage thrombus and spontaneous echo contrast in non-valvular atrial fibrillation patients. BMC Cardiovasc Disord 2022; 22:311. [PMID: 35820838 PMCID: PMC9277967 DOI: 10.1186/s12872-022-02737-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/27/2022] [Indexed: 11/10/2022] Open
Abstract
Background Non-valvular atrial fibrillation (NVAF) significantly increases the risk of stroke. Although there is availability of prediction models, their ability to predict the risk of stroke in NVAF patients remains suboptimal. Therefore, there is need to improve prediction of high-risk individuals, which is critical for efficient management of patients with NVAF.
Objective The objective of our paper is to develop a nomogram for predicting the risk of left atrial appendage thrombus (LAAT) and spontaneous echo contrast (SEC), thereby replacing the risk of stroke in NVAF patients. Design This was a retrospective cohort study that analyzed clinical data and echocardiographic indices of 387 patients with NVAF from October 2018 to June 2021. Multivariable logistic regression was used to evaluate independent factors that were used to construct the prediction nomogram. Analysis The discriminative ability and calibration of the nomogram to predict LAAT/SEC were tested using C-statistic and calibration plot. The performance of the nomogram was assessed against the CHA2DS2 score, CHA2DS2-VASc score and ATRIA score using the receiver operating characteristic curve (ROC), decision curve analysis (DCA), integrated discrimination index (IDI) and net reclassification index (NRI). Result Out of the total 387 patients enrolled in this study, 232 had LAAT/SEC. Multivariable analyses demonstrated that N-terminal pro-B-type natriuretic peptide (NT-proBNP), albumin (ALB), LAA ejection fraction (LAAEF) and LAA global peak longitudinal strain (LAA GPLS) were independent predictors of LAAT/SEC. The constructed nomogram had good discriminative (C = 0.886) and calibration (0.876) abilities after bias correction by the C-index. Compared with other models, the decision curve analyses demonstrated that the nomogram had greater net benefits. Besides, the nomogram had significant improvement in predictive performance, sensitivity and reclassification for LAAT/SEC compared with the CHA2DS2 [(c-index: 0.886 vs. 0.576, p < 0.05), (NRI: 0.539, p < 0.05), (IDI: 0.432, p < 0.05)], CHA2DS2-VASc [(c-index: 0.886 vs0.579, p < 0.05), (NRI: 0.513, p < 0.05), (IDI: 0.432, p < 0.05)] or ATRIA [(c-index: 0.886 vs0.583, p < 0.05), (NRI: 0.546, p < 0.05), (IDI: 0.432, p < 0.05)]. Conclusion Taken together, our data demonstrated that the developed nomogram was effective and had potential clinical application in the prediction of LAAT/SEC in patients with NVAF.
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Affiliation(s)
- Shikun Sun
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Bo Su
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Jia Lin
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Caiming Zhao
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China.
| | - Changsheng Ma
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China.
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21
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Lüscher TF, Davies A, Beer JH, Valgimigli M, Nienaber CA, Camm JA, Baumgartner I, Diener HC, Konstantinides SV. Towards personalized antithrombotic management with drugs and devices across the cardiovascular spectrum. Eur Heart J 2022; 43:940-958. [PMID: 34624084 DOI: 10.1093/eurheartj/ehab642] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 05/06/2021] [Accepted: 09/01/2021] [Indexed: 01/10/2023] Open
Abstract
Intravascular thrombus formation and embolization are among the most frequent events leading to a number of cardiovascular conditions with high morbidity and mortality. The underlying causes are stasis of the circulating blood, genetic and acquired coagulation disorders, and reduced antithrombotic or prothrombotic properties of the vascular wall (Virchow's triad). In the venous system, intravascular thrombi can cause venous thrombosis and pulmonary and even peripheral embolism including ischaemic stroke [through a patent foramen ovale (PFO)]. Thrombi in the left atrium and its appendage or ventricle form in the context of atrial fibrillation and infarction, respectively. Furthermore, thrombi can form on native or prosthetic aortic valves, within the aorta (in particular at sites of ulcers, aortic dissection, and abdominal aneurysms), and in cerebral and peripheral arteries causing stroke and critical limb ischaemia, respectively. Finally, thrombotic occlusion may occur in arteries supplying vital organs such the heart, brain, kidney, and extremities. Thrombus formation and embolization can be managed with anticoagulants and devices depending on where they form and embolize and on patient characteristics. Vitamin K antagonists are preferred in patients with mechanical valves, while novel oral anticoagulants are first choice in most other cardiovascular conditions, in particular venous thromboembolism and atrial fibrillation. As anticoagulants are associated with a risk of bleeding, devices such as occluders of a PFO or the left atrial appendage are preferred in patients with an increased bleeding risk. Platelet inhibitors such as aspirin and/or P2Y12 antagonists are preferred in the secondary prevention of coronary artery disease, stroke, and peripheral artery disease either alone or in combination depending on the clinical condition. A differential and personalized use of anticoagulants, platelet inhibitors, and devices is recommended and reviewed in this article.
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Affiliation(s)
- Thomas F Lüscher
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Allan Davies
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK
| | - Juerg H Beer
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Marco Valgimigli
- CardioCentro, Lugano, Switzerland.,University of Bern, Bern, Switzerland
| | - Christoph A Nienaber
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK
| | - John A Camm
- St. Georges University and Imperial College, London, UK
| | | | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty of the University Duisburg-Essen, Duisburg-Essen, Germany
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22
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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.
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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
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23
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Left Atrial Dysfunction, Fibrosis and the Risk of Thromboembolism in Patients With Paroxysmal and Persistent Atrial Fibrillation. INTERNATIONAL JOURNAL OF HEART FAILURE 2022; 4:42-53. [PMID: 36262195 PMCID: PMC9383342 DOI: 10.36628/ijhf.2021.0043] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/15/2022] [Accepted: 01/21/2022] [Indexed: 12/02/2022]
Abstract
Background and Objectives Left atrial (LA) fibrosis is an important component of the arrhythmogenic substrate and is related to LA dysfunction in patients with atrial fibrillation (AF). However, its relationship with functional changes and the risk of thrombus in patients with paroxysmal AF (PAF) and persistent AF (PeAF) remains unclear. Methods We included 139 patients with preprocedural cardiac magnetic resonance imaging (CMR) and transesophageal echocardiography (TEE) for the first AF catheter ablation. Spontaneous echo contrast (SEC) and multiple parameters of LA were measured from TEE and CMR. LA fibrosis was evaluated by late gadolinium enhancement of LA (LA-LGE) of CMR. Results The presence of SEC was higher in patients with PeAF than in patients with PAF (26.4% vs. 11.9%, p=0.03). The patients with SEC had more enlarged LA size and impaired function of LA and LAA, regardless of AF type. However, the area of LA-LGE was more extensive in patients with SEC in PeAF (27.5±15.9 vs. 20.1±10.3, p=0.033), not in PAF. In PAF, maximal LA volume index was closely related to the presence of SEC with marginal trend toward significance (odd ratio [OR], 1.07; 95% confidence interval [CI], 0.99–1.16; p=0.072). Whereas, a larger area of LA-LGE and lower emptying flux of LA appendage were independently related with SEC (OR, 1.10; 95% CI, 1.0–1.20; p=0.049 and OR, 0.93; 95% CI, 0.86–0.99; p=0.022, respectively) after adjusting related cardiovascular risk factors of SEC Conclusions In this study, we suggest that the risk of thrombus is provoked by LA enlargement with dysfunction in early-stage AF and by stiffened LA with fibrosis rather than LA size when it becomes PeAF.
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24
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Dhorepatil A, Lang AL, Lang M, Butt M, Arbune A, Hoffman D, Almahmeed S, Ziv O. Long-Term Stroke Risk in Patients Undergoing Left Atrial Appendage Ablation With and Without Complete Isolation. Front Cardiovasc Med 2021; 8:762839. [PMID: 34957252 PMCID: PMC8695675 DOI: 10.3389/fcvm.2021.762839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 11/15/2021] [Indexed: 11/19/2022] Open
Abstract
Background: Catheter ablation (CA) for atrial fibrillation (AF), may require ablation beyond the pulmonary veins. Prior data suggest that additional LA ablation, particularly left atrial appendage (LAA) ablation, may alter atrial function leading to increased risk of ischemic stroke or transient ischemic attack (IS/TIA). We sought to study the long-term risk of IS/TIA in patients receiving ablation at the LAA compared to those receiving PVI alone and those receiving PVI with additional non-LAA locations. Methods: 350 patients who underwent CA for AF from 2008 to 2018 were included in the study. Locations of ablation in LA evaluated were the posterior wall, anterior wall, inferior wall, inter-atrial septum, lateral wall and the left atrial appendage (LAA). Patients undergoing LAA ablation were further divided as complete isolation (LAAi) and without complete isolation (LAAa). Results: Mean follow up of 4.8 years. In entire cohort, risk of IS/TIA was 1.62/100 patient-years (pys). The risk was highest in patients with LAAi (3.81/100 pys), followed by ablation LAAa (3.74/100 pys). Amongst all LA locations, only LAAi (HR 3.32, p = 0.03) and LAAa (HR 3.18, p = 0.02) were statistically significant predictors of IS/TIA after adjusting for OAC (Oral anticoagulant) use and baseline CHA2DS2VASc score. Conclusions: During long term follow-up, only ablation at the left atrial appendage with and without complete isolation was independently associated with an increased risk of IS/TIA in patients undergoing CA for AF. Potential strategies to reduce stroke risk, such as LAA closure, should be considered in these patients.
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Affiliation(s)
- Aneesh Dhorepatil
- Heart and Vascular Institute, Tulane University, New Orleans, LA, United States
| | - Angela L Lang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Min Lang
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Muhammad Butt
- Department of Cardiovascular Diseases, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Amit Arbune
- Division of Cardiology, Gill Heart Institute, University of Kentucky, Lexington, KY, United States
| | - David Hoffman
- Heart Associates, Mercy Health St. Elizabeth Youngstown Hospital, Youngstown, OH, United States
| | - Soufian Almahmeed
- Department of Cardiovascular Diseases, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Ohad Ziv
- Department of Cardiovascular Diseases, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, United States
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25
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Gilhofer TS, Abdellatif W, Nicolaou S, Jalal S, Powell J, Inohara T, Starovoytov A, Saw J. Cardiac CT angiography after percutaneous left atrial appendage closure: early versus delayed scanning after contrast administration. DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY (ANKARA, TURKEY) 2021; 27:703-709. [PMID: 34792023 DOI: 10.5152/dir.2021.20349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Cardiac computed tomography angiography (CCTA) is increasingly used for device surveillance after left atrial appendage closure (LAAC). While CT protocols with delayed scans are useful to diagnose thrombus in the LAA, an optimal protocol for post-procedural CCTA has not been established. Therefore, we assessed the role of delayed versus early scans for device surveillance. METHODS We retrospectively reviewed patients who underwent LAAC at Vancouver General Hospital who had follow-up CCTAs using standard (early) and delayed scans. Scans were performed on Toshiba 320-detector (Aquilion ONE). Image quality was interpreted by 2 independent observers for anatomy, LAA contrast patency, and device-related thrombus (DRT) using VitreaWorkstationTM. A Likert scale of 1-5 was used (1= poor quality, 5= excellent) for assessment. RESULTS We included 27 consecutive LAAC patients (9 Amplatzer, 18 WATCHMAN) with mean age 76.0±7.7 years, mean CHADS2 score 2.8±1.3, CHA2DS2-VASc score 4.4±1.6 and HAS-BLED score 3.4±1.0. Subjective quality assessments by both reviewers favored early scans for assessment of anatomy (reviewer 1: 4.63±0.63 [early] vs. 1.74±0.71 [delayed]; reviewer 2: 4.63±0.63 [early] vs. 1.89±0.64 [delayed]) and DRT (reviewer 1: 4.78±0.42 [early] vs. 3.11±1.16 [delayed]; reviewer 2: 4.70±0.47 [early] vs. 3.04±1.29 [delayed]). Inter-rater variability showed good correlation between reviewers (intraclass correlation 0.61-0.95). Mean LAA/LA attenuation ratios were significantly different between scans, with larger mean percent reduction of contrast opacification from LA to LAA in the early scans (57.0±36.6% reduction for early vs. 29.1±30.8% for delayed; p < 0.001) CONCLUSION: For CT device surveillance post-LAAC early phase imaging provides superior image quality objectively and subjectively compared with delayed scanning.
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Affiliation(s)
- Thomas S Gilhofer
- Department of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Waleed Abdellatif
- Department of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Savvas Nicolaou
- Deparment of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Sabeena Jalal
- Deparment of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Jennifer Powell
- Deparment of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Taku Inohara
- Department of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Andrew Starovoytov
- Department of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Jacqueline Saw
- Department of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
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26
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Melehy A, O'Connell G, Ning Y, Kurlansky P, Kaku Y, Topkara V, Yuzefpolskaya M, Colombo PC, Sayer G, Uriel N, Naka Y, Takeda K. Role of left atrial appendage occlusion in patients with HeartMate 3. Interact Cardiovasc Thorac Surg 2021; 34:668-675. [PMID: 34662395 PMCID: PMC8972327 DOI: 10.1093/icvts/ivab285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Left atrial appendage occlusion (LAAO) at the time of implantation may reduce thromboembolic events (TEs) during continuous-flow left ventricular assist device support. The HeartMate 3 (HM3) reduces TEs overall, but the efficacy of LAAO in HM3 is unknown. METHODS Adults receiving first HM3 implantation from November 2014 through December 2019 at a single, large medical centre were retrospectively reviewed. TEs included device thrombosis and ischaemic stroke. Patients were classified by whether they received LAAO or not. Incidence of TEs was compared between groups using cumulative incidence curves with competing risks (death and heart transplant) and risk factors for TEs were assessed with Fine and Gray competing risk regression. RESULTS A total of 182 patients received HM3, of whom 99 (54%) received LAAO versus 83 (46%) who did not. There were 14 TEs, including 13 strokes (7%) and 1 pump thrombosis (0.5%). No significant difference in the incidence of TEs in each group was found (Gray's test: P = 0.35). LAAO was not associated with TEs in multivariable Fine-Gray analysis (P = 0.10) and no significant risk factors for TEs were found. There were zero disabling strokes in those who received LAAO compared to 6 (7%) in those who did not receive LAAO (P = 0.008). CONCLUSIONS A low number of TEs was observed in HM3 recipients. LAAO did not further reduce the overall rate of TEs in this patient population, though its use may be beneficial in preventing disabling ischaemic strokes after HM3 implantation.
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Affiliation(s)
- Andrew Melehy
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY, USA
| | - Gillian O'Connell
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY, USA
| | - Yuming Ning
- Department of Surgery, Center of Innovation and Outcomes Research, Columbia University Medical Center, New York, NY, USA
| | - Paul Kurlansky
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY, USA
| | - Yuji Kaku
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY, USA
| | - Veli Topkara
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Gabriel Sayer
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Nir Uriel
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Yoshifumi Naka
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY, USA
| | - Koji Takeda
- Department of Surgery, Division of Cardiothoracic and Vascular Surgery, Columbia University Medical Center, New York, NY, USA
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27
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Okuno T, Lanz J, Stortecky S, Heg D, Bernhard B, Gräni C, Huber A, Praz F, Räber L, Valgimigli M, Siontis GCM, Windecker S, Pilgrim T. Clinical impact of left atrial appendage filling defects in patients undergoing transcatheter aortic valve implantation. Eur Heart J Cardiovasc Imaging 2021; 23:1354-1364. [PMID: 34463717 DOI: 10.1093/ehjci/jeab142] [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: 03/04/2021] [Accepted: 07/07/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS Incidental detection of left atrial appendage (LAA) filling defects is a common finding on multi-detector computed tomography in aortic stenosis patients under evaluation for transcatheter aortic valve implantation (TAVI). We aimed to investigate the incidence of LAA filling defects before TAVI and its impact on clinical outcomes. METHODS AND RESULTS In a prospective registry, LAA filling defects were retrospectively evaluated and categorized into one of four sub-types: thrombus-like, heterogeneous, horizontal, and Hounsfield Unit (HU)-run-off. The primary endpoint was the composite of cardiovascular death or disabling stroke up to 1-year follow-up. Among 1621 patients undergoing TAVI between August 2007 and June 2018, LAA filling defects were present in 177 patients (11%), and categorized as thrombus-like in 22 (1.4%), heterogeneous in 37 (2.3%), horizontal in 80 (4.9%), and HU-run-off in 38 (2.4%). Compared to patients with normal LAA filling, patients with LAA filling defects had greater prevalence of atrial fibrillation (84.7% vs. 26.4%, P < 0.001) and history of cerebrovascular events (16.4% vs. 10.9%, P = 0.045). The primary endpoint occurred in 131 patients (9.2%) with normal LAA filling and in 36 patients (21.2%) with LAA filling defects (P < 0.001). Subgroup analysis suggested that the risk of disabling stroke was greatest in the thrombus-like pattern (23.0%), followed by the HU-run-off (8.0%), the heterogeneous (6.2%), and the horizontal pattern (1.2%). CONCLUSION LAA filling defects were observed in 11% of aortic stenosis patients undergoing TAVI and associated with an increased risk of cardiovascular death and disabling stroke up to 1 year following TAVI. TRIAL REGISTRATION https://www.clinicaltrials.gov. NCT01368250.
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Affiliation(s)
- Taishi Okuno
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Dik Heg
- Clinical Trials Unit Bern, University of Bern, Bern, Switzerland
| | - Benedikt Bernhard
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Adrian Huber
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - George C M Siontis
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
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28
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Backhaus JF, Pflaumbaum A, Krogias C, Kreimer F, Mügge A, Gold R, Gotzmann M. Short- and long-term outcome of patients with spontaneous echo contrast or thrombus in the left atrial appendage in the era of the direct acting anticoagulants. Clin Res Cardiol 2021; 110:1811-1821. [PMID: 34436659 PMCID: PMC8563546 DOI: 10.1007/s00392-021-01926-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/16/2021] [Indexed: 12/21/2022]
Abstract
Background Thrombi and spontaneous echo contrast (SEC) in the left atrial appendage (LAA) are associated with thromboembolic events and poor prognosis. There are very few data on long-term outcome, especially with the use of direct acting anticoagulants (DOAC). Methods In this retrospective study, all transoesophageal echocardiographies performed at a tertiary care university hospital from 2015 to 2020 were analyzed. All patients with thrombus or SEC in the LAA were included. Medical history, laboratory, echocardiographic parameters and medication at discharge were documented. The primary endpoint of the study was a composite endpoint (all-cause mortality, non-fatal stroke or transient ischaemic attack [TIA], non-fatal systemic embolization, non-fatal major bleeding and non-fatal myocardial infarction). Results Of a total of 4062 transoesophageal echocardiographies, thrombi were detected in 51 patients (1.2%) and SEC in 251 patients (6.2%). These patients formed the final study cohort (n = 302). During a mean follow-up period of 956 ± 663 days, 87 patients (29%) suffered the primary point. The following baseline characteristics predicted the primary endpoint: age, haemoglobin, a previous coronary artery bypass grafting, dialysis and choice of anticoagulation. Prescription of apixaban at discharge was associated with lower rate of adverse events (hazard ratio 0.564, confidence interval 0.331–0.960; p = 0.035) while prescription of dabigatran was associated with higher rate of adverse events (hazard ratio 3.091, confidence interval 1.506–6.347; p = 0.002). Conclusion Even in the DOAC era, the occurrence of thrombus or SEC in the LAA is associated with a high rate of MACCE. Our study suggests that the choice of DOAC therapy may have an impact on long-term survival. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s00392-021-01926-8.
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Affiliation(s)
- Julian Felix Backhaus
- Cardiology and Rhythmology, University Hospital St. Josef Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Andreas Pflaumbaum
- Cardiology and Rhythmology, University Hospital St. Josef Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Christos Krogias
- Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Fabienne Kreimer
- Cardiology and Rhythmology, University Hospital St. Josef Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Andreas Mügge
- Cardiology and Rhythmology, University Hospital St. Josef Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Ralf Gold
- Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Michael Gotzmann
- Cardiology and Rhythmology, University Hospital St. Josef Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany.
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29
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Cohen A, Donal E, Delgado V, Pepi M, Tsang T, Gerber B, Soulat-Dufour L, Habib G, Lancellotti P, Evangelista A, Cujec B, Fine N, Andrade MJ, Sprynger M, Dweck M, Edvardsen T, Popescu BA. EACVI recommendations on cardiovascular imaging for the detection of embolic sources: endorsed by the Canadian Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2021; 22:e24-e57. [PMID: 33709114 DOI: 10.1093/ehjci/jeab008] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/07/2021] [Indexed: 12/28/2022] Open
Abstract
Cardioaortic embolism to the brain accounts for approximately 15-30% of ischaemic strokes and is often referred to as 'cardioembolic stroke'. One-quarter of patients have more than one cardiac source of embolism and 15% have significant cerebrovascular atherosclerosis. After a careful work-up, up to 30% of ischaemic strokes remain 'cryptogenic', recently redefined as 'embolic strokes of undetermined source'. The diagnosis of cardioembolic stroke remains difficult because a potential cardiac source of embolism does not establish the stroke mechanism. The role of cardiac imaging-transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac computed tomography (CT), and magnetic resonance imaging (MRI)-in the diagnosis of potential cardiac sources of embolism, and for therapeutic guidance, is reviewed in these recommendations. Contrast TTE/TOE is highly accurate for detecting left atrial appendage thrombosis in patients with atrial fibrillation, valvular and prosthesis vegetations and thrombosis, aortic arch atheroma, patent foramen ovale, atrial septal defect, and intracardiac tumours. Both CT and MRI are highly accurate for detecting cavity thrombosis, intracardiac tumours, and valvular prosthesis thrombosis. Thus, CT and cardiac magnetic resonance should be considered in addition to TTE and TOE in the detection of a cardiac source of embolism. We propose a diagnostic algorithm where vascular imaging and contrast TTE/TOE are considered the first-line tool in the search for a cardiac source of embolism. CT and MRI are considered as alternative and complementary tools, and their indications are described on a case-by-case approach.
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Affiliation(s)
- Ariel Cohen
- Assistance Publique-Hôpitaux de Paris, Saint-Antoine and Tenon Hospitals, Department of Cardiology, and Sorbonne University, Paris, France.,INSERM unit UMRS-ICAN 1166; Sorbonne-Université, Paris, France
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Mauro Pepi
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20141, Milan, Italy
| | - Teresa Tsang
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bernhard Gerber
- Service de Cardiologie, Département Cardiovasculaire, Cliniques Universitaires St. Luc, Division CARD, Institut de Recherche Expérimental et Clinique (IREC), UCLouvainAv Hippocrate 10/2803, B-1200 Brussels, Belgium
| | - Laurie Soulat-Dufour
- Assistance Publique-Hôpitaux de Paris, Saint-Antoine and Tenon Hospitals, Department of Cardiology, and Sorbonne University, Paris, France.,INSERM unit UMRS-ICAN 1166; Sorbonne-Université, Paris, France
| | - Gilbert Habib
- Aix Marseille Univ, IRD, MEPHI, IHU-Méditerranée Infection, APHM, La Timone Hospital, Cardiology Department, Marseille, France
| | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, CHU SartTilman, Liège, Belgium.,Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy
| | - Arturo Evangelista
- Servei de Cardiologia. Hospital Universitari Vall d'Hebron-VHIR. CIBER-CV. Pº Vall d'Hebron 119. 08035. Barcelona. Spain
| | - Bibiana Cujec
- Division of Cardiology, University of Alberta, 2C2.50 Walter Mackenzie Health Sciences Center, 8440 112 St NW, Edmonton, Alberta, Canada T6G 2B7
| | - Nowell Fine
- University of Calgary, Libin Cardiovascular Institute, South Health Campus, 4448 Front Street Southeast, Calgary, Alberta T3M 1M4, Canada
| | - Maria Joao Andrade
- Maria Joao Andrade Cardiology Department, Hospital de Santa Cruz-Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos 2790-134 Carnaxide, Portugal
| | - Muriel Sprynger
- Department of Cardiology-Angiology, University Hospital Liège, Liège, Belgium
| | - Marc Dweck
- British Heart Foundation, Centre for Cardiovascular Science, Edinburgh and Edinburgh Imaging Facility QMRI, University of Edinburgh, United Kingdom
| | - Thor Edvardsen
- Faculty of medicine, Oslo University, Oslo, Norway and Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Bogdan A Popescu
- Cardiology Department, University of Medicine and Pharmacy 'Carol Davila', Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C. C. Iliescu', Sos. Fundeni 258, sector 2, 022328 Bucharest, Romania
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30
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Özyalçın S, Topçu H. The impact of spontaneous echo contrast on tunneled dialysis catheter patency. J Vasc Access 2021; 24:423-429. [PMID: 34325574 DOI: 10.1177/11297298211035599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Spontaneous echo contrast (SEC) is an ultrasonographic image of swirling blood flow resembling a dynamic, cigarette smoke-like image. It is mostly observed during the insertion of tunneled dialysis catheters (TDC) into internal jugular veins with ultrasound guidance, often different levels of SEC can be seen. The aim of this study is to investigate the impact of SEC detected during TDC insertion on the patency of the catheter. METHODS Patients who had a TDC insertion in our clinic between January 2015 and December 2020 were prospectively evaluated. The patients were grouped into five groups according to the sec level and followed. RESULTS A total of 226 patients were examined, among which 107 were male (47.3%). The mean age of all patients was 63.1 ± 9.5 years. SEC grade and catheter occlusion was evaluated, it was observed that higher SEC grades were correlated with faster catheter thrombosis postinsertion. During the follow-up period, it was found that, compared to the SEC 0 group, catheter thrombosis occurred 3.22 times faster in the SEC 1 group, 2.66 times faster in the SEC 2 group, 5.80 times faster in the SEC 3 group, and 26.33 times faster in the SEC 4 group. (HR: 3.22, 2.66, 5.80, 26.33, respectively). Hematological parameters were evaluated by regression analysis, it was observed that hemoglobin, fibrinogen, and platelet count were not risk factors for SEC formation and SEC grade. CONCLUSION Significant relationship was found between SEC grade detected during catheter insertion and catheter thrombosis in patients undergoing hemodialysis with a TDC.
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Affiliation(s)
- Sertan Özyalçın
- Department of Cardiovascular Surgery, Faculty of Medicine, Hitit University, Çorum, Turkey
| | - Hülya Topçu
- Department of Anesthesiology and Reanimation, Hitit University Faculty of Medicine, Çorum, Turkey
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31
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Porphyromonas gingivalis and left atrial appendage spontaneous echo contrast in atrial fibrillation ablation candidates. Heart Vessels 2021; 36:1721-1729. [PMID: 34021383 DOI: 10.1007/s00380-021-01851-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/02/2021] [Indexed: 10/21/2022]
Abstract
Atrial fibrillation (AF) is associated with a fivefold risk of stroke and thrombotic embolism, which are usually derived from the left atrial appendage (LAA). Spontaneous echo contrast (SEC) is known as a risk factor for thrombosis. Porphyromonas gingivalis (P. gingivalis) has some prothrombotic effects and plays a key role in periodontitis and oral-systemic disease connection. We aimed to clarify the relationship between P. gingivalis and LAA SEC among AF patients. A total of 569 AF ablation candidates were enrolled in the present study. LAA SEC was categorized into nondense SEC and dense SEC based on transesophageal echocardiography. Serum immunoglobulin G antibody titers of P. gingivalis fimA subtypes (types I-IV) were measured with an enzyme-linked immunosorbent assay. The levels of antibody titers were categorized into high (> mean + 3 standard deviation) and low values. A total of 513 (90%) patients were included in the nondense SEC group, and 56 (10%) were included in the dense SEC group. Multivariate regression analysis revealed that the high-value serum antibody titers of P. gingivalis types II and IV were independently associated with dense SEC [type II: adjusted odds ratio (OR) 2.220; 95% confidence interval (CI) 1.062-4.643; P = 0.02; and type IV: adjusted OR 3.169; 95% CI 1.058-6.657; P = 0.002]. The results revealed that P. gingivalis types II and IV are related to LAA SEC severity among AF patients who receive appropriate anticoagulation therapy.
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Hagii J, Metoki N, Saito S, Shiroto H, Sasaki S, Takahashi K, Hitomi H, Baba Y, Yamada N, Seino S, Kamada T, Uchizawa T, Nakamura T, Yasujima M, Tomita H. Persistent or permanent atrial fibrillation is associated with severe cardioembolic stroke in patients with non-valvular atrial fibrillation. Thromb J 2021; 19:22. [PMID: 33789684 PMCID: PMC8011096 DOI: 10.1186/s12959-021-00276-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little is known about the difference in the severity of cardioembolic (CE) stroke between patients with paroxysmal atrial fibrillation (PAF) and persistent/permanent AF (PerAF). We assessed stroke severity in patients with CE stroke divided by the type of AF. METHODS Three hundred and fifty-eight consecutive patients with CE stroke within 48 h of onset and with a modified Rankin Scale (mRS) score ≤ 1 before onset were studied. We compared basic characteristics, stroke severity, and functional outcome between patients with PAF (n = 127) and PerAF (n = 231). RESULTS Patients with PerAF were more likely to take oral anticoagulants (OACs) than those with PAF (37% vs. 13%, P < 0.0001), even though still underuse of OAC in both patients. Regarding stroke severity on admission, patients with PerAF exhibited a tendency toward a higher score on the National Institutes of Health Stroke Scale (NIHSS) compared with patients with PAF (12 [5-20] vs. 9 [4-18]; P = 0.12). Mortality and mRS score at discharge were higher in the PerAF than in the PAF group (13% vs. 4%; P = 0.005, and 3 [1-5] vs. 2 [1-4]; P = 0.01, respectively). Multivariate analyses confirmed that PerAF was a significant determinant of severe stroke (NIHSS score > 8) on admission (odds ratio [OR] to PAF = 1.80; 95% confidence interval [CI] 1.08-2.98; P = 0.02) and of an mRS score ≥ 3 at discharge (OR = 2.07; 95% CI 1.24-3.46; P = 0.006). Patients with PerAF had three times more internal carotid artery occlusion evaluated by magnetic resonance angiography, which indicated a more severe cerebral embolism compared with patients with PAF. CONCLUSIONS We found underuse of OAC in high risk AF patients with CE stroke. PerAF is significantly associated with severe stroke on admission and an unfavorable functional outcome at discharge in Japanese patients with CE stroke.
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Affiliation(s)
- Joji Hagii
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, 036-8104, Japan
| | - Norifumi Metoki
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, 036-8104, Japan
| | - Shin Saito
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, 036-8104, Japan
| | - Hiroshi Shiroto
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, 036-8104, Japan
| | - Satoko Sasaki
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, 036-8104, Japan
| | - Koki Takahashi
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, 036-8104, Japan
| | - Hiroyasu Hitomi
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, 036-8104, Japan
| | - Yoshiko Baba
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, 036-8104, Japan
| | - Natsumi Yamada
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, 036-8104, Japan
| | - Satoshi Seino
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, 036-8104, Japan
| | - Takaatsu Kamada
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, 036-8104, Japan
| | | | - Taigen Nakamura
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, 036-8104, Japan
| | - Minoru Yasujima
- Hirosaki Stroke and Rehabilitation Center, Hirosaki, 036-8104, Japan
| | - Hirofumi Tomita
- Department of Cardiology, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, 036-8562, Japan. .,Department of Stroke and Cerebrovascular Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, 036-8562, Japan.
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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.
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Negrotto SM, Lugo RM, Metawee M, Kanagasundram AN, Chidsey G, Baker MT, Michaud GF, Piana RN, Benjamin Shoemaker M, Ellis CR. Left atrial appendage morphology predicts the formation of left atrial appendage thrombus. J Cardiovasc Electrophysiol 2021; 32:1044-1052. [PMID: 33512055 DOI: 10.1111/jce.14922] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 12/15/2020] [Accepted: 01/03/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nonchicken wing left atrial appendage (LAA) morphology is associated with higher risk for stroke in patients with atrial fibrillation (AF) than chicken wing (CW) morphology. OBJECTIVE Assess whether LAA morphology predicts the formation of LAA thrombus independent of age, sex, presenting rhythm, left ventricular ejection fraction (LVEF), or anticoagulant use. METHODS A cross-sectional analysis was performed on patients prospectively enrolled in the Vanderbilt LAA Registry or presenting for transesophageal echocardiogram (TEE) between January 1, 2015, and November 1, 2017 (n = 306). Two physicians independently reviewed TEEs interpreted as having LAA thrombus. Determination of LAA morphology, ejection velocity, and presence of thrombus (n = 102) were based on 0°, 45°, 90°, and 135° TEE views. The control cohort (n = 204) included consecutive AF patients undergoing TEE without LAA thrombus. RESULTS LAA morphology in patients with LAA thrombus was: 35% windsock, 47% broccoli, and 12% CW. Windsock (odds ratio [OR], 4.0; 95% confidence interval [CI]: 1.7-9.3, p = .001) and broccoli (OR, 6.6; 95% CI: 2.6-16.6; p < .001) morphology were higher risk for thrombus compared to CW. Female sex predicted higher-odds for LAA thrombus (OR, 2.6; 95% CI: 1.4-4.8; p = .002) as did LAA-EV < 20 cm/s (OR, 11.12; 95% CI: 5.6-22.1). Anticoagulation use (OR, 0.5; 95% CI: 0.3-0.9; p = .03) and higher LVEF (OR, 0.95; 95% CI: 0.93-0.98; p < .001) were associated with lower risk. In patients with a CW morphology who had LAA thrombus, 4 of the 7 had an LAA-EV < 20 cm/s and acute systolic heart failure with LVEF < 30% or active malignancy. In multivariable linear regression analysis controlling for presenting rhythm, anticoagulant use, age, sex, and LVEF, CW morphology appears relatively protective from LAA thrombus (p = .001). CONCLUSION CW LAA morphology appears relatively protective against the formation of LAA thrombus.
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Affiliation(s)
- Sara M Negrotto
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ricardo M Lugo
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mohamed Metawee
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Arvindh N Kanagasundram
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Geoffrey Chidsey
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael T Baker
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gregory F Michaud
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Robert N Piana
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Moore Benjamin Shoemaker
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher Randall Ellis
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Linder M, Voigtländer L, Schneeberger Y, Bhadra O, Grundmann D, Demal T, Goßling A, Ludwig S, Schaefer A, Waldschmidt L, Schirmer J, Reichenspurner H, Blankenberg S, Schäfer U, Westermann D, Schofer N, Conradi L, Seiffert M. Spontaneous echo contrast, left atrial appendage thrombus and stroke in patients undergoing transcatheter aortic valve implantation. EUROINTERVENTION 2021; 16:1114-1122. [PMID: 32863242 PMCID: PMC9725018 DOI: 10.4244/eij-d-20-00743] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The relevance of spontaneous echo contrast (SEC) and left atrial appendage thrombus (LAAT) in patients undergoing transcatheter aortic valve implantation (TAVI) remains unclear. In this study, we aimed to assess the prevalence of SEC and LAAT and evaluate the impact on periprocedural outcome after TAVI. METHODS AND RESULTS A total of 2,549 consecutive patients underwent TAVI between 2008 and 2017. After exclusion of cases with insufficient imaging, concomitant procedures or severe intraprocedural complications, 1,558 cases were analysed. Three groups were defined according to (pre)thrombotic formations - moderate or severe SEC (n=89), LAAT (n=53), and reference (n=1,416). The primary outcome was disabling ischaemic stroke within 24 hours. The prevalence was 4.4% for LAAT and 5.4% for moderate/severe SEC. The primary outcome occurred more frequently in patients with moderate/severe SEC (6.8%) compared to the reference (2.1%) and LAAT (1.9%) groups (p=0.020). SEC was identified as an independent risk factor for the primary outcome (OR 3.54 [95% CI: 1.30-9.61], p=0.013). LAAT was associated with an impaired unadjusted one-year survival (43.4%) compared to the SEC (27.3%) and reference groups (18.7%, p<0.001). CONCLUSIONS SEC and LAAT were detected in a relevant number of patients undergoing TAVI. SEC may represent an important risk factor for intraprocedural stroke; increased mortality was observed in patients with LAAT.
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Affiliation(s)
- Matthias Linder
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Lisa Voigtländer
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Germany
| | - Yvonne Schneeberger
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Oliver Bhadra
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - David Grundmann
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Till Demal
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Alina Goßling
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Sebastian Ludwig
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Andreas Schaefer
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Lara Waldschmidt
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Johannes Schirmer
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Germany
| | - Ulrich Schäfer
- Department of Cardiology, Angiology and Intensive Care Medicine, Marienkrankenhaus, Hamburg, Germany
| | - Dirk Westermann
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Germany
| | - Niklas Schofer
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Moritz Seiffert
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistraße 52, 20246 Hamburg, Germany. E-mail:
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Mao Y, Yu C, Yang Y, Ma M, Wang Y, Jiang R, Chen R, Zhao B, Jiang C. Comparison of left atrial and left atrial appendage mechanics in the risk stratification of stroke in patients with atrial fibrillation. Cardiovasc Ultrasound 2021; 19:7. [PMID: 33422087 PMCID: PMC7797160 DOI: 10.1186/s12947-020-00232-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/10/2020] [Indexed: 02/07/2023] Open
Abstract
Background Left atrial (LA) and left atrial appendage (LAA) dysfunction has been demonstrated to contribute to atrial fibrillation (AF)-related stroke. However, usefulness of LA and LAA mechanics has not been fully compared. We sought to investigate the association of LA and LAA mechanics with stroke and to compare their diagnostic values in the risk stratification of stroke in patients with nonvalvular AF. Methods A total of 208 consecutive patients with AF (63.58 ± 10.37 years, 63.9% male,57.7% persistent AF) who underwent echocardiography before catheter ablation were prospectively enrolled. Speckle-tracking was used to measure LA and LAA global longitudinal strain (GLS). LA and LAA mechanical dispersions (MD) were defined as the standard deviation (SD) of time to peak positive strain corrected by the R-R interval. Results Patients with prior stroke/ transient ischemic attack (TIA) (n = 31) had significantly higher LA and LAA MD than those without (n = 177) (11.56 ± 4.38% vs. 8.43 ± 3.44%, 15.15 ± 5.46% vs. 10.94 ± 4.40%, both P < 0.01). In multivariable analysis, LA and LAA MD were independently associated with stroke/TIA (odds ratio, 1.18–1.29, 1.19–1.22, respectively, both P < 0.01), providing incremental values over clinical and standard echocardiographic parameters. In a subgroup analysis, LA MD was more useful than LAA MD in patients with normal LA volumes, while LAA MD was superior to LA MD in patients with LA enlargement. Conclusions Higher LA and LAA mechanical dispersion are independently associated with stroke/TIA in AF patients and had incremental values over clinical and conventional echocardiographic parameters. What’s more, priorities of dispersion assessment are different depending on patients’ LA size. Supplementary Information The online version contains supplementary material available at 10.1186/s12947-020-00232-z.
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Affiliation(s)
- Yankai Mao
- Department of Diagnostic Ultrasound & Echocardiography, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, #3 East Qingchun Road, Hangzhou, China
| | - Chan Yu
- Department of Diagnostic Ultrasound & Echocardiography, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, #3 East Qingchun Road, Hangzhou, China
| | - Yuan Yang
- Department of Diagnostic Ultrasound & Echocardiography, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, #3 East Qingchun Road, Hangzhou, China
| | - Mingming Ma
- Department of Diagnostic Ultrasound & Echocardiography, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, #3 East Qingchun Road, Hangzhou, China
| | - Yunhe Wang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, People's Republic of China
| | - Ruhong Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, People's Republic of China
| | - Ran Chen
- Department of Diagnostic Ultrasound & Echocardiography, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, #3 East Qingchun Road, Hangzhou, China
| | - Bowen Zhao
- Department of Diagnostic Ultrasound & Echocardiography, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, #3 East Qingchun Road, Hangzhou, China.
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, 3 East Qingchun Road, Hangzhou, People's Republic of China.
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Strecker C, Günther F, Harloff A. Who Should Rather Undergo Transesophageal Echocardiography to Determine Stroke Etiology: Young or Elderly Stroke Patients? Front Neurol 2021; 11:588151. [PMID: 33391153 PMCID: PMC7775476 DOI: 10.3389/fneur.2020.588151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 11/30/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: The indication of transesophageal echocardiography (TEE) in acute stroke is unclear. Thus, we systematically studied the impact of TEE on determining stroke etiology and secondary prevention in patients of different age-groups with cryptogenic stroke. Methods: Four hundred and eighty five consecutive patients with acute retinal or cerebral ischemia were prospectively included and underwent routine stroke workup including TEE. Stroke etiology was identified according to the TOAST classification and patients were divided in those with determined and cryptogenic stroke etiology without TEE results. Then, the frequency of high- and potential-risk sources in TEE was evaluated in <55, 55–74, and ≥75 year-old patients with cryptogenic stroke etiology. Results: Without TEE, stroke etiology was cryptogenic in 329(67.8%) patients and TEE determined possible etiology in 158(48.4%) of them. In patients aged <55, 55–74, ≥75, TEE detected aortic arch plaques ≥4 mm thickness in 2(1.2%), 37(23.0%), and 33(40.2%) and plaques with superimposed thrombi in 0(0.0%), 5(3.1%), and 7(8.5%); left atrial appendage peak emptying flow velocity ≤30cm/s in 0(0.0%), 1(0.6%), and 2(2.4%), spontaneous echo contrast in 0(0.0%), 1(0.6%), and 6(7.3%), endocarditis in 0(0.0%), 0(0.0%), and 1(1.2%) and patent foramen ovale (PFO) plus atrial septum aneurysm (ASA) in 18(20.9%), 32(19.9%), and 14(17.1%), respectively. TEE changed secondary prevention in 16.4% of these patients following guidelines of 2010/11 and still 9.4% when applying the guidelines of 2020. Conclusions: TEE was highly valuable for determining stroke etiology and influenced individual secondary prevention based on available treatment guidelines and expert opinion in most cases. In young patients the impact of TEE was limited to the detection of septal anomalies. By contrast, in older patients TEE detected high numbers of complex aortic atheroma and potential indicators of paroxysmal atrial fibrillation.
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Affiliation(s)
- Christoph Strecker
- Department of Neurology and Neurophysiology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Felix Günther
- Department of Internal Medicine, Staufenburg Klinik, Durbach, Germany
| | - Andreas Harloff
- Department of Neurology and Neurophysiology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
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Sonaglioni A, Lombardo M, Nicolosi GL, Rigamonti E, Anzà C. Incremental diagnostic role of left atrial strain analysis in thrombotic risk assessment of nonvalvular atrial fibrillation patients planned for electrical cardioversion. Int J Cardiovasc Imaging 2021; 37:1539-1550. [PMID: 33389359 PMCID: PMC7778706 DOI: 10.1007/s10554-020-02127-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 11/30/2020] [Indexed: 01/18/2023]
Abstract
During the COVID-19 pandemic, transesophageal echocardiography (TEE) for left atrial appendage thrombosis (LAAT) detection should be limited to situations of absolute necessity. We sought to identify the main conventional and functional echocardiographic parameters associated with LAAT on TEE in non-valvular atrial fibrillation (NVAF) patients planned for electrical cardioversion (ECV). This retrospective study included 125 consecutive NVAF patients (71.5±7.8 yrs, 75 males), who underwent TEE at our Institution between April 2016 and January 2020, to exclude LAAT before scheduled ECV. All patients underwent a transthoracic echocardiography (TTE) implemented with speckle tracking echocardiography (STE) analysis of left atrial (LA) strain and strain rate (SR) parameters. 28% of patients were diagnosed with LAAT, while 72% without LAAT. Compared to controls, patients with LAAT had significantly higher CHA2DS2-Vasc Score and average E/e’ ratio, and significantly lower left ventricular ejection fraction (LVEF). Moreover, LA-peak positive global atrial strain (GSA+) and LA-SR parameters were significantly reduced in patients with LAAT. Multivariate logistic regression revealed that, differently from CHA2DS2-Vasc Score, LVEF (OR 0.88, 95%CI 0.81–0.97, p = 0.01), average E/e’ ratio (OR 2.36, 95%CI 1.41–3.98, p = 0.001), and LA-GSA+ (OR 0.57, 95%CI 0.36-0-90, p = 0.01) were independently associated with LAAT. LA-GSA+ (optimal cut-off ≤ 9.1%, AUC 0.95) showed the highest diagnostic performance. Finally, a strong linear correlation of LA peak-to-peak SR with both LA appendage filling (r = 0.86) and emptying (r = 0.83) velocities was demonstrated. TTE implemented with STE analysis of LA mechanics improves thrombotic risk assessment of NVAF patients.
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Affiliation(s)
- Andrea Sonaglioni
- Department of Cardiology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy.
| | - Michele Lombardo
- Department of Cardiology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy
| | | | - Elisabetta Rigamonti
- Department of Cardiology, Ospedale San Giuseppe MultiMedica IRCCS, Via San Vittore 12, 20123, Milan, Italy
| | - Claudio Anzà
- Cardiovascular Department, MultiMedica IRCCS, Via Milanese 300, 20099, Sesto San Giovanni (MI), Italy
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Left Atrial Appendage Morphology and Left Atrial Wall Thickness Are Associated with Cardio-Embolic Stroke. J Clin Med 2020; 9:jcm9123944. [PMID: 33291376 PMCID: PMC7762068 DOI: 10.3390/jcm9123944] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/26/2020] [Accepted: 12/03/2020] [Indexed: 11/30/2022] Open
Abstract
Background. New markers for stroke risk stratification in patients with atrial fibrillation (AF) are on demand. Hence, we aimed to investigate the association of left atrial appendage (LAA) and left atrium (LA) morphological parameters in patients with cardio-embolic (CE) stroke due to AF in comparison to controls without stroke. Methods: A retrospective analysis of cardiac computed tomography angiography (CTA) examinations performed between 2006 and 2017 for clinical indications in 158 patients (median age 65 (54–73) years, 48.7% females) was conducted: 56 patients with CE stroke were compared to 102 controls not differing in gender, body mass index (BMI) and CHA2DS2-VASc score. Results: On multivariable regression analysis adjusted for CHA2DS2-VASc score and LA diameter CE stroke was independently associated with the following parameters: windsock LAA type (OR 2.55; CI: 1.04–6.26, p = 0.041), a greater lobe number (OR 1.54; CI: 1.13–2.10, p = 0.006), a greater LAA ostium area (OR 1.88; CI: 1.38–2.55, p < 0.001) and a greater left atrium wall thickness (LAWT) in the middle and right part, measured along the anterior LA wall in the axial plane (respectively, OR 1.94; CI: 1.26–3.0, p = 0.003 and OR 1.57; CI: 1.07–2.31, p = 0.021). Conclusions: The windsock LAA type, a greater LAA lobe number, a larger LAA ostium and a greater LAWT are associated with CE stroke. These CTA parameters could improve risk stratification for thromboembolic stroke.
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Riddle M, McCallum R, Ojha CP, Paul TK, Gupta V, Baran DA, Prakash BV, Misra A, Mares AC, Abedin M, Kedar A, Mulukutla V, Ibrahim A, Nagarajarao H. Advances in the management of atrial fibrillation with a special focus on non-pharmacological approaches to prevent thromboembolism: a review of current recommendations. J Investig Med 2020; 68:1317-1333. [PMID: 33203786 DOI: 10.1136/jim-2020-001500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2020] [Indexed: 11/04/2022]
Abstract
Atrial fibrillation (AFIB) is the most common heart rhythm abnormality and is associated with significant morbidity and mortality. While the treatment of AFIB involves strategies of rate with or without rhythm control, it is also essential to strategize appropriate therapies to prevent thromboembolic complications arising from AFIB. Previously, anticoagulation was the main treatment option which exposed patients to higher than usual risk of bleeding. However, with the advent of new technology, novel therapeutic options aimed at surgical or percutaneous exclusion or occlusion of the left atrial appendage in preventing thromboembolic complications from AFIB have evolved. This review evaluates recent advances and therapeutic options in treating AFIB with a special focus on both surgical and percutaneous interventions which can reduce and/or eliminate thromboembolic complications of AFIB.
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Affiliation(s)
- Malini Riddle
- Paul L Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Richard McCallum
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Chandra Prakash Ojha
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Timir Kumar Paul
- Internal Medicine, East Tennessee State University James H Quillen College of Medicine, Johnson City, Tennessee, USA
| | - Vineet Gupta
- Department of Internal Medicine, University of California San Diego, La Jolla, California, USA
| | - David Alan Baran
- Cardiovascular Diseases, Sentara Healthcare Inc, Norfolk, Virginia, USA
| | - Bharat Ved Prakash
- Department of Medicine, Texas Tech University Health Sciences Center El Paso, Transmountain Campus, El Paso, Texas, USA
| | - Amogh Misra
- Department of Biochemistry, The University of Texas at Austin, Austin, Texas, USA
| | - Adriana Camila Mares
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Moeen Abedin
- Division of Cardiology, University Medical Center of El Paso, El Paso, Texas, USA
| | - Archana Kedar
- Internal Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | | | - Ahmed Ibrahim
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Harsha Nagarajarao
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
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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.
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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
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Saberwal B, Ioannou A, Lim WY, Beirne AM, Chow AW, Tousoulis D, Ahsan S, Papageorgiou N. Antithrombotic Therapy in Patients with Recent Stroke and Atrial Fibrillation. Curr Pharm Des 2020; 26:2715-2724. [DOI: 10.2174/1381612826666200407150307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/16/2020] [Indexed: 12/31/2022]
Abstract
:
Atrial fibrillation (AF) is a common arrhythmia which carries a significant risk of stroke. Secondary
prevention, particularly in the acute phase of stroke with anti-thrombotic therapy, has not been validated. The aim
of this review is to evaluate the available evidence on the use of antithrombotic therapy in patients with recent
stroke who have AF, and suggest a treatment algorithm for the various time points, taking into account both the
bleeding and thrombosis risks posed at each stage.
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Affiliation(s)
- Bunny Saberwal
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, United Kingdom
| | - Adam Ioannou
- Royal Free Hospital, London NW3 2QG, United Kingdom
| | - Wei Y. Lim
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, United Kingdom
| | - Anne-Marie Beirne
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, United Kingdom
| | - Anthony W. Chow
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, United Kingdom
| | - Dimitris Tousoulis
- First Cardiology Department, Hippokration Hospital, Athens University Medical School, Athens, Greece
| | - Syed Ahsan
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, United Kingdom
| | - Nikolaos Papageorgiou
- Electrophysiology Department, Barts Heart Centre, St. Bartholomew’s Hospital, London EC1A 7BE, United Kingdom
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Anselmino M, Frea S, Gili S, Rovera C, Morello M, Jorfida M, Teodori J, Perversi J, Salvetti I, Grosso Marra W, Faletti R, Righi D, Gaita F, DE Ferrari GM. Left atrial appendage morphology at transesophageal echocardiography: how to improve reproducibility? Minerva Cardiol Angiol 2020; 69:178-184. [PMID: 32657552 DOI: 10.23736/s2724-5683.20.05215-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Left atrial appendage (LAA) morphology, investigated by computed tomography and magnetic resonance imaging, has proved to relate to the risk of cerebrovascular events in patients with atrial fibrillation (AF). The aim of the present study was to assess reproducibility of transesophageal echocardiography (TEE) imaging in describing LAA morphology. METHODS Two-hundred consecutive patients referred for TEE were enrolled. In the first group of 47 (23.5%) patients LAA morphology was analyzed by conventional TEE and described as ChickenWing, Windsock, Cactus or Cauliflower. In the second group of 153 (76.5%) patients, instead, a 3D-Xplane diagnostic algorithm was performed to stratify LAA morphology as linear (ChickenWing) or complex (Windsock/Cactus and Cauliflower). Interobserver variability within three independent readers was assessed in both groups of patients and stratified by operator's experience and training. In a subgroup of 19 (12.4%) patients, the agreement of LAA morphology description by 3D-Xplane diagnostic algorithm was compared to cardiac magnetic resonance. RESULTS By conventional TEE the agreement among operators on LAA morphology classification was poor (ρ<0.13). The 3D-XPlane diagnostic algorithm, significantly increased interobserver agreement up to ρ=0.32 within all readers and up to ρ=0.82 among the experienced and specifically trained operators. LAA morphology description in this latter group provided strong agreement with cardiac magnetic resonance (up to ρ=0.77). CONCLUSIONS LAA morphology assessment is challenging by conventional TEE. To improve reproducibility, the use of the 3D-Xplane technique combined with a specific diagnostic algorithm and training of the operators is fundamental.
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Affiliation(s)
- Matteo Anselmino
- Division of Cardiology, Department of Medical Sciences, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Simone Frea
- Division of Cardiology, Department of Medical Sciences, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Sebastiano Gili
- Interventional Cardiology Unit 3, IRCCS Monzino Cardiac Center, Milan, Italy
| | - Chiara Rovera
- Division of Cardiology, Hospital of Chivasso, Chivasso, Turin, Italy -
| | - Mara Morello
- Division of Cardiology, Department of Medical Sciences, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Marcella Jorfida
- Division of Cardiology, Department of Medical Sciences, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Julien Teodori
- Division of Cardiology, Department of Medical Sciences, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Jacopo Perversi
- Division of Cardiology, Cardinal Massaia Hospital, Asti, Italy
| | - Ilaria Salvetti
- Division of Cardiology, Department of Medical Sciences, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | | | - Riccardo Faletti
- Division of Radiology, Department of Diagnostic Imaging and Radiotherapy, University of Turin, Turin, Italy
| | - Dorico Righi
- Division of Radiology, Department of Diagnostic Imaging and Radiotherapy, University of Turin, Turin, Italy
| | - Fiorenzo Gaita
- Division of Cardiology, Department of Medical Sciences, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Gaetano M DE Ferrari
- Division of Cardiology, Department of Medical Sciences, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
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Park JH, Sohn SH, Choi JW, Park EA, Hwang HY. Safety and Efficacy of Left Atrial Appendage Excision Using a Vascular Stapler. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:127-131. [PMID: 32551293 PMCID: PMC7287222 DOI: 10.5090/kjtcs.2020.53.3.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 12/09/2019] [Accepted: 12/11/2019] [Indexed: 12/03/2022]
Abstract
Background This study was conducted to evaluate the safety and efficacy of left atrial appendage (LAA) excision using a vascular stapler. Methods Fifty consecutive patients (mean age, 68±9 years) who underwent LAA excision using a vascular stapler during concomitant cardiac surgery were enrolled. In all patients, the excision site was evaluated using computed tomography at a median of 7 days (interquartile range, 5–13.3 days) postoperatively. The safety endpoint of this study was the occurrence of LAA excision-related events, which were defined as bleeding from the excision site that required reinforcement sutures or reoperation due to excision site bleeding. The efficacy endpoint was LAA excision failure, which was defined as a remnant LAA (a stump >1 cm in maximum length) or extravasation of radiocontrast dye. Results LAAs were excised using 60- and 45-mm vascular staplers in 49 patients and 1 patient, respectively. Reinforcement sutures were needed in 4 patients due to staple-line bleeding and in 4 patients due to bleeding of the surrounding tissues. No patient underwent reoperation due to staple-related bleeding. A remnant LAA was observed in 2 patients, while extravasation of radiocontrast dye was not observed in any patients. Conclusion LAA excision using a vascular stapler may be an effective technique for LAA exclusion. Delicate handling of the stapler device and LA tissue is required to prevent procedure-related complications.
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Affiliation(s)
- Ji Hyeon Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Suk Ho Sohn
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Woong Choi
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Ah Park
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ho Young Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Ntaios G, Perlepe K, Lambrou D, Sirimarco G, Strambo D, Eskandari A, Karagkiozi E, Vemmou A, Korompoki E, Manios E, Makaritsis K, Vemmos K, Michel P. Identification of patients with embolic stroke of undetermined source and low risk of new incident atrial fibrillation: The AF-ESUS score. Int J Stroke 2020; 16:29-38. [DOI: 10.1177/1747493020925281] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background and aims Only a minority of patients with Embolic Stroke of Undetermined Source (ESUS) receive prolonged cardiac monitoring despite current recommendations. The identification of ESUS patients who have low probability of new diagnosis of atrial fibrillation (AF) could potentially support a strategy of more individualized allocation of available resources and hence, increase their diagnostic yield. We aimed to develop a tool that can identify ESUS patients who have low probability of new incident AF. Methods We performed multivariate stepwise regression in a pooled dataset of consecutive ESUS patients from three prospective stroke registries to identify predictors of new incident AF. The coefficient of each independent covariate of the fitted multivariable model was used to generate an integer-based point scoring system. Results Among 839 patients (43.1% women, median age 67.0 years) followed-up for a median of 24.3 months (2999 patient-years), 125 (14.9%) had new incident AF. The proposed score assigns 3 points for age ≥ 60 years; 2 points for hypertension; −1 point for left ventricular hypertrophy reported at echocardiography; 2 points for left atrial diameter >40 mm; −3 points for left ventricular ejection fraction <35%; 1 point for the presence of any supraventricular extrasystole recorded during all available 12-lead standard electrocardiograms performed during hospitalization for the ESUS; −2 points for subcortical infarct; −3 points for the presence of non-stenotic carotid plaques. The rate of new incident AF during follow-up was 1.97% among the 42.3% of the cohort who had a score of ≤0, compared to 26.9% in patients with > 0 (relative risk: 13.7, 95%CI: 5.9--31.5). The area under the curve of the score was 84.8% (95%CI: 79.9--86.9%). The sensitivity and negative predictive value of a score of ≤0 for new incident AF during follow-up were 94.9% (95%CI: 89.3--98.1%) and 98.0% (95%CI: 95.8--99.3%), respectively. Conclusions The proposed AF-ESUS score has high sensitivity and high negative predictive value to identify ESUS patients who have low probability of new incident AF. Patients with a score of 1 or more may be better candidates for prolonged automated cardiac monitoring. Clinical trial registration URL: https://www.clinicaltrials.gov / Unique identifier: NCT02766205.
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Affiliation(s)
- George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Kalliopi Perlepe
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Dimitris Lambrou
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Gaia Sirimarco
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Davide Strambo
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Ashraf Eskandari
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Efstathia Karagkiozi
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Anastasia Vemmou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Korompoki
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
- Division of Brain Sciences, Department of Stroke Medicine, Imperial College, London, UK
| | - Efstathios Manios
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Makaritsis
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Vemmos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Patrik Michel
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
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Sisti N, Mandoli GE, Sciaccaluga C, Valente S, Mondillo S, Cameli M. Insight into Atrial Fibrillation in LVAD Patients: From Clinical Implications to Prognosis. Pulse (Basel) 2020; 8:2-14. [PMID: 32999873 DOI: 10.1159/000506600] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 02/14/2020] [Indexed: 12/21/2022] Open
Abstract
The use of left ventricular assist devices (LVADs), whether for destination therapy or bridge to transplantation, has gained increasing validation in recent years in patients with advanced heart failure. Arrhythmias can be the most challenging variables in the management of such patients but the main attention has always been focused on ventricular arrhythmias given the detrimental impact on mortality. Nevertheless, atrial fibrillation (AF) is the most common rhythm disorder associated with advanced heart failure and may therefore characterize the LVADs' pre- and postimplantation periods. Indeed, the consequences of AF in the population suffering from standard heart failure may require a more comprehensive evaluation in the presence of or in sight of an LVAD, making the AF clinical management in these patients potentially complex. Several studies have been based on this subject with different and often conflicting results, leaving many questions unresolved. The purpose of this review is to summarize the main pieces of evidence about the clinical impact of AF in LVAD patients, underlining the main implications in terms of hemodynamics, thromboembolic risk, bleeding and prognosis. Therapeutic considerations about the clinical management of these patients are also made according to the latest evidence.
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Affiliation(s)
- Nicolò Sisti
- Department of Cardiovascular Diseases, University of Siena, Siena, Italy
| | | | | | - Serafina Valente
- Department of Cardiovascular Diseases, University of Siena, Siena, Italy
| | - Sergio Mondillo
- Department of Cardiovascular Diseases, University of Siena, Siena, Italy
| | - Matteo Cameli
- Department of Cardiovascular Diseases, University of Siena, Siena, Italy
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47
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Galderisi M, Esposito R, Sorrentino R, Mura LL, Santoro C, Tufano A. Atrial Fibrillation, Cancer and Echocardiography. J Cardiovasc Echogr 2020; 30:S33-S37. [PMID: 32566464 PMCID: PMC7293868 DOI: 10.4103/jcecho.jcecho_8_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/23/2019] [Accepted: 10/03/2019] [Indexed: 01/05/2023] Open
Abstract
Nonvalvular atrial fibrillation (AF) is a relatively frequent arrhythmia in cancer patients; it is possibly due to direct effect of cancer or consequence of cancer therapies. AF creates important problems for both therapeutic management and prognosis in cancer patients. The anticoagulation of cancer patients presenting AF is a main issue because of the difficult balance between thromboembolic and bleeding risks, both elevated in this clinical setting. A comprehensive echo Doppler examination is mandatory to identify the eventual sources of emboli in left atrial (LA) cavity, mainly the transesophageal echocardiography (TEE), but also to predict the subsequent development of heart failure. This evaluation is particularly important to graduate anticoagulation and to prevent and manage symptoms/signs of heart failure. The performance of a TEE precardioversion is highly encouraged to detect possible thrombi in LA appendage. A careful assessment of LA size (LA volume index) and function (LA emptying fraction and/or LA strain) should always be planned to predict the possible recurrence of AF paroxysmal episodes. This is in fact a key action, not only from the cardiologic point of view but also for the oncologic perspectives in individual situations. Patients with larger left atrium and more impaired LA function should be addressed toward a less aggressive cancer treatment, with drugs which are not associated or are poorly related with the risk of AF development. A correct and comprehensive echocardiographic assessment could even induce the oncologist to change the cancer management balancing the oncologic and the cardiac risk.
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Affiliation(s)
- Maurizio Galderisi
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Roberta Esposito
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Regina Sorrentino
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Lucia La Mura
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Antonella Tufano
- Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
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48
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Ding WY, Harrison S, Gupta D, Lip GYH, Lane DA. Stroke and Bleeding Risk Assessments in Patients With Atrial Fibrillation: Concepts and Controversies. Front Med (Lausanne) 2020; 7:54. [PMID: 32154260 PMCID: PMC7047213 DOI: 10.3389/fmed.2020.00054] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 02/05/2020] [Indexed: 12/20/2022] Open
Abstract
Risk assessments are an important element in the management of patients with atrial fibrillation (AF). In this review, we aim to discuss the concepts and controversies surrounding the various risk factors for stroke and bleeding in AF. Indeed, there are a variety of clinical, electrical, biological, and genetic markers to guide stroke and bleeding risk assessments in AF. The more common factors have been used to formulate risk stratification scores. Some risk factors have shown promise, but others remain less well-defined. Our aim is to discuss concepts and controversies surrounding current evidence of risk factors for stroke and bleeding assessments in AF.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom
| | - Stephanie Harrison
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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49
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Darlington A, McCauley MD. Atrial Cardiomyopathy: An Unexplored Limb of Virchow's Triad for AF Stroke Prophylaxis. Front Cardiovasc Med 2020; 7:11. [PMID: 32133372 PMCID: PMC7039862 DOI: 10.3389/fcvm.2020.00011] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 01/27/2020] [Indexed: 01/14/2023] Open
Abstract
The most dreaded complication of atrial fibrillation is stroke, and 70–80% of patients with AF-related stroke die or become disabled. The mechanisms of thromboembolism in AF are multifactorial, with evidence demonstrating that all three criteria of Virchow's triad are satisfied in AF: abnormal stasis of blood, endothelial damage, and hypercoagulability. Mechanistic insights into the latter two limbs have resulted in effective stroke prophylactic therapies (left atrial appendage occlusion and oral anticoagulants); however, despite these advances, there remains an excess of stroke in the AF population that may be due, in part, to a lack of mechanistic understanding of atrial hypocontractility resulting in abnormal stasis of blood within the atrium. These observations support the emerging concept of atrial cardiomyopathy as a cause of stroke. In this Review, we evaluate molecular, translational, and clinical evidence for atrial cardiomyopathy as a cause for stroke from AF, and present a rationale for further investigation of this largely unaddressed limb of Virchow's triad in AF.
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Affiliation(s)
- Ashley Darlington
- Division of Cardiology, Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, IL, United States.,Jesse Brown VA Medical Center, Chicago, IL, United States
| | - Mark D McCauley
- Division of Cardiology, Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, IL, United States.,Jesse Brown VA Medical Center, Chicago, IL, United States.,Department of Physiology and Biophysics, University of Illinois at Chicago, Chicago, IL, United States
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50
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Pathan F, Hecht H, Narula J, Marwick TH. Roles of Transesophageal Echocardiography and Cardiac Computed Tomography for Evaluation of Left Atrial Thrombus and Associated Pathology: A Review and Critical Analysis. JACC Cardiovasc Imaging 2019; 11:616-627. [PMID: 29622180 DOI: 10.1016/j.jcmg.2017.12.019] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 12/21/2017] [Indexed: 01/23/2023]
Abstract
Evaluation of the left atrium and left atrial appendage for the presence of thrombus prior to cardioversion and pulmonary vein isolation, and of the entire heart for embolic sources in the setting of cryptogenic stroke, has long been standard medical care. Guidelines have uniformly recommended transesophageal echocardiography (TEE) to accomplish these goals. In recent years, computed tomographic angiography has demonstrated diagnostic accuracy similar to that of TEE for the detection of thrombus. Analysis of the pertinent data and relative merits of the 2 technologies leads to the conclusions that: 1) both modalities have some unique, nonoverlapping capabilities that may dictate their use in specific situations; 2) computed tomographic angiography is a reasonable alternative to TEE when the primary aim is to exclude left atrial and left atrial appendage thrombus and in patients in whom the risks associated with TEE outweigh the benefits; and 3) both options should be discussed with the patient in the setting of shared decision making.
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Affiliation(s)
- Faraz Pathan
- Menzies Institute for Medical Research, Hobart, Australia
| | - Harvey Hecht
- Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, New York
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