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Zhang Q, Li Y, Zheng G, Li C, Pan Z, Shi S, Rong J. AngioJet thrombectomy in the treatment of pulmonary embolism complicated with left subclavian artery embolism: a case report. J Int Med Res 2024; 52:3000605241258141. [PMID: 38853428 PMCID: PMC11163922 DOI: 10.1177/03000605241258141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/07/2024] [Indexed: 06/11/2024] Open
Abstract
Coexistence of pulmonary embolism (PE) and arterial thrombosis in a single patient is rare. Management of such cases is challenging because there is no unified standard on how to treat this type of disease. We herein report a case involving a 73-year-old man who was admitted to the hospital because of a 2-day history of chest tightness. Pulmonary computed tomography angiography revealed a filling defect of the main pulmonary artery and bilateral branches as well as a left subclavian artery embolism. AngioJet mechanical thrombectomy (Boston Scientific, Marlborough, MA, USA) was used to treat the PE, and this was combined with left brachial artery incision and thrombectomy for treatment of the left subclavian artery embolism. The patient recovered well after the operation. The prognosis was good after 9 months of regular follow-up. AngioJet mechanical thrombectomy combined with left brachial artery incision thrombectomy may be a feasible treatment option for cases of PE combined with left subclavian artery embolism.
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Affiliation(s)
- Qiang Zhang
- Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
| | - Yang Li
- Suzhou Vocational Health College, Suzhou, China
| | - Guangfeng Zheng
- Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
| | - Chuanyong Li
- Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
| | - Zhichang Pan
- Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
| | - Shuming Shi
- Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
| | - Jianjie Rong
- Suzhou TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
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Segan L, Chieng D, Sugumar H, Ling LH, Azzopardi S, Nderitu Z, Voskoboinik A, Morton JB, McLellan AJ, Lee G, Wong M, Kalman JM, Kistler PM, Prabhu S. Impact of Baseline Left Atrial Size on Outcomes Following Catheter Ablation for AF in Patients With Left Ventricular Systolic Dysfunction. Circ Arrhythm Electrophysiol 2024; 17:e012783. [PMID: 38629285 DOI: 10.1161/circep.124.012783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Affiliation(s)
- Louise Segan
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- The Alfred Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- Cabrini Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., A.V., P.M.K.)
- Monash University, Melbourne, Australia (L.S., D.C., H.S., A.V., P.M.K.)
| | - David Chieng
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- The Alfred Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- Cabrini Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., A.V., P.M.K.)
- Monash University, Melbourne, Australia (L.S., D.C., H.S., A.V., P.M.K.)
| | - Hariharan Sugumar
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- The Alfred Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- Cabrini Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., A.V., P.M.K.)
- Monash University, Melbourne, Australia (L.S., D.C., H.S., A.V., P.M.K.)
- St Vincent's Hospital, Melbourne, Australia (H.S., A.J.M.L.)
| | - Liang-Han Ling
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- The Alfred Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- Cabrini Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., A.V., P.M.K.)
| | - Sonia Azzopardi
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- The Alfred Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
| | - Ziporah Nderitu
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- The Alfred Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
| | - Aleksandr Voskoboinik
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- The Alfred Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- Cabrini Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., A.V., P.M.K.)
- Monash University, Melbourne, Australia (L.S., D.C., H.S., A.V., P.M.K.)
| | - Joseph B Morton
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- Royal Melbourne Hospital, Australia (J.B.M., A.J.M.L., G.L., M.W., J.M.K.)
| | - Alex J McLellan
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- St Vincent's Hospital, Melbourne, Australia (H.S., A.J.M.L.)
- Royal Melbourne Hospital, Australia (J.B.M., A.J.M.L., G.L., M.W., J.M.K.)
| | - Geoffrey Lee
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- Royal Melbourne Hospital, Australia (J.B.M., A.J.M.L., G.L., M.W., J.M.K.)
| | - Michael Wong
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- Royal Melbourne Hospital, Australia (J.B.M., A.J.M.L., G.L., M.W., J.M.K.)
- Western Health, Melbourne, Australia (M.W.)
| | - Jonathan M Kalman
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- Royal Melbourne Hospital, Australia (J.B.M., A.J.M.L., G.L., M.W., J.M.K.)
| | - Peter M Kistler
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- The Alfred Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
- Cabrini Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., A.V., P.M.K.)
- Monash University, Melbourne, Australia (L.S., D.C., H.S., A.V., P.M.K.)
| | - Sandeep Prabhu
- The Baker Heart and Diabetes Research Institute, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- The Alfred Hospital, Melbourne, Australia (L.S., D.C., H.S., L.-H.L., S.A., Z.N., A.V., P.M.K., S.P.)
- University of Melbourne, Australia (L.S., D.C., H.S., L.-H.L., J.B.M., A.J.M.L., G.L., M.W., J.M.K., P.M.K., S.P.)
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Ouchi K, Sakuma T, Higuchi T, Yoshida J, Narui R, Nojiri A, Yamane T, Ojiri H. Prediction of spontaneous echocardiographic contrast within the left atrial appendage in cardiac computed tomography of patients with atrial fibrillation. Heart Vessels 2023; 38:1138-1148. [PMID: 37029248 DOI: 10.1007/s00380-023-02263-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 03/23/2023] [Indexed: 04/09/2023]
Abstract
This study aimed to assess the predictors of spontaneous echocardiographic contrast (SEC) using left atrial appendage (LAA) findings in cardiac computed tomography (CT) of patients with atrial fibrillation (AF). We retrospectively analyzed cardiac CT findings of the LAA, including morphology, volume, and filling defects, of 641 patients who underwent transesophageal echocardiography (TEE) prior to pulmonary vein isolation (PVI) from January 6, 2013 through December 16, 2019 at our institution. We investigated potential associated factors that might be predictors of SEC using cardiac CT findings and computed a receiver operator characteristic, choosing a threshold value at which the likelihood of SEC could be predicted based on the LAA volume indexed for body size. SEC correlated significantly with indexed LAA volume (P < 0.001; odds ratio [OR], 1.31; 95% confidence interval [CI], 1.17-1.48) of 7.75 cm3/m2 or greater (sensitivity, 76.0%; specificity, 57.7%), LAA early filling defect (P = 0.005; OR, 2.72; 95% CI, 1.35-5.48), a history of persistent AF (P < 0.001; OR, 3.81; 95% CI, 1.86-7.80), and LAA flow velocity (P < 0.001; OR, 0.97; 95% CI, 0.96-0.99). Findings of LAA in cardiac CT can allow for the noninvasive estimation of SEC to determine the need for additional TEE investigation and the need to obtain additional information for risk stratification and management of thromboembolic events in patients with AF.
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Affiliation(s)
- Kotaro Ouchi
- Department of Radiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan.
| | - Toru Sakuma
- Department of Radiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Takahiro Higuchi
- Department of Radiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Jun Yoshida
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Ryosuke Narui
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Ayumi Nojiri
- Department of Laboratory Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Teiichi Yamane
- Department of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Hiroya Ojiri
- Department of Radiology, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-Ku, Tokyo, 105-8461, Japan
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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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Huang SH, Liao CF, Chen ZY, Chao TF, Chen SA, Tsao HM. Distinct atrial remodeling in patients with subclinical atrial fibrillation: Lessons from computed tomographic images. Pharmacol Res Perspect 2022; 10:e00927. [PMID: 35194973 PMCID: PMC8863578 DOI: 10.1002/prp2.927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 01/17/2022] [Indexed: 11/11/2022] Open
Abstract
AIMS Cardiac implanted electronic devices (CIEDs) can detect atrial high-rate episodes (AHREs) and challenge current management of subclinical atrial fibrillation (AF). METHODS To characterize the anatomic and functional remodeling of cardiac structures between patients with subclinical AF (SCAF) and clinical AF. The predictors for AHREs ≥6 min were also investigated. RESULTS We compared the atrial volume, dynamic function, and peri-atrial fat between 104 CIEDs (AHREs = 0, n = 12; SCAF, n = 66; CIEDs with AF, n = 26) and 40 paroxysmal AF patients who were planning for catheter ablation (AF for ablation) using 256-slice multidetector computed tomography for the duration of the AHREs. The maximal volume of the left atrium (LA) and LA appendage (LAA) were significantly smaller; the total emptying fraction (EF) and active EF of the LA and LAA were significantly better in the patients with SCAF than in those with clinical AF. Less peri-atrial fat (p < 0.001) and a greater LAA/ascending aorta (AA) Hounsfield unit (HU) ratio (p < 0.05) were noted in the patients with SCAF. Significantly increased volume reduced the total EF of LA and LAA and a reduced LAA/AA HU ratio (0.91 ± 0.18 vs 0.98 ± 0.03 vs 0.97 ± 0.05, p < 0.05) were demonstrated in patients with AHREs ≥6 min compared to those with AHREs <6 min and without AHRE. Multivariate analysis showed the reduced LAA/AA HU ratio is an independent predictor for the development of AHREs ≥6 min. CONCLUSION As compared to clinical AF, patients with SCAF show a more favorable LA remodeling process. Among the patients with device-detected AHREs, worse LA remodeling and a reduced LAA/AA HU ratio were associated with the occurrence of AHREs ≥6 min. These findings may provide an incremental value for understanding SCAF.
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Affiliation(s)
- Sung-Hao Huang
- Division of Cardiology, Department of Medicine, National Yang-Ming Chiao-Tung University Hospital, Yilan, Taiwan
| | - Chao-Feng Liao
- Division of Cardiology, Department of Medicine, National Yang-Ming Chiao-Tung University Hospital, Yilan, Taiwan
| | - Zu-Yin Chen
- Division of Cardiology, Department of Medicine, National Yang-Ming Chiao-Tung University Hospital, Yilan, Taiwan
| | - Tze-Fan Chao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Shih-Ann Chen
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan.,Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsuan-Ming Tsao
- Division of Cardiology, Department of Medicine, National Yang-Ming Chiao-Tung University Hospital, Yilan, Taiwan.,School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
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Liu C, Liu S, Li H, Guo YL. A Potential Novel Indication for Preventing Thromboembolism in Patients with Atrial Arrhythmias: Remodeling of the Left Atrium. Curr Med Sci 2021; 41:1187-1191. [PMID: 34705215 DOI: 10.1007/s11596-021-2449-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 08/16/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Thrombosis in patients with atrial arrhythmias might be associated with remodeling of the left atrium (LA). We aimed to describe this relationship and identify a novel factor, in addition to the CHA2DS2-VASc score, to guide therapeutic strategies for preventing thromboembolism in the hope of improving the prognosis for such patients. METHODS Patients diagnosed with atrial arrhythmias and who met our inclusion criteria were enrolled in this study. Various clinical parameters were recorded; diameters reflecting remodeling of the LA were measured and thrombosis was diagnosed by enhanced CT. RESULTS Totally, 192 patients were enrolled in the study. The overall prevalence of left atrial thrombosis was 8.3%. Patients with persistent atrial fibrillation exhibited the highest anteroposterior diameter of the LA (45.1±7.2 mm) and prevalence of thrombosis (15.6%). An anteroposterior LA diameter of ≥50 mm was a strong independent impact risk factor for thrombosis (OR=10.1, 95%CI: 2.8-36.9, P<0.001). The prevalence of LA thrombosis in patients with and without anteroposterior LA diameter of ≥50 mm was 25.8% and 5.0%, respectively. CONCLUSION Marked remodeling of the LA characterized by an anteroposterior LA diameter of ≥50 mm is a strong independent risk factor of thrombosis, and should be considered for the prevention of thromboembolism through various strategies.
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Affiliation(s)
- Chen Liu
- Department of Cardiology, Fuwai Yunnan Cardiovascular Hospital, Kunming, 650000, China
| | - Shuang Liu
- Department of Rheumatology, First Affiliated Hospital of Kunming Medical University, Kunming, 650000, China
| | - Hui Li
- Department of Radiology, Fuwai Yunnan Cardiovascular Hospital, Kunming, 650000, China
| | - Yu-Long Guo
- Department of Cardiology, Fuwai Yunnan Cardiovascular Hospital, Kunming, 650000, China.
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Lucà F, Giubilato S, Di Fusco SA, Piccioni L, Rao CM, Iorio A, Cipolletta L, D’Elia E, Gelsomino S, Rossini R, Colivicchi F, Gulizia MM. Anticoagulation in Atrial Fibrillation Cardioversion: What Is Crucial to Take into Account. J Clin Med 2021; 10:jcm10153212. [PMID: 34361996 PMCID: PMC8348761 DOI: 10.3390/jcm10153212] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 12/15/2022] Open
Abstract
The therapeutic dilemma between rhythm and rate control in the management of atrial fibrillation (AF) is still unresolved and electrical or pharmacological cardioversion (CV) frequently represents a useful strategy. The most recent guidelines recommend anticoagulation according to individual thromboembolic risk. Vitamin K antagonists (VKAs) have been routinely used to prevent thromboembolic events. Non-vitamin K antagonist oral anticoagulants (NOACs) represent a significant advance due to their more predictable therapeutic effect and more favorable hemorrhagic risk profile. In hemodynamically unstable patients, an emergency electrical cardioversion (ECV) must be performed. In this situation, intravenous heparin or low molecular weight heparin (LMWH) should be administered before CV. In patients with AF occurring within less than 48 h, synchronized direct ECV should be the elective procedure, as it restores sinus rhythm quicker and more successfully than pharmacological cardioversion (PCV) and is associated with shorter length of hospitalization. Patients with acute onset AF were traditionally considered at lower risk of thromboembolic events due to the shorter time for atrial thrombus formation. In patients with hemodynamic stability and AF for more than 48 h, an ECV should be planned after at least 3 weeks of anticoagulation therapy. Alternatively, transesophageal echocardiography (TEE) to rule out left atrial appendage thrombus (LAAT) should be performed, followed by ECV and anticoagulation for at least 4 weeks. Theoretically, the standardized use of TEE before CV allows a better stratification of thromboembolic risk, although data available to date are not univocal.
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Affiliation(s)
- Fabiana Lucà
- Division of Cardiology, Big Metropolitan Hospital, Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy;
- Correspondence: (F.L.); (L.P.)
| | - Simona Giubilato
- Division of Cardiology, Cannizzaro Hospital, 95121 Catania, Italy;
| | | | - Laura Piccioni
- Division of Cardiology, Cardiovascular Departiment, Civile Giuseppe Mazzini Hospital, 64100 Teramo, Italy
- Correspondence: (F.L.); (L.P.)
| | - Carmelo Massimiliano Rao
- Division of Cardiology, Big Metropolitan Hospital, Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy;
| | - Annamaria Iorio
- Division of Cardiology, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (A.I.); (E.D.)
| | - Laura Cipolletta
- Division of Cardiology, Department of Cardiovascular Sciences, Ancona University Hospital, 60126 Ancona, Italy;
| | - Emilia D’Elia
- Division of Cardiology, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy; (A.I.); (E.D.)
| | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University Hospital, 6202 AZ Maastricht, The Netherlands;
| | - Roberta Rossini
- Division of Cardiology, S. Croce e Carle Hospital, 12100 Cuneo, Italy;
| | - Furio Colivicchi
- Division of Cardiology, S. Filippo Neri Hospital, 00135 Roma, Italy; (S.A.D.F.); (F.C.)
| | - Michele Massimo Gulizia
- Division of Cardiology, Garibaldi-Nesima Hospital, 95123 Catania, Italy;
- Heart Care Foundation, 50121 Florence, Italy
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Çakır OM. Low vitamin D levels predict left atrial thrombus in nonvalvular atrial fibrillation. Nutr Metab Cardiovasc Dis 2020; 30:1152-1160. [PMID: 32456946 DOI: 10.1016/j.numecd.2020.03.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 03/14/2020] [Accepted: 03/27/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND AIMS We determined the association between left atrial (LA) thrombus occurrence and a non-classic risk marker, plasma levels of vitamin D, in atrial fibrillation (AF) patients on continuous non-vitamin K antagonist oral anticoagulant (NOAC) therapy for ≥4 weeks. Low levels of plasma 25-hydroxy vitamin D (25-OHD) are predictive of fatal stroke. Vitamin D has anticoagulant effects on the coagulation cascade, which are indirectly targeted by NOAC therapy. The impact of plasma levels of vitamin D on the rate of LA thrombus detected by transesophageal echocardiography (TEE) in AF patients is unknown. METHODS AND RESULTS We enrolled 201 (133 female) AF patients who were using continuous NOAC therapy for ≥4 weeks. All patients underwent transthoracic and TEE examination. Serum concentrations of 25-OHD, C-reactive protein (CRP) levels, CHA2DS2-VASc scores and parameters, LA size, and left ventricle ejection fraction (LVEF) were examined before the TEE procedure. LA thrombus occurrence was independently associated with serum levels of 25-OHD (OR: 0.884; 95% CI: 0.839-0.932; P < 0.001), LA diameter (OR: 1.120; 95% CI: 1.038-1.209; P = 0.003), and LVEF(OR: 0.944; 95% CI: 0.896-0.995; P = 0.032). Dense spontaneous echo contrast (SEC) presence was also inversely associated with 25-OHD concentrations. CONCLUSIONS Low 25-OHD levels, as a non-classic risk factor, were independently and significantly associated with dense SEC and LA thrombus occurrence in AF patients under NOAC therapy, as well as LA enlargement and decreased LVEF. Further large-scale studies are needed to explain the role of vitamin D deficiency, or efficacy of replacement, on LA thrombus occurrence.
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Affiliation(s)
- Ozan M Çakır
- Department of Cardiology, Bülent Ecevit University Faculty of Medicine Medical Center, Zonguldak, Turkey.
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9
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Fu Y, Li K, Gao Y, Wang L, Chen M, Yang X. A novel risk score for predicting left atrial and left atrial appendage thrombogenic milieu in patients with non-valvular atrial fibrillation. Thromb Res 2020; 192:161-166. [PMID: 32485419 DOI: 10.1016/j.thromres.2020.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Although the CHADS2 and CHA2DS2-VASc scoring systems are commonly used as measures of thromboembolic risk in patients with nonvalvular atrial fibrillation (NVAF), data are inconsistent as to their value in predicting the presence of left atrial (LA) and/or left atrial appendage (LAA) thrombogenic milieu (TM). The present study aimed to establish a novel risk score to assess the risk of LA and/or LAATM in NVAF patients. METHODS This is a retrospective case-control study that included 125 consecutive patients with NVAF plus TM, as evidenced by transesophageal echocardiography (TEE) during a period from1 January 2010 to 1 February 2017. The controls were 1098 NVAF patients without TM during the same period. Risk factors for LA and/or LAATM were identified using univariable analysis and multivariable logistic regression. The risk score model was developed based on 10-fold validation and multiple regression. Risk model performance was evaluated using receiver operating characteristic (ROC) curves. Net reclassification improvement (NRI) was used for the comparison of C-statistics. The AUCs were compared using the Z test. RESULTS Among all 1223 NVAF patients, 125 (10.22%) patients had LA and/or LAATM. A score system (0-12) was developed based on the following 6 independent variables identified by 10-fold validation with sequential methods. Different points were assigned for each variable, according to multivariable regression using relative coefficients (coefficient of the index risk factor divided by the lowest coefficient among the 6 risk factors; rounded to closest integer): 1 for blood type A and N-terminal B-type natriuretic peptide (NT-proBNP) ≥864.85 pg/mL; 2 for LAD ≥43.5 mm and age ≥ 73.5 years old; 3 for previous heart failure and previous stroke or TIA. The present risk score system had a sensitivity of 58.3%, specificity of 91.4 and accuracy of 81.6%. The area under the ROC curve (AUC) was 0.832, (95% CI: 0.784-0.881; P < 0.001). The negative predictive value (NPV) was 92% when we set the cut-off point at 4; when the cut-off point was set at 8, the positive predictive value (PPV) was 85.7%. Compared with CHADS2 and CHA2DS2-VASc score, the present novel risk score has better predictive power [net reclassification improvement (NRI) +96.3% and +66.2%, respectively; all P < 0.001]. CONCLUSION This study developed a novel risk score to help predicting LA and/or LAATM in NVAF patients, which had higher accuracy than CHADS2 and CHA2DS2-VASc score system.
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Affiliation(s)
- Yuan Fu
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Kuibao Li
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yuanfeng Gao
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Lefeng Wang
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Mulei Chen
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xinchun Yang
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China.
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10
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Yang Y, Du X, Dong J, Ma C. Outcome of Anticoagulation Therapy of Left Atrial Thrombus or Sludge in Patients With Nonvalvular Atrial Fibrillation or Flutter. Am J Med Sci 2019; 358:273-278. [DOI: 10.1016/j.amjms.2019.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 01/02/2023]
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11
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Ioannou A, Papageorgiou N, Falconer D, Rehal O, Sewart E, Zacharia E, Toutouzas K, Vlachopoulos C, Siasos G, Tsioufis C, Tousoulis D. Biomarkers Associated with Stroke Risk in Atrial Fibrillation. Curr Med Chem 2019; 26:803-823. [DOI: 10.2174/0929867324666170718120651] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 12/08/2016] [Accepted: 12/16/2016] [Indexed: 11/22/2022]
Abstract
Background:Atrial fibrillation (AF) is associated with an increased risk of cardioembolic stroke. The risk of cardioembolism is not adequately reduced with the administration of oral anticoagulants, since a number of patients continue to experience thromboembolic events despite receiving treatment. Therefore, identification of a circulating biomarker to identify these high-risk patients would be clinically beneficial.Objective:In the present article, we aim to review the available data regarding use of biomarkers to predict cardioembolic stroke in patients with AF.Methods:We performed a thorough search of the literature in order to analyze the biomarkers identified thus far and critically evaluate their clinical significance.Results:A number of biomarkers have been proposed to predict cardioembolic stroke in patients with AF. Some of them are already used in the clinical practice, such as d-dimers, troponins and brain natriuretic peptide. Novel biomarkers, such as the inflammatory growth differentiation factor-15, appear to be promising, while the role of micro-RNAs and genetics appear to be useful as well. Even though these biomarkers are associated with an increased risk for thromboembolism, they cannot accurately predict future events. In light of this, the use of a scoring system, that would incorporate both circulating biomarkers and clinical factors, might be more useful.Conclusions:Recent research has disclosed several biomarkers as potential predictors of cardioembolic stroke in patients with AF. However, further research is required to establish a multifactorial scoring system that will identify patients at high-risk of thromboembolism, who would benefit from more intensive treatment and monitoring.
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Affiliation(s)
| | | | | | - Onkar Rehal
- University College London Hospital, London, United Kingdom
| | - Emma Sewart
- University College London Medical School, London, United Kingdom
| | - Effimia Zacharia
- 1st Cardiology Department, Athens University Medical School, Hippokration Hospital, Athens, Greece
| | - Konstantinos Toutouzas
- 1st Cardiology Department, Athens University Medical School, Hippokration Hospital, Athens, Greece
| | - Charalambos Vlachopoulos
- 1st Cardiology Department, Athens University Medical School, Hippokration Hospital, Athens, Greece
| | - Gerasimos Siasos
- 1st Cardiology Department, Athens University Medical School, Hippokration Hospital, Athens, Greece
| | - Costas Tsioufis
- 1st Cardiology Department, Athens University Medical School, Hippokration Hospital, Athens, Greece
| | - Dimitris Tousoulis
- 1st Cardiology Department, Athens University Medical School, Hippokration Hospital, Athens, Greece
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12
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Gedikli Ö, Mohanty S, Trivedi C, Gianni C, Chen Q, Della Rocca DG, Burkhardt JD, Sanchez JE, Hranitzky P, Gallinghouse GJ, Al-Ahmad A, Horton R, Di Biase L, Natale A. Impact of dense "smoke" detected on transesophageal echocardiography on stroke risk in patients with atrial fibrillation undergoing catheter ablation. Heart Rhythm 2018; 16:351-357. [PMID: 30312757 DOI: 10.1016/j.hrthm.2018.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Spontaneous echocardiographic contrast ("smoke") within the left atrial cavity on transesophageal echocardiography (TEE) suggests low blood flow velocities in the heart that may lead to thromboembolic (TE) events. OBJECTIVE The purpose of this study was to evaluate the risk of TE events in the periprocedural period and at long-term follow-up in atrial fibrillation (AF) patients having dense smoke on preprocedural TEE. METHODS A total of 2511 patients undergoing AF ablation were included in this analysis. They were classified as group 1 (dense smoke detected on TEE at baseline; n = 234) and group 2 (no smoke on baseline TEE; n = 2277). Patients were followed up for TE events, which included both stroke and transient ischemic attacks (TIAs). In order to attenuate the observed imbalance in baseline covariates between the study groups, a propensity score matching technique was used (covariates were age, sex, AF type, diabetes, and CHADS2VASc score). RESULTS In the periprocedural period, no TE events were reported in group 1 and 3 events (0.13%) were reported in group 2. At follow-up of 6.62 ± 2.01 years, 6 (2.6%) TE complications (2 TIA, 4 stroke) occurred in group 1 and 16 (0.70%) TE complications (6 TIA, 10 stroke) in group 2 (P = .004). In the propensity-matched population, 6 (2.56%) TE complications occurred in group 1 and 1 (0.2%) in group 2 (P = .007). CONCLUSION In our study population, the presence of dense left atrial smoke did not show any correlation with periprocedural TE events in patients undergoing catheter ablation with uninterrupted anticoagulation. However, significant association was observed with late stroke/TIA, irrespective of CHA2DS2-VASc score.
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Affiliation(s)
- Ömer Gedikli
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Department of Cardiology, Ondokuz Mayis University Medicine School, Samsun, Turkey
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Dell Medical School, Austin, Texas
| | - Chintan Trivedi
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Qiong Chen
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Henan Provincial People's Hospital, Zhengzhou, China
| | | | - J David Burkhardt
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Javier E Sanchez
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Patrick Hranitzky
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | | | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Rodney Horton
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Albert Einstein College of Medicine at Montefiore Hospital, New York, New York
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Dell Medical School, Austin, Texas; Interventional Electrophysiology, Scripps Clinic, San Diego, California; Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Cardiology, Stanford University, Stanford, California.
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13
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Radwan HI. Relation between left atrial measurements and thromboembolic risk markers assessed by echocardiography in patients with nonvalvular atrial fibrillation: A cross-sectional study. Egypt Heart J 2018; 69:1-11. [PMID: 29622949 PMCID: PMC5839420 DOI: 10.1016/j.ehj.2016.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 05/20/2016] [Indexed: 11/02/2022] Open
Abstract
Background Left atrium (LA) dilatation has been associated with adverse cardiovascular outcomes in patients with sinus rhythm and atrial fibrillation (AF). Aim of the study We aimed to evaluate the accuracy of left atrial (LA) size to predict transesophageal echocardiographic (TEE) markers of increased thromboembolic risk left atrial appendage (LAA) thrombus, low LAA velocities and dense spontaneous echocardiographic contrast (SEC), and also to assess the best method to evaluate LA size. Patients and methods Cross-sectional study included 64 patients with nonvalvular AF undergoing transthoracic and transesophageal echocardiographic (TTE and TEE) evaluation. LA size was measured on TTE by several methods including the following: anteroposterior diameter (AP), LA area in four and two apical chamber views and volumes by ellipsoid, single plane (1P) and biplane area-length (2P) formulas. All these measures were indexed to the body surface area (BSA). Thromboembolic markers including LAA thrombus, low LAA velocities, dense SEC and LA abnormality (LA ABN) which means the presence of one or more of the previous three parameters were evaluated by TEE. Results There was statistically significant increase in indexed and non-indexed LA parameters in patients with LA ABN compared to patients without LA ABN. According to ROC curve, the study found that all indexed LA parameters were predictive for LAA thrombus with the highest AUC was indexed LA 1P area length volume (AUC 0.91, CI 95% 0.81-1.01, p < 0.000), for LAA low flow velocity were indexed and non-indexed LA AP diameters with the highest AUC was indexed LA AP diameter (AUC 0.89, CI 95% 0.80-0.98, p < 0.000), for LA dense SEC were indexed LA ellipsoid volume (AUC 0.78, CI 95% 0.66-0.96, p = 0.002) and indexed LA 1P area length volume (AUC 0.78, CI 95% 0.66-0.90, p = 0.002) and for LA ABN were all LA parameters with the highest AUC was indexed LA 1P area length volume (AUC 0.87, CI 95% 0.79-0.96, p < 0.000). On multivariate logistic regression analysis of TEE parameters, the study found that the most predictive LA measurement for LAA thrombus was indexed LA AP diameter with cutoff 3 cm/m2 (OR 7.5, 95% CI 1.24-45.2, p = 0.02), for LAA low flow velocity was LA AP diameter with cutoff 6 cm (OR 17.6, 95% CI 3.23-95.84, p = 0.001), for LA dense SEC was indexed LA ellipsoid volume with cutoff 42 cm3/m2 (OR 6.5, 95% CI 1.32-32.07, p = 0.02), and for LA ABN was indexed LA ellipsoid volume with cutoff 42 cm3/m2 (OR 10.45, 95% CI 2.18-51.9, p = 0.008). Conclusion LA enlargement is suitable to predict thromboembolic markers in patients with non-valvular AF. The indexed and non-indexed LA AP diameter and indexed LA ellipsoid volume were the most accurate parameters for predicting thromboembolic markers.
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Key Words
- 1P, single plane
- 2P, biplane
- ABN, abnormality
- AF, atrial fibrillation
- AP, anteroposterior
- BMI, body mass index
- BSA, body surface area
- DM, diabetes mellitus
- EF, ejection fraction
- GFR, glomerular filtration rate
- HTN, hypertension
- ICD, implantable cardioverter defibrillator
- INR, international normalized ratio
- LA, left atrium
- LAA, left atrial appendage
- LV, left ventricle
- Left atrial size
- Nonvalvular atrial fibrillation
- SEC, spontaneous echocardiographic contrast
- TEE, transesophageal echocardiography
- TIA, transient ischemic attack
- TTE, transthoracic echocardiography
- Thromboembolic markers
- Transesophageal echocardiography
- Transthoracic echocardiography
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Affiliation(s)
- Hanan I Radwan
- Faculty of Medicine, Zagazig University, Cardiovascular Department, Egypt
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14
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Atkinson C, Hinton J, Gaisie EB, Yue AM, Roberts PR, Rakhit DJ, Shah BN. Use of the CHA 2DS 2VASc score to reduce utilisation of transoesophageal echocardiography prior to ablation for atrial fibrillation. Echo Res Pract 2017; 4:45-52. [PMID: 28864464 PMCID: PMC5633057 DOI: 10.1530/erp-17-0042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 08/17/2017] [Indexed: 01/15/2023] Open
Abstract
Transoesophageal echocardiography (TOE) is frequently performed prior to atrial fibrillation (AF) ablation to exclude left atrial appendage (LAA) thrombus. However, patients undergoing AF ablation are usually anticoagulated, thus making the presence of thrombus unlikely in most cases. This study aimed to determine whether the CHA2DS2VASc scoring system can be used to identify patients that do not require TOE prior to AF ablation. In this single-centre retrospective study, local institutional and primary care databases and electronic patient records were searched to identify patients that had undergone TOE prior to AF ablation. Patient demographics, CHA2DS2VASc score, TOE findings and anticoagulation status were collected for analysis. Over a 7-year period (2008–2014), 332 patients (age 57 ± 10 years; 74% male) underwent TOE prior to proposed AF ablation. CHA2DS2VASc scores of 0, 1, 2 and >2 were found in 39, 34, 15 and 12% of patients, respectively. The prevalence of LAA thrombus was 0.6% (2 patients) and these 2 patients had risk scores of 2 and 4. No patients with a score of 0 or 1 had LAA thrombus. Patients that are classed as low risk by the CHA2DS2VASc score do not require a pre-ablation TOE to screen for LAA thrombus provided they are adequately anticoagulated. This would lead to a significant reduction in health care expenditures by reducing unnecessary TOE requests and thereby improve patient experience.
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Affiliation(s)
- Charlotte Atkinson
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Jonathan Hinton
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Edmund B Gaisie
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Arthur M Yue
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Paul R Roberts
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Dhrubo J Rakhit
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Benoy N Shah
- Department of Cardiology, University Hospital Southampton, Southampton, UK
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15
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Ikegami Y, Tanimoto K, Inagawa K, Shiraishi Y, Fuse J, Sakamoto M, Momiyama Y, Takatsuki S. Identification of Left Atrial Appendage Thrombi in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation Using Intra-Cardiac Echocardiography and Cardiac Computed Tomography. Circ J 2017; 82:46-52. [PMID: 28740038 DOI: 10.1253/circj.cj-17-0077] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Intracardiac echocardiography (ICE) and cardiac computed tomography (CCT), in addition to standard transesophageal echocardiography (TEE), have been used to identify left atrial (LA) thrombi prior to ablation for atrial fibrillation (AF). The clinical advantages of this, however, remain unclear. This study therefore investigated the advantages of additional pre-procedural LA appendage (LAA) thrombus evaluation using ICE and the clinical value of CCT in persistent and long-standing persistent AF.Methods and Results:We analyzed data from 108 consecutive patients with persistent and long-standing persistent AF who were scheduled to undergo AF ablation. TEE was performed within 24 h prior to ablation. ICE was performed for 97 patients in whom a thrombus was not detected on TEE. CCT was performed in 95 patients. Thrombus or sludge was detected on TEE in 11 patients (10.3%), for whom ablation was cancelled. Four additional patients were diagnosed with LAA thrombus on ICE. When TEE and ICE were used as the reference for thrombus detection, the sensitivity, specificity, positive predictive value, and negative predictive value of CCT for identifying contrast defects in the LAA were 100%, 81.0%, 40.7%, and 100%, respectively. CONCLUSIONS ICE combined with TEE increased the detection rate of LAA thrombi in patients with persistent and long-standing persistent AF. Moreover, CCT had high sensitivity and negative predictive value for LAA thrombus detection.
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Affiliation(s)
- Yukinori Ikegami
- Department of Cardiology, National Hospital Organization Tokyo Medical Center
| | - Kojiro Tanimoto
- Department of Cardiology, National Hospital Organization Tokyo Medical Center
| | - Kohei Inagawa
- Department of Cardiology, National Hospital Organization Tokyo Medical Center
| | | | - Jun Fuse
- Department of Cardiology, National Hospital Organization Tokyo Medical Center
| | - Munehisa Sakamoto
- Department of Cardiology, National Hospital Organization Tokyo Medical Center
| | - Yukihiko Momiyama
- Department of Cardiology, National Hospital Organization Tokyo Medical Center
| | - Seiji Takatsuki
- Department of Cardiology, Keio University School of Medicine
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16
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Fu Y, Li K, Yang X. ABO blood groups: A risk factor for left atrial and left atrial appendage thrombogenic milieu in patients with non-valvular atrial fibrillation. Thromb Res 2017; 156:45-50. [PMID: 28582641 DOI: 10.1016/j.thromres.2017.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 04/28/2017] [Accepted: 05/20/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Previous studies have identified ABO blood groups as predictors of thromboembolic diseases. In patients with atrial fibrillation (AF), however, potential association between ABO blood groups and the risk of left atrial (LA) and/or left atrial appendage (LAA) thrombogenic milieu (TM) has not been established. METHODS This is a retrospective case-control study that included 125 consecutive patients with non-valvular atrial fibrillation (NVAF) plus TM, as evidenced by transesophageal echocardiography (TEE) during a period from1 January 2010 to 31 December 2016. The controls were selected randomly from 1072 NVAF without TM at a 1:2 ratio. Potential association between ABO blood groups and TM was analyzed using multivariate logistic regression analysis. RESULTS The risk of TM was higher in patients with blood group A (33.6% vs. 20.2% in non-A blood groups, P=0.005). After adjusting for age, sex, oral anticoagulant use, AF type and duration, and relevant functional measures (e.g., NT-pro BNP level, left atrium diameter, and left ventricular ejection fraction), blood group A remained associated with an increased risk of TM (OR=2.99, 95% CI 1.4-6.388, P=0.005). CONCLUSION Blood group A is an independent risk factor for TM in NVAF patients.
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Affiliation(s)
- Yuan Fu
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Kuibao Li
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xinchun Yang
- Department of Cardiology, Chaoyang Hospital, Capital Medical University, Beijing, China.
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17
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Bossard M, Knecht S, Aeschbacher S, Buechel RR, Hochgruber T, Zimmermann AJ, Kessel-Schaefer A, Stephan FP, Völlmin G, Pradella M, Sticherling C, Osswald S, Kaufmann BA, Conen D, Kühne M. Conventional versus 3-D Echocardiography to Predict Arrhythmia Recurrence After Atrial Fibrillation Ablation. J Cardiovasc Electrophysiol 2017; 28:651-658. [PMID: 28301685 DOI: 10.1111/jce.13202] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 02/26/2017] [Accepted: 03/07/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Arrhythmia recurrence after atrial fibrillation (AF) ablation remains high and requires repeat interventions in a substantial number of patients. We assessed the value of conventional and 3-D echocardiography to predict AF recurrence. METHODS AND RESULTS Consecutive patients undergoing AF ablation by means of pulmonary vein isolation were included in a prospective registry. Echocardiograms were obtained prior to the ablation procedure, and analyzed offline in a standardized manner, including 3-D left atrial (LA) volumetry and determination of LA function and sphericity. The primary endpoint, AF recurrence (>30 seconds) between 3 to 12 months after AF ablation, was independently adjudicated. We included 276 patients (73% male, mean age 59.9 ± 9.9 years). Paroxysmal and persistent AF were present in 178 (64%) and 98 (36%) patients, respectively. Mean left ventricular ejection fraction and indexed LA volume in 3-D (LAVI) were 52 ± 12% and 42 ± 13 mL/m2 , respectively. AF recurrence was observed in 110 (40%) patients after a single procedure. Median (interquartile range) time to AF recurrence was 123 (92; 236) days. In multivariable Cox regression models, the only predictors for AF recurrence were the minimal, maximal, and indexed 3-D LA volumes, P = 0.024, P = 0.016, and P = 0.014, respectively. Quartile specific analysis of 3-D LAVI showed an HR of 1.885 (95%CI 1.066-3.334; P for trend = 0.015) for the highest compared to the lowest quartile. CONCLUSION Our results show the important role of LA volume for the long-term freedom from arrhythmia after AF ablation. These data also highlight the potential of 3-D echocardiography in this context and may facilitate patient selection for AF ablation.
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Affiliation(s)
- Matthias Bossard
- Cardiology Division, Department of Medicine, University Hospital Basel, University Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, University Basel, Basel, Switzerland.,Division of Cardiology, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada.,Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Hamilton, Ontario, Canada
| | - Sven Knecht
- Cardiology Division, Department of Medicine, University Hospital Basel, University Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, University Basel, Basel, Switzerland
| | - Stefanie Aeschbacher
- Cardiology Division, Department of Medicine, University Hospital Basel, University Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, University Basel, Basel, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Hochgruber
- Cardiovascular Research Institute Basel, University Hospital Basel, University Basel, Basel, Switzerland.,Division of Internal Medicine, Department of Medicine, University Hospital Basel, Basel, Switzerland
| | - Andreas J Zimmermann
- Cardiovascular Research Institute Basel, University Hospital Basel, University Basel, Basel, Switzerland.,Division of Internal Medicine, Department of Medicine, University Hospital Basel, Basel, Switzerland
| | - Arnheid Kessel-Schaefer
- Cardiology Division, Department of Medicine, University Hospital Basel, University Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, University Basel, Basel, Switzerland
| | - Frank-Peter Stephan
- Cardiology Division, Department of Medicine, University Hospital Basel, University Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, University Basel, Basel, Switzerland
| | - Gian Völlmin
- Cardiology Division, Department of Medicine, University Hospital Basel, University Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, University Basel, Basel, Switzerland
| | - Maurice Pradella
- Department of Radiology and Nuclear Medicine, University Hospital Basel, University Basel, Basel, Switzerland
| | - Christian Sticherling
- Cardiology Division, Department of Medicine, University Hospital Basel, University Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, University Basel, Basel, Switzerland
| | - Stefan Osswald
- Cardiology Division, Department of Medicine, University Hospital Basel, University Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, University Basel, Basel, Switzerland
| | - Beat A Kaufmann
- Cardiology Division, Department of Medicine, University Hospital Basel, University Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, University Basel, Basel, Switzerland
| | - David Conen
- Cardiology Division, Department of Medicine, University Hospital Basel, University Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, University Basel, Basel, Switzerland.,Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Hamilton, Ontario, Canada.,Division of Internal Medicine, Department of Medicine, University Hospital Basel, Basel, Switzerland
| | - Michael Kühne
- Cardiology Division, Department of Medicine, University Hospital Basel, University Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital Basel, University Basel, Basel, Switzerland
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18
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Tsao HM, Hu WC, Tsai PH, Lee CL, Wang HH, Chang SL, Chao TF, Chen SA. Functional Remodeling of Both Atria is Associated with Occurrence of Stroke in Patients with Paroxysmal and Persistent Atrial Fibrillation. ACTA CARDIOLOGICA SINICA 2017; 33:50-57. [PMID: 28115807 DOI: 10.6515/acs20160411a] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND It is critical to recognize high risk patients who are prone to develop stroke in the management of atrial fibrillation (AF). The purpose of this study was to identify the determinants of AF related stroke by assessing the anatomical and functional remodeling of cardiac chambers. METHODS We compared the cardiac structure and function of 28 consecutive patients with paroxysmal and persistent AF-related stroke with 69 patients with AF and 21 controls without stroke using contrast-enhanced 64-slice multi-detector computed tomography during sinus rhythm. RESULTS The volume of left atrium (LA), LA appendage (LAA) and right atrium (RA) were significantly increased across the groups with sinus rhythm (SR), AF and AF-related stroke (p < 0.001 for each, respectively). The emptying fraction and booster-pump function of LA, LAA and RA were decreased across the groups (p < 0.001 for each). In addition, the left ventricular mass index was increased in AF related stroke (p = 0.003). Using multivariate analysis, increased age (p = 0.003), reduced booster-pump function of LA (p = 0.01), LAA (p < 0.001) and RA (p < 0.001) were shown to be independently associated with the occurrence of stroke. CONCLUSIONS The dilatation and contractile dysfunction of both atria are related to the development of stroke in patients with paroxysmal and persistent AF. Our results suggested that the use of substrate-based assessment may help improve risk stratification of stroke in patients with AF.
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Affiliation(s)
- Hsuan-Ming Tsao
- Division of Cardiology, National Yang Ming University Hospital, Yi-Lan
| | - Wei-Chih Hu
- Department of Biomedical Engineering, Chung-Yuan Christian University, Chungli
| | | | | | - Hsueh-Han Wang
- Department of Radiology, National Yang Ming University Hospital
| | - Shih-Lin Chang
- Cardiovascular Research Center, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Tze-Fan Chao
- Cardiovascular Research Center, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Shih-Ann Chen
- Cardiovascular Research Center, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
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19
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Kawabata M, Goya M, Sasaki T, Maeda S, Shirai Y, Nishimura T, Yoshitake T, Shiohira S, Isobe M, Hirao K. Left Atrial Appendage Thrombi Formation in Japanese Non-Valvular Atrial Fibrillation Patients During Anticoagulation Therapy ― Warfarin vs. Direct Oral Anticoagulants ―. Circ J 2017; 81:645-651. [DOI: 10.1253/circj.cj-16-1089] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Masahiko Goya
- Heart Rhythm Center, Tokyo Medical and Dental University
| | - Takeshi Sasaki
- Heart Rhythm Center, Tokyo Medical and Dental University
| | - Shingo Maeda
- Heart Rhythm Center, Tokyo Medical and Dental University
| | | | | | | | | | - Mitsuaki Isobe
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Kenzo Hirao
- Heart Rhythm Center, Tokyo Medical and Dental University
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20
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Stabile G, Anselmino M, Soldati E, De Ruvo E, Solimene F, Iuliano A, Sciarra L, Bongiorni MG, Calò L, Gaita F. Effect of left atrial volume and pulmonary vein anatomy on outcome of nMARQ™ catheter ablation of paroxysmal atrial fibrillation. J Interv Card Electrophysiol 2016; 48:201-207. [PMID: 27714605 DOI: 10.1007/s10840-016-0189-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 09/16/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE Left atrial volume (LA) and pulmonary vein (PV) anatomy may potentially relate to technical challenges in achieving stable and effective catheter position in case of atrial fibrillation (AF) ablation by means of "one-shot" catheters. The aim of this study was to investigate whether LA volume and PV anatomy, evaluated by computed tomography (CT) or magnetic resonance (MR) prior to ablation, predict acute and midterm outcome of AF ablation by nMARQ™. METHODS We included 75 patients (mean age 58 ± 11 years, 67 % male) with symptomatic paroxysmal AF. All patients underwent CT/MR scanning prior to catheter ablation to evaluate LA volume and PV anatomy. All the patients underwent PV isolation by nMARQ™, an open-irrigated mapping and radiofrequency (RF) decapolar ablation catheter. Ablation was guided by electroanatomic mapping allowing RF energy delivery in the antral region of PVs from ten irrigated electrodes simultaneously. RESULTS Mean LA volume was 75 ± 40 ml. A normal anatomy (4 PVs) was documented in 40 (53 %) patients and abnormal anatomy (common truncus or accessory PVs) in 35 patients. Mean procedural and fluoroscopy times were 94 ± 55 and 8 ± 5 min, respectively, without significant differences among patients with normal or abnormal anatomy (92 ± 45 vs 95 ± 64 min, p = 0.85 and 6 ± 3 vs 8 ± 4 min, p = 0.65, respectively). Mean ablation time was 14 ± 3 min, and 99 % of the targeted veins were isolated with a mean of 23 ± 5 RF pulses per patient. After a mean follow-up of 17 ± 8 months, 23 (31 %) patients had an atrial arrhythmia recurrence. Neither LA volume nor PV anatomy was a predictor of outcome. CONCLUSIONS LA volume and PV anatomy did not affect procedural data and outcome in patients who underwent PV isolation by an open-irrigated mapping and RF decapolar ablation catheter.
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Affiliation(s)
| | - Matteo Anselmino
- Dipartimento di Scienze Mediche, Università di Torino, Torino, Italy
| | - Ezio Soldati
- Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | | | | | | | | | | | - Fiorenzo Gaita
- Dipartimento di Scienze Mediche, Università di Torino, Torino, Italy
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21
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Procter NE, Stewart S, Horowitz JD. New-onset atrial fibrillation and thromboembolic risk: Cardiovascular syzygy? Heart Rhythm 2016; 13:1355-61. [DOI: 10.1016/j.hrthm.2015.12.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Indexed: 11/25/2022]
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22
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Derivation and validation of E/e′ ratio as a parameter in the evaluation of left atrial appendage thrombus formation in patients with nonvalvular atrial fibrillation. Int J Cardiovasc Imaging 2016; 32:1349-1356. [DOI: 10.1007/s10554-016-0916-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 05/21/2016] [Indexed: 01/20/2023]
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23
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Tsao HM, Hu WC, Tsai PH, Lee CL, Liu FC, Wang HH, Lo LW, Chang SL, Chao TF, Chen SA. The Abundance of Epicardial Adipose Tissue Surrounding Left Atrium Is Associated With the Occurrence of Stroke in Patients With Atrial Fibrillation. Medicine (Baltimore) 2016; 95:e3260. [PMID: 27057876 PMCID: PMC4998792 DOI: 10.1097/md.0000000000003260] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Epicardial adipose tissue (EAT) is positively associated with risk factors for cardiovascular disease, but the role of EAT in the development of atrial fibrillation (AF)-related stroke and its association with the anatomical and functional remodeling of the left atrium (LA) have not been elucidated.This was a comparative cross-sectional study. Twenty-seven patients with paroxysmal or persistent AF and cardioembolic stroke were selected and compared with 68 age- and sex-matched AF patients without stroke. In addition, 20 controls without a history of AF or stroke were included. The periatrial EAT and the structural and functional properties of the LA and left ventricle were evaluated using contrast-enhanced 64-slice multidetector computed tomography during sinus rhythm. Total EAT around the LA was significantly increased across the groups (control vs AF vs AF-related stroke, P < 0.001). The volumes of the LA and the LA appendage (LAA) were also significantly increased across the 3 groups (P < 0.001 for each). The emptying fraction of the LA and LAA and the booster-pump function of the LA and LAA were all reduced across the 3 groups (P < 0.001 for all). In addition, the Hounsfield unit (HU) ratio of the LAA to the ascending aorta (LAA/AA) was also decreased in patients with stroke (P < 0.001). Furthermore, EAT had a negative correlation with the dynamic function of the LA, LAA, and the HU ratio. After a multivariate analysis, increased EAT (P < 0.001) was shown to be independently associated with the occurrence of AF-related stroke.Periatrial EAT was increased and was correlated with atrial dysfunction in patients with AF-related stroke. Hence, EAT assessment may potentially offer an incremental value for grading the risk of cardioembolic stroke in patients with AF.
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Affiliation(s)
- Hsuan-Ming Tsao
- From the Division of Cardiology, National Yang Ming University Hospital, Yi-Lan (H-MT) Department of Biomedical Engineering, Chung-Yuan Christian University, Taoyuan (W-CH); Division of Neurology, (P-HT, C-LL, F-CL); Department of Radiology, National Yang Ming University Hospital, Yi-Lan (H-HW); and Cardiovascular Research Center, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan (L-WL, S-LC, T-FC, S-AC)
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24
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Doukky R, Garcia-Sayan E, Patel M, Pant R, Wassouf M, Shah S, D'Silva O, Kehoe RF. Impact of Diastolic Function Parameters on the Risk for Left Atrial Appendage Thrombus in Patients with Nonvalvular Atrial Fibrillation: A Prospective Study. J Am Soc Echocardiogr 2016; 29:545-53. [PMID: 27021354 DOI: 10.1016/j.echo.2016.01.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND In patients with nonvalvular atrial fibrillation (NVAF), the impact of left ventricular diastolic function on the risk for left atrial appendage (LAA) thrombus has not been prospectively studied. METHODS At two academic medical centers, patients with NVAF were prospectively enrolled to undergo investigational transthoracic echocardiography immediately before clinically indicated transesophageal echocardiography. Mitral inflow E velocity and tissue Doppler septal and lateral mitral annulus velocities (e') were measured, and E/e' ratios were calculated. RESULTS Among 266 subjects (mean age, 65 years; 32% women), 17 (6.4%) had LAA thrombus. Patients with LAA thrombus had a higher mean CHA2DS2-VASc score (4.6 ± 1.7 vs 3.0 ± 1.8, P < .001), a higher mean lateral E/e' ratio (19.4 ± 10.1 vs 10.2 ± 5.6, P < .001), and a lower mean lateral e' velocity (7.0 ± 3.2 vs 10.4 ± 3.7 cm/sec, P = .001). There was a good discriminative capacity for E/e' (area under the curve, 0.83; P < .001) and e' velocity (area under the curve, 0.76; P = .001). None of the patients with normal E/e' ratios or normal e' velocities had LAA thrombus. Both E/e' (odds ratio, 1.13 per point; 95% CI, 1.06-1.20; P < .001) and e' velocity (odds ratio, 0.76 per 1 cm/sec; 95% CI, 0.63-0.92; P = .005) provided independent and incremental predictive value beyond the CHA2DS2-VASc score; however, E/e' provided greater incremental value than e' velocity (P = .036). Analyses using septal and averaged E/e' and septal e' velocity yielded similar results. Diastolic function parameters were also associated with the presence and intensity of left atrial spontaneous echo contrast, a precursor of LAA thrombus. CONCLUSIONS This prospective and concomitant evaluation of diastolic function and LAA thrombus in patients with NVAF demonstrates that E/e' ratio and e' velocity are associated with LAA thrombus, independent of CHA2DS2-VASc score, and may play a role in identifying patients at low risk for LAA thrombus. These data suggest that diastolic function assessment may improve stroke prediction in patients with NVAF.
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Affiliation(s)
- Rami Doukky
- Division of Adult Cardiology, John H. Stroger, Jr Hospital of Cook County, Chicago, Illinois; Division of Cardiology, Rush University Medical Center, Chicago, Illinois.
| | - Enrique Garcia-Sayan
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois; Division of Cardiology, Mount Sinai Hospital, Chicago, Illinois
| | - Mita Patel
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois; Division of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rojina Pant
- Division of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois
| | - Marwan Wassouf
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois; Department of Medicine, Fairview Hospital, Cleveland, Ohio
| | - Saurabh Shah
- Division of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois
| | - Oliver D'Silva
- Division of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois
| | - Richard F Kehoe
- Division of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois
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25
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Pant R, Patel M, Garcia-Sayan E, Wassouf M, D'Silva O, Kehoe RF, Doukky R. Impact of B-type natriuretic peptide level on the risk of left atrial appendage thrombus in patients with nonvalvular atrial fibrillation: a prospective study. Cardiovasc Ultrasound 2016; 14:4. [PMID: 26772738 PMCID: PMC4715322 DOI: 10.1186/s12947-016-0047-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 01/12/2016] [Indexed: 01/20/2023] Open
Abstract
Background The impact of B-type natriuretic peptide (BNP) level on the risk of left atrial appendage (LAA) thrombus in patients with nonvalvular atrial fibrillation (NVAF) has not been prospectively studied. Methods In two academic medical centers, we obtained BNP levels immediately prior to transesophageal echocardiogram performed to exclude LAA thrombus in patients with NVAF. Results Among 261 subjects (mean age 65 ± 12 years; 30 % women) with NVAF, 17 (6.5 %) had LAA thrombus and 85 (32.6 %) had at least mild spontaneous echo contrast (SEC). Mean BNP level was significantly higher in patients with LAA thrombus [775 ± 678 vs. 384 ± 537, P = 0.001]. Receiver operator characteristics analysis demonstrated that BNP has a good discriminatory capacity for LAA thrombus (area under the curve, 0.74; 95 % confidence interval [CI], 0.63–0.85; P = 0.001); BNP ≥ 67 pg/mL was 100 % sensitive and 20 % specific for LAA thrombus. Multivariate logistic regression analysis demonstrated that BNP was not independently associated with LAA thrombus (odds-ratio, 1.05 per 100 pg/mL increment; CI, 0.99–1.12; P = 0.127) after adjusting for CHA2DS2-VASc score; while the latter was independently associated with LAA thrombus after adjusting for BNP level (odds-ratio, 1.46 per CHA2DS2-VASc point; CI, 1.09–1.96; P = 0.011). Nonetheless, BNP was associated with SEC in univariate and multivariate analysis, after adjusting for the CHA2DS2-VASc score, (odds-ratio, 1.08; CI, 1.02–1.14; P = 0.005). Conclusions BNP is predictive of SEC. However, it does not provide significant incremental value in the prediction of LAA thrombus.
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Affiliation(s)
- Rojina Pant
- Division of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Mita Patel
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.,Division of Cardiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Enrique Garcia-Sayan
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.,Division of Cardiology, Mount Sinai Hospital, Chicago, IL, USA
| | - Marwan Wassouf
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA.,Department of Medicine, Fairview Hospital, Cleveland, OH, USA
| | - Oliver D'Silva
- Division of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Richard F Kehoe
- Division of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Rami Doukky
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA. .,Division of Adult Cardiology, John H. Stroger, Jr. Hospital of Cook County, 1901 W. Harrison St, Chicago, IL, 60612, USA.
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26
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Nishikii-Tachibana M, Murakoshi N, Seo Y, Xu D, Yamamoto M, Ishizu T, Atsumi A, Machino-Ohtsuka T, Kuroki K, Yamasaki H, Igarashi M, Sekiguchi Y, Aonuma K. Prevalence and Clinical Determinants of Left Atrial Appendage Thrombus in Patients With Atrial Fibrillation Before Pulmonary Vein Isolation. Am J Cardiol 2015; 116:1368-73. [PMID: 26358509 DOI: 10.1016/j.amjcard.2015.07.055] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 07/21/2015] [Accepted: 07/21/2015] [Indexed: 10/23/2022]
Abstract
The CHADS2 score is considered a reliable predictor of stroke/thromboembolism risk in patients with atrial fibrillation (AF). However, thromboembolism can occasionally occur even in patients with AF with low CHADS2 score (CHADS2 score = 0 or 1). To investigate the incidence and predictors of left atrial appendage (LAA) thrombus (LAAT) formation in patients with AF, we studied consecutive 543 Japanese patients with AF who underwent transesophageal echocardiography before pulmonary vein isolation from 2008 to 2012. All patients were treated with anticoagulation therapy with warfarin, and their clinical and echocardiographic characteristics were evaluated. LAATs were observed in 35 (6.4%) of 543 patients, and the prevalence was clearly correlated with the patient's CHADS2 scores. Of 338 patients with low CHADS2 score, LAATs were observed in 7 patients (2.1%). By multivariate analysis, increased left atrial volume (≥50 ml), decreased ejection fraction (<56%), and increased brain natriuretic peptide level (>75 pg/ml) were significantly associated with increased prevalence of LAATs, even in patients with low CHADS2 score. Accordingly, we proposed a new scoring system to predict LAAT (left atrial volume ≥50 ml: score 2; ejection fraction <56%: score 1; brain natriuretic peptide >75 pg/ml: score 1). Patients with a score ≥2 have a greater risk of LAAT, whereas all patients with score ≤1 have no LAATs. Our scoring system is useful for evaluation of the risk of LAAT in patients with AF even with low CHADS2 score.
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27
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Kim YJ, Yong HS, Kim SM, Kim JA, Yang DH, Hong YJ. Korean guidelines for the appropriate use of cardiac CT. Korean J Radiol 2015; 16:251-85. [PMID: 25741189 PMCID: PMC4347263 DOI: 10.3348/kjr.2015.16.2.251] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 01/03/2015] [Indexed: 01/07/2023] Open
Abstract
The development of cardiac CT has provided a non-invasive alternative to echocardiography, exercise electrocardiogram, and invasive angiography and cardiac CT continues to develop at an exponential speed even now. The appropriate use of cardiac CT may lead to improvements in the medical performances of physicians and can reduce medical costs which eventually contribute to better public health. However, until now, there has been no guideline regarding the appropriate use of cardiac CT in Korea. We intend to provide guidelines for the appropriate use of cardiac CT in heart diseases based on scientific data. The purpose of this guideline is to assist clinicians and other health professionals in the use of cardiac CT for diagnosis and treatment of heart diseases, especially in patients at high risk or suspected of heart disease.
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Affiliation(s)
- Young Jin Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul 120-752, Korea
| | - Hwan Seok Yong
- Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul 152-703, Korea
| | - Sung Mok Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea
| | - Jeong A Kim
- Department of Radiology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang 411-706, Korea
| | - Dong Hyun Yang
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea
| | - Yoo Jin Hong
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul 120-752, Korea
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28
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Vizzardi E, Curnis A, Latini MG, Salghetti F, Rocco E, Lupi L, Rovetta R, Quinzani F, Bonadei I, Bontempi L, D'Aloia A, Dei Cas L. Risk factors for atrial fibrillation recurrence: a literature review. J Cardiovasc Med (Hagerstown) 2014; 15:235-53. [PMID: 23114271 DOI: 10.2459/jcm.0b013e328358554b] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Atrial fibrillation is the most common arrhythmia managed in clinical practice and it is associated with an increased risk of mortality, stroke and peripheral embolism. Unfortunately, the incidence of atrial fibrillation recurrence ranges from 40 to 50%, despite the attempts of electrical cardioversion and the administration of antiarrhythmic drugs. In this review, the literature data about predictors of atrial fibrillation recurrence are highlighted, with special regard to clinical, therapeutic, biochemical, ECG and echocardiographic parameters after electrical cardioversion and ablation. Identifying predictors of success in maintaining sinus rhythm after cardioversion or ablation may allow a better selection of patients to undergo these procedures. The aim is to reduce healthcare costs and avoid exposing patients to unnecessary procedures and related complications. Recurrent atrial fibrillation depends on a combination of several parameters and each patient should be individually assessed for such a risk of recurrence.
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Affiliation(s)
- Enrico Vizzardi
- Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy
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29
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Frequency and significance of right atrial appendage thrombi in patients with persistent atrial fibrillation or atrial flutter. J Am Soc Echocardiogr 2014; 27:1200-7. [PMID: 25240491 DOI: 10.1016/j.echo.2014.08.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) and atrial flutter (AFL) are strong atrial thrombosis (THR) risk factors. In recent-onset tachyarrhythmias, the incidence of left atrial appendage (LAA) THR, detected by transesophageal echocardiography (TEE), has been widely studied, ranging from 6% to 18% (AF) and 4% to 11% (AFL). On the contrary, few studies have assessed right atrial appendage (RAA) THR, and there is no information on the relation between the RAA flow characteristics and the presence of RAA THR. The aims of this study were to evaluate the incidence of RAA THR in a population of patients undergoing TEE-guided cardioversion for recent-onset atrial tachyarrhythmias and to analyze RAA Doppler flow and its relation to thrombus formation. METHODS From 1998 to 2012, patients admitted to the emergency department for persistent, non-self-terminating atrial tachyarrhythmia lasting >2 days who gave informed consent for TEE-guided cardioversion were prospectively enrolled in the study. Among 1,042 patients, complete anatomic and functional studies of the LAA and RAA were feasible in 983 (AF, n = 810 [23%]; AFL, n = 173 [5%]). The presence of RAA and LAA THR, appendage emptying velocities, and the presence of severe spontaneous echocardiographic contrast were studied. RESULTS The overall incidence of atrial THR was 9.7% (96 of 983). The incidence of THR was 9.3% (91 of 983) in the LAA and 0.73% (seven of 983) in the RAA (P < .01). In the AF and AFL groups, the incidence of LAA THR was 10.3% (83 of 805), compared with 0.75% (six of 805) for RAA THR (P < .01). Among patients with AFL, the incidence of LAA THR was 6% (10 of 178), compared with 0.6% (one of 178) for RAA THR (P < .01). The mean LAA peak emptying velocity was 24 cm/sec (range, 10-32 cm/sec) in patients with LAA THR, compared with 38 cm/sec (range, 20-59 cm/sec) in those without THR; the mean RAA peak emptying velocity was 17 ± 7 cm/sec in patients with RAA THR, compared with 34 ± 13 cm/sec in those without THR (P < .001). CONCLUSIONS RAA thrombi are significantly less frequent than LAA thrombi but may reach large dimensions. Multiplane TEE allows RAA morphologic and functional assessment. Before TEE-guided cardioversion, both the LAA and the RAA must be routinely studied.
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30
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Hajjiri M, Bernstein S, Saric M, Benenstein R, Aizer A, Dym G, Fowler S, Holmes D, Bernstein N, Mascarenhas M, Park D, Chinitz L. Atrial fibrillation ablation in patients with known sludge in the left atrial appendage. J Interv Card Electrophysiol 2014; 40:147-51. [DOI: 10.1007/s10840-014-9892-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 02/21/2014] [Indexed: 10/25/2022]
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Santoro F, Di Biase L, Santangeli P, Ieva R, Burkhardt JD, Natale A. The Role of Cardiac Imaging in Stroke Prevention. Card Electrophysiol Clin 2014; 6:17-29. [PMID: 27063818 DOI: 10.1016/j.ccep.2013.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
This article reviews the role of cardiac imaging in stroke prevention, defining how imaging tools can be useful in this field. Cardioembolic sources during atrial fibrillation are discussed. New closure devices can be implanted in the left atrial appendage and routinely monitored with imaging modalities. Acute and chronic left ventricular dysfunction is reviewed, identifying the possible mechanism of thrombus formation and its early detection. Valvular evaluation of native heart disease and possible implications for stroke risk are defined.
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Affiliation(s)
- Francesco Santoro
- Department of Cardiology, University of Foggia, viale L Pinto, 1, 71100, Foggia, Italy
| | - Luigi Di Biase
- Department of Cardiology, University of Foggia, viale L Pinto, 1, 71100, Foggia, Italy; Texas Cardiac Arrhythmia Institute, Heart & Vascular Department, St. David's Medical Center, 3000 N. IH 35 Suite 720, 78705, Austin, TX, USA; Division of Cardiology and Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, 10467, Bronx, New York, NY, USA; Department of Biomedical Engineering, Cockrell School of Engineering, The University of Texas at Austin, 107 W. Dean Keeton, BME Building, 78712, Austin, TX, USA
| | - Pasquale Santangeli
- Department of Cardiology, University of Foggia, viale L Pinto, 1, 71100, Foggia, Italy; Texas Cardiac Arrhythmia Institute, Heart & Vascular Department, St. David's Medical Center, 3000 N. IH 35 Suite 720, 78705, Austin, TX, USA
| | - Riccardo Ieva
- Department of Cardiology, University of Foggia, viale L Pinto, 1, 71100, Foggia, Italy
| | - J David Burkhardt
- Texas Cardiac Arrhythmia Institute, Heart & Vascular Department, St. David's Medical Center, 3000 N. IH 35 Suite 720, 78705, Austin, TX, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Heart & Vascular Department, St. David's Medical Center, 3000 N. IH 35 Suite 720, 78705, Austin, TX, USA; Department of Biomedical Engineering, Cockrell School of Engineering, The University of Texas at Austin, 107 W. Dean Keeton, BME Building, 78712, Austin, TX, USA; EP Services, California Pacific Medical Center, 2100 Webster Street, 94115, San Francisco, CA, USA; Division of Cardiology, Stanford Arrhythmia Service, Stanford University, 300 Pasteur Drive, 94305, Stanford, CA, USA; Division of Cardiovascular Medicine, Case Western Reserve University, University Hospitals of Cleveland, 11100 Euclid Avenue, 44106-5038 Cleveland, OH, USA; Interventional Electrophysiology, Department of Cardiology, Scripps Clinic, 10666 N Torrey Pines Road, 92037, La Jolla, CA, USA.
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Corradi D, Callegari S, Gelsomino S, Lorusso R, Macchi E. Morphology and pathophysiology of target anatomical sites for ablation procedures in patients with atrial fibrillation. Int J Cardiol 2013; 168:1769-78. [DOI: 10.1016/j.ijcard.2013.06.141] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 06/30/2013] [Indexed: 10/26/2022]
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Corradi D, Callegari S, Gelsomino S, Lorusso R, Macchi E. Morphology and pathophysiology of target anatomical sites for ablation procedures in patients with atrial fibrillation. Part I: Atrial structures (atrial myocardium and coronary sinus). Int J Cardiol 2013; 168:1758-68. [DOI: 10.1016/j.ijcard.2013.05.091] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 04/22/2013] [Accepted: 05/04/2013] [Indexed: 12/21/2022]
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Yarmohammadi H, Klosterman T, Grewal G, Alraies MC, Varr BC, Lindsay B, Zurick AO, Shrestha K, Tang WW, Bhargava M, Klein AL. Efficacy of the CHADS₂ scoring system to assess left atrial thrombogenic milieu risk before cardioversion of non-valvular atrial fibrillation. Am J Cardiol 2013; 112:678-83. [PMID: 23726178 DOI: 10.1016/j.amjcard.2013.04.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 04/19/2013] [Accepted: 04/19/2013] [Indexed: 10/26/2022]
Abstract
The CHADS₂ scoring system was found to be a good predictor for risk stratification of stroke in patients with atrial fibrillation. The effectiveness of this scoring system in assessing thrombogenic milieu before direct-current cardioversion has not yet fully been established on a large scale. In this study, data from 2,369 consecutive patients in whom transesophageal echocardiography was performed for screening before direct-current cardioversion from 1999 to 2008 were analyzed. Left atrial (LA) or LA appendage (LAA) thrombogenic milieu (spontaneous echo contrast, sludge, and thrombus) was investigated. The results were correlated with CHADS₂ score findings. The mean age was 66 ± 13 years, and the ratio of men to women was 2.2:1. CHADS₂ scores of 0, 1, 2, 3, 4, 5 and 6 were present in 11%, 25%, 30%, 22%, 8%, 3%, and 1% of the studies, respectively. The prevalence of LA or LAA sludge or thrombus increased with increasing CHADS₂ scores (2.3%, 7%, 8.5%, 9.9%, 12.3%, and 14.1% for scores of 0, 1, 2, 3, 4, and 5 or 6, respectively, p = 0.01). In a multivariate model, an ejection fraction ≤20% was the best predictor of LA or LAA sludge or thrombus (odds ratio 2.99, p <0.001). In conclusion, transesophageal echocardiographic markers of thrombogenic milieu were highly correlated with increasing CHADS₂ scores in patients who underwent transesophageal echocardiography-guided cardioversion. Giving more value to echocardiographic findings, such as the left ventricular ejection fraction, and its different levels (especially an ejection fraction ≤20%) might improve the precision of the CHADS₂ scoring scheme to predict thrombogenic milieu in the left atrium or LAA as a surrogate to cardioembolic risk in patients with atrial fibrillation.
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Willens HJ, Gómez-Marín O, Nelson K, DeNicco A, Moscucci M. Correlation of CHADS2 and CHA2DS2-VASc scores with transesophageal echocardiography risk factors for thromboembolism in a multiethnic United States population with nonvalvular atrial fibrillation. J Am Soc Echocardiogr 2012; 26:175-84. [PMID: 23253435 DOI: 10.1016/j.echo.2012.11.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Indexed: 11/15/2022]
Abstract
BACKGROUND The aims of this study were to evaluate the relationship of the CHA(2)DS(2)-VASc score and risk categories with transesophageal echocardiographic (TEE) risk factors for thromboembolism and to compare the CHA(2)DS(2)-VASc and CHADS(2) risk stratification schemes with respect to their ability to predict these risk factors in a multiethnic US population with nonvalvular atrial fibrillation. METHODS Transesophageal echocardiograms of 167 patients (mean age, 66.3 ± 11.6 years; 146 men [87%]; 100 whites [60%]; 40 Hispanics [24%]; 27 blacks [16%]) with nonvalvular atrial fibrillation were retrospectively reviewed for smoke, sludge, thrombus, and left atrial appendage (LAA) emptying velocity ≤20 cm/sec. The patients' CHA(2)DS(2)-VASc and CHADS(2) risk scores and categories were also calculated. RESULTS Any LAA abnormality, smoke, sludge, thrombus, and abnormal LAA emptying velocity were present in 45%, 38%, 13%, 3%, and 22% of patients, respectively. Heart failure (P < .001), age (P < .001 for age ≥75 vs ≤64 years, P = .013 for age 65-74 vs ≤64 years), and diabetes (P = .019) were independent predictors of LAA abnormalities, while ethnicity was not. The prevalence of TEE risk factors for thromboembolism increased with increasing CHA(2)DS(2)-VASc score and risk category. The CHADS(2) risk categories of 35 patients (21%) were upgraded by the CHA(2)DS(2)-VASc scheme. Using the latter scheme, fewer patients were classified as at intermediate risk compared with the CHADS(2) system (21 [13%] vs 46 [28%]). Patients classified as at low risk by either scheme had almost no TEE risk factors. Of 30 intermediate-risk patients by CHADS(2) score upgraded to high risk using CHA(2)DS(2)-VASc score, eight (27%) had at least one TEE risk factor for thromboembolism. C-statistics, sensitivity, and specificity for predicting any LAA abnormality were 0.607 (95% confidence interval, 0.549-0.665), 92.0%, and 28.9% for CHA(2)DS(2)-VASc score and 0.685 (95% confidence interval, 0.615-0.755), 81.3%, and 54.2% for CHADS(2) score. CONCLUSIONS CHA(2)DS(2)-VASc score is associated with TEE risk factors for thromboembolism in a multiethnic US population. Compared with CHADS(2) score, it has increased sensitivity, decreased specificity, and lower ability for predicting TEE risk factors in this population.
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Affiliation(s)
- Howard J Willens
- Department of Medicine, Division of Cardiology, University of Miami Miller School of Medicine, Miami, Florida, USA.
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FLORIA MARIANA, ROY LUCDE, XHAET OLIVIER, BLOMMAERT DOMINIQUE, JAMART JACQUES, GERARD MARINA, DORMAL FABIEN, DECEUNINCK OLIVIER, AMBARUS VALENTIN, MARCHANDISE BAUDOUIN, SCHROEDER ERWIN. Predictive Value of Thromboembolic Risk Scores Before an Atrial Fibrillation Ablation Procedure. J Cardiovasc Electrophysiol 2012; 24:139-45. [DOI: 10.1111/j.1540-8167.2012.02442.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Saygi S. Atrial Fibrillation and the Role of LAA in Pathophysiology and Clinical Outcomes? J Atr Fibrillation 2012; 5:480. [PMID: 28496767 DOI: 10.4022/jafib.480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Revised: 03/10/2012] [Accepted: 05/21/2012] [Indexed: 11/10/2022]
Abstract
Left atrial appendage (LAA) is a source of thromboembolism especially in patients with non valvular atrial fibrillation (AF). It is reasonable to accept LAA as a distinct part of left atrium (LA) with unique anatomical and physiological properties. Advances in imaging modalities increased the knowledge about anatomical and physiological characteristics of LAA. It is important to prevent the AF patients from systemic thromboembolic events, and new pharmacological and non pharmacological management approaches demonstrate encouraging results. Also pulmonary vein isolation which has been accepted as a curative and useful treatment option for the treatment of drug resistant AF has been helpful in understanding the electrophysiological properties of LAA. Accumulating data revealed that LAA continues to be the one of the most important structure of heart during AF because of its distinctive anatomical, mechanical, and electrophysiological properties.
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Affiliation(s)
- Serkan Saygi
- Department of Cardiology, Canakkale Onsekiz Mart University, Turkey
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Newell MC, Melby D, Schwartz RS, Lesser JR. Cardiac CT for Pre-Procedural Electrophysiologic Study Planning. CURRENT CARDIOVASCULAR IMAGING REPORTS 2012. [DOI: 10.1007/s12410-012-9157-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Yarmohammadi H, Klosterman T, Grewal G, Alraies MC, Lindsay BD, Bhargava M, Tang WW, Klein AL. Transesophageal Echocardiography and Cardioversion Trends in Patients with Atrial Fibrillation: A 10-Year Survey. J Am Soc Echocardiogr 2012; 25:962-8. [DOI: 10.1016/j.echo.2012.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Indexed: 10/28/2022]
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Yarmohammadi H, Varr BC, Puwanant S, Lieber E, Williams SJ, Klostermann T, Jasper SE, Whitman C, Klein AL. Role of CHADS2 score in evaluation of thromboembolic risk and mortality in patients with atrial fibrillation undergoing direct current cardioversion (from the ACUTE Trial Substudy). Am J Cardiol 2012; 110:222-6. [PMID: 22503581 DOI: 10.1016/j.amjcard.2012.03.017] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Revised: 03/07/2012] [Accepted: 03/07/2012] [Indexed: 11/17/2022]
Abstract
The CHADS(2) (congestive heart failure, hypertension, age >75 years, diabetes mellitus, stroke or transient ischemic attack [2 points]) scoring scheme has been found to be a good predictor of stroke risk in patients with nonvalvular atrial fibrillation (AF). However, the value of the CHADS(2) scoring system in the risk stratification of patients with AF who undergo direct-current cardioversion has not yet been specifically investigated. In this study, a subgroup of 541 patients from the Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) study who had AF for >48 hours and planned to undergo transesophageal echocardiography before direct-current cardioversion were enrolled. Each patient had a CHADS(2) score calculated. Of the patients with CHADS(2) scores of 0, 14 (10%) were found to have left atrial appendage thrombi on transesophageal echocardiography. After 6 months of follow up, patients with CHADS(2) scores of 3 to 6 showed a significantly higher mortality rate in comparison with patients with lower CHADS(2) scores (4.3% vs 0.5%, p = 0.004), despite their similar prevalence of left atrial appendage thrombus and stroke (thrombus: 13.4% vs 11.6%, p = 0.60; stroke: 0% vs 0.3%, p = 0.70). In conclusion, the CHADS(2) scoring system may be useful for predicting short-term mortality risk in patients with AF receiving elective direct-current cardioversion. However, in the preprocedural risk assessment of these patients, the CHADS(2) scoring system is not reliable in predicting risk for left atrial appendage thrombus formation, especially in patients with low CHADS(2) scores.
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Affiliation(s)
- Hirad Yarmohammadi
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
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Grewal GK, Klosterman TB, Shrestha K, Yarmohammadi H, Zurick AO, Varr BC, Tang WW, Lindsay BD, Klein AL. Indications for TEE Before Cardioversion for Atrial Fibrillation: Implications for Appropriateness Criteria. JACC Cardiovasc Imaging 2012; 5:641-8. [DOI: 10.1016/j.jcmg.2011.12.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Revised: 11/07/2011] [Accepted: 12/22/2011] [Indexed: 11/26/2022]
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Iwama M, Kawasaki M, Tanaka R, Ono K, Watanabe T, Hirose T, Nagaya M, Noda T, Watanabe S, Minatoguchi S. Left atrial appendage emptying fraction assessed by a feature-tracking echocardiographic method is a determinant of thrombus in patients with nonvalvular atrial fibrillation. J Cardiol 2012; 59:329-36. [DOI: 10.1016/j.jjcc.2012.01.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 12/10/2011] [Accepted: 01/02/2012] [Indexed: 01/24/2023]
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Ailawadi G, Gerdisch MW, Harvey RL, Hooker RL, Damiano RJ, Salamon T, Mack MJ. Exclusion of the left atrial appendage with a novel device: early results of a multicenter trial. J Thorac Cardiovasc Surg 2011; 142:1002-9, 1009.e1. [PMID: 21906756 DOI: 10.1016/j.jtcvs.2011.07.052] [Citation(s) in RCA: 176] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2011] [Revised: 07/04/2011] [Accepted: 07/25/2011] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Up to 90% of embolic strokes that occur in patients with atrial fibrillation originate from the left atrial appendage. Exclusion of the left atrial appendage during cardiac surgery may decrease the future risk of stroke, especially in patients with atrial fibrillation or at high risk for developing atrial fibrillation. We report the initial results of a multicenter Food and Drug Administration trial to assess the safety and efficacy of a novel left atrial appendage exclusion clip. METHODS Patients undergoing elective cardiac surgery via median sternotomy with atrial fibrillation or a Congestive Heart Failure, Hypertension, Age > 75 Years, Diabetes Mellitus, Stroke score greater than 2 were eligible for concomitant AtriClip (Atricure Inc, Westchester, Ohio) device insertion. Device insertion (35, 40, 45, and 50 mm) was performed at any point after sternotomy on or off cardiopulmonary bypass. Safety was assessed at 30 days, and efficacy of left atrial appendage exclusion was assessed at operation (by transesophageal echocardiography) and 3-month follow-up (by computed tomography angiography or transesophageal echocardiography). RESULTS A total of 71 patients (mean age, 73 years) undergoing open cardiac surgery at 7 US centers were enrolled in the study. The left atrial appendage in 1 patient was too small and did not meet eligibility criteria; the remaining 70 patients had successful placement of an AtriClip device. Intraprocedural successful left atrial appendage exclusion was confirmed in 67 of 70 patients (95.7%). Although significant adverse events occurred in 34 of 70 patients (48.6%), there were no adverse events related to the device and no perioperative mortality. At 3-month follow-up, 1 patient died and 65 of 70 patients (92.9%) were available for assessment. Of the patients who underwent imaging, 60 of 61 patients (98.4%) had successful left atrial appendage exclusion by computed tomography angiography or transesophageal echocardiography imaging. CONCLUSIONS In this small study, safe and atraumatic exclusion of the left atrial appendage can be performed during open cardiac surgery with the AtriClip device with greater than 95% success and appears to be durable in the short term by imaging. Long-term studies are needed to evaluate the efficacy in the prevention of stroke.
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Affiliation(s)
- Gorav Ailawadi
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
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Narducci ML, Pelargonio G, Dello Russo A, Casella M, Biasucci LM, La Torre G, Pazzano V, Santangeli P, Baldi A, Liuzzo G, Tondo C, Natale A, Crea F. Role of tissue C-reactive protein in atrial cardiomyocytes of patients undergoing catheter ablation of atrial fibrillation: pathogenetic implications. Europace 2011; 13:1133-1140. [DOI: 10.1093/europace/eur068] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Jahnke C, Fischer J, Mirelis JG, Kriatselis C, Gerds-Li JH, Gebker R, Manka R, Schnackenburg B, Fleck E, Paetsch I. Cardiovascular magnetic resonance imaging for accurate sizing of the left atrium: predictability of pulmonary vein isolation success in patients with atrial fibrillation. J Magn Reson Imaging 2011; 33:455-63. [PMID: 21274989 DOI: 10.1002/jmri.22426] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To prospectively determine the most reproducible approach for left-atrial size assessment using cardiovascular magnetic resonance (CMR) imaging in patients with atrial fibrillation and its value for prediction of pulmonary vein isolation (PVI) treatment success. MATERIALS AND METHODS Eighty patients underwent CMR imaging prior to PVI; the CMR examination included standard cine sequences, a multislice cine sequence in 4-chamber orientation with full left-atrial coverage, and a contrast-enhanced MR angiography of the left atrium. Left-atrial size was determined as: diameter, area, volume segmented from angiography, and diastolic/systolic volumes from cine imaging (Simpson's rule). All measurements were carried out by two independent observers and repeated by one observer to assess inter- and intrareader variability. Treatment success was defined as persisting sinus rhythm after PVI (follow-up period 12.6 ± 6.6 months). RESULTS All left-atrial measurements showed substantial intrareader agreement. Interreader agreement was substantial for diastolic/systolic left-atrial volumes only. Calculated bias was found to be minimal (0.1%-4.9%). Predictability of PVI treatment success was best using cine volumetric measurements (cutoff value for diastolic volume, 112 mL) yielding a sensitivity and specificity of 80% and 70%, respectively. CONCLUSION Left-atrial volumetry based on cine imaging represented the most reproducible approach to determine left-atrial size. PVI success was predicted best using cine volumetry.
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Affiliation(s)
- Cosima Jahnke
- Department of Internal Medicine/Cardiology, German Heart Institute Berlin, Germany.
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Stavrakis S, Madden GW, Stoner JA, Sivaram CA. Transesophageal echocardiography for the diagnosis of pulmonary vein stenosis after catheter ablation of atrial fibrillation: a systematic review. Echocardiography 2011; 27:1141-6. [PMID: 20678129 DOI: 10.1111/j.1540-8175.2010.01250.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIMS Pulmonary vein (PV) stenosis is a potentially serious complication of catheter ablation of atrial fibrillation (AF). The optimal method for diagnosis of PV stenosis has not been established. We undertook a systematic review of the literature to investigate the diagnostic performance of transesophageal echocardiography (TEE) for the detection of PV stenosis after catheter ablation of AF. METHODS We searched MEDLINE and EMBASE databases for studies evaluating the diagnostic performance of TEE for the detection of PV stenosis after catheter ablation of AF, compared to a reference standard of PV angiography, magnetic resonance imaging (MRI), or computed tomography (CT). Study quality was assessed using the QUADAS tool. RESULTS A total of seven studies that included 344 patients (1,344 PVs) met the selection criteria. Of these, three studies used PV angiography as the reference standard, while MRI and CT were used in two studies each. Compared to PV angiography, TEE had sensitivity between 82% and 100% and specificity between 98% and 100%. Compared to MRI, TEE sensitivity was 100% in both studies, while the specificity ranged between 98% and 99%. Compared to CT, TEE had sensitivity between 86% and 100% and specificity of 95%. Quality of the reviewed studies was somewhat limited by the retrospective design in most of the studies. CONCLUSIONS TEE has a high sensitivity and specificity in detecting PV stenosis. Given its wide availability and favorable side effect profile, these data suggest that TEE is very useful tool for the diagnosis of PV stenosis after catheter ablation of AF.
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Affiliation(s)
- Stavros Stavrakis
- Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Characterization of the dynamic function of the pulmonary veins before and after atrial fibrillation ablation using multi-detector computed tomographic images. Int J Cardiovasc Imaging 2010; 27:1049-58. [DOI: 10.1007/s10554-010-9752-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Accepted: 11/11/2010] [Indexed: 10/18/2022]
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Dillier R, Kobza R, Erne S, Zuber M, Arand P, Erne P. Noninvasive detection of left-ventricular systolic dysfunction by acoustic cardiography in atrial fibrillation. Cardiol Res Pract 2010; 2011:173102. [PMID: 20981304 PMCID: PMC2958491 DOI: 10.4061/2011/173102] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Accepted: 09/30/2010] [Indexed: 11/20/2022] Open
Abstract
Objectives. Assessment of left ventricular (LV) systolic function in patients with atrial fibrillation can be difficult. Acoustic cardiography provides several parameters for quantifying LV systolic function. We evaluated the ability of acoustic cardiography to detect LV systolic dysfunction in patients with and without atrial fibrillation. Design. We studied 194 patients who underwent acoustic cardiography and cardiac catheterization including measurement of angiographic ejection fraction (EF) and maximum LV dP/dt. LV systolic dysfunction was defined as LV maximum dP/dt <1600 mmHg/s. Acoustic cardiographic parameters included electromechanical activation time (EMAT) and the systolic dysfunction index (SDI). Results. Acoustic cardiography detected systolic dysfunction with high specificity and moderate sensitivity with similar performance to EF (sensitivity/specificity without afib: EMAT 30/96, SDI 40/90, EF at 35% 30/96; sensitivity/specificity with afib: EMAT 64/82, SDI 59/100, EF at 35% 45/82). Conclusions. Acoustic cardiography can be used for diagnosis of LV systolic dysfunction in atrial fibrillation.
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Affiliation(s)
- Roger Dillier
- Division of Cardiology, Luzerner Kantonsspital, 6000 Luzern 16, Switzerland
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