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Ashraf T, Aamir KF, Nadeem A, Murtaza S, Akhtar P, Haque SY, Ghaffar R, Hassan MU, Tipoo FA. Left atrial appendage thrombus with severe mitral stenosis: Responders and non-responders to anticoagulation. Rev Port Cardiol 2024:S0870-2551(24)00070-2. [PMID: 38401704 DOI: 10.1016/j.repc.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 11/30/2023] [Accepted: 12/02/2023] [Indexed: 02/26/2024] Open
Abstract
INTRODUCTION AND OBJECTIVE Mitral stenosis (MS) is one of the most frequently observed valvular heart lesions in developing countries and is due to different etiologies. The effects of anticoagulation in different types of left atrial appendage (LAA) are unknown. The current study aimed to determine the resolution of LAA thrombus on transesophageal echocardiography (TEE) after three months of optimal anticoagulation in patients with different types of LAA at baseline cardiac computed tomography of patients with severe MS. METHODS This prospective cohort study observed the frequency of LAA thrombus resolution after three months of anticoagulation therapy in patients with severe MS. The response rate in different morphologies of LAA and locations was also assessed. Thrombus resolution after three months of warfarin therapy was assessed on repeat TEE. RESULTS A total of 88 patients were included, mean age 37.95±11.87 years. Repeat TEE showed thrombus resolution in only 27.3% of patients. The rate of thrombus resolution was 8/12 (66.7%), 4/28 (14.3%), 8/36 (22.2%), and 4/12 (33.3%) for patients with cactus, cauliflower, chicken wing, and windsock LAA type, respectively. The resolution rate was 0/12 (0%), 4/44 (9.1%), and 20/32 (62.5%) for patients with thrombus in the base, body, and tip of the LAA, respectively. CONCLUSION The cactus type of LAA morphology and thrombus at the LAA tip responded well to three months of anticoagulation, however, patients with thrombus in the LAA base and body and cauliflower and chicken wing morphology were non-responders and could benefit from early referral for surgical management.
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Affiliation(s)
- Tariq Ashraf
- Karachi Institute of Heart Diseases, Karachi, Pakistan.
| | | | - Asif Nadeem
- Armed Forces Institute of Cardiology & National Institute of Heart Diseases (AFIC-NIHD), Rawalpindi, Pakistan
| | | | - Parveen Akhtar
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
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Ahmed AS, Divani G, Akheela MK. 'Boxing glove' clot in a smoking left atrium. BMJ Case Rep 2021; 14:e244374. [PMID: 34764104 PMCID: PMC8587618 DOI: 10.1136/bcr-2021-244374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 11/03/2022] Open
Affiliation(s)
- Ahamed Shaheer Ahmed
- Department of Cardiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Delhi, India
| | - Gaurav Divani
- Department of Cardiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Delhi, India
| | - Mohamed Kassim Akheela
- Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, Delhi, India
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Mukhopadhyay S, Dwivedi Y, Yusuf J, Uppal A, Mehta V. Prevalence and predictors of left atrial appendage inactivity in patients of rheumatic mitral stenosis in sinus rhythm: An observational study. Echocardiography 2021; 38:1860-1869. [PMID: 34672389 DOI: 10.1111/echo.15223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Systemic thromboembolism is a known complication of rheumatic mitral stenosis (RMS) in sinus rhythm (SR). Left atrial appendage (LAA), the commonest site of thrombus formation is usually hypocontractile (inactive) in such patients. We aimed to study the prevalence of LAA inactivity (LAAI) in severe RMS and assess its independent predictors. METHODS The study population consisted of 100 patients of severe RMS in SR. Transthoracic and transesophageal echocardiography were done to assess LAA contractile function. Patients with LAA-peak emptying velocity < 25 cm/seconds were defined as having LAAI. RESULTS The mean age of study subjects was 31.66±8.69 years and 56% were females. 73% patients had LAAI (Group A), while remaining 27% had normal LAA function (Group B). Mitral-valve area (MVA) and lateral annulus systolic velocity (Sa-wave) were significantly lower while mitral valve mean gradient (MVMG) and serum fibrinogen were significantly higher (all p-values < 0.001) in group A patients. On multivariate binary logistic regression analysis, MVMG (p < 0.001), Sa-wave (p = 0.02), and serum fibrinogen (p = 0.005) were independent predictors of LAAI. Optimal cut-off values of MVMG, Sa-wave and serum fibrinogen for predicting LAAI were 11.5 mm Hg, 6.8 cm/seconds and 300 mg/dl, respectively. Sixty-Seven (90.55%) patients in group A compared to 13(48.1%) in group B had LA/LAA smoke. LAAI was the only independent predictor of left atrium (LA)/LAA smoke with or without associated thrombus. CONCLUSION There is high prevalence of LAAI in patients of severe MS in SR. MVMG, Sa-wave, and serum fibrinogen levels are independent predictors of LAAI. LAAI is an independent predictor of LA/LAA smoke with or without associated thrombus.
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Affiliation(s)
- Saibal Mukhopadhyay
- Department of Cardiology, G.B. Pant Postgraduate Institute of Medical Research (GIPMER), New Delhi, India
| | - Yogesh Dwivedi
- Department of Cardiology, G.B. Pant Postgraduate Institute of Medical Research (GIPMER), New Delhi, India
| | - Jamal Yusuf
- Department of Cardiology, G.B. Pant Postgraduate Institute of Medical Research (GIPMER), New Delhi, India
| | - Abhimanyu Uppal
- Department of Cardiology, G.B. Pant Postgraduate Institute of Medical Research (GIPMER), New Delhi, India
| | - Vimal Mehta
- Department of Cardiology, G.B. Pant Postgraduate Institute of Medical Research (GIPMER), New Delhi, India
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Cohen A, Donal E, Delgado V, Pepi M, Tsang T, Gerber B, Soulat-Dufour L, Habib G, Lancellotti P, Evangelista A, Cujec B, Fine N, Andrade MJ, Sprynger M, Dweck M, Edvardsen T, Popescu BA. EACVI recommendations on cardiovascular imaging for the detection of embolic sources: endorsed by the Canadian Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2021; 22:e24-e57. [PMID: 33709114 DOI: 10.1093/ehjci/jeab008] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/07/2021] [Indexed: 12/28/2022] Open
Abstract
Cardioaortic embolism to the brain accounts for approximately 15-30% of ischaemic strokes and is often referred to as 'cardioembolic stroke'. One-quarter of patients have more than one cardiac source of embolism and 15% have significant cerebrovascular atherosclerosis. After a careful work-up, up to 30% of ischaemic strokes remain 'cryptogenic', recently redefined as 'embolic strokes of undetermined source'. The diagnosis of cardioembolic stroke remains difficult because a potential cardiac source of embolism does not establish the stroke mechanism. The role of cardiac imaging-transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac computed tomography (CT), and magnetic resonance imaging (MRI)-in the diagnosis of potential cardiac sources of embolism, and for therapeutic guidance, is reviewed in these recommendations. Contrast TTE/TOE is highly accurate for detecting left atrial appendage thrombosis in patients with atrial fibrillation, valvular and prosthesis vegetations and thrombosis, aortic arch atheroma, patent foramen ovale, atrial septal defect, and intracardiac tumours. Both CT and MRI are highly accurate for detecting cavity thrombosis, intracardiac tumours, and valvular prosthesis thrombosis. Thus, CT and cardiac magnetic resonance should be considered in addition to TTE and TOE in the detection of a cardiac source of embolism. We propose a diagnostic algorithm where vascular imaging and contrast TTE/TOE are considered the first-line tool in the search for a cardiac source of embolism. CT and MRI are considered as alternative and complementary tools, and their indications are described on a case-by-case approach.
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Affiliation(s)
- Ariel Cohen
- Assistance Publique-Hôpitaux de Paris, Saint-Antoine and Tenon Hospitals, Department of Cardiology, and Sorbonne University, Paris, France.,INSERM unit UMRS-ICAN 1166; Sorbonne-Université, Paris, France
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Mauro Pepi
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20141, Milan, Italy
| | - Teresa Tsang
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bernhard Gerber
- Service de Cardiologie, Département Cardiovasculaire, Cliniques Universitaires St. Luc, Division CARD, Institut de Recherche Expérimental et Clinique (IREC), UCLouvainAv Hippocrate 10/2803, B-1200 Brussels, Belgium
| | - Laurie Soulat-Dufour
- Assistance Publique-Hôpitaux de Paris, Saint-Antoine and Tenon Hospitals, Department of Cardiology, and Sorbonne University, Paris, France.,INSERM unit UMRS-ICAN 1166; Sorbonne-Université, Paris, France
| | - Gilbert Habib
- Aix Marseille Univ, IRD, MEPHI, IHU-Méditerranée Infection, APHM, La Timone Hospital, Cardiology Department, Marseille, France
| | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, CHU SartTilman, Liège, Belgium.,Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy
| | - Arturo Evangelista
- Servei de Cardiologia. Hospital Universitari Vall d'Hebron-VHIR. CIBER-CV. Pº Vall d'Hebron 119. 08035. Barcelona. Spain
| | - Bibiana Cujec
- Division of Cardiology, University of Alberta, 2C2.50 Walter Mackenzie Health Sciences Center, 8440 112 St NW, Edmonton, Alberta, Canada T6G 2B7
| | - Nowell Fine
- University of Calgary, Libin Cardiovascular Institute, South Health Campus, 4448 Front Street Southeast, Calgary, Alberta T3M 1M4, Canada
| | - Maria Joao Andrade
- Maria Joao Andrade Cardiology Department, Hospital de Santa Cruz-Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos 2790-134 Carnaxide, Portugal
| | - Muriel Sprynger
- Department of Cardiology-Angiology, University Hospital Liège, Liège, Belgium
| | - Marc Dweck
- British Heart Foundation, Centre for Cardiovascular Science, Edinburgh and Edinburgh Imaging Facility QMRI, University of Edinburgh, United Kingdom
| | - Thor Edvardsen
- Faculty of medicine, Oslo University, Oslo, Norway and Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Bogdan A Popescu
- Cardiology Department, University of Medicine and Pharmacy 'Carol Davila', Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C. C. Iliescu', Sos. Fundeni 258, sector 2, 022328 Bucharest, Romania
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Babur Guler G, Dogan AC, Kalkan AK, Demir AR, Uygur B, Birant A, Zencirkiran Agus H, Pastore MC, Memiç K, Uzun F, Cameli M, Erturk M. Does patent foramen ovale presence procure favourable outcomes in patients with severe rheumatic mitral stenosis? Int J Cardiovasc Imaging 2021; 37:2871-2879. [PMID: 34109513 DOI: 10.1007/s10554-021-02257-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 04/26/2021] [Indexed: 11/29/2022]
Abstract
Mitral stenosis (MS) is tolerated for an extended period in patients with atrial septal defect (ASD) known as Lutembacher syndrome due to depressurizing effect. In a similar way, patients with patent foramen ovale (PFO) may have clinical benefits in severe MS. We aim to evaluate the clinical effects of PFO in rheumatic MS. Transthoracic and transesophageal echocardiography records of the patients with symptomatic severe MS were screened for the period between 2008 and 2019 in a single center. 320 symptomatic patients with severe MS were included and presence of PFO recorded. Left atrial appendix (LAA) thrombotic status was defined as clear, spontaneous echo contrast, and thrombus. Two different statistical models were used to determine the predictors of either smallest (mitral valve area) MVA at symptomatic presentation or more thrombogenic LAA. 34 patients had PFO. Multivariable ordinary least square model demonstrated that increase in systolic pulmonary arterial pressure, ejection fraction and presence of PFO were associated with smaller MVA on presentation. Multivariable proportional odds logistic regression model demonstrated that advanced age, increased left atrial diameter, absence of PFO were associated with more thrombotic status whereas larger MVA was associated with decreased thrombotic status in LAA. Presence of PFO in severe MS results in two clinical benefits as (i) being asymptomatic with smaller MVA and (ii) having less LAA thrombosis probably caused by depressurizing effect on the left atrial pressure. Our study could serve as an example for patient groups with expected symptomatic benefits from left atrium pressure offloading interventions.
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Affiliation(s)
- Gamze Babur Guler
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey.
| | - Arda Can Dogan
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey
| | - Ali Kemal Kalkan
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey
| | - Ali Rıza Demir
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey
| | - Begum Uygur
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey
| | - Ali Birant
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey
| | - Hicaz Zencirkiran Agus
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey
| | - Maria Concetta Pastore
- Department of Medical Biotecnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Kadriye Memiç
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey
| | - Fatih Uzun
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey
| | - Matteo Cameli
- Department of Medical Biotecnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Mehmet Erturk
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey
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Advances in Rheumatic Mitral Stenosis: Echocardiographic, Pathophysiologic, and Hemodynamic Considerations. J Am Soc Echocardiogr 2021; 34:709-722.e1. [PMID: 33652082 DOI: 10.1016/j.echo.2021.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/21/2021] [Accepted: 02/22/2021] [Indexed: 11/23/2022]
Abstract
Echocardiography is the primary imaging modality used in patients with mitral stenosis. Doppler-derived measurements of mitral pressure half-time are commonly used to calculate mitral valve area, but a number of hemodynamic confounders associated with advanced age limit its utility. Planimetry remains the gold standard for determining mitral valve area and may be performed using two- or three-dimensional imaging. Although the Wilkins score has been used for >30 years to predict balloon mitral valvuloplasty outcomes, newer scoring systems have been proposed to improve predictive accuracy. Some patients undergoing technically successful balloon mitral valvuloplasty may not have satisfactory clinical outcomes. These individuals may be identified by the presence of reduced net atrioventricular compliance, which can be measured echocardiographically. Exercise testing may be useful in patients with mitral stenosis whose symptomatic status is incongruous their mitral valve area. Last, reduced left atrial systolic strain, an indicator of poor left atrial compliance, has been shown to reliably predict adverse outcomes in patients with mitral stenosis. The author discusses the hemodynamics and path ophysiology of mitral stenosis and reviews current and emerging roles of echocardiography in its evaluation.
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H Ozcan Cetin E, S Cetin M, B Ozbay M, C Könte H, M Yaman N, A Erdöl M, Ozcan F, Cay S, Ozeke O, Akçay B, Tufekcioğlu O, Aras D, Topaloglu S. Whole blood viscosity in the evaluation of thrombogenic milieu in mitral stenosis. Biomark Med 2021; 15:181-190. [PMID: 33470829 DOI: 10.2217/bmm-2020-0329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 12/11/2020] [Indexed: 11/21/2022] Open
Abstract
Aim: We aimed to assess the association of whole blood with thromboembolic milieu in significant mitral stenosis patients. Methodology & results: We included 122 patients and classified patients into two groups as having thrombogenic milieu, thrombogenic milieu (+), otherwise patients without thrombogenic milieu, thrombogenic milieu (-). Whole blood viscosity (WBV) in both shear rates were higher in thrombogenic milieu (+) group comparing with thrombogenic milieu (-). WBV at high shear rate and WBV at low shear rate parameters were moderately correlated with grade of spontaneous echo contrast. Adjusted with other parameters, WBV parameters at both shear rates were associated with presence of thrombogenic milieu. Discussion & conclusion: We found that extrapolated WBV at both shear rates was significantly associated with the thrombogenic milieu in mitral stenosis. This easily available parameter may provide additional perspective about thrombogenic diathesis.
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Affiliation(s)
| | - Mehmet S Cetin
- Etimesgut State Hospital, Cardiology Clinic, Ankara, Turkey
| | | | - Hasan C Könte
- Ankara City Hospital, Cardiology Department, Ankara, Turkey
| | | | - Mehmet A Erdöl
- Ankara City Hospital, Cardiology Department, Ankara, Turkey
| | - Fırat Ozcan
- Ankara City Hospital, Cardiology Department, Ankara, Turkey
| | - Serkan Cay
- Ankara City Hospital, Cardiology Department, Ankara, Turkey
| | - Ozcan Ozeke
- Ankara City Hospital, Cardiology Department, Ankara, Turkey
| | - Burak Akçay
- Ankara City Hospital, Cardiology Department, Ankara, Turkey
| | | | - Dursun Aras
- Ankara City Hospital, Cardiology Department, Ankara, Turkey
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Meta-Analysis of the Incidence, Prevalence, and Correlates of Atrial Fibrillation in Rheumatic Heart Disease. Glob Heart 2020; 15:38. [PMID: 32923332 PMCID: PMC7427678 DOI: 10.5334/gh.807] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective: To estimate the incidence, prevalence, and correlates of atrial fibrillation (AF) in a global population with rheumatic heart disease (RHD). Methods: Bibliographic databases were searched to identify all published studies providing data on AF in patients with RHD. Random-effects meta-analysis method was used to pool estimates. Results: Eighty-three studies were included, reporting data from 75,637 participants with RHD in 42 countries. The global prevalence of AF in RHD was 32.8% (range: 4.3%–79.9%). It was higher in severe valvular disease (30.8% vs 20.7%, p = 0.009), in severe mitral valve disease compared to severe aortic disease (30.4% vs 6.3%, p = 0.038). The global cumulative incidence of AF in patients with RHD was 4.8%, 11.4%, 13.2%, and 30.8% at 1, 2, 5, and 10 years of follow-up, respectively. From comparison between patients with and without AF, AF was associated with increased age (mean difference [MD]: 9.5 years; 95% CI: 7.8–1.3), advanced heart failure (odds ratio [OR]: 4.4; 95% CI 2.1–9.3), tricuspid valve involvement (OR: 4.0; 95% CI: 3.0–5.3), history of thromboembolism (OR: 6.2; 95% CI: 3.4–11.4), highly sensitive C-reactive protein (MD: 5.5 mg/dL; 95% CI: 1.2–9.8), systolic pulmonary arterial pressure (MD: 3.6 mmHg; 95% CI: 0.8–6.3), right atrium pressure (MD: 1.5 mmHg; 95% CI: 1.0–2.0), and left atrium diameter (MD: 8.1 mm; 95% CI: 5.5–10.7). Conclusions: About one-third of patients with RHD have AF, with an incidence which almost triples every five years after diagnosis. Factors associated with AF include age, advanced heart failure, thromboembolism, and few cardiac hemodynamics parameters.
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Ahmed K, Rehman Memon A, Liaquat H, Mujtaba M, Parkash C, Sultan FAT, Karim M. The Frequency of Left Atrial Thrombus on Transthoracic Echocardiogram in Patients with Mitral Stenosis. Cureus 2020; 12:e7453. [PMID: 32351832 PMCID: PMC7188021 DOI: 10.7759/cureus.7453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Patients with mitral stenosis (MS) are more prone to develop left atrial (LA) thrombus. This cross-sectional study was conducted to determine the frequency of LA thrombus on transthoracic echocardiography (TTE) in patients with MS. Methods In this study, we included patients diagnosed with MS undergoing TTE at the echocardiography department of the National Institute of Cardiovascular Disease (NICVD), Karachi, Pakistan. The severity of MS was classified based on the mitral valve area (MVA) as follows: very severe: MVA of ≤1.0 cm2; severe: MVA of ≤1.5 cm2; and mild to moderate: MVA of >1.5 cm2. The LA thrombus was observed and noted on TTE. Results A total of 256 MS patients were included in this study, out of which 46.5% (119) were male. The mean age was 33.78 ±11.51 years. MS was classified as mild to moderate in 3.5% of the patients, severe in 54.3%, and very severe in 42.2%. In 98.8% of the patients, the etiology of MS was rheumatic. LA thrombus was observed in 25% (64) of the patients and LA smoke was observed in 12.1% (31). Among other findings, mitral regurgitation (MR) was observed in 17.2% of the patients, aortic regurgitation (AR) in 5.1%, aortic stenosis (AS) in 4.7%, and tricuspid regurgitation (TR) in 48.8%. Five (2%) patients had atrial septal defect (ASD), 17.3% had left ventricular (LV) dysfunction, 15.2% had right ventricular (RV) dysfunction, and vegetation was seen in 11.8% of the patients. Patients with LA thrombus were found to be associated with the following conditions on a higher scale compared to those without: decreased ejection fraction (EF) (52 ±8.5% vs. 54.94 ±6.6%; p: 0.011); RV dysfunction (39.1% vs. 7.3%; p: <0.001); and presence of associated pathologies (82.8% vs. 43.8%; p: <0.001). Conclusion LA thrombus on TTE was detected in a significant number (25%) of patients with MS. It was also found to be strongly associated with the severity of the disease, reduced EF, RV dysfunction, and the presence of associated value pathologies.
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Affiliation(s)
- Khalil Ahmed
- Cardiology, National Institute of Cardiovascular Diseases (NICVD), Karachi, PAK
| | - Aziz Rehman Memon
- Critical Care Medicine, National Institute of Cardiovascular Diseases (NICVD), Karachi, PAK
| | - Hussain Liaquat
- Cardiology, National Institute of Cardiovascular Diseases (NICVD), Karachi, PAK
| | - Mustajab Mujtaba
- Cardiology, National Institute of Cardiovascular Diseases (NICVD), Karachi, PAK
| | - Chander Parkash
- Cardiology, National Institute of Cardiovascular Diseases (NICVD), Karachi, PAK
| | | | - Musa Karim
- Statistics, National Institute of Cardiovascular Diseases (NICVD), Karachi, PAK
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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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Sahin O, Savas G. Relationship between presence of spontaneous echo contrast and platelet-to-lymphocyte ratio in patients with mitral stenosis. Echocardiography 2019; 36:924-929. [PMID: 31002186 DOI: 10.1111/echo.14338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 03/12/2019] [Accepted: 03/20/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Left atrial spontaneous echo contrast (SEC) is an existence of smoke-like echoes with a typical swirling motion of blood in left atrial cavity or appendage, and it is known to be a marker of prothrombotic state. Previous studies have revealed that there is an association between prothrombotic state and the platelet-to-lymphocyte ratio (PLR). Thus, we aimed to investigate the association between the presence of SEC and PLR in patients with mitral stenosis (MS). METHODS A total of 306 consecutive patients with MS were enrolled in the study. Transoesophageal echocardiography was made to assess the SEC for all patients. Recruited patients were divided into two groups according to the formation of SEC in the left atrium. Complete blood counting parameters, biochemical tests and high-sensitive C-reactive protein (Hs-CRP) levels were measured. RESULTS There were 182 patients (mean age 42.7 ± 11.9 and 78% female) in the SEC (-) group, and 124 patients (mean age 45.3 ± 10.5 and 68% female) in the SEC (+) group. Hs-CRP levels (3.9 ± 1.9 vs 5.1 ± 3.6, P < 0.001) were significantly different between the two groups. PLR (143.4 ± 77.7 vs 180.6 ± 108.7, P < 0.001) was significantly higher in the SEC (+) group. ROC curve analysis, PRL ≥123 had 71% sensitivity and 52% specificity in predicting SEC in patients with MS. CONCLUSION Platelet-to-lymphocyte ratio is an inexpensive and easily calculated biomarker, which is useful to predict left atrial SEC in patients with mitral stenosis.
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Affiliation(s)
- Omer Sahin
- Department of Cardiology, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Goktug Savas
- Department of Cardiology, Siyami Ersek Thoracic and Cardiovascular Surgery Center Training and Research Hospital, Istanbul, Turkey
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12
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Pradhan A, Vankar SG, Vishwakarma P, Sethi R. A ping-pong ball in left atrium. BMJ Case Rep 2018; 2018:bcr-2017-221983. [PMID: 29348278 DOI: 10.1136/bcr-2017-221983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Akshyaya Pradhan
- Department of Cardiology, Chatrapati Shahu Maharaj Medical University, Lucknow, Uttar Pradesh, India
| | - Sameer Ganpat Vankar
- Department of Cardiology, Chatrapati Shahu Maharaj Medical University, Lucknow, Uttar Pradesh, India
| | - Pravesh Vishwakarma
- Department of Cardiology, Chatrapati Shahu Maharaj Medical University, Lucknow, Uttar Pradesh, India
| | - Rishi Sethi
- Department of Cardiology, Chatrapati Shahu Maharaj Medical University, Lucknow, Uttar Pradesh, India
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Arava TN, Durgaprasad R, Velam V, Gajjala OR, Neelam VK, Manohar SN. Spontaneous left atrial echo contrast, mitral annular systolic velocity, and left atrial appendage late emptying velocity in predicting improvement of left atrial function after percutaneous balloon mitral valvuloplasty. Echocardiography 2017; 35:162-169. [PMID: 29178504 DOI: 10.1111/echo.13759] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Thromboembolic events are the major cause of morbidity and mortality in patients with mitral stenosis (MS). This study aims to investigate left atrial spontaneous echo contrast (LA SEC), mitral annular systolic velocity (Sa-wave), left atrial appendage (LAA) late emptying velocity (LAAEV), LAA filling velocity (LAAFV) pre- and postpercutaneous balloon mitral valvuloplasty (PBMV) for MS. This also aims to study the association of LA SEC with inflammatory marker, high-sensitivity C-reactive protein (hs-CRP) in MS. METHODS The study population consisted of 100 patients with symptomatic MS with sinus rhythm who underwent PBMV. Transthoracic echo (TTE), tissue Doppler imaging (TDI), and transesophageal echo (TEE) examinations were carried out before and 14 days following PBMV. High-sensitivity C-reactive protein (hs-CRP) was measured at the time of admission. RESULTS The mean age was 33.2 ± 10.3 years with female preponderance (71%). There was a decrease in SEC grading, (pre-PBMV 2.8 ± 0.9 and post-PBMV 0.4 ± 0.1; P < .01), increase in LAAEV (pre-PBMV 23.0 ± 7.9 cm/s and post-PBMV 40.9 ± 8.4 cm/s; P < .01), and LAAFV (pre-PBMV 31.8 ± 9.3 cm/s and post-PBMV 51.2 ± 8.7 cm/s; P < .01).A significant positive correlation was present between LAAEV and Sa-wave (r = .52, P < .01). Correlation between hs-CRP and SEC was positive and significant (r = .33, P < .01). Optimal cutoff value of hs-CRP for prediction of moderate to dense SEC was >2.3 mg/dL, the cutoff value of Sa-wave was≤ 5.5 cm/s for prediction of the presence of inactive LAA (LAAEV < 25 cm/s). CONCLUSION Mitral annular systolic velocity (Sa-wave) is an independent predictor of inactive LAA and a useful parameter in estimating inactive LAA in MS. Sa-wave and hs-CRP are independent predictors for SEC. PBMV improves LAA function in patients with MS.
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Affiliation(s)
- Tirumala Naresh Arava
- Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
| | - Rajasekhar Durgaprasad
- Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
| | - Vanajakshamma Velam
- Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
| | - Obul Reddy Gajjala
- Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
| | - Vinod K Neelam
- Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
| | - Suchitra N Manohar
- Department of Biochemistry, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
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Abstract
Significant advances in our understanding of transient ischemic attack (TIA) have taken place since it was first recognized as a major risk factor for stroke during the late 1950's. Recently, numerous studies have consistently shown that patients who have experienced a TIA constitute a heterogeneous population, with multiple causative factors as well as an average 5–10% risk of suffering a stroke during the 30 days that follow the index event. These two attributes have driven the most important changes in the management of TIA patients over the last decade, with particular attention paid to effective stroke risk stratification, efficient and comprehensive diagnostic assessment, and a sound therapeutic approach, destined to reduce the risk of subsequent ischemic stroke. This review is an outline of these changes, including a discussion of their advantages and disadvantages, and references to how new trends are likely to influence the future care of these patients.
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Affiliation(s)
- Camilo R Gomez
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
| | - Michael J Schneck
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
| | - Jose Biller
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
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Relationship between spontaneous echo contrast and hematological markers in patients with rheumatic mitral stenosis. INTERNATIONAL JOURNAL OF THE CARDIOVASCULAR ACADEMY 2016. [DOI: 10.1016/j.ijcac.2016.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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The association between mean platelet volume and spontaneous echocardiographic contrast or left atrial thrombus in patients with mitral stenosis. Anatol J Cardiol 2016; 16:863-867. [PMID: 27147399 PMCID: PMC5324889 DOI: 10.14744/anatoljcardiol.2015.6675] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective: Although the role of platelet activation has been debated in patients with mitral stenosis (MS) and spontaneous echocardiographic contrast (SEC), data on differences in mean platelet volume (MPV) according to the presence of SEC/left atrial thrombus and the rhythm status are lacking. In this study, MPV was analyzed in patients with MS according to the presence of SEC/left atrial thrombus. Methods: Between January 2005 and March 2014, 188 symptomatic patients having moderate or severe MS (mean age, 45.0±11.7 years; female, 81.4%) with favorable valve morphology for percutaneous mitral balloon valvuloplasty (PMBV) and underwent a transesophageal echocardiogram to assess the eligibility for PMBV were retrospectively enrolled in the study. The relation between MPV and echocardiographic thromboembolic risk factors were evaluated. Independent predictors of SEC/left atrial thrombus presence were determined by multiple logistic regression analyses. Results: Among all patients, MPV did not differ according to the rhythm status or the presence of SEC/left atrial thrombus (p>0.05). Also, MPV did not vary according to the gender and presence of prior stroke in both atrial fibrillation and sinus rhythm groups (p>0.05). In correlation analysis, MPV did not show any significant correlation with the echocardiographic thrombus predictors (p>0.05). Conclusion: Using MPV with echocardiographic and clinical thrombus risk determinants for predicting individual thromboembolism risk in MS is debatable according to our results.
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Association of the CHA2DS2-VASc score with left atrial spontaneous echo contrast: a cross-sectional study of patients with rheumatic mitral stenosis in sinus rhythm. Heart Vessels 2015; 31:1537-43. [DOI: 10.1007/s00380-015-0759-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 10/02/2015] [Indexed: 10/22/2022]
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Kurakula N, Durgaprasad R, Velam V, Akula VS, Kasala L, Muvva KV. Predictive Value of D-Dimer Levels and Tissue Doppler Mitral Annular Systolic Velocity for Detection of Left Atrial Appendage Thrombus in Patients with Mitral Stenosis in Sinus Rhythm. Echocardiography 2015; 33:264-75. [PMID: 26239565 DOI: 10.1111/echo.13026] [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: 11/30/2022] Open
Abstract
BACKGROUND Transesophageal echocardiogram (TEE) is a gold standard test for diagnosis of left atrial (LA) thrombus, but it has limited sensitivity for identification of small thrombi within side lobes. Thus, the absence of visualizing a left atrial appendage (LAA) thrombus does not equate with the absence of a LAA thrombus. AIM To assess the predictive value of mitral annular systolic velocity (Sa) and D-dimer for the detection of LA thrombus and spontaneous echocardiographic contrast (SEC) in mitral stenosis (MS) patients with sinus rhythm (SR). METHODS Transthoracic echocardiogram, TEE, and D-dimer analysis were performed in 104 severe MS patients and divided them into three groups: Group I:no LA thrombus or SEC; Group II:LA SEC only; and Group III:LA thrombus. RESULTS Group III had more severe New York Heart Association (NYHA) class (III-IV) dyspnea and lower Sa (6.9 ± 0.7 vs.10.0 ± 1.2 cm/sec), lower LAA late emptying velocity (17.7 ± 2.1 vs. 24.4 ± 4.2 cm/sec), larger LA transverse dimension, and LAA area (LAAA) than group I+II. Mean D-dimer levels were higher in groups III and II than in group I. In multivariate analysis Sa, D-dimer levels, LAAA, and NYHA class were independent predictors of LA thrombus. ROC curve analysis revealed that higher Sa >8 cm/sec and lower D-dimer levels <370 μg/L predict the absence of LA thrombus and lower Sa <8 cm/sec and higher D-dimer levels >510 μg/L predict the presence of LA thrombus. CONCLUSION Measurement of Sa and D-dimer levels is necessary for better assessment of LA thrombus and SEC, for identification of patients who are at high risk for LA thrombus formation and for initiation of prophylactic anticoagulation.
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Affiliation(s)
- Naresh Kurakula
- Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
| | - Rajasekhar Durgaprasad
- Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
| | - Vanajakshamma Velam
- Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
| | - Vidya Sagar Akula
- Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
| | - Latheef Kasala
- Department of Cardiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, India
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Karthikeyan G, Ananthakrishnan R, Devasenapathy N, Narang R, Yadav R, Seth S, Singh S, Goswami KC, Bahl VK. Transient, subclinical atrial fibrillation and risk of systemic embolism in patients with rheumatic mitral stenosis in sinus rhythm. Am J Cardiol 2014; 114:869-74. [PMID: 25086468 DOI: 10.1016/j.amjcard.2014.06.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 06/10/2014] [Accepted: 06/10/2014] [Indexed: 10/25/2022]
Abstract
Stroke and systemic embolism occur frequently in patients with rheumatic mitral stenosis (MS) in sinus rhythm (SR), but the risk and predictors of embolic events in this population are not well studied. The aim of this study was to determine if transient, subclinical atrial fibrillation (AF) increases the risk of systemic embolism in patients with MS in SR. A single-center, prospective observational study of patients with rheumatic MS in SR was performed. The rate of the composite primary outcome of stroke, transient ischemic attack, or non-central nervous system embolism was determined, as well as the predictive value of Holter-detected episodes of transient (<30 seconds), subclinical AF for this outcome. Hazard ratios were derived for subclinical AF, after adjustment for clinical and echocardiographic predictors of systemic embolism, using Cox regression. The sensitivity, specificity, and area under the receiver-operating characteristic curve of subclinical AF were determined for the primary outcome. Among 179 patients (mean follow-up 10.2 months), the rate of the primary outcome was 5.3/100 patient-years (95% confidence interval [CI] 2.6 to 10.5). In univariate analysis, subclinical AF (hazard ratio 4.54, 95% CI 1.08 to 19.0, p = 0.038) and dense spontaneous echocardiographic contrast (hazard ratio 4.32, 95% CI 1.03 to 18.09, p = 0.045) were predictors of the primary outcome. In multivariate analysis, subclinical AF remained the only significant predictor (hazard ratio 5.02, 95% CI 1.15 to 22.0, p = 0.032). Subclinical AF had an area under the receiver-operating characteristic curve of 0.68 and high negative predictive value (97.7%) for the primary outcome. In conclusion, Holter-detected, transient (<30 seconds), subclinical AF is a predictor of stroke and systemic embolism in patients with rheumatic MS in SR. Considering the high risk for embolism, randomized trials of oral anticoagulation are needed in this population.
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20
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Drissi S, Sabor H, Ounsy A, Mouine N, Sabry M, Benyass A, Zbir EM, Lassana K, Elhaithem N. Predictive factors of left atrial spontaneous echo contrast in patients with rheumatic mitral valve stenosis: a retrospective study of 159 patients. Int Arch Med 2014; 7:32. [PMID: 24995039 PMCID: PMC4081018 DOI: 10.1186/1755-7682-7-32] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 06/20/2014] [Indexed: 11/10/2022] Open
Abstract
Background Mitral valve stenosis is a common manifestation of chronic rheumatic heart disease. The presence of spontaneous echo contrast in the left atrium and left atrial appendage has been reported to be an independent predictor of thrombo-embolic risk in patients with mitral stenosis. The objective of this study was to retrospectively investigate various clinical and echocardiographic variables to predict the spontaneous echo contrast in these patients. Methodology This is a bicentric retrospective study which includes 159 cases of symptomatic mitral stenosis from January 2011 to June 2012. All of the patients had transthoracic and transesophageal echocardiography. Patients who had significant mitral regurgitation (> Grade I), significant aortic valve disease, previous mitral valvulotomy and anticoagulation or antiplatelet therapy were excluded from the study. Our study population was divided into two groups based on the presence (Group I) or absence (Group II) of spontaneous echo contrast. Result Left atrial spontaneous contrast was present in 34.6% of cases. Patients in this group have more frequent atrial fibrillation (P = 0.001), larger left atrial area (P = 0.027) and diameter (P=0.023), smaller mitral valve area (P = 0.025), and higher mean transmitral diastolic gradient (p = 0.003) as compared to patients without spontaneous echo contrast. There were no significant differences in the mean age (p = 0.38), duration of symptoms (p = 0.4) and left ventricular ejection fraction (p = 0.7) between patients with and without spontaneous echo contrast. On multivariate analysis, only mitral valve area and transmitral diastolic gradient (OR: 18.753, 1.21, CI [1,838-191,332], [1,064-1,376], p: 0.013, 0.004, respectively) were found to be independently associated to the presence of spontaneous echo contrast. Conclusion Patients with severe rheumatic mitral stenosis in atrial fibrillation or sinus rhythm have a higher risk of developing spontaneous echo contrast. These patients might benefit from prophylactic anticoagulation. The long-term outcomes can be ascertained in a study over a longer period and with periodic follow-up.
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Affiliation(s)
- Sanaa Drissi
- Department of Cardiology, Mohammed V Military Teaching Hospital, Rabat, Morocco ; Department of Cardiology, Avicenne University Hospital, Rabat, Morocco
| | - Hicham Sabor
- Department of Cardiology, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - Ahlam Ounsy
- Department of Cardiology, Mohammed V Military Teaching Hospital, Rabat, Morocco ; Department of Cardiology, Avicenne University Hospital, Rabat, Morocco
| | - Najat Mouine
- Department of Cardiology, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - Mohamed Sabry
- Department of Cardiology, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - Aatif Benyass
- Department of Cardiology, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - El Mehdi Zbir
- Department of Cardiology, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - Konate Lassana
- Department of Cardiology, Avicenne University Hospital, Rabat, Morocco
| | - Naima Elhaithem
- Department of Cardiology, Avicenne University Hospital, Rabat, Morocco
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Nunes MCP, Handschumacher MD, Levine RA, Barbosa MM, Carvalho VT, Esteves WA, Zeng X, Guerrero JL, Zheng H, Tan TC, Hung J. Role of LA shape in predicting embolic cerebrovascular events in mitral stenosis: mechanistic insights from 3D echocardiography. JACC Cardiovasc Imaging 2014; 7:453-61. [PMID: 24831206 PMCID: PMC4373610 DOI: 10.1016/j.jcmg.2014.01.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Revised: 01/09/2014] [Accepted: 01/10/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This study was designed to assess the role of left atrial (LA) shape in predicting embolic cerebrovascular events (ECE) in patients with mitral stenosis (MS). BACKGROUND Patients with rheumatic MS are at increased risk for ECE. LA remodeling in response to MS involves not only chamber dilation but also changes in the shape. We hypothesized that a more spherical LA shape may be associated with increased embolic events due to predisposition to thrombus formation or to atrial arrhythmias compared with an elliptical-shaped LA of comparable volume. METHODS A total of 212 patients with MS and 20 control subjects were enrolled. LA volume, LA emptying fraction, and cross-sectional area were measured by 3-dimensional (3D) transthoracic echocardiography. LA shape was expressed as the ratio of measured LA end-systolic volume to hypothetical sphere volume ([4/3π r(3)] where r was obtained from 3D cross-sectional area). The lower the LA shape index, the more spherical the shape. RESULTS A total of 41 patients presented with ECE at the time of enrollment or during follow-up. On multivariate analysis, LA 3D emptying fraction (adjusted odds ratio [OR]: 0.96; 95% confidence interval [CI]: 0.92 to 0.99; p = 0.028) and LA shape index (OR: 0.73; 95% CI: 0.61 to 0.87; p < 0.001) emerged as important factors associated with ECE, after adjustment for age and anticoagulation therapy. In patients in sinus rhythm, LA shape index remained associated with ECE (OR: 0.79; 95% CI: 0.67 to 0.94; p = 0.007), independent of age and LA function. An in vitro phantom atrial model demonstrated more stagnant flow profiles in spherical compared with ellipsoidal chamber. CONCLUSIONS In rheumatic MS patients, differential LA remodeling affects ECE risk. A more spherical LA shape was independently associated with an increased risk for ECE, adding incremental value in predicting events beyond that provided by age and LA function.
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Affiliation(s)
- Maria Carmo P Nunes
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil; Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark D Handschumacher
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marcia M Barbosa
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Vinicius T Carvalho
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - William A Esteves
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Xin Zeng
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - J Luis Guerrero
- Cardiovascular Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy C Tan
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Judy Hung
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Pourafkari L, Ghaffari S, Bancroft GR, Tajlil A, Nader ND. Factors associated with atrial fibrillation in rheumatic mitral stenosis. Asian Cardiovasc Thorac Ann 2014; 23:17-23. [DOI: 10.1177/0218492314530134] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background Atrial fibrillation is a complication of mitral valve stenosis that causes several adverse neurologic outcomes. Our objective was to establish a mathematical model to predict the risk of atrial fibrillation in patients with mitral stenosis. Methods Of 819 patients with mitral stenosis who were screened, 603 were enrolled in the study and grouped according to whether they were in sinus rhythm or atrial fibrillation. Demographic, echocardiographic, and hemodynamic data were recorded. Logistic regression models were constructed to identify the relative risks for each contributing factor and calculate the probability of developing atrial fibrillation. Receiver operating characteristic curves were plotted. Results Two hundred (33%) patients had atrial fibrillation; this group was older, in a higher functional class, more likely to have suffered previous thromboembolic events, and had significantly larger left atrial diameters, lower ejection fractions, and lower left atrial appendage emptying flow velocity. The factors independently associated with atrial fibrillation were left atrial strain (odds ratio = 7.53 [4.47–12.69], p < 0.001), right atrial pressure (odds ratio = 1.09 [1.02–1.17], p = 0.01), age (odds ratio = 1.14 [1.05–1.25], p = 0.002), and ejection fraction (odds ratio = 0.92 [0.87–0.97], p = 0.003). The area under the curve for the combined receiver operating characteristic for this model was 0.90 ± 0.12. Conclusion Age, right atrial pressure, ejection fraction, and left atrial strain can be used to construct a mathematical model to predict the development of atrial fibrillation in rheumatic mitral stenosis.
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Affiliation(s)
- Leili Pourafkari
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samad Ghaffari
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - George R Bancroft
- Department of Anesthesiology, University at Buffalo, Buffalo, NY, USA
| | - Arezou Tajlil
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nader D Nader
- Department of Anesthesiology, University at Buffalo, Buffalo, NY, USA
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Echocardiographic Predictors of Left Atrial Thrombus in Patients With Severe Rheumatismal Mitral Stenosis. RAZAVI INTERNATIONAL JOURNAL OF MEDICINE 2014. [DOI: 10.5812/rijm.15602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Cruz-Flores S. Neurologic complications of valvular heart disease. HANDBOOK OF CLINICAL NEUROLOGY 2014; 119:61-73. [PMID: 24365289 DOI: 10.1016/b978-0-7020-4086-3.00006-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Valvular heart disease (VHD) is frequently associated with neurologic complications; cerebral embolism is the most common of these since thrombus formation results from the abnormalities in the valvular surfaces or from the anatomic and physiologic changes associated with valve dysfunction, such as atrial or ventricular enlargement, intracardiac thrombi, and cardiac dysrhythmias. Prosthetic heart valves, particularly mechanical valves, are very thrombogenic, which explains the high risk of thromboembolism and the need for anticoagulation for the prevention of embolism. Infective endocarditis is a disease process with protean manifestations that include not only cerebral embolism but also intracranial hemorrhage, mycotic aneurysms, and systemic manifestations such as fever and encephalopathy. Other neurologic complications include nonbacterial thrombotic endocarditis, a process associated with systemic diseases such as cancer and systemic lupus erythematosus. For many of these conditions, anticoagulation is the mainstay of treatment to prevent cerebral embolism, therefore it is the potential complications of anticoagulation that can explain other neurologic complications in patients with VHD. The prevention and management of these complications requires an understanding of their natural history in order to balance the risks posed by valvular disease itself against the risks and benefits associated with treatment.
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Affiliation(s)
- Salvador Cruz-Flores
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA.
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Choi BH, Ko SM, Hwang HK, Song MG, Shin JK, Kang WS, Kim TY. Detection of left atrial thrombus in patients with mitral stenosis and atrial fibrillation: retrospective comparison of two-phase computed tomography, transoesophageal echocardiography and surgical findings. Eur Radiol 2013; 23:2944-53. [DOI: 10.1007/s00330-013-2944-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 05/28/2013] [Accepted: 05/29/2013] [Indexed: 10/26/2022]
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Whitlock RP, Sun JC, Fremes SE, Rubens FD, Teoh KH. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e576S-e600S. [PMID: 22315272 PMCID: PMC3278057 DOI: 10.1378/chest.11-2305] [Citation(s) in RCA: 428] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2011] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Antithrombotic therapy in valvular disease is important to mitigate thromboembolism, but the hemorrhagic risk imposed must be considered. METHODS The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. RESULTS In rheumatic mitral disease, we recommend vitamin K antagonist (VKA) therapy when the left atrial diameter is > 55 mm (Grade 2C) or when complicated by left atrial thrombus (Grade 1A). In candidates for percutaneous mitral valvotomy with left atrial thrombus, we recommend VKA therapy until thrombus resolution, and we recommend abandoning valvotomy if the thrombus fails to resolve (Grade 1A). In patients with patent foramen ovale (PFO) and stroke or transient ischemic attack, we recommend initial aspirin therapy (Grade 1B) and suggest substitution of VKA if recurrence (Grade 2C). In patients with cryptogenic stroke and DVT and a PFO, we recommend VKA therapy for 3 months (Grade 1B) and consideration of PFO closure (Grade 2C). We recommend against the use of anticoagulant (Grade 1C) and antiplatelet therapy (Grade 1B) for native valve endocarditis. We suggest holding VKA therapy until the patient is stabilized without neurologic complications for infective endocarditis of a prosthetic valve (Grade 2C). In the first 3 months after bioprosthetic valve implantation, we recommend aspirin for aortic valves (Grade 2C), the addition of clopidogrel to aspirin if the aortic valve is transcatheter (Grade 2C), and VKA therapy with a target international normalized ratio (INR) of 2.5 for mitral valves (Grade 2C). After 3 months, we suggest aspirin therapy (Grade 2C). We recommend early bridging of mechanical valve patients to VKA therapy with unfractionated heparin (DVT dosing) or low-molecular-weight heparin (Grade 2C). We recommend long-term VKA therapy for all mechanical valves (Grade 1B): target INR 2.5 for aortic (Grade 1B) and 3.0 for mitral or double valve (Grade 2C). In patients with mechanical valves at low bleeding risk, we suggest the addition of low-dose aspirin (50-100 mg/d) (Grade 1B). In valve repair patients, we suggest aspirin therapy (Grade 2C). In patients with thrombosed prosthetic valve, we recommend fibrinolysis for right-sided valves and left-sided valves with thrombus area < 0.8 cm(2) (Grade 2C). For patients with left-sided prosthetic valve thrombosis and thrombus area ≥ 0.8 cm(2), we recommend early surgery (Grade 2C). CONCLUSIONS These antithrombotic guidelines provide recommendations based on the optimal balance of thrombotic and hemorrhagic risk.
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Affiliation(s)
| | - Jack C Sun
- University of Washington School of Medicine, Seattle, WA
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Arokiaraj MC, Pislaru C, Vellayappan S, Subramanian S, Varghese K, Patil CB, Shetty GG, George C, Gupta V, Iyengar SS. Left Ventricular Lateral Annulus and Left Atrial Free-Wall Velocity Time Integral Indicate Thromboembolism in Patients with Rheumatic Atrial Fibrillation. Echocardiography 2010; 27:1038-48. [DOI: 10.1111/j.1540-8175.2010.01198.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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High levels of high sensitivity C-reactive protein predict the progression of chronic rheumatic mitral stenosis. J Thromb Thrombolysis 2008; 28:63-9. [PMID: 18622582 DOI: 10.1007/s11239-008-0245-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2008] [Accepted: 06/23/2008] [Indexed: 01/23/2023]
Abstract
BACKGROUND High sensitive C-Reactive Protein (hs-CRP) predicts morbidity and mortality in various clinical conditions. The effect of hsCRP on progression of chronic rheumatic mitral stenosis (CRMS) has not been demonstrated. METHODS AND RESULTS A total of 132 patients with CRMS (95 female, 37 male) and 145 control (100 female, 45 male) were included in the study. Baseline clinical, echocardiographic, hematologic and hs-CRP measurements were collected prospectively. Mean mitral valve area (MVA) was 1.4 +/- 0.3 cm(2), mean wilkins valve score value was 8.9 +/- 1.7, left atrial diameter was 5.0 +/- 0.7 cm, left atrial area was 37.2 +/- 12.6 cm(2), and systolic pulmonary arterial pressure (SPAP) was 44 +/- 11 mmHg in patients with CRMS. The mean levels of hs-CRP value, fibrinogen, and mean platelet volume (MPV) were significantly higher in CRMS group compared to control group. The levels of hsCRP were found to be positively correlated with mean Wilkins valve score value, SPAP, presence of atrial fibrillation (AF), left atrial diameter, left atrial area, presence of LASEC(+), fibrinogen, and MPV and inversely correlated with MVA in patients with CRMS. Linear regression analysis revealed that the hsCRP level independently affects mean Wilkins valve score value, left atrial area (LAA), LASEC(+) and AF in the patients with CRMS. CONCLUSIONS These results suggest that increased hsCRP levels are associated with CRMS severity. These association may be important when treating patients with CRMS.
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Salem DN, O'Gara PT, Madias C, Pauker SG. Valvular and Structural Heart Disease. Chest 2008; 133:593S-629S. [DOI: 10.1378/chest.08-0724] [Citation(s) in RCA: 191] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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31
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Karthikeyan G, Thachil A, Sharma S, Kalaivani M, Ramakrishnan L. Elevated high sensitivity CRP levels in patients with mitral stenosis and left atrial thrombus. Int J Cardiol 2007; 122:252-4. [PMID: 17270297 DOI: 10.1016/j.ijcard.2006.11.081] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2006] [Accepted: 11/11/2006] [Indexed: 11/28/2022]
Abstract
Stasis of blood in the left atrium (LA) due to mitral obstruction is the principal mechanism of LA thrombus formation in patients with mitral stenosis (MS). The purpose of this case-control study was to determine the additional contributions of abnormal homosysteine/folate/B12 levels, chronic inflammation and markers of a procoagulant state. We found that elevated hsCRP levels were associated with the presence of left atrial thrombus, independent of the influence of conventional parameters indicating the severity of MS and its consequences.
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Cayli M, Acartürk E, Kanadaşi M, Demir M. Annular systolic velocity predicts the presence of spontaneous echo contrast in mitral stenosis patients with sinus rhythm. Clin Cardiol 2007; 30:459-63. [PMID: 17803227 PMCID: PMC6652863 DOI: 10.1002/clc.20155] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES Thromboembolism is the major cause of morbidity and mortality in mitral stenosis (MS), even in sinus rhythm (SR). Spontaneous echo contrast (SEC) is the strongest predictor of thromboembolism. The aim of the study was to investigate if the annular velocities obtained with tissue Doppler imaging can predict the presence of SEC in MS patients with SR. METHODS One hundred and five MS patients and 100 controls were included. Annular velocities were recorded. All patients underwent transesophageal echocardiography. Subjects were divided into three groups as controls (Group I), the patients without SEC (Group II) and the patients with SEC (Group III). RESULTS Group III patients had lower ejection fraction, annular systolic velocity, smaller mitral valve area, higher transmitral gradient and larger left atrial size. The annular systolic velocity was the only independent predictor for SEC. The cutoff values of annular systolic velocity for prediction of the presence of any SEC and dense SEC were 13.5 and 11.8 cm/s, respectively. CONCLUSION The annular systolic velocity is an independent predictor for SEC in MS patients with SR.
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Affiliation(s)
- Murat Cayli
- Cukurova University, Faculty of Medicine, Department of Cardiology, Adana, Turkey.
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Ozdemir O, Alyan O, Soylu M, Topaloglu S, Aras D, Metin F, Geyik B, Ozbakir C, Demir AD. Relation between Sympathetic Overactivity and Left Atrial Spontaneous Echo Contrast in Patients with Mitral Stenosis and Sinus Rhythm. Heart Lung Circ 2006; 15:242-7. [PMID: 16860607 DOI: 10.1016/j.hlc.2006.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2005] [Accepted: 03/28/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Spontaneous echo contrast (SEC) is common in patients with mitral stenosis (MS) and presence of SEC in left atrium (LA) is associated with a higher risk of thromboembolism. Recently, an increase in activation of platelets was demonstrated in patients with SEC raising the hypothesis that platelets are involved in the pathogenesis of SEC. In this study, we evaluated effects of autonomic nervous system activity on SEC formation in patients with rheumatic MS and sinus rhythm by heart rate variability analysis. METHODS AND RESULTS Twenty-six patients with LASEC were compared with 28 patients without LASEC. Mean heart rate, low frequency (LF) and low frequency/high frequency (LF/HF) ratio were significantly higher, standard deviation of all NN (SDNN), root mean square of successive differences (RMSSD), number of NN intervals that differed by more than 50 ms from adjacent interval divided by the total number of all NN intervals (PNN50) and high frequency (HF) values were lower in the patients with LASEC. A standard deviation of all NN intervals <90ms separated the patients with LASEC from control subjects with a sensitivity of 77% and specificity of 90%; a low frequency >79.5 with a sensitivity of 92% and specificity of 90; a low frequency/high frequency ratio >3.7 with a sensitivity of 96% and specificity of 90%. A left atrial diameter >4.3 cm increased the LASEC formation by 3.0 folds, HR >78 beats/min by 6.4 folds, standard deviation of all NN intervals <90 ms by 9.2 folds, a low frequency/high frequency ratio >3.7 by 6.4 folds, sP-selectin>142 by 5.8 folds. Variables affecting sP-selectin levels were LA diameter, mitral valve area, transmitral mean gradient, left ventricular ejection fraction, the presence of mitral regurgitation, HR, standard deviation of all NN intervals, low frequency, high frequency and low frequency/high frequency ratio. CONCLUSION Sympathetic overactivity and reduced heart rate variability are important determinants for LASEC formation and increased s-P selectin levels. Therefore, platelet activation via increased sympathetic activity may play an important role in pathogenesis of LASEC.
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Affiliation(s)
- Ozcan Ozdemir
- Türkiye Yüksek Ihtisas Hospital, Cardiology Clinics, Ankara, Turkey.
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Caylý M, Kanadaşi M, Demir M, Acartürk E. Mitral Annular Systolic Velocity Reflects the Left Atrial Appendage Function in Mitral Stenosis. Echocardiography 2006; 23:546-52. [PMID: 16911327 DOI: 10.1111/j.1540-8175.2006.00260.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Left atrial appendage (LAA) dysfunction is an independent predictor of thromboembolism in mitral stenosis (MS). OBJECTIVES To investigate whether there is a relation between annular velocities obtained by tissue Doppler imaging and LAA function and to determine if the annular velocities can predict the presence of the inactive LAA in MS. METHODS Eighty-five MS patients and 80 healthy controls were evaluated by transthoracic echocardiography and all patients underwent transesophageal echocardiography. The annular systolic (S-wave) and diastolic (E- and A-waves) velocities were recorded. Inactive LAA was defined as LAA emptying velocity <25 cm/sec. Patients were divided into three groups; group I (n = 43): sinus rhythm (SR) and LAA emptying velocity > or =25 cm/sec, group II (n = 15): SR and LAA emptying velocity <25 cm/sec and group III (n = 27): atrial fibrillation. RESULTS Thrombus was detected in 12 patients and spontaneous echo contrast (SEC) was detected in 48 patients. Both S-wave and peak LAA emptying velocities were decreasing, while SEC frequency and density were increasing from group I to group III. There was a positive correlation between LAA emptying and S-wave velocities (P < 0.001, r = 0.682). Multivariate regression analysis showed that only S-wave is the independent predictor of inactive LAA (P = 0.001, odds ratio = 0.143, 95% CI = 0.047-0.434). In patients with SR, the cutoff value of S-wave was 13.5 cm/sec for the prediction of the presence of inactive LAA (sensitivity: 95.3%, specificity: 93.3%). CONCLUSIONS S-wave is an independent predictor of inactive LAA and a useful parameter in estimating inactive LAA in MS with SR.
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Affiliation(s)
- Murat Caylý
- Department of Cardiology, Cukurova University, School of Medicine, Adana, Turkey.
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Ellis K, Ziada KM, Vivekananthan D, Latif AA, Shaaraoui M, Martin D, Grimm RA. Transthoracic echocardiographic predictors of left atrial appendage thrombus. Am J Cardiol 2006; 97:421-5. [PMID: 16442409 DOI: 10.1016/j.amjcard.2005.08.065] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2005] [Revised: 08/15/2005] [Accepted: 08/15/2005] [Indexed: 12/01/2022]
Abstract
Transesophageal echocardiography (TEE) is commonly performed to detect the presence of a left atrial appendage (LAA) thrombus in the setting of an embolic event or before an anticipated electrical cardioversion for atrial fibrillation. The predictive value of transthoracic echocardiographic (TTE) findings in these patients has not been well defined. This study evaluated whether TTE findings can predict LAA thrombi using TEE as the gold standard for the identification of LAA thrombi. From November 1995 to March 2003, 10,753 patients underwent TEE to exclude LAA thrombi after embolic events or before cardioversion. Of these, 3,768 patients had complete TTE examinations performed <2 weeks before undergoing TEE. Demographics, TTE, and cardiac rhythm variables were analyzed using univariate and multivariate logistic regression to identify predictors of LAA thrombi diagnosed on subsequent TEE. LAA thrombi were identified by TEE in 199 patients (5.3%). Several TTE variables predicted LAA thrombi by TEE, including mitral stenosis, atrial fibrillation, tricuspid regurgitation, valvular prosthesis, left ventricular dysfunction, and right ventricular dysfunction. Mitral regurgitation was associated with a reduced risk for LAA thrombi (odds ratio 0.61, p = 0.003). A structurally normal heart in sinus rhythm (n = 247, 6.9%) had a 100% negative predictive value for LAA thrombi. In conclusion, several TTE variables were found to be predictive of LAA thrombi. The likelihood of LAA thrombi being found on TEE was infinitely small in the absence of these variables and the presence of sinus rhythm.
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Affiliation(s)
- Keith Ellis
- Division of Cardiology, The University of Texas Health Sciences Center, Houston, Texas, USA
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Uslu N, Nurkalem Z, Orhan AL, Aksu H, Sari I, Soylu O, Gurdogan M, Topcu K, Gorgulu S, Eren M. Transthoracic Echocardiographic Predictors of the Left Atrial Appendage Contraction Velocity in Stroke Patients with Sinus Rhythm. TOHOKU J EXP MED 2006; 208:291-8. [PMID: 16565591 DOI: 10.1620/tjem.208.291] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Systemic embolization is a potential complication in patients with thrombi situated in the left atrium and particularly, in the left atrial appendage (LAA). Reduced LAA contraction velocities, determined by the transesophageal echocardiography (TEE), are associated with increased risk of LAA spontaneous echocontrast and thrombus formation, and a history of systemic embolism. However, TEE remains a semi-invasive procedure, limiting its serial application as a screening tool. Therefore, it is desirable to obtain information regarding LAA function by transthoracic echocardiography in patients having cardioembolic stroke. The present study was designed to investigate various echocardiographic variables for patients with stroke to predict LAA dysfunction, reflected as reduced LAA contraction velocity. We studied a total of 61 patients with newly diagnosed acute embolic stroke (42 patients) and transient ischemic attack (19 patients). Computerized tomographic scanning was performed for the diagnosis of embolic stroke. Left atrial functional parameters determined by transthoracic echocardiography, such as left atrial active emptying fraction and acceleration slope of mitral inflow A wave, had significant correlations with the LAA contraction velocity (r = 0.57, p < 0.001; r = 0.54, p < 0.001, respectively). Left atrial volume index, left atrial active emptying volume and left atrial fractional shortening were also correlated with LAA contraction velocity (r = -0.44, p < 0.001; r = 0.38, p = 0.003; r = 0.37, p = 0.004, respectively). In conclusion, transthoracic echocardiography can provide valuable and reliable information about the LAA contraction velocity in stroke patients with sinus rhythm. This finding gives new insights for the appropriate strategy in the evaluation of an acute ischemic stroke.
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Affiliation(s)
- Nevzat Uslu
- Siyami Ersek Thoracic and Cardiovascular Surgery Center, Cardiology Department, Istanbul, Turkey.
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Saidi SJ, Motamedi MHK. Incidence and factors influencing left atrial clot in patients with mitral stenosis and normal sinus rhythm. Heart 2004; 90:1342-3. [PMID: 15486142 PMCID: PMC1768547 DOI: 10.1136/hrt.2003.024315] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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López-Candales A, Edelman KL. Large Atrial Appendage Thrombus in the Presence of Severe Mitral Regurgitation: Contradictory Hemodynamics or Expected Findings. Echocardiography 2004; 21:625-9. [PMID: 15488092 DOI: 10.1111/j.0742-2822.2004.03120.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A case of a large left atrial appendage thrombus in the presence of severe mitral regurgitation is presented. The use of transesophageal echocardiography in this setting was not only useful but also crucial despite the low anticipated diagnostic yield given the expected altered left atrial flow dynamics from the turbulent regurgitant lesion. However, additional confounding factors could have acted as potential mechanisms to enhance thrombosis in this setting and consequently are discussed.
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Affiliation(s)
- Angel López-Candales
- Cardiovascular Institute at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.
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Güler N, Demirbağ R, OZkara C, Eryonucu B, Güneş A, Tuncer M, Güntekin U, Kocabaş S, Agirbasli M. Clinical and echocardiographic predictors of left atrial appendage dysfunction in patients with mitral stenosis in sinus rhythm. J Am Soc Echocardiogr 2004; 17:819-23. [PMID: 15282483 DOI: 10.1016/j.echo.2004.04.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mitral stenosis (MS) causes left atrial (LA) appendage (LAA) dysfunction resulting in reduced LAA flow velocities. Low LAA peak emptying velocity (PEV), determined by transesophageal echocardiography, is a risk for thrombus formation and systemic embolism. OBJECTIVE We sought to investigate various clinical and echocardiographic predictors of low LAA blood flow velocities. METHODS A total of 44 patients with newly diagnosed MS were classified into two groups on the basis of the presence of high (PEV > or = 46 cm/s) or low (PEV < 46 cm/s) LAA flow profile on Doppler transesophageal echocardiography. LAA flow velocities were measured to be 27.38 +/- 8.17 cm/s in patients with LAA dysfunction and 70.75 +/- 16.71 cm/s in high-flow profile (P <.0001). Simultaneous 12-lead electrocardiogram was used to measure P waves. RESULTS P maximum, P dispersion, and LA diameter were significantly higher in patients with low LAA PEV (n = 32) than in those with high LAA PEV (111.87 +/- 16.93 vs 96.66 +/- 14.97, P =.0084; 73.12 +/- 20.7 vs 49.16 +/- 9.96, P <.0001; 46.06 +/- 4.384 vs 38.08 +/- 7.42 mm, P =.004; respectively). Patients with MS and low LAA blood flow had smaller mitral valve area compared with those with high LAA blood flow velocity (1.48 +/- 0.431 vs 1.85 +/- 0.442 cm(2), P =.02). Male sex, spontaneous echocontrast, and thrombus were more frequent in patients with low LAA PEV [7 [21.87%] vs 5 [41.66%], P =.026; 21 [65.62%] vs 4 [33.3%], P =.088; 4 [12.5%] vs none; respectively]. Mild MS was more frequent in patients with high blood flow velocity [6 [27.2%] vs 14 [63.6%], P =.03]. CONCLUSION At linear regression analysis, only P-wave dispersion and LA diameter predicted the LAA mechanical dysfunction reflected as low LAA PEVs.
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Affiliation(s)
- Niyazi Güler
- Department of Cardiology of Medical Faculty, Yüzüncü Yil University, Van, Turkey.
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Topsakal R, Eryol NK, Ozdoğru I, Seyfeli E, Abaci A, Oğuzhan A, Başar E, Ergin A, Cetin S. Color Doppler Tissue Imaging to Evaluate Left Atrial Appendage Function in Patients With Mitral Stenosis in Sinus Rhythm. Echocardiography 2004; 21:235-40. [PMID: 15053785 DOI: 10.1111/j.0742-2822.2004.03077.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Two-dimensional color Doppler tissue imaging (CDTI) has so far been used, in general, to evaluate ventricular function. In this study, the left atrial appendage (LAA) tissue velocity was measured by CDTI. LAA function in 38 patients with mitral stenosis in sinus rhythm (SR) and 19 healthy subjects undergoing transesophageal echocardiography were examined by CDTI. Systolic tissue appendage velocity (SaV, m/s) was measured at the tip of the LAA in the basal short-axis view. LAA emptying (LAAEV) and filling (LAAFV) velocities (m/s) were also recorded 1 cm below the orifice of the appendage. LAA ejection fraction was also measured. In addition, two-dimensional imaging was used to determine the presence of thrombus and/or spontaneous echo contrast (SEC). Patients with mitral stenosis in SR had significantly decreased LAAEV, LAAFV, SaV, and LAA ejection fraction compared to controls (0.34 +/- 0.15 vs 0.72 +/- 0.17, 0.37 +/- 0.13 vs 0.63 +/- 0.19, 0.050 +/- 0.015 vs 0.071 +/- 0.093, and 39 +/- 14% vs 69 +/- 13%, respectively, P < 0.001, P < 0.001, P < 0.001, and P < 0.001). Among the patients with mitral stenosis in SR, 10 patients had SEC and one had LAA thrombus. Compared with patients without SEC, patients with SEC had decreased LAAEV, LAAFV, SaV, and LAA ejection fraction (0.24 +/- 0.05 vs 0.37 +/- 0.16, 0.29 +/- 0.05 vs 0.39 +/- 0.14, 0.039 +/- 0.087 vs 0.055 +/- 0.015, and 28 +/- 14% vs 43 +/- 12%, respectively, P = 0.01, P = 0.02, P = 0.01, and P = 0.006). In conclusion, these results suggest that the LAA dysfunction may occur in patients with mitral stenosis in SR and CDTI can successfully be used for the quantification of contraction at the tip of the LAA.
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Affiliation(s)
- Ramazan Topsakal
- Department of Cardiology, Erciyes University, Medical Faculty, Kayseri, Turkey.
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Lake RM, Davutoglu V. Paroxysmal postural dyspnea related to multiple large organized thrombi in the left atrium. Clin Cardiol 2004; 27:A14; author reply A14,A23. [PMID: 15119689 PMCID: PMC6654138 DOI: 10.1002/clc.4960270418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Vedat Davutoglu
- Department of Cardiology, Sahinbey Medical Center, Gaziantep University, Gaziantep, Turkey
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Krishnamoorthy KM, Tharakan JA, Titus T, Ajithkumar VK, Bhat A, Harikrishnan SP, Padmakumar R. Usefulness of transthoracic echocardiography for identification of left atrial thrombus before balloon mitral valvuloplasty. Am J Cardiol 2003; 92:1132-4. [PMID: 14583375 DOI: 10.1016/j.amjcard.2003.07.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The objectives of this study were (1) to identify clinical and transthoracic echocardiographic features of patients with mitral stenosis who have thrombus recognized on transesophageal echocardiography, and (2) to define a clinical and echocardiographic model to predict the presence of left atrial thrombus in these patients.
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Agarwal AK, Venugopalan P. Left atrial spontaneous echo contrast in patients with rheumatic mitral valve stenosis in sinus rhythm: relationship to mitral valve and left atrial measurements. Int J Cardiol 2001; 77:63-8. [PMID: 11150627 DOI: 10.1016/s0167-5273(00)00415-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We studied 37 consecutive patients with mitral stenosis in sinus rhythm using transthoracic and transesophageal echocardiography to relate the presence of spontaneous echo contrast (SEC) in the left atrium with mitral valve area and left atrial dimensions. We also compared the value of left atrial area by planimetry with that of left atrial dimension by M mode in predicting presence of SEC and monitored the effect of anticoagulation on SEC. Transesophageal echocardiography demonstrated spontaneous echo contrast in 9/37 (24%) patients and thrombus in none. SEC continued to be present despite anticoagulation. Mitral valve orifice area by pressure half time method (P=0.001) and by planimetry (P=0.01), and left atrial area by planimetry (P<0.05) were predictors to presence of SEC. Left atrial dimension by M mode examination failed to predict SEC. Cut off values were mitral valve orifice </=1.4 cm(2) (agreement 86%) and left atrial area >/=25 cm(2) (agreement 81%). On multivariate analysis mitral valve area was the only independent predictor. SEC persisted despite anticoagulation. This supports the view that more than one mechanism is involved in the development of SEC.
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Affiliation(s)
- A K Agarwal
- Department of Cardiology, Sultan Qaboos University, PO Box 35, PC 123, Sultanate of, Muscat, Oman.
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