P263 Characterisation of patients with acute myocardial infarction complicated by left ventricular thrombus

Funding Acknowledgements

None

Background/Introduction

Left ventricular (LV) thrombus is a widely recognized complication of acute myocardial infarction (AMI).  Limited data are available from South East Asian patients with this post-infarction complication nor on whether patients with non-ST segment elevation myocardial infarction (NSTEMI) or STEMI with associated LV thrombosis exhibit differing clinical characteristics and/or outcomes. Left Ventricular Ejection Fraction (LVEF) ≤ 40% is a recognized predictor of LV thrombus formation, but there is limited data on LV thrombus patients with EF > 40% or in NSTEMI patients.

Purpose

This study aims to investigate and compare the clinical characteristics, treatment and outcomes of post-AMI patients with LV thrombus formation, with a particular emphasis on those with EF ≤ 40% and in NSTEMI patients. 

Methods

Among 5829 consecutive echocardiogram results containing the keyword "thrombus" from August 2006 to September 2017, we identified 289 post-AMI patients with acute LV thrombus formation. Demographics, treatment and outcome measures were analysed.

Results

Cardiovascular risk factors such as dyslipidaemia (54.0%) and hypertension (50.5%) were commonly present in post-AMI patients with LV thrombus. Mean LVEF was 33.0 ± 10.4%. The majority (68.0%) of patients received triple therapy and 59.5% achieved thrombus resolution. NSTEMI patients had greater number of co-morbidities including heart failure (p < 0.01), documented history of  ischaemic heart disease preceding the AMI leading to thrombus formation (p < 0.01) and lower LVEF (28.3 ± 9.3% vs. 34.8 ± 10.3% , p < 0.01) compared with STEMI cases. On multivariate analysis, having a lower EF was a significant independent predictor of stroke (HR 0.96, 95% CI 0.93-1.00, p = 0.03) and all-cause mortality (HR 0.95, 95% CI 0.92-0.99, p < 0.01). The categories of STEMI and NSTEMI did not predict thrombus resolution, stroke events or all-cause mortality after adjustment.

Conclusion(s)

  Post-AMI LV thrombus patients with NSTEMI and STEMI differed in terms of their co-morbidities in their demographics and co-morbidities but it was a lower EF that was associated with an increased risk of stroke and all-cause mortality. Further studies on this topic are required.

P910An Asian perspective on left ventricular outflow tract cut-offs and the resulting discrepancy in severity grading of aortic stenosis

Objectives

Inconsistencies in grading of aortic stenosis (AS) severity have been reported based on measurement of left ventricular outflow tract diameter (LVOTd), but this remains to be studied in an Asian population. We investigated consistency of grading AS severity at various LVOTd, and subsequently postulated alternative cut-offs for more consistent grading of AS severity.

Methods

350 consecutive patients with index echocardiographic diagnosis of severe AS were divided them into three groups based on LVOTd: “small” (<20mm), “average” (20–22mm), “large” (>22mm). In each group, the consistency of flow-dependent (transaortic mean pressure gradient (MG)) and flow-independent parameters (AVA) were used for classification of AS severity.

Results

Of 350 patients, 51.7% had small LVOTd, while 30.8% and 17.5% had average and large LVOTd respectively. Consistent grading by LVOTd based on AVA and MG, was seen in 33.7% of patients with small, 47.6% with average, 57.7% with large LVOTd. When the hypothetical AVA cut-off of 0.9cm2 was used, consistent grading improved to 38.0% in small, 56.5% in average and 70% in large LVOTd. At an AVA cut-off of 0.8cm2, there was further incremental improvement in the small LVOTd group to 54.1% (p<0.05).

Table 1. Consistent grading by LVOTd based on current guidelines Small LVOTd (<20mm, n=181) Average LVOTd (20–22mm, n=108) Large LVOTd (>22mm, n=61) Consistent grading AVA < cut-off MG >40 Consistency (%) Consistent grading AVA < cut-off MG >40 Consistency (%) Consistent grading AVA < cut-off MG >40 Consistency (%) n=61 33.7 n=51 47.6 n=35 57.7 n=69 38 n=61 56.5 n=43 70* n=98 54.1*+ n=70 65.1* n=43 70.8* *p-value <0.05 when compared with AVA cut-off 0.8cm2 for each LVOTd category; +p-value <0.05 when compared with AVA cut-off 0.9cm2 for each LVOTd category.

Figure 1

Conclusion

Current severe AS guidelines are most consistent with those in the large LVOTd group. However, the majority of the study's Asian population is in the small LVOTd group, which is the group most susceptible to discrepancy in AS grading. Improved consistency in echocardiographic grading may be attained with a lower AVA cut-off in this Asian cohort.

An unusual case of anomalous origin of the right coronary artery and hepatic focal nodular hyperplasia

Anomalous origin of the right coronary artery (ARCA) and focal nodular hyperplasia (FNH) are frequently reported in association with congenital heart abnormalities but not with each other. We propose that both conditions may share common origins in a maladative hyperplastic response to differential vascular flow due to developmental arterial malformations or aberrant Notch signalling during simultaneous gut and cardiac vasculorigenesis.