Low-density lipoprotein apheresis therapy during pregnancy

Pregnancy in patients with severe hypercholesterolemia and coronary artery disease results in multiple problems both for mother and fetus; the most potent agents for low-density lipoprotein (LDL) cholesterol reduction, the HMG-CoA reductase inhibitors (statins) cannot be used during pregnancy. We present a case in which LDL apheresis via heparin-induced extracorporeal LDL precipitation was employed safely and efficaciously during pregnancy in a woman with heterozygous familial hypercholesterolemia and stable coronary artery disease.

Restrictive left ventricular filling patterns in very old patients with congestive heart failure: clinical correlates and prognostic significance

OBJECTIVES

In certain younger patients with congestive heart failure (CHF), Doppler/echocardiography has identified a "restrictive" pattern of early diastolic ventricular filling characterized by very rapid early filling and a steep deceleration slope. We asked whether a similar restrictive pattern can be identified in very old patients with CHF, and if so, what are its clinical correlates and prognostic implications.

DESIGN

Retrospective cohort with prospective follow-up.

SETTING

Academic long-term care facility.

PARTICIPANTS

Thirty-nine residents with clinical CHF (age 89 +/- 5 (SD) years)

MEASUREMENTS

Transmitral Doppler flow, clinical characteristics, recurrent CHF episodes, hospitalizations, and mortality were measured.

RESULTS

Fifteen (38%) of the subjects had restrictive filling patterns, characterized by a ratio of early to late flow (E/A) > 1.00 and 24 (62%) had nonrestrictive patterns. The restrictive pattern was associated with a longer duration of CHF, more angina, and higher rate of symptomatic recurrences of CHF.

CONCLUSION

A restrictive diastolic filling pattern may represent a late stage in the evolution of congestive heart failure when left ventricular filling pressure is markedly increased. The treatment of CHF in older patients may need to account for different patterns of diastolic filling.

Accuracy of transesophageal echocardiography for identifying left atrial thrombi. A prospective, intraoperative study

OBJECTIVE

To determine the ability of transesophageal echocardiography to accurately identify or exclude left atrial thrombi.

DESIGN

Prospective cohort study.

SETTING

University hospital.

PATIENTS

231 consecutive patients having transesophageal echocardiography before elective repair or replacement of the mitral valve or excision of a left atrial tumor. Fifty-six percent of patients had a history of atrial fibrillation, and 17% had a history of thromboembolism.

MEASUREMENT

Identification of left atrial thrombi during transesophageal echocardiographic examination and comparison with direct near-simultaneous visualization during cardiac surgery.

RESULTS

Transesophageal echocardiography identified 14 left atrial thrombi in 14 patients (6%). Thrombus size range from 3 to 80 mm. Surgery confirmed 12 of 14 thrombi (86%), including 9 thrombi confined to the left appendage. No additional thrombi were found on direct inspection of the atria (sensitivity, 100% [95% CI, 74% to 100%]; specificity, 99% [CI, 97% to 99.9%]; positive predictive value, 86% [12/14]; negative predictive value, 100% [217/217]; for a population that had a 5.2% prevalence of thrombi). All 12 surgically confirmed thrombi were identified by two independent observers. Neither thrombus seen by only a single observer on transesophageal echocardiography was confirmed during direct inspection of the atria at surgery.

CONCLUSION

Transesophageal echocardiography is highly accurate for identifying left atrial thrombi and can be used clinically to exclude left atrial thrombi.

Prevalence of residual left atrial thrombi among patients with acute thromboembolism and newly recognized atrial fibrillation

BACKGROUND

Thromboembolism related to atrial fibrillation (AF) is a major cause of morbidity and mortality. Patients with acute thromboembolism and AF are at high risk for early recurrent events.

OBJECTIVE

To determine the prevalence of left atrial thrombi in patients who had acute thromboembolism and newly diagnosed AF.

PATIENTS AND METHODS

Adult inpatients with AF were screened to identify those with acute (< 36 hours) systemic thromboembolism and newly recognized AF. Of 41 qualifying patients, 31 (76%) agreed to undergo transesophageal echocardiographic study, including 24 with acute neurologic events and seven with peripheral thromboembolism. A control population consisted of 88 adults with newly recognized AF without clinical thromboembolism.

RESULTS

Transesophageal echocardiography identified left atrial thrombi in 13 (43%) of the 30 study patients who underwent transesophageal echocardiography compared with nine (10%) of 87 controls (P < .001). Spontaneous echo contrast was identified in 27 (87%) of the study population vs 42 (48%) of controls (P < .001). The prevalence of this marker of blood stasis did not differ between patients with left atrial thrombi without thromboembolism (P = .69). Duration of AF, prevalence of abnormal left ventricular function, left atrial size, and mitral regurgitation were similar in both groups.

CONCLUSIONS

Left atrial thrombi were identified in more than 40% of patients with acute thromboembolism and newly recognized AF. These data suggest that a major source of recurrent thromboembolism in this group may be residual thrombus migration. Among patients with AF and atrial thrombi, clinical thromboembolism seems to occur randomly, or is related to an unidentified process.

Remnant of the common pulmonary vein mistaken for a left atrial mass: clarification by transoesophageal echocardiography

Faulty incorporation of the common pulmonary vein leaves it as a distinct structure posteriorly, into which the pulmonary veins empty. This "chamber" is separated from the anterior "fetal" left atrium (containing the left atrial appendage and communicating with the mitral valve) by a diaphragm, and is known as cor triatriatum, one of the rarest of cardiac malformations. Less pronounced but still incomplete regression of this vein would result in the persistence of a portion of the common pulmonary vein appearing as a mass along the lateral wall of the left atrium at the junction of the left atrial appendage and left upper pulmonary vein. In two patients, both referred for evaluation of a left atrial mass, transoesophageal echocardiography identified the "mass" as a remnant of the common pulmonary vein. Cardiologists need to be aware of this structural remnant and its possible variants so as to avoid misdiagnosis of this prominence as an atrial tumour or mass.

Coronary artery dissection secondary to blunt chest trauma

A 38-yr-old woman presented with an anterolateral myocardial infarction following blunt chest trauma sustained in a motor vehicle accident. Subsequent cardiac catheterization revealed a large left ventricular aneurysm and angiographic evidence of dissection of the proximal left anterior descending artery. Review of the literature and management are discussed.