Clinical Characteristics of Non-Valvular Atrial Fibrillation Patients With a Large Left Atrial Appendage Ostium-Limiting Percutaneous Closure.

BACKGROUND: The left atrial appendage (LAA) is a therapeutic target for preventing cardioembolic stroke in patients with non-valvular atrial fibrillation (NVAF). A large LAA ostium limits percutaneous LAA closure. This study investigated the characteristics and factors associated with a large LAA ostium in Japanese patients with NVAF.Methods and Results: In 1,102 NVAF patients, the maximum LAA diameter was measured using transesophageal echocardiography (TEE). A large LAA ostium was defined by a maximum diameter of >30 mm. Forty-four participants underwent repeated TEEs, and changes in LAA size under lasting AF were assessed. A large LAA ostium was observed in 3.1% of all participants and 8.9% of patients with long-standing persistent AF (LSAF). The large LAA group had greater CHA2DS2-VASc (P=0.024) and HAS-BLED scores (P=0.046) and a higher prevalence of LAA thrombus (P=0.004) than did the normal LAA group. LSAF, moderate or severe mitral regurgitation, left atrial volume ≥42 mL/m2, E/E' ratio ≥9.5, and left ventricular mass ≥85 mg/m2were independently associated with a large LAA ostium (P<0.001, P<0.001, P=0.009, P=0.009, and P=0.032, respectively). In 44 patients with lasting AF, the LAA ostial diameter increased over time (P<0.001). CONCLUSIONS: NVAF patients with a large LAA ostium may have a higher risk of stroke and bleeding. LSAF and factors leading to LA overload may be closely associated with LAA ostial dilatation and can promote it.

Cardiac Reversibility and Survival After Transcatheter Aortic Valve Implantation in Patients With Low-Gradient Aortic Stenosis.

Background Prognostic implications of transcatheter aortic valve implantation (TAVI) in low-gradient (LG) aortic stenosis (AS) remain controversial. The authors hypothesized that differences in cardiac functional recovery may solve this ongoing controversy. The aim was to evaluate clinical outcomes and the response of left ventricular (LV) function following TAVI in patients with LG AS. Methods and Results This multicenter retrospective study included 1742 patients with severe AS undergoing TAVI between January 2015 and March 2019. Patients were subdivided into low-flow (LF) LG, normal-flow (NF) LG, LF high-gradient, and NF high-gradient AS groups according to the mean gradient of the aortic valve (LG <40 mm Hg) and LV stroke volume index (LF <35 mL/m2). Outcomes and changes in echocardiographic parameters after TAVI were compared between the groups. A total of 227 patients (13%) had reduced ejection fraction, and 486 patients (28%) had LG AS (LF-LG 143 [8%]; NF-LG 343 [20%]). During a median follow-up period of 747 days, 301 patients experienced a composite end point of cardiovascular death and rehospitalization for cardiovascular events, which was higher in the LF-LG and NF-LG groups than in the high-gradient groups. LG AS was independently associated with the primary outcome (hazard ratio, 1.69; P<0.001). Among 1239 patients with follow-up echocardiography, LG AS showed less improvement in the LV mass index and LV end-diastolic volume compared with high-gradient AS after 1 year, while LV recovery was similar between the LF AS and NF AS groups. Conclusions LG AS was associated with poorer outcomes and LV recovery, regardless of flow status after TAVI. Careful evaluation of AS severity may be required in LG AS to provide TAVI within the appropriate time and advanced care afterward.

Association between right ventricular longitudinal strain and cardiovascular events in patients with cardiac sarcoidosis.

BACKGROUND: While right ventricular (RV) involvement is commonly observed in patients with cardiac sarcoidosis (CS), the utility of strain imaging to detect RV involvement is unclear. We aimed to investigate the association between RV free wall longitudinal strain (RVFWLS) and cardiovascular events in patients with CS. METHODS: We studied 51 patients with CS who were diagnosed between 2012 and 2020. All patients underwent comprehensive echocardiographic evaluation, and RVFWLS was assessed using 2-dimensional speckle tracking echocardiography. The primary outcome was major adverse cardiovascular events (MACEs). RESULTS: During a median follow-up duration of 548 days, 11 patients exhibited MACEs. In the univariable Cox proportional hazards model, the baseline RVFWLS was associated with MACEs (hazard ratio: 1.29, p = 0.008). The addition of RVFWLS to the conventional echocardiographic parameters exhibited a significant incremental value associated with MACEs. Patients with reduced RVFWLS showed a higher prevalence of late gadolinium enhancement on cardiac magnetic resonance imaging in RV wall (p = 0.02) and trends toward higher prevalence of fluorodeoxyglucose uptake in RV (p = 0.06). A serial echocardiographic evaluation revealed that patients with events showed a worsening in RVFWLS, while others showed a trend toward improvement. CONCLUSIONS: Impaired RVFWLS at baseline was associated with MACEs in patients with CS. RVFWLS could be an important surrogate of disease activity and prognosis by detecting active RV involvement in CS.

Embolization of the Deep Vein Thrombus During Ultrasound Examination.

Thrombus embolization is a rare consequence of ultrasonographic examination of the vessels of the lower limbs. We present a case of a 77-year-old woman with lung cancer who developed pulmonary embolism originating from the right femoral deep vein thrombus during the compression maneuver of the ultrasonographic examination of the lower limbs. (Level of Difficulty: Beginner.).