Clinical and echocardiographic markers of mortality risk in patients with atrial fibrillation.

Atrial fibrillation (AF) is independently associated with increases in cardiovascular and all-cause mortality. Although cardiovascular co-morbidities predict stroke risk in AF, their relation with mortality has not been well described. To identify clinical and echocardiographic markers of mortality in patients with AF, 524 patients with AF underwent transesophageal echocardiography from August 2000 to March 2005. Clinical risk factors for systemic thromboembolism were determined for each patient. A CHADS2 (congestive heart failure, hypertension, age>75 years, diabetes, and previous stroke or transient ischemic attack) score ranging from 0 to 6 was calculated for each patient. Transesophageal echocardiographic reports were reviewed for the presence of left atrial spontaneous echocardiographic contrast, left atrial thrombus, the left ventricular ejection fraction, aortic arch atheroma, and the presence and severity of mitral regurgitation. Mortality data were obtained from the Social Security Death Master File. Univariate and multivariate models were structured to assess which variables predicted mortality. In a multivariate model, a history of heart failure, age>75 years, the absence of systemic anticoagulation with warfarin, the presence of left atrial spontaneous echocardiographic contrast, and greater than moderate mitral regurgitation were independent predictors of mortality. Increasing CHADS2 score was also an independent predictor of mortality. A CHADS2 score of 5 or 6 was associated with a >50-fold increase in mortality compared with patients with CHADS2 scores of 0. In conclusion, a history of heart failure, age>or=75 years, the absence of chronic oral anticoagulation, a CHADS2 score>0, and greater than moderate mitral regurgitation are independent predictors of mortality in patients with AF.

Contrast administration reduces interobserver variability in determination of left ventricular ejection fraction in patients with left ventricular dysfunction and good baseline endocardial border delineation.

Echocardiographic contrast agents improve endocardial border delineation in patients with technically difficult baseline studies. With medical and device therapy for heart failure increasingly based on left ventricular (LV) ejection fraction (EF) partition values, the accurate and reproducible assessment of LV function is necessary. It was hypothesized that routine contrast enhancement would significantly reduce interobserver variability in the determination of LVEFs in a cohort of patients with LV dysfunction and good baseline endocardial delineation. All patients underwent baseline noncontrast studies followed by contrast-enhanced imaging using Definity. Two experienced echocardiographers, blinded to the clinical data, determined LVEFs using 4 different techniques: noncontrast estimated (NCE), noncontrast calculated (NCC), contrast estimated (CE), and contrast calculated (CC). Using a mixed-model procedure that allows for fixed and random events, the variance due to error and that due to the patient was obtained (interclass correlation). The proportion of variation due to the reader was calculated as 1--interclass correlation. Mean standardized percentage differences ([reader 1 EF--reader 2 EF]/mean EF) were also calculated for each method. The proportion of variation due to the reader was smallest in the CC group and largest in the NCC group (NCE = 0.21, NCC = 0.33, CE = 0.25, CC = 0.11). The results were similar when only patients with NCE EFs >or=20% and or=20% and or=20% and

Usefulness of myocardial contrast echocardiography in predicting late mortality in patients with anterior wall acute myocardial infarction.

We investigated whether myocardial contrast echocardiography (MCE) performed soon after acute myocardial infarction (AMI) improves risk stratification for late mortality. MCE after AMI identifies microvascular "no-reflow" and predicts early outcomes; however, the predictive value of MCE for late mortality is unknown. One hundred sixty-seven patients with anterior AMI and left ventricular dysfunction underwent MCE 2 days after admission, and a perfusion score index (PSI) was calculated. Long-term follow-up (mean 39 months) was available for all patients. Patients with normal and abnormal perfusion had similar baseline characteristics. Myocardial contrast echocardiographic PSI was a predictor of mortality as a continuous variable (odds ratio 3.2 for each 1.0 increase in PSI, 95% confidence interval 1.1 to 9.7, p = 0.04). In a logistic regression model, age (odds ratio 2.6 per decade, 95% confidence interval 1.6 to 4.4, p = 0.0002) and PSI (odds ratio 4.5 for each 1.0 increase in PSI, 95% confidence interval 1.3 to 15.4, p = 0.02) were the only significant predictors of mortality. In a subanalysis comparing patients >70 years old with abnormal PSI with all other patients, Kaplan-Meier estimates showed a marked difference in survival over a mean follow-up of 39 months (24% vs 4% mortality, p = 0.0002). In conclusion, MCE refines risk stratification soon after anterior AMI in patients with left ventricular dysfunction. Patients at very high and very low risk of mortality can be identified, and myocardial contrast echocardiographic data are incrementally useful compared with existing clinical and angiographic variables.

Transesophageal echocardiographic diagnosis of Aspergillus fumigatus aortitis after percutaneous coronary intervention.

Aspergillus aortitis is an uncommon infection with high mortality and has been reported in patients after cardiopulmonary bypass. We report the first case of Aspergillus aortitis in an immunocompetent man immediately after percutaneous coronary intervention to an aortocoronary bypass graft. In this case, transesophageal echocardiography played a pivotal role in diagnosis.