Left Atrial Strain for Predicting Atrial Fibrillation Onset in Hypertensive Patients.

INTRODUCTION: We aimed to find new predictive parameters for atrial fibrillation (AF) onset in hypertensive patients using two-dimensional (2D) conventional and speckle tracking echocardiography of the left atrium (LA). METHODS: One hundred and eight patients with essential hypertension (HTN) were prospectively enrolled, from which 67 patients had no other important comorbidities (HTN group), while 41 patients had a recent AF episode, but were in sinus rhythm at the moment of enrollment (HTN and AF group). LA diameters and maximal volume, LV mass, LV ejection fraction and diastolic function were assessed through 2D conventional echocardiography. Moreover, peak longitudinal and contractile strain of LA walls (PALS and PACS, respectively) were analyzed by speckle tracking technique. Patients were followed up for 1 year and recurrent 24-h rhythm monitoring was done, in order to identify atrial fibrillation. RESULTS: Age and time from diagnosis of HTN were higher in HTN and AF group than in HTN group (68.02 ± 19 years versus 57.2 ± 1.52 years, p = 0.001 and 62.2 ± 9.2 months versus 40.4 ± 6.4 months, p = 0.04). All LA diameters and LA maximal volume were significantly larger in HTN and AF group (for LA antero-posterior diameter p = 0.02, for all the rest p < 0.0001). LV ejection fraction was preserved in both groups, being significantly lower in HTN and AF patients (58.44 ± 0.79 versus 60.75 ± 0.57, p = 0.02). LV mass was higher in HTN and AF group and these patients had also a more severe diastolic dysfunction, (E/A ratio 1.8 ± 0.51 versus 0.9 ± 0.02, p = 0.04) and lower septal and lateral A' velocities (p < 0.0001 and p = 0.002). The peak LA longitudinal and contractile strain values were also significantly lower in HTN and AF group versus HTN group (for all p < 0.0001). Among the echocardiographic parameters, we identified PALS and PACS as predictors for AF, with a good discriminating capacity (AUC = 0.88 for PALS and AUC = 0.86 for PACS). CONCLUSIONS: Compared to patients with isolated hypertension, patients with hypertension and AF display several echocardiographic differences. Among them, LA strain parameters could be useful predictors of AF occurrence in hypertensive patients.

Catheter Closure Through a Venous Approach of Patent Ductus Arteriosus in Small Pediatric Patients Using Combined Angiographic and Echocardiographic Guidance.

The standard technique of catheter closure of patent ductus arteriosus (PDA) may be associated with arterial complications particularly in small pediatric patients. The aim of this study was to evaluate whether catheter closure of PDA in small children using an exclusive venous approach is a safe and effective alternative to closure with the standard technique. One hundred-twelve patients, aged 2 to 24 months, were randomly assigned in a 1:1 ratio to catheter closure of PDA using the standard technique (group 1) and an exclusive venous approach (group 2), respectively. In group 2, the procedure was guided using hand injections of contrast media through the delivery sheath and 2-dimensional and color Doppler echocardiography. Group 1: the PDA diameter ranged from 2 to 5.5 mm and the device diameter ranged from 4 to 8 mm. The PDA occluders were permanently implanted in all patients. Five losses of the arterial pulses that were restored with intravenous infusion of heparin and recombinant tissue plasminogen activator (rtPA), and 4 groin hematomas were the main complications of the procedure. Group 2: the mean PDA diameter ranged from 2.5 to 6 mm and the device diameter ranged from 3 to 8 mm. The PDA occluders were permanently implanted in all but 2 patients. There were no complications. Complete echocardiographic closure of PDA at 1-month follow-up was observed in all 110 patients. Exclusive transvenous PDA occlusion is an effective and safe technique that prevents the arterial complications of the standard approach in small children.

Coronary fistula - an unexpected preanaesthetic finding.

Coronary artery fistulae are congenital vascular anomalies defined as aberrant communications between a coronary artery and a cardiac chamber, large vessel or another vascular structure. In the present case the preanaesthetic clinical assessment led to a fortuitous detection of a rare coronary artery anomaly, which changed the initial therapeutic option. A 21-year-old female patient was admitted for a right ankle fracture. She had a two years history of constrictive chest pain inconsistently generated by effort of medium intensity, which had not been investigated previously. Clinical examination identified a grade V systolic-diastolic murmur audible on the entire anterior thorax, with no other abnormalities. The patient underwent cardiological evaluation including transthoracic (TTE) and transesophageal echocardiography (TEE). TTE and TEE revealed an important dilatation of the left main coronary artery (LM) and a dilated circumflex artery (CX), with a very turbulent flow and a fistulous traject drawing most probably in the right atrium. The TTE and TEE evaluation raised the suspicion of a coronaro-cavitary fistula between the CX and the right atrium. The patient underwent coronary catheterization which confirmed a coronary fistula connecting CX with a superior vena cava-right atrium junction, with a hemodynamic significant left- to-right shunt. Surgeons opted for a conservative orthopedic management of the fracture; the patient continued to present exertional chest pain and was scheduled for interventional fistula closure. Our case confirms the importance of the preanaesthetic clinical examination, as a gold standard, that was decisive in identifying this rare, but potentially lethal congenital anomaly, as it triggered a series of tests, which established the diagnosis.