Clinical value of left atrial appendage flow for prediction of long-term sinus rhythm maintenance in patients with nonvalvular atrial fibrillation.

OBJECTIVES: This study evaluated the role of various clinical and echocardiographic parameters, including the left atrial appendage (LAA) anterograde flow velocity, for prediction of the long-term preservation of sinus rhythm (SR) in patients with successful cardioversion (CV) of nonvalvular atrial fibrillation (AF). BACKGROUND: Echocardiographic parameters for assessing long-term SR maintenance after successful CV of nonvalvular AF are not accurately defined. METHODS: Clinical, transthoracic echocardiographic and transesophageal echocardiographic (TEE) data--measured in AF lasting >48 h--of 186 consecutive patients (116 men, mean age: 65 +/- 9 years) with successful CV (electrical or pharmacologic) were analyzed for assessment of one-year maintenance of SR. RESULTS: At one-year follow-up, 91 of 186 (49%) patients who underwent successful CV continued to have SR. Mean LAA peak emptying flow velocity was higher in patients remaining in SR for one year than in those with AF relapse (41.7 +/- 20.2 cm/s vs. 27.7 +/- 17.0 cm/s; p < 0.001). On multivariate logistic regression analysis, only the mean LAA peak emptying velocity >40 cm/s (p = 0.0001; chi(2): 23.9, odds ratio [OR] = 5.2, confidence interval [CI] 95% = 2.7 to 10.1) and the use of preventive antiarrhythmic drug treatment (p = 0.0398; chi(2): 4.2; OR = 2.0, CI 95% = 1.0 to 3.8) predicted the continuous preservation of SR during one year, outperforming other univariate predictors such as absence of left atrial spontaneous echocardiographic contrast during TEE, the left atrial parasternal diameter <44 mm, left ventricular ejection fraction >46% and AF duration <1 week before CV. The negative and positive predictive values of the mean LAA peak emptying velocity >40 cm/s for assessing preservation of SR were 66% (CI 95% = 56.9 to 74.2) and 73% (CI 95% = 62.4 to 83.3), respectively. CONCLUSIONS: In TEE-guided management of nonvalvular AF, high LAA flow velocity identifies patients with greater likelihood to remain in SR for one year after successful CV. Low LAA velocity is of limited value in identifying patients who will relapse into AF.

Coronary flow velocity reserve and indices describing aortic distensibility in patients after coronary angiography.

BACKGROUND: The purpose of this study was to assess the elastic properties of the descending aorta and the coronary flow velocity reserve (CFR) in patients after coronary angiography. METHODS AND PATIENTS: We recruited 112 subjects with stable angina pectoris without a previous myocardial infarction: 17 consecutive patients with anatomically normal coronary arteries, 24 patients with non-significant coronary artery disease (CAD), 31 patients with significant left anterior descending coronary artery (LAD) disease and 40 patients with multivessel disease (MVD). Transoesophageal echocardiography (TEE) is useful for evaluation of the elastic properties of the descending aorta. The physical behaviour of vessels in response to an intraluminal force is described by the elastic modulus (E(p)) and Young's circumferential static elastic modulus (E(s)). Coronary flow velocities can be measured in the LAD under baseline conditions and during dipyridamole stress. The CFR was calculated as the ratio of the average peak diastolic flow velocity during hyperaemia to that at rest. RESULTS: The indices of aortic distensibility, CFR and mean CFR, were different in patients with LAD disease and in those with normal coronary angiograms. There were no further changes in these parameters in cases with MVD. In patients with non-significant CAD, the CFR, mean CFR and stiffness moduli lie between those for negative cases and those for patients with LAD disease/MVD. CONCLUSIONS: When there was significant stenosis of the LAD, the CFR was significantly decreased, while indices of aortic distensibility were increased as compared with the negative controls. Interestingly, not only the CFR, but also E(p) and E(s) displayed no further changes in cases with MVD as compared with LAD disease.

Atherosclerosis of the descending aorta predicts cardiovascular events: a transesophageal echocardiography study.

PURPOSE: Previous studies have shown that atherosclerosis of the descending aorta detected by transesophageal echocardiography (TEE) is a good marker of coexisting coronary artery disease. The aim of our study was to evaluate whether the presence of atherosclerosis on the descending aorta during TEE has any prognostic impact in predicting cardiovascular events. MATERIAL AND METHODS: The study group consisted of 238 consecutive in-hospital patients referred for TEE testing (135 males, 103 females, mean age 58 +/- 11 years) with a follow up of 24 months. The atherosclerotic lesions of the descending aorta were scored from 0 (no atherosclerosis) to 3 (plaque >5 mm and/or "complex" plaque with ulcerated or mobile parts). RESULTS: Atherosclerosis was observed in 102 patients, (grade 3 in 16, and grade 2 in 86 patients) whereas 136 patients only had an intimal thickening or normal intimal surface. There were 57 cardiovascular events in the follow-up period. The number of events was higher in the 102 patients with (n = 34) than in the 136 patients without atherosclerosis (n = 23, p < 0.01). The frequency of events was in close correlation with the severity of the atherosclerosis of the descending aorta. Fifty percent of the patients with grade 3 experienced cardiovascular events. Excluding patients with subsequent revascularization, the multivariate analysis only left ventricular function with EF < 40% (HR 3.0, CI 1.3-7.1) and TEE atherosclerotic plaque >=2 (HR 2.4, CI 1.0-5.5) predicted hard cardiovascular events. CONCLUSION: Atherosclerosis of the descending aorta observed during transesophageal echocardiography is a useful predictor of cardiovascular events.

[Aortic distensibility indices evaluated by transoesophageal echocardiography in patients with coronary artery disease or aortic valve stenosis]. / A transoesophagealis echokardiográfia segítségével számított, az aorta descendens tágulékonyságát jellemzo indexek értéke koszorúér-betegségben és aortastenosis esetén.

INTRODUCTION: The authors examined the aortic distensibility indices evaluated by transoesophageal echocardiography (TEE) in patients with ischaemic heart disease and in aortic stenosis cases with normal epicardial coronary arteries. PATIENTS AND METHODS: 126 consecutive patients with chest pain were enrolled into the study with the following results: 17 patients showed normal epicardial coronary arteries, 23 patients had non-significant coronary artery disease, 44 patients had significant one-vessel disease and 42 patients had significant multivessel disease. Their results were compared to 16 aortic stenosis cases but with negative coronary angiograms. All patients underwent transthoracic and transoesophageal echocardiography and coronary angiography. During a complete TEE the following data were recorded: systolic and diastolic blood pressure and heart rate, systolo-diastolic aortic diameters and intimo-medial thickness. According to these data elastic and Young's moduli were calculated. RESULTS: The indices of aortic distensibility were significantly increased (the aortic distensibility was decreased) in patients with coronary artery disease (CAD) as compared to cases with normal epicardial coronary arteries independently the number of affected vessels. In cases of aortic stenosis but with normal epicardial coronary arteries, the aortic distensibility indices were similarly increased as in patients with CAD. CONCLUSIONS: There is a considerable stiffness of the descending aorta of patients with CAD than in cases with normal epicardial coronary arteries. The aortic distensibility of aortic stenosis patients with negative coronary angiograms are similarly decreased that in patients with CAD.

[Clinical role of flow velocity of left atrial auricle for prediction of short and long term success of cardioversion in patients with non-valvular atrial fibrillation]. / A bal pitvari fülcse áramlás szerepe a cardioversio rövid és hosszú távú sikerességének elórejelzésében nem valvularis eredetú pitvarfibrilláció fennállásakor.

INTRODUCTION: Echocardiographic parameters for predicting cardioversion (CV) outcome and long-term sinus rhythm (SR) maintenance in patients with nonvalvular atrial fibrillation (AF) are not accurately defined. AIMS: The authors aim was to evaluate the role of left atrial appendage (LAA) flow velocity detected by transesophageal echocardiography before CV for prediction of short and long-term (1 year) outcome of CV in patients with nonvalvular AF. METHODS: One hundred and nine patients (66 males, mean age: 57 +/- 13 years) with nonvalvular AF lasting more than 48 hours but less than 1-year duration underwent transthoracic and transesophageal echocardiography before either electrical or pharmacological CV attempt. RESULTS: Cardioversion was successful in restoring SR rhythm in 83 (76%) and unsuccessful in patients 26 (24%). Mean LAA peak emptying flow was higher in patients with successful than in those with unsuccessful CV (36.7 +/- 14.7 vs 26.3 +/- 9.2 cm/sec; p < 0.01). At multivariate analysis the left LAA emptying velocity > 32 cm/sec was the only independent predictor of CV success. Seventy-four out of the 83 patients with successful CV had a complete follow-up of 1 year. At the end of the 1-year follow-up, 40 of the 74 (54%) patients who underwent successful CV preserved the SR. Mean LAA peak emptying velocity was higher in patients remaining in SR for 1 year than in those with AF relapse (40.3 +/- 15.6 vs 32.2 +/- 12.2 cm/sec cm/sec; p < 0.001). On multivariate analysis, only the mean LAA peak emptying velocity > 39 cm/sec and the use of preventive antiarrhythmic drug treatment predicted the continuous preservation of SR during 1 year. CONCLUSION: In patients with nonvalvular AF, measurement of precardioversion LAA flow velocity profile by transesophageal echo cardiography provides valuable information for prediction of both short and long-term success of CV.

Indices of aortic distensibility and coronary flow velocity reserve in patients with different grades of aortic atherosclerosis.

OBJECTIVE: The purpose of this study was to evaluate the correlation of the elastic properties of the descending aorta, the coronary flow velocity reserve (CFR) and the grade of aortic atherosclerosis (AA) in patients who have undergone coronary angiography. METHODS: A total of 113 consecutive patients (77 men and 36 women, aged 31-80 years) underwent stress transoesophageal echocardiographic (STEE) assessment of the CFR. The grade of AA and the indices of aortic distensibility were evaluated during the same session of STEE. All patients had chest pain without previous myocardial infarction. Coronary angiography was performed in all cases. RESULTS: The resting systolic and diastolic coronary flow velocities increased, while the coronary flow velocities measured at the peak of stress and the ratio Smax/Srest decreased in parallel with the aortic grade. The CFR and mean CFR were impaired in patients who exhibited aortic intimal thickening, but no further decrease was found in the event of aortic plaque. The elastic moduli E(p) and E(s) increased in parallel with the grade of AA. The occurance of a negative coronary angiogram was more common in patients without AA, but significant left anterior descending coronary artery disease or multivessel disease were more frequent at a higher grade of AA (in cases with aortic plaque). CONCLUSIONS: The CFR was decreased in patients with aortic intimal thickening, but no further decrease was observed in the presence of aortic plaque. The indices of aortic distensibility increased continuously in parallel with the aortic grade.

Relationship between hypercholesterolemia, lipid-lowering therapy and coronary flow velocity reserve evaluated by stress transesophageal echocardiography in patients with a negative coronary angiogram.

UNLABELLED: The coronary flow velocity reserve (CFR) depends not only on vascular, extravascular, and rheological factors, but also on metabolic factors, such as the cholesterol level. The aim of the present study was to examine the relationship between hypercholesterolemia, the application or not of 6 months lipid-lowering therapy, and the CFR evaluated by pharmacological stress transesophageal echocardiography (PSTEE) in patients without major coronary artery disease. PATIENTS AND METHODS: Sixty-nine patients with a negative coronary angiogram were enrolled in the study. Thirty-two of these patients received lipid-lowering therapy, while 37 did not. The CFR was measured by means of dipyridamole PSTEE in all cases, and was calculated as the ratio of posthyperemic to basal peak diastolic flow velocities. RESULTS: Of the 32 patients who received lipid-lowering medication, the cholesterol level was normal in 16 cases (CFR 2.47 +/- 0.88), while it remained increased in 16 patients (CFR 2.18 +/- 0.67) at the time of the examination. The 7 patients who did not participate in lipid-lowering therapy and who exhibited an increased cholesterol level were also examined (CFR 2.03 +/- 0.88). In 30 patients with normal cholesterol level, who did not receive any lipid-lowering medication, the CFR was significantly increased compared to cases with an increased level (CFR 2.65 +/- 0.79). CONCLUSION: It may be stated that in the patients who did not receive lipid-lowering medication and who displayed normocholesterolemia, the CFR evaluated by means of PSTEE was significantly higher than in the patients who had an increased cholesterol level.