Prevalence of left chamber cardiac thrombi in patients with dilated left ventricle at sinus rhythm: the role of transesophageal echocardiography.

BACKGROUND: Left atrial appendage (LAA) may be a source of thrombi in patients with dilated cardiomyopathy at sinus rhythm. The objectives of our study were to assess the prevalence of intracardiac left chamber thrombus and/or spontaneous echo contrast and to identify clinical and echocardiographic predictors for left ventricle (LV), left atrium (LA), and/or LAA thrombus formation, particularly as regard to LV, LA, and LAA size, in heart failure patients at sinus rhythm. METHODS: We included 45 patients with dilated cardiomyopathy of ischemic or idiopathic origin with mild to moderate systolic dysfunction, who were at sinus rhythm and without anticoagulation therapy. RESULTS: Mean left ventricular end diastolic diameter was 64.9 ± 6.1 mm, and mean LV ejection fraction was 39.9 ± 7.3%. LV thrombus was found in 13.3% of patients and LAA thrombus in 68. 9%. Left ventricular end diastolic diameter was correlated with LA volume (r = 0.59, p < 0.0001) and LV thrombus (r = 0.38, p = 0.005). LA volume was correlated with LAA maximal area (r = 0.34, p = 0.01), which was an independent predictor for LAA thrombus formation (p = 0.003). CONCLUSIONS: Dilation of left cardiac chambers offers a suitable terrain for thrombus formation. The high probability of LAA thrombosis should be kept in mind when designing the treatment strategy for patients with dilated cardiomyopathy at sinus rhythm.

Right bundle branch block as a marker for interatrial septal abnormalities.

BACKGROUND: Interatrial septal anomalies, which include atrial septal defect, patent foramen ovale, and atrial septal aneurysm, are common disorders among adult patients. Early detection of interatrial septal anomalies is important in order to prevent haemodynamic consequences and/or thromboembolic events. Electrocardiogram offers some clues that should serve as hints for detection of interatrial abnormalities. The aim of our study was to analyse the interatrial septum by transoesophageal echocardiography in patients with electrocardiogram signs of right bundle branch block and in those without right bundle branch block. METHODS AND RESULTS: In a prospective study, 87 adult patients were included, that is, 41 with electrocardiogram signs of right bundle branch block forming the first group and 46 without right bundle branch block forming the second group. Interatrial septal anomalies were present in 80.5% of the patients with right bundle branch block, with patent foramen ovale (39.02%) being the most prevalent disorder, followed by atrial septal aneurysm (21.9%) and atrial septal defect (19.5%). Interatrial septal abnormalities were significantly more frequent in the first group compared with the second group (80.5% versus 6.5%, p value less than 0.001). Independently, patent foramen ovale was significantly more prevalent in patients with right bundle branch block (39.02% versus 4.3%, p value less than 0.001), as were atrial septal aneurysm (21.9% versus 2.2%, p value equal 0.01) and atrial septal defect (19.5% versus 0%, p value equal 0.004). CONCLUSIONS: Right bundle branch block should serve as a valuable indicator to motivate a detailed search for interatrial septal abnormalities.

The influence of left ventricular diameter on left atrial appendage size and thrombus formation in patients with dilated cardiomyopathy.

OBJECTIVES: Patients with dilated cardiomyopathy are considered a high risk group for left ventricular (LV) thrombus formation. However, the left atrial appendage (LAA) might be an additional site for thrombus formation in this patient group. We evaluated the association between LV size and left atrium/LAA size and determined the incidence of spontaneous echo contrast (SEC)/thrombus in the LV, left atrium, and LAA in patients with and without enlarged LV dimensions. STUDY DESIGN: In a prospective design, we examined 45 patients with transthoracic and transesophageal echocardiography. Nineteen patients had an enlarged LV dimension (group 1: LV end-diastolic diameter = or >58 mm), and 26 patients had a normal LV size (group 2). Nonvalvular atrial fibrillation (AF) was present in 13 patients (68.4%) in group 1 and in 14 patients (53.9%) in group 2. Echocardiographic parameters included LV dimension and ejection fraction, left atrial diameter, LAA maximal area, and detection of SEC/thrombus in the LV, left atrium, and LAA. RESULTS: The two groups were similar with regard to demographic and clinical features. Patients in group 1 had a significantly increased LV end-diastolic diameter (63.5+/-3.8 mm vs. 50.9+/-0.9 mm; p<0.001) and decreased ejection fraction (45.3+/-11.7% vs. 56.0+/-10.2%; p=0.002). Left atrial diameter did not differ significantly, but maximal LAA area was significantly greater in group 1 (4.9+/-2.3 cm2 vs. 3.3+/-0.8 cm2; p=0.002). Among the frequencies of SEC and thrombus in the LV, left atrium, and LAA, only the frequency of thrombus in the LAA was significantly higher in group 1 (36.8% vs. 7.7%; p=0.05). Compared to patients with a normal LV size and AF, the coexistence of AF with dilated LV was significantly associated with a greater LV end-diastolic diameter (p<0.001) and LAA maximal area (p=0.02). CONCLUSION: Patients with a dilated LV have a larger LAA and seem to be at a higher risk for LAA thrombus formation.

The effects of combined therapy of rheumatoid arthritis on the acute phase reactants.

The paper presents the results of studies of acute phase reactants in the 60 treated patients with rheumatoid arthritis. Patients were divided into two groups, depending on the applied treatment: group I (n = 30) was treated with methotrexate, sulfasalazine and hydroxychloroquine, and group II (n = 30) with methotrexate. The results of our study shows that there is a statistically significant reduction in the value of acute phase reactants and clinical parameters after treatment in both investigated groups of patients, and also a significant statistical difference between the first and second group of treated patients.

Atrioventricular septal defect with common atrioventricular junction guarded by a common valve consisting of left atrioventricular trifoliate valve.

INTRODUCTION: Atrioventricular septal defect with common atrioventricular junction is a rare adult congenital cardiac syndrome. This occurrence with prolonged survival is exceptionally rare. CASE REPORT: We present the case of a patient who presented with this defect with common atrioventricular junction who survived to the age of 32. We describe a 32-year-old man with atrioventricular septal defect with common atrioventricular junction guarded by a common valve. His history, clinical course, and anatomic findings are discussed along with the factors which may have contributed to his longevity, which is unique in the medical literature. His management reflected the state of medical knowledge at the time when he presented, and although alternate approaches may have been utilized if the patient presented today. We discuss the findings, frequency, classifi cation, and management of congenital defects. Development of embryonic structure is altered by interaction between genetics and environmental factors toward a rare associated of congenital cardiac defects-complex congenital heart disease. CONCLUSION: This case demonstrates that patients with very complex congenital cardiac disease may survive to adulthood, presenting challenges in both medical and surgical treatment.

Limitations of CHADS2 scoring system in predicting stroke risk--need to change the age criteria.

INTRODUCTION: Atrial fibrillation (AF) is the most common arrhythmia with a strong association with age. The aim of this study was to evaluate the rate of stroke in relation to age and anticoagulation status based on CHADS2 risk criteria. METHODS: This study included all patients with non-valvular atrial fibrillation admitted to our clinic between 1/11/2007 and 1/11/2009, with minimum one year follow up for patients without stroke. We calculated risk based on CHADS2 (C-cardiac failure, H- hypertension, A-age >75 years, D-diabetes mellitus, S-stroke) point system and evaluated anticoagulation status at the moment of first occurrence of stroke. We observed the rate of stroke in different group age. RESULTS: The average of participants with AF was 67.9 +/- 10.3 years. Amongst 302 patients with non-valvular atrial fibrillation, 32.5% had been anticoagulated while 13.9% of experienced stroke. The stroke were more present in patients who used aspirin in age group 65-74 (22.5%, P = 0.014). The mean age of patients who experienced stroke were 67.2, SD +/- 10.8 vs. 71.6, SD +/- 5.1, P = 0.000. Of the patients with stroke from age group 65-74 years, 23 were in CHADS2 0-1 scoring system. CONCLUSION: The higher rate of stroke was in the 65-74 years age group, with CHADS2 scoring system 0-1, and without anticoagulation therapy. Therefore modification has to be considered for the CHADS2 scoring system to account the age as a risk factor for population in different regions.

Association of interatrial septal abnormalities with cardiac impulse conduction disorders in adult patients: experience from a tertiary center in Kosovo.

INTERATRIAL SEPTAL DISORDERS, WHICH INCLUDE: atrial septal defect, patent foramen ovale and atrial septal aneurysm, are frequent congenital anomalies found in adult patients. Early detection of these anomalies is important to prevent their hemodynamic and/or thromboembolic consequences. The aims of this study were: to assess the association between impulse conduction disorders and anomalies of interatrial septum; to determine the prevalence of different types of interatrial septum abnormalities; to assess anatomic, hemodynamic, and clinical consequences of interatrial septal pathologies. Fifty-three adult patients with impulse conduction disorders and patients without ECG changes but with signs of interatrial septal abnormalities, who were referred to our center for echocardiography, were included in a prospective transesophageal echocardiography study. Interatrial septal anomalies were detected in around 85% of the examined patients. Patent foramen ovale was encountered in 32% of the patients, and in combination with atrial septal aneurysm in an additional 11.3% of cases. Atrial septal aneurysm and atrial septal defect were diagnosed with equal frequency in 20.7% of our study population. Impulse conduction disorders were significantly more suggestive of interatrial septal anomalies than clinical signs and symptoms observed in our patients (84.91% vs 30.19%, P=0.002). Right bundle branch block was the most frequent impulse conduction disorder, found in 41 (77.36%) cases. We conclude that interatrial septal anomalies are highly associated with impulse conduction disorders, particularly with right bundle branch block. Impulse conduction disorders are more indicative of interatrial septal abnormalities in earlier stages than can be understood from the patient's clinical condition.

Acute myocardial infarction and pulmonary tuberculosis in a young female patient: a case report.

INTRODUCTION: Tuberculous coronaritis is known to be a very rare phenomenon, although Mycobacterium tuberculosis, as some other infectious agents, may also act in the coronary vessels by activating the inflammatory mechanism of atherosclerosis. The association between active pulmonary tuberculosis and acute myocardial infarction has not been reported for around three and a half decades. CASE PRESENTATION: We presented here a case of a young, 30 year old, Caucasian woman who presented to Emergency Ward with severe chest pain, ECG and enzyme profile typical for acute myocardial infarction. Chest X-ray displayed high intensity shades in the left lung field, which after additional laboratory tests were shown to be due to active pulmonary tuberculosis. CONCLUSION: As the patient did not have any other known coronary artery disease risk factors, we held responsible Mycobacterium tuberculosis for occurrence of acute myocardial infarction in this young female patient. We believe that the presentation of this rare case of myocardial infarction in a patient with active pulmonary tuberculosis should encourage researchers to investigate the potential role of Mycobacterium tuberculosis in pathogenesis of coronary heart disease.

Atrial septal aneurysm associated with additional cardiovascular comorbidities in two middle age female patients with ECG signs of right bundle branch block: two case reports.

INTRODUCTION: Atrial septal aneurysm (ASA) is often associated with other atrial septal abnormalities, particularly with atrial septal defect type ostium secundum or patent foramen ovale. ECG signs of incomplete or complete right bundle branch block are known to be associated with atrial septal defects, however such correlation with other atrial septal abnormalities is not documented. CASE PRESENTATIONS: We report here two cases of middle age female patients that presented with dyspnea on physical effort, right bundle branch block (RBBB) on ECG and ASA combined with other cardiac disorders. Transesophageal echocardiography revealed additional information to the ones obtained by surface echocardiography, in both cases. CONCLUSION: ASA associated with RBBB on ECG may serve as a hint for the presence of additional cardiac abnormalities, thus rousing the demand for a detailed cardiac investigation.