Left atrial thrombus in patients with atrial fibrillation and under oral anticoagulant therapy; 3-D transesophageal echocardiographic study.

Ischemic stroke is the major complication of atrial fibrillation (AF) and only proven preventive therapy is oral anticoagulant therapy (OAC). Previous studies reported the presence of thrombus in the left atrium (LA) or left atrial appendage (LAA) despite anticoagulant therapy. We aim to investigate the predictors of LA/LAA thrombus in patients under OAC therapy and long-term clinical impact of thrombus. We prospectively enrolled consecutive patients with permanent AF under OAC therapy. Patients baseline characteristics were recorded. Transesophageal echocardiographic study performed after complete transthoracic echocardiographic study. 3-D evaluation of LAA was made using 3-D zoom mode and thrombus was defined when echo reflecting, mobile mass detected. Patients clinical outcomes were decided according to hospital records or via phone calls. Among 184 patients, 28 LAT were detected. Mean CHA2DS2-VASc score was significantly higher in patients with LAT in comparison to patients without LAT. CHA2DS2-VASc score (p: 0.001), left atrial volume (p: 0.001), left atrial flow velocity (p: 0.006) and left ventricular ejection fraction (p: 0.014) were independently associated with LAT. Among the parameters in CHA2DS2-VASc score, the previous history of stroke and age were independently related to LAT. After 12 months of follow-up, patients with LAT had more ischemic stroke than patients without LAT (7.1% vs 4.4%, p: 0.001 respectively). Although oral anticoagulation is the default treatment strategy for prevention of LAT and thromboembolism in patients with non-valvular AF, LAT still can be detected especially in patients with a high CHA2DS2-VASc score. Furthermore, the presence of LAT is significantly associated with future ischemic stroke.

Serum carbohydrate antigen 125 levels in advanced heart failure: relation to B-type natriuretic peptide and left atrial volume.

AIMS: To assess the relation between serum levels of carbohydrate antigen 125 (CA 125) and parameters of left ventricular (LV) filling pressure in patients with advanced heart failure (AHF). METHODS: Forty-nine patients (mean age 67+/-10 years) with LV ejection fraction (EF) < or =0.35 and New York Heart Association (NYHA) class III or IV symptoms of heart failure were enrolled. Left atrial volume indexed to body surface area (LAVI) and the ratio of mitral inflow early diastolic velocity to annulus velocity (E/e) were evaluated with pulsed wave and tissue Doppler. Plasma B-type natriuretic peptide (BNP) was also measured. RESULTS: The median overall CA 125 value was 44.0 (17.7-140) U/ml. CA 125 above the normal value (<35 U/ml) was found in 28 of the 49 patients (57%). Compared to patients with normal CA 125 levels, those with elevated CA 125 had a higher NYHA class and increased serum BNP levels, LAVI and E/e. In multivariate analysis, serum CA 125 levels were significantly associated with BNP (standardized beta coefficient=0.58, p<0.001) and LAVI (standardized beta coefficient 0.34, p<0.005). CONCLUSION: Our study demonstrates that elevated serum CA 125 levels are associated with increased LAVI in parallel to increased neurohormonal activation in patients with AHF.

Effects of levosimendan versus dobutamine on left atrial function in decompensated heart failure.

BACKGROUND: Although the effects of levosimendan on the left ventricle (LV) have been studied, its effect on left atrial (LA) function is poorly understood, despite its key role in optimizing LV function. OBJECTIVE: To compare the effects of levosimendan and dobutamine on LA and LV function in patients with decompensated heart failure (DHF). METHODS: Seventy-four patients (mean [+/- SD] age 64+/-10 years) with DHF and an LV ejection fraction of 35% or lower were randomly assigned to receive levosimendan (n=37) or dobutamine (n=37). LA active emptying fraction, LA passive emptying fraction (PEF) and the ratio of mitral inflow early diastolic velocity to annulus velocity (E/e) were evaluated with pulsed wave and tissue Doppler imaging along with plasma B-type natriuretic peptide (BNP) level measurements before and after drug infusion. RESULTS: The ejection fraction was significantly increased in both groups. The levosimendan group had a greater decrease in BNP and a greater increase in active emptying fraction at 24 h compared with the dobutamine group. The PEF, E/e and deceleration time of the E wave were significantly improved in the levosimendan group, but not in the dobutamine group. Levosimendan- induced percentage change of BNP was significantly correlated with the percentage change of E/e and PEF (r=0.48 [P<0.005] and r=-0.38 [P<0.05], respectively). CONCLUSIONS: In patients with DHF, levosimendan and dobutamine both improve LV systolic function. However, levosimendan also improves LV diastolic function and LA performance in parallel with a greater improvement in neurohormonal activation compared with dobutamine.