Rare Case of a Giant Left Atrium With Cerebrovascular Accident.

Left atrium enlargement is very common in patients with valvular heart disease and atrial fibrillation but an extremely dilated left atrium is a very rare condition and rarely reported in the literature. It is a risk factor for ischemic cerebrovascular accidents due to blood stasis as the cavity diameter increases. We are reporting a case of rarely seen severely dilated left atrium with a normal functioning prosthetic mechanical mitral valve with a cerebrovascular accident on anti-vitamin K and aspirin. The patient had a left atrium diameter of 12.7 cm, an area of 200 cm square, and a volume of 2000 cc. We elected to keep the international normalized ratio (INR) slightly above the therapeutic range in order to decrease the risk of ischemic events. It might be necessary to do the same for patients with a similar condition to decrease the stroke rates.

Three-dimensional transoesophageal echocardiography for cardiac output in critically ill patients: A pilot study of ultrasound versus the thermodilution method.

BACKGROUND: Three-dimensional transoesophageal echocardiography (3D-TOE) is a new noninvasive tool for quantitative assessment of left ventricular (LV) volumes and ejection fraction. AIM: The objective of this pilot study was to evaluate the feasibility and accuracy of 3D-TOE for the estimation of cardiac output (CO), using transpulmonary thermodilution with the Pulse index Contour Continuous Cardiac Output (PiCCO) system as the reference method, in intensive care unit (ICU) patients. METHODS: Fifteen ICU patients on mechanical ventilation prospectively underwent PiCCO catheter implantation and 3D-TOE. 3D-TOE LV end-diastolic and end-systolic volumes were determined using semi-automated software. CO was calculated as the product of LV stroke volume (end-diastolic volume-end-systolic volume) multiplied by heart rate. CO was also determined invasively by transpulmonary thermodilution as the reference method. RESULTS: Among 30 haemodynamic evaluations, 29 (97%) LV 3D-TOE datasets were suitable for CO calculation. The mean 3D-TOE image acquisition and post-processing times were 46 and 155seconds, respectively. There was a correlation (r=0.78; P<0.0001) between PiCCO and 3D-TOE CO. Compared with PiCCO, the 3D-TOE CO mean bias was 0.38L/min, with limits of agreement of -1.97 to 2.74L/min. CONCLUSIONS: Noninvasive estimation of CO by 3D-TOE is feasible in ICU patients. This new semi-automated modality is an additional promising tool for noninvasive haemodynamic assessment of ICU patients. However, the wide limits of agreement with thermodilution observed in this pilot study require further investigation in larger cohorts of patients.

Left atrial volume predicts abnormal exercise left ventricular filling pressure.

AIMS: Latent heart failure at rest can be observed in a number of patients upon exercise. Considering left atrial (LA) remodelling as the reflection of the cumulative effects of the LV filling pressure (FP) over time, our aim was to investigate whether the LA volume would predict abnormal exercise LVFP. METHODS AND RESULTS: Ninety patients (58.6 ± 10.8 years, 74 men) underwent exercise echocardiography. The LA maximal volume was measured by the Simpson method and indexed to body surface area. LVFP was assessed by the ratio between early peak diastolic velocities of mitral inflow and the septal annular mitral plane (E/e'). Exercise E/e' >13 was used as a threshold to define abnormal LVFP. Indexed LA volume was correlated with E/e' at rest (r = 0.37, P = 0.003), but the correlation was better with exercise E/e' (r = 0.54, P < 0.0001). In multivariate analysis, age, LV end-diastolic volume index, LVEF, and exercise E/e' were the independent determinants of LA volume index (R(2) = 0.47, P < 0.0001). Eleven patients had exercise E/e' >13; compared with the rest of the population, these patients were older and achieved a milder effort. LA volume index >33 mL/m(2) predicted an abnormal exercise LVFP with a 91% sensitivity and a 78% specificity. None of the patients with an LA volume index <26 mL/m(2) (n = 31, 34%) had an exercise E/e' >13. CONCLUSION: Exercise LVFP is a determinant of LA size. LA volume index seems to be helpful for predicting abnormal exercise LVFP. The potential use of LA remodelling to identify the patients benefitting most from exercise echocardiography should be investigated in larger studies.

Pretest probability of a normal echocardiography: validation of a simple and practical algorithm for routine use.

BACKGROUND: Management of increased referrals for transthoracic echocardiography (TTE) examinations is a challenge. Patients with normal TTE examinations take less time to explore than those with heart abnormalities. A reliable method for assessing pretest probability of a normal TTE may optimize management of requests. AIM: To establish and validate, based on requests for examinations, a simple algorithm for defining pretest probability of a normal TTE. METHODS: In a retrospective phase, factors associated with normality were investigated and an algorithm was designed. In a prospective phase, patients were classified in accordance with the algorithm as being at high or low probability of having a normal TTE. RESULTS: In the retrospective phase, 42% of 618 examinations were normal. In multivariable analysis, age and absence of cardiac history were associated to normality. Low pretest probability of normal TTE was defined by known cardiac history or, in case of doubt about cardiac history, by age>70 years. In the prospective phase, the prevalences of normality were 72% and 25% in high (n=167) and low (n=241) pretest probability of normality groups, respectively. The mean duration of normal examinations was significantly shorter than abnormal examinations (13.8 ± 9.2 min vs 17.6 ± 11.1 min; P=0.0003). CONCLUSION: A simple algorithm can classify patients referred for TTE as being at high or low pretest probability of having a normal examination. This algorithm might help to optimize management of requests in routine practice.