Artificial intelligence in detecting left atrial appendage thrombus by transthoracic echocardiography and clinical features: the Left Atrial Thrombus on Transoesophageal Echocardiography (LATTEE) registry.

AIMS: Transoesophageal echocardiography (TOE) is often performed before catheter ablation or cardioversion to rule out the presence of left atrial appendage thrombus (LAT) in patients on chronic oral anticoagulation (OAC), despite associated discomfort. A machine learning model [LAT-artificial intelligence (AI)] was developed to predict the presence of LAT based on clinical and transthoracic echocardiography (TTE) features. METHODS AND RESULTS: Data from a 13-site prospective registry of patients who underwent TOE before cardioversion or catheter ablation were used. LAT-AI was trained to predict LAT using data from 12 sites (n = 2827) and tested externally in patients on chronic OAC from two sites (n = 1284). Areas under the receiver operating characteristic curve (AUC) of LAT-AI were compared with that of left ventricular ejection fraction (LVEF) and CHA2DS2-VASc score. A decision threshold allowing for a 99% negative predictive value was defined in the development cohort. A protocol where TOE in patients on chronic OAC is performed depending on the LAT-AI score was validated in the external cohort. In the external testing cohort, LAT was found in 5.5% of patients. LAT-AI achieved an AUC of 0.85 [95% confidence interval (CI): 0.82-0.89], outperforming LVEF (0.81, 95% CI 0.76-0.86, P < .0001) and CHA2DS2-VASc score (0.69, 95% CI: 0.63-0.7, P < .0001) in the entire external cohort. Based on the proposed protocol, 40% of patients on chronic OAC from the external cohort would safely avoid TOE. CONCLUSION: LAT-AI allows accurate prediction of LAT. A LAT-AI-based protocol could be used to guide the decision to perform TOE despite chronic OAC.

Bicuspid aortic valve morphology and its impact on aortic diameters-A systematic review with meta-analysis and meta-regression.

AIM: To evaluate the impact of the 2 most common bicuspid aortic valve (BAV) morphology patterns [right-left (RL) vs right-noncoronary (RN) cusp fusion] on the aortic diameters and the impact of gender, aortic stenosis (AS), aortic regurgitation (AR), and age on the observed effects. METHODS: The PubMed databases was searched up to December 31, 2016 to identify studies investigating the morphology of BAV and aortic diameters. Inclusion criteria were as follows: the data on diameter of sinuses of Valsalva (SVD) and/or ascending aorta (AAD) and BAV morphology. The additional characteristics [gender, AS and AR (% of patients with moderate or severe AS/AR) and mean age] were collected to perform a meta-regression analysis. RESULTS: A total of 12 studies with 2192 patients with indexed AAD, 15 studies with 3104 patients with nonindexed AAD and 8 studies with 1271 patients with indexed SVD, and 16 studies with 3454 patients with nonindexed SVD were included. There was no difference between RL and RN group in indexed/nonindexed AAD-mean difference (MD): 0.06 mm/m2 (95% CI: -0.65 to 0.77 mm/m2 , P = .87) and -0.06 mm (95% CI: 1.10-0.97 mm, P = .91). Differently, the RL BAV was associated with larger indexed/nonindexed SVD than RN phenotype-MD: 1.66 mm/m2 (95% CI: 0.83-2.49 mm/m2 , P < .001) and 2.03 mm (95% CI: 0.97-3.09 mm, P < .001). Age, gender, AS, and AR had no influence on observed differences. CONCLUSIONS: RL BAV phenotype is associated with larger SVD than RN BAV, and the observed differences are independent from aortic valve dysfunction degree, age, and gender.

Incremental value of left atrial mechanical dispersion over CHA2 DS2 -VASc score in predicting risk of thrombus formation.

PURPOSE: To assess the potential ability of two-dimensional speckle tracking analysis (STE) during atrial fibrillation (AF) to identify patients with LA appendage thrombi (LAAT). METHODS: This study involved 93 patients with AF (39% female, 67.1 ± 9.5 years) who were referred for a clinical indication for transesophageal echocardiography (TEE). TEE revealed LAAT in 39 (42%) patients. We analyzed standard parameters of the left ventricle (LV) and LA in transthoracic echocardiography. Using STE, we assessed LV global longitudinal strain (LVGLS), peak atrial longitudinal strain (PALS), and intra-atrial asynchrony. The PALS was calculated using the global strain curve (GPALS) and as the mean of peaks derived from segmental strain curves (MPALS). RESULTS: Patients were comparable with regard to the clinical data. A subgroup with LAAT had lower LV ejection fraction (LVEF) and a lower absolute value of the LVGLS, as well as greater impairment in the LA standard parameters, PALS, and asynchrony. Receiver operating characteristic curve analysis revealed that the LVEF of 30% (P < .001), the LVGLS of -7% (P < .0001), the GPALS of 11% (P < .005), and the LA asynchrony of 22% (P < .01) were the optimal cutoff values for distinguishing both subgroups. LA asynchrony, LVEF, and LVGLS were independently associated with the presence of LAAT in multivariate analyses, and PALS had additional significance over the CHA2 DS2 -VASc score. CONCLUSIONS: Left ventricular systolic dysfunction characterized by both LVEF and LVGLS is an independent factor for LAAT. LA asynchrony provides additional diagnostic value for discriminating between patients with and without LAAT.

The impact of the latest echocardiographic chamber quantification recommendations on the prediction of left atrial appendage thrombus presence by transthoracic echocardiography.

INTRODUCTION: The latest recommendations for echocardiographic chamber quantification have implemented updated normal values for all cardiac chambers. PURPOSE: To evaluate the incidence of normal and abnormal values of routine echocardiographic parameters such as left ventricular ejection fraction (LVEF) and left atrial volume indexed to body surface area (LAVi) in patients with non-valvular atrial fibrillation (AF) and to determine the influence of LVEF and LAVi reclassification on the prediction of LAAT by transthoracic echocardiography. METHODS: We retrospectively analysed the database of 1674 transesophageal echocardiograms performed between 2012 and 2015 in our echo lab. The study involved patients (mean age 70 ± 7 years, 80% men) with paroxysmal or persistent AF (35 patients with left atrial appendage thrombus [LAAT] and 35 sex- and age-matched controls without LAAT). LVEF and LAVi were categorised in two ways: semi-quantitative using four-degree scale (normal or abnormal graded from mild and moderate to severe) and qualitative (normal vs. abnormal). RESULTS: We reclassified 6 (9%) and 4 (6%) patients with regard to LVEF as well as 38 (54%) and 16 (23%) with regard to LAVi on semi-quantitative and qualitative scale, respectively. After adjustment for effective anticoagulation and approved risk factors in the multivariate models, we identified LVEF categorised in semi-quantitative manner according to both documents, LAVi categorised in a binary manner by new guidelines and semi-quantitative scale by both recommendations as independently associated with LAAT. CONCLUSIONS: Differentiation between normal and abnormal value enhanced the diagnostic meaning of LAVi in the aspect of higher LAAT risk. LVEF reclassification had no significant influence.

Left Atrial Dysfunction Assessed by Two-Dimensional Speckle Tracking Echocardiography in Patients with Impaired Left Ventricular Ejection Fraction and Sleep-Disordered Breathing.

AIMS: To evaluate the relationship between left atrial (LA) structure and deformation obtained by two-dimensional speckle tracking echocardiography (2DSTE): peak longitudinal systolic strain (LAs), peak longitudinal systolic strain rate (LAS-SR), peak longitudinal early diastolic strain rate (LAE-SR), peak longitudinal late diastolic strain rate (LAA-SR), and sleep-disordered breathing (SDB) estimated by means of apnea-hypopnea index (eAHI). METHODS: Thirty-two individuals with ischemic heart disease (IHD) and impaired left ventricular ejection fraction (EF < 50%) were included in the study. LA function was assessed using 2DSTE. eAHI index was calculated by means of the 24-hour ambulatory Holter electrocardiogram monitoring. Patients were categorized into two subgroups: SDB group (eAHI ≥ 15; n = 15) and non-SDB group (eAHI < 15; n = 17). RESULTS: All 2DSTE parameters were decreased in the SDB group: LAS-SR (0.90 [0.60-1.25] 1/sec vs. 1.25 [1.00-1.27] 1/sec, P = 0.043), LAE-SR (-0.76 ± 0.49 1/sec vs. -1.18 ± 0.55 1/sec, P = 0.033), and LAA-SR (-1.26 ± 0.71 1/sec vs. -1.48 ± 0.75 1/sec, P = 0.049). The eAHI was negatively correlated with LA reservoir function: LAS (r = -0.53, P = 0.002) and LAS-SR (r = -0.47, P = 0.006), while it is positively correlated with LAE-SR (r = 0.67, P < 0.001) and LAA-SR (r = 0.46, P = 0.009). Moreover, SDB severity was an independent predictor of impaired LA compliance (P = 0.016) and conduit function (P = 0.002) in multivariate linear regression model, even after adjustment for age, BMI, gender, LV systolic (EF), and diastolic (E/e') function and comorbidities. CONCLUSIONS: LA dysfunction and remodeling assessed using 2DSTE in patients with impaired systolic LV function, and IHD is influenced by the severity of sleep apnea independently from LV function.

The use of artificial intelligence for predicting postinfarction myocardial viability in echocardiographic images.

BACKGROUND: Evaluation of standard echocardiographic examination with artificial intelligence may help in the diagnosis of myocardial viability and function recovery after acute coronary syndrome. METHODS: Sixty-one consecutive patients with acute coronary syndrome were enrolled in the present study (43 men, mean age 61 ± 9 years). All patients underwent percutaneous coronary intervention (PCI). 533 segments of the heart echo images were used. After 12 ± 1 months of follow-up, patients had an echocardiographic evaluation. After PCI each patient underwent cardiac magnetic resonance (CMR) with late enhancement and low-dose dobutamine echocardiographic examination. For texture analysis, custom software was used (MaZda 5.20, Institute of Electronics).Linear and non-linear (neural network) discriminative analyses were performed to identify the optimal analytic method correlating with CMR regarding the necrosis extent and viability prediction after follow-up. Texture parameters were analyzed using machine learning techniques: Artificial Neural Networks, Namely Multilayer Perceptron, Nonlinear Discriminant Analysis, Support Vector Machine, and Adaboost algorithm. RESULTS: The mean concordance between the CMR definition of viability and three classification models in Artificial Neural Networks varied from 42% to 76%. Echo-based detection of non-viable tissue was more sensitive in the segments with the highest relative transmural scar thickness: 51-75% and 76-99%. The best results have been obtained for images with contrast for red and grey components (74% of proper classification). In dobutamine echocardiography, the results of appropriate prediction were 67% for monochromatic images. CONCLUSIONS: Detection and semi-quantification of scar transmurality are feasible in echocardiographic images analyzed with artificial intelligence. Selected analytic methods yielded similar accuracy, and contrast enhancement contributed to the prediction accuracy of myocardial viability after myocardial infarction in 12 months of follow-up.

European Association of Cardiovascular Imaging survey on the evaluation of mitral regurgitation.

AIMS: To evaluate the diagnosis and imaging of patients with mitral regurgitation (MR) and the management in routine clinical practice across Europe, the European Association of Cardiovascular Imaging Scientific Initiatives Committee performed a survey across European centres. In particular, the routine use of echocardiography, advanced imaging modalities, heart valve clinics, and heart valve teams was explored. METHODS AND RESULTS: A total of 61 responders, mainly from tertiary centres or university hospitals, from 26 different countries responded to the survey, which consisted of 22 questions. For most questions related to echocardiography and advanced imaging, the answers were relatively homogeneous and demonstrated good adherence to current recommendations. In particular, the centres used a multi-parametric echocardiographic approach and selected the effective regurgitant orifice and vena contracta width as their preferred assessments. 2D measurements are still the most widely used parameters to assess left ventricular structure; however, the majority use 3D trans-oesophageal echocardiography (TOE) to evaluate valve morphology in severe MR. The majority of centres reported the onsite availability and clinical use of ergometric stress echocardiography, cardiac computed tomography (CCT), and cardiac magnetic resonance (CMR) imaging. Heart valve clinics and heart valve teams were also widely prevalent. CONCLUSION: Consistent with current guidelines, echocardiography (transthoracic echocardiography and TOE) remains the first-line and central imaging modality for the assessment of MR although the complementary use of 3D TOE, CCT, and CMR appears to be growing. Heart valve clinics and heart valve teams are now widely prevalent.

Can transesophageal echocardiography be safely omitted in patients scheduled for elective ablation of atrial arrhythmias? Data based on the LATTEE registry.

BACKGROUND: According to the present guidelines, transesophageal echocardiography (TEE) before scheduled catheter ablation (CA) for atrial arrhythmias (atrial fibrillation [AF] or atrial flutter [AFL]) is not deemed obligatory for optimally anticoagulated patients. However, daily clinical practice significantly differs from the recommendations. AIMS: We aimed to identify transthoracic echocardiographic parameters that could be useful in identifying patients without left atrial thrombus (LAT), which makes it possible to avoid unnecessary TEE before scheduled CA. METHODS: This is a sub-analysis of a multicenter, prospective, observational study - the LATTEE registry. A total of 1346 patients referred for TEE before scheduled CA of AF/AFL were included. RESULTS: LAT was present in 44 patients (3.3%) and absent in the remaining 1302, who were younger, more likely to have paroxysmal AF, and displayed sinus rhythm during TEE. Additionally, they exhibited a lower incidence of heart failure, diabetes, systemic connective tissue disease, and chronic obstructive pulmonary disease. Furthermore, they had a lower CHA2DS2-VASc score and a higher prevalence of direct oral anticoagulants. Echocardiographic parameters, including left ventricular ejection fraction (LVEF) >65%, left atrial diameter (LAD) <40 mm, left atrial area (LAA) <20 cm2, left atrial volume (LAV) <113 ml, and left atrial volume index (LAVI) <51 ml/m2, demonstrated 100% sensitivity and 100% negative predictive value for the absence of LAT and were met by 417 patients. Additional echocardiographic indices: LVEF/LAD ≥1.4, LVEF/LAVI ≥1.6, and LVEF/LAA ≥2.7 identified 57 additional patients, bringing the total of predicted LAT-free patients to 474 (35%). CONCLUSIONS: Simple echocardiographic parameters could help identify individuals for whom TEE could be safely omitted before elective CA due to atrial arrhythmias.

EACVI SIMULATOR-online study: evaluation of transoesophageal echocardiography knowledge and skills of young cardiologists.

AIMS: To assess the level of transesophageal echocardiography (TOE) knowledge and skills of young cardiologists. METHODS AND RESULTS: A European Association of Cardiovascular Imaging (EACVI) online study using the first fully virtual simulation-based software was conducted in two periods (9-12 December 2021 and 10-13 April 2022). All young cardiologists eligible to participate (<40 years) across the world were invited to participate. After a short survey, each participant completed two tests: a theoretical test to assess TOE knowledge and a practical test using an online TOE simulator to investigate TOE skills. Among 716 young cardiologists from 81 countries, the mean theoretical test score was 56.8 ± 20.9 points, and the mean practical test score was 47.4 ± 7.2 points (/100 points max each), including 18.4 ± 8.7 points for the acquisition test score and 29.0 ± 6.7 points for the anatomy test score (/50 points max each). Acquisition test scores were higher for four-chamber (2.3 ± 1.5 points), two-chamber (2.2 ± 1.4 points) and three-chamber views (2.3 ± 1.4 points) than for other views (all P < 0.001). Prior participation to a TOE simulation-based training session, a higher number of TOE exams performed per week, and EACVI certification for TOE were independently associated with a higher global score (all P < 0.001). CONCLUSION: Online evaluation of young cardiologists around the world showed a relatively low level of TOE skills and knowledge. Prior participation to a TOE simulation-based training session, a higher number of TOE exams performed per week, and the EACVI certification for TOE were independently associated with a higher global score.

Diagnostic utility and clinical usefulness of the pocket echocardiographic device.

BACKGROUND: The pocket echocardiograph (PE) with color Doppler imaging belongs to a new class of diagnostic tools, the feasibility and accuracy of which is not well established. The aim of this study was to assess the feasibility and diagnostic value of transthoracic echocardiography (TTE) performed with the use of PE by a cardiology resident (2nd year of training) and by an experienced cardiologist. METHODS: The study population comprised 220 consecutive patients (142 men, mean age 63 ± 8 years), 110 of whom were admitted to our intensive cardiac care unit (ICU) and 110 patients referred for TTE from the outpatient clinic. All patients had PE TTE performed by a resident (60 ICU patients, 60 outpatients) or a cardiologist (50 ICU patients, 50 outpatients). Within 24 h of PE TTE, all subjects had a standard TTE (sTTE) performed by an experienced echocardiographer. RESULTS: 96% of patients had echocardiographic measurements completed by both PE TTE and sTTE. The dimensions measured with PE TTE by the resident and the cardiologist showed good to excellent correlation with sTTE (r = 0.64-0.96, P < 0.001). The agreement in detection of various pathologies between PE TTE performed by the resident and sTTE examinations was moderate to very good, whereas it was good to excellent if PE TTE was performed by the experienced cardiologist. CONCLUSION: The diagnostic accuracy of the PE in basic assessment of cardiac morphology and function as compared to standard echocardiography is moderate to very good for a cardiology resident and good to excellent for an experienced cardiologist. (Echocardiography 2012;29:1-6).

Relationship of Mechanical Dyssynchrony and LV Remodeling With Improvement of Mitral Regurgitation After CRT.

OBJECTIVES: The aim of this study was to explore the association between mechanical dyssynchrony of the left ventricle before cardiac resynchronization therapy (CRT) and improvement of mitral regurgitation (MR) after CRT. BACKGROUND: MR is very frequent among patients with dilated cardiomyopathy and conduction delay. METHODS: Echocardiograms (pre-CRT and 12 ± 3.8 months thereafter) of 314 patients with dilated cardiomyopathy and any degree of MR, who underwent CRT device implantation according to guidelines, were analyzed. Left ventricular (LV) mechanical dyssynchrony was assessed by apical rocking (ApRock) and septal flash (SF), while MR severity was graded from I to IV on the basis of vena contracta width, regurgitation jet size, and proximal isovelocity surface area. RESULTS: At baseline, 30% of patients presented with severe MR (grade III or IV). In 62% of patients, MR decreased after CRT, and these patients more frequently had left bundle branch block, had more severe MR, had more dilated left ventricles, had lower ejection fractions, and more often had ApRock and SF. Reverse remodeling was more frequent among patients with MR reduction (ΔLV end-systolic volume -35.5% ± 27.2% vs -4.1% ± 33.2%; P < 0.001). In a multivariable logistic stepwise regression, only ApRock (odds ratio [OR]: 3.8; 95% CI: 1.7-8.5; P = 0.001), SF (OR: 3.6; 95% CI: 1.6-7.9; P = 0.002), and baseline MR (OR: 1.4; 95% CI: 1.0-1.9; P = 0.046) remained significantly associated with MR reduction. CONCLUSIONS: ApRock, SF, and severity of MR at baseline are strongly associated with MR reduction after CRT, while LV reverse remodeling is its underlying mechanism. Therefore, in patients with heart failure with LV dyssynchrony on optimal medical treatment, CRT should be the primary treatment attempt for relevant MR.

EACVI survey on the multi-modality imaging assessment of the right heart.

AIMS: The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey to evaluate the use of different cardiac imaging modalities for the evaluation of the right heart. METHODS AND RESULTS: Delegates from 250 EACVI registered centres were invited to participate in a survey which was also advertised on the EACVI bulletin and on social media. One hundred and thirty-eight respondents from 46 countries across the world responded to the survey. Most respondents worked in tertiary centres (79%) and echocardiography was reported as the commonest imaging modality used to assess the right ventricle (RV). The majority of survey participants (78%) included RV size and function in >90% of their echocardiographic reports. The RV basal diameter obtained from the apical four-chamber view and the tricuspid annular plane systolic excursion were the commonest parameters used for the echocardiographic assessment of RV size and function as reported by 82 and 97% respondents, respectively. Survey participants reported arrhythmogenic cardiomyopathy as the commonest condition (88%) where cardiac magentic resonance (CMR) imaging was used for right heart assessment. Only 52% respondents included RV volumetric and ejection fraction assessments routinely in their CMR reports, while 30% of respondents included these parameters only when RV pathology was suspected. Finally, 73% of the respondents reported pulmonary hypertension as the commonest condition where right heart catheterization was performed. CONCLUSION: Echocardiography remains the most frequently used imaging modality for the evaluation of the right heart, while the use of other imaging techniques, most notably CMR, is increasing.

Left atrial strain determinants and clinical features according to the heart failure stages. New insight from EACVI MASCOT registry.

Few studies analyzed left atrial (LA) peak atrial longitudinal strain (PALS) determinants, particularly across heart failure (HF) stages. We aimed to analyze the pathophysiological and clinical PALS correlates in a large multicentric prospective study. This is a multicenter prospective observational study enrolling 745 patients with HF stages. Data included PALS and left ventricular global longitudinal strain (LV-GLS). Exclusion criteria were: valvular prosthesis; atrial fibrillation; cardiac transplantation; poor acoustic window. Median global PALS was 17% [24-32]. 29% of patients were in HF-stage 0/A, 35% in stage-B, and 36% in stage-C. Together with age, the echocardiographic determinants of PALS were LA volume and LV-GLS (overall model R2 = 0.50, p < 0.0001). LV-GLS had the strongest association with PALS at multivariable analysis (beta: -3.60 ± 0.20, p < 0.0001). Among HF stages, LV-GLS remained the most important PALS predictor (p < 0.0001) whereas age was only associated with PALS in lower HF-stage 0/A or B (R = - 0.26 p < 0.0001, R = - 0.23 p = 0.0001). LA volume increased its association to PALS moving from stage 0/A (R = - 0.11; P = 0.1) to C (R = - 0.42; P < 0.0001). PALS was the single most potent echocardiographic parameter in predicting the HF stage (AUC for B vs. 0/A 0.81, and AUC vs. 0/A for C 0.76). PALS remained independently associated with HF stages after adjusting for ejection fraction, E/e' ratio, and mitral regurgitation grade (p < 0.0001). Although influenced by LV-GLS and LA size across HF stages, PALS is incrementally and independently associated with clinical status. LA function may reflect a substantial part of the hemodynamic consequences of ventricular dysfunction.

Left Atrial Thrombus in Atrial Fibrillation/Flutter Patients in Relation to Anticoagulation Strategy: LATTEE Registry.

Background: Atrial fibrillation (AF) and flutter (AFl) increase the risk of thromboembolism. The aim of the study was to assess the prevalence of left atrial thrombus (LAT) in AF/AFl in relation to oral anticoagulation (OAC). Methods: LATTEE (NCT03591627) was a multicenter, prospective, observational study enrolling consecutive patients with AF/AFl referred for transesophageal echocardiography before cardioversion or ablation. Results: Of 3109 patients enrolled, 88% were on chronic, 1.5% on transient OAC and 10% without OAC. Of patients on chronic OAC, 39% received rivaroxaban, 30% dabigatran, 14% apixaban and 18% vitamin K antagonists (VKA). Patients on apixaban were oldest, had the worst renal function and were highest in both bleeding and thromboembolic risk, and more often received reduced doses. Prevalence of LAT was 8.0% (7.3% on chronic OAC vs. 15% without OAC; p < 0.01). In patients on VKA, prevalence of LAT was doubled compared to patients on non-VKA-OACs (NOACs) (13% vs. 6.0%; p < 0.01), even after propensity score weighting (13% vs. 7.5%; p < 0.01). Prevalence of LAT in patients on apixaban was higher (9.8%) than in those on rivaroxaban (5.7%) and dabigatran (4.7%; p < 0.01 for both comparisons), however, not after propensity score weighting. Conclusions: The prevalence of LAT in AF is non-negligible even on chronic OAC. The risk of LAT seems higher on VKA compared to NOAC, and similar between different NOACs.

Echocardiographic predictors of thrombus in left atrial appendage-The role of novel transthoracic parameters.

Introduction: The left atrium appendage thrombus (LAAT) formation is a complex process. A CHA2DS2-VASc scale is an established tool for determining the thromboembolic risk and initiation of anticoagulation treatment in patients with atrial fibrillation or flutter (AF/AFL). We aimed to identify whether any transthoracic echocardiography (TTE) parameters could have an additional impact on LAAT detection. Methods: That is a sub-study of multicenter, prospective, observational study LATTEE (NCT03591627), which enrolled 3,109 consecutive patients with AF/AFL referred for transesophageal echocardiography (TEE) before cardioversion or ablation. Results: LAAT was diagnosed in 8.0% of patients. The univariate logistic regression analysis [based on pre-specified in the receiver operating characteristic (ROC) analysis cut-off values with AUC ≥ 0.7] identified left ventricular ejection fraction (LVEF) ≤ 48% and novel TTE parameters i.e., the ratios of LVEF and left atrial diameter (LAD) ≤ 1.1 (AUC 0.75; OR 5.64; 95% CI 4.03-7.9; p < 0.001), LVEF to left atrial area (LAA) ≤ 1.7 (AUC 0.75; OR 5.64; 95% CI 4.02-7.9; p < 0.001), and LVEF to indexed left atrial volume (LAVI) ≤ 1.1 (AUC 0.75, OR 6.77; 95% CI 4.25-10.8; p < 0.001) as significant predictors of LAAT. In a multivariate logistic regression analysis, LVEF/LAVI and LVEF/LAA maintained statistical significance. Calculating the accuracy of the abovementioned ratios according to the CHA2DS2-VASc scale values revealed their highest predictive power for LAAT in a setting with low thromboembolic risk. Conclusion: Novel TTE indices could help identify patients with increased probability of the LAAT, with particular applicability for patients at low thromboembolic risk.

Heart failure and the risk of left atrial thrombus formation in patients with atrial fibrillation or atrial flutter.

AIMS: The aim of the study was to evaluate the prevalence of left atrial thrombus (LAT) on transoesophageal echocardiography (TOE) in patients with atrial fibrillation or atrial flutter (AF/AFl) with reference to the presence of heart failure (HF) and its subtypes. METHODS AND RESULTS: The research is a sub-study of the multicentre, prospective, observational Left Atrial Thrombus on Transoesophageal Echocardiography (LATTEE) registry, which comprised 3109 consecutive patients with AF/AFl undergoing TOE prior to direct current cardioversion or catheter ablation. TOE parameters, including presence of LAT, were compared between patients with and without HF and across different subtypes of HF, including HF with preserved (HFpEF), mid-range (HFmrEF), and reduced ejection fraction (HFrEF). HF was diagnosed in 1336 patients (43%). HF patients had higher prevalence of LAT than non-HF patients (12.8% vs. 4.4%; P < 0.001). LAT presence increased with more advanced type of systolic dysfunction (HFpEF vs. HFmrEF vs. HFrEF: 7.4% vs. 10.5% vs. 20.3%; P < 0.001). Univariate analysis revealed that HFrEF (odds ratio [OR] 4.13; 95% confidence interval [95% CI]: 3.13-5.46), but not HFmrEF or HFpEF, was associated with the presence of LAT. Multivariable logistic regression indicated that lower left ventricular ejection fraction (OR per 1%: 0.94; 95% CI 0.93-0.95) was an independent predictor of LAT formation. Receiver operator characteristic analysis showed LVEF ≤48% adequately predicted increased risk of LAT presence (area under the curve [AUC] 0.74; P < 0.0001). CONCLUSION: The diagnosis of HFrEF, but neither HFmrEF nor HFpEF, confers a considerable risk of LAT presence despite widespread utilization of adequate anticoagulation.

Increased Body Mass Index and Risk of Left Atrial Thrombus in Nonvalvular Atrial Fibrillation Patients-Data from the Left Atrial Thrombus on Transesophageal Echocardiography (LATTEE) Registry.

An increased body mass index (BMI) is associated with a higher incidence of atrial fibrillation (AF) and a higher risk of thromboembolic complications in AF patients. The aim of this study was to investigate the effect of BMI on the risk of left atrial thrombi (LATs) in patients with nonvalvular AF/atrial flutter (AFl) (NV AF/AFl). Patients diagnosed with NVAF/AFl (between November 2018 and May 2020) were selected from the multicenter, prospective, observational Left Atrial Thrombus on Transesophageal Echocardiography (LATTEE) registry that included AF/AFl patients referred for cardioversion or ablation followed by transesophageal echocardiography. A total of 2816 AF/AFl patients (63.6% males; mean age 65.8 years; mean BMI 29.8 kg/m2) were included in the study. Two hundred and twenty-two of them (7.9%) had LATs. Compared with normal-weight patients, those with BMIs ≥ 25 kg/m2 more frequently presented clinical factors potentially provoking LATs, such as non-paroxysmal AF/AFl (p = 0.04), hypertension (p < 0.001), and diabetes (p < 0.001); had higher CHA2DS2 scores (p < 0.001); and had larger LA dimensions (LA diameter and LA area) (p < 0.001 for both parameters). On the other hand, they showed some features negatively related to thromboembolic risk; for example, they were younger (p < 0.001) and were more often male (p = 0.002). In addition, patients with abnormal BMIs were more likely to be smokers (p = 0.006) and to be treated with oral anticoagulants (p = 0.005). Despite these differences in the prevalence of thromboembolic risk factors, the incidence of LATs was not increased in patients with abnormal body weight (overweight and obese compared to normal-weight patients) in this large real-life cohort of AF/AFl patients. This is probably due to the balanced composition regarding the prevalence of positive and negative thromboembolic risk factors.

Risk factors for left atrial thrombus in younger patients (aged < 65 years) with atrial fibrillation or atrial flutter: Data from the multicenter left atrial thrombus on transesophageal echocardiography (LATTEE) registry.

Background: Our aim was to assess the characteristics and to identify predictors of left atrial thrombus (LAT) in patients under age 65 with atrial fibrillation (AF) or atrial flutter (AFl). Methods: We conducted a subanalysis of a multicenter, prospective, observational study [the LATTEE registry]. Consecutive AF/AFl patients referred for cardioversion or ablation were enrolled. Results: Of the 3,109 patients included in the study, 1,276 were under age 65 (41%). Compared to non-LAT patients, those with LAT (n = 76) had higher CHA2DS2-VASc score (p < 0.001), more frequently had non-paroxysmal AF/AFl (p < 0.001), heart failure (p < 0.001), history of diabetes mellitus (p = 0.001), transient ischemic attack (p = 0.04), coronary artery disease (p = 0.02), and chronic kidney disease (p < 0.001). The LAT patients were also more often smokers (p = 0.004) and were more frequently treated with vitamin K antagonists (VKAs) (p < 0.001). Transthoracic echocardiography revealed a higher left atrial area (p < 0.001), lower left ventricular ejection fraction (LVEF) (p < 0.001), and lower value of LA appendage emptying volume in LAT than in non-LAT patients (p < 0.001). LVEF (OR 2.95; 95% CI: 1.32-6.59, p = 0.008), non-paroxysmal AF/AFl (OR 7.1; 95% CI: 2.05-24.63, p = 0.002) and treatment with VKAs (OR 4.92; 95% CI: 2.48-9.75, p < 0.001) were identified as independent predictors of LAT in younger patients. Conclusions: Our study, which focused on younger patients with AF/AFl, indicated substantial clinical and echocardiographic differences between participants with and without LAT. In the AF/AFl patients younger than age 65, the independent predictors of LAT included non-paroxysmal AF/AFl, lower LVEF, and treatment with VKAs.

Usefulness of three-dimensional echocardiography for evaluation of pathological mass in the right atrium.

The authors present a case of 51-year-old male patient with symptoms of congestive heart failure. Two-dimensional transthoracic echocardiography (2D TTE) at the time of admission revealed a spherical, highly mobile structure in the right atrium (4.5 cm in diameter). Despite using multiple views it was impossible to distinguish if this structure had a stalk or was free-floating. The real time three-dimensional transthoracic echocardiography (3D TTE) revealed the presence of thin stalk attached to the roof of the right atrium. Guidance of 2D TTE by 3D TTE findings finally allowed the recognition of the stalk in modified subcostal view.

Pharmacotherapy of atrial fibrillation in COVID-19 patients.

The coronavirus pandemic disease 2019 (COVID-19) has changed the face of contemporary medicine. However, each and every medical practitioner must be aware of potential early and late complications of COVID-19, its impact on chronic diseases - especially ones as common as atrial fibrillation (AF) - and the possible interactions between patients' chronic medications and pharmacotherapy of COVID-19. Patients with AF due to comorbidities and, often, elderly age are assumed to be at a higher risk of a severe course of COVID-19. This expert consensus summarizes the current knowledge regarding the pharmacotherapy of AF patients in the setting of the COVID-19 pandemic. In general, anticoagulation principles in quarantined or asymptomatic individuals remain unchanged. Nevertheless, it is advisable to switch from vitamin K antagonists to non-vitamin K antagonist oral anticoagulants (NOACs) whenever possible due to their consistent benefits and safety with fixed dosing and no monitoring. Additionally, in AF patients hospitalized due to mild or moderate COVID-19 pneumonia, we recommend continuing NOAC treatment or to switching to low-molecular-weight heparin (LMWH). On the other hand, in severely ill patients hospitalized in intensive care units, intravenous or subcutaneous dosing is preferable to oral, which is why the treatment of choice is either LMWH or unfractionated heparin. Finally, particularly in critical scenarios, the treatment strategy in COVID-19 patients with AF should be individualized based on possible interactions between anticoagulants, antiarrhythmics, antivirals, and antibiotics. In this consensus, we also discuss how to safely perform COVID-19 vaccination in anticoagulated AF patients.