Which method of left atrium size quantification is the most accurate to recognize thromboembolic risk in patients with non-valvular atrial fibrillation?

BACKGROUND: Left atrial (LA) size is a predictor of cardiovascular outcomes in patients in sinus rhythm, whereas conflicting results have been found in atrial fibrillation (AF). This study aims to: (1) Evaluate the accuracy of LA size to identify surrogate markers of an increased thromboembolic risk in patients with AF; (2) Assess the best method to evaluate LA size in this setting. METHODS: Cross-sectional study enrolling 500 consecutive patients undergoing transthoracic and transesophageal echocardiography evaluation during a non-valvular AF episode. LA size was measured on transthoracic echocardiography using several methods: anteroposterior diameter, area in four-chamber view, and volumes by the ellipsoid, single- and biplane area-length formulas. Surrogate markers of stroke were evaluated by transesophageal echocardiography: LA appendage (LAA) thrombus, LAA low flow velocities, dense spontaneous echocardiographic contrast and LA abnormality. RESULTS: Except for non-indexed anteroposterior diameter, increased LA size quantified by all the other methods showed a moderate to high discriminatory power to identify all the surrogate markers of stroke. A higher accuracy was observed for indexed LA area in four-chamber view (LAA thrombus: AUC = 0.708, CI95% 0.644- 0.772, p<0.001; LAA low flow velocities: AUC = 0.733, CI95% 0.674- 0.793, p<0.001; dense spontaneous echocardiographic contrast: AUC = 0.693, CI95% 0.638- 0.748, p<0.001; LA abnormality: AUC = 0.705, CI95% 0.654-0.755, p<0.001), indexed single-plane area-length volume (LAA thrombus: AUC = 0.701, CI95% 0.633-0.770, p<0.001; LAA low flow velocities: AUC = 0.726, CI95% 0.660-0.792, p<0.001; dense spontaneous echocardiographic contrast: AUC = 0.673, CI95% 0.611-0.736, p<0.001; LA abnormality: AUC = 0.687, CI95% 0.629-0.744, p<0.001), and indexed biplane area-length volume (LAA thrombus: AUC = 0.707, CI95% 0.626-0.788, p<0.001; LAA low flow velocities: AUC = 0.737, CI95% 0.664-0.810, p<0.001; dense spontaneous echocardiographic contrast: AUC = 0.651, CI95% 0.578-0.724, p<0.001; LA abnormality: AUC = 0.683, CI95% 0.617-0.749, p<0.001), without significant difference between them. Indexed LA area in four-chamber view and indexed area-length volumes also were independent predictors of surrogate markers of stroke. CONCLUSIONS: Left atrium enlargement is associated with an increased prevalence of surrogate markers of stroke in patients with non-valvular AF. Indexed LA area in four-chamber view and indexed area-length volumes displayed the strongest association.

Decreased glomerular filtration rate and markers of left atrial stasis in patients with nonvalvular atrial fibrillation.

BACKGROUND: It is currently unknown if the increased risk of stroke in subjects with chronic kidney disease and atrial fibrillation (AF) is due to the presence of left atrial stasis or to any other vascular or systemic conditions. METHODS: This was a retrospective study of 372 subjects undergoing evaluation during an AF episode. The following markers of left atrial stasis were sought on transesophageal echocardiogram: left atrial or left atrial appendage thrombus (LAAT), dense spontaneous echocardiographic contrast (DSEC), and low flow velocities (LFV) in the left atrial appendage. Subgroup comparisons were performed according to the level of estimated glomerular filtration rate (eGFR) using the Chronic Kidney Disease Epidemiology Collaboration equation as follows: ≥90, 45-89.9, and <45 ml/min/1.73 m2. RESULTS: LAAT was found in 11.6%, DSEC in 29.0%, and LFV in 14.9% of cases. A significant increase in the prevalence of DSEC was observed in the lower categories of eGFR: 37.8% in eGFR <45 ml/min, 30.7% in eGFR 45-89.9 ml/min, and 17.0% in eGFR ≥90 ml/min (p = 0.009; γ for trend = 0.297, p = 0.002). The same was observed when assessing left atrial abnormality, i.e. the presence of at least one of the former transesophageal echocardiogram changes. On multivariate analysis, clinical parameters from CHADS2 (congestive heart failure, hypertension, age ≥75, diabetes mellitus and stroke) and CHA2DS2-VASc (age 65-74, history of vascular disease, and female gender along with the clinical variables from CHADS2) were predictors of transesophageal echocardiogram changes and an additive predictive value was found for eGFR. CONCLUSIONS: Our results suggest an association between compromised renal function as assessed through eGFR and markers of left atrial stasis in patients with AF. The increased risk of stroke in this population may be due to thromboembolism.

Mean platelet volume is associated with the presence of left atrial stasis in patients with non-valvular atrial fibrillation.

BACKGROUND: Mean platelet volume has been associated with stroke in patients with atrial fibrillation. However, its role as a predictor of left atrial stasis, assessed by transesophageal echocardiography, in patients with non-valvular atrial fibrillation has not yet been clarified. METHODS: Single center cross-sectional study comprising 427 patients admitted to the emergency department due to symptomatic atrial fibrillation and undergoing transesophageal echocardiogram evaluation for exclusion of left atrial appendage thrombus before cardioversion. All patients had a complete blood count performed in the 12 hours prior to transesophageal echocardiogram. Markers of left atrial stasis were sought: left atrial appendage thrombus, dense spontaneous echocardiographic contrast and low flow velocities in the left atrial appendage. The presence of at least one of the former markers of left atrial stasis was designated left atrial abnormality. Binary logistic multivariate analysis was used for obtaining models for the prediction of transesophageal echocardiogram endpoints. RESULTS: Left atrial appendage thrombus was found in 12.2%, dense spontaneous echocardiographic contrast in 29.7%, low flow velocities in 15.3% and left atrial abnormality in 34.2%. Mean platelet volume (exp ß = 3.41 p = 0.048) alongside with previous stroke or transient ischemic attack (exp ß = 5.35 p = 0.005) and troponin I (exp ß = 5.07 p = 0.041) were independent predictors of left atrial appendage thrombus. Mean platelet volume was also incorporated in the predictive models of dense spontaneous echocardiographic contrast, low flow velocities and left atrial abnormality, adding predictive value to clinical, echocardiographic and laboratory variables. CONCLUSIONS: These findings suggest that mean platelet volume may be associated with the presence of markers of left atrial stasis, reinforcing a likely cardioembolic mechanism for its association with stroke in patients with non-valvular atrial fibrillation.

Evaluation of left atrial deformation to predict left atrial stasis in patients with non-valvular atrial fibrillation - a pilot-study.

BACKGROUND: Speckle tracking-derived strain and strain rate are recently available parameters to assess left atrial (LA) deformation. We hypothesized that such new parameters could be of interest to evaluate the risk of LA stasis among patients with atrial fibrillation (AF). METHODS: Single-centre study enrolling all patients with non-valvular AF lasting longer than 48 hours for whom no therapeutic anticoagulation was given in the preceding 3 weeks and who were assessed through transesophageal and transthoracic echocardiogram during a 6 month time interval. LA deformation was assessed by transthoracic echocardiogram through speckle tracking analysis, whereas LA stasis parameters were sought on transesophageal echocardiogram. RESULTS: Among the 82 assessed patients, LA appendage thrombi or sludge were found in 16 (19.5%). A moderate positive correlation was found between peak positive strain rate and maximum emptying velocity (r = 0.589; P <0.001) and peak positive strain rate and maximum filling velocity of the LA appendage (r = 0.651; P <0.001). Peak negative strain rate was also found to be associated with both maximum emptying velocity (r = -0.513; P <0.001) and maximum filling velocity of the LAA (r = -0.552; P <0.001). AF duration, peak negative strain rate and time-to-peak positive strain were independent predictors of LAA thrombi or sludge on multivariate analysis logistic regression. The area under the curve for the estimated probabilities using the obtained logistic regression model was 0.89 (95%CI 0.81-0.96; P <0.001). CONCLUSION: Our findings suggest that LA mechanical dysfunction assessed through speckle tracking may be of interest to predict LA stasis in the setting of AF.

Possible refinement of clinical thromboembolism assessment in patients with atrial fibrillation using echocardiographic parameters.

AIM: Some transoesophageal echocardiogram (TEE) findings are associated with an increased risk of stroke in patients with atrial fibrillation (AF). This study was designed to evaluate and compare the accuracy of CHADS(2) and CHA(2)DS(2)-VASc in the prediction of these findings and test the additive value of transthoracic echocardiogram (TTE)-derived parameters as a possible refinement for these classifications. METHODS AND RESULTS: Cross-sectional study of 405 consecutive patients who underwent TTE and TEE evaluation during AF. Stroke risk assessment was performed using the CHADS(2) and CHA(2)DS(2)-VASc scores, alone and alongside with the addition of two TTE-derived parameters (left atrium area and left ventricle global systolic function). Comparisons regarding the presence of left atrial appendage thrombi (LAA T), dense spontaneous echo contrast (SEC), and left atrial appendage (LAA) low flow velocities (LFV) were performed using receiver operating characteristic curves. In low-risk patients, as assessed through the CHA(2)DS(2)-VASc score and CHADS(2) and CHA(2)DS(2)-VASc scores plus echo parameters, no high-risk features were found on TEE. In subjects classified as low risk using CHADS(2), this figure rose to 10%. No significant differences were found between CHADS(2) and CHA(2)DS(2)-VASc in the prediction of LAA T, dense SEC, and LAA LFV. The addition of TTE-derived parameters to the previous clinical-risk scores resulted in improved prediction of the TEE endpoints. CONCLUSION: These findings suggest that the use of TTE-derived parameters may be a valuable way of refining the available clinical risk schemes for the detection of surrogate markers of stroke. Follow-up studies using clinical endpoints will be necessary to confirm this hypothesis.

Implementation of a pre-hospital network favoring primary angioplasty in STEMI to reduce mortality: the Algarve Project.

OBJECTIVE: To analyze the impact of reperfusion by either primary percutaneous coronary intervention (PPCI) or fibrinolysis, and mortality rates of a pre-hospital fast-track network for treating patients with ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS: A pre-hospital network for STEMI patients, designated the Green Lane for Acute Myocardial Infarction (GL-AMI), has been implemented in the southern region of Portugal --the Algarve Project. We performed an observational study based on a prospective registry of 1338 patients admitted to Faro Hospital between 2004 and 2009, classified in two groups according to the method of admission: emergency department group (EDG) and GL-AMI group (GLG). More patients from GLG were reperfused (p < 0.0001). PPCI was the preferred method of reperfusion, 73.1% in GLG and 45.3% in EDG. Time delays were significantly shorter in GLG, except for pre-hospital delay: pre-hospital delay (p = 0.11); door-to-needle (p < 0.0001); door-to-balloon (p < 0.0001); and delay between symptoms and reperfusion (p < 0.0001). In-hospital mortality (4.3% vs 9.2%, p = 0.0007) and 6-month mortality (6.3% vs 13.8%, p < 0.0001) were significantly lower in GLG. CONCLUSIONS: The Algarve Project significantly reduced the time delay between onset of symptoms and reperfusion, significantly increased the rate of reperfusion, and significantly reduced in-hospital and six-month mortality.

[Endomyocardial fibrosis with massive calcification of the left ventricle]. / Fibrose endomiocárdica com calcificação maciça do ventrículo esquerdo.

Endomyocardial fibrosis is a rare disease, endemic in tropical countries. It is characterized by fibrosis of the endocardium that can extend to myocardium. Important calcification of the endocardium is rare with only a few cases reported in the literature. We report a case of endomyocardial fibrosis in a european caucasian patient, associated with massive calcification of left ventricle.

Female gender: an independent factor in ST-elevation myocardial infarction.

INTRODUCTION: Cardiovascular disease is the leading cause of death in women. In ST-elevation myocardial infarction (STEMI) in particular, the question has been raised whether specific characteristics of women confer a worse prognosis. OBJECTIVE: To evaluate the differences in STEMI patients between the genders in cardiovascular risk profile, clinical presentation, therapeutic approach and in-hospital and 6-month mortality rates. METHODS: We analyzed 1578 patients admitted consecutively with STEMI during a 7-year period (from January 13, 2002 to December 31, 2008). The patients were divided into two groups according to gender, and compared in terms of baseline clinical and demographic characteristics, pre-hospital and in-hospital delay, clinical presentation on admission, reperfusion therapy, severity of coronary disease and in-hospital and 6-month mortality. RESULTS: Of the 1578 patients, 26% were female. Women were older (by 8 years), and had a higher cardiovascular risk profile. On admission, their clinical presentation was more severe, with a higher frequency of anterior myocardial infarction and acute heart failure symptoms. Women had longer ischemic times and lower rates of reperfusion therapy. Mortality in women was significantly higher than in men, both in-hospital (17.5 vs. 5.3%) and at 6 months (23.5% vs. 8.2%). After adjustment in multivariate analysis, mortality in women remained higher. CONCLUSIONS: The adverse demographic and clinical profile could partially explain the worse prognosis of STEMI in women. This, together with longer pre-hospital delays, led to underuse of reperfusion therapy. Even so, female gender by itself had a negative and independent influence on mortality in STEMI patients.

In-hospital delay in ST-segment-elevation myocardial infarction after Manchester Triage.

INTRODUCTION: In ST-segment elevation myocardial infarction (STEMI), time to reperfusion influences morbidity and mortality, and reducing in-hospital delay (IHD) continues to be important. Doubts have been expressed whether the Manchester Triage System (MTS) contributes to this objective. OBJECTIVE: To evaluate the effectiveness of the MTS in classifying STEMI patients and its effect on IHD. METHODS: We analyzed 278 patients with STEMI admitted to the Coronary Care Unit through the Emergency Department between January 13 2005 and November 26 2006. The patients were divided into two groups according to their MTS classification: Group A--emergent and very urgent patients; Group B--urgent and standard patients. The two groups were compared in terms of clinical and demographic characteristics, pre-hospital delay (PHD), IHD and door-to-needle (DNT) and door-to-balloon (DBT) times. RESULTS: The mean age of the patients studied was 68 +/- 14 years, and 184 patients (65.7%) were male. Group A comprised 220 patients (79%) and Group B 58 patients (21%). There were no significant differences between the two groups in clinical or demographic characteristics or in PHD. IHD, DNT and DBT were significantly longer in Group B. CONCLUSIONS: 1) Although the majority of STEMI patients were classified as emergent or very urgent, the percentage not classified as such by the MTS was excessively high. 2) This could not be explained by clinical characteristics or by PHD. 3) The incorrect classification by the MTS of patients with STEMI resulted in significantly increased IHD in a large proportion of patients, limiting prompt access to reperfusion therapy.

Left atrial volume index: Can it provide additional prognostic information in ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention?

INTRODUCTION: We sought to assess the prognostic impact of left atrial (LA) size on long-term outcomes of ST-segment elevation myocardial infarction (STEMI). METHODS: We studied 200 consecutive patients admitted to a single center between January 2010 and December 2014 with non-fatal STEMI treated with primary percutaneous coronary intervention (pPCI) who underwent a comprehensive echocardiographic examination at discharge. LA volume was estimated by the area-length method. The left atrium was classified as normal, mildly, moderately or severely enlarged by LA volume index (LAVI). The endpoints were defined as all-cause mortality, a cardiac composite endpoint (all-cause mortality, reinfarction, unplanned revascularization and hospitalization for heart failure) and a cardiovascular composite endpoint (cardiac endpoint plus atrial fibrillation and ischemic stroke) during follow-up. RESULTS: In this STEMI population, 58% had normal LA size, 22.5% had mild LA enlargement, 10% had moderate LA enlargement and 9.5% had severe LA enlargement. During a median follow-up of 28 (IQR 21-38) months, 14 (7.0%) patients died, 53 (26.5%) had the cardiac and 58 (29%) the cardiovascular composite endpoints. There was a stepwise increase in the incidence of all-cause mortality (p=0.020) and both cardiac (p<0.001) and cardiovascular (p<0.001) endpoints with each increment of LAVI class. In multivariate analysis, severe LA enlargement by LAVI was an independent predictor of all-cause mortality (HR: 11.153; 95% CI: 1.924-64.642, p=0.007) and the cardiac (HR: 4.351; 95% CI: 1.919-9.862, p<0.001) and cardiovascular (HR: 4.351; 95% CI: 1.919-9.862, p<0.001) endpoints during follow-up. CONCLUSIONS: This contemporary study confirms the prognostic effect of LA size at discharge, applying the most recent reference values in STEMI patients treated with pPCI.

Cardiac device infection: Review based in the experience of a single center. / Endocardite de dispositivos, revisão com base na experiência de um centro.

INTRODUCTION: The incidence of cardiac implantable electronic device infections has increased significantly over the years and they are associated with significant morbidity and mortality. The epidemiology in the Central region of Portugal is not known. OBJECTIVE AND METHODS: To characterize cardiac implantable electronic device infections through a retrospective study of 3158 patients admitted to our center between January 2008 and September 2014 and to review the subject in the light of the current state of the art. RESULTS: The infection rate was 1.48% (pacemakers 1.21%, cardiac defibrillator/resynchronization devices 5.40%). The study population consisted of 47 patients with a mean age of 65±19 years, predominantly male (72.3%). Infections were mainly of pacemakers, the main device implanted in our population (n=2954), and most occurred late after first implantation. Clinically, most patients presented with fever and local inflammation. Blood cultures identified mainly Gram-positive microorganisms. Empiric antibiotic therapy with vancomycin was instituted in all patients, associated with gentamicin in 57%. The device was extracted in the majority of cases (72%). During follow-up (32±22 months) eight patients died (17%), seven of cardiovascular cause (15%), and seven were readmitted with device infection (15%). CONCLUSIONS: Our rate of infection was low, similar to other published series, with a higher rate in cardiac defibrillator/resynchronization devices. After standard treatment with antibiotic therapy and device extraction, the prognosis was good.

Diagnostic approach to cardiac amyloidosis: A case report. / Amiloidose cardíaca - abordagem diagnóstica, a propósito de um caso clínico.

The authors present a case of systemic amyloidosis with cardiac involvement. We discuss the need for a high level of suspicion to establish a diagnosis, diagnostic techniques and treatment options. Our patient was a 78-year-old man with chronic renal disease and atrial fibrillation admitted with acute decompensated heart failure of unknown cause. The transthoracic echocardiogram revealed severely impaired left ventricular function with phenotypic overlap between hypertrophic and restrictive cardiomyopathy. After an extensive diagnostic workup, which included an abdominal fat pad biopsy, the final diagnosis was amyloidosis.

High left ventricular outflow tract gradient: Aortic stenosis, obstructive hypertrophic cardiomyopathy or both?

The authors report the case of a patient diagnosed with both hypertrophic cardiomyopathy and aortic stenosis. Due to clinical deterioration, additional investigation was performed, and a high left ventricular outflow tract gradient was identified. Correct identification of the condition causing the symptoms was challenging, and involved several imaging techniques, the contribution of transesophageal echocardiography being crucial. The final diagnosis of severe aortic stenosis led to successful valve replacement surgery. The presence of these two conditions in the same patient has been documented, although it is uncommon. This association poses particular diagnostic and therapeutic challenges, which are discussed in this paper.

Fever-induced type 1 Brugada pattern.

Brugada syndrome, first described over 20 years ago, is characterized by a typical electrocardiographic pattern with coved-type ST-segment elevation in the right precordial leads and a high risk of sudden death in otherwise healthy young adults. The electrocardiographic pattern is sometimes intermittent, and fever is a possible trigger. The authors present the case of a 68-year-old woman who came to the emergency department with fever and syncope. A diagnosis of community-acquired pneumonia was made. The electrocardiogram performed when the patient had fever revealed a type 1 Brugada pattern, which disappeared after the fever subsided. After other causes of Brugada-like pattern were excluded, Brugada syndrome was diagnosed and a cardioverter-defibrillator was implanted. This case demonstrates that this entity can be diagnosed at more advanced ages and highlights the usefulness of electrocardiography in a febrile state.

When what appears to be mitral stenosis is not: diagnostic and therapeutic implications.

The authors report the case of a 53-year-old man, with a long-standing history of mild mitral stenosis, admitted for worsening fatigue. Transthoracic echocardiography (limited by poor image quality) showed mitral annular calcification, leaflets that were difficult to visualize and an estimated mitral valve area of 1.8 cm(2) by the pressure half-time method. However, elevated mean transmitral and right ventricle/right atrium gradients were identified (39 and 117 mmHg, respectively). This puzzling discrepancy in the echocardiographic findings prompted investigation by transesophageal echocardiography, which revealed an echogenic structure adjacent to the mitral annulus, causing severe obstruction (effective orifice area 0.7 cm(2)). The suspicion of supravalvular mitral ring was confirmed during surgery. Following ring resection and mitral valve replacement there was significant improvement in the patient's clinical condition and normalization of the left atrium/left ventricle gradient. Supravalvular mitral ring is an unusual cause of congenital mitral stenosis, characterized by an abnormal ridge of connective tissue on the atrial side of the mitral valve, which often obstructs mitral valve inflow. Few cases have been reported, most of them in children with concomitant congenital abnormalities. Diagnosis of a supravalvular mitral ring is challenging, since it is very difficult to visualize in most diagnostic tests. It was the combination of clinical and various echocardiographic findings that led us to suspect this very rare condition, enabling appropriate treatment, with excellent long-term results.

Phenotypic expression in hypertrophic cardiomyopathy and late gadolinium enhancement on cardiac magnetic resonance.

INTRODUCTION AND AIM: The prognostic value of late gadolinium enhancement (LGE) for risk stratification of hypertrophic cardiomyopathy (HCM) patients is the subject of disagreement. We set out to examine the association between clinical and morphological variables, risk factors for sudden cardiac death and LGE in HCM patients. METHODS: From a population of 78 patients with HCM, we studied 53 who underwent cardiac magnetic resonance. They were divided into two groups according to the presence or absence of LGE. Ventricular arrhythmias and morbidity and mortality during follow-up were analyzed. RESULTS: Patients with LGE were younger at the time of diagnosis (p=0.046) and more often had a family history of sudden death (p=0.008) and known coronary artery disease (p=0.086). On echocardiography they had greater maximum wall thickness (p=0.007) and left atrial area (p=0.037) and volume (p=0.035), and more often presented a restrictive pattern of diastolic dysfunction (p=0.011) with a higher E/É ratio (p=0.003) and left ventricular systolic dysfunction (p=0.038). Cardiac magnetic resonance supported the association between LGE and previous echocardiographic findings: greater left atrial area (p=0.029) and maximum wall thickness (p<0.001) and lower left ventricular ejection fraction (p=0.056). Patients with LGE more often had an implantable cardioverter-defibrillator (ICD) (p=0.015). At follow-up, no differences were found in the frequency of ventricular arrhythmias, appropriate ICD therapies or mortality. CONCLUSIONS: The presence of LGE emerges as a risk marker, associated with the classical predictors of sudden cardiac death in this population. However, larger studies are required to confirm its independent association with clinical events.