Left atrial appendage flow velocity after successful ablation of persistent atrial fibrillation: clinical perspective from transesophageal echocardiographic assessment during sinus rhythm.

BACKGROUND: Left atrial appendage flow velocity (LAAFV) is a predictor of thromboembolism in atrial fibrillation (AF) patients, as well as CHA2DS2-VASc score. However, little is known about LAAFV in sinus rhythm (SR) after catheter ablation. The aim of this study was to determine clinical predictors of low LAAFV in patients in whom stable SR had been maintained after catheter ablation for persistent AF. METHODS: The study comprised 104 patients with persistent AF (median AF duration 24 months) in whom SR had been achieved and maintained for at least 6 months after the final ablation procedure. Transesophageal echocardiography was performed to assess LAAFV during SR after ablation. Lower LAAFV was defined as ≤40 cm/s. RESULTS: Mean LAAFV before ablation was 29 ± 11 cm/s (range 10-67 cm/s). In 23 (22%) patients, LAAFV remained low even after being in SR for at least 6 months. Multiple logistic regression analysis showed that CHA2DS2-VASc scores of ≥2 (odds ratio 2.18, 95% CI 1.19-3.99, P = .012) was an independent predictor of lower LAAFV after successful ablation. Seventeen (74%) of the 23 patients with low LAAFV during SR presented CHA2DS2-VASc scores of ≥2 complicated by spontaneous echo contrast during AF. CONCLUSIONS: Long-term maintenance of SR after catheter ablation for persistent AF does not guarantee LAAFV recovery. The CHA2DS2-VASc score appears to predict poor recovery of LAAFV. Further studies are necessary to confirm the usefulness of LAAFV during SR as a surrogate marker predicting thromboembolism in patients after AF ablation.

Assessment of echo-attenuated plaque by optical coherence tomography and its impact on post-procedural creatine kinase-myocardial band elevation in elective stent implantation.

OBJECTIVES: This study examined morphological characteristics of echo-attenuated plaques by optical coherence tomography (OCT) and evaluated their influence on creatine kinase-myocardial band (CK-MB) elevation after percutaneous coronary intervention (PCI) in patients with elective stent implantation. BACKGROUND: Recent intravascular ultrasound studies have described atherosclerotic plaques with echo attenuation (EA) without associated bright echoes that are correlated with no-reflow phenomenon after PCI. METHODS: We studied 135 native de novo culprit coronary lesions in 135 patients with normal pre-PCI CK-MB levels (28 with unstable angina; 107 with stable angina) who underwent intravascular ultrasound and OCT examinations before elective stent implantation. The lesions were divided into 2 groups based on the presence or absence of EA, and OCT findings were compared. We then determined predictors of post-PCI CK-MB elevation. RESULTS: EA was found in 47 (34.8%) lesions and was associated with the presence of OCT-derived thin-capped fibroatheroma, ruptured plaques, greater lipid content, intravascular ultrasound-derived large reference and plaque area, lesion eccentricity, and microcalcification. Elevated CK-MB levels were observed in 36 (26.7%) lesions, and significantly more frequently in lesions with EA than without. In multivariable analysis, EA (odds ratio [OR]: 3.49; 95% confidence interval [CI]: 1.53 to 7.93; p = 0.003) and OCT-derived ruptured plaque (OR: 2.92; 95% CI: 1.21 to 7.06; p = 0.017) were independent predictors of post-PCI CK-MB elevation. CONCLUSIONS: Atherosclerotic plaques with EA were associated with characteristics considered to be high risk or unstable. OCT examination showed an additive predictive value to the presence of EA for post-PCI CK-MB elevation.

Assessment of acute injuries and chronic intimal thickening of the radial artery after transradial coronary intervention by optical coherence tomography.

AIMS: Transradial coronary intervention (TRI) introduces a trauma to the radial artery (RA), possibly influencing quality as a bypass conduit if subsequently used. We sought to determine the acute and chronic effects of TRI on the RA by optical coherence tomography (OCT). METHODS AND RESULTS: Immediately after TRI completion, 73 RAs in 69 patients were examined. The sheath was pulled back 2 cm distal to the puncture site, and OCT imaging was performed. The acute injuries and intimal thickening were compared between first-TRI RAs and repeat-TRI RAs. Intimal tears were observed in 49 RAs (67.1%) and were more frequent in the distal than in the proximal RA (P = 0.001). Medial dissections were not uncommon (26 RAs, 35.6%). The frequency of acute injury was significantly higher in repeat-TRI RAs (P < 0.001). Intima/medial area, the maximum intimal thickness/medial thickness ratio, and per cent narrowing were all significantly greater in repeat-TRI RAs in the distal and proximal RA. Multivariate analysis revealed that a repeated TRI procedure was the only independent predictor of intimal thickening. CONCLUSION: Optical coherence tomography clearly demonstrated significant acute injuries and chronic intimal thickening of RA after TRI. Further study should evaluate the impact of these effects when TRI RAs are subsequently used as conduits, on long-term graft patency and on clinical outcomes after bypass surgery.