Feasibility of TEE-guided stroke risk assessment in atrial fibrillation-background, aims, design and baseline data of the TIARA pilot study.

BACKGROUND: Antithrombotic management in atrial fibrillation (AF) is currently based on clinical characteristics, despite evidence of potential fine-tuning with transoesophageal echocardiography (TEE). This open, randomised, multicentre study addresses the hypothesis that a comprehensive strategy of TEE-based aspirin treatment in AF patients is feasible and safe. METHODS: Between 2005 and 2009, ten large hospitals in the Netherlands enrolled AF patients with a moderate risk of stroke. Patients without thrombogenic TEE characteristics were randomised to aspirin or vitamin K antagonists (VKA). The primary objective is to show that TEE-based aspirin treatment is safe compared with VKA therapy. The secondary objective tests feasibility of TEE as a tool to detect echocardiographic features of high stroke risk. This report compares randomised to non-randomised patients and describes the feasibility of a TEE-based approach. RESULTS: In total, 310 patients were included. Sixty-nine patients were not randomised because of non-visualisation (n = 6) or TEE risk factors (n = 63). Compared with non-randomised patients, randomised patients (n = 241) were younger (65 ± 11 vs. 69 ± 9 years, p = 0.004), had less coronary artery disease (9 vs. 20%, p = 0.018), previous TIA (1.7 vs. 7.2%, p = 0.029), AF during TEE (25 vs. 54%, p < 0.001), mitral incompetence (55 vs. 70%, p = 0.038), VKA use (69 vs. 82%, p = 0.032), had a lower mean CHADS(2) score (1.2 ± 0.6 vs. 1.6 ± 1.0, p = 0.004), and left ventricular ejection fraction (59 ± 8 vs. 56 ± 8%, p = 0.016). CONCLUSIONS: This study shows that a TEE-based approach for fine-tuning stroke risk in AF patients with a moderate risk for stroke is feasible. Follow-up data will address the safety of this TEE-based approach.

Assessment of the left atrial appendage mechanical function by three-dimensional echocardiography.

AIMS: We evaluated the feasibility of three-dimensional echocardiography, in the assessment of left atrial appendage (LAA) function. METHODS AND RESULTS: Forty-five patients underwent multiplane transoesophageal echocardiography. In addition to Doppler and two-dimensional echocardiography, data for three-dimensional echocardiography reconstruction were obtained during transoesophageal echocardiography. Left atrial appendage ejection fraction based on three-dimensional echocardiography volume measurements (EFv) and two-dimensional echocardiography area measurements (EFa), coupled with other echocardiographic data, were related to left atrial appendage late peak emptying velocity, a frequently used indicator of left atrial appendage function. Multiple regression analysis has revealed a significant association of peak emptying velocity with EFv (P<0.0001), spontaneous echocardiographic contrast (P=0.001), tricuspid regurgitation (P=0.03) and left ventricular hypertrophy (P=0.05). No significant relation was observed between peak emptying velocity and EFa, presence or absence of atrial fibrillation, left ventricular dysfunction, mitral stenosis and insufficiency, left atrial dilatation, pulmonary venous peak systolic, diastolic and peak reverse flow velocity at atrial contraction as well as left atrial appendage volumes derived from two-dimensional echocardiography and three-dimensional echocardiography. In a simple linear correlation, the degree of association between peak emptying velocity and EFv was higher as between peak emptying velocity and EFa (r=0.7 vs 0.4, both P<0.001). Observer variabilities for calculating EFv were considerably lower than for two-dimensional echocardiography derived EFa. Ejection fractions determined by two-dimensional echocardiography area measurements at 45 degrees, 90 degrees and 135 degrees cutplane angulations were related to EFv only at 135 degrees. CONCLUSIONS: Left atrial appendage ejection fraction calculation by three-dimensional echocardiography is feasible, more accurate than by two-dimensional echocardiography and has lower observer variability. Furthermore, an optimal cutplane angulation of the left atrial appendage view at 135 degrees has been demonstrated.

Rate control versus electrical cardioversion for atrial fibrillation: A randomised comparison of two treatment strategies concerning morbidity, mortality, quality of life and cost-benefit - the RACE study design.

BACKGROUND: Persistent atrial fibrillation (AF) does not terminate spontaneously and may cause left ventricular dysfunction and thromboembolic complications. For restoration of sinus rhythm electrical cardioversion (ECV) is most effective. However, AF frequently relapses, necessitating re-ECV and institution of potentially harmful antiarrhythmic drugs. If AF is accepted, rate control and prevention of thromboembolic complications using negative chronotropic drugs and warfarin is pursued. It is our hypothesis that rate control therapy is not inferior to ECV therapy in preventing morbidity and mortality. METHODS: RACE (RAte Control versus Electrical cardioversion for atrial fibrillation) is a randomised comparison of serial ECV therapy (repeat ECV as soon as possible after a relapse and institution of an antiarrhythmic drug: sotalol, class IC drug and amiodarone) and rate control therapy (resting heart rate <100 bpm using digitalis, calcium channel blockers and/or ß-blockers) in patients with persistent AF. Morbidity (heart failure, side effects of drugs, thromboembolic complications, bleeding and pacemaker implantation), mortality, quality of life and cost-effectiveness are primary and secondary endpoints. Included are patients with a recurrence of persistent AF, present episode <1 year and a maximum of two previous successful ECVs during the last two years. This study is a multicentre study in 31 centres throughout the Netherlands. All 520 patients have now been included. Follow-up is two years. The results are expected this year.

Quantitative assessment of mechanical prosthetic valve area by 3-dimensional transesophageal echocardiography.

OBJECTIVE: The goal of this study was to assess the geometric orifice area of mechanical valve prostheses by transesophageal 3-dimensional echocardiographic planimetry. METHODS AND RESULTS: Currently used Doppler methods for prosthetic assessment (orifice area-Doppler) were compared with 3D planimetry for orifice area (orifice area-3D) and with manufacturer's values (orifice area-manufacturer) for the corresponding prosthesis types and sizes and with historical controls provided by Doppler literature (orifice area-literature). Twenty-four mechanical valve prostheses (in 22 patients) were studied: 13 in mitral position and 11 in aortic position. Orifice area-manufacturer, orifice area-Doppler, orifice area-literature, and orifice area-3D were 3.6 +/- 1.1 cm(2), 2.3 +/- 0.9 cm(2), 2.4 +/- 0.9 cm(2), and 2.6 +/- 0.7 cm(2), respectively. Orifice area-manufacturer values were significantly larger. Correlation coefficients between orifice area-3D and orifice area-manufacturer, and between orifice area-3D and orifice area-Doppler and orifice area-literature were 0.83, 0.90, and 0.73, respectively (all P < .0001). CONCLUSION: Three-dimensional transesophageal echocardiography is feasible and has good correlation with orifice area-Doppler (in aortic position) and good correlation with orifice area-manufacturer (in aortic and mitral positions) methods.

Assessment of myocardial reperfusion by intravenous myocardial contrast echocardiography and coronary flow reserve after primary percutaneous transluminal coronary angioplasty [correction of angiography] in patients with acute myocardial infarction.

BACKGROUND: This study investigated whether the extent of perfusion defect determined by intravenous myocardial contrast echocardiography (MCE) in patients with acute myocardial infarction (AMI) treated by primary percutaneous transluminal coronary angioplasty (PTCA) relates to coronary flow reserve (CRF) for assessment of myocardial reperfusion and is predictive for left ventricular recovery. METHODS AND RESULTS: Twenty-five patients with first AMI underwent intravenous MCE with NC100100 with intermittent harmonic imaging before PTCA and after 24 hours. MCE before PTCA defined the risk region and MCE at 24 hours the "no-reflow" region. The no-reflow region divided by the risk region determined the ratio to the risk region. CFR was assessed immediately after PTCA and 24 hours later. Left ventricular wall motion score indexes were calculated before PTCA and after 4 weeks. CFR at 24 hours defined a recovery (CFR >/=1.6; n=17) and a nonrecovery group (CFR <1.6; n=8). Baseline CFR did not differ between groups. MCE ratio to the risk region was smaller in the recovery group compared with the nonrecovery group (34+/-49% vs 81+/-46%, P=0.009). A ratio to the risk region of

NC100100, a new echo contrast agent for the assessment of myocardial perfusion--safety and comparison with technetium-99m sestamibi single-photon emission computed tomography in a randomized multicenter study.

BACKGROUND AND HYPOTHESIS: Myocardial contrast echocardiography using second-generation agents has been proposed to study myocardial perfusion. A placebo-controlled, multicenter trial was conducted to evaluate the safety, optimal dose, and imaging mode for NC100100, a novel intravenous second-generation echo contrast agent, and to compare this technique with technetium-99m sestamibi (MIBI) single-photon emission computed tomography (SPECT). METHODS: In a placebo-controlled, multicenter trial, 203 patients with myocardial infarction > 5 days and < 1 year previously underwent rest SPECT and MCE. Fundamental and harmonic imaging modes combined with continuous and electrocardiogram-- (ECG) triggered intermittent imaging were used. Six dose groups (0.030, 0.100, and 0.300 microliter particles/kg body weight for fundamental imaging; and 0.006, 0.030, and 0.150 microliter particles/kg body weight for harmonic imaging) were tested. A saline group was also included. Safety was followed for 72 h after contrast injection. Myocardial perfusion by MCE was compared with myocardial rest perfusion imaging using MIBI as a tracer. RESULTS: NC100100 was well tolerated. No serious adverse events or deaths occurred. No clinically relevant changes in vital signs, laboratory parameters, and ECG recordings were noted. There was no significant difference between adverse events in the NC100100 (25.7%) and in the placebo group (17.9%, p = 0.3). Intermittent harmonic imaging using the intermediate dose was superior to all other modalities, allowing the assessment of perfusion in 76% of all segments. Eighty segments (96%) with normal perfusion by SPECT imaging also showed myocardial perfusion with MCE. However, a substantial percentage of segments (61-80%) with perfusion defects by SPECT imaging also showed opacification by MCE. This resulted in an overall agreement of 66-81% and a high specificity (80-96%), but in low sensitivity (20-39%) of MCE for the detection of perfusion defects. CONCLUSION: NC100100 is safe in patients with myocardial infarction. Intermittent harmonic imaging with a dose of 0.03 microliter particles/kg body weight can be proposed as the best imaging protocol. Myocardial contrast echocardiography with NC 100100 provides perfusion information in approximately 76% of segments and results in myocardial opacification in the vast majority of segments with normal perfusion as assessed by SPECT. Although the discrepancies between MCE and SPECT with regard to the definition of perfusion defects requires further investigation, MCE with NC 100100 is a promising technique for the noninvasive assessment of myocardial perfusion.

Left atrial appendage flow velocity assessment using transesophageal echocardiography in nonrheumatic atrial fibrillation and systemic embolism.

Fifty-four patients with nonrheumatic atrial fibrillation (AF) were studied: 16 patients with (group I) and 38 patients without (group II) documented systemic embolism. Transesophageal echocardiography (TEE) was performed to evaluate the presence of left atrial (LA) appendage thrombus and LA spontaneous contrast, LA size, systolic and diastolic peak velocity of the left pulmonary vein, and forward and backward peak velocity of the LA appendage. No difference was observed in the presence of LA thrombus between the 2 groups. The occurrence of LA spontaneous contrast was significantly (p = 0.01) higher in the group with embolism. LA size, measured by atrial length (4.96 +/- 0.84 vs 4.79 +/- 1.38 cm; p = NS) and atrial width (4.50 +/- 0.96 vs 4.31 +/- 1.24 cm; p = NS), was the same for both groups and thus not associated with embolism. There was no difference in systolic peak velocity (0.39 +/- 0.22 vs 0.44 +/- 0.22 m/s; p = NS), and a trend toward a higher diastolic peak velocity (0.50 +/- 0.17 vs 0.42 +/- 0.15 m/s; p = 0.08) was seen in the left pulmonary vein in the group with embolism. Forward (0.25 +/- 0.19 vs 0.39 +/- 0.23 m/s; p < 0.05) and backward (0.23 +/- 0.15 vs 0.33 +/- 0.16 m/s; p < 0.05) peak velocities of the LA appendage were significantly lower in the embolism group. Assessment of LA appendage flow velocity may potentially identify patients with nonrheumatic AF at high risk for systemic embolism.

Value of pulmonary venous flow characteristics in the assessment of severity of native mitral valve regurgitation: an angiographic correlated study.

To evaluate the relation between left ventricular angiography and pulmonary venous flow velocity in native mitral valve regurgitation, 28 patients with sinus rhythm and valvular and/or coronary artery disease underwent transesophageal echocardiography within 24 hours after cardiac catheterization. Group I consisted of 17 patients, seven patients without (grade 0) and 10 patients with angiographically mild to moderate mitral regurgitation (grades 1 and 2). Group II consisted of 11 patients with angiographically severe mitral regurgitation (grades 3 and 4). Mitral regurgitation by transesophageal echocardiography was evaluated by measuring the regurgitant jet sizes and color-guided pulsed Doppler pulmonary venous flow velocities. Multivariate analysis revealed that the most powerful predictor (p less than 0.001) of angiographically severe (grades 3 and 4) mitral regurgitation was reversed systolic flow into the left upper pulmonary vein (sensitivity 82%, specificity 100%, positive predictive value 100%). If this variable was excluded from analysis, jet area and jet length (p less than 0.001) were the next best predictors for angiographically severe mitral regurgitation. Mean values of systolic peak pulmonary venous flow velocities were significantly lower in patients from group II, 13.0 +/- 11.1 cm/s versus 43.4 +/- 20.6 cm/s (group I) with p less than 0.005. This finding was also true for systolic time velocity integral, 1.3 +/- 1.3 cm (group II) versus 7.8 +/- 5.3 cm (group I) with p less than 0.005.(ABSTRACT TRUNCATED AT 250 WORDS)

Transesophageal color flow Doppler mapping in the assessment of native mitral valvular regurgitation: comparison with left ventricular angiography.

Transesophageal echocardiography (TEE) was performed within 24 hours after cardiac catheterization in 45 patients for assessment of native mitral valvular regurgitation. Color flow mapping was used in evaluating systolic regurgitant jet sizes. A jet demonstrated by TEE was 96% sensitive and 44% specific for angiographic mitral regurgitation. The presence of angiographic mitral regurgitation was best predicted by (single measurement) (1) a holosystolic jet, (2) a jet length greater than 2.5 cm, and (3) a jet area greater than 2 cm2. Severe angiographic mitral regurgitation (grades 3 and 4) was best predicted by (single measurement) (1) a jet area greater than 5 cm2, and (2) a jet length greater than 4 cm. It is concluded that the assessment of angiographic mitral regurgitation by TEE is improved by the measurement of these jet parameters, which have a high sensitivity and higher specificity than the presence of a jet alone. Furthermore, with TEE one is able to differentiate severe (grades 3 and 4) from absent or mild mitral regurgitation (grades 0, 1, and 2).

Transesophageal echocardiography and magnetic resonance imaging for the assessment of saccular aneurysm of the transverse thoracic aorta.

We report a patient who initially presented with hoarseness and was admitted to our hospital with chest pain, caused by a saccular aneurysm of the thoracic aortic arch. The initial diagnosis was made by cross-sectional echocardiography, the extension and morphology of the saccular aneurysm being detected by transesophageal echocardiography. Magnetic resonance imaging confirmed the measurements of the aneurysm and clearly showed the anatomic relation with surrounding structures and arch vessels. The patient refused operation and died during in-hospital stay. A rupture of the thoracic aneurysm was the cause of death.