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.

Echocardiographic assessment of secundum-type atrial septal defects in the adult: role in treatment decisions.

The purpose of this study is to evaluate morphologic patterns of ostium secundum-type atrial septal defects (osASD) in the adult, analyzing their role in treatment decisions. The population was composed of 155 adults (age 43.3 +/- 18.9 years) consecutively diagnosed with osASD in our center, and confirmed by transthoracic and transesophageal echocardiography, between January 2000 and December 2007. Of these, 83 (53.5%) underwent successful percutaneous closure. Surgical closure was used in 31 patients (20.0%). The remaining 42 patients (27.1%) received conservative medical treatment. The mean diameter of the defects was 15.8 +/- 8.5 mm. The prevalence of mitral valve prolapse and severe pulmonary hypertension was also assessed. Based on the criteria in the literature, we detected 14 different morphologic patterns of osASD. There was a central defect in 45/155; 40/155 had a short rim and 20/155 two short rims, 24/155 were multifenestrated and 15/155 PFO-like, and 12/155 had three or more short rims. The different morphologic patterns in each treatment arm, as well as the criteria leading to their inclusion in each, are described. While percutaneously closed defects had a simpler morphology, those that were surgically closed were normally larger and had a more complex shape (with two or more deficient rims or multifenestrated, and thus not suitable for percutaneous closure).