The diagnostic yield of transesophageal echocardiography in patients with cryptogenic cerebral ischaemia: a meta-analysis.

BACKGROUND AND PURPOSE: The diagnostic utility of transesophageal echocardiography (TEE) in patients with cryptogenic ischaemic stroke (IS) or transient ischaemic attack (TIA) remains controversial. METHODS: A systematic review and meta-analysis was performed according to PRISMA guidelines to estimate the pooled prevalence of potential cardioembolic causes detected by TEE in prospective observational studies of cryptogenic IS/TIA. Cardiac conditions causally associated with cerebral ischaemia were considered to be intramural thrombi and intracardiac tumors according to ASCO phenotyping of IS. RESULTS: Thirty-five eligible studies, comprising 5772 patients (mean age 53.6 years, 56.9% men) were identified. The most common TEE finding was ascending aorta and/or aortic arch atheroma [51.2% (27.4%-74.5%)], followed by patent foramen ovale (PFO) [43.2% (36.3%-50.4%)]. Complex aortic plaques and large PFOs were reported in 14% (10.2%-18.9%) and 19.5% (16.6%-22.8%) of TEE evaluations. The prevalence of atrial septal aneurysm was 12.3% (7.9%-18.7%) and was significantly higher in conjunction with PFO presence (risk ratio 2.04, 95% confidence interval 1.63-2.54, P < 0.001). The prevalence of left atrial thrombus [3.0% (1.1%-8.3%)] and spontaneous echo contrast [3.8% (2.3%-6.2%)] was low. The prevalence of intracardiac tumors was extremely uncommon [0.2% (0%-0.7%)]. Significant heterogeneity was identified (I(2) > 60%) in the majority of analyses. Heterogeneity was not affected by cryptogenic stroke definition (TOAST versus alternative criteria). After dichotomizing available studies using a cut-off of 50 years, PFO was significantly (P = 0.001) more prevalent in younger than in older patients. CONCLUSION: Routine TEE in patients with cryptogenic IS/TIA commonly identifies abnormal findings. However, the prevalence of cardiac conditions considered to be causally associated with cerebral ischaemia (intracardiac thrombi and tumors) is low.

Adult congenital heart disease in Greece: Preliminary data from the CHALLENGE registry.

BACKGROUND: The majority of patients with congenital heart disease (CHD), nowadays, survives into adulthood and is faced with long-term complications. We aimed to study the basic demographic and clinical characteristics of adult patients with congenital heart disease (ACHD) in Greece. METHODS: A registry named CHALLENGE (Adult Congenital Heart Disease Registry. A registry from Hellenic Cardiology Society) was initiated in January 2012. Patients with structural CHD older than 16years old were enrolled by 16 specialized centers nationwide. RESULTS: Out of a population of 2115 patients with ACHD, who have been registered, (mean age 38years (SD 16), 52% women), 47% were classified as suffering from mild, 37% from moderate and 15% from severe ACHD. Atrial septal defect (ASD) was the most prevalent diagnosis (33%). The vast majority of ACHD patients (92%) was asymptomatic or mildly symptomatic (NYHA class I/II). The most symptomatic patients were suffering from an ASD, most often the elderly or those under targeted therapy for pulmonary arterial hypertension. Elderly patients (>60years old) accounted for 12% of the ACHD population. Half of patients had undergone at least one open-heart surgery, while 39% were under cardiac medications (15% under antiarrhythmic drugs, 16% under anticoagulants, 16% under medications for heart failure and 4% under targeted therapy for pulmonary arterial hypertension). CONCLUSIONS: ACHD patients are an emerging patient population and national prospective registries such as CHALLENGE are of unique importance in order to identify the ongoing needs of these patients and match them with the appropriate resource allocation.

Comparison of frequency of left atrial thrombus in patients with mechanical prosthetic cardiac valves and stroke versus transient ischemic attacks.

Transesophageal echocardiography performed in a group of 36 patients who had a first cerebral embolic event after implantation of a mechanical cardiac valvular prosthesis revealed that stroke is associated with the presence of left atrial thrombi more frequently than transient ischemic attacks. Intracardiac embolic sources other than thrombi are possibly related more often to the latter type of cerebral embolism in this patient population.

Effects of pravastatin on thoracic aortic atherosclerosis in patients with heterozygous familial hypercholesterolemia.

Data regarding the effects of plasma lipid lowering on the evolution of thoracic aortic atherosclerosis (TAA) are scarce. In this study, we performed transesophageal echocardiography to characterize TAA in 16 newly diagnosed patients with heterozygous familial hypercholesterolemia and to follow its evolution after 2 years of statin treatment. TAA was graded as follows: grade I = normal intima; grade II = increased intimal echo density without thickening; grade IIIA = increased intimal echo density with single atheromatous plaque < or = 3 mm; grade IIIB = multiple plaques < or = 3mm; grade IV = > or = 1 plaque >3 mm; and grade V = mobile or ulcerated plaques. Baseline aortic intimal morphology was grade I in one patient, grade II in 4, grade IIIA in 6, grade IIIB in 3, and grade IV in 2 patients. Hypolipidemic treatment resulted in significant reductions in plasma total cholesterol and low-density lipoprotein (LDL) cholesterol. Follow-up aortic morphology was grade I in 5 patients, grade II in 2, grade IIIA in 3, grade IIIB in 3, and grade IV in 3 patients. TAA remained stable in 7 patients, progressed in 3, and regressed in 6 patients. TAA evolved in a uniform manner in the ascending aorta, aortic arch, and descending aorta. Patients with TAA regression were younger (39+/-14 vs 52+/-8 years, p=0.038) and had a greater decrease in plasma LDL cholesterol as a result of treatment (138+/-56 vs 73+/-55 mg/dl, p=0.036) than patients with TAA stability or progression. These observations support the hypothesis that hypolipidemic treatment may favorably affect the course of TAA in patients with heterozygous familial hypercholesterolemia.

Pacing for adult patients with left atrial isomerism: efficacy and technical considerations.

AIM: Left atrial isomerism (LAI) is an uncommon congenital heart disease, which is combined with a range of intracardiac abnormalities. Atrial arrhythmia is common in LAI. We hypothesized that permanent pacing will decrease arrhythmia recurrence in adult patients with LAI. METHODS AND RESULTS: Patients with LAI and permanent pacing were identified from the Royal Brompton Adult Congenital Heart Database. Hospital records were reviewed, and patients' current status was assessed with clinic reviews including standard and Holter ECGs, and transthoracic echocardiograms. Four patients who underwent permanent pacing at the age of 27.5+/-11.7 years fulfilled inclusion criteria, namely permanent pacing in the setting of LAI. All 4 had sick sinus syndrome-with sustained supraventricular arrhythmia in 3-requiring several hospitalizations for arrhythmia management prior to pacing. All 4 patients remained free of clinical arrhythmia and hospital admission at a mean follow-up of 67.0+/-59.5 months from pacing. The latest ECG revealed paced rhythm in all. NYHA functional class remained stable. There were no pacemaker related complications at implantation or during follow-up. CONCLUSION: Adults with LAI benefit from pacemaker implantation, which reduces recurrence of supraventricular tachycardia and maintains atrioventricular synchrony. Future studies need to determine the preferred pacemaker mode and optimal timing for pacing.

Relevance of adenosine deaminase and lysozyme measurements in the diagnosis of tuberculous pericarditis.

OBJECTIVE: To assess the value of pericardial fluid adenosine deaminase (ADA) and pericardial lysozyme (Lys) as tools in diagnosing tuberculous pericarditis. METHODS: Forty-one patients (age range 17--77 years) with significant pericardial effusion were included in the study. Diagnostic pericardiocentesis and pericardial biopsy were performed while serum and pericardial fluid ADA and Lys were measured in all patients. Grouping of patients resulted as follows: group I = 7 patients with tuberculous pericarditis; group II = patients with neoplastic pericarditis; group III = 30 patients with idiopathic pericarditis. RESULTS: Pairwise multiple comparison procedures revealed a significant difference of ADA in group I versus group III (p < 0.05) but not versus group II. Furthermore, pericardial Lys in group I was higher than in groups II and III (p < 0.05). A strong correlation between pericardial ADA and Lys was found (r = 0.733, p = 0.01) for all the patients. Receiver operating curves showed a value of 72 U/l as cutoff point of pericardium ADA, with a sensitivity of 100% and a specificity of 94% in the diagnosis of tuberculous pericarditis. Similarly for pericardial Lys, a value of 6.5 microg/dl had a sensitivity and specificity of 100 and 91.17%, respectively. CONCLUSIONS: Both measurements of pericardial ADA and Lys need to be taken into account when attempting the early diagnosis of tuberculous pericarditis.