Two-dimensional versus three-dimensional transesophageal echocardiography in percutaneous left atrial appendage occlusion.

BACKGROUND: Real-time three-dimensional transesophageal echocardiography (RT3D TEE) enables better visualization of the left atrial appendage (LAA) and may be superior to real-time two-dimensional transesophageal echocardiography (RT2D TEE) for LAA occlusion (LAAO). The aim of this study was to assess inter- and intra-observer variability of RT2D TEE and RT3D TEE measurements of LAA, and to assess the accordance of RT2D TEE and RT3D TEE with appropriate occluder selection. METHODS: Transesophageal echocardiography was performed in 40 patients during LAAO. RT2D TEE and RT3D TEE measurements of the ostium and landing zone were performed independently by two echocardiographers. The appropriate choice of occluder was confirmed with fluoroscopic criteria. After the procedures, RT2D TEE and RT3D TEE evaluation were repeated separately by the same echocardiographers. RESULTS: The mean ostium diameters by RT2D TEE obtained by the two observers were 23.6 ± 4.2 vs. 24.8 ± 5.2 (p = 0.04), and the mean landing zone diameters were 17.7 ± 4.4 vs. 19.4 ± 3.9 (p < 0.01). In the case of RT3D TEE, the ostium diameters were 29.6 ± 5.3 vs. 29.4 ± 6.4 (p = not significant [NS]) and the landing zone diameters were 21.4 ± 3.8 vs. 21.6 ± 3.9 (p = NS). Intra-observer differences were absent in the case of RT3D TEE. The comparison of RT2D TEE vs. RT3D TEE analyses performed by the same echocardiographer revealed significant differences in the ostium and landing zone measurements (both p < 0.01). Agreement between the suggested device size was better for RT3D TEE (weighted kappa was 0.62 vs. 0.28, respectively). CONCLUSIONS: The results obtained with RT3D TEE showed significantly larger dimensions of the ostium and the landing zone. RT3D TEE showed lesser inter- and intra-observer variability and better agreement with the implanted device.

The influence of iatrogenic interatrial septum leaks after left atrial appendage closure on cardiac function test results.

AIM: Left atrial appendage occlusion (LAAO) is a technique for preventing thromboembolism in patients with atrial fibrillation and a high risk of irreversible bleeding. In some patients, a spontaneous iatrogenic transseptal leak (ITL) remains after LAAO. The aim of this study was to assess the correlation between ITL incidence and the results of cardiac function tests in patients who underwent LAAO. METHODS AND RESULTS: LAOO was performed in 62 consecutive patients using the Amplatzer Amulet. Before and 3 months after LAA occlusion, the 6-min walking distance (6MWD) test was performed in all patients and oxygen consumption assessment (VO2max ) was performed in 32. All patients had transesophageal echocardiography before and 3 months after LAAO to assess ITL incidence. The patients were divided according to the presence and absence of ITL and the subgroup of patients with heart failure (HF) were further analyzed. In patients with HF and ITL, an increased VO2max (12.8 ± 5.2 vs 15.3 ± 4.7; P < 0.05) and 6MWD (350.1 ± 77.4 vs 414.3 ± 70.6; P < 0.05) was observed after the procedure comparing to the results before the procedure. The 6MWD was also significantly higher in the patients with transseptal leaks in comparison to those without (P < 0.0001). CONCLUSION: The presence of transseptal leaks after LAAO does not influence overall cardiac function test results. However, in patients with HF, there is an increase in oxygen consumption and 6MWD. These results indicate that ITLs in patients with HF decrease left atrial pressure, which is the key contributor to the symptoms of heart failure during physical activity.

The intracardiac concentrations of the N-terminal-pro B-type natriuretic peptide (NT-proBNP) and the determinants of its secretion in patients with atrial fibrillation.

BACKGROUND: N-terminal-pro B-type natriuretic peptide (NT-proBNP) is elevated not only in heart failure (HF) but also in atrial fibrillation (AF). The role and secretion pattern of NT-proBNP in AF is still undetermined. AIM: The study aimed to assess NT-proBNP concentrations in patients with and without preserved left ventricular ejection fraction (LVEF) depending on the type of AF. It was also intended to define the main source of NT-proBNP production within the heart. In addition, it aimed to study the relation of NT-proBNP with some echocardiographic parameters reflecting the stretch of heart chambers as well as with the chosen parameters of physical capacity. METHODS: Blood samples were collected from the right atrium (RA), left atrium (LA), and femoral artery (FA) in 53 patients referred for occlusion of the LA appendage. Thirty patients were assigned into Group I (LVEF ≥ 50%, no HF symptoms) and the remaining 23 patients to Group II (LVEF < 50%, HF symptoms). NT-proBNP concentrations were determined using the ELISA test. RESULTS: In Group I, the lowest NT-proBNP level was found in RA (460.47 ± 723.15 pg/mL and 1097.72 ± 851.42 pg/mL for paroxysmal and permanent AF, respectively), higher in LA (481.5 ± 724.56 pg/mL and 1188.06 ± 851.42 pg/mL for paroxysmal and permanent AF), and the highest values in FA (537.77 ± 808.49 pg/mL and 1188.04 ± 798.28 pg/mL for paroxysmal and permanent AF). In Group II the NT-proBNP values were significantly higher compared to Group I (p < 0.01), but similarly values in RA were the lowest (183.47 ± 1826.08 pg/mL and 2141.68 ± 1801.69 pg/mL for paroxysmal and permanent AF), intermediate values were observed in LA (1857.57 ± 2221.39 pg/mL and 2386.81 ± 2067.2 pg/mL for paroxysmal and permanent AF), and the highest were seen in FA (1936.27 ± 2149.85 and 2437.33 ± 1999.37 pg/mL for paroxysmal and permanent AF, respectively). In Group I, NT-proBNP from LA best correlated with LA area (r = 0.56) and RA area (r = 0.56). In Group II, the strongest correlations were found between NT-proBNP from LA and left ventricular end-systolic dimension (r = 0.57) and volume (r = 0.6). CONCLUSIONS: NT-proBNP is markedly elevated in the majority of patients with AF even in the absence of HF. LA secretion of NT-proBNP is an important contributor to the overall increase of NT-proBNP also in HF patients. In AF patients, the concentration of NT-proBNP correlates with the remodelling of heart chambers, but not with physical capacity.

Usefulness of N-terminal-pro B-type natriuretic peptide as a heart failure marker in patients undergoing percutaneous left atrial appendage occlusion.

BACKGROUND: The left atrial appendage is involved in secretion of N-terminal-pro B-type natriuretic peptide (NT-proBNP). Percutaneous left atrial appendage occlusion (LAAO) for prevention of stroke may cause variations in NT-proBNP release. AIM: This study aimed to assess the diagnostic value of NT-proBNP after LAAO. METHODS: The study group comprised 53 patients in whom LAAO was performed. The patients with heart failure (HF) and reduced ejection fraction (EF) were allocated to group I (n = 16) whereas patients with no HF symptoms and EF > 40% were allocated to group II (n = 37). The symptomatic patients with EF > 40% were excluded. NT-proBNP values were measured prior to LAAO, at one-two days, and at three-month follow-up. EF, six-minute walk test (6MWT), and peak oxygen consumption (VO2max) were assessed 24 h prior to LAAO and after three months. RESULTS: Prior to LAAO the NT-proBNP level was higher in group I, when compared to group II (3084.74 ± 559.53 pg/mL vs. 808.02 ± 115.83 pg/ml, p < 0.01). In both groups there was a nonsignificant increase in NT-proBNP level at one-two days after LAOO (3100.14 ± 690.08 pg/mL in group I and 1012.09 ± 166.71 pg/mL in group II). At the three-month follow-up a further increase of NT-proBNP level in group I (3852.73 ± 1025.78 pg/mL) and a decrease in group II (855.03 ± 107.49 pg/mL) was observed. The pairwise comparison between the means of 6MWT and VO2max showed no significant changes during follow-up. At baseline, NT-proBNP level of 988 pg/mL presented 87.5% sensitivity and 75.7% specificity for prediction of HF. Three months after LAAO, it increased to 1358 pg/mL (sensitivity 81.2%, specificity 78.4%). CONCLUSIONS: When diagnosing HF in atrial fibrillation patients, the higher cut-off value of NT-proBNP should be used. NT-proBNP remains an appropriate diagnostic marker of HF in patients after LAAO.

Percutaneous left atrial appendage occlusion procedures in patients with heart failure.

BACKGROUND: Atrial fibrillation (AF) is the most common supraventricular tachyarrhythmia. Percutaneous left atrial appendage occlusion (LAAO) may be considered for stroke prophylaxis in patients with nonvalvular AF (NVAF), especially in contraindications for oral anticoagulants (OAC) or high risk of bleeding. The data about implantation, safety, efficacy, and follow-up are limited. Moreover, there are no studies on patients with NVAF and heart failure with severe left ventricular systolic dysfunction (left ventricular ejection fraction [LVEF] ≤ 35%). AIM: To assess the safety, efficacy, and mid-term outcomes of LAAO procedures with Amplatzer Cardiac Plug (ACP) and Amplatzer Amulet device in patients with NVAF and heart failure with LVEF ≤ 35% (group I) and to perform a comparative analysis of the patients who had LAAO with NVAF and LVEF > 35%. METHODS: The analysis included 80 patients (group I: 19, group II: 61) with NVAF. The patients were enrolled for the study if they had: CHA2DS2VASc ≥ 2 and high risk of bleeding assessed in HAS-BLED (≥ 3) or less points in HAS-BLED but coexisting contraindications for OAC, or thromboembolic complications while using OAC. Time of follow-up was six months. RESULTS: In the studied population, the median CHA2DS2VASc score was 4 and the average HAS-BLED score was 3.2. Device implantation was successful in all patients from group I and in 59/61 patients from group II. The periprocedural clinical ef-ficacy (no thromboembolic complications) was 100% in group I and 98.4% in group II. Serious periprocedural complications (cardiac tamponade: 2.5%, device embolisation: 1.25%, unexplained death: 1.25%) occurred only in patients from group II (p = NS). The mid-term clinical efficacy was 100% in group I and 98.3% in group II (p = NS). During follow-up, one transient ischaemic attack and three deaths not related to the procedure occurred. CONCLUSIONS: Percutaneous LAAO is an effective and safe procedure in patients with NVAF and severe systolic heart failure. No significant periprocedural and mid-term differences, in terms of safety and efficacy, between the group with severe systolic heart failure (LVEF ≤ 35%) and the group without severe left ventricular systolic dysfunction (LVEF > 35%) were found.

3D and 2D left ventricular systolic function imaging-- from ejection fraction to deformation. Cardiac resynchronization therapy--substudy.

INTRODUCTION: 3D echocardiography offers options of left ventricular systolic function analysis. The aims of this study are: to assess the usefulness of 3D echocardiography, to test 3D regional measurements (with area strain) among a spectrum of patients and then to check prospectively the value of 3D echocardiography vs 2D in the assessment of response to resynchronization. METHODS: The first retrospective study group comprises 42 subjects: 23 consecutive patients with left ventricular systolic heart failure and 19 healthy control subjects. The left ventricle was assessed by: 2D-Simpson's biplane, 3D-triplane and -automated volumetric method. Next, 24 patients undergoing cardiac resynchronization therapy were prospectively assessed before and after 6 months. A haemodynamic response criterion of 15% left ventricular end-systolic volume (ESV) reduction was used. RESULTS: The 3D volumetric method was the fastest method for left ventricular ejection fraction assessment (bi-33 vs tri-53 vs145 sec, ANOVA P < 0.001). In heart failure the only strain parameter associated with QRS width was global peak longitudinal strain (r = 0.47, P = 0.023). A high agreement in left ventricular ejection fraction and volumes between methods was observed. The following measures select resynchronization candidates in the heart failure group: (1) 3D global longitudinal strain (AUC-0.756; P = 0.022; the cut-off value > -9.52%; 78% sensitivity, 80% specificity), radial strain (AUC-0.739; P = 0.086; cut-off value 20%; 78% sensitivity, 80% specificity) and area strain (AUC-0.733; P = 0.045; cut-off value > -13.5%; 67% sensitivity, 80% specificity). The agreement between the response assessment by Simpson's biplane and 3D was 78% with a negative predictive value of 100%. The lack of global area strain improvement after cardiac resynchronization therapy has a negative predictive value of 100% in the selection of non-responders. CONCLUSIONS: 3D echocardiography is applicable in the assessment of both preserved and reduced left ventricular ejection fraction. This assessment is fast and requires minimal user intervention. 3D strain may help in cardiac resynchronization therapy candidates and response assessment. After cardiac resynchronization, none of the patients were incorrectly identified as responder to cardiac resynchronization therapy by 3D algorithms compared to 2D Simpson's reference.

Percutaneous closure of the left atrial appendage using the Amplatzer Cardiac Plug in patients with atrial fibrillation: evaluation of safety and feasibility.

BACKGROUND: Ischaemic stroke is a common complication of atrial fibrillation (AF). Cardiology societies recommend assessing the risk of ischaemic stroke and using adequate prevention in patients with AF. Currently, oral anticoagulants and antiplatelet drugs are the most commonly used methods of stroke prevention. Left atrial appendage (LAA) is thought to be the main source of thrombi in patients with AF. LAA closure procedures that have been recently introduced into the clinical practice are an alternative method of stroke prevention in patients with contraindications to oral anticoagulants or with a high risk of bleeding. Two systems of percutaneous LAA closure are currently available, the Watchman plug and the Amplatzer Cardiac Plug, but experience with these procedures is still very limited. AIM: To provide early results regarding safety and feasibility of percutaneous LAA closure with the Amplatzer Cardiac Plug in patients with AF and multiple comorbidities resulting in a high risk of stroke and bleeding complications. METHODS: Twenty one patients with AF, at least 2 points in the CHADS2/CHA2DS2VASc score and a high risk of bleeding as assessed by the HAS-BLED score (at least 3 points) underwent percutaneous Amplatzer Cardiac Plug implantation. Patients with less than 3 points in the HAS-BLED score were also included in the study if they had contraindications to oral anticoagulants (e.g. previous haemorrhage, recurrent bleeding, epidermolysis) or suffered from recurrent ischaemic stroke despite anticoagulant treatment. The Amplatzer Cardiac Plug was implanted using the standard technique under fluoroscopic and echocardiographic guidance. RESULTS: Percutaneous LAA closure with the Amplatzer Cardiac Plug was performed in a group of patients with many comorbidities who had a high risk of ischaemic stroke (CHA2DS2VASc score 4.43 ± 1.4 points) as well as a high risk of bleeding (HAS-BLED score 3.0 ± 0.7 points). LAA occlusion was successfully performed in 20 (95.2%) patients. A serious periprocedural complication (cardiac tamponade requiring pericardiocentesis) occurred in 1 (4.76%) patient. CONCLUSIONS: Successful LAA occlusion is feasible in a vast majority of patients undergoing this procedure. The rate of serious periprocedural complications is relatively low. LAA occlusion is justified in a group of patients with a high risk of ischaemic stroke and a high risk of bleeding or contraindications to oral anticoagulants.