Outcomes of Routine Intracardiac Echocardiography to Guide Left Atrial Appendage Occlusion.

OBJECTIVES: The aim of this study was to compare the safety and hospital charges between intracardiac echocardiography (ICE)- and transesophageal echocardiography (TEE)-guided left atrial appendage occlusion (LAAO). BACKGROUND: TEE has been the gold standard imaging modality to guide LAAO. Although ICE has emerged as an alternative to guide LAAO, data on the safety, and cost effectiveness of its routine remain limited. METHODS: Consecutive patients who underwent LAAO with ICE or TEE guidance at the West Virginia University Clinic were compared for the following endpoints: 1) technical success; 2) procedure-related events; 3) hospital charges; and 4) peri-device leak, device embolization, or device thrombus at 45 days. RESULTS: After excluding patients who underwent a concomitant non-LAAO intervention, 286 patients (n = 196 TEE, n = 90 ICE) were enrolled. Baseline characteristics were similar. Technical success was achieved in 97.8% and 97.4% of the patients in the ICE and TEE groups, respectively (p = 0.88). No patients in the ICE group required conversion to TEE or general anesthesia. Major procedure-related events occurred in 3.3% and 4.1% of the patients in the ICE and TEE groups, respectively (p = 0.76). Procedural and fluoroscopy times were similar (35.2 ± 11.3 min vs. 36.6 ± 15.6 min; p = 0.42 and 14.2 ± 3.6 min vs. 13.8 ± 8.9 min; p = 0.67, respectively). However, in-room time was shorter with ICE (78.7 ± 19.5 min vs. 113.6 ± 18.1 min; p < 0.001). Hospital charges were higher with ICE ($76,366 ± $8,028 vs. $71,114 ± $10,802; p < 0.001), whereas professional fees were higher with TEE ($6,033 ± $1,081 vs. $2,654 ± $395; p < 0.001). However, global charges were similar with ICE and TEE ($79,020 ± $8,241 vs. $77,147 ± $10,941; p = 0.15). Follow-up imaging at 45 ± 15 days showed similar rates of peri-device leaks, device thrombi, and iatrogenic atrial septal defects. CONCLUSIONS: ICE-guided LAAO is associated with similar outcomes and hospital charges compared with TEE-guided LAAO.

Sex-dependent difference in the relationship between adipose-tissue cholesterol efflux and estradiol concentrations in young healthy humans.

BACKGROUND: Impaired adipose tissue function and lower levels of high density lipoprotein cholesterol (HDL-C) have been implicated in the development of vascular dementia, and metabolic diseases such as hypertension, atherosclerosis, type 2 diabetes (T2D) and metabolic syndrome. Interestingly, both the substrate fluxes in adipose tissue and HDL-C concentration differ between men and women. Moreover, adipose tissue cholesterol efflux has been implicated in modulation of HDL-C levels. Thus, we aimed to determine if the association between serum estradiol levels and adipose tissue cholesterol efflux is sex-dependent. METHOD: We evaluated the serum estradiol levels and adipose tissue cholesterol efflux in young healthy men (n=5) and women (n=3). Adipose tissue cholesterol efflux was determined using subcutaneous microdialysis probes. Linear regression analyses were used to determine the relationship between the parameters, p<0.05 was considered as statistically significant. RESULTS: Our data demonstrated that serum estradiol levels directly associated with adipose tissue cholesterol efflux; however, the relationships may be sex-dependent. We discussed our results in the context of currently available data regarding sex-dependent variability in adipose tissue function and HDL-C metabolism as a potential contributor to higher rates of vascular dementia in men. Further research is required to understand the sex-dependent and -independent variabilities in adipose tissue metabolism to determine novel targets for interventions to prevent the development of vascular dementia.

Real time three-dimensional echocardiography for the evaluation of cardiomyopathy.

Cardiomyopathy refers to a set of diseases that are characterized by myocardial dysfunction. Classically, two-dimensional echocardiography has been used in the diagnosis of these disorders and to help guide their management. Three-dimensional transthoracic echocardiography is now increasingly being used in the diagnosis, management, and prognostication of intrinsic cardiomyopathies. In this article, we summarize the available data on the use of three-dimensional transthoracic echocardiography in various forms of intrinsic cardiomyopathy as well as some of its advantages over traditional two-dimensional transthoracic echocardiography.

Comparison of the prognostic value of normal regadenoson with normal adenosine myocardial perfusion imaging with propensity score matching.

OBJECTIVES: The aim of this study was to test the hypothesis that patients with normal regadenoson myocardial perfusion imaging (MPI) have a low rate of cardiac events, similar to patients with normal adenosine MPI. BACKGROUND: Regadenoson, a new selective adenosine A(2A) receptor agonist, is now a widely used stress agent for MPI. The low rate of cardiac events in patients with normal adenosine MPI is well-documented, but the prognostic implications of a normal regadenoson MPI have not been examined and compared with those with adenosine. METHODS: Data on primary composite endpoint (cardiac death, myocardial infarction, and coronary revascularization) were collected for 2,000 patients (1,000 regadenoson, and 1,000 adenosine stress) with normal myocardial perfusion and left ventricular ejection fraction referred for vasodilator MPI. In addition, propensity scores were used to assemble a balanced cohort of 505 pairs of patients who were balanced on 36 baseline characteristics. RESULTS: The primary endpoint occurred in 21 (2.1%; 1.1%/year) patients in the regadenoson group and 33 (3.3%; 1.7%/year) patients in the adenosine group (hazard ratio [HR] for regadenoson vs. adenosine: 0.62; 95% confidence interval [CI]: 0.36 to 1.08; p = 0.090). In the propensity-matched pairs, the primary endpoint occurred in 7 (1.4%; 0.7%/year) patients in the regadenoson group and 13 (2.6%; 1.3%/year) patients in the adenosine group (matched HR: 0.58; 95% CI: 0.23 to 1.48; p = 0.257). Cardiac deaths were infrequent in the entire sample and in the propensity-matched groups; the cardiac death rate was 0.9%/year and 1.15%/year in the regadenoson and adenosine groups (HR: 0.77; 95% CI: 0.42 to 1.43; p = 0.404) in the pre-match sample and 0.5%/year and 0.7%/year in the matched groups, respectively (HR: 0.83; 95% CI: 0.25 to 2.73; p = 0.763). CONCLUSIONS: Major cardiac events are infrequent in patients with normal regadenoson MPI. These findings provide assurance that normal MPI using a simpler stress protocol with regadenoson provides prognostic data similar to normal adenosine MPI.

Real time three-dimensional transthoracic echocardiography in congenital heart disease.

Diagnosing congenital heart disease (CHD) depends heavily on imaging. Traditionally, two-dimensional (2D) echocardiography has been the most widely used but since this imaging modality utilizes a 2D technique to evaluate three-dimensional (3D) structures it suffers from inherent limitations. The more recently developed 3D echocardiography is poised to be superior in providing comprehensive evaluation prior to intervention on such complex conditions. In this review, we summarize the applications of 3D echocardiography in evaluating patients with CHD.

Incremental value of live/real time three-dimensional transesophageal echocardiography over the two-dimensional technique in the assessment of sinus of valsalva aneurysm rupture.

We present an adult patient with rupture of the right sinus of Valsalva aneurysm in whom the two-dimensional transesophageal echocardiogram failed to show the rupture. On the other hand, live/real time three-dimensional transesophageal echocardiography clearly delineated the site of rupture into the pericardium and mediastinum.

Transesophageal echocardiographic detection of thrombus superimposed on metastatic left atrial tumor.

We present a 32-year-old male with metastatic thymic carcinoma invading the left atrium in whom two-dimensional transesophageal echocardiography was able to differentiate a thrombus superimposed on the tumor.