Idiopathic atrial fibrillation patients rapidly outgrow their low thromboembolic risk: a 10-year follow-up study.

BACKGROUND: Healthy atrial fibrillation (AF) patients will eventually outgrow their low thromboembolic risk. The purpose of this study is to compare the development of cardiovascular disease in healthy AF patients as compared to healthy sinus rhythm patients and to assess appropriate anticoagulation treatment. METHODS: Forty-one idiopathic paroxysmal AF patients (56 ± 10 years, 66% male) were compared with 45 healthy sinus rhythm patients. Patients were free of hypertension, antihypertensive and antiarrhythmic drugs, diabetes, congestive heart failure, coronary artery or peripheral vascular disease, previous stroke, thyroid, pulmonary and renal disease, and structural abnormalities on echocardiography. RESULTS: Baseline characteristics and echocardiographic parameters were the same in both groups. During 10.7 ± 1.6 years, cardiovascular disease and all-cause death developed significantly more often in AF patients as compared to controls (63% vs 31%, log rank p < 0.001). Even after the initial 5 years of follow-up, survival curves show divergent patterns (log rank p = 0.006). Mean duration to reach a CHA2DS2-VASc score > 1 among AF patients was 5.1 ± 3.0 years. Five of 24 (21%) patients with CHA2DS2-VASc > 1 did not receive oral anticoagulation therapy at follow-up. Mean duration of over- or undertreatment with oral anticoagulation in patients with CHA2DS2-VASc > 1 was 5 ± 3.0 years. CONCLUSION: The majority of recently diagnosed healthy AF patients develop cardiovascular diseases with a consequent change in thromboembolic risk profile within a short time frame. A comprehensive follow-up of this patient category is necessary to avoid over- and undertreatment with anticoagulants.

Multidisciplinary decision-making in mitral valve disease: the mitral valve heart team.

BACKGROUND: Although decision-making using the heart-team approach is apparently intuitive and has a class I recommendation in most recent guidelines, supportive data is still lacking. The current study aims to demonstrate the individualised clinical pathway for mitral valve disease patients and to evaluate the outcome of all patients referred to the dedicated mitral valve heart team. METHODS: All patients who were evaluated for mitral valve pathology with or without concomitant cardiac disease between 1 January 2016 and 31 December 2016 were prospectively followed and included. Patients were evaluated, and a treatment strategy was determined by the dedicated mitral valve heart team. RESULTS: One hundred and fifty-eight patients were included; 67 patients were treated surgically (isolated and concomitant surgery), 20 by transcatheter interventions and 71 conservatively. Surgically treated patients had a higher 30-day mortality rate (4.4%), which decreased when specified to a dedicated surgeon (1.7%) and in primary, elective cases (0%). This was also observed for major adverse events within 30 days. Residual mitral regurgitation >grade 2 was more frequent in the catheter-based intervention group (23.5%) compared to the surgical group (4.8%). CONCLUSION: In conclusion, the implementation of a multidisciplinary heart team for mitral valve disease is a valuable approach for the selection of patients for different treatment modalities. Our research group will focus on a future comparative study using historical cohorts to prove the potential superiority of the dedicated multidisciplinary heart-team approach.

The occurrence of cardiovascular disease during 5-year follow-up in patients with idiopathic atrial fibrillation.

AIMS: Idiopathic atrial fibrillation (AF) may be an expression of as yet undetected underlying heart disease. We found it useful for clinical practice to study the long-term development of cardiovascular disease (CVD) in patients diagnosed with idiopathic AF. METHODS AND RESULTS: Forty-one consecutive idiopathic AF patients (56 ± 10 years, 66% male) were compared with 45 healthy control patients in permanent sinus rhythm. Patients were free of hypertension, antihypertensive and antiarrhythmic drugs, diabetes, congestive heart failure, coronary artery or peripheral vascular disease, previous stroke, thyroid, pulmonary and renal disease, and structural abnormalities on echocardiography. Baseline characteristics and echocardiographic parameters were equal in AF cases and controls. During a mean follow-up of 66 ± 11 months, CVD occurred significantly more often in idiopathic AF patients compared with controls (49 vs. 20%, P= 0.006). Patients with idiopathic AF were significantly younger at the time of their first CV event compared with controls (59 ± 9 vs. 64 ± 5 years, P= 0.027), and had more severe disease. Multivariable Cox regression analysis revealed that age, a history of AF, and echocardiographic left ventricular wall width were significant predictors of CVD development. CONCLUSION: Patients originally diagnosed with idiopathic AF develop CVD more often, at younger age, and with a more severe disease profile compared with healthy sinus rhythm control patients. The detection and treatment of CVD in an early stage could improve the prognosis of these patients. At present it seems prudent to regularly check idiopathic AF patients for the insidious development of CVD.

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.

A challenging lead endocarditis.

Pacemaker/implantable cardioverter-defibrillator (ICD) lead endocarditis remains a challenging diagnosis in cardiology. Several parameters can be involved in the clinical path leading to the definite diagnosis. Clinical appearance and physical findings, together with transoesophageal echocardiography and serum levels of inflammatory parameters, are necessary in the workup towards the diagnosis. It is highly unlikely that ICD-lead vegetation is accompanied by positive blood cultures solely. We describe a case of ICD-infected endocarditis with positive blood cultures for Staphylococcus epidermidis without any physical findings or raised inflammatory parameters in serum plasma levels. In this case, three-dimensional echocardiography demonstrated an added value to two-dimensional echocardiography.

Bilobar apical pseudoaneurysm after left ventricular venting in a Marfan's patient.

A Marfan patient presented with a bilobar apical pseudoaneurysm after repeated surgery. These abnormalities were demonstrated by three-dimensional-echo, Doppler, and CT-reconstruction. The pseudoaneurysm was related to an apical venting procedure. In this case, a conservative approach was chosen, although in general, pseudoaneurysms form an indication for operative correction, because of the risk of rupture and acute tamponade.

Superior vena cava syndrome as a complication of colon carcinoma.

Superior vena cava syndrome is a group of signs and symptoms resulting from the impairment of blood flow through the SVC into the right atrium. We present a case of a 54-year-old female with superior vena cava syndrome due to metastasis of colon carcinoma into the SVC leading to an intraluminal obstruction. To our knowledge this is the first published report of an intraluminal metastasis of colon adenocarcinoma into the superior vena cava causing SVC syndrome.

Atrial tissue Doppler imaging for prediction of new-onset atrial fibrillation.

BACKGROUND: The total atrial conduction time (TACT) is an independent predictor of atrial fibrillation (AF). A new transthoracic echocardiographic tool to determine TACT by tissue Doppler imaging (PA-TDI (the time from the initiation of the P wave on the ECG (lead II) to the A' wave on the lateral left atrial tissue Doppler tracing)) has been developed recently. OBJECTIVE: To test the hypothesis that measurement of PA-TDI enables prediction of new-onset AF. METHODS: 249 Patients without a history of AF were studied. All patients underwent an echocardiogram and the PA-TDI interval was measured. Patient characteristics and rhythm at follow-up were recorded. RESULTS: During a mean (SD) follow-up of 680 (290) days, 15 patients (6%) developed new-onset AF. These patients had a longer PA-TDI interval than patients who remained in sinus rhythm (172 (25) ms vs 150 (20) ms, p = 0.001). Furthermore, the patients developing AF were older, more often had a history of heart failure or chronic obstructive pulmonary disease, more often used alpha blockers, had enlarged left atria and more frequently mitral incompetence on the echocardiogram. After adjusting for potential confounders, Cox regression showed that PA-TDI was independently associated with new-onset AF (OR = 1.375; 95% CI 1.037 to 1.823; p = 0.027). The 2-year incidence of AF was 33% in patients with a PA-TDI interval >190 ms versus 0% in patients with a PA-TDI interval <130 ms (p = 0.002). CONCLUSIONS: A prolonged PA-TDI interval may predict the development of new-onset AF. This measure may be used to identify patients at risk in future strategies to prevent the development or complications of AF.

Effect of upper arm brachial basilic and prosthetic forearm arteriovenous fistula on left ventricular hypertrophy.

BACKGROUND: Creation of an arteriovenous fistula (AVF) may increase left ventricular hypertrophy in the hemodialysis population. Aim of this study was to compare the effects of a brachial-basilic (BB) AVF and the prosthetic brachial-antecubital forearm loop access (PTFE) on cardiac performance. METHODS: Patients were randomized to receive BB-AVF or prosthetic brachial-antecubital forearm loop access. Before and three months after AVF creation patients underwent an echocardiographic examination. Mann-Whitney U-test was used to compare relative increase between the measured cardiac parameters for the two groups. RESULTS: Twenty-seven patients participated in the study. The relative increase in left ventricular parameters was not significantly different between the two groups. Only left ventricular end-diastolic diameter tended to be of significance. Mean blood flow through the brachial artery was 1680+/-156 and 1450+/-221 mL/min three months after surgery for the PTFE and the BB-AVF group, respectively. CONCLUSION: After three months of follow-up, changes in cardiac structure were comparable between patients with BB and PTFE AVFs. Also access flow was comparable at this time. In general, the effects of creation of a fistula on LV structure were limited. Longer follow up time may be needed to explore the long term effects of different vascular accesses on cardiac function.

Abdominal aortic aneurysm screening during transthoracic echocardiography in an unselected population.

OBJECTIVE: We sought to investigate the echocardiographic prevalence of abdominal aortic aneurysm (AAA) in an unselected group of patients referred for regular transthoracic echocardiography (TTE). METHODS: Prospectively, during a 3-month period, a limited ultrasound examination of the infrarenal aorta was performed. AAA was defined as a diameter of 30 mm or more. RESULTS: The abdominal aorta could be visualized in 742 patients. The prevalence of AAA was 4.6%. AAA prevalence increased with age, especially in men. In 34 patients AAA was unknown and aortic diameters exceeded 50 mm in 4 patients. Two underwent elective but urgent operation. Patients with AAA were older and had an increased ascending aorta diameter, larger left ventricular dimensions, higher left ventricular mass index, and lower ejection fraction. CONCLUSION: AAA is prevalent in patients referred for regular TTE. Routine rapid screening of the abdominal aorta during TTE is beneficial and should, therefore, be part of a standard TTE examination for patients older then 50 years.

Validity of conjoint analysis to study clinical decision making in elderly patients with aortic stenosis.

OBJECTIVE: Written case simulations are increasingly being used to investigate clinical decision making. Our study was designed to determine the validity of written case simulations within a conjoint analysis approach. STUDY DESIGN AND SETTING: We developed a series of 32 written case simulations that differed with respect to nine clinical characteristics. These case simulations represented elderly patients with aortic stenosis. The clinical characteristics varied according to a fractional factorial design. We analyzed retrospectively all consecutive patients of 70 years of age or older with an aortic stenosis in three university hospitals. RESULTS: 34 cardiologists from three Dutch hospitals gave their treatment advice to each of these case simulations on a six-point scale (ranging from 'certainly no' to 'certainly yes' to surgical treatment). We compared the influence that the clinical characteristics had on the responses to these case simulations with their influence on the actual treatment decision for 147 actual patients in the same three hospitals. We found a strong agreement. This agreement was only slightly affected by the cut-off value used to dichotomize the treatment advice into a recommendation in favor of or against surgical treatment. CONCLUSION: Written case simulations reflect well how clinicians are influenced by specific clinical characteristics of their patients.

Prospective echocardiographic assessment of androgenic-anabolic steroids effects on cardiac structure and function in strength athletes.

Since the abuse of androgenic-anabolic steroids (AAS) has been associated with the occurrence of serious cardiovascular disease in young athletes, we performed two studies to investigate the effects of short-term AAS administration on heart structure and function in experienced male strength athletes, with special reference to dose and duration of drug abuse. In Study 1 the effects of AAS were assessed in 17 experienced male strength athletes (age 31 +/- 7 y) who self-administered AAS for 8 or 12 - 16 weeks and in 15 non-using strength athletes (age 33 +/- 5 y) in a non-blinded design. In Study 2 the effects of administration of nandrolone decanoate (200 mg/wk i. m.) for eight weeks were investigated in 16 bodybuilders in a randomised double blind, placebo controlled design. In all subjects M-mode and two-dimensional Doppler-echocardiography were performed at baseline and after 8 weeks AAS administration. In the athletes of Study 1 who used AAS for 12 - 16 weeks a third echocardiogram was also made at the end of the AAS administration period. Echocardiographic examinations included the determination of the aortic diameter (AD), left atrium diameter (LA), left ventricular end diastolic diameter (LVEDD), interventricular septum thickness (IVS), posterior wall end diastolic wall thickness (PWEDWT), left ventricular mass (LVM), left ventricular mass index (LVMI), ejection fraction (EF) and right ventricular diameter (RVD). For assessment of the diastolic function measurements of E and A peak velocities and calculation of E/A ratio were used. In addition, acceleration and deceleration times of the E-top (ATM and DT, respectively) were determined. For evaluation of factors associated with stroke volume the aorta peak flow (AV) and left ventricular ejection times (LVET) were determined. In Study 1 eight weeks AAS self-administration did not result in changes of blood pressure or cardiac size and function. Additionally, duration of AAS self-administration did not have any impact on these parameters. Study 2 revealed that eight weeks administration of nandrolone decanoate did not induce significant alterations in blood pressure and heart morphology and function. Short-term administration of AAS for periods up to 16 weeks did not lead to detectable echocardiographic alterations of heart morphology and systolic and diastolic function in experienced strength athletes. The administration regimen used nor the length of AAS abuse did influence the results. Moreover, it is concluded that echocardiographic evaluation may provide incomplete assessment of the actual cardiac condition in AAS users since it is not sensitive enough to detect alterations at the cellular level. Nevertheless, from the present study no conclusions can be drawn of the cardiotoxic effects of long term AAS abuse.

Effect of closure of the arteriovenous fistula on left ventricular dimensions in renal transplant patients.

BACKGROUND: Left ventricular hypertrophy is common in renal transplant patients. One of the factors that might contribute to this phenomenon is the persisting presence of an arteriovenous (AV) fistula. Several reports have described the presence of high-output cardiac failure, which subsided after closure of the AV fistula. However, the long-term effects of elective closure of the AV fistula on left ventricular dimensions in stable renal transplant patients have never been prospectively studied. SUBJECTS AND METHODS: Twenty patients (15 male, 5 female; mean age 51+/-12 years) with a well-functioning renal transplant were included. Patients with severe heart failure (NYHA III or IV) were excluded. Before and 3-4 months after closure of the AV fistula, an echocardiogram was performed. Fistula flow was assessed by colour duplex-Doppler sonography. RESULTS: Mean fistula flow was 1790+/-648 ml/min. After closure of the fistula, left ventricular end-diastolic diameter (LVEDD) (51.5+/-5.8 vs 49.3+/-5.4 mm, P<0.01) and left ventricular mass index (LVMi) (135.0+/-34.1 vs 119.8+/-23.2) decreased. The change in LVMi after fistula closing was significantly related to the LVMi and LVEDD before operation (r=0.74 and r=0.60, P<0.01), but not to fistula flow. Interventricular septal and posterior-wall diastolic thickness did not change. Heart rate decreased (72+/-10 vs 69+/-9, P:=0.03) Blood pressure and creatinine clearance did not change. CONCLUSION: Closure of the arteriovenous fistula in stable renal transplant patients results in a decrease in LVMi, due to a reduction in LVEDD. The change in LVMi is significantly related to the LVMi and LVEDD before fistula closing. In patients with a well-functioning allograft and persistent LV dilatation, closure of the AV fistula might be considered.

Management of atrial arrhythmias secondary to severe congenital heart disease with the Atrioverter.

An atrial defibrillator was implanted in a patient with congenitally corrected transposition of the great arteries, associated cardiac abnormalities, and persistent atrial arrhythmias. During a 15-month follow-up, 14 of 20 spontaneous episodes of his arrhythmias were successfully treated with the device. Two of these episodes were converted to sinus rhythm during ambulatory use of the device. Successful use of the device required implantation of a third defibrillation lead in the persistent left-sided superior caval vein and rigid control of congestive heart failure. An atrial defibrillator may be a valid treatment option in patients with congenital heart disease crippled by atrial fibrillation.

Changes in hemodynamic parameters and volume homeostasis with the menstrual cycle among women with a history of preeclampsia.

OBJECTIVE: Among women with a history of preeclampsia the prevalence of hemodynamic and clotting disorders is elevated. In this study we tested the hypothesis that the normal cyclic variation in hemodynamic and renal function parameters with the menstrual cycle that is seen among healthy women would be preserved in women with a history of preeclampsia irrespective of whether they had an underlying hemodynamic or clotting disorder. STUDY DESIGN: We compared the hemodynamic and volume cyclic variations during the menstrual cycle among women with a history of preeclampsia (n = 39) with those among healthy parous control women (control group, n = 10). The participants with a history of preeclampsia were subdivided into groups of women with hypertension with or without thrombophilia (hypertension group, n = 10), women with a normotension and a thrombophilic disorder (thrombophilia group, n = 17), and women without either of these abnormalities (symptom-free group, n = 12). We measured > or =5 months post partum, once during the follicular phase of the menstrual cycle (day 5 +/- 2) and once during the luteal phase (day 22 +/- 2), the following variables: body weight and length, mean arterial pressure, heart rate, cardiac output, plasma volume, glomerular filtration rate, effective renal plasma flow, and concentrations of renal volume homeostatic hormones, reproductive hormones, and catecholamines. From the measured data we calculated body mass index, cardiac index, left ventricular work, total peripheral and renal vascular resistances, effective renal blood flow, and renal filtration fraction. RESULTS: The hypertension group differed from the control group in having higher baseline (follicular phase) values for cardiac output, cardiac output, left ventricular work, renal vascular resistance, and atrial natriuretic peptide and norepinephrine levels. The symptom-free group differed from the control group in having a lower baseline plasma volume and higher baseline cardiac output and left ventricular work values. Women in the thrombophilia group were comparable to those in the control group with respect to baseline hemodynamic and renal function variables except for a higher renal vascular work value. In the control group heart rate, plasma volume, effective renal plasma volume, effective renal blood flow, and concentrations of renin-angiotensin-aldosterone system hormones and norepinephrine were increased during the luteal phase with respect to values during the follicular phase, whereas the renal vascular resistance and atrial natriuretic peptide values were decreased. In the three subgroups of women with a history of preeclampsia this cyclic pattern with the menstrual cycle was preserved for most of these parameters. CONCLUSION: Although baseline hemodynamic and volume status among women with a history of preeclampsia differed from that among healthy parous control subjects, the cyclic variation with the menstrual cycle was largely preserved.

Latent hemodynamic abnormalities in symptom-free women with a history of preeclampsia.

OBJECTIVE: Most women with a pregnancy complicated by preeclampsia have either hypertension or a disorder with a thrombophilic phenotype or both of these. In this study we evaluated whether hemodynamic variables and volume homeostasis in a subgroup of normotensive women with a history of preeclampsia with normal clotting function (defined as the symptom-free subgroup) were comparable with those in a healthy parous control group. STUDY DESIGN: In a group of 58 subjects with a history of preeclampsia and a group of 11 healthy parous control subjects we measured the following variables > or = 5 months post partum at day 5 +/- 2 of the menstrual cycle: body weight and length, mean arterial pressure, heart rate, cardiac output, plasma volume, glomerular filtration rate, effective renal plasma flow, and plasma concentrations of volume regulatory hormones, clotting factors, antiphospholipid antibodies, and homocysteine before and after a methionine load. From the measured data we calculated body mass index, body surface area, cardiac index, left ventricular work, total peripheral and renal vascular resistances, effective renal blood flow, and renal filtration fraction. RESULTS: Among women with a history of preeclampsia 26 were normotensive with thrombophilia (45%), 14 had hypertension (24%), and 18 were normotensive without thrombophilia (31%). These last symptom-free subjects with a history of preeclampsia were more obese than were control subjects. They also had higher cardiac output and left ventricular work and a lower plasma volume than the healthy parous control subjects. Thus they resemble the second subgroup of subjects (subjects with hypertension and a history of preeclampsia) rather than the control subjects. The hemodynamic and renal functions in the subgroup of subjects with a history of preeclampsia with normotension and thrombophilia were similar to those in healthy parous control subjects. CONCLUSION: On the basis of this study we conclude that hemodynamic parameters and volume homeostasis in the symptom-free subgroup of women with a history of preeclampsia are different from those in healthy parous control subjects. Hemodynamic parameters and volume homeostasis in this subgroup resemble those of women with hypertension and a history of preeclampsia. We therefore propose the classification of these symptom-free subjects with a history of preeclampsia as having "latent" hypertension.

Efficacy and safety of fluoxetine in the treatment of patients with major depression after first myocardial infarction: findings from a double-blind, placebo-controlled trial.

OBJECTIVE: Depression and hostility are significant risk factors for mortality and morbidity after myocardial infarction (MI). Much research is still needed to identify effective ways to reduce emotional distress in patients with cardiovascular disease. This double-blind, placebo-controlled study investigated the efficacy and safety of the antidepressant fluoxetine in patients with depression after their first MI. METHODS: Fifty-four patients with major depression after MI were randomly assigned to receive a flexible-dose regimen of fluoxetine or placebo for the first 9 weeks of a double-blind, placebo-controlled trial. Patients without serious adverse effects who wished to continue participating in the study were given fluoxetine or placebo for an additional 16 weeks. To evaluate the efficacy of fluoxetine, the 17-item Hamilton Depression Rating Scale (HAMD-17) and the Hostility Scale of the 90-item Symptom Check List (SCL-90) were used as primary measures of outcome. To evaluate the safety of fluoxetine, cardiac function was measured before and after treatment with echocardiography and electrocardiography. RESULTS: The a priori difference in antidepressive efficacy (4-point difference in HAMD-17 scores between the fluoxetine and placebo groups) was not met. However, the response rate among patients receiving fluoxetine was significantly greater than that among patients receiving placebo at week 25 (48 vs. 26%, p = .05). Among patients with mild depression (HAMD-17 score < or =21), HAMD-17 scores were significantly different (p < .05) between the fluoxetine and placebo groups at weeks 9 (by 5.4 points) and 25 (by 5.8 points). Also, hostility scores at week 25 were significantly reduced among patients receiving fluoxetine (p = .02). Analysis of electrocardiographic and echocardiographic parameters revealed no decrease in cardiac function as a result of treatment with fluoxetine. CONCLUSIONS: Although the overall difference between the fluoxetine and placebo groups was not significant, there was a trend favoring fluoxetine in this relatively small sample. The response rate in the group receiving fluoxetine was comparable with that observed in other studies of patients with cardiovascular disease. In addition, fluoxetine seemed to be particularly effective in patients with mild depression and was associated with a statistically significant reduction in hostility. The results of this study suggest that fluoxetine can be safely used to treat patients with post-MI depression beginning 3 months after the event.