Electrical cardioversion for atrial fibrillation improves microvascular flow independent of blood pressure changes.

OBJECTIVE: This study tested the hypothesis that there is a discrepancy between global hemodynamic parameters and microvascular flow in patients before and after successful elective electrical cardioversion (ECV) for atrial fibrillation (AF). DESIGN: Prospective observational study. SETTING: Preanesthesia holding area in a teaching hospital. PARTICIPANTS: Adult patients who underwent successful elective ECV for AF. INTERVENTIONS: ECV. MEASUREMENTS AND MAIN RESULTS: Routine measurements of heart rate and noninvasive blood pressure were recorded and the sublingual microcirculation was visualized by sidestream darkfield imaging before and after the conversion of AF to sinus rhythm by elective ECV. The conversion to sinus rhythm significantly improved the microvascular flow index for smaller and larger microvessels. For smaller microvessels, perfused vessel density did not reach significance after conversion to sinus rhythm, whereas the proportion of perfused vessels was significantly larger and indices of heterogeneity for microvascular flow index decreased significantly. No correlation could be identified for the changes in mean blood pressure, perfused vessel density, and microvascular flow index for smaller microvessels. CONCLUSIONS: Successful ECV in patients with AF improves indices of sublingual microvascular perfusion. This change has no clear relation to the change in blood pressure and cannot be predicted from it. It may be prudent not to rely solely on global hemodynamic parameters to assess end-organ perfusion in this setting.

Carotid artery stenting and cardiac surgery in symptomatic patients.

OBJECTIVES: The purpose of this study was to evaluate the feasibility and safety of the combined outcome of carotid artery stenting (CAS) and coronary artery bypass graft (CABG) surgery in neurologically symptomatic patients. BACKGROUND: The risk of perioperative stroke in patients undergoing CABG who report a prior history of transient ischemic attack or stroke has been associated with a 4-fold increased risk as compared to the risk for neurologically asymptomatic patients. It seems appropriate to offer prophylactic carotid endarterectomy to neurologically symptomatic patients who have significant carotid artery disease and are scheduled for CABG. The CAS-CABG outcome for symptomatic patients remains underreported, notwithstanding randomized data supporting CAS for high-risk patients. METHODS: In a prospective, single-center study, the periprocedural and long-term outcomes of 57 consecutive patients who underwent CAS before cardiac surgery were analyzed. RESULTS: The procedural success rate of CAS was 98%. The combined death, stroke, and myocardial infarction rate was 12.3%. The death and major stroke rate from time of CAS to 30 days after cardiac surgery was 3.5%. The myocardial infarction rate from time of CAS to 30 days after cardiac surgery was 1.5%. CONCLUSIONS: This is the first single-center study reporting the combined outcome of CAS-CABG in symptomatic patients. The periprocedural complication rate and long-term results of the CAS-CABG strategy in this high-risk population support the reliability of this approach. In such a high-risk population, this strategy might offer a valuable alternative to the combined surgical approach; however, a large randomized trial is clearly warranted.

Relation between migraine and size of echocardiographic intrapulmonary right-to-left shunt.

An increased prevalence of intrapulmonary right-to-left shunt (RLS) has been shown in patients with migraine. The aim of this study was to determine whether the size of intrapulmonary RLS was associated with migraine with aura (MA+) and migraine without aura (MA-) in subjects screened for hereditary hemorrhagic telangiectasia. A total of 462 consecutive subjects were screened for hereditary hemorrhagic telangiectasia and underwent transthoracic contrast echocardiography. A pulmonary shunt was established when contrast appeared in the left atrium after 4 cardiac cycles. Shunt size was assessed semiquantitatively as small (<30 microbubbles), moderate (30 to 100 microbubbles), or large (>100 microbubbles). A headache questionnaire was completed by 420 subjects (91%). Two independent neurologists diagnosed migraine according to the International Headache Society criteria. Of 420 screened subjects (mean age 43.4 ± 15.4 years, 61.4% women), 44 (10.5%) had MA+ and 45 (10.7%) had MA-. MA+ was an independent predictor for an intrapulmonary RLS (odds ratio [OR] 2.96, 95% confidence interval [CI] 1.36 to 6.47, p=0.006) in multivariate analysis. MA- was not correlated with RLS (OR 1.21, 95% CI 0.56 to 2.64, p=0.60). When comparing patients with MA+ to those without migraine in a multivariate analysis, the presence of an intrapulmonary shunt predicted MA+ (OR 2.5, 95% CI 1.2 to 5.2, p=0.01), as did female gender (OR 3.15, 95% CI 1.29 to 7.65, p<0.01). The correlation of MA+ and RLS could be entirely attributed to large intrapulmonary shunts (OR 7.61, 95% CI 3.11 to 18.61, p<0.001), as small (OR 0.6, 95% CI 0.13 to 2.78, p=0.52) and moderate (OR 1.33, 95% CI 0.35 to 5.02, p=0.68) shunts did not appear to be risk factors for MA+. In conclusion, patients with large intrapulmonary RLS have an increased risk for MA+.

Percutaneous atrial shunt closure using the novel Occlutech Figulla device: 6-month efficacy and safety.

BACKGROUND: The Occlutech Figulla Occluder is a new innovative device for percutaneous closure of a patent foramen ovale (PFO) and an atrial septum defect (ASD). We describe the safety and efficacy of this new device at 6-month follow-up. METHODS: All 82 consecutive patients (51% female, mean age 49.0 ± 13.6 years) who underwent percutaneous PFO (n = 48) or ASD (n = 34) closure between October 2008 and October 2009 were included. RESULTS: Implantation success was 100%. The in-hospital complications were two new onset supraventricular tachycardia (SVT) (2.4%, both ASD patients), nine minimal groin hematoma's (11.0%, 4 PFO and 5 ASD patients), and one transient ST elevation during the procedure (1.2%, ASD patient). During 6 months follow-up (n = 79), no major complications or reoccurrences of cerebral thrombo-embolic events did occur. Seven patients (8.9%, 6 PFO and 1 ASD patient) experienced a new SVT. One patient developed a recurrent cerebral hemorrhage 5 months after ASD closure, which appeared not to be related to the procedure. Using contrast transthoracic echocardiography 6 months after PFO closure (n = 45), a residual shunt was present in 30.2% of the patients (small 25.6%, moderate 4.6%, severe 0%). In the ASD group (n = 34), a residual shunt was observed in 32.5% (small 17.7%, moderate 14.7%, severe 2.9%). CONCLUSION: The Occlutech Figulla Occluder appears to be easy to use, effective, and safe for percutaneous closure of PFO and ASD. We report a low complication rate but a relative high percentage of small residual shunts 6 months after closure.

Is carotid artery disease responsible for perioperative strokes after coronary artery bypass surgery?

The coronary and extracranial carotid vascular beds are often simultaneously affected by significant atherosclerotic disease, and stroke is one of the potential major complications of coronary artery surgery. As a result, there is no shortage of reports in the vascular surgery literature describing simultaneous coronary and carotid artery revascularizations. Generally, these reports have found this combination of operations safe, but have stopped short of proving that it is necessary. Intuitively, simultaneous carotid endarterectomy and coronary artery bypass surgery could be justified if most perioperative strokes were the result of a significant carotid stenosis, either directly or indirectly. At first glance this appears to be a fairly straightforward issue; however, much of the evidence on both sides of the argument is circumstantial. One significant problem in analyzing outcome by choice of treatment in patients presenting with both coronary and carotid disease is the multiple potential causes of stroke in coronary bypass patients, which include hemorrhage and atheroemboli from aortic atheromas during clamping. But this controversial subject is now open to discussion, and our debaters have been given the challenge to clarify the evidence to justify their claims.

The emerging burden of hospital admissions of adults with congenital heart disease.

OBJECTIVE: To assess the extent and the characteristics of hospital admissions in registered adult patients with congenital heart disease. DESIGN: Observational cohort study. SETTING: The Netherlands. PATIENTS: 5798 adult patients with congenital heart disease from the Dutch CONCOR national registry linked to the Dutch National Medical Registration (Prismant). MAIN OUTCOME MEASURES: All hospital admissions from the years 2001 up until 2006. RESULTS: During 28 990 patient-years, 2908 patients (50%) were admitted to hospital. Median age at admission was 39 years (range 18-86 years); 46% were male. Admission rate in CONCOR patients was high among all ages (range 11-68%) and exceeded that of the general Dutch population two to three times; this difference was most pronounced in the older age groups. Altogether there were 8916 admissions, 5411 (61%) of which were for cardiovascular indications. Among cardiovascular admissions, referrals for arrhythmias were most common (31%). Of 4926 interventions, 2459 (50%) were cardiovascular, most often reparative interventions or cardioversion (53%). Most non-cardiovascular admissions were obstetric. Among defects, univentricular heart and tricuspid atresia had the highest incidence and duration of admission. CONCLUSIONS: Healthcare utilisation in registered and medically supervised adult patients with congenital heart disease is high and increases with age. Admission rates are at least two times higher than in the general population, and most marked in the older age groups. With the ageing of this population, a major increase in healthcare utilisation is imminent in the near future. Timely preparation of healthcare resources is crucial to sustain optimal care.

Real prevalence of pulmonary right-to-left shunt according to genotype in patients with hereditary hemorrhagic telangiectasia: a transthoracic contrast echocardiography study.

BACKGROUND: Transthoracic contrast echocardiography (TTCE) can detect pulmonary right-to-left shunting (RLS) and is used to screen for pulmonary arteriovenous malformations (PAVMs) in patients with hereditary hemorrhagic telangiectasia (HHT). We studied the prevalence and size of pulmonary RLS in HHT type 1, HHT type 2, and HHT-negative controls, and its positive predictive value (PPV) and negative predictive value (NPV) for PAVMs that can be treated by embolotherapy. METHODS: In 343 consecutive persons referred for possible HHT as first-degree family members of index patients a TTCE and chest CT scan were performed. All persons were offered genetic analysis. RESULTS: An HHT-causing mutation was confirmed in 92 (mean age 41 ± 15 y; 59% female) HHT1 relatives and in 97 (mean age 47 ± 14 y; 52% female) HHT2 relatives. TTCE showed a pulmonary RLS in 78 (85%) HHT1- and 34 (35%) HHT2-related mutation carriers, respectively (P < .0001). In HHT1 relatives, 29 of 53 (55%) PAVMs and in HHT2 relatives three of 17 (18%) PAVMS were treated, resulting in a PPV of TTCE for treatable PAVMs of 36.3% and 8.3%, respectively. The accompanying NPV was 100%. A minimal, moderate, or large shunt was present in 12 (13%), 24 (26%), and 42 (46%) HHT1-related, and in 20 (21%), 6 (6%), and 8 (8%) HHT2-related mutation carriers, respectively (P for trend < .0001). A large shunt predicted treatable PAVMs in 55.8% of HHT1 relatives and 37.5% of HHT2 relatives. TTCE was positive in four (6%) of 63 persons without HHT. CONCLUSIONS: A pulmonary shunt on TTCE is more prevalent and larger in HHT1- compared with HHT2-related mutation carriers. Shunt grading is helpful to predict treatable PAVMs, particularly in the HHT2 group. TTCE is also positive in a small fraction of persons without HHT.

Myocardial perfusion SPECT identifies patients with left bundle branch block patterns at high risk for future coronary events.

BACKGROUND: The value of myocardial perfusion SPECT (MPS) for patients with left bundle branch block (LBBB) or right ventricular apical (RVA) pacing seems reduced. The prognosis of patients with only abnormal activation related perfusion defects (AARD) due to LBBB or RVA-pacing is similar to those with a normal MPS. We assessed the prognostic value of MPS in patients with LBBB or RVA pacing. METHODS: Patients with LBBB or RVA pacing referred for vasodilator stress MPS between April 2002 and January 2006 were analyzed. Group 1 are patients with normal MPS and MPS with AARD. Group 2 are patients with an MPS with a perfusion defect extending outside the AARD area. Events were cardiac death, acute myocardial infarction and coronary revascularization. RESULTS: In Group 1 (101 patients) 12 events and in Group 2 (96 patients) 45 events occurred during a mean follow-up of 2.6 +/- 1.5 years. The prognosis of Group 2 was significantly worse (49%) compared with Group 1 (91%). The annual cardiac death rate was 0.7%/year in Group 1 and 6.4%/year in Group 2 (P < .001). The prognosis of patients with LBBB was not different from those with RVA pacing. CONCLUSION: Group 2 had a significantly worse cardiac prognosis compared to Group 1. The annual cardiac death rate of <1% in Group 1 warrants a watchful waiting strategy, whereas the cardiac death rate in Group 2 warrants aggressive invasive coronary strategies.

Grading of pulmonary right-to-left shunt with transthoracic contrast echocardiography: does it predict the indication for embolotherapy?

RATIONALE: Pulmonary arteriovenous malformations (PAVMs) are associated with severe neurologic complications in patients with hereditary hemorrhagic telangiectasia (HHT). Therefore, screening is warranted. Transthoracic contrast echocardiography (TTCE) can effectively detect a pulmonary right-to-left shunt (RLS). OBJECTIVES: To determine prospectively the predictive value of TTCE grading to detect PAVMs on high-resolution CT (HRCT) scans of the chest and the indication for embolotherapy. METHODS: Three hundred seventeen patients, referred for possible HHT, were screened for PAVMs. Patients who underwent both chest HRCT scanning and TTCE were included in the study (n = 281). For the purposes of this study we used a 3-point grading scale, and shunt grades 3 and 4 according to the classification model of Barzilai et al were combined. Embolotherapy was performed of all PAVMs judged large enough for treatment. RESULTS: Echocardiographic criteria for a pulmonary RLS were present in 105 patients (41%) [mean (+/- SD) age, 43.7 +/- 15.7 years; female gender, 63%]. Chest HRCT scan findings were positive in 55 patients (52%) in this group. The positive predictive value of shunt grade for the presence of PAVMs on chest HRCT scans was 22.9% for grade 1 (n = 35), 34.8% for grade 2 (n = 23), and 83.0% for grade 3 (n = 47), respectively. None of the patients with PAVMs seen on chest HRCT scans and a TTCE grade 1 (n = 8) or 2 (n = 8) were candidates for embolotherapy. Of 39 patients with TTCE grade 3 and PAVMs seen on chest HRCT scans, 26 patients (67%) underwent embolotherapy. CONCLUSION: An increased echocardiographic shunt grade correlates with an increased probability of PAVMs seen on chest HRCT scans. Only patients with a TTCE grade 3 displayed PAVMs on chest HRCT scans that were large enough for embolotherapy.

Increased prevalence of migraine in Marfan syndrome.

OBJECTIVE: A high prevalence of migraine has been described in various forms of congenital heart disease, with and without shunt. In this study we investigated the prevalence of migraine in patients with Marfan syndrome (MFS). METHODS: All 457 adult patients with MFS from the participating centres and 194 controls received a validated questionnaire about headache. Migraine was diagnosed according to the International Headache Society criteria, by three independent neurologists, blinded to patient files. RESULTS: Response rate was 68% and 56% in Marfan patients and controls, respectively. Forty percent of the 309 responding MFS patients (mean age 40+/-14 years; 51% females) and 28% of the 102 controls (mean age 43+/-15 years; 58% females), suffered from migraine (p=0.03). The prevalence of migraine with aura (MA) was 22% in MFS patients and 14% in controls (p=0.06). We found MFS to be an independent risk factor for having overall migraine (OR 1.7; 95%CI 1.1-2.8), also after adjustment for age and gender (OR 1.9; 95%CI 1.1-3.1; p=0.02) and for MA after adjustment for gender (OR 2.0; 95%CI 1.1-3.7; p=0.04). In patient with MFS, previous aortic root surgery appeared to be an independent risk factor for having MA (OR 2.2; 95%CI; 1.2.-4.0, p=0.01) adjusted for gender. CONCLUSION: MFS is an independent risk factor for having overall migraine and MA. Moreover, we found that a history of aortic root surgery seems to be associated with an increased risk of MA.