Aortic Atheroma Research Articles

Effect modification of aortic atheroma on the prognostic value of heart rate in hypertension

Although some epidemiological studies have advocated a prognostic value of heart rate (HR) in hypertensive patients, the influence of vascular damages on this prognostic value has not been tested yet. HRs were collected by pulse palpation in 1204 primary hypertensive patients in sinus rhythm without cardiac-slowing drugs. Aortic damages were assessed by aortography, whereas cardiac disease was assessed by medical history, symptoms and electrocardiogram. In a multivariable Cox model adjusted for major confounders, HR was of prognostic significance for all-cause [hazard ratio 1.12 (1.06-1.19) for 10 bpm increment and 1.39 (1.18-1.64) for HR ≥82 vs. <82 bpm] and cardiovascular death [hazard ratio 1.10 (1.02-1.20) for 10 bpm increment and 1.37 (1.09-1.72) for HR ≥82 vs. <82 bpm] after 35 years of follow-up. This association was particularly manifested at 15 years of follow-up. At that time, with the same multivariable survival model, the association between HR and cardiovascular death was stronger in patients with aortic atheroma [2.76 (1.47-5.18) for an HR ≥82 vs. <82 bpm] than in patients without [hazard ratio 1.36 (0.76-2.43) for an HR ≥82 vs. <82 bpm, P for interaction = 0.054]. Similarly, the association between HR and cardiovascular death was stronger in patients with an overt cardiac disease than those without (P for interaction = 0.044). In hypertensive patients, the prognostic significance of HR for cardiovascular outcome is modulated by the presence of aortic atherosclerosis or cardiac disease. This should prompt us to a thorough examination of cardiovascular damages in hypertensive patients when HR is elevated.

Case of the Season: Saturday Night Palsy

The case of an 86-year-old man presenting with isolated left index finger palsy caused by infarction on the lateral side of the right precentral knob is presented. Embolization from aortic atheroma was considered the cause of infarction. Cases with selective palsy of a particular group of fingers without sensory deficits due to cortical infarction of the precentral knob have been reported by several authors, and predominant weakness of radial-side fingers is known to be usually caused by laterally located infarction of the precentral knob. Among the previous reports, only 1 case involved isolated index finger palsy by an atypical, medially located infarction of the precentral knob in association with a concurrent nonrelated lesion. This is the first reported isolated index finger palsy caused by a single lateral precentral knob infarction.

Aortic stenosis, atherosclerosis, and skeletal bone: is there a common link with calcification and inflammation?

The pathophysiology of aortic stenosis shares many similarities with atherosclerosis and skeletal bone formation. Using non-invasive imaging, we compared aortic valve calcification and inflammation activity with that measured in atherosclerosis and bone. Positron emission and computed tomography was performed using 18F-sodium fluoride (18F-NaF, calcification) and 18F-fluorodeoxyglucose (18F-FDG, inflammation) in 101 patients with calcific aortic valve disease (81 aortic stenosis and 20 aortic sclerosis). Calcium scores and positron emission tomography tracer activity (tissue-to-background ratio; TBR) were measured in the aortic valve, coronary arteries, thoracic aorta, and bone. Over 90% of the cohort had coexistent calcific atheroma, yet correlations between calcium scores were weak or absent (valve vs. aorta r(2) = 0.015, P = 0.222; valve vs. coronaries r(2) = 0.039, P = 0.049) as were associations between calcium scores and bone mineral density (BMD vs. valve r(2) = 0.000, P = 0.766; vs. aorta r(2) = 0.052, P = 0.025; vs. coronaries r(2) = 0.016, P = 0.210). 18F-NaF activity in the valve was 28% higher than in the aorta (TBR: 2.66 ± 0.84 vs. 2.11 ± 0.31, respectively, P < 0.001) and correlated more strongly with the severity of aortic stenosis (r(2) = 0.419, P < 0.001) than 18F-NaF activity outwith the valve (valve vs. aorta r(2) = 0.167, P < 0.001; valve vs. coronary arteries r(2) = 0.174, P < 0.001; valve vs. bone r(2) = 0.001, P = 0.806). In contrast, 18F-FDG activity was lower in the aortic valve than the aortic atheroma (TBR: 1.56 ± 0.21 vs. 1.81 ± 0.24, respectively, P < 0.001) and more closely associated with uptake outwith the valve (valve vs. aorta r(2) = 0.327, P < 0.001). In patients with aortic stenosis, disease activity appears to be determined by local calcific processes within the valve that are distinct from atherosclerosis and skeletal bone metabolism.

The Significance of the Ultrasound Diagnostics in Evaluation of the Emboligenic Pathogenesis of Transient Ischemic Attacks

The objective of this study was to examine the possibilities of ultrasound diagnostics in the evaluation of emboligenic pathogenesis of transient ischemic attacks (TIAs) and the frequency of specific origins of embolism. A total of 150 adult patients with TIA and 50 control patients, were examined by neurosonologic, echocardiographic and venous ultrasound examination. Emboligenic pathogenesis of TIA was established in 36.6% of patients. Microembolic signals were detected in 22.7% of the whole group, and 61.8% in emboligenic TIA subgroup. Artery-to-artery embolism from ulcerated plaque of the carotid arteries was found in 12.6% of patients, from the aortic arch atheroma in 3.3% and cardioembolism in 12.6% (atrial fibrillation 7.3%, atrial septal aneurysm 2%, mitral valve prolapse 2%, mechanical heart valve 0.7%, left atrium thrombus 0.7%). Paradoxic embolism with the patent foramen ovale was established in 6% of patients, and with the pulmonary right-to-left shunt in 2%. Correlation with controls showed significantly higher frequency of the ulcerated carotid plaque and frequency of microembolic signals in the TIA group (p < 0.05). The patients with potential sources of embolism had a greater risk of developing TIA than those without these sources.

Abstract WP230: The Yield of Echocardiography in Cancer Patients with Suspected Cardioembolic Stroke

Background: Autopsy studies demonstrate that cardioembolism from nonbacterial thrombotic endocarditis (NBTE) is a common cause of stroke in patients with cancer. Echocardiography is often used to clinically diagnose NBTE, but it has unknown yield for NBTE lesions, which are typically small and difficult to detect. Methods: We identified all patients with active cancer admitted to Memorial Sloan-Kettering Hospital from 2008 to 2010 with acute ischemic stroke who underwent transthoracic (TTE) or transesophageal echocardiography (TEE). Two neurologists independently reviewed all clinical data and classified patients as having suspected cardioembolic (CE) strokes if brain MRI showed embolic-appearing infarcts in more than one vascular territory. They also reviewed TTE and TEE reports and adjudicated whether these studies revealed a definite or possible source of stroke. Definite sources included complex aortic arch atheroma, valve vegetation, left atrial or ventricular thrombus, patent foramen ovale (PFO) with documented venous thromboembolism (VTE), severe cardiomyopathy, or cardiac tumor. Possible sources consisted of PFO without VTE, atrial septal aneurysm, dyskinetic left ventricular segment, spontaneous echo contrast, and simple aortic arch atheroma. NBTE was diagnosed if valve vegetations were seen on echocardiography, blood cultures were negative, and clinical signs of infection were absent. Results: Among 119 patients with cancer and ischemic stroke (mean age 66 [SD 13], 51% men), 99 (83%) had TTE and 16 (13%) had TEE. TTE revealed a definite source in 3 (3%) patients and a possible source in 15 (15%). Conversely, TEE revealed a definite source in 6 (38%) patients and a possible source in 5 (31%). No vegetations were seen on TTE, but 4 were discovered on TEE, all from NBTE. In 42 of 52 patients with suspected CE stroke who underwent TTE, 3 (7%) had a definite source and 8 (19%) a possible source. Eleven of these patients also underwent TEE, which demonstrated a definite or possible source in 9 (81%). Conclusions: The yield of TTE for detecting NBTE and other cardiac sources of stroke in patients with cancer is poor, but TEE may be helpful in targeted patients.

Abstract WP220: Determinants for Cryptogenic Stroke: Clinico-radiologic Findings

Background: Cryptogenic stroke accounts for 30-40% of all strokes. Aortic arch atheroma(AAA), patent foramen ovale(PFO) and paroxysmal atrial fibrillation(PAF) are common causes which require different treatment strategies. However not all patients could undergo extensive work-ups. We investigated clinico-radiological characteristics of these 3 common causes of cryptogenic stroke to find a model helping decision-making. Method: We enrolled 194 patients with cryptogenic stroke at the time of admission. After performing extensive work-ups including electrocardiography, transthoracic or transesophageal echocardiography, transcranial right-to-left shunt test, coronary computed tomography angiography or cardiac telemetry, patients were allocated into 3 groups; (1) AAA(n=25), (2) PFO(n=94), and (3) PAF(n=75). Vascular risk factors and findings on diffusion-weighted image were analyzed. Results: Clinico-radiologic features were different. Patients with PFO were younger (mean, 56.1[PFO] vs. 73.9[AAA] vs. 70.6[PAF] years; p &lt;0.001) and hypertension was less common ( p &lt;0.001). Smoking was more common in AAA group ( p =0.018). PAF-related strokes had higher NIHSS ( p &lt;0.001) and a larger lesion (≥20mm, 81.1%[A-fib] vs. 16.0%[AAA] vs. 46.2%[PFO]; p &lt;0.001). By contrast, AAA-related strokes showed small but multiple lesions scattered in multiple vascular territories ( p &lt;0.001). Patients with PFO had subcortical lesions ( p =0.029) in posterior circulation ( p =0.004). Multivariate regression analysis revealed that age, NIHSS, hypertension, multiple(≥3) lesions and involvement of multiple vascular territories could differentiate 3 groups (R 2 =0.6581). We calculated probability for 3 groups and performed external validation. Conclusion: Patients with cryptogenic stroke showed distinct features which may provide clues for stroke mechanisms. Our data suggested that etiologic work-ups for cryptogenic stroke could be guided by these features.

Optimization of a Low Magnesium, Cholesterol-Containing Diet for the Development of Atherosclerosis in Rabbits

The cholesterol-fed rabbit is useful for atherosclerosis research. We describe development of a low-magnesium (Mg) cholesterol-containing diet to accelerate atherosclerosis in this model. Male New Zealand White rabbits were fed either chow or one of four atherogenic diets: 1% cholesterol 10% fat 0.11% Mg, 1% cholesterol 10% fat 0.40% Mg, 2% cholesterol 20% fat 0.11% Mg, or 2% cholesterol 20% fat 0.40% Mg. While feed intake decreased in cholesterol-fed rabbits, they were able to maintain their body weights. Rabbits consuming cholesterol experienced profound hypercholesterolemia and tissue lipid accumulation, with plasma cholesterol levels above 1500 mg/dl for all groups at the completion of the study. Liver and spleen lipid content and liver cholesterol content also increased. Aortic arch atheroma thickness was greatest in 1% cholesterol 10% fat 0.11% Mg animals. Tissue Mg levels decreased in cholesterol-fed animals compared to chow-fed controls, despite equal or greater serum Mg levels. Our results indicate that the 1% cholesterol 10% fat 0.11% Mg diet was optimal at promoting hypercholesterolemia and atherosclerosis while minimizing health complications for the animals. The low Mg cholesterol diet will be useful to other biomedical researchers interested in utilizing the rabbit for cardiovascular disease research.

Cardiovascular MRI in Detection and Measurement of Aortic Atheroma in Stroke/TIA patients.

BackgroundAortic Atheroma (AoA) is an independent risk factor for new and recurrent stroke. AoA ulceration and mobility are associated with an increased risk for brain embolism. Transesophageal echocardiography (TEE) is the gold standard for detection and measurement of AoA in stroke/TIA patients. Cardiovascular MRI (cMRI) could be an alternative, non-invasive imaging modality for stroke/TIA patients. The objective of this study was to assess the accuracy and correlation of AoA detected and measured by cMRI versus TEE in patients with recent stroke/TIA.Methods and resultsTwenty-two stroke/TIA patients undergoing TEE as a part of their stroke workup consented to a protocol-mandated cMRI performed on a 1.5 T magnet. The protocol included an axial non-breathhold EKG-gated dual-echo spin echo MRI of the thoracic aorta (TR/TE1/TE2=900/29/69) and a contrast-enhanced breathhold 3D gradient-echo image of the thorax (flip/TR/TE=12/4.0/1.71). Maximum plaque thickness, ulceration (≥ 2 mm) and mobility of AoA were assessed in the proximal (ascending and proximal arch) and distal (distal arch and descending) segments of thoracic aorta by a cardiologist to interpret the TEE and a radiologist to interpret the cMRI. There was good correlation between cMRI and TEE in measurement of plaque thickness in the proximal segments (R=0.73, p<0.0001) and the distal segments (R=0.81, p<0.0001) of the aortic arch (AA). cMRI had a high degree of accuracy in detecting measurable AoA (≥ 1 mm) in the proximal segments (sensitivity 90%, specificity 100%), as well as the distal segments (sensitivity 67%, specificity 100%). cMRI also had a high degree of accuracy in detecting significant AoA (≥ 4 mm) in proximal segments (sensitivity 71%, specificity 93%), as well as distal segments (sensitivity 71%, specificity 100%).ConclusionThe study showed a high degree of accuracy and correlation of AoA detected and measured by cMRI as compared to TEE in patients with recent stroke/TIA. This technique has limitations in detection of AoA ulceration, and protocols assessing AoA mobility need to be developed.

Difference between cerebral embolic events following Transcatheter Aortic Valve Implantation (TAVI) and Surgical Aortic Valve Replacement (SAVR): a diffusion weighted MRI study

Background Transcatheter Aortic Valve Implantation (TAVI) is used to treat symptomatic severe aortic stenosis in a non-surgical high risk population. The incidence of stroke and micro-infarction is higher in the TAVI population compared to surgical aortic valve replacement (SAVR) at 30 days, which may be due to various factors such as valve calcification and aortic atheroma. However, the natural history and clinical consequences of micro-infarction is unknown.

112: A new morphological and quantitative approach of aortic atheroma: a preliminary 3D transesophageal echocardiography study

Aortic atheroma is a disease causing vascular complications including ischemic stroke. Transesophageal echocardiography (TEE) is the diagnostic method of reference for characterization of aortic atherosclerotic plaques (AAP) at risk. The aim of our study was to evaluate the feasibility and contribution of 3D TEE in the evaluation of aortic atheroma. We prospectively included 82 patients referred for TEE. In addition to conventional 2D TEE, a 3D TEE study of AAP of the descending and horizontal thoracic aorta was performed. Overall, 308 AAP were identified in 2D, 98% of them were analyzed using the 3D approach. We identified 3 morphological types of plaques using the 3D approach (figure 1), 2D characteristics of the 3D types of AAP were different. Type I AAP are thin and rarely calcified; type III AAP are thicker and often calcified; the 3D type II AAP have intermediate 2D characteristics (Table). All AAP ulcerations seen in 2D were identified in 3D TEE. 2D thickness measurements from 3D acquisitions correlated well with measurements performed directly on the 2D acquisitions (r=0.91; p <0.001). Area measurements of AAP were feasible in 58%, 14% and 23% of 3D types I, II and III AAP, respectively. The areas of type I AAP were not correlated with those of thickness in 2D (p=0.83). 3D TEE is a feasible method for the analysis of the AAP. It provides a new morphological and quantitative approach of AAP whose clinical applications remain to be validated. Figure – 3D morphological types of plaques Table Results Type I (n=115) Type II (n=97) Type III (n=89) N Descending Aorta (n) 77 63 49 189 Horizontal Aorta (n) 38 34 40 112 Plaque thickness (mean ± SD; mm) 1.2±0.5 2.6±1.2 3.2±1.5 Not calcified plaques (n,%) 103 (80.5) 22 (17.2) 3 (2.3) 128 Slightly calcified plaques (n,%) 9 (8.8) 62 (60.8) 31(30.4) 102 Very calcified plaques (n,%) 3 (4.2) 13 (18.3) 55 (77.5) 71

Effects of Medical Treatment on the Prognosis and Risk of Embolic Events in Patients with Severe Aortic Plaque

The optimal treatment strategy for patients with aortic atheroma is not well established because data regarding medical treatment for such patients are lacking, especially with respect to the Japanese population. The purpose of this study was to clarify the effects of medical treatment on the risk of embolic events and mortality in patients with severe aortic plaque. We retrospectively investigated 75 consecutive patients with severe aortic plaque detected on transesophageal echocardiography (TEE) between 1995 and 2005. The occurrence of embolic events and all-cause death in the period after TEE was assessed. The cumulative incidence of subsequent embolic events and death was evaluated in relation to specific medical treatments, including statins, antiplatelet drugs and warfarin. Embolic events occurred in 27 patients (36%) and death occurred in 37 patients (49%) during follow-up (5.6±3.0 years). The patients who experienced embolic events had a significantly higher prevalence of previous embolic events, atrial fibrillation and hemodialysis than the patients who did not experience embolic events. Univariate and multivariate analyses showed that the use of statins and/or antiplatelet drugs was significantly associated with a low incidence of death but not with a low incidence of embolic events. On the other hand, warfarin exhibited neither beneficial nor harmful effects on the incidence of embolic events or death. Statin and antiplatelet drugs have beneficial effects on the prognosis of patients with severe aortic plaque diagnosed on TEE.

Study Design of PROCEDURE Study a Randomized Comparison of the Dose-Dependent Effects of Pitavastatin in Patients with Abdominal Aortic Aneurysm with Massive Aortic Atheroma: Prevention of Cholesterol Embolization during Endovascular and Open Aneurysm Repair with Pitavastatin(PROCEDURE) Study

Outcomes of abdominal aortic aneurysm (AAA) repair have improved in the 2 decades since the emergence of endovascular aneurysm repair (EVAR). However, EVAR is considered a contraindication for shaggy aorta because of the high risk of shower embolization. Recently, statins have been implicated in preventing embolization in patients with shaggy aorta via its pleiotropic effects, including atheroma reduction and coronary artery stabilization. We selected pitavastatin, a statin with potent effects, discovered and developed by a Japanese company because it has shown excellent pleiotropic effects on atheromatous arteries in the Japanese population. A randomized comparison study of dose-dependent effects of pitavastatin in patients with AAA with massive atheromatous aortic thrombus (PROCEDURE study) has begun. PROCEDURE has an enrollment goal of up to 80 patients with AAA with massive aortic atheroma (excluding intrasac atheroma), randomly allocated into 2 groups receiving pitavastatin at a dose of 1 or 4 mg/day. The endpoints of the PROCEDURE study include change in atheroma volume, major adverse events related to shower embolization after aneurysm repair, and lipid-lowering effects. When complete, results of the PROCEDURE study should provide objective evidence to use statins preoperatively for AAA with massive aortic atheroma.

Statins Reduce Extensive Aortic Atheromas in Patients with Abdominal Aortic Aneurysms

Statins have been used widely to reduce dyslipidemia and recently have been reported to have pleiotropic effects such as plaque reduction and stabilization. This study retrospectively evaluated the regression of extensive thoracic atheromas ("shaggy aorta") in abdominal aortic aneurysm (AAA) patients who underwent contrast-enhanced computed tomography (CECT) before and after statin administration. CECT was used to examine thoracic aortas of 29 patients (statin group; n = 22, non-statin group; n = 7) with extensive atheromas from the ostium of the left subclavian artery to that of the more proximal renal artery. Extensive thoracic atheroma was defined by: (1) thickness >5 mm, (2) involved circumference of thoracic aorta >50%, and (3) length >30 mm. The areas of atheroma (cm(2)) were measured before and after administration of statins, and the atheroma reduction ratio (ARR) was evaluated. The area of atheroma decreased after administration of statins, and the ARR was significant (P <0.01). The ARR increased with all cases in non-statin group. No complications associated with extensive atheroma were observed during the follow-up period. This pilot study indicates statins can reduce extensive thoracic atheromas and lower lipid concentrations.

Abstract 18370: Role and Potential Impact of TEE in Detecting Markers of Thromboembolism in Non Valvular Atrial Fibrillation Patients with a CHADS2 score = 0?

Background: Transesophageal echocardiography (TEE) parameters (left atrial appendage, LAA thrombus or spontaneous echocardiographic contrast (SEC), aortic atheroma (AAA) are powerful markers of thromboembolism (TE) in non-valvular atrial fibrillation (NVAF) patients. However, the prevalence and potential impact of these abnormalities have not been evaluated in patients at very low risk of TE. We evaluated TEE-detected LASEC, thrombus and AAA in AF patients referred for cardioversion and analyzed the subgroup of patients with a CHADS 2 score=0. Methods: Among 763 consecutive patients hospitalized for NVAF, prior to cardioversion, TEE was systematically performed within 24h after admission; 205 patients had a CHADS 2 score=0. The following parameters were described: presence and severity of LASEC, LA thrombus, aortic atheroma (AAA). Results: Mean age was 54.5 ± 13.5 years. AF was paroxysmal in 101 patients (49.3%), persistent in 82 (40.0%) and permanent in 22 (10.7%). Transthoracic echocardiography showed LVEF&lt;40% in 12 (5.9%) and median of mean LA area was 18 (15-23) cm 2 . LA thrombus was found in 1 patient (0.5%), LASEC in 60 (29.3%), classified as mild in 43 (21.0%), moderate in 14 (6.8%) and severe in 3 (1.5%). AAA was present in 6 patients (2.9%). The table compares some baseline characteristics in patients with (LAASEC/thrombus or aortic atheroma ≥ 4 mm) or without TEE abnormalities, defined as an endpoint. In the multivariate analysis, age (OR, 1.04, 95% CI 1.01-1.07), non paroxysmal AF (OR, 3.23, 95% CI 1.54-6.78) and LA area (OR, 1.08, 95% CI 1.02-1.16) were predictors of TEE-detected LASEC/thrombus or aortic atheroma. Conclusions: TEE prior to cardioversion in NVAF found TEE-detected risk markers of thromboembolism (LASEC/thrombus or aortic atheroma) in one third of patients with a CHADS 2 score = 0.

Abstract 18759: Benefit of TEE in Patients Over 50 with Unexplained Stroke and Normal TTE Study

Objective: Aside from oral anticoagulation in patients with intracardiac thrombus, current guidelines and scientific evidence do not support specific therapeutic interventions for most other TEE findings. We sought to examine the effect of performing TEE on therapeutic management in patients over age 50 with unexplained stroke. Specific TEE findings sought to explain the cause of stroke generally include cardiac thrombi (particularly LA and LAA) or spontaneous contrast, inter atrial septal anomalies (particularly PFO), and atheromatous disease of the aorta. We hypothesized that there would be minimal incremental value in performing TEE added to a normal TTE study. Methods: We retrospectively analyzed consecutive patients over 50 yrs who underwent TEE for unexplained stroke. Patients in sinus rhythm were included if TTE results were normal. Normal TTE was defined as normal LVEF, no intracardiac masses or shunts, absence of severe valvular heart disease. Results: TEE images and clinical data of 263 patients were analyzed. Baseline characteristics included mean age of 66.7 yrs, (range 50-91 yrs), 42.5% were female. TEE findings demonstrated complex plaque of the ascending aorta or arch in 44/263 (16.7%). PFO was found in 18/263(%), 25/263(%) had atrial spetal aneurysm (ASA), and 11/263(%) had both ASA and PFO. Spontaneous contrast was seen in 13/263 (4.9%). 1 patient had LA thrombus. Overall 38% had a TEE finding which could explain the etiology of stroke but 1/263 (0.4%) had a finding which changed therapy based on current guidelines or substantial scientific evidence. 6 months follow up was available on 85 patients, and 13(15%) of these patients developed new PAF. Conclusions: Our study demonstrates no incremental value of TEE to a normal TTE study in patients over 50 with unexplained stroke in sinus rhythm. As reported in prior studies, it is not uncommon for TEE to disclose findings such as aortic atheroma or interatrial septal anomalies, however these findings generally do not alter therapeutic management and therefore routine performance of TEE in these patients may not be justified. It needs to be determined whether subsequent PAF episodes were etiology or result of stroke.

Abstract 18972: A 36-Year-Old Man with Stroke and Severe Hyperlipidemia: From Phenotype to Genotype

A 36-year-old man with a history of hypertension and hyperlipidemia was admitted to the hospital with headaches, a left visual field deficit and a right occipital lobe infarct. Family history is notable for multiple maternal relatives with premature coronary artery disease and severe hyperlipidemia. Laboratory testing revealed an LDL level of 325 mg/dl. Echocardiography demonstrated a bicuspid aortic valve and two highly mobile thrombi at the sinotubular junction. Because there was no aortic false lumen and the clinical picture was most suspicious for a ruptured aortic root atheroma, we administered intravenous heparin with plans for aortic thrombectomy pending his hemodynamics, neurological status and changes in the echocardiographic apperance of the presumed thrombi. On day three, the patient experienced acute chest pain and ST elevation concerning for abrupt occlusion of the right coronary artery. He was taken emergently to the operating room where two thrombi_one of which was lodged in the right coronary ostium_were removed and aortic endarterectomy was performed. Histology of the aortic specimen showed atherosclerosis and inflammation but no evidence of medial degeneration. The histologic evidence of atherosclerosis focused attention on the patient’s personal and family history of severe hypercholesterolemia. To assess for a genetic defect in cholesterol metabolism, we directly sequenced the LDL receptor gene and identified a heterozygous missense mutation associated with familial hypercholesterolemia (FH). Aortic root disease is common in FH homozygotes, but its presence in a heterozygote suggests an additional inherited or acquired risk factor and prompts further investigation. The bicuspid valve raises the possibility of a subclinical aortic condition that may have contributed to this unusual syndrome. This case directly illustrates the consequences of aortic plaque rupture and emphasizes the multidisciplinary clinical approaches that are central to understanding the complex links between genotype and phenotype even in a well-characterized "simple" monogenic disorder.

Abstract 18286: Left Atrial Spontaneous Echocardiographic Contrast is a Predictor of Cardiovascular Events (Death, Stroke, Heart Failure) Beyond the CHA2DS2VASc Score at Long-term Follow-up in a Single-Center Cohort of Patients with Non Valvular Atrial Fibrillation

Background: The CHA 2 DS 2 VASc score has been proposed as an additional tool in thromboembolic (TE) risk stratification, beyond the CHADS 2 score, in patients with non-valvular atrial fibrillation (NVAF). The role of additional TE risk markers, i.e. derived from echocardiography, has not been yet fully evaluated. We aimed to evaluate in a multivariate model the role of clinical versus TEE parameters in predicting cardiovascular (CV) events at long-term follow-up. Methods: In 763 consecutive patients hospitalized for NVAF, TEE was systematically performed within 24h after admission. All patients were followed-up (mean 5.8 ± 4.1 years) and cardiovascular (CV) events (stroke, death, or heart failure) defining a composite endpoint were recorded. Results: Two hundred and five patients (26.9%) had a CHADS 2 =0, 228 (29.9%) a CHADS 2 =1, and 330 (43.3%) a CHADS 2 ≥2. The corresponding figures for the CHA 2 DS 2 VASc score were 92 (12.1%), 115 (15.1) and 556 (72.9%), respectively. Left atrial spontaneous contrast (LASEC) was present in 358 (46.9%), described as mild in 212 (27.8%), moderate in 111 (14.6%) and severe in 35 (4.6%). LA thrombus was found in 17 patients (2.2%) and protruding aortic atheroma ≥4 mm in 116 (15.2%). Six hundred thirty three patients (83%) were prescribed warfarin and 158 (27%) aspirin at discharge. At follow-up, death occurred in 253 patients (33.2%), stroke in 29 (3.8%) and heart failure in 100 (13.1%). The Kaplan-Meier curves showed that a CHA 2 DS 2 VASc score &gt;3 was associated with a higher risk of CV events. In the multivariate analysis, non paroxysmal AF (HR 1.54, 95%CI 1.17-2.01), CHA 2 DS 2 VASc score (HR 1.47, 95%CI 1.38-1.57) and LASEC (presence/absence, HR 1.42 95%CI 1.11-1.82) were predictors of CV events. Warfarin treatment at discharge was protective (HR 0.65, 95%CI 0.48-0.87). Conclusions: TEE-detected LA spontaneous echocardiographic contrast in NVAF patients is associated with a higher risk of CV events, beyond the CHA 2 DS 2 VASc score and the type of AF.

Détection de signaux micro-emboliques : revue de la littérature

The detection of micro-embolic signals (MES), by transcranial Doppler sonography might be useful for risk stratification in patients with symptomatic and asymptomatic carotid or cerebral artery stenosis, dissections, aortic atheroma, interventional procedures, and right to left cardiac shunts. Review of the technique and clinical situations of MES detection. PubMed search from 1990 to 2012. MES were found in 0,19, 48% versus 0,3, and 12% of patients with symptomatic and asymptomatic inferior than 30, 30 to 69, and 70 to 99% carotid stenosis, respectively. MES were related to the risk of recurrent stroke or transient ischemic attack (TIA). In the ACES study, the absolute annual risk of stroke or TIA after 2 years was 7% with vs 3% without MES. In patients with intracranial stenosis, the risk of stroke recurrence was 48% with vs 7% without MES at 13.6 months follow-up. MES were reported in 25% of the symptomatic versus none of the asymptomatic patients with intracranial stenosis. Detection of MES is feasible and reproducible for multicenter studies, using rigourous methodology and long lasting recordings. It may contribute to risk stratification, especially in patients with extra- or intracranial stenosis.

Clinical Observations and Outcome of Ventricular Tachycardia Ablation in Patients with Left Ventricular Assist Devices

Ablation of ventricular tachycardia (VT) in patients with left ventricular assist devices (LVAD) is challenging and not well documented. This report describes our experience with endocardial VT ablation in six patients with an LVAD. We retrospectively reviewed the clinical records of LVAD patients who underwent an ablation procedure for refractory VT. A total of eight ablation procedures were performed in six patients who, during the last 2 weeks before the ablation procedure, received a total of 101 appropriate shocks for VT. A closed aortic valve (n = 2) or aortic atheroma (n = 1) required a transseptal catheterization in three of six patients. The apical LVAD cannula served as a VT substrate in two of six patients. VT was eliminated in four patients and markedly reduced in two others. The latter two patients experienced a total of only four implantable cardioverter defibrillator (ICD) shocks during a follow-up of 130 and 493 days. Intravenous antiarrhythmic medications used in five of six patients before ablation were discontinued in all. The ablation procedures permitted hospital discharge in four of six patients. Five patients died during follow-up (228 ± 207 days after the procedure). The cause of death was unrelated to cardiac arrhythmias. One patient is still alive 1,205 days after the procedure. Ablation of VT in LVAD patients is feasible and can result in a markedly decreased VT burden with a reduction of ICD shocks. The subsequent discontinuation of intravenous antiarrhythmic medications may facilitate hospital discharge.

Alternative Access in Transcatheter Aortic Valve Implantation: Brachiocephalic Artery Access

Direct ascending aortic access is an accepted alternative approach for transcatheter aortic valve implantation (TAVI) that can be preferred in case of excessive atherosclerosis or small caliber of femoral and subclavian vessels or after previous coronary artery bypass grafting with a patent left internal mammary artery graft. However, not all patients are suitable for this direct aortic approach. In these patients, we now use direct access through the brachiocephalic artery. The direct brachiocephalic access can be obtained with or without partial upper sternotomy, depending on the anatomy, which should be evaluated by preprocedural angiographic computed tomography scan. During the procedure, the cerebral tissue oxygen saturation is continuously monitored. We treated two patients with severe aortic valve stenosis, classified as not suitable for surgical aortic valve replacement, by means of TAVI through the brachiocephalic artery. Both patients had excessive iliac atherosclerotic disease. One had patent left internal mammary artery and venous grafts after previous coronary artery bypass grafting so the femoral, direct aortic, nor left subclavian access was suitable; the other had a severely atheromatous and calcified aorta. No procedural or late complications were seen. If transfemoral, subclavian, and direct aortic accesses for TAVI are contraindicated, the direct brachiocephalic access seems to be a safe and feasible alternative.