Atrial Level Research Articles

Investigating the combinatorial effects of radiofrequency ablation and anticoagulants in patients with atrial fibrillation and left atrial appendage thrombosis after successful thrombolysis.

The present study investigated the synergistic effects of radiofrequency ablation and various anticoagulants on adverse outcomes in patients with atrial fibrillation (AF) and left atrial appendage thrombosis following successful thrombolysis. Patients diagnosed with AF and left atrial appendage thrombosis post-successful thrombolysis (n=92) were retrospectively analysed. They were divided into two groups: Group A received radiofrequency ablation combined with an anticoagulant, while Group B received an anticoagulant alone and in combination with antiarrhythmic drugs. Subgroup analyses were conducted based on left atrial diameter (>45 mm), duration of AF (>1 year) and types of anticoagulants. Univariate and multivariate logistic regression analyses were performed to assess stroke and mortality risks in patients with AF with left atrial appendage thrombosis after dissolution. Multivariate logistic regression analysis identified AF duration (>1 year), left atrial diameter (>45 mm) and BNP level as significant risk factors for stroke (P<0.05). Compared with NOACs, the traditional anticoagulants (warfarin) demonstrated higher survival rates and lower stroke incidence in Group B (P<0.05); however, no significant difference was observed within Group A (P>0.05). Radiofrequency ablation combined with anticoagulants appeared to be more effective in treating AF with left atrial appendage thrombosis post-dissolution compared with anticoagulants alone. Attention to AF duration and left atrial diameter is crucial during early patient management. However, the choice between warfarin or NOACs for patients with AF and left atrial appendage thrombosis warrants further investigation.

Macrophage-mediated interleukin-6 signaling drives ryanodine receptor-2 calcium leak in postoperative atrial fibrillation

Abstract Background Postoperative atrial fibrillation (poAF) is self-limited AF that occurs within days after cardiac surgery in one-third of patients. Clinical and preclinical studies have demonstrated that the magnitude of the perioperative increase in systemic inflammation, in particular mediated by interleukin (IL)-6, correlates with poAF risk. However, no studies to-date have mechanistically linked IL-6 signaling to fundamental arrhythmia mechanisms or identified the specific cell types driving postoperative atrial IL-6 signaling. Methods We performed single-cell RNA sequencing (scRNAseq), followed by pseudotime trajectory and cell-cell communication analyses on atrial non-myocytes comparing mice with and without poAF. We followed up our scRNAseq findings with pharmacologic and genetic approaches in mice to validate pathways related to macrophage-mediated IL-6 signaling. We used confocal imaging to assess calcium-signaling mechanisms at the single atrial cardiomyocyte (ACM) level and performed parallel patch-clamp studies in isolated human ACMs as well as biochemical analyses of human atrial tissue to assess the translational relevance of our findings. Results Our scRNAseq results demonstrated macrophages to be the most prominently altered cell type in the atria of mice with poAF. Pseudotime trajectory analyses revealed IL-6 to be one of the top inflammatory pathways implicated in macrophage transcriptional state. Indeed, both macrophage depletion and conditional knockout of IL-6 receptors in macrophages were sufficient to prevent poAF. We found that inhibition of STAT3, which is downstream of the IL-6Ra, with FDA-approved phospho-STAT3 inhibitor TTI-101 prevented poAF in mice. Lastly, we demonstrate that enhanced STAT3 activity in poAF promotes arrhythmogenic Ca2+ sparks and waves through ryanodine receptor-2 dysfunction, and that CaMKII inhibition is sufficient to ameliorate Ca2+ mishandling at the single atrial myocyte level. Conclusions Taken together, we use an integrated approach incorporating mouse and human biochemical, functional, and single-cell sequencing data to demonstrate that infiltrating atrial macrophages are fundamentally required for poAF. IL-6 was found to be a critical pathway upregulated in poAF leading to downstream ryanodine receptor-2 dysfunction and atrial arrhythmogenesis. Our findings portend significant therapeutic utility by providing robust mechanistic evidence that targeting the IL-6 axis may be used for poAF prevention and treatment in a clinically amenable timeframe.

Association between Inflammation and New-Onset Atrial Fibrillation in Acute Coronary Syndromes.

Acute coronary syndrome (ACS) is a complex clinical syndrome that encompasses acute myocardial infarction (AMI) and unstable angina (UA). Its underlying mechanism refers to coronary plaque disruption, with consequent platelet aggregation and thrombosis. Inflammation plays an important role in the progression of atherosclerosis by mediating the removal of necrotic tissue following myocardial infarction and shaping the repair processes that are essential for the recovery process after ACS. As a chronic inflammatory disorder, atherosclerosis is characterized by dysfunctional immune inflammation involving interactions between immune (macrophages, T lymphocytes, and monocytes) and vascular cells (endothelial cells and smooth muscle cells). New-onset atrial fibrillation (NOAF) is one of the most common arrhythmic complications in the setting of acute coronary syndromes, especially in the early stages, when the myocardial inflammatory reaction is at its maximum. The main changes in the atrial substrate are due to atrial ischemia and acute infarcts that can be attributed to neurohormonal factors. The high incidence of atrial fibrillation (AF) post-myocardial infarction may be secondary to inflammation. Inflammatory response and immune system cells have been involved in the initiation and development of atrial fibrillation. Several inflammatory indexes, such as C-reactive protein and interleukins, have been demonstrated to be predictive of prognosis in patients with ACS. The cell signaling activation patterns associated with fibrosis, apoptosis, and hypertrophy are forms of cardiac remodeling that occur at the atrial level, predisposing to AF. According to a recent study, the presence of fibrosis and lymphomononuclear infiltration in the atrial tissue was associated with a prior history of AF. However, inflammation may contribute to both the occurrence/maintenance of AF and its thromboembolic complications.

History of stroke as a predictor of high left atrial fibrosis in patients with persistent atrial fibrillation-insight from the DECAAF II randomized trial.

There is a strong relationship between left atrial (LA) remodeling and ischemic stroke (IS) risk in atrial fibrillation (AF) patients. The Efficacy of Delayed Enhancement MRI-Guided Ablation vs. Conventional Catheter Ablation of Atrial Fibrillation (DECAAF-II) is the biggest MRI-based, randomized, multicenter clinical trial performed on persistent AF patients. The aim of this study is to evaluate the relationship between history of stroke and atrial fibrosis in the DECAAF II population. Persistent AF patients who underwent Late Gadolinium Enhancement Magnetic Resonance Imaging (LGE-MRI) were included in the study and divided into two different groups: those with a history of stroke and those without. Propensity score matching was performed to adjust for covariates. Atrial fibrosis was compared in both groups. Then, patients were divided into different fibrosis groups, using three different cut-offs of baseline atrial fibrosis: ≥ 15%, ≥ 20%, and ≥ 25%. Univariate logistic regression and adjusted multivariate analysis were performed to assess the effect of clinical characteristics and risk factors on baseline fibrosis. Eight-hundred forty-three patients were recruited in DECAAF II, of whom 70 (8.3%) had a history of stroke. Patients with history of stroke had a higher prevalence of hypertension (p = 0.043), diabetes (p = 0.014), and hyperlipidemia (p = 0.001). Seventy patients with no history of strokes were matched with patients with history of stroke to adjust for covariates using propensity score analysis. Patients in the stroke group had a significantly higher level of fibrosis than those without (20.2% vs. 8.1%, p = 0.017). Increased age was a significant predictor of all three baseline fibrosis classes (≥ 15%, ≥ 20%, and ≥ 25%). Additionally, history of stroke was found to be a predictor of baseline fibrosis ≥ 25% even after adjusting for other clinical characteristics and risk factors (OR = 1.98 [1.14-3.43], p = 0.01). Left atrial fibrosis level greater than 25% correlates with the history of previous stroke episodes in patients with persistent atrial fibrillation.

Left atrial reservoir strain is a marker of atrial fibrotic remodeling in patients undergoing cardiovascular surgery: Analysis of gene expression.

Left atrial strain (LAS) measured by two-dimensional speckle tracking echocardiography (2DSTE) is considered to be a marker of LA structural remodeling, but it remains unsettled. We investigated the potential usefulness and clinical relevance of LAS to detect atrial remodeling including fibrosis by analyzing gene expression in cardiovascular surgery patients. Preoperative 2DSTE was performed in 131 patients (92 patients with sinus rhythm [SR] patients including paroxysmal AF [PAF], 39 atrial fibrillation [AF]) undergoing cardiovascular surgery. Atrial samples were obtained from the left atrial appendages, and mRNA expression level was analyzed by real-time reverse transcription polymerase chain reaction (RT-PCR) in 59 cases (24 PAF, 35 AF). Mean value of left atrial reservoir strain (mLASr) correlated with left atrial volume index (LAVI), and left atrial conduit strain (mLAScd). mLASr also correlated with left atrial contractile strain (mLASct) in SR patients including PAF. mLASr was significantly lower, and LAVI was higher, in the AF group, compared with SR patients including PAF. The expression of COL1A1 mRNA encoding collagen type I α1 significantly increased in AF patients (p = 0.031). mLASr negatively correlated with COL1A1 expression level, and multivariate regression analysis showed that mLASr was an independent predictor of atrial COL1A1 expression level, even after adjusting for age, sex, and BMI. But, neither mLAScd / mLASct nor LAVI (bp) correlated with COL1A1 gene expression. The expression level of COL1A1 mRNA strongly correlated with ECM-related genes (COL3A1, FN1). It also correlated ECM degradation-related genes (MMP2, TIMP1, and TIMP2), pro-fibrogenic cytokines (TGFB1 encoding TGFβ1, END1, PDGFD, CTGF), oxidant stress-related genes (NOX2, NOX4), ACE, inflammation-related genes (NLRP, IL1B, MCP-1), and apoptosis (BAX). Among the fibrosis-related genes examined, univariable regression analysis showed that log (COL1A1) was associated with log (TGFB1) (adjusted R2 = 0.685, p<0.001), log (NOX4) (adjusted R2 = 0.622, p<0.001), log (NOX2) (adjusted R2 = 0.611, p<0.001), suggesting that TGFB1 and NOX4 was the potent independent determinants of COL1A1 expression level. mLASr negatively correlated with the ECM-related genes, and fibrosis-related gene expression level including TGFB1, NOX2, and NLRP3 in PAF patients. PAF patients with low mLASr had higher expression of the fibrosis-related gene expression, compared with those with high mLASr. These results suggest that LASr correlates with atrial COL1A1 gene expression associated with fibrosis-related gene expression. Patients with low LASr exhibit increased atrial fibrosis-related gene expression, even those with PAF, highlighting the utility of LAS as a marker for LA fibrosis in cardiovascular surgery patients.

Cyanotic heart disease due to a hypoplastic right ventricle with pulmonary valve atresia, an intact ventricular septum, with atrial level shunting in a day‐old Arabian foal

AbstractAn 8‐h‐old Arabian foal was presented for evaluation of progressive weakness since birth. The foal presented laterally recumbent with pale and muddy mucous membranes, a grade III/VI left basilar murmur, and an irregularly, irregular rhythm. Transthoracic echocardiogram along with an electrocardiogram (EKG) was performed. Atrial fibrillation was recorded throughout the examination. The left and right atria were both significantly enlarged. A right to left shunt across the atrial septum was confirmed via an intravenous injection of agitated saline. The tricuspid valve was rudimentary without apparent atrioventricular flow and no ventricular septal defect was appreciated. The animal was euthanased, and necropsy found dysplasia of the tricuspid valve, a hypoplastic right ventricle with pulmonary valve atresia, and an intact ventricular septum. This condition is similar, both haemodynamically and in terms of prognosis, to tricuspid atresia, which has been described previously in Arabian foals, with the exception that there is the complete absence of connection between the atrium and ventricle in the case of tricuspid atresia. Of 14 previously reported cases of tricuspid atresia in neonatal foals, nine were Arabian foals. Further investigation into the possibility of hypoplastic right ventricle as a familial condition in the Arabian breed should be considered.

PULMONARY HYPERTENSION AND CONGENITAL HEART DISEASE: THE CLINIC BEYOND THE EVIDENCE

Abstract Eisenmenger syndrome (ES), first described by Victor Eisenmenger, was defined by Paul Wood in pathophysiologic terms as “pulmonary hypertension (PH) at systemic level, caused by a high pulmonary vascular resistance (PVR), with reversed or bidirectional shunt at aorto–pulmonary, ventricular, or atrial level.” It represents the most severe hemodynamic phenotype of pulmonary arterial hypertension (PAH) in association with congenital heart disease (CHD) and develops in the presence of large, unrepaired atrial or ventricular septal defects, arterial shunts, or complex forms of CHD. Although therapeutic management has rapidly advanced in recent years, these patients were not included in randomized controlled trials for specific pulmonary arterial hypertension drugs, except for bosentan. However, in clinical practice we apply treatment strategies combining drugs targeting multiple pathobiological pathways. The clinical case we describe is that of a 44–year–old patient, suffering from Down syndrome, with ES due to subaortic VSD and a a patency of Botallo duct, followed in our PH clinic of the "Ruggi D‘Aragona" University Hospital for about 9 years. The patient, on dual therapy with Macitentan 10 mg and Sildenafil 60 mg, was in the intermediate–high risk class, stationary. During the last two checks, there was a progressive worsening of the hemodynamic parameters, walking distance of only 100 meters, with SpO2 at baseline 90% and desaturation during the 6mwt. On cardiac color Doppler ultrasound evidence of TAPSE 18 mm, PAPS 100 mmHg, RAA 20 cm²; TAPSE/PAPS 0.18. The patient presented in WHO class 3. The only RCTs currently available concern the use of bosentan, but in clinical practice, initial monotherapy with an endothelin receptor antagonist or a phosphodiesterase type 5 inhibitor for symptomatic patients is proposed. Reassess and consider escalation to a double combination therapy in case of clinical worsening or inadequate clinical response. Consider uptitration with the addition of prostanoids when inadequate response and timely assess the eligibility for transplantation. For our patient therefore, in consideration of the impossibility of surgery, although there is little evidence on prospective observational studies based on cohorts of a few patients, we added selexipag 200 ug x 2/day to titrate therapy.This case opens the door to still unclear scenarios in which unfortunately the only weapon available remains the clinician‘s judgment and experience.

Invasive haemodynamics predict outcomes in paediatric pulmonary artery hypertension.

Invasive haemodynamics are often performed for initiating and guiding pulmonary artery hypertension therapy. Little is known about the predictive value of invasive haemodynamic indices for long-term outcomes in children with pulmonary artery hypertension. We aimed to evaluate invasive haemodynamic data to help predict outcomes in paediatric pulmonary artery hypertension. Patients with pulmonary artery hypertension who underwent cardiac catheterisation (2006-2019) at a single centre were included. Invasive haemodynamic data from the first cardiac catheterisation and clinical outcomes were reviewed. The combined adverse outcome was defined as pericardial effusion (due to right ventricle failure), creation of a shunt for pulmonary artery hypertension (atrial septal defect or reverse Pott's shunt), lung transplant, or death. Among 46 patients with a median [interquartile range (IQR)] age of 13.2 [4.1-44.7] months, 76% had CHD. Median mean pulmonary artery pressure was 37 [28-52] mmHg and indexed pulmonary vascular resistance was 6.2 [3.6-10] Woods units × m2. Median pulmonary artery pulsatility index was 4.0 [3.0-4.7] and right ventricular stroke work index was 915 [715-1734] mmHg mL/m2. After a median follow-up of 2.4 years, nine patients had a combined adverse outcome (two had a pericardial effusion, one underwent atrial level shunt, one underwent reverse Pott's shunt, and six died). Patients with an adverse outcome had higher systolic and mean pulmonary artery pressures, higher diastolic and transpulmonary pressure gradients, higher indexed pulmonary vascular resistance, higher pulmonary artery elastance, and higher right ventricular stroke work index (p < 0.05 each). Invasive haemodynamics (especially mean pulmonary artery pressure and diastolic pressure gradient) obtained at first cardiac catheterisation in children with pulmonary artery hypertension predicts outcomes.

Perioperative atrial fibrillation : Diagnosis with underestimated relevance

Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults, both in general and perioperatively and is associated with significant morbidity and mortality. The age of the patients is amajor risk factor. The prevalence of AF in noncardiac surgery (NCS) varies widely from 0.4% to 30% and for cardiac surgery, especially major combined procedures, up to approximately 50%. Ectopic excitation centers and reentry mechanisms at the atrial level are favored as the main process of uncoordinated electrical atrial activity. The loss of atrial contraction can lead to areduction in cardiac output of up to 20-25%. The increased risk of thromboembolism due to AF extends beyond the perioperative period. Medication-based prevention strategies have not yet gained widespread acceptance. Treatment strategies include frequency and rhythm control as well as the avoidance of thromboembolisms through anticoagulation.

Study design and rationale of COMPETE: Comparison of the effect of medication therapy in alleviating migraine with patent foramen ovale

Previous studies have examined the impact of antithrombotic agents on Patent Foramen Ovale (PFO) in relation to migraine. However, differences in effectiveness of different antithrombotic agents and traditional migraine medications are not known. This study is an investigator-initiated, randomized, multicenter, single-masked (outcomes assessor), and active-controlled parallel-group trial (ClinicalTrials.gov Identifier: NCT05546320), with the objective of evaluating the prevention efficacy of antithrombotic agents compared to first-line migraine medication in PFO patients. The trial involves 1,000 migraine patients with a right-to-left shunt at the atrial level, randomized in a 1:1:1:1 fashion to receive either aspirin 300 mg QD, clopidogrel 75 mg QD, rivaroxaban 20 mg QD, or the active-control metoprolol 25 mg BID. The primary efficacy end point is the response rate, defined as a 50% or greater reduction in the average migraine attack days per month or in the average number of migraine attacks per month at 12-week visit compared to baseline. The COMPETE trial aims to provide valuable insights into the comparative effectiveness of antithrombotic agents and standard migraine therapies in patients with PFO. This study holds the promise of advancing treatment approaches for individuals having migraines associated with PFO, thus addressing an important gap in current migraine management strategies.

Balloon atrial septostomy for transposition of the great arteries: Safety and experience with the Z-5 balloon catheter.

Balloon atrial septostomy (BAS)is an emergent and essential cardiac intervention to enhance intercirculatory mixing at atrial level in deoxygenated patients diagnosed with transposition of the great arteries (TGA)and restrictive foramen ovale. The recent recall of several BAS catheters and the changes in the European legal framework for medical devices (MDR2017/745), has led to an overall scarcity of BAS catheters and raised questions about the use, safety, and experience of the remaining NuMED Z-5 BAS catheter. To evaluate and describe the practice and safety of the Z-5 BAS catheter, and to compare it to the performance of other BAS catheters. A retrospective single-center cohort encompassing all BAS procedures performed with the Z-5 BAS catheter in TGA patients between 1999 and 2022. A total of 182 BAS procedures were performed in 179 TGA-newborns at Day 1 (IQR0-5) days after birth, with median weight of 3.4 (IQR1.2-5.7) kg. The need for BAS was urgent in 90% of patients. The percentage of BAS procedures performed at bedside increased over time from 9.8% (before 2010) to 67% (2017-2022). Major complication rate was 2.2%, consisting of cerebral infarction (1.6%) and hypovolemic shock (0.5%). The rate of minor complications was 9.3%, including temporary periprocedural AV-block (3.8%), femoral vein thrombosis (2.7%), transient intracardiac thrombus (0.5%), and atrial flutter (2.2%). BAS procedures performed at bedside and in the cardiac catheterization laboratory had similar complication rates. BASusing the Z-5 BAS catheter is both feasible and safe at bedside and at the cardiac catheterization laboratory with minimal major complications.

Abstract 11649: Serum Adiponectin Levels Correlate With Atrial PPARγ and TGFβ1 mRNA Expression in Patients Receiving Cardiac Surgery: Involvement of PPARγ on Atrial Fibrotic Remodeling

Introduction: The peroxisome proliferator-activated receptor gamma (PPAR γ) plays important roles in regulating processes related to fibrogenesis. On the other hand, adiponectin, a marker for PPARγ activity, is a hormone involved in maintaining energy homeostasis, and exerts anti-profibrotic effects in various organs. However, the roles of PPARγ and adiponectin on atrial fibrotic remodeling are still unknown. Hypothesis: We investigated the association of serum adiponectin levels and atrial gene expression of adiponectin, PPARγ and fibrosis-related genes in cardiovascular surgery patients including heart valve disease. Methods: Atrial mRNA expression levels including adiponectin and PPARγ were analyzed by real-time reverse transcription polymerase chain reaction (RT-PCR) in 59 cases (sinus rhythm (SR) 24 patients, atrial fibrillation (AF) 35 patients) in which left atrium (LA) tissues were removed from the appendage during surgery. The immunohistochemical studies were used to identify the protein expression. The serum levels of adiponectin were measured by ELISA. Results: The immunohistochemical staining showed the expression of adiponectin, PPARγ and PPARα. The significant correlations were observed among the mRNA expression levels of extracellular matrix (ECM) (COL1A1, COL3A1, fibronectin) and the fibrosis-related genes such as TGFβ1, TIMP1, MMP2, NOX2, CTGF and PDGFD attributed to the fibrosis of myocardium. The mRNA expression level of PPARγ, but not PPARα, positively correlated with that of the ECM and the fibrosis-related gene expression level. The mRNA expression level of adiponectin also positively correlated with that of ECM. Patients with AF had higher atrial expression level of adiponectin, PPARγ, COL1A1 and TGFβ than those with SR. Serum adiponectin levels significantly correlated with atrial mRNA expression level of PPARγ and TGFβ1. Patients with AF had serum higher levels of adiponectin than those with SR. Conclusions: Atrial PPARγ and adiponectin associate with atrial fibrotic remodeling in cardiovascular surgery patients. Serum adiponectin levels correlate with atrial PPARγ and TGFβ1 mRNA expression, and might have potential utility as a biomarker in atrial fibrotic remodeling.

Abstract 14080: Broadening Indications for Neonatal Balloon Atrial Septostomy in Dextro-Transposition of the Great Arteries Reduce Predictive Value of Fetal Echocardiography

Introduction: Neonates with dextro-transposition of the great arteries (d-TGA) require adequate mixing at the atrial level. If not present, these infants experience severe cyanosis, necessitating an urgent balloon atrial septostomy (BAS). Multiple studies have identified various fetal echocardiography (FE) findings as risk factors for postnatal BAS. Anecdotally, the predictive value of these findings remains poor in clinical use. Hypothesis: We aimed to determine the relationship between inter-rater reliability (IRR) of FE BAS predictors and need for postnatal BAS, hypothesizing that IRR would be poor and perhaps contributing to limited predictive value of FE findings. Methods: We identified d-TGA pregnancies followed at our institution between 2012 and 2022, excluding fetuses with large ventricular septal defects and pregnancies that were either terminated or lost to follow up. Three independent readers blinded to BAS outcome assessed 7 FE predictors: pulmonary vein Doppler velocity &gt; 41 cm/sec, reverse flow in patent ductus arteriosus (PDA), restrictive PDA, restrictive patent foramen ovale (PFO), bidirectional PFO flow, flat septum primum, and hypermobile septum primum. IRR was determined with the S metric. Clinical information immediately before BAS was collected to evaluate postnatal physiology. A multivariable logistic regression was used to determine significant associations between FE findings and postnatal BAS. Results: Fifty-six fetuses were included in this study, of whom 25 (45%) underwent BAS. IRR was lowest for PFO flow direction and highest for restrictive PDA, likely due to its rarity. The remainder of FE predictors had either a moderate or substantial level of IRR. The last pre-BAS range of PaO 2 (24-49 mmHg), O 2 saturation (56-86%) and pH (7.18-7.52) reflected variable physiology. Of the 5 FE characteristics that could be included in the regression analysis, none were found to be significantly associated with odds of a BAS. Conclusions: Our results demonstrate substantial but not excellent IRR for current FE BAS predictors, but no significant association between these predictors and postnatal BAS in d-TGA patients. Poor predictive value of FE for postnatal BAS could be impacted by broadening indications for BAS.

Abstract 18093: History of Stroke as a Predictor of High Left Atrial Fibrosis in Patients With Persistent Atrial Fibrillation

Introduction: The relationship between left atrial (LA) remodeling and ischemic stroke (IS) risk in patients with atrial fibrillation (AF) is well-established. The DECAAF II trial is the largest MRI-based, multicenter, randomized study conducted on persistent AF patients. Hypothesis: Our research investigates whether a history of stroke correlates with the extent of atrial fibrosis, as determined by late gadolinium enhancement magnetic resonance imaging (LGE-MRI), among the DECAAF II trial population. Methods: Patients with persistent AF who underwent LGE-MRI were enrolled and categorized into two cohorts: those with a history of stroke and those without. Covariates were adjusted using propensity score matching, and atrial fibrosis was compared between groups. Participants were then subdivided according to three baseline atrial fibrosis cut-off values: ≥ 15%, ≥ 20%, ≥ 25%. Univariate logistic regression and adjusted multivariate analyses were applied to evaluate the impact of clinical characteristics and risk factors on baseline fibrosis. Results: From the 843 patients involved in the DECAAF II trial, 70 (8.3%) had a stroke history. Those with stroke history had higher rates of hypertension, diabetes, and hyperlipidemia. Seventy patients without a stroke history were matched to stroke patients using propensity score analysis, revealing a significantly higher fibrosis in the stroke group (20.2% vs. 8.1%, p = 0.017). Increasing age significantly predicted all three baseline fibrosis categories (≥15%, ≥20%, ≥25%). Notably, stroke history was as a predictor of baseline fibrosis ≥25%, even after adjusting for other risk factors and clinical characteristics (OR = 1.98 [1.14-3.43], p = 0.01). Conclusions: There is a significant correlation between high left atrial fibrosis level and an increased risk of ischemic stroke in patients with persistent atrial fibrillation. This suggests that atrial fibrosis may provide insights into stroke risk classification.

Abstract 15357: Assessing the Utility of Serial Fetal Echocardiography in Detecting In-Utero Changes for Single Ventricle Lesions

Introduction: Current guidelines recommend serial fetal echocardiograms (FE) for fetuses with single ventricle lesions (SV) to identify in-utero changes that can impact delivery management, but there is sparse data on the utility of serial FE. We aim to evaluate the incidence of serial FE changes in fetuses with SV. Hypothesis: There is a low incidence of in-utero changes in serial FE for fetuses with SV. Methods: Fetuses with SV and &gt; 1 serial visit between 1/1/2012 to 1/1/2023 were retrospectively reviewed. FE were reviewed for significant, defined serial changes in the following: atrioventricular valve, ventricular function, atrial communication, ductus arteriosus, umbilical artery, umbilical vein, systemic venous Dopplers, hydrops, arrhythmias. Fisher’s exact test was used to compare proportions with change between both segmental findings and SV sub-type. Results: A total of 721 FE for 248 patients were reviewed, the majority with hypoplastic left heart syndrome (HLHS) (64%) and tricuspid atresia (15%). There was a mean of 2.9 visits per patient and 21 days between FE. Out of 3,699 possible changes, there was a total of 56 (1.5%) changes in 41 patients seen on all follow-up FE (Table 1). The most common changes were worsening atrial level restriction (10, 2.4%) and arrhythmias (10, 2.4%), all of which were premature atrial contractions (p&lt;0.01). Out of 56 changes, only 20 (36%) were critical with clinical impact on perinatal management and 2 (4%) showed progressive, serial worsening. Most changes (85%) were noted in the third trimester. There were no differences in incidence of change on serial FE between SV sub-types (p=0.10). Conclusions: SV fetuses have a low incidence of significant physiologic change on serial FE, and progressive worsening of physiologic findings is even rarer. Special consideration should be given to those with HLHS who may develop atrial level restriction. This data should be considered in planning clinical follow-up intervals for fetal SV.

Association between regional oxygen saturation and central venous saturation in pediatric patients undergoing cardiac surgery: A prospective observational study.

We evaluated the correlation between regional oxygen saturation (rSO2 ) in the frontal and right renal dorsum (cerebral rSO2 and somatic rSO2 ) measured by near-infrared spectroscopy (INVOS™ 5100C, Medtronic) and central venous oxygen saturation (ScvO2 ) measured with a fiber-optic oximetry catheter (PediaSat™, Edwards Lifesciences) during surgery in order to determine whether noninvasive rSO2 could be used as an alternative to ScvO2 in pediatric cardiac surgery patients. We evaluated the correlation between regional tissue oxygen saturation (cerebral rSO2 and somatic rSO2 ) measured by near-infrared spectroscopy and other patient measures with central venous oxygen saturation (ScvO2 ) measured with a fiber-optic oximetry catheter to track global oxygen supply demand as a potential alternative or supplement to ScvO2 . This single-center prospective observational study enrolled 33 children (weight < 10 kg) who underwent cardiac surgery for congenital heart disease between February 2018 and November 2021. ScvO2 , cerebral rSO2 , and somatic rSO2 were recorded simultaneously after anesthesia induction and central venous catheter placement. Pearson's correlation coefficient and Bland-Altman analysis were used to determine the relationship between ScvO2 and rSO2 . We conducted correlation, Bland Altman, and multiple regression analyses to identify associations between rSO2 , patient measures, and ScvO2 values. The patients' median age was 11.0 (quartile 2.0-16.0) months. Their weight was 7.2 (quartile 4.5-9.2) kg. Cerebral rSO2 was significantly positively correlated with ScvO2 (r2 = 0.29, p = .002 in all patients; r2 = 0.61, p = .013 in the patients without mixing at the atrial level), whereas somatic rSO2 was not. The Bland-Altman analysis demonstrated biases [95% confidence interval; 95% CI] (lower and upper limits of agreement [95% CI]) of 0.27% [-4.26 to 4.80] (-24.79 [-32.61 to -16.96] to 25.33 [17.50 to 33.16]) between cerebral rSO2 and ScvO2 and 0.91% [-5.48 to 7.30] (-34.43 [-45.47 to -23.39] to 36.25 [25.21 to 47.29]) between somatic rSO2 and ScvO2 . Preoperative brain natriuretic peptide (BNP) and SpO2 were independent variables associated with ScvO2 and cerebral and somatic rSO2 . Cerebral rSO2 , SpO2 , and BNP were significantly correlated with ScvO2 , although the cerebral rSO2 correlation was greater for lesions without atrial mixing. rSO2 , BNP, and SpO2 might be used to track changes in ScvO2 but cerebral rSO2 is not sufficiently precise to replace it.

Left atrial enlargement and high uric acid level are risk factors for left atrial thrombus or dense spontaneous echo contrast in atrial fibrillation patients with low to moderate embolic risk assessed by CHA2DS2-VASC score.

To investigate the correlation and predictive value of left atrial diameter and blood uric acid levels with the occurrence of left atrial thrombus or dense spontaneous echo contrast in atrial fibrillation patients with low to moderate CHA2DS2-VASc scores. A total of 849 inpatients diagnosed with atrial fibrillation who had low to moderate CHA2DS2-VASc scores and complete transesophageal echocardiography were included in this study. Among them, 66 patients had left atrial thrombus or dense spontaneous echo contrast. When different models were used to correct other known risk factors, acid levels and abnormal left atrial diameter were identified as additional risk factors for left atrial thrombus or dense spontaneous echo contrast. The incidence of left atrial thrombus or dense spontaneous echo contrast was higher in patients with abnormal serum uric acid levels than in the control group (12.4% vs. 5.6%, p < 0.05), and this difference persisted after correcting the baseline data with propensity score matching (10.6% vs. 4.1%, p < 0.05). Abnormal left atrial diameter was another risk factor suggested by regression analysis, with an increased incidence of left atrial thrombus or dense spontaneous echo contrast in the abnormal left atrial diameter group compared to the control group, both before (18.0% vs. 3.5%, p < 0.05) and after (15.5% vs. 5.2%, p < 0.05) propensity score matching. The best predictive value was obtained by adding both abnormal serum uric acid levels and abnormal left atrial diameter. Left atrial enlargement and high uric acid levels increase the risk of left atrial thrombus or dense spontaneous echo contrast in atrial fibrillation patients with low to moderate CHA2DS2-VASc scores.

Echocardiographic features and influencing factors of pulmonary hypertension of total anomalous pulmonary venous connection in adults.

Patients with total anomalous pulmonary venous connection (TAPVC) generally have symptoms during the neonatal period and infancy, and the fatality rate is extremely high. Most patients do not survive to adulthood. This study analyzed the clinical and transthoracic echocardiographic (TTE) manifestations of adult patients with TAPVC, summarized the echocardiographic characteristics of TAPVC, and identified the factors influencing pulmonary hypertension. Data from adult patients with TAPVC from Beijing Anzhen Hospital, China, were retrospectively collected for analyses, including sex, age, history of gestation, clinical manifestations, echocardiographic parameters, and blood oxygen levels. Patients were grouped for comparative analyses based on their pulmonary artery systolic pressure (PASP) (≥60 vs. <60 mmHg); 32 atrial septal defect (ASD) patients were included as a control group. (I) Sixteen patients were identified with TAPVC (11 women and 5 men; mean age: 32.2±9.5 years), including 8, 4, and 4 patients with supra-cardiac, mixed, and intracardiac type TAPVC, respectively. Furthermore, 10 patients had moderate or severe tricuspid regurgitation, and 6 had a PASP of ≥60 mmHg. Echocardiography misdiagnosed 2 patients with an ASD. (II) The TAPVC group patients had a smaller left atrium (LA) and a lower aorta/pulmonary artery ratio than ASD-only group patients. However, the right ventricular diameter (RVd) and right atrium were larger in patients with TAPVC than in those with only ASD. (III) The RVd was larger and the LA was smaller in patients with a PASP of ≥60 mmHg than in those with a PASP of <60 mmHg. (IV) Of those with a PASP of ≥60 mmHg, TAPVC patients had a smaller LA and a larger RVd than those with only ASD. (V) Pregnancy affected the PASP (adjusted odds ratio: 15.000, 95% confidence interval: 1.031-218.300, P=0.047). (VI) Echocardiography indicated that TAPVC patients with ASD had a right to left shunt at the atrial level and the pulmonary vein (PV) was not connected to the LA. Searching for the PV by TTE is necessary for patients with ASDs, which may help avoid misdiagnosis. Moreover, pregnancy affects the PASP. Patients with TAPVC may present with a larger right heart, smaller LA, and lower aorta/pulmonary artery ration than those with only ASD.

Аnalysis of preoperative and postoperative electrocardiogram in children with total anomalous pulmonary venous connection

Introduction. TAPVC is a condition that requires diagnosis and surgical treatment in a short period of time. As the result of an absence of the direct connection between pulmonary veins and left atrium, systemic and pulmonary venous return drainage to the right heart with volume and pressure overload. At the same time, left heart preload is depending on atrial septal defect. The hemodynamic features of the TAPVC create conditions for abnormal spread of electric impulses, whereas necessity of surgical reconstruction on the atrial level — reasons for rhythm and conduction disturbance in postoperative period.Aim of the study: detection of specific EKG markers of TAPVC for differential diagnosis of critical conditions in children, analysis of basis preand postoperative EKG to determine EKG pattern in children with TAPVC, registration of EKG changing in early and late postoperative period to define the potential rhythm and conduction disturbance in patients with TAPVC.Materials and methods. The data of biventricular TAPVC patients were reviewed. We estimated characteristic of P, PQ, QRS, QT, rhythm and conduction disturbance and evaluated preand postoperative EKG data, with their comparison in 30 patients. Results. Preoperative EKG (9,3 ± 6,5 days) showed sinus rhythm in all cases, P wave was 62,6 ± 10,6 (40–80) msec, PQ — 104,1 ± 15 (80–160) msec, QRS — 64,3 ± 13,5 (40–100) msec, QT — 253,1 ± 29,5 (210–350) msec, electric axis of the heart — 130,9 ± 44,4 (-70 ± 185). Postoperative rhythm was sinus in 83,3 % cases, atrial ectopic — 13,3 %, AV node rhythm — 3,3 %. The comparison of preand postoperative EKG data showed significant (p &lt; 0,05) difference in P, QT, and electric axis of the heart measurements. In late postoperative period we detected non-pathological differences in P, PQ, QRS, QT compared early posleoperative period, but sinus node dysfunction frequency was high in late postoperative period.Conclusion. There are no specific ECG markers in preoperative TAPVC patients. The standard EKG showed right heart volume and pressure overloud with positive changing of it after surgical correction of TAPVC. The early postoperative EKG did not showed “typical” rhythm and conduction disturbance after surgery at the atrial level, but patients require a long-time dynamic observation after TAPVC surgery because of higy frequency of sinus node dysfunction in late postoperative period.

P74 NIGHT SWEATS AND AN UNUSUAL RIGHT ATRIAL MASS

Abstract Background Primary cardiac tumors are infrequently, usually benign, and diagnosed incidentally. Among primary cardiac tumors, cardiac hemangiomas are exceptionally rare with only a 1–2% incidence. In most cases, histological diagnosis is made after surgical removal or at autopsy. Case presentation: A 36–year–old male patient is suffering from several months of bothering night sweats. He has no previous medical history and is not taking medication. After performing various exams, including an electrocardiogram and chest rx–ray that were unremarkable, the patient performed a chest TC scan that shows a large mass at right atrial level (Figure 1). Surprisingly, at transthoracic echocardiography the mass was not visible and moreover the exam was normal. To better visualize the mass, a transesophageal echocardiography was performed, showing a inhomogeneous, round–shape, intracavitary mass of 70x65 mm in size. The mass appear to be fixed, expansive, with no embolic–features and seem to be initially–obstructing the upper–cava blood flow (Figure 2), even the patient was hemodynamically stable. A diagnosis of lymphoma was initially suspected and an Total–body PET–TC was performed, showing that the heart mass was metabolically inactive and an intestinal metabolic active mass. Intestine mass biopsy, made by colonscopy, showed a non–malignous villous adenoma. Before undergoing heart surgery, to understand the nature of the mass, we performed a intracavitary ecocardiography (ICE)–guided percutaneous biopsy. Histologically, the heart tumor was composed of cavernous channels embedded in a loose fibrous stroma, compatible with Cavernous hemangioma. At heart surgery, the mass was localized inside the right atrium, at upper–front level, adhered to a small part of atrial myocardium, and was removed without complications. The right atrium was rebuilt with artificial patch. (Figure 3). Conclusions Cavernous cardiac Hemangioma is a rare tumor that may have an atypical clinical presentation. To our knowledge, this is the first case of cardiac hemangioma diagnosed by ICE–guided endomyocardial biopsy.