Left Atrial Cavity Research Articles

Diagnostic value of echocardiographic indices of left atrial and ventricular morphology in dogs with myxomatous mitral valve disease (MMVD)

Myxomatous mitral valve disease (MMVD) is one of the most common acquired diseases of the cardiovascular system of genetic etiology in small breed dogs. A long asymptomatic course characterizes the disease. Presently, the main diagnostic technique for heart diseases is echocardiography. This study evaluates individual echocardiographic indices of the left atrial and ventricular morphology with the determination of the diagnostic value of each of them in predicting the course of the disease. The study was conducted in a private veterinary hospital “Eurovet” and on the basis of the clinic of the Department of internal animal diseases and clinical diagnostics of Stepan Gzhytskyi National University of Veterinary Medicine and Biotechnology Lviv during 2018–2019. The objects consisted of 46 dogs with a confirmed diagnosis of myxomatous mitral valve disease according to the recommendations of the American College of Veterinary Internal Medicine (ACVIM) and no signs of comorbidities. During the study, three experimental groups of animals were formed according to the clinical and functional status characteristic of each stage of MMVD development – B1, B2, C. According to the results, all experimental dogs showed changes in the mitral apparatus in the form of thickening of the anterior and posterior cusps, mitral valve (MV) prolapse into the left atrial (LA) cavity and regurgitation (MR), the severity of which increased with the stage of the disease (from 20 % to 60 %). In 44.4 % of animals in group B2, thickening of the left ventricular walls was diagnosed in diastole and in 22.2 % in systole. Instead, these values increase to 46.1 % and 53.8 % in group C, respectively. However, the degree of hypertrophy is disproportionate. With the development of the disease, we detect its decrease from 0.64 ± 0.03 (group B1) to 0.50 ± 0.04 (group B2) and 0.51 ± 0.03 (group C) also we observed an increase in LVEDD/2 from 1.30 ± 0.05 cm (group B1) to 1.46 ± 0.12 cm (group B2) and 1.54 ± 0.13 cm (group C). The value of nLVEDD in B1 was 1.36 times (P < 0.001) lower compared to B2 and C. Higher values of this parameter were found in 23.1 % of dogs in group C compared to the maximum value of B2. As MV insufficiency progresses, the LA/Ao index increases slightly (1.08 times) in B2, followed by an increase in C (1.38 times, P < 0.001). At the same time, we diagnose an increase (P < 0.05) in PV/PA by 1.18 times in B2 and 1.46 times (P < 0.001) in C. Thus, an increase in the severity of mitral regurgitation, a rapid increase in nLVEDD, the dynamics of the decrease in the degree of hypertrophy h/R, as well as an increase in LA/AO, PV/PA indices are predictors of unfavorable prognosis of myxomatous degeneration of the mitral valve in dogs.

Percutaneous Transapical Access for Performing Interventional Procedures in Patients with Structural Heart Pathologies: a Single Center Experience

The paper describes the experience of percutaneous transapical access (PTA) usage for performing transcatheter structural interventions in 7 patients. Four patients had paravalvular insufficiency of the prosthetic mitral valve, one patient had a reshunt of ventricular septal defect and a pseudoaneurysm in the area of fibrous mitral-aortic continuity. Two patients underwent PTA for diagnostic examination. The visualization methods, planning algorithm, and technique of the procedure have been described. The overall efficiency was 100%, the degree of paravalvular leak was reduced in all treatment procedures. The main reported complication was hemothorax in two cases. In one case, the occluder migrated from the paravalvular fistula channel into the left atrial cavity with subsequent endovascular extraction.
 The aim. This study was designed to evaluate modern outlooks about the use of PTA during interventions, enhance the available data and extrapolate the authors’ own experience with the development of their own conclusions and recommendations.
 Materials and methods. To differentiate structural pathology, the initial selection of patients was performed according to the findings of transthoracic and transesophageal ultrasound. The next step in planning of PTA is analysis of computed tomography (CT) data with 3D reconstruction.
 PTA and subsequent interventions were performed in the hybrid catheterization laboratory after evaluation of CT data, guided by transesophageal echocardiography (TEE), and with the establishment of optimal angles of the angiograph arc for the best fluoroscopic imaging. Besides, in order to avoid trauma of left anterior descending coronary artery, selective angiography was performed. Surgical team support was essential in all cases.
 Results. The overall efficiency was 100%, reduction of the degree of paravalvular leak was achieved in all treatment procedures. The main reported complication was hemothorax in two cases. In one case, the occluder migrated from the paravalvular fistula channel into the left atrial cavity with subsequent endovascular extraction.
 Discussion. The subject of our research was PTA for structural interventions. Available data of the world literature shows that this technology has been developed since the end of the last century.
 The main complications that can be encountered during the intervention by PTA were: hemothorax; hemopericardium/tamponade; rupture of the coronary artery; pneumothorax; arrhythmia; death.
 In four out of five cases, we used a Lifetech HeartR PDA occluder to close the puncture site of the left ventricular apex. In the fifth case, LifeTech mVSD occluder was used.
 Conclusions. Correction of structural pathology by routine use of PTA requires a comprehensive approach to the diagnosis of this pathology using transthoracic and transesophageal echocardiography, contrast-enhanced CT and 3D reconstruction. Support of a multidisciplinary team to provide transition to conventional cardiac surgery access in case of periprocedural complications is mandatory. Due to the emergence of specialized implants, as well as the development of imaging techniques, PTA requires attention and further study.

Left atrial deformation in estimating left atrial pressure

Abstract Background In the absence of mitral valve disease, elevated left atrial (LA) pressure reflects reduced left ventricular (LV) compliance and raised diastolic pressures, hence an important explanation for exertional breathlessness. Methods We studied 145 symptomatic patients, age 63±14 years, 55 males, using conventional transthoracic echocardiography guidelines protocol, including LA and LV myocardial deformation investigations along with simultaneous right heart catheterization using conventional techniques. From invasive measurements, pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP) were measured and pulmonary vascular resistance (PVR) calculated. No patient had more than mild mitral or aortic valve disease. Results LA strain rate during atrial systole (LASRa) was the strongest correlate with PCWP (r2=−0.39, p<0.001), over and above LASR during LV systole (LASRs) and peak LA longitudinal strain (PALS) (r2=−0.21 and −0.19, respectively, p<0.001 for both). Both LASRa and PALS predicted elevated PCWP >15 mmHg but only modestly (AUC= 0.55 and 0.52). The relationship between LASRa and PCWP was stronger in patients with post-capillary pulmonary hypertension compared to those with pre-capillary pulmonary hypertension (r2=0.21 vs. r2=0.02). However, the strongest relationship between LASRa and PCWP was in patients with LA volume >34 ml/m2 (r2=0.59, p<0.001, see figure) but other strain relationships did not improve after only including patients with increased LA volume. Finally, LASRa correlated modestly with the respective LVSRa (r=0.53, P<0.01), and to lesser extent with other cavity interaction correlations (r=0.26–0.48, p<0.01). Conclusion Despite being somehow related to ventricular function, left atrial strain rate during atrial contraction is the closest correlate to PCWP, particularly in patients with dilated LA cavity. These data should be of significant clinical value in daily management of symptomatic patients. LASRaecho and PCWPrhc in patients with d Funding Acknowledgement Type of funding source: None

Initiation of Sacubitril Valsartan in an Inotrope Dependent Patient

A 41-year-old man, with a history ACC/AHA stage C heart failure with reduced ejection fraction secondary to idiopathic dilated cardiomyopathy, presented at the HF clinic for follow-up visits, status post hospitalization due to acute decompensated heart failure in March 2019. After the initiation of milrinone during the hospitalization, two attempts to wean off milrinone were made but failed due to malperfusion and symptomatic hypotension with significant drops of the cardiac index to 1.3 L/min/m2 and 1.76 L/min/m2, respectively. As such the patient was discharged on inotropic support with milrinone 0.25 mcg/kg/min and guideline-directed medical treatment. Lisinopril was held right before discharge due to hypotension.The patient returned to the clinic one month after discharge for 2nd follow-up visit. The BP was 136/98 mmHg with a HR of 90 beats/min. He was generally well with a stable weight and had no major/new complaints. The NT-proBNP level was reduced significantly. Given the considerable improvement of his clinical status, sacubitril/valsartan 24/26 mg twice daily was initiated. No hypotension was reported thereafter. Two weeks after the initiation of sacubitril/valsartan therapy, the NT-proBNP normalized and the patient was admitted to the cardiac observation unit as planned to discontinue milrinone, followed by same-day discharge. His mixed venous oxygen saturation 6-hour after discontinuation of milrinone was 64.1%. His BP was 122/87 mmHg before the admission and remained stable with systolic BP in the low 120s, and HR of 70s beats/min. During the exam, he was warm and well-perfused without clinical evidence of hypoperfusion. Thus, this patient was successfully weaned from milrinone after the initiation of sacubitril/valsartan. The trend in NT-proBNP levels during treatment is shown in the Figure. The latest echocardiogram in the 8th month after discharge showed that left ventricular internal diameter in diastole (LVIDd) decreased to 5.91 cm from 8.35 cm measured before discharge. Left atrial cavity size diminished from severely increased to mildly increased with a reduction of left atrial dimension from 5.5 cm to 4.3 cm. Mitral valve regurgitation improved from moderate to mild. Left ventricular systolic function remained severely reduced with estimated ejection fraction

Results of surgical correction of gigantic left atrium

We presented a clinical case of surgical treatment of gigantic left atrium in longstanding mitral regurgitation due to mitral valve disease diagnosed 23 years ago (patient refused surgery and was on medical treatment) and complicated by atrial fibrillation. The patient was referred for surgery with complaints on severe dyspnea on minimal exertion, weakness, fatigue, palpitations and massive leg edema. Diagnosis was established using electrocardiography, chest X-Ray, transthoracic and transesophageal echocardiography, and computed tomography. The patient underwent mitral valve replacement, tricuspid valve annuloplasty and left atrial reduction surgery (atrioplasty by Kawazoe). After surgery, left atrial volume decreased from 813 ml to 294 ml and antero-posterior size from 11.2 to 6.2 cm. The patient was discharged on 8th day after surgery. Control examinations after 6 months and 1 year showed reduction of left atrial volume (319 ml and 294 ml); patient feels well and has no complaints. Thus, our case demonstrated reduction of left atrium early in postoperative period and its slow reduction after surgery during 1 year. It is also showed human reserve capacity and possibility of left atrial dilatation to such sizes. Late diagnosis of such changes in heart is possibly related to the fact that patient was afraid to see doctors and undergo surgery. The left atrial cavity size determination can be done intraoperatively using method of surgical glove we suggested.

Reoperations after the correction of partial abnormal venous return: a clinical case series

Rationale: The surgical procedure for partial abnormal pulmonary venous return (PAPV) implies the formation of a tunnel between the orifices of the right pulmonary veins and the left atrial cavity with the interatrial septum repair. To avoid any obstruction of the tunnel, a direct anastomosis between the superior vena cava (SVC) and the right atrial appendage is placed in a number of cases. However, the reparative procedure is potentially associated with such complications as SVC stenosis and/or pulmonary vein stenosis. Aim: To present our experience of reoperations for stenosis of systemic and pulmonary veins after primary PAPV repair. Materials and methods: From 2014 to 2018, seven patients (boys, 4) with SVC stenosis and/or with stenosis of the right pulmonary veins have been admitted to the FCHMT (Kaliningrad). Their mean bodyweight was 29.1 kg (± 12.5 kg), mean age 9.3 years (± 3.6 years). Three patients had an isolated SVC stenosis. In two patients, there was a combination of SVC stenosis and pulmonary vein obstruction (from stenosis to complete occlusion); in one patient the right pulmonary vein stenosis had been caused by thrombosis. SVC stenosis with subaortal obstruction after the repair of double-outlet right ventricle was diagnosed in one case. In six patients, various procedures for correction of SVC and/or pulmonary vein stenosis were performed. Only in one case the obstruction of systemic veins, confirmed by cardiac catheterization, turned out to be non-significant, making a reoperation unnecessary. Results: There were no deaths in this patient group. Endovascular procedures were performed in two patients. In one case, there was an unsuccessful attempt of transluminal balloon angioplasty for SVC stenosis, with subsequent Warden procedure. In another case, a 16-year old patient with SVC stenosis and high pulmonary hypertension was admitted after two previous surgeries had failed. We used a homograft as SVC prosthesis; however, after one year, a re-stenosis was identified. In this case, a SVC stent placement was successful. Due to sick sinus syndrome at one year after the Warden procedure and the repair of pulmonary veins by a homograft, an implantation of electric cardiac pacemaker was necessary in one patient. Conclusion: The curative repair of partial abnormal venous return is a well-established surgical technique with satisfactory shortand long-term results. A potential complication of the procedure is an obstruction of systemic and pulmonary veins. To prevent such complications during primary defect repair, as well as with reoperations for vein stenosis, the Warden procedure seems effective and highly reproducible technique associated with lower surgical risks.

Atrial Fibrillation, Cancer and Echocardiography.

Nonvalvular atrial fibrillation (AF) is a relatively frequent arrhythmia in cancer patients; it is possibly due to direct effect of cancer or consequence of cancer therapies. AF creates important problems for both therapeutic management and prognosis in cancer patients. The anticoagulation of cancer patients presenting AF is a main issue because of the difficult balance between thromboembolic and bleeding risks, both elevated in this clinical setting. A comprehensive echo Doppler examination is mandatory to identify the eventual sources of emboli in left atrial (LA) cavity, mainly the transesophageal echocardiography (TEE), but also to predict the subsequent development of heart failure. This evaluation is particularly important to graduate anticoagulation and to prevent and manage symptoms/signs of heart failure. The performance of a TEE precardioversion is highly encouraged to detect possible thrombi in LA appendage. A careful assessment of LA size (LA volume index) and function (LA emptying fraction and/or LA strain) should always be planned to predict the possible recurrence of AF paroxysmal episodes. This is in fact a key action, not only from the cardiologic point of view but also for the oncologic perspectives in individual situations. Patients with larger left atrium and more impaired LA function should be addressed toward a less aggressive cancer treatment, with drugs which are not associated or are poorly related with the risk of AF development. A correct and comprehensive echocardiographic assessment could even induce the oncologist to change the cancer management balancing the oncologic and the cardiac risk.

Myocardial remodeling and arterial stiffness depending on aldosterone level in patients with chronic kidney disease and arterial hypertension

The aim. To analyze the relationship between serum aldosterone levels and myocardial remodeling and changes in elastic properties of arteries in patients with chronic kidney disease (CKD) and hypertension (AH).Materials and methods. A cross-secitonal study of 44 patients (14 men and 30 women, aged 56.0 [52.0; 60.5] years) with CKD and AH who were treated with angiotensine-converting enzyme inhibitors or angiotensine receptor blockers at a stable dose for at least of 3 months was performed. Serum aldosterone levels, elastic properties of the arteries, and transthoracic echocardiography using a standard method were performed. Arterial stiffness was defined as a pulse wave velocity, which was calculated using equation proposed by Arterial Stiffness Society and was measured using a device BAT41-2.Results. In 8 patients (18.2 %) we detected serum aldosterone levels above 90 pg/ml. The proportion of female patients among patients with normal aldosterone levels was significantly higher (P = 0.03). Patients with elevated aldosterone levels had a 5-year higher median age and 10 ml/min lower glomerular filtration rate. Serum aldosterone levels correlated significantly with myocardial structural and functional parameters (left ventricle (LV) end-systolic and end-diastolic dimensions and volumes, LV myocardial mass and LV mass index, thickness of interventricular septum) in men and patients over 55 years of age. Women showed a weak correlation of aldosterone levels with systolic and diastolic blood pressure.Conclusions. An association was found between serum aldosterone levels above 90 pg/ml in patients with CKD and hypertension with dilatation of left ventricular and atrial cavities, and with left ventricular hypertrophy (by LV mass and mass index). This association was stronger for males and for patients aged >55 years. A correlation between aldosterone level and arterial stiffness (augmentation index on the brachial artery and aorta) has only been found in patients over 55 years of age.

Criteria for adverse prognosis for mitral valve prolapse.

On the basis of a survey of 151 patients, diagnostic criteria for an unfavorable prognosis of mitral valve prolapse were revealed according to echocardiography. Transthoracic and transesophageal echocardiography, daily Holter ECG monitoring were performed. Repeated echocardiography was performed in 12-18 months. Statistical analysis of the material allowed us to identify criteria for poor prognosis of mitral valve prolapse according to echocardiography: severe mitral regurgitation, mitral valve leaflet thickness in diastole 6 mm or more, dilatation of the left ventricular cavity, dilatation of the left atrial cavity, dilatation of the mitral ring.

Interleaved, undersampled radial multiple-acquisition steady-state free precession for improved left atrial cine imaging.

Balanced steady-state free precession (bSSFP) left atrial (LA) cine suffers from off-resonance artifacts, particularly in the pulmonary veins (PVs). Linear combination or multiple-acquisition SSFP (MA-SSFP) effectively removes banding but greatly increases scan time. We hypothesized that MA-SSFP with interleaved radial undersampling, where each phase-cycling is acquired with an interleaved set of radial projections, would improve image quality of LA cine with a small increase of scan time and streak artefacts. Undersampled radial MA-SSFP with and without interleaving was compared with fully sampled radial bSSFP by means of simulations, phantoms, and in vivo imaging. Ten healthy subjects were imaged on a 3T scanner, with bSSFP and MA-SSFP cine of the left atrium, and B0-mapping. Images were assessed (1 = worst, 5 = best) by 2 independent readers, with respect to 5 qualitative criteria and apparent signal-to-noise ratio. In healthy subjects, off-resonance differed from the right inferior PVs to the LA cavity by 163 Hz ± 73 Hz at 3T. Compared with fully sampled radial bSSFP, interleaved radial MA-SSFP significantly improved image quality with respect to off-resonance artifacts (3.8 ± 0.6 versus 2.3 ± 1.0; P = 0.005), PV conspicuity (2.8 ± 1.0 versus 4.3 ± 0.5; P = 0.005), and the number of visualized PVs (1.7 ± 0.4 versus 0.9 ± 0.7; P = 0.008), although with greater streak artifacts (3.4 ± 0.4 versus 4.9 ± 0.2; P = 0.004) and lower measured apparent signal-to-noise ratio (24 ± 9 versus 69 ± 36; P = 0.002). Flow artifacts were similar. Interleaved radial MA-SSFP reduced streaking artifacts and increased apparent signal-to-noise ratio versus noninterleaved radial. Interleaved radial MA-SSFP cine reduces banding artifacts with an acceptable increase of scan time and streak artifacts. The proposed technique improves the LA and PV visualization in bSSFP cine imaging.

Low incidence of atrial septal defects in nonmammalian vertebrates.

The atrial septum enables efficient oxygen transport by separating the systemic and pulmonary venous blood returning to the heart. Only in placental mammals will the atrial septum form by the coming‐together of the septum primum and the septum secundum. In up to one of four placental mammals, this complex morphogenesis is incomplete and yields patent foramen ovale. The incidence of incomplete atrial septum is unknown for groups with the septum primum only, such as birds and reptiles. We found a low incidence of incomplete atrial septum in 11 species of bird (0% of specimens) and 13 species of reptiles (3% of specimens). In reptiles, there was a trabecular interface between the atrial septum and the atrial epicardium which was without a clear boundary between left and right atrial cavities. In developing reptiles (four squamates and one crocodylian), the septum primum initiated as a sheet that acquired perforations and the trabecular interface developed late. We conclude that atrial septation from the septum primum only results in a low incidence of incompleteness. In reptiles, the atrial septum and atrial wall develop a trabecular interface, but previous studies on atrial hemodynamics suggest this interface has a very limited capacity for shunting.

A RARE CASE OF PRIMARY CARDIAC MYXOFIBROSARCOMA

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Primary cardiac myxofibrosarcoma is a rare malignancy of mesenchymal origin which is associated with poor prognosis. Patients are generally asymptomatic in the earlier stages, however can present with life threatening hemodynamic instability. CASE PRESENTATION: Patient is a 25-year-old Caucasian male with history of asthma who presented with sudden onset of unresponsiveness, refractory shock and extensive bilateral pulmonary infiltrates. He was treated for bronchitis and pneumonia as outpatient on and off for two months prior to presentation. A transthoracic echocardiography showed large rounded mobile mass (5.5 cm by 4.5 cm) in left atrial cavity which was attached to anterior mitral leaflet causing severe mitral stenosis. CT showed extensive bilateral pulmonary consolidations. The patient was not deemed a candidate for surgical resection of the atrial mass. In the light of grave prognosis and failed aggressive medical therapy, family opted for comfort care measures. Autopsy of the left atrial mass showed low grade primary cardiac atrial myxofibrosarcoma. DISCUSSION: Myxofibrosarcoma most commonly occurs in the extremities but rarely can be seen in the heart. Primary cardiac myxofibrosarcoma is seen in the left atrium about 75% of the time [1]. Prognosis is poor because of its invasive nature and poor response to therapy including radiation, resection and chemotherapy [2]. Patients tend to be asymptomatic in the earlier stages. Clinical presentation is usually due to mass effect from the tumor. Tumor specifically located in the left atrium can cause obstruction of the mitral valve which manifests as symptoms of functional mitral stenosis leading to symptoms associated with heart failure. It can produce “tumor plop” (sound from tumor bounding around in the heart) and murmur similar to the mid-diastolic rumble of mitral stenosis [3]. This case is significant not only because of rarity of primary myxofibrosarcoma but also the clinical presentation and acute decompensation. Per our literature review, there are no reports of primary cardiac myxofibrosarcoma that presented with acute respiratory distress syndrome (ARDS). Our patient’s acute decompensation is likely synergistic result of cardiogenic shock from functional mitral stenosis (tumor mass effect) as well as underlying septic shock from pneumonia. CONCLUSIONS: Primary cardiac myxofibrosarcoma is a rare tumor which is usually detected when there are apparent hemodynamic changes form the mass effect, at which time treatment is limited given its extensive spread. Palliative care is generally the final outcome. Reference #1: Ujihira, Kosuke et al. “A case report of primary cardiac myxofibrosarcoma presenting with severe congestive heart failure” Journal of cardiothoracic surgery vol. 11,1 95. 7 Jul. 2016. Reference #2: Lazaros GA, et al. Primary myxofibrosarcoma of the left atrium: case report and review of the literature. Angiology. 2008;59(5):632–635. Reference #3: Vaideeswar, P. Butany, JW. (Feb 2008). "Benign cardiac tumors of the pluripotent mesenchyme". Semin Diagn Pathol. 25 (1): 20–8. DISCLOSURES: No relevant relationships by Bishal Bhandari, source=Web Response No relevant relationships by Cameron Koester, source=Web Response No relevant relationships by Abhishek Kalidas Kulkarni, source=Web Response No relevant relationships by Manjari Regmi, source=Web Response

P4507Left atrial conduit function modulates functional capacity in heart failure patients acting through the pulsatile component of right ventricular afterload

Abstract Background It has been suggested that left atrial (LA) characteristics modulate the functional capacity in heart failure (HF) patients through the impact that LA cavity exerts on the pulmonary circulation and the pulsatile component of right ventricular (RV) afterload, as represented by pulmonary arterial compliance (PAC). Purpose Thus, we hypothesized that, in a HF patients' population, a larger relative contribution of LA phasic conduit function (PCF) to the left ventricular (LV) stroke volume would be associated with a heavier right ventricular hemodynamic burden and a reduced functional capacity. Methods 60 sinus rhythm HF subjects (42 males, 67±11 years, ejection fraction [EF] 39±11%, range 20% - 62%) underwent 6 minute walking test (6MWT) and routine transthoracic echocardiography, plus real time 3D acquisitions analyzed with a dedicated echo software package. LV ejection fraction (EF) was obtained from 3D echo acquisitions. LV diastolic dysfunction (DD) was assessed according to current guidelines. Computation of PCF was made by simultaneous gathering real time 3D multibeats (6 cycles) LA and LV volumes, using the formula: PCF(time) = [LV(time) − LV minimum] − [LA maximum − LA(time)] as proposed by Bowman & Kovacs (2004), with PCF expressed as % of LV stroke volume. Atrioventricular compliance (Cn) was also assessed, as proposed by Flachskampf et al. (1992): 1270*(mitral valve area/E wave downslope) and expressed in ml/mmHg. Finally, PAC was obtained as the ratio between RV stroke volume (pulmonary velocity time integral*pulmonary valve annulus area measured from the RV outflow tract diameter) and pulse pressure (obtained from pulmonary and tricuspid regurgitant envelopes) and expressed in ml/mmHg. Results Maximal LA and LV volumes averaged 69±21 ml and 147±47 ml, respectively. The mean value of PCF was 33±12% (range 7% - 58%). Mean 6MWT was 397±162 m. Mean PAC was (3.1±1.1 ml/mmHg). DD grade I, II and III were detected in 38 (63%), 18 (30%) and 4 (7%) of the patients' population, respectively. PCF was independent of LA or LV volumes and EF, but showed a strong direct relation with DD (r=0.62; p<0.0001) and a relevant inverse dependence on Cn (r=−0.48; p=0.0001). For a comparable Cn, dividing patients into tertiles according to 6MWT, it was clear that highest PCF was significantly associated with lowest functional capacity (ANCOVA, figure left). Similarly, dividing patients into tertiles according to PAC, it emerges that highest PCF is significantly associated with most deranged PAC (ANCOVA, figure right), suggesting outmost RV hemodynamic burden. Conclusion PCF is an important parameter to be quantified in HF patients that is dependent on global left heart compliance, being affected by DD, but not LV EF. Furthermore, at a given Cn, PCF is increased in HF patients with lowest functional capacity, likely because RV pulsatile afterload is highest in these subjects.

35. A referred case of probable PMR with a different outcome

IntroductionThis is the case of a 67-year-old woman who presented to the rheumatology clinic with suspected diagnosis of polymyalgia rheumatica on prednisolone with complaints of flu-like illness, muscle aches and occasionally low-grade fever. Initial investigation showed anaemia with a significantly raised CRP and ESR. Further investigation revealed a different outcome.Case descriptionA 67-year-old woman presented to the rheumatology clinic with the suspected diagnosis of polymyalgia rheumatica with prednisolone commenced in primary care. Three months before, she presented in primary care with a flu-like illness, muscle aches and occasionally low-grade fever. On investigation, she was found to have anaemia (Hb 92 gm/dl with MCV of 109 femtoliters per cell) with a significantly raised ESR of 123 mm/hr and CRP of 258 mg/L. Initially, there was a history of mild weight loss which she attributed to her diet and subsequently, she regained weight.Her symptoms were not typical of PMR and upon further questioning, she complained of shortness of breath on inclines. She denied any symptoms of dizziness or any symptoms suggestive of embolic manifestation. Her previous medical history includes hypertension and hyperlipidemia for which she was on bendroflumethiazide and statins which were stopped in primary care three months back. Her blood pressure in the clinic was 156/77mmHg with a pulse of 82 beats per minute. There was no clubbing or any signs suggestive of polymyalgia rheumatica or any other connective tissue disease. On auscultation of heart, the first heart sound was loud and the chest was clear. Abdominal and neurological examination was unremarkable. Rest of investigations including urea and electrolytes, liver function test, ANA, anti ENA, Complement C3 &C4, immunoglobulins, creatine kinase, ferritin and thyroid function tests were unremarkable. An echocardiogram was requested as workup of unexplained raised inflammatory markers and non-resolving symptoms which showed a large echogenic mass in the left atrium attached to atrial septum and prolapsing through the mitral valve into the left ventricle, suggestive of left atrial myxoma. She was referred to cardiothoracic surgeons for resection. Her aches and pains subsided and she is doing very well after surgery. DiscussionMyxomas account for 40-50% of primary cardiac tumours. 75-85% occur in the left atrial cavity and up to 25% in the right atrium. Symptoms range from nonspecific and constitutional to sudden cardiac death. In 20% of cases, atrial myxoma may be asymptomatic and reported as an incidental finding. Other reported symptoms are exertional dyspnoea (75%) which may get worse leading to pulmonary oedema. Other symptoms may be due to obstruction of mitral valve leading to dizziness (20%), Symptoms of right heart failure, embolization to the central nervous system and retinal artery involvement may lead to blindness, coronary artery disease, and PE. Constitutional symptoms include fever, weight loss, arthralgias, and Raynaud’s phenomenon and are observed in 50% of patients, 15% of the atrial myxoma patients present with hemoptysis which may be due to an infraction or pulmonary oedema.Laboratory studies include raised inflammatory markers including ESR and CRP, leukocytosis and anaemia. Transesophageal echocardiography has better specificity and 100% sensitivity compared to transthoracic echocardiography.Histologic studies demonstrate the presence of lipidic cells embedded in a vascular myxoid stroma. Other investigation modalities include MRI, CT, and nuclear imaging.Conventional treatment of atrial myxoma is surgical removal by median sternotomy. Mini thoracotomy with robotically assisted surgery has been reported, resulting in a shorter length of hospital stay, and it is considered a safe and feasible method for atrial myxoma excision. The investigators did not observe any difference in the quality of life between the two strategies. A case report of total endoscopic robotic resection of a left atrial myxoma in an elderly patient with persistent left superior vena cava also demonstrated the good outcome. No recurrence of myxoma was observed during the 2-year follow-up period if resected completely.Key learning pointsPolymyalgia rheumatica, raised inflammatory markers, malignancy, atrial myxoma, large vessel vasculitis.Conflicts of interestThe authors have declared no conflicts of interest.

Compromised left atrial function and increased size predict raised cavity pressure: a systematic review and meta-analysis.

This meta-analysis assesses left atrial (LA) cavity and myocardial function measurements that predict pulmonary capillary wedge pressure (PCWP). PubMed-MEDLINE, EMBASE, Scopus, Google Scholar and the Cochrane Central Registry were searched up to December 2018 for studies on the relationship of LA diameter, LA indexed volume (LAVI max, LAVI min), peak atrial longitudinal (PALS), peak atrial contraction (PACS) strain and total emptying fraction (LAEF) with PCWP. Eighteen studies with 1343 patients were included. Summary sensitivity and specificity (with 95% CI) for evaluation of diagnostic accuracy and the best cut-off values for different LA indices in predicting raised PCWP were estimated using summary receiver operating characteristic analysis. The pooled analysis showed association between PCWP and LA diameter: Cohen's d=0·87, LAVI max: d=0·92 and LAVI min: d=1·0 (P<0·001 for all). A stronger correlation was found between PCWP and PALS: d=1·26, and PACS: d=1·62, total EF d=1·22 (P<0·0001 for all). PALS ≤19% had a summary sensitivity of 80% (65-90) and summary specificity of 77% (52-92), positive likelihood ratio (LR+) 3·74, negative likelihood ratio (LR-) <0·25 and DOR>15·1 whereas LAVI ≥34mlm-2 had summary sensitivity of 75% (55-89) and summary specificity 77% (57-90), with LR+ >3, LR- 0·32 and DOR >10·1. Compromised LA myocardial function and increased size predict raised cavity pressure. These results should assist in optimum follow-up of patients with fluctuating LA pressure.

Prevalence of extra-appendage thrombosis in non-valvular atrial fibrillation and atrial flutter in patients undergoing cardioversion: a large transoesophageal echo study.

The aim of our study was to evaluate the prevalence of left atrial cavity and appendage thrombosis in patients undergoing cardioversion for non-valvular atrial tachyarrhythmias. In persistent atrial tachyarrhythmias, 90% of thromboses are reported to be located inside the left atrial appendage. This prevalence refers to old studies and meta-analysis in a mixed population of valvular and non-valvular atrial fibrillation. Left atrial cavity thrombosis in non-valvular atrial fibrillation has not been investigated recently in large-scale studies. A total of 1,420 consecutive adult patients with paroxysmal or persistent atrial tachyarrhythmias, candidates to cardioversion, who opted for a transoesophageal echocardiography-guided strategy, were enrolled in the study. Mitral stenosis, rheumatic valve disease and mechanical prostheses were excluded. In total there were 91 thrombi in 87 patients with a prevalence of 6.13% (87/1,420). Patients with left atrial thrombosis had predisposing clinical and echo characteristics (heart failure, lower ventricular function and higher atrial volume). Except for one case in which the thrombus was located in the left atrial cavity (0.07%), and three in the right appendage, all thromboses were detected in the left atrial appendage. Extra-appendage thrombosis is a very rare finding in non-valvular persistent and paroxysmal atrial tachyarrhythmias and, when present, a left appendage thrombus is usually concomitant.

Relationship between presence of spontaneous echo contrast and platelet-to-lymphocyte ratio in patients with mitral stenosis.

Left atrial spontaneous echo contrast (SEC) is an existence of smoke-like echoes with a typical swirling motion of blood in left atrial cavity or appendage, and it is known to be a marker of prothrombotic state. Previous studies have revealed that there is an association between prothrombotic state and the platelet-to-lymphocyte ratio (PLR). Thus, we aimed to investigate the association between the presence of SEC and PLR in patients with mitral stenosis (MS). A total of 306 consecutive patients with MS were enrolled in the study. Transoesophageal echocardiography was made to assess the SEC for all patients. Recruited patients were divided into two groups according to the formation of SEC in the left atrium. Complete blood counting parameters, biochemical tests and high-sensitive C-reactive protein (Hs-CRP) levels were measured. There were 182 patients (mean age 42.7±11.9 and 78% female) in the SEC (-) group, and 124 patients (mean age 45.3±10.5 and 68% female) in the SEC (+) group. Hs-CRP levels (3.9±1.9 vs 5.1±3.6, P<0.001) were significantly different between the two groups. PLR (143.4±77.7 vs 180.6±108.7, P<0.001) was significantly higher in the SEC (+) group. ROC curve analysis, PRL ≥123 had 71% sensitivity and 52% specificity in predicting SEC in patients with MS. Platelet-to-lymphocyte ratio is an inexpensive and easily calculated biomarker, which is useful to predict left atrial SEC in patients with mitral stenosis.

Dual-Energy Computed Tomography-Enabled Material Separation in Diagnosing Left Atrial Appendage Thrombus.

We explored the potential clinical value of material separation enabled by dual-energy spectral computed tomography in detecting left atrial appendage thrombi. The study enrolled 24 patients who were scheduled to undergo atrial fibrillation ablation (12 with and 12 without left atrial appendage thrombi). Computed tomograms were acquired in gemstone spectral imaging mode; the densities in the regions of the left atrial appendage cavities, pectinate muscles, and left atrial appendage thrombi were analyzed on monochromatic 70-keV images. Iodine and blood were chosen as the material basis pair; the iodine and blood densities were observed and quantitatively determined from the iodine- and blood-specific material decomposition images. On the 70-keV monochromatic and iodine-specific images, the left atrial appendage pectinate muscles and thrombi appeared as areas of hypodense attenuation. On the blood-specific images, similar areas of high attenuation were observed in the thrombi and cavities, whereas lower attenuation was noticed in the pectinate muscles. The quantitative iodine and blood densities in the pectinate muscles were lower than those in the cavities (P <0.001). The iodine densities in the thrombi were lower than those in the cavities (P <0.001); however, blood densities did not differ significantly between the thrombi and cavities (P=0.192). Compared with the pectinate muscles, the thrombi showed lower blood-density differences (P=0.003) and higher iodine-density differences (P=0.006) in relation to the cavities. Spectral computed tomography-enabled material separation is a novel method for differentiating left atrial appendage thrombi from pectinate muscles. The potential applications of this technology warrant further studies.

Impact of dense “smoke” detected on transesophageal echocardiography on stroke risk in patients with atrial fibrillation undergoing catheter ablation

Spontaneous echocardiographic contrast ("smoke") within the left atrial cavity on transesophageal echocardiography (TEE) suggests low blood flow velocities in the heart that may lead to thromboembolic (TE) events. The purpose of this study was to evaluate the risk of TE events in the periprocedural period and at long-term follow-up in atrial fibrillation (AF) patients having dense smoke on preprocedural TEE. A total of 2511 patients undergoing AF ablation were included in this analysis. They were classified as group 1 (dense smoke detected on TEE at baseline; n = 234) and group 2 (no smoke on baseline TEE; n = 2277). Patients were followed up for TE events, which included both stroke and transient ischemic attacks (TIAs). In order to attenuate the observed imbalance in baseline covariates between the study groups, a propensity score matching technique was used (covariates were age, sex, AF type, diabetes, and CHADS2VASc score). In the periprocedural period, no TE events were reported in group 1 and 3 events (0.13%) were reported in group 2. At follow-up of 6.62 ± 2.01 years, 6 (2.6%) TE complications (2 TIA, 4 stroke) occurred in group 1 and 16 (0.70%) TE complications (6 TIA, 10 stroke) in group 2 (P = .004). In the propensity-matched population, 6 (2.56%) TE complications occurred in group 1 and 1 (0.2%) in group 2 (P = .007). In our study population, the presence of dense left atrial smoke did not show any correlation with periprocedural TE events in patients undergoing catheter ablation with uninterrupted anticoagulation. However, significant association was observed with late stroke/TIA, irrespective of CHA2DS2-VASc score.

A male with multiple cardiac masses

SummaryThirty-seven-year-old male presented with cough, dyspnea, significant weight loss (20 kg) and subacute fever for the past 2 months. Physical examination revealed inspiratory and expiratory wheezing bilaterally. A normal S1, S2 and a 3/6 systolic ejection murmur at the left upper parasternal border with respiratory variation were found during cardiac auscultation. Kidney and bone marrow biopsy reported a high-grade B-cell lymphoma. Echocardiography and cardiac CT findings consisted of multiple intracardiac masses affecting the right ventricular (RV) outflow track, RV apex, medial portion of the right atrium and posterior left atrium, as well as mild impairment of the RV systolic function. The masses in the RV outflow track caused partial obstruction (pulmonary valve peak velocity 2.3 m/s) with a RV systolic pressure of 43 mmHg. The infiltrative mass in the interatrial septum extended into both the right and left atrial cavities. The right superior pulmonary vein was occluded. This patient was treated with aggressive chemotherapy and had a good clinical response that resulted in mass size reduction after the first course of chemotherapy. Multimodality imaging techniques such as echocardiography, cardiac CT and PET scan can provide complementary information to better evaluate, stage and manage these patients.