Normal Flow Group Research Articles

121. Neonatal outcome after natural course of preterm IUGR fetuses with abnormal umbilical Doppler flow in combination with preeclampsia

Introduction The natural course of preterm IUGR pregnancies with absent or reversed end diastolic flow (AREDF) in the umbilical artery and preeclampsia has not been investigated so far. Objectives Determine neonatal outcome of preterm IUGR pregnancies with AREDF and preeclampsia after expectant obstetric management. Methods Patients were admitted between 2004 and 2014 in the Erasmus Medical Centre with preterm IUGR. Inclusion criteria: singletons, IUGR, 24–32 weeks, birth weight 500–1250 g. Admission was on clinical grounds and/or because of AREDF. Patients were allocated to the AREDF group or the normal end-diastolic flow (NEDF) group. After expectant management, pregnancies were terminated because of fetal distress or for maternal reasons. Short-term primary outcomes: idiopathic respiratory distress syndrome (IRDS), sepsis, bronchopulmonary dysplasia, necrotizing enterocolitis, intraventricular hemorrhage, composite neonatal outcome and perinatal mortality. Long-term primary outcome: cognitive and motor neurodevelopment at two years of age with Bayley III (BSID III). Results 433 women with preterm IUGR were admitted, 184 met the inclusion criteria, 33 were also diagnosed with preeclampsia. AREDF had no adverse effects on perinatal morbidity and mortality. NEDF seemed to increase the risk for IRDS (P = 0.021). Between the two groups, no differences were found on cognitive (P = 0.078) and motor development (P = 0.568). There were no differences in gestational age at delivery. Expectant management had positive effects on sepsis (P = 0.006) and perinatal mortality (P = 0.042). Delivery was postponed between 1 day and 10 weeks. Preeclampsia had no additional adverse effects on the prevalence of perinatal morbidity and mortality (P = 0.402) and cognitive and motor neurodevelopment (P = 0.611 and P = 0.640). Discussion No significant differences in neonatal outcome were found between the AREDF and NEDF group irrespective of co-existing preeclampsia after expectant management. It seems that postponing the delivery reduces perinatal morbidity and mortality. NEDF seemed to increase the risk of IRDS.

Impact of salivary hypofunction on incidence of orofungal infections with use of topical steroids for management of oral lichen planus and xerostomia

The aim of this study was to determine if salivary hypofunction increases the incidence of oral fungal infections (OFIs) after topical steroid use for the management of oral lichen planus (OLP). Patients with a diagnosis of OLP, treated for at least 2 weeks with topical steroids, had baseline salivary flow evaluations completed, and had a follow-up visit within 5 weeks of steroids being prescribed were assessed. Patients were evaluated for clinical signs of fungal infection at follow-up visits. Forty-Seven patients (91% female) met the inclusion criteria, with 21.3% developing an OFI after topical steroid use. Demographic characteristics, type of OLP, steroid used, and antifungal used did not impact the development of an OFI. The mean stimulated salivary flow was significantly lower in the group that developed an OFI compared with the group that did not develop an OFI (8.31 mL/15 min vs 15.4 mL/15 min, respectively; P = 0.0006). A higher incidence of OFIs occurred in the low stimulated flow group versus the normal flow group (39% vs 4%, respectively). Most patients in the OFI group received a preventative antifungal (90%). OFIs increased after steroid treatment in patients with OLP who had low stimulated salivary flows. Antifungals (90%) were not effective in preventing OFIs in patients with OLP who had salivary hypofunction and were treated with topical steroids.

Association between the Syntax Score II and Electrocardiographic Evidence of No-Reflow in Patients with ST Segment Elevation Myocardial Infarction

This study was performed to examine the association between the SYNTAX II score (SS-II) and no-reflow observed on electrocardiography and examine their use in the evaluation of risk of an in-hospital major adverse cardiovascular event (MACE) in patients with ST-segment elevation myocardial infarction (STEMI). A total of 126 consecutive STEMI patients who underwent primary percutaneous coronary intervention (pPCI) were recruited. The SS-II was derived using angiographic and basic patient clinical features. The difference in the sum of Stsegment elevations measured between before the pPCI and the assessment determined approximately 60 minutes after the pPCI was interpreted as the sum of ST-segment resolution (ΣSTR). MACE is a composite endpoint frequently used in cardiovascular research and usually includes endpoints reflecting safety and effectiveness. ΣSTR <50% was defined as incomplete ΣSTR (no-reflow group; n=44), while ΣSTR <50% was defined as complete ΣSTR (normal-flow group, n=82). The SS-II was significantly higher in the no-reflow group (p<0.001). SS-II and no-reflow findings were associated with MACE. Logistic regression analysis demonstrated significant predictive values of SS-II (Odds ratio [OR]: 1.169; 95% confidence interval [CI]: 1.084-1.260; p<0.001) and ΣSTR (OR: 0.764; 95% CI: 0.632-0.924; p=0.006) for in-hospital MACE. SS-II was significantly associated with no-reflow as assessed by electrocardiography. In patients with STEMI, SS-II and no-reflow (incomplete ΣSTR) may be important predictive factors for in-hospital MACE.

Concomitant mitral regurgitation and aortic stenosis: one step further to low-flow preserved ejection fraction aortic stenosis

Patients with severe aortic stenosis (AS) and normal ejection fraction (EF) can paradoxically present low-transaortic flow and worse prognosis. The role of co-existing mitral regurgitation (MR) in determining this haemodynamic inconsistency has never been quantitatively explored. The hypothesis is that MR influences forward stroke volume and characterizes the low-flow AS pattern. Consecutive patients with indexed aortic valve area (AVA) ≤0.6 cm2/m2 and EF > 50% formed the study population. Complete echocardiographic data were collected, and mitral effective regurgitant orifice area (ERO) and regurgitant volume were obtained with proximal isovelocity surface area method. Patients were divided into subgroups according to indexed stroke volume (SV index). Included patients were 273 [age 79 ± 10 years, 53% female, EF 65 ± 7%, indexed AVA 0.47 ± 0.09 cm2/m2, mean transaortic gradient (MG) 32 ± 17 mmHg]. Mitral regurgitation was present in 89 (32%); ERO was 0.12 ± 0.08 cm2 (range 0.02-0.49 cm2). A low-flow state (SV index ≤35 mL/m2) was diagnosed in 41 (15%) patients. The prevalence of MR was higher in with low-flow vs. normal-flow group (56 vs. 28%, P = 0.03). Effective regurgitant orifice was associated to low-flow state univariately (OR: 1.75 [1.59-2.60]; P = 0.004) and after comprehensive adjustment (OR:1.76 [1.12-2.75]; P = 0.01). When MG was forced in the model, ERO remained significant (P < 0.009). On average, there was a 6 mL reduction in forward SV appeared per each 0.1 cm2 of ERO. In patients with severely reduced AVA and preserved EF, MR is a major determinant of the low-flow condition. Furthermore, MR quantification by ERO predicts the presence of reduced flow independently of chamber volumes, systolic function, and transaortic gradient.

Feasibility and utility of portable ultrasound during retrieval of sick preterm infants.

Document the incidence of haemodynamic pathology in critically ill preterm newborns requiring transport. A transport neonatologist performed cardiac and cerebral ultrasound before and after transportation of infants born ≤30weeks gestation. Forty-four newborns were studied in 2008-2015; of them, 21 were transported by road, 19, by helicopter and four, by fixed wing: median birthweight, 1130g (680-1960g) and median gestation, 27weeks (23-30); 30 of 44 were male babies. Antenatal steroid course was complete in two babies. Ultrasound in the referring hospital was at a mean of two hours: 47 minutes (00:15-7:00) of age. Low systemic blood flow was common: 50% had right ventricular output <150mL/kg/min and 23%, a superior vena cava flow <50mL/kg/min. at stabilisation. Cranial US: 10 Grade I IVH, 2 Grade II IVH, 1 Grade IV IVH and 32 normal scans pretransport. After transport, three further Grade I IVH were reported. Mortality was higher in the babies with low systemic blood flow: 4 of 12 (33%) died vs 1 of 31 (6%) in the normal flow group (OR=7.2, 95% CI: 1.1 to 47, p=0.022). Point-of-care ultrasound during the retrieval of preterm infants confirms a high incidence of haemodynamic pathology. The use of ultrasound during transport may provide an opportunity for earlier targeted circulatory support.

Predictors of coronary slow flow in stable coronary artery disease

BackgroundAlthough several studies have shown that endothelial dysfunction and inflammation may play roles in coronary slow flow phenomenon (CSFP), its etiology and pathogenesis still unclear and based on this observation our aim was detection of clinical and laboratory predictors of primary CSFP judged by TIMI frame count in coronary angiography (CA) for stable coronary artery disease patients (SCAD). MethodsCase control study included 120 patients with SCAD who underwent CA. They were classified into two groups: PCSF group and normal coronary flow group. All patients subjected to CBC, platelet count, leucocytic count (total and differential), platelet-to lymphocyte ratio (PLR), neutrophil-to lymphocyte ratio (NLR), uric acid, albumin, Hs.CRP levels and CA with TIMI frame count. ResultsIncidence of diabetic mellitus and smoking were significantly higher in PCSF compared to control (P=0.01), also we found PLR, NLR, uric acid and Hs-CRP levels were significantly higher in PCSF compared to control (P<0.0001). The sensitivity of PLR≥150, NLR≥2, albumin level≤3.5g/dl, uric acid≥6mg/dl and Hs.CRP≥6mg/L for prediction of CSFP were (83.3%, 90.0%, 50.0%, 76.7% and 83.3% respectively) while the specificity were (86.7%, 90.0%, 53.3%, 83.3% and 86.7%) respectively. The multivariate analysis showed NLR≥2 as the only independent predictor of PSCF. ConclusionPCSF was common in smokers and diabetic patients and this phenomenon is associated with high PLR, NLR, Serum uric acid and Hs.CRP. The only independent predictor of CSFP was neutrophil-to lymphocyte ratio (NLR).

Is Left Atrial Function Affected by Coronary Slow Flow? A Two-dimensional Speckle-Tracking Echocardiographic Study.

Background:The coronary slow flow phenomenon (CSFP) is the slow passage of the angiographic contrast agent to the distal portion of the coronary artery in the absence of significant stenosis. We evaluated the left atrial (LA) function in patients with the CSFP using two-dimensional speckle-tracking echocardiography (2DSTE).Methods:The LA function was compared through 2DSTE between 36 patients with the CSFP and 36 participants with a normal coronary flow. The two groups were matched for age, sex, hypertension, diabetes mellitus, and the left ventricular function.Results:There were no statistically significant differences between the CSFP group and the control group regarding longitudinal systolic strain, early and late diastolic strains, and the strain rate of the LA myocardium.Conclusions:The LA function as evaluated with 2DSTE was not different between the CSFP group and the normal coronary flow group when they were matched for age, sex, hypertension, diabetes, and the left ventricular function.

Correlation between epicardial adipose tissue thickness and slow flow of non-obstructive coronary artery

Objective: To investigate the correlation between epicardial adipose thickness and slow flow of non-obstructive coronary artery. Methods: Clinical data of patients with coronary angiography examination evidenced stenosis<50% in our department from May 2014 to May 2015 were retrospectively analyzed.According to the level of TIMI in angiography, patients were divided into slow blood flow group (TIMI Ⅰ-Ⅱ, n=16) and normal blood flow group (TIMI Ⅲ, n=127). All epicardial adipose thickness was determined by echocardiography and data of biochemical data (fibrinogen, whole blood viscosity at high shear rate, erythrocyte aggregation index, platelet count, and platelet aggregation rate) were also analyzed.Multivariate logistic regression analysis was used to identify whether epicardial adipose thickness was a risk factor for the occurrence of slow flow of non-obstructive coronary artery.A linear regression analysis was used to identify the correlation between epicardial adipose thickness and severity of slow flow of non-obstructive coronary artery.Receiver operating characteristic (ROC) curve was used to analyze the predicting value of epicardial adipose thickness on slow flow of non-obstructive coronary artery. Results: The epicardial adipose thickness was significantly thicker in slow blood flow group than in normal blood flow group ((8.18±2.25) mm vs. (4.65±0.88) mm, P<0.01). The plasma fibrinogen concentration((4.17±1.13) g/L vs.(2.29±0.92) g/L, P<0.01), erythrocyte aggregation index (7.88±1.07 vs. 5.46±1.17, P<0.01), platelet count ((274.1±8.6)×109/L vs.(215.3±72.3)×109/L, P<0.01) and platelet aggregation rate ((0.81±0.11)% vs.(0.64±0.12)%, P<0.01) were significantly higher in slow blood flow group than in normal blood flow group.Whole blood viscosity at high shear rate was similar between the two groups ((4.16±0.56) mPa·s vs.(3.88±0.51) mPa·s, P>0.05). Multivariate logistic regression analysis showed that epicardial adipose thickness was a risk factor for slow flow of non-obstructive coronary artery(OR: 6.813, 95%CI 1.130-41.074, P<0.05). Linear regression analysis showed that there was a negative association between epicardial adipose thickness and TIMI level of non-obstructive coronary artery (R=0.802, R2=0.644, B=-0.237, P<0.01). ROC analysis showed that the accuracy of prediction of epicardial adipose thickness on coronary artery slow flow was high(area under the curve was 0.941, 95%CI 0.876-1.000, P<0.01). When the thickness reached 6.1 mm, the prediction index was maximum (0.766), and the sensitivity was 0.813, and the specificity was 0.953. Conclusion: Epicardial adipose thickness is related to slow flow of non-obstructive coronary artery and epicardial adipose thickness can be used as a predictor for slow flow of non-obstructive coronary artery.

Abstract 12861: Assessment of Both Coronary Microvascular Damage and Epicardial Flow Velocity Measurement Immediately After Successful Percutaneous Coronary Intervention Predicts In-Hospital Complications and Survival in ST-Segment Elevation Myocardial Infarction

Background: Quantitative measurement of post-reperfusion epicardial flow velocity by a Doppler guidewire can predict clinical cardiac events in ST-segment elevation myocardial infarction (STEMI). It has also been reported that the coronary flow velocity pattern in patients with microvascular obstruction is characterized by the presence of early systolic retrograde flow and a rapid diastolic deceleration time (DDT). The purpose of this study was to examine the role of assessing both epicardial flow velocity and microvascular damage in the prediction of in-hospital complications and survival after percutaneous coronary intervention (PCI). Methods: Two hundred and fifty-one consecutive patients with first anterior STEMI who underwent successful PCI were subjected to coronary flow measurement with a Doppler guidewire. The coronary flow velocity spectrum provided the following parameters: time-averaged peak velocity (cm/s, APV), systolic peak velocity (cm/s) and DDT (ms). We defined the presence of microvascular obstruction as DDT ≤600 ms and the presence of systolic flow reversal, and slow epicardial flow as resting APV ≤10cm/s. We classified the patients into three categories: without microvascular obstruction (group 1, n=140), with microvascular obstruction and normal epicardial flow (group 2, n= 51, with microvascular obstruction and slow epicardial flow (group 3, n=60). The clinical event rate was compared among the 3 groups. Results: The in-hospital event rates for congestive heart failure (15/140 [11%], 15/51 [29%] and 34/60 [57%], respectively; P &lt; 0.01), left ventricular thrombus (3/140 [2%], 9/51 [18%] and 14/60 [23%], respectively; P &lt; 0.01), and cardiac rupture (0/140 [0%], 5/51 [10%], and 16/60 [27%]; P &lt; 0.01) were highest in group 3 and lowest in group 1. Group 3 was at the highest risk of cardiac death, while group 1 was at the lowest (0/140 [0%], 3/51 [6%], and 12/60 [20%]; P &lt; 0.01). Conclusions: Assessment of both coronary microvascular damage and epicardial flow velocity can accurately predict in-hospital complications and survival in STEMI patients who underwent successful reperfusion of the infarct-related coronary artery, identifying a subset of high risk patients.

Plasma apelin-12 levels may predict in-hospital major adverse cardiac events in ST-elevation myocardial infarction and the relationship between apelin-12 and the neutrophil/lymphocyte ratio in patients undergoing primary coronary intervention.

We aimed to investigate the compliance of plasma apelin-12 levels to show angiographic properties and hospital MACE in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). The association of apelin-12 levels with the N/L ratio on admission was assessed in 170 consecutive patients with primary STEMI undergoing primary PCI. All patient SYNTAX scores and thrombolysis in myocardial infarction (TIMI) flow grades were also assessed. Patients were divided into two groups according to their TIMI flow grade. Patients with a TIMI 0-2 flow and TIMI 3 flow with grade 0/1 myocardial blush grade (MBG) score were defined as the no-reflow group and patients with TIMI grade 3 flow with ⩾2 MBG were considered as the normal flow group. Baseline apelin-12 levels were significantly lower in the no-reflow group than in the normal flow group (3.3±1.81 vs 6.2±1.74, p<0.001). In-hospital events, including death, myocardial infarction (MI) and re-infarction were significantly higher in patients in the no-reflow group than normal flow group (23% vs 7%, p<0.001). Apelin-12 level was negative correlated with the N/L ratio (r= -0.352, p<0.001), Hs-Crp (r=-0.272, p=0.01) and SYNTAX score (r= -0.246, p=0.029). In the multivariate regression analysis, apelin-12, presence of no-reflow and the SYNTAX score were independent predictors of in-hospital MACE (odds ratio [OR] 1.41, 95% confidence interval (CI) [1.27 to 1.67], p=0.001 for apelin-12, OR 1.085, [0.981 to 1.203], p<0.001 for no-reflow and OR 0.201, 95% CI [0.05 to 0.47], p= 0.004 for SYNTAX score). We have shown that lower apelin-12 level on admission is associated with higher SYNTAX scores and no-reflow phenomenon and may be used as a prognostic marker for hospital MACE in patients with STEMI.

Association of endothelial dysfunction and no-reflow during primary percutaneous coronary intervention for ST-elevation myocardial infarction.

Coronary no-reflow during primary percutaneous coronary intervention (PPCI) is a predictor of poorer cardiovascular outcome. Both endothelial dysfunction and no-reflow involves abnormal vascular function and hemostasis. Our aim was to assess the association between endothelial dysfunction and no reflow during primary PCI. Thirty consecutive patients with ST elevation myocardial infarction (STEMI) and normal flow during primary PCI were compared to 19 consecutive patients who had no reflow. All subjects underwent assessment of peripheral endothelial function by reactive hyperemia index (RHI) 48-72h post PCI using the EndoPAT device. Age, sex and hypertension were similar in both groups. Smokers were less likely to have no-reflow. Post PPCI there was less ST segment resolution in the no-reflow group (48%±7 vs. 81%±6; p=0.001). Patients who had no reflow had subsequently lower ejection fraction (39%±10 vs. 47%±10; p=0.015). There was no difference in vascular function (RHI), between the no-reflow and normal flow groups (1.91±0.3 vs. 2.09±0.11; p=0.24). Systemic peripheral endothelial function does not differ between STEMI patients with and without no reflow during primary PCI.

The Importance of Magnesium Values in Patients With STEMI Admitted to the Emergency Department.

The aim of this study is to examine the relationship between initial magnesium (Mg) levels, electrocardiographic no-reflow, and long-term mortality in patients who underwent primary percutaneous coronary intervention (pPCI) due to ST-segment elevation myocardial infarction (STEMI). A total of 111 patients with pPCI participated in the study. Magnesium and high-sensitive C-reactive protein (hs-CRP) were measured. The sum of ST-segment elevation was measured immediately before and 60 minutes after the restoration of coronary flow. The difference between the 2 measurements was taken as the amount of ST-segment resolution and defined as sum of ST-segment resolution (∑STR). The ∑STR <50% was determined as electrocardiographic sign of no-reflow phenomenon. After the patients were discharged, they were followed up for major adverse cardiac events for up to 51 months after discharge. Forty patients in the no-reflow group and 71 patients in the normal-flow group were included in the study. Magnesium value ≤1.87 mg/dL initially measured had 77% sensitivity and 59% specificity in predicting no-reflow on receiver operating characteristic curve analysis. In multivariate analyses, Mg (odds ratio [OR]: 0.01, <95% confidence interval [CI]: 0.01-0.12; P = .004), hs-CRP (OR: 1.06, <95% CI: 1.00-1.14; P = .05), left anterior descending artery lesion (OR: 6.66, <95% CI: 1.45-3.05; P = .01), and reperfusion time (OR: 1.01, <95% CI: 1.00-1.01; P = .03) were still independent predictors of electrocardiographic no-reflow, and only Mg (OR: 0.08, <95% CI: 0.01-1.03; P = .05) was still an independent predictor of long-term mortality. Serum Mg level is an independent predictor of electrocardiographic no-reflow and long-term mortality in patients with STEMI.

Association of thiol disulfide homeostasis with slow coronary flow

Objective The aim of this study was to investigate the role of thiol disulfide homeostasis in the presence of slow coronary flow. Material and methods In this cross-sectional study, a total of 110 patients who admitted to our hospital between March 2014 and December 2015 were included in the study. There were 65 patients in the slow coronary flow, and 45 patients in the normal flow groups. Results We found significant differences between slow coronary flow and the normal flow groups for thiol disulfide homeostasis, and the results of our study indicated that hsCRP, and thiol disulfide ratio were independently associated with slow coronary flow. Conclusion Our study showed that thiol disulfide homeostasis was significantly and independently related to the presence of slow coronary flow.

High urinary flow in women with stress incontinence: corrected flow-age nomogram evaluation after a transobturator tape procedure.

We noninvasively compared urinary flow in both pre- and post-transobturator tape (TOT) procedures in stress urinary incontinence (SUI) patients using previously reported corrected flow-age nomograms in healthy women. This retrospective cohort study included patients who underwent a successful TOT procedure to treat SUI. Non-instrumented uroflowmetry was performed before and 3months after surgery. Corrected maximum flow rate (cQmax) and average flow rate (cQave) were calculated using Qmax/√voided volume (VV) and Qave/√VV respectively. The ratio of corrected flow to age-adjusted corrected flow in healthy women was calculated in each patient. Each parameter was compared against pre-TOT and 3-months post-TOT values. Sixty-two patients were eligible for study inclusion. All urinary flow parameters were significantly higher pre-TOT than at 3months post-TOT. The number of patients with cQmax and cQave over mean flow-age nomogram, compared with healthy women, before the TOT procedure decreased 3months post-TOT; however, in many patients, cQmax and cQave were higher than in the corrected flow-age nomogram post-TOT. No significant difference in the ratio of cQmax to age-adjusted cQmax between pre- and post-TOT in the normal urinary flow group was observed, but significantly decreased in the high urinary flow group 3months after TOT. Urinary flow rates were higher in SUI patients compared with age-matched controls and successful TOT procedures normalized urinary flows in patients with high urinary flow. A simple evaluation of urinary flow using a corrected flow-age nomogram may be clinically useful in SUI patients.

The Relationship between Interleukin-6 Promotor Polymorphisms and Slow Coronary Flow Phenomenon.

Several lines of evidence suggest that slow coronary flow (SCF) phenomenon seems to be an early form of atherosclerosis and low-grade inflammation plays a role in the development of SCF. Interleukin-6 (IL-6) is a pleiotropic cytokine, functions as a mediator of inflammatory response, and has both pro-inflammatory and anti-inflammatory properties. The aim of the present study is to investigate the relationship between IL-6 -634C/G polymorphism and SCF in Han Chinese. 250 subjects who underwent coronary angiography and had normal coronary arteries of varying coronary flow rates without any atherosclerotic lesion were enrolled in this study. 41 patients who had thrombolysis in myocardial infarction frame counts (TFC) above the normal cutoffs were considered to have SCF and 209 subjects within normal limits served as normal coronary flow (NCF) group. The PCR-based restriction fragment length polymorphism (PCR-RFLP) technique was used to assess the genotypes. The distribution of the IL-6 -634C/G genotypes (CC, CG, and GG) was 56.94%, 37.80%, and 5.26% in the NCF subjects, and 36.59%, 48.78%, and 14.63% in the SCF group, respectively (p = 0.0173). The frequency of the G allele in the SCF (39.02%) group was significantly higher than that in the NCF (24.16%) group (p = 0.0054). Compared with the CC genotype, the G allele carriers (CG + GG genotypes) had increased risk of SCF in both unadjusted and adjusted analyses. In SCF patients, the average serum IL-6 levels (pg/mL) in CG + GG genotype (4.78 ± 0.42) were statistically higher than in CC genotype (3.93 ± 0.36) (p = 0.0000). Our data support that IL-6 -634C/G polymorphism is associated with SCF and the G allele has increased risk for SCF in Han Chinese.

Abstract 15589: Relationship Between Left Atrial Volume Index and Left Atrial Appendage Function in Patients With Non-Valvular Atrial Fibrillation and a Cha2ds2-vasc Score of 0-1

Introduction: The management of patients with non-valvular atrial fibrillation (NVAF) and low CHA2DS2-VASc scores remains controversial. Left atrial appendage (LAA) function is a known risk factor for embolisms. Hypothesis: In this study, we aimed to investigate the value of the relationship between transthoracic echocardiography (TTE) parameters and LAA function in low-risk (CHA2DS2-VASc score, 0-1) patients with NVAF. Methods: This retrospective study included 370 consecutive patients with NVAF who underwent both TTE and transesophageal echocardiography (TEE). The LAA emptying flow velocity was assessed using TEE. We established that an LAA emptying flow velocity of &lt;25 cm/s was associated with a high risk of thrombus formation. Results: Of the 370 patients, 146 (40%) had a CHA2DS2-VASc score of 0-1. These patients with low-risk NVAF were further stratified into the low-flow (LAA emptying flow velocity &lt; 25 cm/s, n = 19) and normal-flow (LAA emptying flow velocity ≥ 25 cm/s, n = 127) groups according to LAA function (atrial fibrillation during TEE: n = 63). The age, gender, CHA2DS2-VASc score, and left ventricular ejection fraction did not differ between the two groups. The low-flow group had a significantly greater left atrial volume index (LAVI) than the normal-flow group (51.6 ± 19.8 vs. 32.3 ± 12.1 ml/m2, p &lt; 0.01). A LAVI of 37.8 ml/m2 predicted a LAA emptying flow velocity of &lt;25 cm/s with a sensitivity of 73% and specificity of 83% among patients with low-risk atrial fibrillation (area under the curve, 0.818, p &lt; 0.001, Figure). Conclusions: Approximately 13% of patients with NVAF and CHA2DS2-VASc score of 0-1 had reduced LAA emptying flow velocity as well as left atrial enlargement. The use of LAVI may improve the current embolism risk stratification system among these patients.

Differences in Natural History of Low- and High-Gradient Aortic Stenosis from Nonsevere to Severe Stage of the Disease

The aim of the present study was to assess and compare the disease progression of aortic stenosis (AS) subtypes from nonsevere to severe disease on the basis of measures of gradient and flow. Seventy-seven patients with AS (mean aortic valve area, 1.3±0.3cm(2) at baseline) underwent echocardiographic examination, including two-dimensional speckle-tracking strain measurements. Patients were retrospectively grouped according to mean transvalvular pressure gradient (40mm Hg) into low-gradient (LG/AS) and high-gradient (HG/AS) groups. The LG/AS group was further subdivided into low-flow (LF/LG; i.e., stroke volume index<35mL/m(2)) and normal-flow (NF/LG) groups. For subanalysis, the LF/LG group was split into two groups: "paradoxical" (P-LF/LG; ejection fraction>50%) and "classical" LF/LG (C-LF/LG; ejection fraction<50%). Follow-up echocardiography was performed in patients with severe AS after 3.3±1.7years. Survival status was ascertained after 5.0±2.0years. Coronary artery disease was more frequent in LG/AS than HG/AS patients. Already at baseline, LF/LGpatients showed reduced left ventricular global systolic strain and reduced systemic arterial compliancecompared with HG/AS patients (HG/AS, 1.0±0.4 mL · mm Hg-(1) · m(-2); NF/LG, 0.9±0.2 mL·mm Hg-(1) · m(-2); LF/LG, 0.6±0.2 mL · mm Hg(-1) · m(-2); P<.001). The initially elevated valvuloarterial impedance increased significantly more in LG/AS than in the other groups (HG/AS, 2.2±0.9 mm Hg · mL-(1) · m(-2); NF/LG, 2.2±0.5 mm Hg · mL-(1) · m(-2); LF/LG, 3.2±0.8 mm Hg · mL(-1) · m-(2); P<.001), while aortic valve area decreased by 42% in HG/AS versus 34% in NF/LG and 32% in LF/LG (P<.001). At follow-up, global systolic strain was significantly reduced in C-LF/LG (7.7±2.5 vs 13.5±2.9 in P-LF/LG, P<.001). In P-LF/LG, mitral E/E' ratio increased significantly from 8.9±4.0 to 26.4±9.2 (P<.05). In patients with AS with high-gradient physiology, the valve constitutes the primary problem. By contrast, low-gradient AS is a systemic disease with valvular, vascular, and myocardial components, resulting in a slower progression of transvalvular gradient, but worse clinical outcome. In C-LF/LG, impaired systolic function leads to an LG flow pattern, whereas the pathophysiology in P-LF/LG is predominantly a diastolic dysfunction.

Evaluation of clinical and angiographic characteristics of no reflow phenomenon after emergency PCI in AMI patients

Objective To investigate the clinical and angiographic characteristics of no reflow phenomenon after primary percutaneous coronary intervention (PCI) with acute myocardial infarction (AMI). Methods A total of 319 patients with AMI undergoing primary-PCI was divided into no-reflow and normal reflow groups. The incidence of no-reflow phenomenon, the clinical date, angiography findings, and surgical date were compared between two groups. Results No-reflow phenomenon occurred in forty(13.4%)of the patients after primary PCI. There was dramatic difference in combined hyperlipidemia, angina pectoris history before AMI, heart function ≥2 grades on admission, the length of the vascular lesions, vascular stenosis degree, blood clot load level, coronary artery opening time, and the expansion of the balloon between no-reflow and normal blood flow groups. Multiple logistic regression analysis identified that angina pectoris history before AMI, heart function classification on admission, high thrombus burden, the expansion of the balloon, and coronary artery opening time on angiography as independent predictors of no-reflow phenomenon. Conclusions The occurrence of no-reflow phenomenon after primary PCI was associated with high cholesterol history, no history of pre-infarction angina, heart function classification on admission, long vascular lesions, narrow degree of heavy, blood clots in the high load, coronary artery opened long time, and the expansion of the balloon more frequently. Key words: Myocardial infarction/TH/PP; Angioplasty, transluminal, percutaneous coronary

Impact of Classic and Paradoxical Low Flow on Survival After Aortic Valve Replacement for Severe Aortic Stenosis

BackgroundLow flow (LF) can occur with reduced (classic) or preserved (paradoxical) left ventricular ejection fraction (LVEF). ObjectivesThe objective of this study was to compare outcomes of patients with low ejection fraction (LEF), paradoxical low flow (PLF), and normal flow (NF) after aortic valve replacement (AVR). MethodsWe examined 1,154 patients with severe aortic stenosis (AS) who underwent AVR with or without coronary artery bypass grafting. ResultsAmong these patients, 206 (18%) had LEF as defined by LVEF of <50%; 319 (28%) had PLF as defined by LVEF of ≥50% but stroke volume indexed to body surface area (SVi) of ≤35 ml ∙ m−2; and 629 (54%) had NF, as defined by LVEF of ≥50% and SVi of >35 ml ∙ m2. Aortic valve area was lower in low flow/LVEF groups (LEF: 0.71 ± 0.20 cm2 and PLF: 0.65 ± 0.23 cm2 vs. NF: 0.77 ± 0.18 cm2; p < 0.001). The 30-day mortality was higher (p < 0.001) in LEF and PLF groups than in the NF group (6.3% and 6.3% vs. 1.8%, respectively). SVi and PLF group were independent predictors of operative mortality (odds ratio [OR]: 1.18, p < 0.05; and OR: 2.97, p = 0.004; respectively). At 5 years after AVR, overall survival was 72 ± 4% in LEF group, 81 ± 2% in PLF group, and 85 ± 2% in NF group (p < 0.0001). ConclusionsPatients with LEF or PLF AS have a higher operative risk, but pre-operative risk score accounted only for LEF and lower LVEF. Patients with LEF had the worst survival outcome, whereas patients with PLF and normal flow had similar survival rates after AVR. As a major predictor of perioperative mortality, SVi should be integrated in AS patients’ pre-operative evaluation.

Abstract 14897: Gender Differences and Flow Category Effects on Left Ventricular Remodelling in Patients With Severe Aortic Stenosis and Preserved Left Ventricular Ejection Fraction

Introduction: Gender differences in the pattern of adaptive left ventricular (LV) hypertrophy to pressure overload from aortic stenosis (AS) has previously been identified. Differential effects in low versus normal-flow AS have not been investigated. We aim to examine effect of gender on LV remodeling in patients with low flow (LF) compared with normal flow (NF) AS. Methods: We studied 486 patients over a 12-year period with severe AS (valve area &lt;1cm2) and preserved left ventricular ejection fraction (LVEF ≥50%). They were divided into LF (stroke volume index &lt;35 ml/m2) and NF. Parameters were compared between genders. Results: There were 287 (59%) females, 93 (32%) were LF. In both genders, LV was smaller with lower mass index and higher relative wall thickness in the LF group. In the NF group, although aortic valve area index (AVAI) was larger in the females, mean gradient, peak velocity, degree of LV hypertrophy and LVEF were similar between the genders. LV volumes and LA dimensions were significantly smaller and larger in females respectively. Conversely in the LF group, all parameters indicate consistently more severe AS in males (Table). LVEF was lower and LV mass indexed to body surface area was higher in males (Table). The gender differences of end diastolic LV volume and LA dimension were similar between the categories. Valvuloarterial impedance was elevated and systemic compliance was reduced in the LF group in both genders compared to the NF group (Table). Conclusions: In patients with severe AS and preserved LVEF, LV appears smaller with lower mass and higher remodeling in LF compared to NF. Greater gender disparity in LV remodeling is documented in LF. Further studies on the prognostic significance are warranted.