Rheumatic Atrial Fibrillation Research Articles

Reply to Zisis

We thank you Dr Zisis [1] for the comment on our article [2]. We reported a woman with rheumatic heart disease and atrial fibrillation. Computed tomography angiography (CTA) revealed a thrombus in the left atrium, occlusion in the infrarenal aorta and efficient development of collateral circulation of the epigastric arteries. Fig. 2 shows the occlusion suspected to be of embolic origin in the infrarenal aorta because we could not accurately diagnose whether it was aorto-iliac occlusive disease (Leriche syndrome) with significant collateralization or results from cardiac thrombus. However, the development of such a bypassing collateral vascular network obviously indicates it was not an acute aortic occlusion (AAO). The patient did not have a previous peripheral arterial reconstruction and atherosclerotic cardiac disease but suffered from rheumatic heart disease. Severe mitral valve

“A case of mobile giant left atrial thrombus which vascularized with coronary arteries in severe mitral valve stenosis,” published in Cardiovascular Revascularization Medicine 2010;11(2):71–138

We have read with interest the article of Acet et al. [1] published in this journal. We recently had a similar case of a 61-year-oldmale patient with severe rheumatic mitral stenosis and atrial fibrillation. The patient was admitted in our clinic for minimal exertional dyspnea (NYHAClass 3). Clinically, we noted the augmentation of the intensity of the first cardiac sound, complete arrhythmia corresponding with atrial fibrillation on the EKG, and hepatomegaly. The transthoracic echocardiogram revealed a severe rheumatic mitral stenosis with a planimetric area of the mitral orifice of 0.8 cm and the presence of an echogenic pediculated mass of large dimensions (Fig. 1) inside the left atrium. The mass seemed to be attached to the atrial dome and was partially mobile. The left atrium was also dilated. The very severe pulmonary hypertension (140 mmHg) in the presence of the 0.8-cm mitral valve area raises the question about the etiology of pulmonary hypertension: Was it secondary to mitral valve disease? Does it have an essential component or was it caused by an obstructive mechanism created by the atrial mass?

Left Ventricular Lateral Annulus and Left Atrial Free‐Wall Velocity Time Integral Indicate Thromboembolism in Patients with Rheumatic Atrial Fibrillation

Low wall motion and stasis increase the likelihood of clot formation. We hypothesized that tissue Doppler indices of left atrial (LA) motion are reduced in the presence of LA thrombi and may be predictive for clot formation in patients with atrial fibrillation (AF). We did an observational study for 3 years in 118 patients with rheumatic mitral valve disease in chronic AF who had not received anticoagulation, with (Group 1, n = 36) and without (Group 2, n = 82) thromboembolism. Pulsed tissue Doppler systolic velocities and velocity time integrals (VTIs) were measured in all four chambers. A mean LA VTI was calculated. LA strain during ventricular systole was calculated using VTI and distance between two LA locations. Logistic regression analysis showed that, after adjusting for age, gender, diabetes, hypertension, LA size, and left ventricular (LV) ejection fraction, mean LA VTI [Odds ratio (OR) 0.69, 95%CI (0.56-0.86, P = 0.03)] and lateral mitral annulus VTI [OR 0.15 (0.04-0.56, P = 0.03)] were associated with clot formation. The addition of these two parameters to the conventional risk factors increased the ability to predict thromboembolism (Nagelkerke R² = 0.32-0.50, P = 0.01; area under the curve 0.83 by receiver operating characteristic analysis, P = 0.01). LA strain also had potential to indicate clot formation (0.9 ± 13.8 vs. -8.2 ± 15.1%, group 1 vs. 2, respectively, P = 0.01). Patients with chronic AF and thromboembolism have reduced LA and LV motion independently of LA size and LV ejection fraction. Tissue Doppler parameters may have potential to predict clot formation in these patients.

Current Perspectives: Rheumatic Atrial Fibrillation.

Current Perspectives: Rheumatic Atrial Fibrillation.

Current Perspectives: Rheumatic Atrial Fibrillation

Current Perspectives: Rheumatic Atrial Fibrillation

Elevated platelet microparticle levels in valvular atrial fibrillation

Platelet activation occurs in peripheral blood of patients with rheumatic mitral stenosis (MS) and atrial fibrillation (AF) and could be related to abnormal thrombogenesis. However, the plasma level of platelet microparticles (PMPs), a marker of platelet activation, in patients with valvular AF remains unresolved. We performed a case control study of 20 patients with chronic rheumatic MS and chronic long AF and 10 healthy volunteers who were in sinus rhythm. Peripheral plasma levels of PMP were assessed by quantifying CD41-positive microparticles by flow cytometry. The mitral valve area was calculated by means of the Doppler pressure half-time method. The levels of circulating PMP were elevated significantly in valvular AF patients when compared with controls (12·36±5·51 × 105/ml versus 7·56±0·86 × 105/ml, P=0·011). Correlation analysis demonstrated that there was a significantly direct relationship between the severity of MS and PMP levels (r=−0·507, P=0·004). We conclude that in patients with rheumatic MS and AF, there is evidence of platelet activation detected by high PMP levels which have a significantly direct relationship with the severity of MS.

Abstract 5620: Relationship Between Stroke Risk (CHADS 2 Score) and C-reactive Protein in Patients With Non- Rheumatic Atrial Fibrillation

Background- CHADS 2 score is used for the stroke risk stratification in patients with atrial fibrillation (AF). Although C-reactive protein (CRP) has been shown as a possible correlate of left atrial (LA) thrombus formation in patients with non-rheumatic AF (NRAF), the relationship between CHADS 2 score and CRP is unclear. Methods- A total of 165 patients with NRAF (105 male, age 71±10 years) who underwent transesophageal echocardiography (TEE) were enrolled and analyzed. Patients with prosthetic valve, aortic dissection and infectious disease were excluded from this study. The CHADS 2 score was calculated based on a presence or absence of risk factors ( C ongestive heart failure, H ypertension, A ge≥75years, D iabetes mellitus, S troke or transient ischemic attack) as reported previously. Based on the CHADS 2 score, study patients were grouped into low (0 to 1 score), moderate (2 to 3 score) and high (4 to 6 score) risk categories. Results- Patients at low risk had significantly lower CRP levels than those at moderate or high risk (Low: 0.27±0.46 vs. Moderate: 0.40±0.56 vs. High: 0.93±0.85mg/dl, p<0.01). As expected, incidence of LA spontaneous echo contrast and LA thrombus by TEE increased with increasing CHADS 2 score. Conclusion- In patients with NRAF, CHADS 2 score is related to CRP and LA thrombus formation.

Effect of single intraoperative dose of amiodarone in patients with rheumatic valvular heart disease and atrial fibrillation undergoing valve replacement surgery

Maintenance of sinus rhythm (SR) is superior to rate control in atrial fibrillation (AF). In order to achieve SR, we administered single-dose intravenous amiodarone intraoperatively and evaluated its effect on conversion of rheumatic AF to SR in patients undergoing valvular heart surgery. Patients were randomly assigned to amiodarone (n = 42) or control (n = 40) group in a double blind manner. The amiodarone group received amiodarone (3 mg/kg) intravenously prior to the institution of cardiopulmonary bypass and the control group received the same volume of normal saline. In the amiodarone group, the initial rhythm after the release of aortic cross clamp was noted to be AF in 14.3% (n = 6) and remained so in 9.5% (n = 4) of patients till the end of surgery. In the control group, the rhythm soon after the release of aortic cross clamp was AF in 37.5% (n = 15) (p = 0.035) and remained so in 32.5% (n = 13) of patients till the end of surgery (p = 0.01). At the end of first post-operative day 21.4% (n = 9) of patients in amiodarone group and 55% (n = 22) of patients in control group were in AF (p = 0.002). The requirement of cardioversion/defibrillation was 1.5 (+/-0.54) in amiodarone group and 2.26 (+/-0.73) in the control group (p = 0.014), and the energy needed was 22.5 (+/-8.86) joules in the amiodarone group and 40.53 (+/-16.5) in the control group (p = 0.008). A single intraoperative dose of intravenous amiodarone increased the conversion rate of AF to normal sinus rhythm, reduced the need and energy required for cardioversion/defibrillation and reduced the recurrence of AF within one day.

Histologically benign but clinically malignant: an unusual case of recurrent atrial myxoma

Sir, A 59-year-old male was admitted following an episode of chest pain and a ventricular fibrillation (VF) arrest in the community from which he was successfully resuscitated. He had a past medical history of moderate rheumatic mitral stenosis and atrial fibrillation and 12 months previously had uneventfully undergone 6 pulses of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP) chemotherapy for high-grade diffuse B-cell gastric lymphoma. Electrocardiogram (ECG) following restoration of sinus rhythm revealed antero-septal T-wave inversion and Troponin I (TnI) was raised at 4.5 ng/ml indicating acute myocardial infarction (MI). Coronary angiography revealed normal epicardial coronary arteries and echocardiography showed no progression of his mitral stenosis but now demonstrated a left ventricular …

Prognostic Predictors of Sinus Rhythm Control by Amiodarone and Electrical Cardioversion in Patients Undergoing Percutaneous Transluminal Mitral Valvuloplasty for Rheumatic Atrial Fibrillation

Conversion to sinus rhythm (SR) is rarely attempted in patients with rheumatic atrial fibrillation (AF) because the length of AF duration and the dilation of left atrium (LA) make maintenance of SR difficult. In this study, predictors of the successful maintenance of SR with amiodarone and electrical cardioversion in rheumatic AF patients receiving percutaneous transluminal mitral valvuloplasty (PTMV) were identified. This study included 23 consecutive patients undergoing PTMV for rheumatic AF (6 men, 53+/-11 years; AF duration 25 +/-24 months; LA diameter 44+/-6 mm; mitral valve area (MV) 1.1+/-0.2 cm(2)). Electrical cardioversion was required for the successful conversion to SR in all patients regardless of whether they had received amiodarone (400 mg/day) 2 months before PTMV (n=8) or 2 months after (n=15). After cardioversion, all patients received amiodarone 200 mg/day. With a follow-up period of 35+/-8 months, 14 patients (61%) remained in SR. A greater reduction in LA size (-4+/-3 mm vs 1+/-1 mm; p=0.004) and an greater increase in MV area (0.8+/-0.4 cm(2) vs 0.5+/-0.2 cm(2); p=0.01) by PTMV, not AF duration, were found to be the independent predictors for patients with successful maintenance of SR as compared with patients with recurrence of AF. In rheumatic AF patients receiving PTMV, the successful maintenance of SR with amiodarone and electrical cardioversion can be predicted by the degree to which LA size is reduced and MV area is increased.

Fibrilación auricular como factor de riesgo de acontecimientos cerebrovasculares en personas mayores de 65 años: ¿es adecuada la práctica clínica en profilaxis anticoagulante?

To describe the clinical practice in antithrombotic therapy to prevent stroke in older patients with atrial fibrillation (AF). Cross-sectional study. Ourense's area with 95,840 inhabitants over 65 years. Patients over 65 with non rheumatic AF, chronic or paroxistic; 411 cases, 69.6% older than 75 year. Demographic characteristics, personal history, stroke risk, diagnostic characteristics of AF, antithrombotic treatment, and its adequacy. Only 33% high risk patients received oral anticoagulation (OCA) with warfarin at diagnosis. Some features were found to be significant independent risk factors for OCA: age (older than 75 vs 65-74 years; odds ratio =0.32; 95% confidence interval, 0.18-0.59), and prior stroke (odds ratio =2.02; 95% confidence interval, 1.16-3.55). Warfarin prophylactic is insufficiently prescribed, especially in older than 75 years (with high baseline risk of stroke and no counter-indications). There was inadequate prescription in 73.4% cases.

549 Efficiency of candesartan in hypertensives with rheumatic mitral stenosis and atrial fibrillation

549 Efficiency of candesartan in hypertensives with rheumatic mitral stenosis and atrial fibrillation

549 Efficiency of candesartan in hypertensives with rheumatic mitral stenosis and atrial fibrillation

549 Efficiency of candesartan in hypertensives with rheumatic mitral stenosis and atrial fibrillation

Near Patient Monitoring of Anticoagulant Therapy in General Practice

Background and aims: New systems for monitoring anticoagulation in routine clinical practice should be evaluated to inform future service development. The aim of this study was to investigate the workload, patient characteristics and bleeding complications in a nurse run, near patient monitoring service serving a population of 23,368. Methods: Retrospective review of coagulometer and general practice case records. Results: Between 1995 and 2000 workload increased from 154 to 269 consultations per month. Three hundred and forty four patients were followed up during a cumulative period of 664.8 years. The 8 week period prevalence of anticoagulation was 8.6 per thousand patients at the close of the study. The median age at enrolment was 71 years. Eighteen per cent of treatment episodes were started when patients were 80 years or older. The most common indication was non rheumatic atrial fibrillation (NRAF) in 51% of treatment episodes. During the study 49.6% [95% confidence interval (CI) 47.8%–50.6%] of international normalised ratio (INR) tests were within target range and INR was estimated to be within the target range 62% (95% CI 61.8%–62.2%) of the time. INR control varied markedly between individual patients. There were 4 fatal bleeding events (0.6 per hundred patient years) and 14 major bleeding events (2.1/hundred patient years). Conclusion: Demand for anticoagulant therapy with warfarin has increased substantially. Service development is required to ensure that appropriately selected patients have access to adequately resourced monitoring which promotes optimum INR control and a minimum of bleeding complications.

Conversion of rheumatic atrial fibrillation by amiodarone after percutaneous balloon mitral commissurotomy

Amiodarone, used in conjunction with percutaneous balloon mitral commissurotomy, can safely convert rheumatic atrial fibrillation in 38% of patients compared with 0% in those without it. However, whether this treatment exerts long-term benefits on prognosis awaits further investigation.

Embolism from the heart in the young patient: a short review

Embolism from the heart causes about one-fifth of ischemic strokes and transient ischemic attacks. Although a potential embolic source may be found in up to one-third of cases, which are actually caused by other mechanisms, in the young patient more than one source of embolism is less likely. The most-important embolic sources are non-rheumatic and rheumatic atrial fibrillation (AF), infective endocarditis, prosthetic heart valves, recent myocardial infarction, dilated cardiomyopathy, intracardiac tumors, and rheumatic mitral stenosis. Uncomplicated mitral valve prolapse should no longer be considered a cause of embolism from the heart to the brain; an additional disorder (i.e., gross mitral regurgitation, AF, infective endocarditis) must be present to suggest a cardioembolic origin of the stroke.

Rectilinear biphasic rather than monophasic waveforms for transthoracic cardioversion of patients with rheumatic heart disease and longstanding atrial fibrillation after corrective mitral valve procedures

Rectilinear biphasic rather than monophasic waveforms for transthoracic cardioversion of patients with rheumatic heart disease and longstanding atrial fibrillation after corrective mitral valve procedures

Atrial activation during sinus rhythm in patients with rheumatic and non-rheumatic paroxysmal atrial fibrillation. Frequency-domain analysis using signal-averaged electrocardiography.

Using P-wave signal-averaged electrocardiography, we assessed the patterns of atrial electrical activation in patients with idiopathic atrial fibrillation as compared with patterns in patients with atrial fibrillation associated with structural heart disease. Eighty patients with recurrent paroxysmal atrial fibrillation were divided into 3 groups as follows: group I - 40 patients with atrial fibrillation associated with non-rheumatic heart disease; group II - 25 patients with rheumatic atrial fibrillation; and group III - 15 patients with idiopathic atrial fibrillation. All patients underwent P-wave signal-averaged electrocardiography for frequency-domain analysis using spectrotemporal mapping and statistical techniques for detecting and quantifying intraatrial conduction disturbances. We observed an important fragmentation in atrial electrical conduction in 27% of the patients in group I, 64% of the patients in group II, and 67% of the patients in group III (p=0.003). Idiopathic atrial fibrillation has important intraatrial conduction disturbances. These alterations are similar to those observed in individuals with rheumatic atrial fibrillation, suggesting the existence of some degree of structural involvement of the atrial myocardium that cannot be detected with conventional electrocardiography and echocardiography.

Mejoría de la función fibrinolítica tras el tratamiento anticoagulante en la fibrilación auricular reumática crónica

Patients with rheumatic atrial fibrillation are considered at high risk of systemic embolism and require oral anticoagulation. Fibrinolytic function has been little studied. We evaluated fibrinolytic activation markers before starting anticoagulation, at 1 and 6 months following the introduction of oral anticoagulation therapy. We analyzed the relationship with left atrial diameter and mitral area. Tissue plasminogen activator (tPA), its inhibitor (PAI-1), plasmin-antiplasmin complexes (PAP) and D-dimer were measured in 13 patients with rheumatic atrial fibrillation. Basal levels were compared with those found in plasma of 20 healthy subjects matched by sex and age. Transthoracic echocardiography was made. A significant increase for PAI-1 and D-dimer levels were detected in patients with atrial fibrillation group (p < 0.05), with no differences in tPA and PAP concentrations. Significant correlation between left atrial diameter and basal t-PA levels was found. Levels of t-PA, PAI-1 and D-dimer decreased significantly under anticoagulation therapy, whereas PAP levels were significantly increased. Patients with rheumatic atrial fibrillation show a relative hypofibrinolytic state due to elevated PAI-1 levels with no increase in PAP concentration. At six months of anticoagulation therapy, an improvement of fibrinolytic function markers was observed. This is consistent with the prophylactic effect of oral anticoagulants therapy against thromboembolic risk.

Hypofibrinolysis in atrial fibrillation

Background There is a high incidence of systemic embolism in patients with chronic atrial fibrillation. A hypercoagulable state has been demonstrated, but the fibrinolytic system is rarely studied. Methods Plasma levels of modified antithrombin III (ATM), tissue plasminogen activator (TPA), its inhibitor (PAI-1), TPA–PAI-1 complexes and plasmin-antiplasmin complexes (PAP), d -dimer, and fibrinogen were measured in plasma from 36 patients with chronic atrial fibrillation. Fifteen patients had rheumatic mitral stenosis and 21 had nonrheumatic atrial fibrillation. Levels were compared with those found in the plasma of 20 healthy subjects. Transthoracic echocardiographic studies were done. Results Patients with atrial fibrillation had higher plasma levels of ATM, d -dimer, PAI-1, and TPA–PAI-1 complexes than controls ( P < .001). The rheumatic atrial fibrillation group also showed elevated levels of fibrinogen ( P < .05). No significant differences were found in TPA and PAP. There were no differences between rheumatic and nonrheumatic atrial fibrillation. Conclusions Atrial fibrillation shows a hypofibrinolytic state caused by elevated PAI-1 levels with no increase in PAP complex concentration. Elevated plasma d -dimer levels suggest increased intravascular thrombogenesis. This may contribute to increased risk of thrombosis. (Am Heart J 1998;136:956-60.)