Transesophageal Echocardiography Parameters Research Articles

Island Flap Rotation Technique as a Novel Repair Surgery Method for Severe Degenerative Mitral Valve Regurgitation

Background: The current study was done to assess the efficacy and safety of the island flap rotation technique as a novel method for severe mitral valve regurgitation. Methods: Twenty-three patients were selected to undergo mitral valve repair with the island flap rotational technique. It takes the principle of doing quadrangular resection of the P2 leaflet and flipping the dissected area so that the ruptured primary chordae are replaced with the secondary or tertiary chordae. Transesophageal echocardiography parameters were evaluated before surgery and 1 week after surgery, just prior to discharge. Results: The procedure was done successfully with 100% mitral regurgitation reduction to ≤1+ along with significantly reduced left ventricular end-diastolic diameter (p = 0.001) and left atrial dimension (p = 0.000). The left ventricular ejection fraction was significantly reduced after the procedure (p = 0.000). Older age significantly affects the presence of residual mitral regurgitation (p = 0.02). No thromboembolic adverse events and mortality were observed during the 3-month follow-up. Conclusions: The use of island flap rotation technique as a novel method for severe mitral regurgitation with P2 lesions has been proven to be effective and safe with preserving the valve tissue.

Island Flap Rotation Technique as a Novel Repair Surgery Method for Severe Degenerative Mitral Valve Regurgitation

Background: The current study was done to assess the efficacy and safety of the island flap rotation technique as a novel method for severe mitral valve regurgitation. Methods: Twenty-three patients were selected to undergo mitral valve repair with the island flap rotational technique. It takes the principle of doing quadrangular resection of the P2 leaflet and flipping the dissected area so that the ruptured primary chordae are replaced with the secondary or tertiary chordae. Transesophageal echocardiography parameters were evaluated before surgery and 1 week after surgery, just prior to discharge. Results: The procedure was done successfully with 100% mitral regurgitation reduction to ≤1+ along with significantly reduced left ventricular end-diastolic diameter (p = 0.001) and left atrial dimension (p = 0.000). The left ventricular ejection fraction was significantly reduced after the procedure (p = 0.000). Older age significantly affects the presence of residual mitral regurgitation (p = 0.02). No thromboembolic adverse events and mortality were observed during the 3-month follow-up. Conclusions: The use of island flap rotation technique as a novel method for severe mitral regurgitation with P2 lesions has been proven to be effective and safe with preserving the valve tissue.

Comparative Assessment of Percutaneous Left-Atrial Appendage Occlusion (LAAO) Devices-A Single Center Cohort Study.

Percutaneous left-atrial appendage closure (LAAC) is an established method for preventing strokes in patients with atrial fibrillation, offering an alternative to oral anticoagulation. Various occluder devices have been developed to cater to individual anatomical needs and ensure a safe and effective procedure. In this retrospective, monocentric cohort study, we compare different LAAO devices with respect to clinical outcomes, LAA sealing properties, and device-related complications. We conducted a retrospective analysis of 270 patients who underwent percutaneous LAA closure in our center between 2009 and 2023. Patient data were extracted from medical records, including gender, age at implantation, indication, device type and size, laboratory values, LAA anatomy, periprocedural complications, ECG parameters, transthoracic and transesophageal echocardiography parameters (TTE and TEE), as well as medication at discharge. Moreover, fluoroscopy time and implantation duration, as well as post-implantation clinical events up to 1 year, were collected. Endpoints were bleeding events, recurrent stroke, thrombi on devices, and death. The implanted devices were the Watchman 2.5, Watchman FLX, Amplatzer Cardiac Plug (ACP), and Amulet. The procedural success rate was 95.7% (n = 265), with cactus anatomy posing the most challenges across all devices. The mean patient age was 75.5 ± 7.7 years, with 64.5% being male. The median CHA2DS2-VASc score was 4.8 ± 1.5 and the median HAS-BLED score was 3.8 ± 1.0. Indications for LAA closure included past bleeding events and elevated bleeding risk. Periprocedural complications were most commonly bleeding at the puncture site, particularly after ACP implantation (p = 0.014). Significant peridevice leaks (PDL) were observed in 21.4% of simple sealing mechanism devices versus 0% in double sealing mechanism devices (p = 0.004). Thrombi were detected on devices in six patients, with no subsequent ischemic stroke or thromboembolic event. Comparative analysis revealed no significant differences in the occurrence of stroke, transient ischemic attack (TIA), thromboembolic events, device-related thrombi, or mortality among different device types. A 62.3% relative risk reduction in thromboembolic events and 38.6% in major bleedings could be observed over 568.2 patient years. In summary, our study highlights the efficacy and safety of LAA closure using various occluder devices despite anatomical challenges. Our long-term follow-up findings support LAA closure as a promising option for stroke prevention in selected patient cohorts. Further research is needed to refine patient selection criteria and optimize outcomes in LAA closure procedures.

Outcomes of Patent Foramen Ovale Transcatheter Closure: Should a Short Aortic Rim Preclude Closure?

BackgroundThe risk of erosion of an atrial septal closure device, in particular the Amplatzer Septal Occluder, has been described as higher in patients with a short aortic rim. Similar concern has been applied to patent foramen ovale (PFO) closure devices, but there are only rare reported cases of erosion. It may be that smaller devices are chosen due to fear of device erosion in PFO patients when this is not necessarily an issue. ObjectivesThe authors aimed to assess outcomes after PFO closure with the Amplatzer PFO device in patients with a short (<9 mm) aortic rim. MethodsWe performed a retrospective analysis of PFO closure for any indication, between 2006 and 2017 at a quaternary center. Preprocedural transesophageal echocardiographic parameters including the aortic rim were remeasured. Long-term outcomes were obtained by linkage to provincial administrative databases. ResultsOver the study period, 324 patients underwent PFO closure with the Amplatzer PFO device, with a mean age of 49.8 years; 61% had a short aortic rim (<9 mm). The most common indication was cryptogenic stroke (72%); those with longer aortic distance were more likely to have a non-stroke indication for closure, diabetes (15% vs 6.5%, P = 0.04), and heart failure (15.7% vs 4%, P < 0.001). Over a median 7 years of follow-up, there were no cases of device erosion or embolization requiring cardiac surgery. ConclusionsIn a large cohort with long-term administrative follow-up (1,394 patient-years), implantation of an Amplatzer PFO device was performed safely even in patients with a short aortic rim.

Utility of 3D Echocardiography for Device Sizing During Transcatheter ASD Closure: A Comparative Study.

Two-dimensional (2D) transesophageal echocardiography (TEE) is commonly used for assessing patients undergoing transcatheter atrial septal defect (ASD) device closure. 3D TEE, albeit providing high resolution en-face images of ASD, is used in only a fraction of cases. We aimed to perform a comparative analysis between 3D and 2D TEE assessment for ASD device planning. This was a prospective, observational study conducted over a period of one year. Patients deemed suitable for device closure underwent 2D and 3D TEE at baseline. Defect characteristics, assessed separately in both modalities, were compared. Using regression analysis, we aimed to derive an equation for predicting device size using 3D TEE parameters. Thirty patients were included in the study, majority being females (83%). The mean age of the study population was 40.5 ± 12.05 years. Chest pain, dyspnea and palpitations were the common presenting complaints. All patients had suitable rims on 2D TEE. A good agreement was noted between 2D and 3D TEE for measured ASD diameters. 3D TEE showed that majority of defects were circular in shape (60%). The final device size used had high degree of correlation with 3D defect area and circumference. An equation was devised to predict device size using 3D defect area and circumference. The mean device size obtained from the equation was similar to the actual device size used in the study population (p = 0.31). Device sizing based on 3D TEE parameters alone is equally effective for transcatheter ASD closure as compared to 2D TEE.

Heart failure and the risk of left atrial thrombus formation in patients with atrial fibrillation and atrial flutter: insights from the LATTEE registry

Abstract Background The aim of the study was to evaluate the prevalence of left atrial thrombus (LAT) on transesophageal echocardiography (TEE) in patients with atrial fibrillation and atrial flutter (AF/AFl) with reference to the presence of heart failure (HF) and its subtypes. Methods The research is a substudy of multicenter, prospective, observational Left Atrial Thrombus on Transesopahgeal Echocardiography (LATTEE) registry, which comprised 3109 consecutive patients with AF/AFl undergoing TEE prior to direct current cardioversion or catheter ablation. TEE parameters, including presence of LAT, were compared between patients with and without HF, as well as different subtypes of HF, including HF with preserved (HFpEF), mid-range (HFmrEF) and reduced ejection fraction (HFrEF). Results HF was diagnosed in 1336 patients (43%). HF patients had higher prevalence of LAT than non-HF patients (12.8% vs. 4.4%, P&amp;lt;0.001). The rate of LAT increased with the more advanced type of systolic dysfunction (HFrEF vs. HFmrEF vs. HFpEF: 20.3% vs. 10.5% vs. 7.4%, P&amp;lt;0.001; Figure 1). Univariate analysis revealed that HFrEF (OR 4.13, 95% CI: 3.13–5.46) but not HFmrEF or HFpEF predicted the presence of LAT. Multivariable logistic regression indicated that left ventricular ejection fraction (unit OR=0.94 per 1%, 95% CI: 0.93–0.95) was an independent predictor of LAT formation. Receiver operator characteristic analysis showed LVEF ≤48% predicted presence of LAT (AUC=0.74, P&amp;lt;0.0001). Conclusion The diagnosis of HFrEF, but not HFpEF, confers a considerable risk of LAT presence despite widespread utilization of adequate anticoagulation in the assessed population. TEE should be considered in these patients prior to cardioversion or catheter ablation despite adequate oral anticoagulation. Funding Acknowledgement Type of funding sources: None.

Selected Transesophageal Echocardiographic Parameters of Left Ventricular Diastolic Function Predict Length of Stay Following Coronary Artery Bypass Graft-A Prospective Observational Study.

(1) Importance: Abnormal left ventricular (LV) diastolic function, with or without a diagnosis of heart failure, is a common finding that can be easily diagnosed by intra-operative transesophageal echocardiography (TEE). The association of diastolic function with duration of hospital stay after coronary artery bypass (CAB) is unknown. (2) Objective: To determine if selected TEE parameters of diastolic dysfunction are associated with length of hospital stay after coronary artery bypass surgery (CAB). (3) Design: Prospective observational study. (4) Setting: A single tertiary academic medical center. (5) Participants: Patients with normal systolic function undergoing isolated CAB from September 2017 through June 2018. (6) Exposures: LV function during diastole, as assessed by intra-operative TEE prior to coronary revascularization. (7) Main Outcomes and Measures: The primary outcome was duration of postoperative hospital stay. Secondary intermediate outcomes included common postoperative cardiac, respiratory, and renal complications. (8) Results: The study included 176 participants (mean age 65.2 ± 9.2 years, 73% male); 105 (60.2%) had LV diastolic dysfunction based on selected TEE parameters. Median time to hospital discharge was significantly longer for subjects with selected parameters of diastolic dysfunction (9.1/IQR 6.6–13.5 days) than those with normal LV diastolic function (6.5/IAR 5.3–9.7 days) (p < 0.001). The probability of hospital discharge was 34% lower (HR 0.66/95% CI 0.47–0.93) for subjects with diastolic dysfunction based on selected TEE parameters, independent of potential confounders, including a baseline diagnosis of heart failure. There was a dose–response relation between severity of diastolic dysfunction and probability of discharge. LV diastolic dysfunction based on those selected TEE parameters was also associated with postoperative cardio-respiratory complications; however, these complications did not fully account for the relation between LV diastolic dysfunction and prolonged length of hospital stay. (9) Conclusions and Relevance: In patients with normal systolic function undergoing CAB, diastolic dysfunction based on selected TEE parameters is associated with prolonged duration of postoperative hospital stay. This association cannot be explained by baseline comorbidities or common post-operative complications. The diagnosis of diastolic dysfunction can be made by TEE.

Interobserver Variation in Echocardiographic Measurements and Grading of Tricuspid Regurgitation Based on a Novel Web-Based Assessment Environment

The primary aim of this study was to assess interobserver variability in grading tricuspid regurgitation (TR) severity. The authors' secondary goals were to delineate which transesophageal echocardiographic (TEE) parameters best correlate with severity and how consistent the participants were at grading severity. This was a prospective cohort study of how clinicians evaluated previously acquired TEE images and videos. The 19 TEE studies of patients with TR were recorded by 4 senior echocardiographers across 4 US academic institutions. The participants evaluated these cases on a novel, web-based, assessment environment designed specifically for this study. Twenty-nine fellowship-trained and board-certified cardiologists and cardiothoracic anesthesiologists volunteered to participate in the study as observers from 19 different institutions. No interventions were performed on the participants. For each case, participants measured the vena contracta (VC), proximal isovelocity surface area (PISA), and jet area before giving a final classification on the severity of TR. Variation was highest for effective regurgitant orifice area and lowest for VC and PISA. The coefficient of variation, defined as the standard deviation from the mean divided by the mean, for all cases of trace, mild, moderate and severe TR were as follows: Jet Area-111%, 46%, 48%, 76%; VC-67%, 44%, 43%, 36%; PISA-52%, 48%, 31%, 35%; and effective regurgitant orifice area-127%, 95%, 66%, 58%. The interobserver variation in quantifying TEE parameters for TR is high, suggesting these may be difficult to measure reliably in a busy perioperative setting. Of the parameters assessed, VC and PISA radius had the highest interobserver agreement and the highest correlation with severity.

Prognostic Value of Preoperative Echocardiographic Findings in Patients Undergoing Transvenous Lead Extraction.

(1) Background: In patients referred for transvenous lead extraction (TLE) transesophageal echocardiography (TEE) often reveals abnormalities related to chronically indwelling endocardial leads. The purpose of this study was to determine whether the results of pre-operative TEE might influence the long-term prognosis. (2) Methods: We analyzed data from 936 TEE examinations performed at a high volume center in patients referred for TLE from 2015 to 2019. The follow-up was 566.2 ± 224.5 days. (3) Results: Multivariate analysis of TEE parameters showed that vegetations (HR = 2.631 [1.738–3.983]; p < 0.001) and tricuspid valve (TV) dysfunction unrelated to the endocardial lead (HR = 1.481 [1.261–1.740]; p < 0.001) were associated with increased risk for long-term mortality. Presence of fibrous tissue binding sites between the lead and the superior vena cava (SVC) and/or right atrium (RA) wall (HR = 0.285; p = 0.035), presence of penetration or perforation of the lead through the cardiac wall up to the epicardium (HR = 0.496; p = 0.035) and presence of excessive lead loops (HR = 0.528; p = 0.026) showed a better prognosis. After adjustment the statistical model with recognized poor prognosis factors only vegetations were confirmed as a risk factor (HR = 2.613; p = 0.039). A better prognosis was observed in patients with fibrous tissue binding sites between the lead and the superior vena cava (SVC) and/or right atrium (RA) wall (HR = 0.270; p = 0.040). (4) Conclusions: Non-modifiable factors may have a negative influence on long-term survival after TLE. Various forms of connective tissue overgrowth and abnormal course of the leads modifiable by TLE can be a factor of better prognosis after TLE.

Utility of Three-Dimensional Transesophageal Echocardiography for Mitral Annular Sizing in Transcatheter Mitral Valve Replacement Procedures: A Cardiac Computed Tomographic Comparative Study

Three-dimensional (3D) transesophageal echocardiographic (TEE) imaging is frequently used as an initial screening tool in the evaluation of patients who are candidates for transcatheter mitral valve replacement (TMVR). However, little is known about the imaging correlation with the gold standard, computed tomographic (CT) imaging. The aims of this study were to test the quantitative differences between these two modalities and to determine the best 3D TEE parameters for TMVR screening. Fifty-seven patients referred to the heart valve clinic for TMVR with prostheses specifically designed for the mitral valve were included. Mitral annular (MA) analyses were performed using commercially available software on 3D TEE and CT imaging. Three-dimensional TEE imaging was feasible in 52 patients (91%). Although 3D TEE measurements were slightly lower than those obtained on CT imaging, measurements of both projected MA area and perimeter showed excellent correlations, with small differences between the two modalities (r=0.88 and r=0.92, respectively, P<.0001). Correlations were significant but lower for MA diameters (r=0.68-0.72, P<.0001) and mitroaortic angle (r=0.53, P=.0001). Receiver operating characteristic curve analyses showed that 3D TEE imaging had a good ability to predict TMVR screening success, defined by constructors on the basis of CT measurements, with ranges of 12.9 to 15cm2 for MA area (area under the curve [AUC]=0.88-0.91, P<.0001), 128 to 139mm for MA perimeter (AUC=0.85-0.91, P<.0001), 35 to 39mm for anteroposterior diameter (AUC=0.79-0.84, P<.0001), and 37 to 42mm for posteromedial-anterolateral diameter (AUC=0.81-0.89, P<.0001). Three-dimensional TEE measurements of MA dimensions display strong correlations with CT measurements in patients undergoing TMVR screening. Three-dimensional TEE imaging should be proposed as a reasonable alternative to CT imaging in this vulnerable population.

A new risk model of assessing left atrial appendage thrombus in patients with atrial fibrillation – Using multiple clinical and transesophageal echocardiography parameters

BackgroundsPredicting left atrial appendage thrombus (LAAT) in non-valvular atrial fibrillation (NVAF) patients need more precisely quantified risk models. In this study, we attempted to review the risk markers for LAAT and develop a simple and reliable model for LAAT prediction. MethodsThe study included 307 patients with NVAF who were scheduled for transesophageal echocardiography (TEE) to exclude LAA thrombus before synchronized electrical cardioversion or radiofrequency ablation for atrial fibrillation (AF). We analyzed the relationship between echo, clinical parameters and the presence or absence of LAAT. ResultsA total of 33 patients were found having LAAT (10.7%, 33/307). The age, left atrial appendage emptying velocity (LAAEV), left atrial or left atrial appendage spontaneous echocardiographic contrast (SEC), less than moderate to severe mitral regurgitation (≤mild MR), and left atrial enlargement showed association with LAAT. The multivariate logistic regression analysis revealed that LAAEV, SEC and ≤mild MR were independent risk factors of the LAAT. We used LAAEV ≤ 21.5 cm/s, SEC and ≤mild MR to construct a combined predictive model for LAAT in NVAF patients (the area under receiver operator characteristic curve: 0.88; 95% confidence interval: 0.82–0.95, P < 0.0001). ConclusionComprehensive evaluation of LAAEV, SEC, and MR with associated LAAT may help risk stratifying the NVAF patients, especially if the LAA imaging quality was suboptimal for identifying thrombus. These parameters may facilitate the decision-making process at the time of TEE.

514 Post-burn Malnutrition and Associated Cardiomyopathy

Abstract Introduction It is known that systolic dysfunction (dilated cardiomyopathy) may occur in a high percentage of patients with large TBSA burns. The reversible myocardial depression may be due to many factors: thermal injury, sepsis, severe malnutrition. Malnutrition and delayed wound healing may occur with a combination of primary and secondary protein-energy undernutrition. Methods Serial transthoracic and transesophageal echocardiographic parameters were measured during perioperative care (ejection fraction, fractional shortening, pericardial fluid) in 8 patients with evidence of malnutrition (low BMI, low albumin and prealbumin, muscle wasting) and a delayed presentation to the hospital. Initial echocardiography was performed post-injury day 30 -142; follow-up exams were performed in some patients at 2 years post-injury. Acutely-injured patients or those with sepsis were excluded. Results From 2015–2017, echocardiographic measurements were obtained in 8 patients, ages 7–21. The presenting TBSA ranged from 30–82% and included flame injury, electrical burns, and 1 case of pemphigus vulgaris. The initial ejection fraction ranged from 12–45% in patients with a BMI range of 10–25. The mean initial albumin was 2g/dL; the mean prealbumin was 9.5mg/dL. Two patients had mild to moderate pericardial effusions, which resolved after 1 month of proper nutrition. Selenium deficiency was noted in 1 patient. Four patients required perioperative short-term dobutamine. Conclusions Patients presenting with malnutrition and impaired wound healing all had evidence of cardiomyopathy; however, the degrees of systolic dysfunction varied significantly. BMI, albumin, and prealbumin all had a strong correlation with the degree of myocardial depression. Despite the lower ejection fractions, many patients maintained an adequate cardiac index and did not require inotropic medications. With time and adequate nutrition, cardiac function improved, although many remained with mild dysfunction in the first year. Applicability of Research to Practice This case series demonstrates the continued need for early recognition of malnutrition and cardiomyopathy in this patient population and the need for early intervention. Echocardiographic diagnosis may improve acute perioperative care. In addition, future studies are needed to determine the chronic cardiac effects of reversible dilated cardiomyopathy. Nutrition, refeeding, and perioperative management require a multidisciplinary team.

Can echocardiography improve the prediction of thromboembolic risk in atrial fibrillation? Evidences and perspectives

Atrial fibrillation is the most common arrhythmia and its prevalence is expected to further increase. Patients with atrial fibrillation have an increased risk of stroke (fivefold increased risk), heart failure, and death. In patients with non-valvular atrial fibrillation, the most recent guidelines recommend the use of the CHA2DS2-VASc (congestive heart failure, arterial hypertension, age > 75years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65-74years, sex category) scoring system to identify those who may benefit from oral anticoagulant treatment. Guidelines recommend initiation of oral anticoagulation with vitamin K antagonists or direct oral anticoagulants in men with a score ≥ 2 and in women with a score ≥ 3, while oral anticoagulation in individuals with a score of 0 is not recommended. Accordingly, men with CHA2DS2VASc score = 1 (and women with CHA2DS2VASc = 2) represent a grey zone where guidelines do not provide a definite oral anticoagulant indication. Implementation of risk stratification with transthoracic echocardiography could be extremely useful. Both prospective and observational studies using transthoracic echocardiography prediction of events and studies utilizing transesophageal echocardiographic parameters as surrogate markers of thromboembolic events make sustainable the hypothesis that echocardiography could improve thromboembolism prediction in non-valvular atrial fibrillation. However, because of some controversial results of different studies, determination of the best echocardiographic parameter predicting thromboembolic events in atrial fibrillation remains uncertain. The combination of left atrial enlargement with left atrial function (in particular assessing left atrial strain) appears to be very valuable, but needs to be confirmed in large-scale multi-center trials.

The value of left atrial structural and functional parameters combined with cardiac biomarkers in predicting left atrial spontaneous echo contrast in patients with non-valvular atrial fibrillation

Objective To investigate the relationships between the structure, function of left atrial as well as cardiac biomarkers and left atrial spontaneous echo contrast (SEC) in patients with non-valvular atrial fibrillation (NVAF), and evaluate its predictive value for left atrial SEC. Methods Thirty-four control subjects and 80 patients with NVAF were included, patients with NVAF were divided into positive group (30 cases) and negative group (50 cases) according to whether SEC was presented on transesophageal echocardiography (TEE). Clinical and laboratory data were collected, including medical history, cardiac troponin I (cTnI), and pro-brain natriuretic peptide (pro-BNP), etc. Then CHA2DS2-VASc scores were calculated.The left atrial appendage width (WLAA), left atrial appendage depth (DLAA), left atrial appendage blood flow velocity (VLAA), left atrial volume index (LAVI) and other parameters were measured by TEE and transthoracic echocardiography (TTE), and left atrial ejection fraction (LAEF) was calculated. The clinical and TEE parameters were compared between the positive and negative group, TTE parameters and cardiac biomarkers levels were compared among the three groups, and ROC curve was used to evaluate the diagnostic efficiency. Results ①Compared with those in control group, the value of LAVI and pro-BNP were significantly increased and LAEF was significantly decreased in negative group (all P 0.05), but presented a significant increase in positive group compared with those in control group and negative group (all P<0.01). The AUC, sensitivity and specificity of CHA2DS2-VASc scores for SEC were 0.71 (95% CI: 0.60~0.82), 73.3% and 62.0%, respectively. When left atrial structural and functional parameters (LAVI and LAEF) combined with cardiac biomarkers (cTnI and pro-BNP), the AUC, sensitivity and specificity for SEC were 0.90 (95%CI: 0.84~0.97), 74.0% and 100%, respectively, both enhanced when compared with CHA2DS2-VASc scores alone(P<0.01). Conclusions Left atrial enlargement, decreased function and elevated levels of cardiac biomarkers are associated with left atrial SEC in patients with NVAF.CHA2DS2-VASc scores can be used for perdicting left atrial SEC, left atrial structural and functional parameters (LAVI and LAEF) combined with cardiac biomarkers (cTnI and pro-BNP) provide significant increments in prediction of left atrial SEC. Key words: Echocardiography, transesophageal; Atrial fibrillation; Atrial function, left; Spontaneous echo contrast; Cardiac biomarker

THE INCREMENTAL ROLE OF IMAGING IN THROMBOEMBOLIC RISK ASSESSMENT FOR PATIENTS WITH ATRIAL FIBRILLATION

Background: The CHA2DS2-VASc score is the standard of care in thromboembolic risk assessment for patients with non-valvular atrial fibrillation (AF). Most patients will undergo transthoracic echocardiography (TTE) for further evaluation, and many also having transesophageal echocardiography (TEE) performed prior to cardioversion or ablation. We sought to evaluate the relationship between left atrial (LA) abnormalities detected on TEE and TTE parameters, to determine if imaging may be additive in risk assessment.Methods: Clinical, TEE and TTE data for patients in AF at the time of their study were included in this retrospective analysis. LA/LA appendage (LAA) abnormalities on TEE included the presence of spontaneous echo contrast, sludge, thrombus and LAA emptying velocity 90% in both groups. Median LAVI, septal e’ and E wave velocity in the ≤ 1 vs ≥2 groups were 46ml/m2vs 48ml/m2, 8cm/s vs 6cm/s and 0.8m/s vs 0.8m/s, respectively. Overall, increased LAVI and reduced septal e’ on TTE was associated with TEE LA/LAA abnormalities (p=0.02, p=0.005 respectively). In subgroup analysis, it was found that LAVI and septal e’ was statistically significant in the low CHA2DS2-VASc group (p=0.03, p =0.01), but not in the higher CHA2DS2-VASc group (p=0.21, p=0.30).Conclusion: TEE LA/LAA abnormalities were not infrequently noted in those patients traditionally deemed low risk (CHA2DS2-VASc ≤ 1). LAVI and septal e’ on TTE appear to be associated with LA/LAA abnormalities detected on TEE, which was particularly relevant in lower CHA2DS2-VASc patients and may be additive to conventional clinical risk assessment. Further study is needed to evaluate the role of imaging in AF thromboembolic risk stratification, and whether this translates to prognostic and clinical endpoints.

Transesophageal Echocardiography in Swine: Establishment of a Baseline

The porcine model is a commonly used animal model in cardiovascular research. Along with new innovative operative techniques, choice of the optimal imaging technique is crucial. Transesophageal echocardiography (TEE) is a reliable imaging tool is highly important in a large number of experimental evaluations. But so far, TEE data for swine are limited, and few standard values have been established for the porcine model. The experience and baseline results for TEE in 45 swine are presented in this study. A full TEE examination was conducted in 45 German landrace or German large white swine, with an average body weight of 49 ± 3 kg, before experimental off-pump mitral valved stent implantation. Additionally hemodynamic measurements were evaluated. The valve implantation procedure was guided solely by real-time 3-D TEE. Baseline values of standard echocardiographic parameters are provided and, where appropriate, compared with human reference values. TEE proved to be an adequate imaging technique in this experimental porcine animal model. The baseline TEE and hemodynamic parameters established for the widely used porcine model can serve as a reference in future studies.

Effects of postural change on transesophageal echocardiography views and parameters in healthy dogs.

The purpose of the present study is to investigate the effect of postural change on transesophageal echocardiography (TEE) views and parameters of interest anesthesia monitoring in healthy dogs. Twelve Beagle dogs were anesthetized and randomly positioned in one of four postures: right lateral-recumbency, left lateral-recumbency, supine position and prone position. After examinations in one posture, the same examination was demonstrated in another posture and repeated in all postures. In each posture, several standard TEE views were demonstrated: longitudinal cranial-esophageal aorta long-axis-view, transverse middle-esophageal mitral valve long-axis-view and transgastric middle short-axis-view. Additionally, echocardiographic parameters were attempted to measure, and direct blood pressure monitoring was performed in each view. As a result, oriented views, except for transgastric middle short-axis-view, could be obtained in all postures. Stroke volume and peak early diastolic velocity of mitral inflow were lower in supine position compared with those in right and left lateral-recumbency. Heart rate (HR) and systemic vascular resistance were higher in supine position compared with those in right and left lateral-recumbency. Left ventricular pre-ejection period/left ventricular ejection time corrected and uncorrected by HR were higher in supine position compared with those in right and left lateral-recumbency. In conclusion, longitudinal cranial-esophageal aorta long-axis-view and transverse middle-esophageal mitral valve long-axis-view provide useful information of interest anesthesia monitoring, because of their views enable to certainly obtain TEE parameters in various postures. Furthermore, TEE parameters allow to detect the changes of preload, afterload and HR that occur in supine position dogs.

Is CHA2DS2-VASc appropriate for hyperthyroid patients with atrial fibrillation? Implications of adding a transesophageal echocardiography evaluation

BackgroundAnticoagulation remains a controversial issue among hyperthyroid patients with atrial fibrillation (AF). We aimed to evaluate the prevalence of the thrombogenic milieu (TM), detected using transesophageal echocardiography (TEE), among patients with AF related to hyperthyroidism, and to correlate these findings with the clinical embolic risk classification (CHA2DS2-VASc). MethodsCHA2DS2-VASc score, thyroid hormonal status, time since hyperthyroidism diagnosis, transthoracic echocardiography (TTE) and TEE were assessed in 47 consecutive patients aged between 18 and 65years with AF related to hyperthyroidism. The following TEE parameters defined TM: dense spontaneous echo contrast, thrombi, or left atrial appendage (LAA) blood flow velocities <0.20m/s. Non-classic TM was defined as non-dense SEC plus LAA flow velocity 0.20–0.40m/s. ResultsPulmonary hypertension was present in 39/47 (81.4%) and TM in 22/47 (46.8%) patients. Despite a low CHA2DS2-VASc score of 0/1, 10 of 19 (52.6%) patients had a TM, whereas 16 of 28 (57.1%) patients with score ≥2 had none. The probability of having a TM did not correlate with CHA2DS2-VASc scores. On regression binary analysis, hyperthyroidism diagnosed more than 12months previous was independently associated with non-classic TM (p=0.031). ConclusionAmong patients younger than 65years of age with AF related to hyperthyroidism, pulmonary hypertension and TM on TEE were highly prevalent. There was no association between CHA2DS2-VASc with TEE markers of TM. Thyroid status, especially longer duration of hyperthyroidism might influence thrombogenic abnormalities. TEE adds useful information that may change antithrombotic therapy if otherwise guided solely by clinical risk classification.

Relation between left atrial measurements and thromboembolic risk markers assessed by echocardiography in patients with nonvalvular atrial fibrillation: A cross-sectional study.

BackgroundLeft atrium (LA) dilatation has been associated with adverse cardiovascular outcomes in patients with sinus rhythm and atrial fibrillation (AF).Aim of the studyWe aimed to evaluate the accuracy of left atrial (LA) size to predict transesophageal echocardiographic (TEE) markers of increased thromboembolic risk left atrial appendage (LAA) thrombus, low LAA velocities and dense spontaneous echocardiographic contrast (SEC), and also to assess the best method to evaluate LA size.Patients and methodsCross-sectional study included 64 patients with nonvalvular AF undergoing transthoracic and transesophageal echocardiographic (TTE and TEE) evaluation. LA size was measured on TTE by several methods including the following: anteroposterior diameter (AP), LA area in four and two apical chamber views and volumes by ellipsoid, single plane (1P) and biplane area-length (2P) formulas. All these measures were indexed to the body surface area (BSA). Thromboembolic markers including LAA thrombus, low LAA velocities, dense SEC and LA abnormality (LA ABN) which means the presence of one or more of the previous three parameters were evaluated by TEE.ResultsThere was statistically significant increase in indexed and non-indexed LA parameters in patients with LA ABN compared to patients without LA ABN. According to ROC curve, the study found that all indexed LA parameters were predictive for LAA thrombus with the highest AUC was indexed LA 1P area length volume (AUC 0.91, CI 95% 0.81–1.01, p < 0.000), for LAA low flow velocity were indexed and non-indexed LA AP diameters with the highest AUC was indexed LA AP diameter (AUC 0.89, CI 95% 0.80–0.98, p < 0.000), for LA dense SEC were indexed LA ellipsoid volume (AUC 0.78, CI 95% 0.66–0.96, p = 0.002) and indexed LA 1P area length volume (AUC 0.78, CI 95% 0.66–0.90, p = 0.002) and for LA ABN were all LA parameters with the highest AUC was indexed LA 1P area length volume (AUC 0.87, CI 95% 0.79–0.96, p < 0.000). On multivariate logistic regression analysis of TEE parameters, the study found that the most predictive LA measurement for LAA thrombus was indexed LA AP diameter with cutoff 3 cm/m2 (OR 7.5, 95% CI 1.24–45.2, p = 0.02), for LAA low flow velocity was LA AP diameter with cutoff 6 cm (OR 17.6, 95% CI 3.23–95.84, p = 0.001), for LA dense SEC was indexed LA ellipsoid volume with cutoff 42 cm3/m2 (OR 6.5, 95% CI 1.32–32.07, p = 0.02), and for LA ABN was indexed LA ellipsoid volume with cutoff 42 cm3/m2 (OR 10.45, 95% CI 2.18–51.9, p = 0.008).ConclusionLA enlargement is suitable to predict thromboembolic markers in patients with non-valvular AF. The indexed and non-indexed LA AP diameter and indexed LA ellipsoid volume were the most accurate parameters for predicting thromboembolic markers.

Abstract 14839: Association of Silent Brain Infarction With CHADS2 Score and Left Atrial Abnormalities in Patients With Nonvalvular Atrial Fibrillation

Introduction: The CHADS2 score is widely used for risk stratification of thromboembolism in patients with nonvalvular atrial fibrillation (NVAF). Furthermore, LA abnormalities detected by transesophageal echocardiography (TEE) are also well known risk factors for thromboembolism in NVAF patients. On the other hand, silent brain infarction (SBI) relates to subsequent symptomatic brain infarction; however little is known regarding association among CHADS2 score, TEE parameters and SBI. Methods: The study population consisted of 103 neurologically asymptomatic patients with NVAF (mean age 63 ± 10 years) who underwent TEE. All participating patients underwent brain MRI and were calculated CHADS2 score. SBI was defined as an area of hypointense lesions that measured &gt;3 mm on T1-weighted images and hyperintense lesions on T2-weighted images by brain magnetic resonance imaging (MRI). LA abnormalities were defined as LA thrombus, spontaneous echo contrast, or low LA appendage emptying velocity (&lt;20 cm/s) detected by TEE. Results: Of 103 patients, 31 (30%) showed SBI on brain MRI. Over all mean CHADS2 score was 1.1 ± 0.9, and LA abnormalities were detected in 24 patients by TEE (23%). Mean CHADS2 score in patients with SBI was significantly higher than that in patients without SBI (P&lt;0.05). The prevalence of SBI increased along with increases in CHADS2 score (CHADS2 score of 0, 1, 2 and 3-6 in 13%, 23%, 47% and 80%, respectively, P&lt;0.05). Patients with SBI had a higher prevalence of LA abnormalities than those without SBI (P&lt;0.05). In patients with SBI with CHADS2 score of 0-1, LA abnormalities were detected in 5 of 14 patients (36%). Conclusions: In this study, both CHADS2 score and prevalence of LA abnormalities by TEE were higher in patients with SBI on MRI. LA abnormalities detected by TEE may discriminate risk for SBI even in patients with low CHADS2 score.