Usefulness of transesophageal echocardiography before cardioversion in atrial arrhythmias

Background: Although many thromboembolism risk factors are well defined, formation of thrombus ordense spontaneous contrast (sludge) in the left atrium remains enigmatic and confounding. Exclusionof the thrombus is extremely important with respect to planned reversal of sinus rhythm. Data regardingthe routine transesophagal echocardiography (TEE) before cardioversion are inconclusive. The authorsfocused on analyzing the usefulness of TEE before cardioversion by assessment of factors influencing therisk of thrombus and/or dense spontaneous echo contrast with the intention of extending indications forTEE in the group with a high risk of thrombus or to forgo TEE in the low risk group. Methods: Two hundred sixty-nine consecutive patients with persistent (> 48 h) atrial fibrillationor atrial flutter, in whom a direct current cardioversion was planned, were undergoing TEE for thedetection of the left atrial thrombus or dense spontaneous echo contrast. Additional clinical and echocardiographic data were collected. The relationship between both thrombus and dense spontaneous echo contrast and covariates was analyzed with the use of binary logistic regression. Results: Left atrium (LA) appendage (LAA) thrombus and/or sludge were detected in 79 (29%)patients. Signs of dementia in mini-mental state examination (hazard ratio [HR]: 1.16; p = 0.005),low velocities in LAA (HR: 3.38; p = 0.032); presence of spontaneous echo contrast in LA (HR: 3.38;p = 0,003) consecutive episode of AF (HR: 2.27; p = 0,046); longer duration of atrial fibrillation (HR:1.009; p = 0.022); were significant predictors of thrombus and/or dense spontaneous echo contrast.None of the patients with a CHA2DS2VASc score ≤ 1 had thrombus or sludge in the LAA. Among patientswith a CHA2DS2VASc score > 1, the prevalence of thrombus or sludge in LAA was independentof the CHA2DS2VASc score value.Conclusions: Amongst many factors, including an established as risk for thromboembolism onlya few of them increased the risk for the presence of thrombus in LAA: low velocities in LAA, presenceof spontaneous echo contrast, longer duration of arrhythmia, consecutive (not first) arrhythmia episodeand signs of dementia from a mini-mental state examination questionnaire. It was believed that therecould be a need for an extension of indications of TEE in vast majority of the patients with atrial arrhythmias, due most often to an unpredictable occurrence of thrombus and potentially disastrousthromboembolism. The only exception could have been the group of the patients with a CHA2DS2VAScscore ≤ 1

Left ventricular function after takotsubo is not fully recovered in long-term follow-up: A speckle tracking echocardiography study

Background: Complete improvement of left ventricle (LV) systolic function is an essential feature of takotsubo cardiomyopathy (TTC). It is suggested that 2-dimensional speckle tracking echocardiography (2D STE) can evaluate LV dysfunction more accurately than conventional echocardiography. Thus, the purpose of this research was to assertain whether LV function recovery is complete after the acute phase of TTC using 2D STE commencing 6 to 9 months after discharge. Methods: Thirty patients (29 females, 67 ± 11 years) with an apical ballooning TTC pattern 225.5 ± 27.4 days after their index event were enrolled. The control group consisted of 20 (19 females, 64  ± 9 years) age- and sex-matched volunteers without structural heart disease. Classic echocardiographic parameters, longitudinal strain and LV twist parameters were assessed and compared between the groups. Results: There were no differences in traditional LV systolic, diastolic parameters and in global peak longitudinal strain. In comparison to controls, patients with TTC had lower mean apical rotation (14.4° ± 6.5° vs. 18.3° ± 6.7°; p = 0.048), slower mean peak early diastolic apical rotation rate (–85.1−°/s ± 40.9−°/s vs –119.4−°/s ± 41.9−°/s; p = 0.006) and higher pre-stretch index in the apex (2.16, IQR 0.33–5.50 vs. 0.00, IQR 0.00–2.95, p = 0.008). Conclusions: The improvement of LV function in patients with TTC as assessed by 2D STE may not always be complete. Some residual abnormalities in LV apex function were observed in long-term recovery following TTC episodes.

Long-term lipoprotein apheresis in the treatment of severe familial hypercholesterolemia refractory to high intensity statin therapy: Three year experience at a lipoprotein apheresis centre

Background: Severe familial hypercholesterolemia (FH) individuals, refractory to conventional lipidloweringmedications are at exceptionally high risk of cardiovascular events. The established therapeuticoption of last choice is lipoprotein apheresis (LA). Herein, it was sought to investigate the clinical usefulnessof LA in a highly selected group of severe heterozygous FH (HeFH), as recently described by theInternational Atherosclerosis Society (IAS), for their efficacy in lipid reduction and safety.Methods: Efficacy and safety of LA were investigated in 318 sessions of 7 severe HeFH females withcardiovascular disease, over a mean period of 26.9 ± 6.5 months. Relative reduction of low density lipoproteincholesterol (LDL-C) ≥ 60%, clinical complications and vascular access problems were evaluatedand compared between the direct adsorption of lipoproteins (DALI) and lipoprotein filtration (MembraneFiltration Optimized Novel Extracorporeal Treatment [MONET]). Additionally, lipoprotein (a)[Lp(a)], total cholesterol (TC), high density lipoprotein cholesterol (HDL-C), triglycerides (TG) andfibrinogen concentrations were investigated.Results: The relative reduction of LDL-C, TC, TG and Lp(a) were 69.4 ± 12.9%, 59.7 ± 9.1, 51.5 ±± 14.2% and 71.3 ± 14.4%, respectively. A similar efficacy was found in both systems in LDL-C removal.DALI system led to larger depletions of Lp(a) (80.0 [76–83]% vs. 73.0 [64.7–78.8]%; p < 0.001).The frequency of clinical side effects and vascular access problems were low (8.5%).Conclusions: Long-term LA in severe HeFH individuals is safe and efficiently reduces LDL-C andLp(a). Higher efficacy of the DALI system than MONET in Lp(a) removal may indicate the need for individualizedapplication of the LA system in severe HeFH individuals

Cardiovascular End Points and Mortality Are Not Closer Associated With Central Than Peripheral Pulsatile Blood Pressure Components

Pulsatile blood pressure (BP) confers cardiovascular risk. Whether associations of cardiovascular end points are tighter for central systolic BP (cSBP) than peripheral systolic BP (pSBP) or central pulse pressure (cPP) than peripheral pulse pressure (pPP) is uncertain. Among 5608 participants (54.1% women; mean age, 54.2 years) enrolled in nine studies, median follow-up was 4.1 years. cSBP and cPP, estimated tonometrically from the radial waveform, averaged 123.7 and 42.5 mm Hg, and pSBP and pPP 134.1 and 53.9 mm Hg. The primary composite cardiovascular end point occurred in 255 participants (4.5%). Across fourths of the cPP distribution, rates increased exponentially (4.1, 5.0, 7.3, and 22.0 per 1000 person-years) with comparable estimates for cSBP, pSBP, and pPP. The multivariable-adjusted hazard ratios, expressing the risk per 1-SD increment in BP, were 1.50 (95% CI, 1.33–1.70) for cSBP, 1.36 (95% CI, 1.19–1.54) for cPP, 1.49 (95% CI, 1.33–1.67) for pSBP, and 1.34 (95% CI, 1.19–1.51) for pPP (P\u3c0.001). Further adjustment of cSBP and cPP, respectively, for pSBP and pPP, and vice versa, removed the significance of all hazard ratios. Adding cSBP, cPP, pSBP, pPP to a base model including covariables increased the model fit (P\u3c0.001) with generalized R2 increments ranging from 0.37% to 0.74% but adding a second BP to a model including already one did not. Analyses of the secondary end points, including total mortality (204 deaths), coronary end points (109) and strokes (89), and various sensitivity analyses produced consistent results. In conclusion, associations of the primary and secondary end points with SBP and pulse pressure were not stronger if BP was measured centrally compared with peripherally

The International Database of Central Arterial Properties for Risk Stratification: Research Objectives and Baseline Characteristics of Participants

OBJECTIVE To address to what extent central hemodynamic measurements, improve risk stratification, and determine outcome-based diagnostic thresholds, we constructed the International Database of Central Arterial Properties for Risk Stratification (IDCARS), allowing a participant-level meta-analysis. The purpose of this article was to describe the characteristics of IDCARS participants and to highlight research perspectives. METHODS Longitudinal or cross-sectional cohort studies with central blood pressure measured with the SphygmoCor devices and software were included. RESULTS The database included 10,930 subjects (54.8% women; median age 46.0 years) from 13 studies in Europe, Africa, Asia, and South America. The prevalence of office hypertension was 4,446 (40.1%), of which 2,713 (61.0%) were treated, and of diabetes mellitus was 629 (5.8%). The peripheral and central systolic/diastolic blood pressure averaged 129.5/78.7 mm Hg and 118.2/79.7 mm Hg, respectively. Mean aortic pulse wave velocity was 7.3 m per seconds. Among 6,871 participants enrolled in 9 longitudinal studies, the median follow-up was 4.2 years (5th–95th percentile interval, 1.3–12.2 years). During 38,957 person-years of follow-up, 339 participants experienced a composite cardiovascular event and 212 died, 67 of cardiovascular disease. CONCLUSIONS IDCARS will provide a unique opportunity to investigate hypotheses on central hemodynamic measurements that could not reliably be studied in individual studies. The results of these analyses might inform guidelines and be of help to clinicians involved in the management of patients with suspected or established hypertension