Transesopnageal echocardiographic anatomical and functional assessment of right atrial appendage: comparison with left atrial appendage and implications for local thrombus formation in patients with mitral stenosis

Right atrial appendage [RAA] thrombi and dysfunction have been reported in patients with atrial fibrillation [AF]. Although pulmonary embolism was a life-threatening complication of AF, there are little data about RAA and its thrombi in AF. Furthermore, to date there have been no prospective studies designed to examine RAA in patients with rheumatic mitral stenosis [MS]. To define RAA anatomical and functional parameters and to compare them with left atrial appendage [LAA] parameters in patients with moderate MS both in AF and in sinus rhythm [SR] and to study the implications for local thrombus formation. Transthoracic [TTE] and multiplane transesophageal echo [TEE] were performed in 31 patients with moderate MS [16 in SR. Group I and 15 in AF, Group II]. We measured mitral valve area [MVA], mean pulmonary artery pressure [MPAP], left atrial diameter [LAD], LV EDD and ESD, EF%, RAA and LAA neck width, length, area, ratio of neck to area, and emptying velocity. We assessed also the incidence of RA-RAA and LALAA SEC and thrombi. Adequate visualization of RAA was highly feasible by TEE in 31/34 [91%] of patients. RAA anatomic and functional parameters were independent of imaging plane. Patients in AF had significantly increased LAD [p=0.004] and MPAP [p<0.0001] than those in SR. The RAA area was proportional to the LAA area [r=0.87, p<0.0001] only in patients with SR. On the other hand, RAA neck width and ratio of neck width to area were greater than those of LAA while LAA length and area were greater than those of RAA regardless the presence of AF. AF caused more enlargement in LAA [10.21 +/- 4.15 Vs 5.41 +/- 1.78, p<0.0001] compared to RAA [5.37 +/- 2.08 Vs 4.40 +/- 1.44, p=NS] while more dysfunction in RAA / [reduced emptying velocities [0.45 +/- 0.11]-[0.28 +/- 0.08], [40%] p<0.0001] compared to that of the LAA [0.43 +/- 0.08] - [0.32 +/- 0.14], [25.6%] p<0.01/ ]. AF caused higher prevalence of RAA spontaneous echo contrast [SEC] [66.7%] than in SR [37.5%], [p<0.0001]. Also it caused higher RAA thrombosis [46.7%] than in SR [25%], [p=0.001]; and finally RAA SEC was the only independent predictor of RAA thrombosis in SR [p=0.04] while the reduced ejection velocity was the only independent predictor of RAA thrombosis in MS patients with AF [p=0.04]. RAA imaging was highly feasible. RAA anatomic and functional parameters were independent of imaging plane. AF was associated with RAA minimal remodeling, maximal dysfunction and subsequently thrombosis. RAA dysfunction and SEC were independent predictors for RAA thrombosis. RAA SEC and thrombosis were directly proportional to LAA remodeling and dysfunction. Therefore, assessment of not only LAA but also RAA may be important during TEE examination of patients with MS

Study of changes in P wave dispersion and duration as predictors of AF in patients with primary dilated cardiomyopathy

Background: P wave duration on signal averaging ECG [PD SAECG] and P wave dispersion [PWD] on standard ECG are non invasive markers of intra-atrial conduction time disturbances, the major electrophysiological cause of atrial fibrillation [AF]. P wave abnormalities have been previously studied in some cardiac conditions, however little data are available in patients with primary dilated cardiomyopathy [DCM]

Objectives: to study changes in PD and PWD as predictors of AF among patients with primary DCM and to correlate these changes with degree of severity of CHF

Patients and Methods: Surface ECG, SAECG and Transthoracic [TTE] echo were performed in 33 patients with primary DCM [Group I] and 30 age and sex matched healthy controls [Group II]. We measured heart rate [HR], minimal p wave [P min], maximal p wave [P max], P wave dispersion [difference between P min and P max = PWD] in surface ECG, P wave duration [PD] in SAECG, Left atrial maximal [LAMX], minimal [LAMN], LA volume at onset of p-wave [LAV p], LA ejection fraction [LA EF], and left ventricular ejection fraction [LV EF] by TTE

Results: There was no significant difference between groups regarding age [42.06 +/- 12.9 Vs 38.5 +/- 10.9, p=0.25] or sex distribution [24/33 [72.7%] Vs 21/30 [70%] males, p=0.81]. Patients with primary DCM showed significantly increased HR, P max and P mm, prolonged PD, and increased PWD, [p<0.0001 for all]. They showed also significantly depressed LV EF and LA EF, with a significantly increased LAMX and LAMN volume, and LAV p, [p<0.0001 for all]. Patients with DCM showed significant positive correlation between PD; and LAMX volume, LAMN volume, and LAVP, [p<0.0001 for all] and significant negative correlation between PD and both LV EF [p<0.0001] and LA EF [p=0.002]. They showed significant positive correlation between PWD; and LAMX, LAMN volume, and LAV p, [p<0.0001] and significant negative correlation between PWD and both LVEF and LAEF [p<0.0001]. Patients with severe DCM [LV EF<25%] showed significantly prolonged P max [p=0.004], P min [p=0.002], PD [p<0.0001] and increased PWD [p=0.004] compared to those with less severe form of the disease [LVER >/= 25%]

Conclusion: The prolonged P-wave duration and increased P-wave dispersion were significantly associated with the increased left atrial volumes, depressed left atrial and left ventricular systolic functions in patients with primary DCM

Rotational versus standard quantitative coronary angiography: a comparative study

Standard coronary angiography [SA] has some limitations and complications. Technology has been developed to perform rotational coronary angiography [RA] that may overcome SA limitations and complications while keeping the diagnostic accuracy. RA is a technique that provides with one contrast injection, a panoramic or dynamic cineangiogram of the coronary tree, during up to 180 rotation of the gantry. The purpose was to compare RA and SA regarding diagnostic accuracy and patient safety. Our study included 20 patients with a clinical indication for diagnostic coronary angiography [CA] at Cardiology Department, El Minia University Hospital. Patients were subjected to: SA [4 fixed projections for LCA and 2 for RCA] and RA [2 projections for LCA [RAO 60- LAO 60- caudal and cranial] and [1 projection for RCA [RAO 30- LAO 90- cranial]]. Acquisition of additional static angiographic projections was done for better diagnostic assessment whenever needed after SA and/or RA. QCA analyses were performed on two views [first from SA and second from RA] showing a significant lesion. Radiation dose [RD], contrast volume [CV], total number of frames [TNF], total number of image acquisitions [TNIA], additional projections [AP], reference vessel diameter [RVD], minimal lumen diameter [MLD], lesion percent stenosis [LPS] and lesion length [LL] were evaluated and compared between the two angiographic techniques. We analyzed 38 lesions. Their distributions were: 19[50%] in LAD, 9[23.68%] in RCA, 7[18.42%] in circumflex and 3 [7.89%] in the diagonals. There were no statistically significant differences between SA and RA derived QCA data in MLD[1.197 +/- 0.651 Vs 1.175 +/- 0.642], RVD[2.8l9 +/- 0.961 Vs 2.752 +/- 0.99], LPS [65.495 +/- 16.225 Vs 64.989 +/- 16.426], and in LL [12.575 +/- 6.392 Vs 12.406 +/- 6.338], p ns for all. At the same time, RA derived QCA data strongly correlated with SA derived QCA data with correlation coefficient, 0.99 1, 0.975, 0.994, and 0.996 respectively. On the other hand, RD was 44% less [245.83 +/- 132.17 Vs. 442.23 +/- 272.55 mGy], CV was 45% lower. [24.28 +/- 10.78 Vs. 43.98 +/- 20.77 ml], TNF was 45% fewer [162 +/- 65.54 vs. 293.21 +/- 142.83], TNIA was 59% lower [1.82 +/- 0.67 vs. 4.46 +/- 1.88], and AP was 82% lower beyond the pre specified protocol [0.21 +/- 0.49 vs. 1.179 +/- 1.249] in the RA compared to the SA technique, p<0.0001 for all. RA-derived QCA has similar diagnostic accuracy and strongly correlates with SA derived QCA. Furthermore, RA has better safety as it leads to a significant reduction in radiation exposure and contrast use. In the future therefore, RA may replace SA and should be compared with MSCT CA in diagnosis of CAD especially if coupled with minimally invasive approaches such as radial access and use of 4 French devices

Utility of ambulatory event electrocardiographic recorders in the diagnosis of palpitations

The aim of this study was to quantify the diagnostic yield of event ECG recorders over Holter 24-hour ECG monitoring in the evaluation of patients with palpitations. Seventy-two patients were studied, but the results of 60 patients were included in the study. Echocardiography was done for all subjects of the study. Holter ECG monitor for 24 hours was done for all subjects. All patients underwent event recorder for three-week use. The patients were classified into two groups: Group I included 25 patients with heart disease and group II included 35 patients without heart disease. It was concluded that by capturing the cardiac rhythm out the time of typical symptoms, event ECG recording may eventually be considered the standard diagnostic test in patients with recurrent palpitations