Clinical outcomes of acute myocardial infarction arising from non-lipid-rich plaque determined by NIRS-IVUS.

Acute myocardial infarction (AMI) can rarely arise from non-lipid-rich coronary plaques. This study sought to compare the clinical outcomes after percutaneous coronary intervention (PCI) between AMI showing maximum lipid-core burden index in 4 mm (maxLCBI4mm) < 400 and ≥ 400 in the infarct-related lesions assessed by near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS). We investigated 426 AMI patients who underwent NIRS-IVUS in the infarct-related lesions before PCI. Major adverse cardiovascular events (MACE) were defined as the composite of cardiac death, non-fatal MI, clinically driven target lesion revascularization (TLR), clinically driven non-TLR, and congestive heart failure requiring hospitalization. 107 (25%) patients had infarct-related lesions of maxLCBI4mm < 400, and 319 (75%) patients had those of maxLCBI4mm ≥ 400. The maxLCBI4mm < 400 group had a younger median age at onset (68 years [IQR: 57-78 years] vs. 73 years [IQR: 64-80 years], P = 0.007), less frequent multivessel disease (39% vs. 51%, P = 0.029), less frequent TIMI flow grade 0 or 1 before PCI (62% vs. 75%, P = 0.007), and less frequent no-reflow immediately after PCI (5% vs. 11%, P = 0.039). During a median follow-up period of 31 months [IQR: 19-48 months], the frequency of MACE was significantly lower in the maxLCBI4mm < 400 group compared with the maxLCBI4mm ≥ 400 group (4.7% vs. 17.2%, P = 0.001). MaxLCBI4mm < 400 was an independent predictor of MACE-free survival at multivariable analysis (hazard ratio: 0.36 [confidence interval: 0.13-0.98], P = 0.046). MaxLCBI4mm < 400 measured by NIRS in the infract-related lesions before PCI was associated with better long-term clinical outcomes in AMI patients.

Serial changes of coronary flow reserve over one year after transcatheter aortic valve implantation in patients with severe aortic stenosis.

Background: Impaired coronary flow reserve (CFR) portends a poor prognosis in patients with aortic stenosis. The present study aims to investigate how CFR changes over one year after transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis, and to explore factors related to the changes. Methods: Consecutive patients undergoing TAVI were registered. CFR in the left anterior descending artery was measured by transthoracic echocardiography on three occasions pre-TAVI, one-day post-TAVI, and one-year post-TAVI. Results: A total of 59 patients were enrolled, 46 of whom completed one-year follow-up. CFR was impaired in 35 (59.3%) patients pre-TAVI, but the impairment was only seen in 2 patients (4%) one-year post-TAVI. CFR value improved from 1.75 (1.50-2.10) cm/s pre-TAVI, to 2.00 (1.70-2.30) one-day post-TAVI, and further to 2.60 (2.30-3.10) one-year post-TAVI (P < 0.001). The median difference in CFR between pre-TAVI and one-year post-TAVI was 0.90 (0.53-1.20). Patients with significant improvement of CFR (more than the median value of 0.9) had larger aortic valve area (1.55 [1.38-1.92] vs. 1.36 cm2 [1.26-1.69], P = 0.042) and greater improvement in left ventricular ejection fraction (3.10 [-1.67-4.24] vs. -1.46 [-3.42-1.48] percentage points, P = 0.019) than those without. Conclusions: CFR is impaired in a considerable proportion of patients with severe aortic stenosis, but improvement is seen immediately after TAVI, and one year later. Patients with significant improvement of CFR had larger aortic valve area and greater increase in left ventricular ejection fraction after TAVI.

Effect of Atherectomy on Lesion Preparation in Heavily Calcified Coronary Artery Disease.

Background: Percutaneous coronary intervention (PCI) of heavily calcified lesions remains challenging. This study examined whether calcified lesion preparation is better with an ablation-based than balloon-based technique. Methods and Results: Results of lesion preparations with and without atherectomy devices were compared in 121 patients undergoing optical coherence tomography (OCT)-guided PCI of heavily calcified lesions. Lesion preparation was performed with the ablation-based technique in 59 patients (atherectomy group) and with the balloon-based technique in 62 patients (balloon group). Lower grades of angiographic coronary dissections (National Heart, Lung, and Blood Institute [NHLBI] classification) occurred in the atherectomy than balloon group (atherectomy group: none, 33%; NHLBI A, 59%; B, 8%; C, 0%; D, 0%; balloon group: none, 1%; NHLBI A, 24%; B, 58%; C, 15%; D, 2%). On OCT, a large dissection was less common (49% vs. 90%; P<0.001) and calcium fractures were more frequent (75% vs. 18%; P<0.001) in the atherectomy than balloon group. In multivariable analyses, the ablation-based technique was associated with a lower grade of angiographic coronary dissection (adjusted odds ratio [aOR] 0.04; 95% confidence interval [CI] 0.01-0.12; P<0.001), a lower incidence of OCT-detected large dissection (aOR 0.09; 95% CI 0.03-0.30; P<0.001), and a higher incidence of OCT-detected calcium fracture (aOR 18.19; 95% CI 6.45-58.96; P<0.001). Conclusions: The ablation-based technique outperformed the balloon-based technique in the lesion preparation of heavily calcified lesions.

Feasibility of tissue-tracking mitral annular displacement in single four-chamber view as a simple index of left ventricular longitudinal deformation.

BACKGROUND: Left ventricular global longitudinal strain (LVGLS) has prognostic value for adverse cardiac events. Application of speckle-tracking technology to mitral annulus provides easy assessment of tissue-tracking mitral annular displacement (TMAD) in apical four-chamber view. The study aimed to examine whether TMAD can be used as a simple index of LV longitudinal deformation in patients with and without preserved ejection fraction (EF). METHODS: The study population consisted of 95 consecutive subjects. GLS was assessed from three apical views. TMAD was evaluated as the base-to-apex displacement of septal (TMADsep), lateral (TMADlat), and mid-point of annular line (TMADmid) in apical 4-chamber view. The percentage of TMADmid to LV length from the mid-point of mitral annuls to the apex at end-diastole (%TMADmid) was calculated. We compared each TMAD parameter with GLS by linear regression analysis, and analyzed each TMAD parameter by receiver operating characteristic (ROC) curve to detect impaired LV longitudinal deformation (|GLS|< 15.0%). RESULTS: There were good correlations between each TMAD parameter and GLS (TMADsep: r2 = 0.59, p < 0.01. TMADlat: r2 = 0.65, p < 0.01. TMADmid: r2 = 0.68, p < 0.01. %TMADmid: r2 = 0.75, p < 0.01). According to ROC curve, %TMADmid < 10.5% was the best cut-off value in determining impaired LV longitudinal deformation (|GLS|≤ 15.0%) with a sensitivity of 95% and a specificity of 93%. The area under the curve (AUC) of %TMADmid was 0.98 (95% confidence intervals (CI) 0.93-0.99). CONCLUSIONS: TMAD using speckle-tracking echocardiography quickly estimated from single apical four-chamber view can be used as a simple index for detection of impaired LV longitudinal deformation in patients with and without preserved EF.

Telecardiology in Rural Practice: Global Trends.

The management of cardiovascular diseases in rural areas is plagued by the limited access of rural residents to medical facilities and specialists. The development of telecardiology using information and communication technology may overcome such limitation. To shed light on the global trend of telecardiology, we summarized the available literature on rural telecardiology. Using PubMed databases, we conducted a literature review of articles published from January 2010 to December 2020. The contents and focus of each paper were then classified. Our search yielded nineteen original papers from various countries: nine in Asia, seven in Europe, two in North America, and one in Africa. The papers were divided into classified fields as follows: seven in tele-consultation, four in the telemedical system, four in the monitoring system, two in prehospital triage, and two in tele-training. Six of the seven tele-consultation papers reported the consultation from rural doctors to urban specialists. More reports of tele-consultations might be a characteristic of telecardiology specific to rural practice. Further work is necessary to clarify the improvement of cardiovascular outcomes for rural residents.

Prevalence of myocardial perfusion scintigraphy derived ischemia in coronary lesions with discordant fractional flow reserve and non-hyperemic pressure ratios.

BACKGROUND: Whether a coronary lesion with discordant fractional flow reserve (FFR) and non-hyperemic pressure ratios (NHPRs) causes myocardial ischemia remains unclear. This study investigates the prevalence of myocardial ischemia as assessed by myocardial perfusion scintigraphy (MPS) in coronary lesions with discordant FFR and instantaneous wave-free ratio (iFR), and, additionally, other NHPRs: resting full-cycle ratio (RFR), diastolic pressure ratio (dPR), and resting Pd/Pa. METHODS: A total of 484 coronary arteries in 295 patients with stable coronary artery disease that underwent MPS and invasive physiological pressure measurements were categorized into four groups (FFR+/NHPR+, FFR+/NHPR-, FFR-/NHPR+, and FFR-/NHPR-) using the respective cut-off values of FFR ≤ 0.80, iFR ≤ 0.89, RFR ≤ 0.89, dPR < 0.89, and Pd/Pa ≤ 0.92. The proportions of MPS-derived myocardial ischemia in a relevant myocardial territory were compared between the four groups. RESULTS: In total, 175 (36%), 61(13%), 35(7%) and 213(44%) vessels were classified into FFR+/iFR+, FFR+/iFR-, FFR-/iFR+ and FFR-/iFR- groups, respectively. The FFR+/iFR+ group had the highest proportion of MPS-derived ischemia (70%), followed by the FFR+/iFR- group (38%), the FFR-/iFR+ group (23%), and the FFR-/iFR- group (10%) (P < 0.001). Similar proportions of MPS-derived ischemia were found when RFR. (70%, 34%, 24%, and 10%, P < 0.001), dPR (70%, 38%, 26%, and 10%, P < 0.001), and Pd/Pa (70%, 31%, 22%, and 10%, P < 0.001) were used in place of iFR. CONCLUSIONS: The prevalence of MPS-derived myocardial ischemia in coronary lesions with discordance between FFR and NHPRs is lower than those with concordantly positive FFR and NHPRs, but higher than those with concordantly negative FFR and NHPRs.

Impact of cavotricuspid isthmus depth on the ablation index for successful first-pass typical atrial flutter ablation.

Cavotricuspid isthmus (CTI) linear ablation has been established as the treatment for typical atrial flutter. Recently, ablation index (AI) has emerged as a novel marker for estimating ablation lesions. We investigated the relationship between CTI depth and ablation parameters on the procedural results of typical atrial flutter ablation. A total of 107 patients who underwent CTI ablation were retrospectively enrolled in this study. All patients underwent computed tomography before catheter ablation. From the receiver-operating curve, the best cut-off value of CTI depth was < 4.1 mm to predict first-pass success. Although the average AI was not different between deep CTI (DC; CTI depth ≥ 4.1) and shallow CTI (SC; CTI depth < 4.1), DC required a longer ablation time and showed a lower first-pass success rate (p < 0.01). In addition, the catheter inversion technique was more frequently required in the DC (p < 0.01). The lowest AI sites of the first-pass CTI line were determined in both the ventricular (2/3 segment of CTI) and inferior vena cava (IVC, 1/3 segment of CTI) sides. The best cut-off values of the weakest AIs at the ventricular and IVC sides for predicting first-pass success were > 420 and > 386, respectively. Among patients with these cut-off values, the first-pass success rate was 89% in the SC and 50% in the DC (p < 0.01). Although ablation parameters were not significantly different, the first-pass success rate was lower in the DC than in the SC. Further investigation might be required for better outcomes in deep CTIs.

Noninvasive estimation of impaired left ventricular untwisting velocity by peak early diastolic intra-ventricular pressure gradients using vector flow mapping.

BACKGROUND: Introduction of vector flow mapping (VFM) based on the combination of color Doppler and speckle-tracking echocardiography provides noninvasive assessment of early diastolic intra-ventricular pressure gradient (ED-IVPG). The purpose of this study was to evaluate the value of peak ED-IVPG measurement just after aortic valve closure using VFM for noninvasive estimation of impaired LV untwisting velocity as the index of LV relaxation in the clinical setting. METHODS AND RESULTS: The study included 65 consecutive patients in whom echocardiography was performed for the assessment of LV function. We assessed peak ED-IVPG between LV apex and base by VFM analysis software. We also measured peak LV untwisting velocity and LV twisting by speckle-tracking strain analysis. Peak ED-IVPG was successfully and quickly assessed in all the study patients. Peak ED-IVPG was significantly reduced in patients with impaired peak LV untwisting velocity (< 70 degrees/s) compared with patients without impaired peak LV untwisting velocity. The receiver operating characteristic analysis showed the best cut-off value of peak ED-IVPG for determining impaired peak LV untwisting velocity was 0.40 mmHg (sensitivity 81%, specificity 74%, and area under the curve 0.81). There was a well correlation between peak ED-IVPG and peak LV untwisting velocity (r = 0.64, p < 0.0001). CONCLUSIONS: The present results suggest that peak ED-IVPG just after aortic valve closure measured by VFM may be used as noninvasive index for estimation of impaired LV untwisting velocity in the clinical setting.

Prognostic value of tissue-tracking mitral annular displacement by speckle-tracking echocardiography in asymptomatic aortic stenosis patients with preserved left ventricular ejection fraction.

BACKGROUND: Tissue-tracking mitral annular displacement (TMAD) by speckle-tracking echocardiography provides rapid and simple assessment of left ventricular (LV) longitudinal deformation. The purpose of this study was to evaluate the value of TMAD for the assessment of LV longitudinal deformation in patients with severe AS and preserved LV ejection fraction (LVEF). METHODS: We studied 44 patients with severe AS preserved and LVEF in whom TMAD was assessed. Using TMAD analysis software, the base-to-apex displacement of automatically defined mid-point of mitral annular line in four-chamber view was quickly assessed, and the percentage of its displacement to LV length at end-diastole (%TMAD) was calculated. We investigated the association between %TMAD and the cardiac events including appearance of symptom (dyspnea on exertion and hospitalization due to heart failure), decreased LVEF (< 50%), and cardiac death. RESULTS: During follow-up, the cardiac events developed in 16 (36%) of 44 patients. %TMAD was significantly impaired in patients with the cardiac events compared with those without the cardiac events (9.6 ± 1.9 vs 12.1 ± 2.6, p = 0.002). The cardiac events were predicted by %TMAD (HR 0.68, 95% CI 0.54-0.85; p = 0.0012). CONCLUSIONS: The present study suggests that TMAD easily and rapidly estimated by speckle-tracking echocardiography may be used as a simple method to predict occurrence of the cardiac events in asymptomatic severe AS patients with preserved LVEF.

Prevalence, Features, and Prognosis of Artery-to-Artery Embolic ST-Segment-Elevation Myocardial Infarction: An Optical Coherence Tomography Study.

Background The major underlying mechanisms contributing to acute coronary syndrome are plaque rupture, plaque erosion, and calcified nodule. Artery-to-artery embolic myocardial infarction (AAEMI) was defined as ST-segment-elevation myocardial infarction caused by migrating thrombus formed at the proximal ruptured plaque. The aim of this study was to investigate the prevalence and clinical features of AAEMI by using optical coherence tomography. Methods and Results This study retrospectively enrolled 297 patients with ST-segment-elevation myocardial infarction who underwent optical coherence tomography before percutaneous coronary intervention. Patients were divided into 4 groups consisting of plaque rupture, plaque erosion, calcified nodule, and AAEMI according to optical coherence tomography findings. The prevalence of AAEMI was 3.4%. The culprit vessel in 60% of patients with AAEMI was right coronary artery. Minimum lumen area at the culprit site was larger in AAEMI compared with plaque rupture, plaque erosion, and calcified nodule (4.0 mm2 [interquartile range (IQR), 2.2-4.9] versus 1.0 mm2 [IQR, 0.8-1.3] versus 1.0 mm2 [IQR, 0.8-1.2] versus 1.1 mm2 [IQR, 0.7-1.6], P<0.001). Lumen area at the rupture site was larger in patients with AAEMI compared with patients with plaque rupture (4.4 mm2 [IQR, 2.5-6.7] versus 1.5 mm2 [IQR, 1.0-2.4], P<0.001). In patients with AAEMI, the median minimum lumen area at the occlusion site was 1.2 mm2 (IQR, 1.0-2.1), 40% of them had nonstent strategy, and the 3-year major adverse cardiac event rate was 0%. Conclusions AAEMI is a rare cause for ST-segment-elevation myocardial infarction and has unique morphological features of plaque including larger lumen area at rupture site and smaller lumen area at the occlusion site.

Very late-phase vascular response after everolimus-eluting stent implantation assessed by optical coherence tomography.

Long-term safety of second generation drug-eluting stents (DES) has not yet been evaluated. We sought to evaluate the very late phase (> 3 years) vascular response after second generation everolimus-eluting stent (EES) as compared with first generation sirolimus-eluting stent (SES) by using optical coherence tomography (OCT). We examined the vascular response in 39 patients with a total of 55 DESs [31 EESs (mean 54 months after stenting) and 24 first generation SES (mean 66 months after stenting)] by OCT. The frequency of lesions with any malapposed stent struts (19% vs. 46%, p = 0.035) and evagination (6% vs. 42%, p = 0.002) was significantly lower. Segments with malapposed stent struts were significantly shorter (0.4 ± 0.9 mm vs. 1.9 ± 3.5 mm, p = 0.024), maximal malapposition area and malapposition volume were significantly smaller (0.26 ± 0.38 mm2 vs. 0.95 ± 1.54 mm2, p = 0.019, and 0.78 ± 1.35 mm3 vs. 6.22 ± 15.76 mm3, p = 0.016, respectively) in EES. Compared with first generation SES, second generation EES showed more favourable vascular responses at the very late phase.

Extent of the difference between microcatheter and pressure wire-derived fractional flow reserve and its relation to optical coherence tomography-derived parameters.

BACKGROUND: Although previous studies demonstrated that microcatheter-derived fractional flow reserve (mc-FFR) tends to overestimate lesion severity compared to pressure wire-derived FFR (pw-FFR), the clinical utility of mc-FFR remains obscure. The extent of differences between the two FFR systems and its relation to a lesion-specific parameter remain unknown. In this study, we sought to compare mc-FFR with pw-FFR and determine the lower and upper mc-FFR cut-offs predicting ischemic and non-ischemic stenosis, using an ischemic and a clinical FFR threshold of 0.75 and 0.80 as references, respectively. We further explored optical coherence tomography (OCT) parameters influencing the difference in FFR between the two systems. METHODS AND RESULTS: In this study, 44 target vessels with intermediate de novo coronary artery lesion in 36 patients with stable ischemic heart disease were evaluated with mc-FFR, pw-FFR and OCT. Bland-Altman plots for mc-FFR versus pw-FFR showed a bias of -0.04 for lower mc-FFR values compared to pw-FFR values. The mc-FFR cut-off values of 0.73 and 0.79 corresponded to the 0.75 ischemic pw-FFR and 0.80 clinical pw-FFR thresholds with high predictive values, respectively. The differences in the two FFR measurements (pw-FFR minus mc-FFR) were negatively correlated with OCT-derived minimum lumen area (MLA) (R = -0.359, p = 0.011). The OCT-derived MLA of 1.36 mm2 was a cut-off value for predicting the clinically significant difference between the two FFR measurements defined as >0.03. CONCLUSION: Mc-FFR is clinically useful when the specific cut-offs are applied. An OCT-derived MLA accounts for the clinically significant difference in FFR between the two systems.

Relationship between tissue Doppler measurements of left ventricular diastolic function and silent brain infarction in patients with non-valvular atrial fibrillation.

AIMS: Left ventricular (LV) diastolic function assessed by tissue Doppler imaging (TDI) is reported to be associated with left atrial (LA) blood stasis in patients with non-valvular atrial fibrillation (AF). This study aimed to evaluate the relationship of diastolic TDI parameters with silent brain infarction (SBI) on brain magnetic resonance imaging (MRI), and in turn the risks of subsequent stroke or dementia, in non-valvular AF patients. METHODS AND RESULTS: The study population consisted of 171 neurologically asymptomatic patients with non-valvular AF who underwent transoesophageal echocardiography (TOE) (128 men; mean age, 63 ± 11 years). We measured diastolic TDI parameters by transthoracic echocardiography, and also screened for SBI employing brain MRI. Early transmitral flow velocity (E) and mitral annular velocity by TDI (e') were measured, and E/e' ratios were calculated. An increased tertile of the E/e' ratio was significantly related to high prevalences of LA abnormalities detected by TOE (32% vs. 12% vs. 9%; P =0.002) and SBI on brain MRI (46% vs. 23% vs. 14%; P < 0.001). In multivariate logistic regression analyses after adjustment for age, hypertension, chronic kidney disease, and CHA2DS2-VASc score ≥2, the E/e' ratio ≥12.4 was found to be an independent predictor of the presence of SBI (OR 3.98, 95% CI 1.74-9.07; P = 0.001). CONCLUSIONS: Impaired LV diastolic function evaluated by increased E/e' ratio was closely associated with the presence of SBI independent of CHA2DS2-VASc score. TDI measurements are non-invasive and useful for risk stratification of the early stage of cerebral damages in patients with non-valvular AF.

Plaque surface irregularity and calcification length within carotid plaque predict secondary events in patients with coronary artery disease.

BACKGROUND AND AIMS: Although comprehensive risk factor modification is recommended, a uniform management strategy does not necessarily prevent secondary events in patients with coronary artery disease (CAD). Therefore, identification of high-risk patients who may benefit from more intensive interventions may improve prognosis. Carotid ultrasound can reliably identify systemic atherosclerosis, and carotid plaque and intima-media thickness (IMT) are known independent risk factors for CAD. However, it is unclear whether findings on carotid ultrasound can improve prediction of secondary CAD events. METHODS: The study population comprised 146 consecutive patients with CAD (mean age, 66 ± 9 years; 126 with angina pectoris, 20 with acute myocardial infarction). IMT, plaque score, plaque area, plaque surface irregularity, and calcification length (calculated by summing the calcified lesions within each plaque accompanied by acoustic shadow) were measured at baseline. Patients were followed for 10 years to ascertain secondary CAD events defined as hard major adverse cardiovascular events (MACE; cardiac death and acute myocardial infarction) and as total MACE (hard MACE and angina pectoris with coronary revascularization). RESULTS: Multiple regression analysis demonstrated that calcification length (p < 0.05) and plaque surface irregularity (p < 0.01) remained independently associated with total MACE after adjustment for age, sex, diabetes mellitus, dyslipidemia, hypertension, chronic kidney disease, smoking, and multivessel CAD. CONCLUSIONS: These findings suggest that the combination of calcification length and plaque surface irregularity has additional value beyond traditional risk classification. Intensive intervention for these high-risk patients may avoid or delay progression of atherosclerosis towards secondary CAD events.

Four cases of investigational therapy with interleukin-11 against acute myocardial infarction.

We describe four cases of the patients with ST-elevation myocardial infarction (STEMI) that were treated with interleukin-11 (IL-11), a cardioprotective cytokine. Recombinant human IL-11 (rhIL-11), was intravenously administered to two cases at low dose (6 µg/kg) and to two at high dose (25 µg/kg). The cytokine administration started just after the coronary occlusion was confirmed by coronary angiography (CAG), taking 3 h. Following CAG, percutaneous coronary intervention (PCI) was performed as a standard therapy. No serious adverse drug reactions were observed. All the cases left the hospital without the symptom of heart failure. We discuss the possibility of the clinical use of rhIL-11 as an adjunct therapy to PCI for the STEMI patients.

Predictors of silent brain infarction on magnetic resonance imaging in patients with nonvalvular atrial fibrillation: A transesophageal echocardiographic study.

BACKGROUND: Silent brain infarction (SBI) is often found in patients with atrial fibrillation (AF) and may be related to cognitive decline. We investigated the predictors of SBI on brain magnetic resonance imaging (MRI) using transesophageal echocardiography (TEE) in patients with nonvalvular AF. METHODS: The study population consisted of 103 neurologically asymptomatic patients with nonvalvular AF who underwent TEE before transcatheter AF ablation (76 men; mean age 63 ± 10 years). Left atrial (LA) abnormalities such as LA thrombus, spontaneous echo contrast, or abnormal LA appendage emptying velocity (<20 cm/s) and complex plaques in the aortic arch defined as large plaques ≥4 mm thickness, ulcerated plaques, or mobile plaques were evaluated by TEE. All patients were screened for SBI by brain MRI. RESULTS: Of 103 patients, 31 (30%) showed SBI on brain MRI. Most lesions were multiple (61%) and small (<15 mm) in diameter (84%). Patients with SBI had a higher prevalence of LA abnormalities (45% vs 14%; P < .001) and complex arch plaques (45% vs 7%; P < .001) compared with those without SBI. In a multivariate logistic regression analysis including age and CHADS2 score ≥2, LA abnormalities (odds ratio 4.13; 95% CI 1.34-12.72; P = .014) and complex arch plaques (odds ratio 4.82; 95% CI 1.23-18.92; P = .024) were independent predictors of SBI. CONCLUSIONS: Left atrial abnormalities and complex arch plaques detected by TEE were closely associated with the presence of SBI on brain MRI, suggesting that microembolization of small thrombi derived from the fibrillating LA or advanced aortic atherosclerotic lesions may be important causes of SBI in patients with nonvalvular AF.

Aortic arch atherosclerosis in patients with severe aortic stenosis can be argued by greater day-by-day blood pressure variability.

BACKGROUND AND PURPOSE: Although it is well known that the prevalence of aortic arch plaques, one of the risk factors for ischemic stroke, is high in patients with severe aortic stenosis, the underlying mechanisms are not well understood. Increased day-by-day blood pressure (BP) variability is also known to be associated with stroke; however, little is known on the association between day-by-bay BP variability and aortic arch atherosclerosis in patients with aortic stenosis. Our objective was to clarify the association between day-by-day BP variables (average values and variability) and aortic arch atherosclerosis in patients with severe aortic stenosis. METHODS: The study population consisted of 104 consecutive patients (mean age 75 ± 8 years) with severe aortic stenosis who were scheduled for aortic valve replacement. BP was measured in the morning in at least 4 consecutive days (mean 6.8 days) prior to the day of surgery. Large (≥4 mm), ulcerated, or mobile plaques were defined as complex plaques using transesophageal echocardiography. RESULTS: Cigarette smoking and all systolic BP variables were associated with the presence of complex plaques (p < 0.05), whereas diastolic BP variables were not. Multiple regression analysis indicated that day-by-day mean systolic BP and day-by-day systolic BP variability remained independently associated with the presence of complex plaques (p < 0.05) after adjustment for age, male sex, cigarette smoking, hypertension, hypercholesterolemia, and diabetes mellitus. CONCLUSIONS: These findings suggest that higher day-by-day mean systolic BP and day-by-day systolic BP variability are associated with complex plaques in the aortic arch and consequently stroke risk in patients with aortic stenosis.

Association between chronic kidney disease and thoracic aortic atherosclerosis detected using transesophageal echocardiography.

OBJECTIVE: Accelerated atherosclerosis occurs with a high frequency in patients with chronic kidney disease (CKD). We evaluated the association between CKD and thoracic aortic plaques using transesophageal echocardiography (TEE). METHODS: This study population consisted of 297 patients who underwent TEE. Aortic plaques were evaluated in the proximal thoracic aorta (PTA) (from the ascending aorta to the aortic arch) and the distal thoracic aorta (DTA) (the descending aorta) using TEE. Aortic plaques were defined as complex plaques of ≥4 mm thickness and with ulceration or mobile components. CKD was defined as the estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2). The association between CKD and aortic plaques was evaluated using multivariate analysis after adjusting for traditional atherosclerotic risk factors. RESULTS: Patients with CKD (n = 144) had a higher incidence of any plaques and complex plaques compared with those without CKD (n = 153) (85% vs. 47% and 42% vs. 17%, respectively, both P < 0.001). Univariate analysis indicated that the presence of CKD was significantly associated with complex plaques both in the DTA and the PTA (both, P < 0.001); however, multivariate analysis indicated that the presence of CKD was associated with only complex plaques in the DTA (P < 0.05), but not with those in the PTA. CONCLUSION: The presence of CKD was associated with complex aortic plaques, with this association being stronger for complex plaques in the DTA than those in the PTA.

Relationship between CHADS2 score and complex aortic plaques by transesophageal echocardiography in patients with nonvalvular atrial fibrillation.

The CHADS2 score is widely used for risk stratification of thromboembolism in patients with non-valvular atrial fibrillation (NVAF). Although the correlation of CHADS2 score with left atrial (LA) abnormality as detected by transesophageal echocardiography (TEE) has been reported in previous studies, the relationship between CHADS2 score and complex aortic plaque, which is also a significant risk factor for thromboembolism, has not been fully investigated. We assessed aortic plaques by TEE in 150 patients age ≥ 55 y with NVAF. The prevalence of complex aortic plaques increased along with increases in CHADS2 score (p = 0.001). In a multivariate analysis that included atherosclerotic risk factors and LA abnormality, a CHADS2 score ≥2 was independently associated with the presence of complex aortic plaques (odds ratio [OR] 3.39; 95% confidence interval [CI], 1.29-8.90). A high CHADS2 score is closely associated with the presence of complex aortic plaques, which explains, in part, the increased risk of thromboembolism in NVAF patients with high CHADS2 score.