Left atrial appendage morphology at transesophageal echocardiography: how to improve reproducibility?

BACKGROUND: Left atrial appendage (LAA) morphology, investigated by computed tomography and magnetic resonance imaging, has proved to relate to the risk of cerebrovascular events in patients with atrial fibrillation (AF). The aim of the present study was to assess reproducibility of transesophageal echocardiography (TEE) imaging in describing LAA morphology. METHODS: Two-hundred consecutive patients referred for TEE were enrolled. In the first group of 47 (23.5%) patients LAA morphology was analyzed by conventional TEE and described as ChickenWing, Windsock, Cactus or Cauliflower. In the second group of 153 (76.5%) patients, instead, a 3D-Xplane diagnostic algorithm was performed to stratify LAA morphology as linear (ChickenWing) or complex (Windsock/Cactus and Cauliflower). Interobserver variability within three independent readers was assessed in both groups of patients and stratified by operator's experience and training. In a subgroup of 19 (12.4%) patients, the agreement of LAA morphology description by 3D-Xplane diagnostic algorithm was compared to cardiac magnetic resonance. RESULTS: By conventional TEE the agreement among operators on LAA morphology classification was poor (ρ<0.13). The 3D-XPlane diagnostic algorithm, significantly increased interobserver agreement up to ρ=0.32 within all readers and up to ρ=0.82 among the experienced and specifically trained operators. LAA morphology description in this latter group provided strong agreement with cardiac magnetic resonance (up to ρ=0.77). CONCLUSIONS: LAA morphology assessment is challenging by conventional TEE. To improve reproducibility, the use of the 3D-Xplane technique combined with a specific diagnostic algorithm and training of the operators is fundamental.

Predictors of survival in patients undergoing cardiac rehabilitation after transcatheter aortic valve implantation.

AIMS: Cardiac rehabilitation may improve physical and functional recovery after transcatheter aortic valve implantation (TAVI), but outcome predictors in TAVI patients are usually based on assessments made before or at the time of TAVI without regard to cardiac rehabilitation referral. We aimed to assess exercise-based cardiac rehabilitation-derived parameters that may predict 3-year outcome in TAVI patients undergoing residential cardiac rehabilitation. METHODS AND RESULTS: In 95 consecutive TAVI patients (82.7 ±â€Š4.9 years, 65% women) who underwent a 3-week cardiac rehabilitation program, at 3-year follow-up 35 deaths occurred. Compared with survivors, nonsurvivors had longer stay in cardiac rehabilitation (29.5 ±â€Š12.3 vs. 21.6 ±â€Š7.5 days, P = 0.0001), worse serum creatinine at admission/discharge (1.59 ±â€Š0.86 vs. 1.26 ±â€Š0.43 mg/dl, P = 0.0164; 1.52 ±â€Š0.61 vs. 1.23 ±â€Š0.44 mg/dl, P = 0.011), higher Cumulative Illness Rated State Comorbidity Index (5.4 ±â€Š1.5 vs. 4.6 ±â€Š1.8, P = 0.036) and Barthel Index at admission/discharge (51.8 ±â€Š24.5 vs. 68.1 ±â€Š23.2, P = 0.0016; 73.5 ±â€Š27.2 vs. 88.6 ±â€Š15.3, P = 0.0007), higher Morse Fall Risk score (35.6 ±â€Š24 vs. 24.3 ±â€Š14.1, P = 0.0056), and were less likely to train above the median exercise workload (fit) (11 vs. 35%, P = 0.008) or perform the 6-min walk test (6MWT) at admission/discharge (NO-6MWT: 34 vs. 12%, P = 0.008) and walked less distance on admission (6MWT: 129.6 ±â€Š88.3 vs. 193.3 ±â€Š69.8 m, P = 0.008). Univariate predictors of 3-year survival were cardiac rehabilitation duration, serum creatinine, Cumulative Illness Rated State Comorbidity Index, Barthel Index and NO-6MWT at admission/discharge, 6MWT at admission, Morse Fall Risk score at discharge and fit. Multivariate analysis confirmed exercise tolerance, Barthel Index and sCr at discharge as predictors. CONCLUSION: In TAVI patients who undergo cardiac rehabilitation, lower exercise tolerance, higher Barthel Index and sCr at discharge may predict 3-year mortality.

Cardiac rehabilitation after transcatheter aortic valve implantation compared to patients after valve replacement.

AIMS: To evaluate feasibility, safety, and outcome of an exercise-based residential cardiac rehabilitation program in transcatheter aortic valve implantation (TAVI) patients compared to elderly patients after surgical valve replacement (sAVR). METHODS: From January 2010 to January 2013, 65 consecutive TAVI and 70 sAVR older than 70 years were enrolled. Six-min walk test (6MWT) distance, Barthel index, Morse Fall Scale (MFS) on admission and discharge, Cumulative Illness Rated State-Comorbidity Index (CIRS-CI), and echocardiography were assessed. Patients underwent a 3-week intensive cardiac rehabilitation program. RESULTS: Compared with sAVR, TAVI had worse CIRS-CI (4.8 ±â€Š1.5 vs. 3.4 ±â€Š1.5; P = 0.00001), left ventricle ejection fraction (55.3 ±â€Š9 vs. 59.2 ±â€Š7.7; P = 0.008), Barthel index (67 ±â€Š24 vs. 79 ±â€Š21; P = 0.0018), and MFS (36 ±â€Š22 vs. 25 ±â€Š19; P = 0.002) on admission and at discharge (Barthel index 85 ±â€Š17 vs. 93 ±â€Š14; P = 0.005 and MFS 30 ±â€Š20 vs. 20 ±â€Š12; P = 0.0001), despite a significant improvement at discharge of Barthel index (85 ±â€Š17 vs. 67 ±â€Š24; P = 0.001) and MFS (36 ±â€Š22 vs. 30 ±â€Š20; P > 0.01). TAVI attended safely cardiac rehabilitation, but tolerated a significantly lower workload and had reduced 6MWT both on admission and discharge compared with sAVR (162 ±â€Š87vs. 216 ±â€Š82; P = 0.00001, and 240 ±â€Š92 vs. 33295; P = 0.00001, respectively), despite a net improvement at discharge in 6MWT (240 ±â€Š92 vs. 162 ±â€Š92; P < 0.001). CONCLUSION: Intensive cardiac rehabilitation after TAVI is safe, well tolerated, and leads to a net improvement in disability, risk of falls, and exercise capacity, similar to that observed in less disabled sAVR patients, favoring home discharge and relatively independent life at home. A persistent higher disability, comorbidity profile, and risk of falls at discharge characterize TAVI patients compared with sAVR patients of similar age.

The day when the echocardiographist went mushrooming .

We report a case of partial congenital absence of the pericardium associated with severe aortic stenosis on a bicuspid valve in a 72-year-old man. Diagnosis was based on echocardiography and confirmed with magnetic resonance imaging, and the patient benefited from pericardioplasty and aortic valve replacement.

Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation? Results from a multicenter study.

OBJECTIVES: This study investigated the left atrial appendage (LAA) by computed tomography (CT) and magnetic resonance imaging (MRI) to categorize different LAA morphologies and to correlate the morphology with the history of stroke/transient ischemic attack (TIA). BACKGROUND: LAA represents one of the major sources of cardiac thrombus formation responsible for TIA/stroke in patients with atrial fibrillation (AF). METHODS: We studied 932 patients with drug-refractory AF who were planning to undergo catheter ablation. All patients underwent cardiac CT or MRI of the LAA and were screened for history of TIA/stroke. Four different morphologies were used to categorize LAA: Cactus, Chicken Wing, Windsock, and Cauliflower. RESULTS: CT scans of 499 patients and MRI scans of 433 patients were analyzed (age 59 ± 10 years, 79% were male, and 14% had CHADS(2) [Congestive heart failure, hypertension, Age >75, Diabetes mellitus, and prior stroke or transient ischemic attack] score ≥2). The distribution of different LAA morphologies was Cactus (278 [30%]), Chicken Wing (451 [48%]), Windsock (179 [19%]), and Cauliflower (24 [3%]). Of the 932 patients, 78 (8%) had a history of ischemic stroke or TIA. The prevalence of pre-procedure stroke/TIA in Cactus, Chicken Wing, Windsock, and Cauliflower morphologies was 12%, 4%, 10%, and 18%, respectively (p = 0.003). After controlling for CHADS2 score, gender, and AF types in a multivariable logistic model, Chicken Wing morphology was found to be 79% less likely to have a stroke/TIA history (odd ratio: 0.21, 95% confidence interval: 0.05 to 0.91, p = 0.036). In a separate multivariate model, we entered Chicken Wing as the reference group and assessed the likelihood of stroke in other groups in relation to reference. Compared with chicken wing, cactus was 4.08 times (p = 0.046), Windsock was 4.5 times (p = 0.038), and Cauliflower was 8.0 times (p = 0.056) more likely to have had a stroke/TIA. CONCLUSIONS: Patients with Chicken Wing LAA morphology are less likely to have an embolic event even after controlling for comorbidities and CHADS2 score. If confirmed, these results could have a relevant impact on the anticoagulation management of patients with a low-intermediate risk for stroke/TIA.

Quantitative coronary angiography in the current era: principles and applications.

Coronary angiography, despite its inherent invasiveness and need for contrast media and radiographic exposure, is still routinely employed every year for the diagnostic and therapeutic management of millions of patients with or at risk for coronary artery disease. Whereas approximate visual estimation is the most common way to evaluate coronary angiography findings, since the late 1980s a number of investigators have developed and investigated methods of quantitative coronary angiography (QCA) analysis exploiting automated or semi-automated edge detection. Despite the inherent drawback of QCA due to its focus on the contrast-filled lumen of the vessel, QCA has offered and continues to offer important insights for clinical research and, in selected cases, clinical practice. This review aims thus to provide a comprehensive and updated viewpoint on the actual role of QCA.