Immediate Improvement in Left Atrial Function After Transcatheter Aortic Valve Replacement on Doppler Echocardiography.

BACKGROUND: More than 50% of embolic strokes occur >24 hours after transcatheter aortic valve replacement (TAVR) and are therefore not directly procedure related. We aimed to determine immediate changes in left atrial (LA) function after TAVR, that may alter short-term and long-term stroke risk after TAVR. METHODS: Transesophageal and transthoracic echocardiography were performed before and immediately after TAVR to evaluate left atrial appendage (LAA) velocities and Doppler echocardiographic markers of LA function. RESULTS: Eighty-five patients (mean age, 83.1 ± 7.5 years; 54% male) underwent TAVR. Patients in sinus rhythm (n = 57) during TAVR had immediate improvement of LA function, with an increase in A-wave velocity (92.3 ± 33.7 cm/s to 104.9 ± 34.6 cm/s), mitral inflow velocity time integral (VTI; 27.8 ± 3.6 to 29.6 ± 9.5), A-wave VTI (10.8 ± 4.1 to 12.8 ± 4.2), and lateral A´ velocity (8.8 ± 3.6 cm/s to 9.7 ± 3.6 cm/s; P<.05 for all), and a decrease in E/A ratio (1.2 ± 0.73 to 1.05 ± 0.59; P<.01) after TAVR. Low baseline LAA emptying velocities were common (53%), and velocities significantly increased after TAVR (mean change, +4.9 cm/s; P<.01). We identified several clinical and echocardiographic determinants of low LAA emptying velocity at baseline (<35 cm/s). CONCLUSIONS: There is immediate improvement in LA function and an increase in LAA velocities after TAVR. This improvement may benefit hemodynamics immediately after TAVR, but may also increase the short-term stroke risk (as recently shown in two independent studies) in patients with LAA thrombus or low emptying velocities. Therefore, evaluation of LA function and LAA thrombus may be warranted to identify patients at high risk for periprocedural stroke and guide the need for anticoagulation therapy.

Are ejection fraction measurements by echocardiography and left ventriculography equivalent?

BACKGROUND: Left ventricular ejection fraction (EF) is an important parameter in the diagnosis and treatment of patients with coronary heart disease. Previous studies comparing echocardiography and contrast left ventriculography (CVG) for the measurement of EF have shown considerable variation in results, yet, in clinical practice, EF measurements are used interchangeably. The purpose of this study was to assess the concordance between echocardiography and CVG for the determination of EF in routine clinical practice and to identify factors associated with variation in test results. METHODS: We reviewed the medical records of 5,385 patients hospitalized for acute myocardial infarction between 1997 and 2005 as part of a community-based surveillance project. Of these, 741 patients had EF measurements recorded by both echocardiography and CVG during hospitalization. RESULTS: While good correlation (r = 0.73) and no systematic bias were noted between the measurement of EF by echocardiogram compared to CVG, there was wide variation between the 2 methods for any given patient. In approximately one third of patients with acute myocardial infarction, the measurement of EF by echocardiography and CVG differed by >10 points, while in approximately 1 in 20 patients, EF measurements by echocardiography and CVG differed by >20 points. The number of days between tests to measure EF, level of EF, temporal order of EF testing, and patient-related factors made only a minor contribution to the variation in test results. CONCLUSIONS: Our results demonstrate that, in routine clinical practice, EF determinations obtained by echocardiography and CVG may vary widely, with potentially important clinical implications.

Trends in the use of echocardiography and left ventriculography to assess left ventricular ejection fraction in patients hospitalized with acute myocardial infarction.

BACKGROUND: Although current guidelines strongly recommend the measurement of ejection fraction (EF) in all patients hospitalized with acute myocardial infarction (AMI), there are limited data available describing trends in the use of diagnostic modalities to assess EF in these patients. The purpose of this study was to evaluate trends in the use of ventriculography and echocardiography to measure EF in a community sample of patients hospitalized with AMI. METHODS: The medical records of 5,380 residents of the Worcester (MA) metropolitan area hospitalized with AMI at 11 greater Worcester medical centers between 1997 and 2005 were reviewed. RESULTS: Between 1997 and 2005, the proportion of patients hospitalized with AMI undergoing measurement of EF by both ventriculography and echocardiography increased from 11% to 18%, whereas the percentage of patients who did not receive an evaluation of EF by either modality decreased from 37% to 27%. The percentage of patients undergoing measurement of EF by ventriculography alone increased from 14% to 20%, whereas the percentage of patients undergoing measurement of EF by echocardiography alone remained stable at 37%. In 1997, echocardiography was performed before ventriculography in approximately two thirds of hospitalized patients, whereas in 2005, ventriculography was performed before echocardiography in approximately two thirds of patients with AMI. CONCLUSIONS: The use of left ventriculography and the concurrent use of both ventriculography and echocardiography to assess EF in patients with AMI are increasing. Although the proportion of patients who do not have their EF assessed has declined during recent years, many still do not receive a determination of their EF.