The relation between the atrial blood supply and the complexity of acute atrial fibrillation.

BACKGROUND: Patients with a history of myocardial infarction and coronary artery disease (CAD) have a higher risk of developing AF. Conversely, patients with atrial fibrillation (AF) have a higher risk of developing myocardial infarction, suggesting a link in underlying pathophysiology. The aim of this study was to assess whether coronary angiographic parameters are associated with a substrate for AF in patients without a history of AF. METHODS: During cardiac surgery in 62 patients (coronary artery bypass grafting (CABG;n = 47), aortic valve replacement (AVR;n = 9) or CABG + AVR (n = 6)) without a history of clinical AF (age 65.4 ± 8.5 years, 26.2% female), AF was induced by burst pacing. The preoperative coronary angiogram (CAG) was assessed for the severity of CAD, and the adequacy of atrial coronary blood supply as quantified by a novel scoring system including the location and severity of right coronary artery disease in relation to the right atrial branches. Epicardial mapping of the right atrium (256 unipolar electrodes) was used to assess the complexity of induced AF. RESULTS: There was no association between the adequacy of right atrial coronary blood supply on preoperative CAG and AF complexity parameters. Multivariable analysis revealed that only increasing age (B0.232 (0.030;0.433),p = 0.03) and the presence of 3VD (B3.602 (0.187;7.018),p = 0.04) were independently associated with an increased maximal activation time difference. CONCLUSIONS: The adequacy of epicardial right atrial blood supply is not associated with increased complexity of induced atrial fibrillation in patients without a history of clinical AF, while age and the extent of ventricular coronary artery disease are.

Preoperative Planning of Transapical Beating Heart Mitral Valve Repair for Safe Adaptation in Clinical Practice.

OBJECTIVE: Transapical off-pump minimally invasive mitral valve repair (TOP-MINI) is a new technique for the surgical repair of degenerative mitral regurgitation based on mitral valve prolapse. The aim of this study is to demonstrate the preoperative planning tools available for starting this new procedure in a safe manner. METHODS: The first patients undergoing TOP-MINI by a single surgeon in 2016 were prospectively included. All patients underwent identical clinical pathways and underwent extensive preoperative planning for a safe start of the program. Patients were discussed in our dedicated mitral valve heart-team consisting of diagnostic and interventional mitral valve specialists. All patients underwent computed tomography, transthoracic and transesophageal echocardiography, and mitral valve replication using rapid prototyping. All procedures were performed by the same surgical team. RESULTS: Thirty-six patients were discussed for isolated mitral valve repair in our dedicated mitral valve heart team of which seven patients were deemed eligible for this novel approach. Three-dimensional (3D) reconstructions of computed tomography images allowed the surgical team to determine skin incision level and ideal level of device insertion near the apex of the heart. Echocardiography and rapid prototyping allowed us to assess surgical success probability by determining the amount of tissue overlap and was used intraoperatively for guidance. All patients were operated on successfully, without any major adverse events. CONCLUSIONS: We demonstrate a method to safely start the TOP-MINI program with precise patient selection and preoperative planning, allowing us to determine procedural strategy and assessment of surgical success probability.

Aortic elongation part I: the normal aortic ageing process.

OBJECTIVES: Differentiation between normal and abnormal features of vascular ageing is crucial, as the latter is associated with adverse outcomes. The normal aortic ageing process is accompanied by gradual luminal dilatation and reduction of vessel compliance. However, the influence of age on longitudinal aortic dimensions and geometry has not been well studied. This study aims to describe the normal evolution of aortic length and shape throughout life. METHODS: A total of 210 consecutive patients were prospectively enrolled in this cross-sectional single-centre study. All subjects underwent CT on a third-generation dual-source CT scanner. Morphometric measurements, including measurements of segmental length and tortuosity, were performed on three-dimensional models of the thoracic aorta. RESULTS: The length of the thoracic aorta was significantly related to age (r=0.54) and increased by 59 mm (males) or 66 mm (females) between the ages of 20 and 80 years. Elongation was most pronounced in the proximal descending aorta, which showed an almost 2.5-fold length increase during life. The lengthening of the thoracic aorta was accompanied by a marked change of its geometry: whereas the aortic apex was located between the branch vessels in younger patients, it shifted to a more distalward position in the elderly. CONCLUSIONS: The normal ageing process is accompanied by gradual aortic elongation and a notable change of aortic geometry. Part II of this two-part article investigates the hypothesis that excessive elongation could play a role in the occurrence of acute aortic dissection.

Aortic elongation part II: the risk of acute type A aortic dissection.

OBJECTIVES: Prophylactic surgery for prevention of acute type A aortic dissection (ATAAD) is reserved for patients with an ascending aortic aneurysm ≥55 mm. Identification of additional risk predictors is warranted since over 70% of patients presenting with ATAAD have a non-dilated aorta or an aneurysm that would not have met the diameter criterion for preventative surgery. Aim of the study was to evaluate ascending aortic elongation as a risk factor for ATAAD and to compare aortic lengths between ATAAD patients and healthy controls. METHODS: Aortic lengths and diameters of ATAAD patients were measured on three-dimensional modelled computed tomography and adjusted to predissection dimensions in this cross-sectional single-centre study. Logistic regression was used to evaluate the relation between ATAAD and aortic dimensions. Lengths of different aortic segments were compared with a healthy control group using propensity score matching. RESULTS: Two-hundred and fifty patients were included in the study (ATAAD, n=40; controls, n=210). Ascending aortic length and diameter proved to be independent predictors for ATAAD (OR=5.3, CI 2.5 to 11.4, p<0.001 and OR=8.6, CI 2.4 to 31.0, p=0.001). Eighty patients were matched based on propensity scores (ATAAD n=40, controls n=40). The ascending aorta was longer and more dilated in ATAAD patients compared with healthy controls (78.6±8.8 mm vs 68.9±7.2 mm, p<0.001, 34.4 mm ±3.2. vs 39.4 mm ±5.7, p<0.001, respectively). No differences were found in lengths of the aortic arch and descending aorta. CONCLUSIONS: Ascending aortic length could serve as an independent predictor for ATAAD. Future studies addressing indications for prophylactic surgery should also investigate aortic length.

The mechanical fibrillation pattern of the atrial myocardium is associated with acute and long-term success of electrical cardioversion in patients with persistent atrial fibrillation.

BACKGROUND: Electrophysiological studies demonstrate that a short atrial fibrillation cycle length (AFCL) is related with poor outcome of electrical cardioversion (ECV) of atrial fibrillation (AF). We found previously that the mechanical AFCL (AFCL-tvi) and atrial fibrillatory velocity (AFV-tvi) may be determined noninvasively using color tissue velocity imaging (TVI) and closely relates to the electrophysiological AFCL. OBJECTIVE: To evaluate the relation between AFCL-tvi, AFV-tvi, and success of ECV in patients with AF. METHODS: We prospectively studied 133 patients with persistent AF by performing echocardiography before ECV and measured the AFCL-tvi and AFV-tvi in the right atrium and left atrium. Recurrent AF was monitored. RESULTS: Nineteen (14%) patients had failure of ECV, 42 (32%) remained in sinus rhythm after 1-year follow-up, and 72 (54%) had a recurrence of persistent AF. Patients with immediate ECV failure had a lower median AFV-tvi measured in the right atrium than did patients with a successful ECV: 0.7 cm/s (0.2-1.0 cm/s) vs. 1.7 cm/s (0.9-2.8 cm/s) (P = .008). Patients with maintenance of sinus rhythm after 1 year had a longer AFCL-tvi measured in the left atrium than did patients with recurrence of AF (150 ms vs 137 ms; P = .017) and had a higher AFV-tvi in both atria (1.4 vs. 0.9 cm/s in the left atrium; P = .013 and 2.2 vs 1.4 cm/s in the right atrium; P = .011). Multivariate analyses showed that all atrial TVI parameters were independently associated with the maintenance of sinus rhythm after 1 year. CONCLUSION: Higher atrial fibrillatory wall velocities and longer AFCLs determined by echocardiography are associated with acute and long-term success of ECV.

An FBN1 deep intronic mutation in a familial case of Marfan syndrome: an explanation for genetically unsolved cases?

Marfan syndrome (MFS) is caused by mutations in the FBN1 (fibrillin-1) gene, but approximately 10% of MFS cases remain genetically unsolved. Here, we report a new FBN1 mutation in an MFS family that had remained negative after extensive molecular genomic DNA FBN1 testing, including denaturing high-performance liquid chromatography, Sanger sequencing, and multiplex ligation-dependent probe amplification. Linkage analysis in the family and cDNA sequencing of the proband revealed a deep intronic point mutation in intron 56 generating a new splice donor site. This mutation results in the integration of a 90-bp pseudo-exon between exons 56 and 57 containing a stop codon, causing nonsense-mediated mRNA decay. Although more than 90% of FBN1 mutations can be identified with regular molecular testing at the genomic level, deep intronic mutations will be missed and require cDNA sequencing or whole-genome sequencing.

Aspirin versus vitamin K antagonist treatment guided by transoesophageal echocardiography in patients with atrial fibrillation: a pilot study.

OBJECTIVE: Current stroke risk schemes need improvement of predictive value in patients with atrial fibrillation. Transoesophageal echocardiography (TEE) may facilitate stroke risk assessment in such patients and guide antithrombotic treatment. METHODS: We randomised 238 patients with non-valvular atrial fibrillation and a moderate stroke risk to aspirin or adjusted vitamin K antagonist therapy after TEE had ruled out thrombogenic features in the atria and aorta. The primary outcome was a composite of stroke, major bleeding, peripheral embolism and all-cause mortality. RESULTS: Mean CHA2DS2-VASc score was 2.1±1.1. The incidences of the composite primary outcome at a mean follow-up of 1.6 years were 3.2% (2.02% per year) in the aspirin group compared to 6.1% (3.84% per year) in the vitamin K antagonists group with an absolute advantage of 2.9 percentage points. Aspirin was non-inferior to vitamin K antagonists (p<0.0001) because the upper limit of the 90% CI did not exceed the 7% absolute difference in event rate between the two treatment arms. CONCLUSIONS: This hypothesis-generating pilot trial has found that TEE may be used for refinement of stroke risk in paroxysmal atrial fibrillation patients. A larger trial is needed to confirm these data. (ClinicalTrials.gov number NTC00224757).

Incremental value of cardiovascular magnetic resonance over echocardiography in the detection of acute and chronic myocardial infarction.

BACKGROUND: Although echocardiography is used as a first line imaging modality, its accuracy to detect acute and chronic myocardial infarction (MI) in relation to infarct characteristics as assessed with late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) is not well described. METHODS: One-hundred-forty-one echocardiograms performed in 88 first acute ST-elevation MI (STEMI) patients, 2 (IQR1-4) days (n = 61) and 102 (IQR92-112) days post-MI (n = 80), were pooled with echocardiograms of 36 healthy controls. 61 acute and 80 chronic echocardiograms were available for analysis (53 patients had both acute and chronic echocardiograms). Two experienced echocardiographers, blinded to clinical and CMR data, randomly evaluated all 177 echocardiograms for segmental wall motion abnormalities (SWMA). This was compared with LGE-CMR determined infarct characteristics, performed 104 ± 11 days post-MI. Enhancement on LGE-CMR matched the infarct-related artery territory in all patients (LAD 31%, LCx 12% and RCA 57%). RESULTS: The sensitivity of echocardiography to detect acute MI was 78.7% and 61.3% for chronic MI; specificity was 80.6%. Undetected MI were smaller, less transmural, and less extensive (6% [IQR3-12] vs. 15% [IQR9-24], 50 ± 14% vs. 61 ± 15%, 7 ± 3 vs. 9 ± 3 segments, p < 0.001 for all) and associated with higher left ventricular ejection fraction (LVEF) and non-anterior location as compared to detected MI (58 ± 5% vs. 46 ± 7%, p < 0.001 and 82% vs. 63%, p = 0.03). After multivariate analysis, LVEF and infarct size were the strongest independent predictors of detecting chronic MI (OR 0.78 [95%CI 0.68-0.88], p < 0.001 and OR 1.22 [95%CI0.99-1.51], p = 0.06, respectively). Increasing infarct transmurality was associated with increasing SWMA (p < 0.001). CONCLUSIONS: In patients presenting with STEMI, and thus a high likelihood of SWMA, the sensitivity of echocardiography to detect SWMA was higher in the acute than the chronic phase. Undetected MI were smaller, less extensive and less transmural, and associated with non-anterior localization and higher LVEF. Further work is needed to assess the diagnostic accuracy in patients with non-STEMI.

Clinical and echocardiographic correlates of intra-atrial conduction delay.

AIMS: The total atrial conduction time (TACT) is an important electrophysiological parameter. We developed a new transthoracic echocardiographic tool (PA-TDI). The PA-TDI interval is a reflection of the TACT. In the present study, we evaluated the clinical and echocardiographic correlates of intra-atrial conduction delay. METHODS AND RESULTS: We studied 427 patients without class I anti-arrhythmic agents or amiodarone. All patients underwent an echocardiogram and the PA-TDI interval was measured. Patient characteristics were recorded. The mean PA-TDI was 157 ± 22 ms. Multivariate linear regression analysis revealed that atrial fibrillation (AF) in history (B = 9.7; 95%CI 5.7-13.8; P < 0.001), hypertension (B = 5.5; 95%CI 1.4-9.8; P = 0.01), clinically relevant valve disease (B = 5.7; 95%CI 0.5-10.8; P = 0.03), age (B = 5; 95%CI 3.3-6.6; P < 0.001), and body mass index (BMI; B = 2.6; 95%CI 0.3-4.9; P = 0.026) were independently associated with the PA-TDI interval. On the echocardiogram: the aortic diameter (B = 0.7; 95%CI 0.2-1.2; P = 0.009), left atrial dimension (B = 0.9; 95%CI 0.5-1.3; P < 0.001), mitral valve E-wave deceleration time (B = 0.1; 95%CI 0.1-0.1; P < 0.001), aortic incompetence (B = 13; 95%CI 3.3-22.6; P = 0.008), and mitral incompetence (B = 11; 95%CI 3.6-17.5; P < 0.003) were independently associated with the PA-TDI interval. CONCLUSION: This study is the largest to investigate the relation between the atrial conduction time, underlying heart diseases, and echocardiographic parameters. We found that the PA-TDI was independently prolonged in patients with a history of AF, hypertension, valve disease, higher age, and a higher BMI. Signs of diastolic dysfunction, valve incompetence, and enlarged atrium or aortic root on the echocardiogram were associated with a prolonged PA-TDI. This suggests that early and aggressive treatment of hypertension, diastolic dysfunction, and obesity could prevent intra-atrial conduction delay.

Hemorrhagic myocardial infarction after percutaneous coronary intervention: Echographic versus autopsy findings.

We present a case of hemorrhagic myocardial infarction after early percutaneous coronary intervention which was suggested by cardiac echocardiography, and later confirmed by post-mortem examination.

Atrial fibrillatory wall motion and degree of atrial remodeling in patients with atrial fibrillation: a tissue velocity imaging study.

INTRODUCTION: The atrial fibrillation cycle length (AFCL) and the intracardiac atrial electrogram morphology may be used to characterize atrial fibrillation (AF). However, assessment of these parameters requires an invasive electrophysiological study. We assessed clinical and electrophysiological correlates of noninvasive tissue velocity imaging (TVI) of the right and left atrial myocardial fibrillatory wall motion. METHODS AND RESULTS: We performed an electrophysiological study in 12 patients with AF referred for His bundle ablation. Using atrial electrograms, we determined the AFCL (AFCL-egm) and electrophysiological AF type. Simultaneously, transthoracic echocardiography was performed. We used the TVI traces to determine the cycle length of the atrial fibrillatory wall motion (AFCL-tvi) and atrial fibrillatory wall velocities (AFV-tvi). AFCL-tvi matched very well with AFCL-egm (r(2)= 0.98; P < 0.001), both in the left and right atrium. Patients with permanent AF had shorter AFCL-tvi (155 +/- 15 ms vs 216 +/- 23 ms; P < 0.001), higher AFCL-tvi variability, and lower AFV-tvi compared to patients with paroxysmal AF. Three electrophysiological AF types were found based on the morphology of the electrograms and these related to specific TVI patterns. CONCLUSION: TVI of the atrial fibrillatory wall motion may enhance noninvasive characterization of atrial remodeling in patients with atrial fibrillation.

Apical rotating flow and right ventricular cerebral compression.

A 59-year-old male was admitted to the emergency room with signs of heart failure. The echocardiogram showed an extensive apical infarction with large mobile thrombi in the left ventricle. Doppler examination demonstrated apical rotating flow. Despite adequate anticoagulant therapy, the patient suffered a massive right-sided cerebral infarction leading to right ventricular cerebral compression. The thrombogenic risk of apical rotating flow and the need for anticoagulation are discussed.

Qualitative observation of left ventricular multiphasic septal motion and septal-to-lateral apical shuffle predicts left ventricular reverse remodeling after cardiac resynchronization therapy.

A multiphasic septal motion and typical septal-to-lateral apical shuffle of the left ventricle can be observed echocardiographically in some patients with left branch bundle block. The relation of both with left ventricular (LV) dyssynchrony according to tissue Doppler and LV reverse remodeling after cardiac resynchronization therapy was investigated. Fifty-three patients (37 men; age 68+/-8 years) with ischemic (n=26) or idiopathic (n=27) cardiomyopathy, baseline QRS duration 171+/-30 ms, LV ejection fraction 21+/-7%, and LV end-diastolic volume 257+/-91 ml were studied. LV dyssynchrony using tissue Doppler was considered present if the SD of the interval between QRS and onset of systolic velocity of 6 basal LV segments was >20 ms. Shuffle was evaluated visually independently by 5 cardiologists and considered present if observed in>or=1 view. LV reverse remodeling, defined as LV end-systolic volume decrease>or=10%, was observed in 37 patients (70%) after 3 months of CRT. Sensitivity and specificity of either shuffle or multiphasic septal motion for all 5 observers (range 90% to 97% and 67% to 83%, respectively) were found to predict LV dyssynchrony. To predict LV reverse remodeling, sensitivity and specificity from 87% to 92% and 69% to 81% were observed, respectively. In conclusion, the qualitative observation of a typical shuffle or multiphasic septal motion predicts LV dyssynchrony and LV reverse remodeling adequately.

Ventricular pseudoaneurysm after subacute myocardial infarction.

A 55-year-old woman with a blank cardiac history was admitted in a regional hospital because of acute left sided heart failure. Initial evaluation showed a subacute inferior wall myocardial infarction with preserved left ventricular function and moderately severe mitral regurgitation. Before referral, coronary angiography was performed. Ventriculography revealed a posterior pseudoaneurysm that was missed initially. Fortunately she survived two almost fatal episodes of cardiac asthma in that hospital. After the diagnosis was made, she was sent to our tertiary care hospital, where she was urgently and successfully operated. A short review, with emphasis on diagnosing left ventricular pseudoaneurysm is presented.

Ventricular remodeling during long-term right ventricular pacing following His bundle ablation.

To investigate ventricular remodeling during long-term right ventricular (RV) pacing after His bundle ablation (HBA) in patients with atrial arrhythmias, a retrospective analysis was performed on echocardiographic data from 45 patients (mean age 57 +/- 11 years) with atrial arrhythmias who underwent HBA and pacemaker implantation (HBA-PI) to control ventricular rate. Echocardiography was performed 1 year before HBA-PI, and up to 7 +/- 2 years of follow-up was conducted. An inverse linear relation was found between the relative increase of left ventricular (LV) end-diastolic diameter (EDD) during long-term RV pacing and LVEDD before HBA-PI (r = -0.61, p<0.001). Patients were divided into 2 groups: those with LVEDDs smaller than the mean LVEDD of 50 mm (group I, 46 +/- 2 mm, n = 28) and those with LVEDDs >50 mm (group II, 56 +/- 4 mm, n = 17). Before HBA-PI, patients in group I had significantly smaller LV weights (167 +/- 44 vs 238 +/- 56 g) and LV end-systolic diameters (30 +/- 2 vs 42 +/- 7 mm) and higher LV ejection fractions (64 +/- 5% vs 49+/- 12%) than those in group II. In group I, long-term RV pacing increased LVEDD, LV end-systolic diameter, LV weight, and left atrial diameter; increased mitral regurgitation; and decreased the LV ejection fraction and LV fractional shortening. No significant changes were observed during long-term RV pacing in group II. In conclusion, long-term RV pacing after HBA adversely affects LV structure and function in patients with initially normal LV dimensions and function.

Atrial activation time determined by transthoracic Doppler tissue imaging can be used as an estimate of the total duration of atrial electrical activation.

BACKGROUND: Currently, the total atrial activation time, as indicated by the P-wave duration using signal-averaged (SA) electrocardiogram (ECG) (SA-ECG), is the most powerful predictor of atrial fibrillation. However, because of practical limitations, this technique is not used in clinical routine. In this study we evaluated several alternative techniques to measure the total atrial activation time, including a new parameter that uses atrial Doppler tissue imaging (DTI). METHODS: For 30 patients who were in sinus rhythm and underwent a transthoracic echocardiogram, we determined the P-wave duration on surface ECG and SA-ECG, and the interval from the onset of the P wave (lead II) until the onset of the echocardiographic flow Doppler A wave over the mitral valve. In addition, using pulsed wave DTI in the 4-chamber view, we measured the interval of time from initiation of the ECG P wave (lead II) until the peak of the local lateral left atrial (LA) DTI signal. Correlation between the SA-ECG, surface ECG, and echocardiographic parameters were evaluated by Spearman correlation tests. RESULTS: All parameters that were used to estimate total atrial activation time showed a significant correlation with the SA-ECG P-wave duration. Although the interval of time from initiation of the ECG P wave until the peak of the local lateral LA DTI signal was significantly longer than the SA-ECG P-wave duration (151.12 +/- 19.4 vs 128.4 +/- 15.8 milliseconds, respectively, P < .01), it showed the highest correlation (R = 0.91, P < .001). There was no significant correlation between the SA-ECG and routine echocardiographic parameters such as LA, right atrial, or total atrial size. Measurement of the interval of time from initiation of the ECG P wave until the peak of the local lateral LA DTI signal added 1 +/- 0.5 minutes to a routine echocardiographic evaluation, whereas measurement of the SA-ECG P-wave duration took 20 +/- 5 minutes (P < .01). CONCLUSION: LA DTI is an easy, fast, and reliable method to estimate the total atrial electrical activation time, and may be useful in the identification of those prone to develop atrial fibrillation.

Pre-dilution on-line haemofiltration vs low-flux haemodialysis: a randomized prospective study.

BACKGROUND: Accumulation of larger molecular weight uraemic toxins molecules may have a negative effect on the cardiovascular and nutritional state of dialysis patients and influence uraemic symptomatology. Their clearance can be enhanced by the use of haemofiltration (HF). METHODS: The effects of low-flux haemodialysis (HD) (ultrapure dialysate; polyamide membranes) and pre-dilution on-line HF (1:1 blood/substitution ratio; target filtration volume: 1.2 times body weight) on cardiovascular and nutritional parameters, interdialytic levels of uraemic toxins and quality of life (QOL; Laupacis questionnaire) were assessed during 1 year follow-up. Forty patients were randomized. RESULTS: After 1 year, 27 patients were eligible for analysis (HF: 13 patients; HD: 14 patients). Left ventricular mass index did not change in the HF patients (127+/-33 --> 131+/-36 g/m(2) after 12 months) or in the HD group (135+/-34 --> 138+/-32 g/m(2)). Also, there were no changes in pulse wave velocity, and 48 h systolic and diastolic blood pressures. Lean body mass, assessed by dual-energy X-ray absorptiometry, increased in the HF group (44.8+/-8.9 --> 46.2+/-9.6 kg; P<0.05), but not in the HD group (49.4+/-9.2 --> 50.6+/-8.8 kg), although differences between groups were not significant. Insulin-like growth factor-1 levels remained stable in the HF patients, but decreased in the HD group (P<0.05 between groups). QOL for physical symptoms improved in the HF group (4.2+/-1.2 --> 5.0+/-1.1; P<0.05 within the HF group and P = 0.06 between groups), but not in the HD group (4.0+/-1.0 --> 4.4+/-1.4). beta2-microglobulin, complement factor D and homocysteine decreased significantly in the HF but not in the HD group, whereas l-ADMA, leptin and advanced glycation end-products-related fluorescence did not change. CONCLUSIONS: No changes in cardiovascular parameters were observed during pre-dilution on-line HF compared with low-flux HD. Treatment with on-line HF resulted in marked changes in the uraemic toxicity profile, an improvement in physical well-being and a small improvement in nutritional state.

Late left ventricular pseudoaneurysm formation following subacute myocardial infarction.

We describe a patient with a subacute inferior myocardial infarction who developed a pseudo-aneurysm more than 18 days after the acute event. This is an unusual case with three different complications of a myocardial infarction: Firstly, ventricular rupture is usually the result following transmural myocardial infarction without reperfusion. However, coronary angiography confirmed reperfusion after late thrombolysis in this patient. The subacute rupture could potentially be caused or aggravated by the late thrombolysis. Secondly, this patient developed a mural apical thrombus in a non-infarcted region. It seems most likely that the new infarct caused a low flow state which enhanced thrombus formation. Against expectations, this developed at the apex rather than the site of the recent inferior wall myocardial infarction. Thirdly, we documented the development of a pseudo-aneurysm more than 18 days after the myocardial infarction. This complication is rarely seen at this stage after a myocardial infarction, as most pseudo-aneurysms are formed within 7 days after a myocardial infarction. We have beautifully visualised the apical thrombus and pseudo-aneurysm with echocardiography. This report shows that serial echocardiography is a very useful tool in evaluating the patient's clinical and cardiac status in the period after a myocardial infarction.

Which elderly patients with severe aortic stenosis benefit from surgical treatment? An aid to clinical decision making.

BACKGROUND AND AIM OF THE STUDY: Clinical decision-making in an individual elderly patient with severe aortic stenosis (AS) is difficult. The prognosis is influenced by increased age and various cardiac morbidity and comorbidity, and the benefit of surgery is uncertain because the prognosis with conservative treatment has rarely been described. The study aim was to identify those patients who would gain from surgical therapy. METHODS: The long-term survival of a cohort of elderly patients after an initial diagnosis of severe aortic stenosis was analyzed. Multivariate analysis was used to develop patient profiles on the basis of four main variables of age, severity of AS, cardiac morbidity, and comorbidity, to illustrate the benefit of surgical treatment over conservative treatment. RESULTS: A total of 280 consecutive patients aged > or = 70 years (median age 78 years) with a first-time diagnosis of isolated AS made between 1991 and 1993 was included. Of these patients, 120 underwent surgery. The seven-year predicted survival ranged from 6.9% to 83% in surgically treated patient, and from 0.6% to 48% in conservatively treated patients. The benefit of surgical treatment over conservative treatment was greatest in patients aged < 80 years, with a more critical AS, cardiac morbidity, and without (7-year survival 78% versus 14%) or with (7-year survival 56% versus 1%) comorbidity. Minimal benefit was seen in patients aged > 80 years with a less critical AS and without cardiac morbidity. CONCLUSION: This model illustrated the benefit of surgical treatment over conservative treatment in 16 different profiles of elderly patients with severe AS. These findings may provide support for clinical decision making in individuals within this patient group.