Evaluation of contemporary echocardiographic and histomorphology parameters in predicting mortality in patients with endomyocardial biopsy-proven cardiac AL amyloidosis.

Introduction: This study examined the role of echocardiographic and cardiac histomorphology parameters in predicting mortality in patients with cardiac AL amyloidosis. Methods: Patients with endomyocardial biopsy-proven cardiac AL amyloidosis treated at MD Anderson Cancer Center between 6/2011 and 6/2020 were identified. Stored echocardiographic images and endomyocardial biopsy samples were processed for myocardial strain analysis and a detailed histomorphology characterization. Results: Of 43 patients; 44% were women and 63% white. Median age was 65 years; 51% underwent stem cell transplantation (SCT). Thirty patients (70%) died during follow up (median follow up: 4.1 years). Lower LA strain (<13.5%) and absence of SCT as a time-varying covariate were significantly associated with increased risk of death in the multivariate cox regression analysis. Higher LV mass and lower RV tricuspid annular plane systolic excursion were associated with increased odds of having ≥5% interstitial amyloid deposition on biopsy in the multivariate logistic regression analysis. Conclusion: Lower LA strain independently predicted mortality in our cohort, and its performance in the routine assessment of AL amyloidosis may be beneficial. Furthermore, SCT for cardiac AL amyloidosis was associated with improved OS. These findings need to be confirmed by larger studies in the era of contemporary systemic therapies.

ITSUS: Integrated, Tiered, Self-Directed Ultrasound Scanning for Learning Anatomy.

Ultrasound is being introduced into many medical schools and incorporated into the anatomy curriculum; however, in most cases, this consists of proctored sessions which can be limited by faculty time and availability. Additionally, the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic has significantly impacted medical education, especially ultrasound education, which has traditionally depended on hands-on practice and instruction. A structured, independent, hands-on learning curriculum using ultrasound would have many benefits. In this study, eight self-guided system-based modules were developed mirroring the undergraduate anatomy curriculum. For each scan, a beginner, intermediate, and advanced component was designed. Each module contains clear, stepwise directions for image acquisition, optimization, and interpretation of the anatomical structures and suggestions for troubleshooting. Students save ultrasound images as part of their digital portfolios for review with ultrasound faculty. This design provides an educational model to increase medical student opportunities for independent, structured, self-directed anatomy learning with ultrasound that can be integrated with existing educational programs.

Predictors of left atrial appendage thrombus despite NOAC use in nonvalvular atrial fibrillation and flutter.

OBJECTIVE: A small but significant proportion of patients with atrial fibrillation or atrial flutter (AF) develop left atrial appendage thrombus (LAAT) despite non-vitamin K antagonist oral anticoagulant (NOAC) prescription. This study examines clinical and echocardiographic risk factors associated with LAAT by transesophageal echocardiogram (TEE) despite NOAC use in patients with non-valvular AF, to inform the decision whether a TEE should be performed prior to cardioversion. METHODS: We compared clinical and echocardiographic characteristics of patients with LAAT despite NOAC prescription for >3 weeks (n = 38) with a consecutive sample of patients on NOAC without LAAT (n = 101). RESULTS: The prevalence of LAAT despite NOAC prescription was 2.6%. Left atrial dilation (adjusted odds ratio [aOR] 3.310, 95% CI 1.144-9.580, p = 0.02) and greater CHA2DS2-VASC score (per-point increase, aOR 1.293, 1.027-1.628, p = 0.03) increased the odds for LAAT. Higher LVEF (per 5%, aOR 0.834, 0.704-0.987, p = 0.03) and presence of severe mitral regurgitation (aOR 0.147, 0.048-0.446, p = 0.002) were protective against LAAT. LAA emptying velocities were also independently associated with presence of LAAT (aOR per 10 cm/s, 0.46, 0.27-0.77). CONCLUSION: Left atrial dilation, greater CHA2DS2-VASC score, absence of severe mitral regurgitation and lower left ventricular ejection fraction are associated with LAAT despite NOAC therapy. In addition to suspected NOAC noncompliance, presence of such high-risk features may warrant pre-cardioversion TEE. Similarly, in patients with LVEF > 50% and CHA2DS2-VASC < 2, risk of LAAT was exceedingly low and thus TEE before cardioversion is low-yield.

Prevalence and Resolution of Left Atrial Thrombus in Patients With Nonvalvular Atrial Fibrillation and Flutter With Oral Anticoagulation.

Left atrial appendage (LAA) thrombus in nonvalvular atrial fibrillation or flutter (AF) is a major cause of stroke and presents a therapeutic dilemma in a rhythm-control strategy. The prevalence and resolution of LAA thrombus has not been studied well in the era of non-vitamin K antagonist oral anticoagulant use. This study sought to establish (1) the prevalence of LAA thrombus (2) the prevalence of LAA thrombus despite antithrombotic therapy, (3) the rate of persistence of LAA thrombus despite appropriate anticoagulant prescriptions, and (4) determinants of LAA thrombus persistence. Consecutive transesophageal echocardiograms (TEE) performed in patients with AF were reviewed to estimate the overall prevalence of LAA thrombus and the resolution rate in those with repeat studies. Multivariable logistic regression was used to identify clinical and echocardiographic predictors of thrombus resolution. Of 1,485 patients with AF, 117 (8%) had LAA thrombus. Of those, 62 had repeat TEE within 1 year and 58 (94%) were prescribed adequate anticoagulation in TEE studies (mean interval 96 ± 72 days). Thirty-seven patients (60%) had LAA thrombus resolution. Thrombus resolution rate was only 79% in patients considered on appropriate anticoagulation. Patients with persistent LAA thrombus were more likely to have diabetes; no other clinical or echocardiographic variable was independently associated with thrombus resolution. There was no significant difference in LAA thrombus resolution between non-vitamin K antagonist oral anticoagulants and warfarin. LAA thrombus persistence despite adequate anticoagulation is relatively common and difficult to predict clinically; TEE before electrical cardioversion should be considered regardless of anticoagulation status.