Comprehensive left atrial appendage optimization of thrombus using surface echocardiography: the CLOTS multicenter pilot trial.

BACKGROUND: The aim of this study was to determine the ability to identify thrombus within the left atrial appendage (LAA) in the setting of atrial fibrillation (AF) using transthoracic echocardiography (TTE). In AF, the structure and function of the LAA has historically been evaluated using transesophageal echocardiography (TEE). The role of TTE remains undefined. METHODS: The Comprehensive Left Atrial Appendage Optimization of Thrombus (CLOTS) multicenter study enrolled 118 patients (85 men; mean age, 67 +/- 13 years) with AF of >2 days in duration undergoing clinically indicated TEE. On TEE, the LAA was evaluated for mild spontaneous echo contrast (SEC), severe SEC, sludge, or thrombus. Doppler Tissue imaging (DTI) peak S-wave and E-wave velocities of the LAA walls (anterior, posterior, and apical) were acquired on TTE. Transthoracic echocardiographic harmonic imaging (with and without intravenous contrast) was examined to determine its ability to identify LAA SEC, sludge, or thrombus. RESULTS: Among the 118 patients, TEE identified 6 (5%) with LAA sludge and 2 (2%) with LAA thrombi. Both LAA thrombi were identified on TTE using harmonic imaging with contrast. Anterior, posterior, and apical LAA wall DTI velocities on TTE varied significantly among the 3 groups examined (no SEC, mild SEC, severe SEC, sludge or thrombus). An apical E velocity < or = 9.7 cm/s on TTE best identified the group of patients with severe SEC, sludge, or thrombus. An anterior S velocity < or = 5.2 cm/s on TTE best identified the group of patients with sludge or thrombus. CONCLUSIONS: The CLOTS multicenter pilot trial determined that TTE is useful in the detection of thrombus using harmonic imaging combined with intravenous contrast (Optison; GE Healthcare, Milwaukee, WI). Additionally, LAA wall DTI velocities on TTE are useful in determining the severity of LAA SEC and detecting sludge or thrombus.

Right atrial volume index in chronic systolic heart failure and prognosis.

OBJECTIVES: The aim of this study was to determine the relationship between right atrial volume index (RAVI) and right ventricular (RV) systolic and diastolic function, as well as long-term prognosis in patients with chronic systolic heart failure (HF). BACKGROUND: RV dysfunction is associated with poor prognosis in patients with HF, although echocardiographic assessment of RV systolic and diastolic dysfunction is challenging. The ability to visualize the RA allows a quantitative, highly reproducible assessment of the RA volume that can be indexed to body surface area. METHODS: The ADEPT (Assessment of Doppler Echocardiography for Prognosis and Therapy) trial enrolled 192 subjects with chronic systolic HF (left ventricular ejection fraction [LVEF]

Contrast-enhanced tissue Doppler imaging of the left atrial appendage is a new quantitative measure of spontaneous echocardiographic contrast in atrial fibrillation.

AIMS: Although left atrial appendage spontaneous echo contrast (LAASEC) is a marker of increased thromboembolic risk in atrial fibrillation, it has previously only been evaluated qualitatively. We sought to determine if an intravenous contrast echocardiographic agent combined with tissue Doppler imaging (TDI) of the LAA could accurately quantify LAA-SEC in patients with atrial fibrillation. METHODS AND RESULTS: We prospectively identified 55 patients with persistent atrial arrhythmias (mean age 63+/-13 years) undergoing a transesophageal echocardiography (TEE), with LAA-SEC prior to direct current cardioversion. In addition to off-line calculation of backscatter index and shear rate, quantification of the velocity in a color TDI region of interest was performed in the LAA cavity following a 0.5-mL intravenous bolus of Optison. LAA-SEC was qualitatively graded by a blindedreader as mild (n = 29) or severe (n = 26), and was compared off-line to TEE-derived quantitative variables. Compared to patients with mild LAA-SEC, those with severe LAA-SEC had significantly decreased LAA emptying velocity, LAA TDI mean velocities and shear rate. Over the whole group, the mean maximal velocity of the LAA using TDI correlated with LAA emptying velocity (r = 0.59; P < 0.0001), shear rate (r = 0.55; P < 0.0001) and LAA area (r = 0.34; P = 0.014). Severe LAA-SEC was found with 72% sensitivity and 82% specificity if TDI mean velocity was <6.13 cm/s. On logistic regression analysis, LAA-TDI was the only predictor of qualitative LAA-SEC grade. CONCLUSION: Contrast-enhanced TDI is an original new tool that provides a quantification of the mean velocity of LAA-SEC that might improve our decision making in patients with atrial fibrillation.

Natural history of valvular regurgitation using side-by-side echocardiographic analysis in anorexigen-treated subjects.

In 1997, the US Food and Drug Administration (FDA) reported valvular regurgitation (aortic regurgitation [AR] mild or greater and/or mitral regurgitation [MR] moderate or greater) in 32.8% of patients treated with anorexigens. This study sought to determine the natural history of valvular regurgitation in patients who were included in the FDA's original report. This was a nonrandomized, natural history study of these subjects. Cohort I consisted of 155 of 186 patients (83%) who were reported to the FDA. Cohort II consisted of a similar group of 311 patients who were not included. Initial echocardiograms were obtained for medical indications before the study initiation, and study echocardiograms were standardized and obtained at 3-month intervals. Level III echocardiographers performed blinded, side-by-side comparison of the first and last study echocardiograms at a core laboratory. Cohorts I and II consisted of predominantly female, middle-aged, obese subjects. At enrollment, patients in cohorts I and II had mild or greater AR (17.9%, 13.5%) and moderate or greater MR (3.3%, 4.0%), respectively, which was less than in the FDA's report. At follow-up, there were no statistically significant changes in the degree of valvular regurgitation in either cohort when the first and last study echocardiograms were read side by side. In conclusion, this natural history follow-up study demonstrates that MR and AR in long-term anorexigen-treated patients was less than reported to the FDA, did not progress, and remained echocardiographically stable during the 10-month duration of the study.

B-type natriuretic peptide levels in patients in the emergency department with possible heart failure and previous stable angina pectoris and/or healed myocardial infarction.

We examined the relation between B-type natriuretic peptide (BNP) levels and a history of stable angina pectoris and/or healed myocardial infarction in 1,240 patients who were evaluated in the emergency department for possible heart failure. In patients who had heart failure, there was no relation between BNP levels and previous stable angina pectoris and/or healed myocardial infarction. However, in patients who did not have heart failure, there was a relation between BNP levels and previous stable angina pectoris and/or healed myocardial infarction but no significant independent relation in multiple regression analysis.

Tissue Doppler imaging in the evaluation of patients with cardiac amyloidosis.

PURPOSE OF REVIEW: Although two-dimensional, M-mode, and Doppler echocardiography have played a major role in the assessment of amyloid deposition in the heart, diagnosis of cardiac amyloidosis (CA) based on these conventional techniques is often only possible once the disease is in a relatively advanced stage. To optimize survival, early diagnosis and institution of therapy are essential. Recently, tissue Doppler imaging (TDI) and myocardial strain rate (SR) have emerged as important clinical tools in the assessment of CA. RECENT FINDINGS: Tissue Doppler imaging-derived modalities including TDI velocities, strain, and SR are currently being used in the early diagnosis and evaluation of patients with CA. Although these new indices have been examined in relatively few patients, findings suggest an important and expanding role of TDI in amyloid infiltration of the heart. SUMMARY: This review summarizes the recent literature addressing the role of TDI velocities, strain, and SR in the diagnosis and assessment of CA.

Use of beta-blockers in congestive heart failure.

While beta-adrenergic blockers have been used for decades in a variety of cardiovascular illnesses, they have traditionally been avoided in chronic heart failure. In spite of significant advances in management, mortality in patients suffering from heart failure remains unacceptably high and new therapies are urgently needed. Recently, several large clinical trials have shown a significant reduction in both morbidity and mortality in heart failure patients when beta-blockers are added to standard therapy. While further investigation is warranted in certain subgroups, the use of beta-adrenergic blockers in New York Heart Association (NYHA) class II to IV heart failure should now be considered routine. The purpose of this article is to outline and review the five major clinical trials of beta-blocker therapy in chronic heart failure; the US Carvedilol heart failure Program (USCP), the Cardiac Insufficiency Bisoprolol Study II (CIBIS-II), the Metoprolol CR/XL Randomized Intervention Trial in chronic Heart Failure (MERIT-HF), the Beta-blocker Evaluation of Survival Trial (BEST) and the Carvedilol Prospective Randomized Cumulative Survival trial (COPERNICUS), and to aid the reader in the selection of appropriate candidates for beta-blocker therapy.

Volume of pleural fluid required for diagnosis of pleural malignancy.

STUDY OBJECTIVES: To determine if the diagnosis of pleural malignancy is dependent on the volume of pleural fluid sampled. DESIGN AND SETTING: Single-center retrospective chart review. PATIENTS: Two hundred eighty-two patients who underwent diagnostic thoracentesis between October 1, 1998, and June 30, 1999. INTERVENTIONS: Charts were analyzed for volume of fluid, pathologic and clinical diagnoses, and demographics. Patients were classified into quartiles based on the volume of pleural fluid collected. Sensitivity and negative predictive value (NPV) were calculated for each quartile for diagnosis of pleural malignancy by cytology of pleural fluid. Further analyses were done regarding the effect of sex, race, age, smoking history, and personal history of malignancy on diagnosis. RESULTS: In total, 374 samples from 282 patients were identified (140 men and 142 women). Pleural malignancy within 6 months of initial thoracentesis was diagnosed in 99 patients (35.1%). No differences were detected for sensitivity and NPV for diagnosis of pleural malignancy between any two quartiles (p > 0.05). Samples collected from women had a higher sensitivity for predicting pleural malignancy (p = 0.0011), and those collected from nonsmokers had a slightly higher but not statistically significant sensitivity for predicting pleural malignancy (p = 0.057). Samples collected from subjects with no history of malignancy had a significantly higher NPV than samples collected from subjects with a history of malignancy (p < 0.001). After adjusting for these demographic and medical history factors, the associations of the pleural fluid volume quartiles with sensitivity and NPV did not change. CONCLUSION: The sensitivity for diagnosis of pleural malignancy is not dependent on the volume of pleural fluid extracted during thoracentesis.