The association between congestive heart failure (CHF) of the CHA2DS2-VASc scores and thromboembolic (TE) events in patients with atrial fibrillation (AF) is a topic of debate due to conflicting results. As the importance of diastolic impairment in the occurrence of TE events is increasingly recognized, it is crucial to evaluate the predictive power of CHA2DS2-VASc scores with C criterion integrating diastolic parameters. We analyzed 4200 Korean nonvalvular AF patients (71 years of age, 59% men) to compare multiple echocardiographic definitions of CHF. Various guideline-suggested echocardiographic parameters for systolic or diastolic impairment, including left ventricular ejection fraction (LVEF) ≤ 40%, the ratio of early diastolic mitral inflow velocity to early diastolic velocity of the mitral annulus (E/E’) ≥ 11, left atrial volume index > 34 mL/m2, and many others were tested for C criteria. Multivariate-adjusted Cox regression analysis showed that CHA2DS2-VASc score was an independent predictor for composite thromboembolic events only when CHF was defined as E/E’ ≥ 11 (hazard ratio, 1.26; p = 0.044) but not with other criteria including the original definition (hazard ratio, 1.10; p = 0.359). Our findings suggest that C criterion defined as diastolic impairment, such as E/E’ ≥ 11, may improve the predictive value of CHA2DS2-VASc scores.
BACKGROUND Aberrant right subclavian artery (ARSA) is the most common congenital anomaly of the aortic arch. When patients having such anomalies receive transradial intervention (TRI), aortic dissection (AD) may occur. Herein, we discuss a case of iatrogenic type B AD occurring during right TRI in an ARSA patient, that was later salvaged by percutaneous angioplasty. CASE SUMMARY A 73-year-old man presented to our hospital with intermittent chest pain. Coronary computed tomography (CT) angiography revealed significant stenosis in the left anterior descending artery. Diagnostic coronary angiography was performed via the right radial artery without difficulty. However, we were unable to advance the guiding catheter past the ostium of the right subclavian artery to the aortic arch for percutaneous coronary intervention, while the guidewire tended to go down the descending aorta. The patient suddenly complained of chest and back pain. Emergent CT aortography revealed type B AD propagating to the left renal artery (RA) with preserved renal perfusion. However, after 2 d, the patient suddenly complained of right lower limb pain where the femoral pulse was suddenly undetectable. Follow-up CT indicated further progression of dissection to the right external iliac artery (EIA) and left RA with limited flow. We performed percutaneous angioplasty of the right EIA and left RA without complications. Follow-up CT aortography at 8 mo showed optimal results. CONCLUSION A caution is required during right TRI in ARSA to avoid AD. Percutaneous angioplasty can be a treatment option.
Background: A recent study demonstrated that transmitral mean diastolic pressure gradient (MDPG) in patients with mitral annular calcification (MAC) is associated with increased mortality, however, the longitudinal hemodynamic progression over time in patients with MAC and its characteristics are unclear. In this study, the clinical and echocardiographic characteristics of MAC correlated with hemodynamic progression and its clinical implications were investigated. Methods: In total, 161 patients (mean age 74.7±10.5 yeas, 63 men) with MAC were identified by index transthoracic echocardiography (TTE) between January 2012 and June 2016 and performed follow-up TTE after 3 years. Stable MAC (n=146, 90.7%) was defined as a difference of transmitral mean pressure gradient (MDPG) less than 2 mmHg between initial and follow-up TTE, and progressive MAC (n=15. 9.5%) was defined as MDPG increased above 2mmHg. Results: There was no significant difference of baseline characteristics between the group with stable MAC and progressive MAC. In the group of progressive MAC compared to that of stable MAC, a proportion of moderate-to-severe MAC (66.7 vs. 28.1%, p =0.002), significant MS (26.7 vs. 8.2%, p =0.046), maximal thickness of MAC (0.7±0.5 vs. 0.5±0.3, p =0.023), and MDPG (2.8±1.7 vs. 2.2±1.5, p =0.048) were significantly higher at the index TTE ( Figure ). In the group with progressive MAC, increase in left atrial (LA) volume index and pulmonary artery systolic pressure were significant. In-5-year mortality and newly developed atrial fibrillation tended to be more common in progressive MAC group, but there was no statistical significance. Conclusions: Hemodynamic progression occurs in about 10% of patients over 3 years. Patients with progressive MAC have larger baseline MAC thickness and calcification extent, even if MDPG is less than 3 mmHg. Patients with progressive MAC are more likely to develop LA enlargement and pulmonary hypertension, which are prone to poor outcome.
Introduction & Hypothesis: Surgical septal myectomy is an effective treatment in patients with symptomatic hypertrophic obstructive cardiomyopathy (HOCM). Reducing the hemodynamic burden through septal myectomy in HOCM patients is expected to result in cardiac reverse remodeling, but it is unknown whether it improves myocardium functional parameters, which are proven prognosticators for clinical outcome. Therefore, this study aimed to investigate the left atrial (LA) and left ventricular (LV) size and function using conventional and speckle tracking echocardiography (STE) before and after septal myectomy in patients with HOCM. Methods: A total of 65 patients with symptomatic HOCM who underwent surgical septal myectomy from 2006 to 2021 were retrospectively analyzed. Patients were excluded if they underwent a valve repair or replacement at the same time. Finally, clinical, echocardiographic, and electrocardiographic variables before and after the surgery were comprehensively analyzed. Results: After septal myectomy, there were significant decreases in LA volume index (72±22 vs. 57±18 ml/m 2 , p <0.001) suggestive of improvement of diastolic function. In the analysis of STE, there was no significant difference in LA strain (19.3±8.5 vs. 19.1±8.2%, p=0.883) and LV global longitudinal strain (LS) (-10.3±3.6 vs. -9.6±3.4%, p=0.150) before and after septal myectomy. When we analyzed LV regional LS by dividing into septum and non-septum, septal LS showed a little aggravation (-8.7±4.5 vs. -7.6±3.7 %, p=0.077) with marginal statistical significance. In addition, non-septal LS was not significantly different after septal myectomy (-10.9±4.5 vs. -10.5 ±4.2 %, p= 0.458). The change of LA volume index was significantly correlated with change of QRS duration. Interestingly, the septal LS was deteriorated and non-septal LS tended to be improved as widening of QRS duration. Conclusions: After septal myectomy, as hemodynamic load due to LVOT obstruction relieves, there is a significant reduction in LA volume. However, there is no improvement in the global LA and LV mechanical function. Widening of QRS duration, a marker of effective septal myectomy, is associated with LA volume reduction and improvement of longitudinal strain in non-septal LV.
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