BackgroundWe aimed to correlate left atrial appendage (LAA) structure and function with the history of stroke/transient ischemic attack (TIA) in patients with atrial fibrillation (AF).MethodsWe analyzed data of 649 patients with AF who were scheduled for catheter ablation. Patients underwent cardiac CT and transesophageal echocardiography prior to ablation. LAA morphologies depicted by cardiac CT were categorized into four groups: cauliflower, chicken wing, swan and windsock shapes. ResultsMean age was 61.3±10.5 years, 33.9% were female. Prevalence of stroke/TIA was 7.1%. After adjustment for the main risk factors, LAA flow velocity ≤35.3 cm/sec (OR=2.18; 95%CI=1.09-4.61; p=0.033) and swan LAA shape (OR=2.69; 95%CI=0.96-6.86; p=0.047) independently associated with higher, while windsock LAA morphology with lower risk of stroke/TIA (OR=0.32; 95%CI=0.12-0.77; p=0.017) as compared to cauliflower LAA shape. When comparing the differences between LAA morphology groups, we measured significantly smaller LAA orifice area (389.3±137.7 mm2 in windsock vs 428.3±158.9 ml in cauliflower, p=0.021) and LAA volume (7.4±3.0 mm2 in windsock vs 8.5±4.8 mm2 in cauliflower, p=0.012) in patients with windsock LAA morphology, while LAA flow velocity did not differ significantly. ConclusionReduced LAA function and swan LAA morphology were independently associated with higher, while windsock LAA shape with lower prevalence of stroke/TIA. When comparing the differences between the various LAA morphology types, significantly lower LAA volume and LAA orifice area were measured in windsock LAA shape as compared to cauliflower LAA shape.

Introduction There is considerable uncertainty about the reproducibility of the various instruments used to measure dyspnea, their ability to reflect changes in symptoms, whether they accurately reflect the patient's experience and if its evolution is similar between acute heart failure syndrome patients and nonacute heart failure syndrome patients. URGENT was a prospective multicenter trial designed to address these issues. Methods Patients were interviewed within 1 hour of first physician evaluation, in the emergency department or acute care setting, with dyspnea assessed by the patient using both a five-point Likert scale and a 10-point visual analog scale (VAS) in the sitting (60º) and then supine (20º) position if dyspnea had not been considered severe or very severe by the sitting versus decubitus dyspnea measurement. Results Very good agreements were found between the five-point Likert and VAS at baseline (0.891, P <0.0001) and between changes (from baseline to hour 6) in the five-point Likert and in VAS (0.800, P <0.0001) in acute heart failure (AHF) patients. Lower agreements were found when changes from baseline to H6 measured by Likert or VAS were compared with the seven-point comparative Likert (0.512 and 0.500 respectively) in AHF patients. The worse the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours; this relationship is stronger when dyspnea is measured with VAS (Spearman's rho coefficient = 0.672) than with the five-point Likert (0.272) (both P <0.0001) in AHF patients. By the five-point Likert, only nine patients (3% (1% to 5%)) reported an improvement in their dyspnea, 177 (51% (46% to 57%)) had no change, and 159 (46% (41% to 52%)) reported worse dyspnea supine compared with sitting up in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Conclusions Both clinical tools five-point Likert and VAS showed very good agreement at baseline and between changes from baseline to tests performed 6 hours later in AHF patients. The PDA test with VAS was markedly different between AHF and non-AHF patients. Dyspnea is improved within 6 hours in more than threequarters of the patients regardless of the tool used to measure the change in dyspnea. The greater the dyspnea at admission, the greater the amplitude of improvement in the first 6 hours.

Article Kisiel et al., see p. 1441 The study by Kisiel et al. [1] retrospectively investigated the prognostic value of various parameters in 552 chronic heart failure patients undergoing cardiac resynchronisation therapy (CRT). The goal of the study was to set up a risk score system able to predict long-term mortality following CRT implantation and easily applicable in clinical practice.The main strength of the created score system, termed "AL-FINE CRT score" (Age [> 75 years], non-LBBB morphology [according to Strauss criteria], Furosemide dose [> 80 mg], Ischaemic aetiology, NYHA class (> III) and left ventricular EF [< 20%]), lies in the fact that its components can be easily obtained during the routine preimplantation check-up (medical history, physical examination, electrocardiography, and echocardiography) to assess the long-term mortality risk. The presence of any of the above variables equates to one point, so a maximum of six points could be achieved. Depending on the AL-FINE CRT score, the patients can be divided into three risk categories: low risk (0-1 points, five-year survival of approx. 80%), medium risk (2 points, five-year survival of approx. 60%), and high risk (3-6 points, five-year survival of approx. 40%). A high-risk score, according to the authors, should alert both the physician and the patient to evaluate the long-term benefit of the procedure more realistically and should identify those patients, in whom the implantation procedure might require more attention and maybe more experienced implanters in order to maximise the benefit [1]. The identified high-risk patients might also need "special care" following the implantation: more frequent follow-ups, strict device optimisation, multidisciplinary patient care, aggressive up-titration of medication, participation in rehabilitation programs, etc. Nevertheless, because the results are derived from a retrospective analysis, further prospective studies should validate the usefulness of the AL-FINE CRT model.Altogether there is a clear need to create applicable risk scores for patients who have undergone CRT implantation, to predict their long-term outcome. However, the validation and further assessment of the utility of such a score system are always challenging. A risk score system should not only be useful in risk prediction, but ideally it should also allow the clinicians to guide therapy or make therapeutic decisions, for instance regarding the choice of the device (implantable defibrillator [CRT-D] vs. pacemaker [CRT-P]), or the selection of pacemaker patients requiring CRT upgrade. To date, no such risk score systems exist, and the current guidelines do not clearly define the decision algorithm for the above processes [2,3]. On the other hand, one should be cautious about relying on risk score systems alone, as an automated procedure, because the therapeutic decisions, circumstances of the implantation, and further device programming also have an impact on the long-term clinical outcome of patients; therefore, risk score systems are ...

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