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Karuna Chilukuri, Susan A Mayer,
Daniel Scherr,
Darshan Dalal,
Theodore Abraham,
Charles A Henrikson,
Alan Cheng,
Saman Nazarian,
Sunil Sinha,
David Spragg,
Ronald Berger,
Hugh Calkins,
Joseph E Marine
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ABSTRACT: To assess the utility of transoesophageal echocardiography (TEE) parameters such as spontaneous echo contrast (SEC), left atrial (LA) appendage velocities, and aortic plaque in predicting periprocedural cerebrovascular accidents (CVAs) in patients undergoing catheter ablation of atrial fibrillation (AF).
Five hundred and seventy-nine consecutive patients underwent catheter ablation of AF with pre-procedural TEE, 94% of whom also received pre-procedural warfarin and enoxaparin bridging. Of the 579 patients, 10 patients (cases) who developed periprocedural CVA (1.7%) and 40 randomly selected patients who did not develop CVA (controls) were included (50 study patients, age 58 ± 11 years, 82% male, 54% persistent AF). Periprocedural CVA was defined as a new neurological deficit that occurred anytime between the start of the procedure and 30 days after AF ablation. Demographic, clinical, and TEE variables of cases and controls were compared using standard statistical analyses. Patients with CVA more often had coronary artery disease [odds ratio (OR) 6.0, P = 0.03], previous history of CVA (OR 8.2, P = 0.02), and CHADS(2) score ≥ 2 (OR 5.4, P = 0.03) than patients without CVA. There was no difference in any of the TEE parameters (SEC, LA appendage velocity and area, patent foramen ovale, atrial septal aneurysm, valve abnormality, and aortic plaque). When these TEE parameters were adjusted for coronary artery disease, prior CVA and CHADS(2) ≥ 2, none emerged as an independent predictor of CVA.
Transoesophageal echocardiographic variables (other than LA thrombus) were not associated with the occurrence of periprocedural CVA in our patients undergoing catheter ablation of AF who generally received pre-procedural anticoagulation. Despite serving as markers of a thrombogenic milieu, the presence of SEC, low LA appendage velocities, and aortic plaque may not increase the risk of periprocedural CVA after AF ablation.
Europace 11/2010; 12(11):1543-9. · 1.98 Impact Factor
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Ilan Gottlieb,
Aurélio Pinheiro,
Jeff A Brinker,
Mary C Corretti, Susan A Mayer,
David A Bluemke,
Joao A C Lima,
Joseph E Marine,
Ronald D Berger,
Hugh Calkins,
Theodore P Abraham,
Charles A Henrikson
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ABSTRACT: Multidetector CT (MDCT) is used prior to atrial fibrillation ablation (AFA) to anatomically guide ablation procedures. Whether 64-slice MDCT also can be used to diagnose left atrial thrombus is not known.
We sought to determine the accuracy and interobserver variability of MDCT in the evaluation of left atrial thrombus prior to AFA. We enrolled 50 patients scheduled for AFA who underwent 64-slice MDCT scan and transesophageal echocardiography prior to the procedure. Three experienced observers reviewed all the MDCT images for the presence of a left atrial thrombus, and two different readers interpreted the transesophageal echocardiograms (TEE), which were used as the gold standard. All observers were blinded to clinical data and each other.
Interobserver variability between the three MDCT readers was poor (highest kappa statistic 0.43, P = 0.001). Diagnostic accuracy was highly variable, with sensitivities ranging from 100% to 50% and specificities ranging from 85% to 44%. TEE reader agreement was 98%.
MDCT demonstrates high interobserver variability and has only modest diagnostic accuracy for the detection of left atrial thrombus in patients undergoing AFA procedure. Potential factors affecting the accuracy of MDCT include image quality and the difficulty of distinguishing clot from pectinate muscle. MDCT likely is not the optimal method to detect left atrial thrombus using current techniques and standards of interpretation.
Journal of Cardiovascular Electrophysiology 04/2008; 19(3):247-51. · 3.06 Impact Factor
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ABSTRACT: Structural cardiovascular alterations in the classical and hypermobile forms of Ehlers-Danlos syndrome(EDS) warrant investigation. We have examined a cohort of 38 patients with hypermobile and classical EDSs using two-dimensional echocardiography. The cohort includes 7 males and 31 females, with an age range from 12-60 years. Altered echocardiographic parameters were seen in the initial cross-sectional data analysis in 24/38 patients. Five of the 38 participants had mildly dilated aortic root (AR) or sinuses of Valsalva (SV), and an additional 7 patients had an abnormal pouching of the SV, although the absolute dimensions did not exceed the normal range. Ten patients had mild mitral, tricuspid, or aortic regurgitation, and only one patient had mitral valve prolapse (MVP). Three patients had low normal systolic function; three had evidence of mildly elevated pulmonary pressures, and two patients had mild concentric left ventricular hypertrophy (LVH). Five patients had evidence of impaired left ventricular relaxation (LVR) based on mitral valve E to A velocity ratio. Interestingly, 26/38 subjects demonstrated a prominent right coronary artery (RCA) easily visualized by trans-thoracic echocardiography, and 10/38 had an elongated cardiac silhouette on the 4-chamber apical views. The "pouching" shape of the SV was more common in hypermobile type than in the classical type of EDS. The study is ongoing and will accrue longitudinal data on 100 subjects with classical and hypermobile EDSs at 2-year intervals.
American Journal of Medical Genetics Part A 02/2006; 140(2):129-36. · 2.39 Impact Factor
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ABSTRACT: Functional mitral regurgitation (MR) occurs most often in patients with heart failure (HF) and is associated with an adverse prognosis. Recently, B-type natriuretic peptide (BNP) has been validated as a marker of cardiac function and prognosis. We sought to assess the relation between functional MR and BNP levels in patients with HF, and hypothesized that MR is associated with higher BNP levels. In all, 201 patients admitted with the diagnosis of HF had a transthoracic echocardiogram and measurement of BNP levels within 48 hours. MR was graded as none/trace, mild, moderate, or severe using recently published guidelines of the American Society of Echocardiography. BNP was measured by a commercially available instrument (Biosite). The relation of MR to BNP was assessed using multivariable linear regression methods with a Tobin estimation to account for the truncation of BNP values at an upper limit of 1,300 pg/ml. Mean age of the patients was 67 +/- 11 years. The median BNP level was 826 pg/ml. The etiology of HF was predominantly diastolic in 64 patients (32%); 137 patients (68%) had significant left ventricular (LV) systolic dysfunction. Mean LV ejection fraction was 37 +/- 17%. MR was present in 112 patients (56%). After adjusting for clinical, hemodynamic, and echocardiographic variables, only LV ejection fraction (p = 0.016) and moderate or severe MR (p = 0.023) were significantly associated with BNP. When MR was grouped as any MR versus no MR, only LV ejection fraction (p = 0.017) and any degree of MR (p = 0.029) were significantly associated with BNP.
The American Journal of Cardiology 05/2004; 93(8):1002-6. · 3.37 Impact Factor
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Eric J Eichhorn,
Paul A Grayburn, Susan A Mayer,
Martin St John Sutton,
Christopher Appleton,
Jonathan Plehn,
Jae Oh,
Barry Greenberg,
Anthony DeMaria,
Robert Frantz,
Heidi Krause-Steinrauf
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ABSTRACT: beta-Blockers improve survival and reduce hospitalization in chronic heart failure (CHF) by biologically improving left ventricular ejection fraction (LVEF). However, a good predictor of improvement with this therapy has not been identified. This substudy of BEST examined whether myocardial contractile reserve, as determined by dobutamine stress echocardiography, predicts improvement in LVEF.
Seventy-nine patients with class III/IV CHF underwent dobutamine stress echocardiography before treatment with bucindolol (n=41) or placebo (n=38). Regional wall motion score index (WMSI) was calculated as the sum of the scores in each segment divided by the total number of segments visualized. WMSI was compared with change in LVEF after 3 months of therapy as determined by gated radionuclide scan. Change in WMSI correlated inversely with change in LVEF after 3 months of bucindolol (r=-0.72, P<0.0001) and was the most significant multivariate predictor of change in LVEF (P=0.0002). Patients with contractile reserve had demographics similar to those of patients without contractile reserve, including RVEF, LVEF, systolic blood pressure, and CHF duration. However, patients without contractile reserve had higher baseline plasma norepinephrine levels (687+/-333 versus 420+/-246 pg/mL, P<0.05) and greater decrease in plasma norepinephrine in response to bucindolol (-249+/-171 versus -35+/-277 pg/mL, P<0.05).
This study suggests a direct relationship between contractile reserve and improvement in LVEF with beta-blocker therapy in patients with advanced CHF. Patients without contractile reserve have higher resting adrenergic drive, as reflected by plasma norepinephrine, and may experience greater sympatholytic effects from bucindolol.
Circulation 11/2003; 108(19):2336-41. · 14.74 Impact Factor
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The American Journal of Cardiology 08/2003; 92(2):241-2. · 3.37 Impact Factor
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ABSTRACT: Microbubble destruction during contrast echocardiography is known to cause capillary leaks and red blood cell extravasation in skeletal muscle. This study evaluated the biological effects of microbubble destruction on cardiac muscle.
Contrast echocardiography was performed in 36 rats randomized to receive either Definity or Optison at a mechanical index (MI) of 1.6, 1.2, or 0.8. Myocardial bioeffects were assessed by measuring left ventricular (LV) size and fractional area shortening and histopathology. In addition, blood samples for troponin T were drawn at baseline, postinfusion (30 minutes), day 1, day 4, and day 7. LV size and function were measured at baseline and immediately prior to euthanasia on day 7, after which the heart was removed and sectioned for histopathology.
There was no statistical difference in LV size or function regardless of the contrast agent or MI, nor was there any histopathological evidence of myocardial damage. However, troponin T increased over time (F = 3.77, P = 0.012), peaking at 30 minutes and returning to normal by day 4. The difference between Definity and Optison was not statistically significant. However, troponin T values were higher at a higher MI (F = 5.01, P = 0.012). Of 12 rats imaged at a MI of 1.6, 9 (75%) had elevated troponin T as compared to 4 (33%) of 12 at a MI of 1.2. None of the 12 rats imaged at a MI of 0.8 had an elevated troponin T at any time point.
Microbubble destruction at high acoustic power (MI 1.6) can cause mild troponin T elevations that are not associated with LV dysfunction or histopathological evidence of myocardial damage.
Echocardiography 09/2002; 19(6):495-500. · 1.24 Impact Factor
