Hajo Müller

Biatrial anatomical reverse remodelling after radiofrequency catheter ablation for atrial fibrillation: evidence from real-time three-dimensional echocardiography

AIMS Reports using two-dimensional echocardiography have indicated that radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) results in a reduction in the left atrial (LA) size. Furthermore, the effect of pulmonary vein isolation (PVI) on right atrial (RA) anatomical remodelling has not been studied. Three-dimensional echocardiography (3DE) allows us to more precisely quantify atrial volume. Our aim was to assess the effect of PVI on biatrial anatomical remodelling using real-time 3DE. METHODS AND RESULTS We prospectively studied 91 patients (age 59 +/- 8 years, 79 males) referred for RFCA of paroxysmal (n = 79) or chronic (n = 19) AF. Left atrial and RA volumes were measured using real-time 3DE at baseline and after 6 months of follow-up. Data on AF recurrences were also collected. Left atrial volume was significantly reduced at follow-up when compared with baseline (51 +/- 16 vs. 60 +/- 21 mL, P < 0.001). The same occurred with RA volume (43 +/- 17 vs. 50 +/- 20 mL, P = 0.001). The reduction in the LA volume was more marked in patients with chronic than in those with paroxysmal AF (17 +/- 16 vs. 6 +/- 17 mL, P = 0.017). Patients with AF recurrence (23%) showed similar atrial volume reduction compared with those who were seemingly cured. CONCLUSION Three-dimensional echocardiography shows evidence of biatrial anatomical reverse remodelling after RFCA for AF. A reduction in the atrial volume occurs despite recurrence of AF.

Diagnostic accuracy of pocket-size handheld echocardiographs used by cardiologists in the acute care setting.

AIMS Pocket-size echographs may be useful for bedside diagnosis in acute cardiac care, but their diagnostic accuracy in this setting has not been well tested. Our aim was to evaluate this tool in patients requiring an urgent echocardiogram. METHODS Trained cardiologists performed echocardiograms with a pocket-size echograph (Vscan) in consecutive patients requiring urgent echocardiography. The exams were then compared in a blinded manner with echocardiograms performed with a high-end standard echocardiograph. RESULTS A total of 104 patients were studied. There was an excellent agreement between the Vscan and the high-end echocardiograph for the left ventricular systolic function and pericardial effusion (Kappa: 0.89 and 0.81, respectively), and the agreement was good or moderate for evaluating the aortic, mitral, and tricuspid valve function and the left ventricular size (Kappa: 0.55-0.66). Visualization of the Vscan images in full-screen format on a PC did not in general confer added value. CONCLUSION The Vscan used by a trained cardiologist has good diagnostic accuracy in the emergency setting compared with a high-end echocardiograph, despite small screen size and lack of pulse-wave and continuous Doppler.

Platypnea–orthodeoxia syndrome in the elderly treated by percutaneous patent foramen ovale closure: A case series and literature review

BACKGROUND Platypnea-orthodeoxia syndrome (POS) is a rare clinical phenomenon, associating normal oxygen saturation in a supine position and arterial hypoxemia in an upright position. This pathology can be secondary to an intracardiac shunt, a pulmonary vascular shunt or a ventilation-perfusion mismatch. Cardiac POS occurs in the presence of a right-to-left cardiac shunt, most commonly through a patent foramen ovale (PFO). METHODS AND RESULTS From our single-center prospective database of percutaneous PFO closure we identified five patients (4 females, mean age: 77 ± 11 years) out of 224 (2.2%) patients with a PFO who presented with a POS of cardiac origin. Transthoracic and transoesophageal echocardiographic examinations revealed the underlying mechanisms of POS and the diagnosis was confirmed by right-and-left cardiac catheterization (RLC) and by measuring serial blood oxygen saturation in the pulmonary veins and left atrium in supine and upright positions. PFO was associated with atrial septal aneurysm and a persistent prominent Eustachian valve in 3 patients. All patients underwent a successful percutaneous PFO closure without any immediate or subsequent complications (mean follow-up of 24 ± 18 months). Immediately after the procedure, mean arterial oxygen saturation improved from 83% ± 3 to 93% ± 2 in an upright position and symptoms disappeared. CONCLUSION POS is a rare and under-diagnosed pathology that must be actively investigated in the presence of position-dependent hypoxemia. The diagnostic work-up must exclude other causes of hypoxemia and confirm the intracardiac shunt using either contrast echocardiography or RLC. For cardiac POS, percutaneous PFO closure is a safe and effective technique that immediately relieves orthodeoxia and patient symptoms.

Evaluation of Right Atrial Size in Patients with Atrial Arrhythmias: Comparison of 2D versus Real Time 3D Echocardiography

Aim: This study compares different parameters of right atrial size evaluated by two‐dimensional (2D) echocardiography with right atrial volume measured using three‐dimensional echocardiography (3DE). Methods and Results: One hundred sixty‐three consecutive patients with a history of atrial arrhythmias were studied by standard two‐dimensional and by real time 3DE. Of these 142 (87%) recordings were of sufficient quality for interpretation of the right atrium by both imaging techniques. The following parameters of right atrial size were measured: apical four‐chamber short‐axis diameter (4CH short axis), apical four‐chamber long axis diameter (4CH long axis), and apical four‐chamber planimetry area. The 2D‐derived right atrial volume was calculated by using the single plane area‐length method (4CH area‐length). The 2D parameters were then correlated with right atrial volume measured by real time 3DE. Linear regression analysis showed moderate correlation for four‐chamber planimetry area (r = 0.72, P < 0.001) and 2D‐derived volume calculation (r of 4CH single plane area‐length RA volume = 0.70, P < 0.001). Diameters correlated clearly less well with 3DE volume (r of 4CH short axis = 0.61, 4CH long axis = 0.59, P < 0.001 respectively). Conclusion: Real time 3DE is highly feasible for right atrial volume determination. The results demonstrate that measurements of dimensions using 2D echocardiography may not accurately assess right atrial size. If 3DE is not available, apical 4CH planimetry area is a simple alternative that may be used for evaluating right atrial size in clinical practice. The 2D‐derived right atrial volume by single plane area‐length method was not better correlated with 3DE volume than four‐chamber planimetry area.

Evaluation of Left Atrial Size in Patients with Atrial Arrhythmias: Comparison of Standard 2D Versus Real Time 3D Echocardiography

Aim: Two‐dimensional echocardiography may not correctly indicate size in nonspherical atria. The present study compares different parameters of left atrial size evaluated by standard two‐dimensional echocardiography with left atrial volume measured using three‐dimensional echocardiography (3DE). Methods and results: One hundred seventy consecutive patients with a history of atrial arrhythmias were studied by standard two‐dimensional and by real time 3DE. Of these 166 (98%) recordings were of sufficient quality for interpretation by both imaging techniques. The following parameters of left atrial size were measured: parasternal long axis diameter (PLAX), apical 4‐chamber short‐axis diameter (4CH short axis), apical 4‐chamber (4CH long axis), and 2‐chamber long‐axis diameters and planimetry areas. Two‐dimensional‐derived left atrial volumes were calculated by using both single plane (4CH area‐length) and biplane area‐length methods. The 2D parameters were then correlated with left atrial volume measured by 3D echocardiography. Linear regression analysis showed moderate correlation for 4‐chamber planimetry area (r = 0.76, P < 0.0001) and 2D‐derived volume calculations (r of 4CH single plane area‐length LA volume = 0.74 and biplane area‐length LA volume = 0.78, P < 0.0001). Diameters correlated less well with 3DE volume (r of PLAX = 0.67, 4CH short axis = 0.68, 4CH long axis = 0.63, P < 0.0001 respectively). Conclusion: The results demonstrate that measurements of dimensions using standard echocardiography are of limited accuracy to assess left atrial volume. If 3DE is not available, 4‐chamber planimetry area is a valid simple parameter for evaluating left atrial size in clinical practice. Two‐dimensional‐derived volume by biplane area‐length method was only slightly better correlated with 3DE volume than 4‐chamber planimetry area.

Midterm results of valve repair with a biodegradable annuloplasty ring for acute endocarditis.

BACKGROUND Conventional annuloplasty rings consist of woven, nondegradable prosthetic material. Their use should theoretically be limited in acute infective endocarditis. Novel biodegradable annuloplasty rings, which are implanted into the annulus, carry theoretical advantages, but have never been evaluated for feasibility and mid-term outcome in such patients. METHODS Between 2004 and 2009, 17 consecutive patients with acute infective endocarditis (age, 34.5+/-21.6 years; range, 11-82 years; 8 men) had mitral (n=13), tricuspid (n=3), and mitral and tricuspid (n=1) annuloplasty to conclude valve repair. Repair was performed by complete excision of the infected tissue, valvar reconstruction, and biodegradable ring annuloplasty. Prospectively collected clinical and echocardiographic data were analyzed retrospectively. RESULTS Indications for surgery were heart failure (n=9; 52.9%), hemodynamic instability (n=8; 47%), and persistent infection or sepsis despite antibiotics (n=6; 35.3%). Staphylococci (n=7) and Streptococci (n=4) were the most common causes. Three patients died on postoperative days 1, 2, and 34 because of massive gastrointestinal bleeding; heart failure and pneumonia; and sepsis and acute renal failure, respectively. During a median follow-up of survivors at 29.6 months (range, 2.0 to 51.0 months), no mortality, recurrence, or reoperation occurred. At follow-up, transthoracic echocardiography revealed no or trivial regurgitation in 11 and mild in 3 patients. Left ventricular dimensions regressed significantly after mitral repair. CONCLUSIONS Valve repair using a biodegradable ring showed good structural and functional properties up to 4 years after repair. Implantation of the biodegradable ring is feasible and effective in patients with acute infective endocarditis. Its intraannular implantation, hindering direct blood contact and associated risk of colonization, represents a theoretical advantage in such patients. Larger comparative studies are needed for further conclusions.

Measurement of left atrial volume in patients undergoing ablation for atrial fibrillation: comparison of angiography and electro-anatomic (CARTO) mapping with real-time three-dimensional echocardiography

AIMS Left atrial (LA) volume can be determined during radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) with angiography or electro-anatomic (CARTO) mapping. We compared these volumes with LA volume measured using transthoracic real-time three-dimensional echocardiography (3DE). METHODS AND RESULTS One hundred and twenty-seven consecutive patients undergoing RFCA for AF were studied using biplane pulmonary vein angiography with opacification of the LA. LA volume was calculated from the diameter measurements with a formula using an ellipsoid model. A subset of 22 patients also underwent LA volume determination by CARTO mapping. These volumes were then correlated with LA volume determined non-invasively by real-time 3DE. Linear regression showed a significant correlation between LA volume determined by angiography and 3DE volume (r = 0.56, P < 0.0001). Bland-Altman analysis showed a bias of 38 +/- 22 ml by the angiographic method. LA volume measured using CARTO correlated better (r = 0.67, P < 0.001), but 3DE yielded smaller values (mean difference of -30 +/- 19 ml). CONCLUSION LA volume determination by angiography and CARTO mapping correlate significantly with 3DE volume. However, both invasive techniques yield larger values for LA volume. The results indicate that LA volume obtained by angiography or CARTO should not be used as baseline value for non-invasive follow-up of LA remodelling by 3DE.

Papillary fibroelastoma of the left atrial wall: a case report

Cardiac papillary fibroelastoma is a rare, benign cardiac tumor. It often arises from valvular endocardium, and non-valvular endocardial location is rare. Although transthoracic echocardiography is usually sufficient for the diagnosis of most cardiac tumors, small tumors such as papillary fibroelastoma may be missed. Transesophageal echocardiography is superior to transthoracic echocardiography in diagnosing these tumors. Despite their benign histology, and independent of their size, they should be resected surgically because of their high potential for embolization.In this report, we present a case of papillary fibroelastoma located on the left atrial wall, presenting with symptoms of cerebral ischemia. The patient was treated surgically for the prevention of further embolic complications. Pertinent literature is also reviewed for this rare and benign cardiac tumor.

Effect of oral nitrate supplementation on pulmonary hemodynamics during exercise and time trial performance in normoxia and hypoxia: a randomized controlled trial

Background: Hypoxia-induced pulmonary vasoconstriction increases pulmonary arterial pressure (PAP) and may impede right heart function and exercise performance. This study examined the effects of oral nitrate supplementation on right heart function and performance during exercise in normoxia and hypoxia. We tested the hypothesis that nitrate supplementation would attenuate the increase in PAP at rest and during exercise in hypoxia, thereby improving exercise performance. Methods: Twelve trained male cyclists [age: 31 ± 7 year (mean ± SD)] performed 15 km time-trial cycling (TT) and steady-state submaximal cycling (50, 100, and 150 W) in normoxia and hypoxia (11% inspired O2) following 3-day oral supplementation with either placebo or sodium nitrate (0.1 mmol/kg/day). We measured TT time-to-completion, muscle tissue oxygenation during TT and systolic right ventricle to right atrium pressure gradient (RV-RA gradient: index of PAP) during steady state cycling. Results: During steady state exercise, hypoxia elevated RV-RA gradient (p > 0.05), while oral nitrate supplementation did not alter RV-RA gradient (p > 0.05). During 15 km TT, hypoxia lowered muscle tissue oxygenation (p < 0.05). Nitrate supplementation further decreased muscle tissue oxygenation during 15 km TT in hypoxia (p < 0.05). Hypoxia impaired time-to-completion during TT (p < 0.05), while no improvements were observed with nitrate supplementation in normoxia or hypoxia (p > 0.05). Conclusion: Our findings indicate that oral nitrate supplementation does not attenuate acute hypoxic pulmonary vasoconstriction nor improve performance during time trial cycling in normoxia and hypoxia.

Subaortic aneurysm caused by Paecilomyces lilacinus endocarditis

MOTS CLES Anevrisme sous-aortique ; Endocardites ; Echocardiographie A 41-year-old male white patient with a history of intravenous drug abuse and hepatitis C presented with bilateral peripheral thromboembolism resulting in acute occlusion of the left popliteal and the right common iliac arteries and requiring emergency surgical embolectomie. History taking and clinical examination revealed weight loss of 20 kg over 18months, asthenia and a diastolic murmur suspicious of aortic regurgitation. The patient was afebrile and CRP was only slightly elevated (18mg/l). Blood cultures and examination of the thrombi revealed fungi identified as Paecilomyces lilacinus. Transesophageal echocardiography (TEE) showed a moderately severe aortic regurgitation, a bicuspid valve with vegetations, a pseudo aneurysm of one leaflet (Fig. 1, arrow in panel A) and a subannular aneurysm communicating with the left ventricular outflow tract (Fig. 1, arrow in panel B) (see movies 1 and 2). Imaging with the real-time transesophageal three-dimensional echocardiography (3DE) yielded additional information to the 2D images and showed more clearly the bicuspid aortic valve with two equally sized leaflets and its relationship to the subannular aneurysm (Fig. 1, arrow in panel C and 3DTEE movies 3 and 4). The patient received antifungal treatment with amphotericin B and voriconazole replaced by posaconazole alone after a few days. The patient underwent uneventful surgery on the fifth day of treatment with replacement of the aortic valve and the ascending aorta by a homograft.