Karolina Kupczyńska

Prognostic significance of spontaneous echocardiographic contrast detected by transthoracic and transesophageal echocardiography in the era of harmonic imaging.

Introduction Echocardiographic diagnosis of spontaneous intracardiac contrast is the reflection of interactions between erythrocytes and plasma proteins. Underlying conditions are associated with low blood flow velocities in the heart. We sought to determine whether spontaneous echo contrast (SEC) detected in the era of widespread use of harmonic imaging still reflects poor prognosis and risk of thromboembolism. Material and methods We retrospectively analyzed the database of a tertiary cardiology centre echocardiographic laboratory and identified 60 patients with SEC, but without solid intracardiac structures, and subsequently selected 60 sex- and age-matched controls without SEC. Data regarding baseline characteristics, treatment and clinical course during follow-up (median: 33.5 months; 95% CI: 24.79–40) were gained based on hospital and out-patient clinic documentation and telephone interviews. The clinical end-points included: all-cause death, cardiovascular death, stroke or transient ischemic attack (TIA), pulmonary embolism, peripheral embolism and composite thromboembolic end-point. Results We observed that in the whole study group (p = 0.0016) and in the subgroup evaluated by TTE (p = 0.005) SEC predicted higher mortality. In the group assessed by TEE, SEC correlated with higher probability of stroke or TIA (p = 0.04). By multivariate analysis, in all patients SEC was a predictor of cardiovascular death (OR = 7.63; p = 0.008) and its localization in the left atrium independently predisposed to thromboembolism (OR = 10.15; p = 0.012). Furthermore, left ventricular SEC detected by TTE also emerged as an independent determinant of higher mortality (OR = 5.26; p = 0.015). Conclusions Despite a lower threshold of detection using harmonic imaging SEC is still a risk factor of poor prognosis, especially when observed on transthoracic examination.

Bicuspid aortic valve morphology and its impact on aortic diameters-A systematic review with meta-analysis and meta-regression

To evaluate the impact of the 2 most common bicuspid aortic valve (BAV) morphology patterns [right‐left (RL) vs right‐noncoronary (RN) cusp fusion] on the aortic diameters and the impact of gender, aortic stenosis (AS), aortic regurgitation (AR), and age on the observed effects.

The differences in the relationship between diastolic dysfunction, selected biomarkers and collagen turn-over in heart failure patients with preserved and reduced ejection fraction.

BACKGROUND The aim of the study was to assess the correlation of the selected biomarkers and collagen turn-over indices with advanced echocardiographic parameters among patients with preserved and reduced ejection fraction (EF). METHODS We included 62 patients with the symptomatic heart failure. The patients were divided in to two groups according to the evaluated ejection fraction (EF - Simpson method): heart failure with reduced ejection fraction (HFrEF) group - 30 patients with low EF - 35-50% (16 male, mean age 54.9 ± 12.6), heart failure with preserved ejection fraction (HFpEF) group - 32 patients with EF > 50% (16 male, mean age 62.3 ± 7.6). Clinical evaluation included 6-min walk test, biochemistry, procollagen type I N-terminal propeptide (PINP), procollagen type III N-terminal propetide (PIIINP), matrix metaloproteinase-2 (MMP2), ghrelin, and galectin-3 levels measurements. Echocardiographic examination was performed with analysis of diastolic function and global longitudinal strain (GLS). RESULTS The GLS in the HFrEF group was significantly lower than in the HFpEF group at the baseline (GLS: 9.56 vs. 16.03, p < 0.01). There was a strong negative correlation of the PIIINP and GLS in HFrEF group (r = -0.74, p = 0.005), but only a moderate negative correlation in HFpEF (r = -0.55, p = 0.02). In the HFrEF group, there was a moderate negative correlation between the baseline level of galectin-3 and GLS (r = -0.59, p = 0.03). The correlation of ghrelin and tissue inhibitor of matrix metalloproteinase-1 with EF in the HFrEF group was moderate and statistically significant (r = 0.62, p = 0.02 and r = -0.63, p = 0.02, respectively). CONCLUSIONS Procollagen type III peptide has a strong negative correlation with left ventricular GLS. Galectin-3 relationship with strain may indicate novel pathophysiological pathways and requires further investigation.

The role of selected adipokines and ghrelin in the prognosis after myocardial infarction in a 12-month follow-up in the presence of metabolic syndrome

Introduction The aim of this study was to evaluate the predictive value of selected adipokines in the improvement in the ejection fraction and in the development of adverse cardiac remodeling during 12 months of follow-up among patients with an ST-segment elevation acute myocardial infarction (STEMI) in the presence of metabolic syndrome (MeS). Material and methods The study population consisted of 69 patients (49 male; mean age: 59 ±10 years) with a first STEMI that was treated with a primary percutaneous coronary intervention (pPCI). In this group, 36 patients (18 male; mean age: 60 ±15 years) had MeS according to the definition of the International Diabetes Federation. The baseline clinical evaluation included a clinical examination and evaluation of the blood levels of C-reactive protein, ghrelin, resistin, and fasting glucose. Within 72 h after the STEMI, an echocardiographic examination was performed. A complete clinical evaluation was repeated after 12 months. Adverse cardiac remodeling was defined as an increase in the left ventricular end-diastolic volume of ≥ 8%. An improvement of the ejection fraction (EF) was defined as an increase of more than 5% in the EF. Results A concentration of ghrelin ≤ 160.46 pg/ml (AUC = 0.71, p = 0.032) had a good predictive value for the occurrence of adverse left ventricular remodeling but only in the patients without MeS. Among the patients with MeS, a concentration of resistin ≤ 5196 pg/ml (AUC = 0.073, p = 0.024) had a good predictive value for the occurrence of left ventricular remodeling. A concentration of leptin > 52.18 pg/ml (AUC = 0.81, p < 0.0001) and resistin > 4419.27 ng/ml (AUC = 0.67, p = 0.049) had a good predictive value for improvement of the LVEF in the patients without MeS. Conclusions The selected adipokines had a good predictive value for the development of adverse cardiac remodeling and for improvement of the ejection fraction among patients after a STEMI in the presence of metabolic syndrome.

Incremental value of left atrial mechanical dispersion over CHA2DS2-VASc score in predicting risk of thrombus formation

To assess the potential ability of two‐dimensional speckle tracking analysis (STE) during atrial fibrillation (AF) to identify patients with LA appendage thrombi (LAAT).

The impact of the latest echocardiographic chamber quantification recommendations on the prediction of left atrial appendage thrombus presence by transthoracic echocardiography

Abstract Introduction: The latest recommendations for echocardiographic chamber quantification have implemented updated normal values for all cardiac chambers. Purpose: To evaluate the incidence of normal and abnormal values of routine echocardiographic parameters such as left ventricular ejection fraction (LVEF) and left atrial volume indexed to body surface area (LAVi) in patients with non-valvular atrial fibrillation (AF) and to determine the influence of LVEF and LAVi reclassification on the prediction of LAAT by transthoracic echocardiography. Methods: We retrospectively analysed the database of 1674 transesophageal echocardiograms performed between 2012 and 2015 in our echo lab. The study involved patients (mean age 70 ± 7 years, 80% men) with paroxysmal or persistent AF (35 patients with left atrial appendage thrombus [LAAT] and 35 sex- and age-matched controls without LAAT). LVEF and LAVi were categorised in two ways: semi-quantitative using four-degree scale (normal or abnormal graded from mild and moderate to severe) and qualitative (normal vs. abnormal). Results: We reclassified 6 (9%) and 4 (6%) patients with regard to LVEF as well as 38 (54%) and 16 (23%) with regard to LAVi on semi-quantitative and qualitative scale, respectively. After adjustment for effective anticoagulation and approved risk factors in the multivariate models, we identified LVEF categorised in semi-quantitative manner according to both documents, LAVi categorised in a binary manner by new guidelines and semi-quantitative scale by both recommendations as independently associated with LAAT. Conclusions: Differentiation between normal and abnormal value enhanced the diagnostic meaning of LAVi in the aspect of higher LAAT risk. LVEF reclassification had no significant influence.

Recurrent endocarditis causing severe obstruction of bioprosthetic tricuspid valve

A 24-year-old woman, intravenous drug user, was admitted to the hospital with severe dyspnoea, fluid retention, and high fever lasting for a week. Five months prior to admission the patient underwent tricuspid valve replacement with a 31-mm Edwards Lifesciences bioprosthesis due to staphylococcal endocarditis and severe tricuspid valve regurgitation. The symptoms had aggravated for the previous two days. Inflammatory markers were elevated and increased during the hospitalisation. Combined empiric antibiotic therapy was immediately initiated. Blood culture confirmed methicillin-sensitive Staphylococcus aureus infection. Transthoracic echocardiography revealed large vegetations on bioprosthesis and in the right ventricular cavity protruding into the right ventricular outflow tract (Fig. 1A–C). The bioprosthetic valve was stenotic with peak velocity 2.4 m/s and mean transvalvular pressure gradient 14 mm Hg (Fig. 2A, B). Three-dimensional image acquisition was challenging because of respiratory instability, however feasible. It confirmed the presence of large pathologic masses and impaired motion of bioprosthetic leaflets (Fig. 2C). Computed tomography (CT) pulmonary angiogram excluded pulmonary embolism, and a CT scan of the brain and abdomen showed no evidence of systemic embolism. The patient was immediately referred to cardiac surgery and underwent tricuspid valve replacement. Intraoperative inspection revealed that not only tricuspid bioprosthesis and adjacent endocardium but also parietal endocardium was involved in the inflammatory process with vegetations. Extensive debridement without the necessity of reconstruction was performed. A Labcor 33 mm bioprosthesis was implanted. Due to third-degree atrioventricular block during the operation epicardial leads with external pacemaker were implanted. However, complete heart block persisted and the patient was qualified for transthoracic implantation of an epicardial screw-in electrode and permanent single-chamber pacemaker system. The postoperative course was uneventful. Replacement of a tricuspid valve is an infrequent cardiac surgery procedure. The majority of right-sided endocarditis cases are diagnosed in intravenous drug users. The mortality is lower than in left-sided localisation (5–10%). The decision about re-implantation of the prosthesis is a challenge because most addicts usually resume drug use after discharge. Recurrences of endocarditis in injection drug addiction are reported as relatively often. In the literature there is a lack of controlled studies assessing the prognosis after valve replacement in that group of patients. This fact makes the decision difficult and requires an individual approach. Another subject of debate remains the choice between mechanical or bioprosthetic valve. Injury of the conduction system is a possible complication, especially in the case of debridement, and some patients need permanent pacing. To the best of our knowledge, our patient represents the first reported case of severe bioprosthetic tricuspid valve obstruction caused by staphylococcal vegetations.

Conscious sedation for transcatheter implantation of atrial septal occluders with two- and three-dimensional transoesophageal echocardiography guidance — a feasibility and safety study

BACKGROUND General anaesthesia may have negative impact on patient mortality and morbidity, as well as overall procedure costs, in atrial septal occluder (ASO) implantation. AIM We sought to evaluate the safety, efficacy, and feasibility of conscious sedation for transcatheter implantation of ASOs. METHODS A total of 122 patients referred for transcatheter implantation of ASO were included. Mean patient age was 51 ± 15 years, and 43 (35%) patients were male. The initial dose of midazolam was 2 mg and fentanyl dose was 25 μg. Additional doses of midazolam and fentanyl were administered, if necessary. Patient responsiveness was assessed every 10 min, and the sedatives doses were titrated in order not to exceed grade 3 sedation in the Ramsey scale. RESULTS Atrial septal occluders were successfully implanted in the majority of patients (98.4%). In two (1.6%) cases the proce-dure failed because of too small patent foramen ovale (PFO) diameter (n = 1, 0.8%) or device instability (n = 1, 0.8%). The mean duration of procedure was 47.6 ± 28.4 min and was similar for ASD and PFO closure (p = 0.522). The overall mean dose of midazolam was 4.7 ± 2.2 mg (63.9 ± 32.5 μg/kg) and fentanyl was 30.0 ± 11.9 μg (0.43 ± 0.17 μg/kg). Median entrance dose of radiation at the patient plane was 25 (interquartile range: 16-57) mGy, and did not differ between ASD and PFO procedures (p = 0.614). The majority of patients were free of complications (91.0%). The following early complications were observed: transient ischaemic attack (n = 2, 1.6%), supraventricular arrhythmias (n = 4, 3.3%), left atrial thrombus formation (n = 1, 0.8%), symptomatic bradycardia (n = 1, 0.8%), and femoral venous bleeding (n = 5, 4.1%). After mean follow-up of 386 days residual shunt was observed in eight (6.6%) patients. CONCLUSIONS Conscious sedation for transcatheter implantation of ASO is a feasible, safe, and efficient technique, allowing successful PFO and ASD closure in the majority of patients.