Marcin Szulc

Long-term sinus rhythm maintenance after cardioversion of persistent atrial fibrillation: is the treatment's success predictable?

The aim of our study was to identify the clinical and echocardiographic predictors of long-term success of cardioversion in patients with persistent atrial fibrillation (AF). Our study comprised 104 patients (F/M 33/71; mean age 60.4 ± 7.9 years) assigned to SR restoration and maintenance with sequentially administered antiarrhythmic drugs. Their clinical and transthoracic echocardiographic (TTE) variables were recorded prior to cardioversion and examined for correlation with sinus rhythm (SR) maintenance at 1 year. The variables under consideration included age, gender, echo parameters such as long and short left atrial (LA) axis, LA and right atrial (RA) area, fractional shortening (FS) and left ventricular end-diastolic diameter, AF duration, New York Heart Association functional class, and concomitant diseases. Generalized additive logistic regression method was used to investigate impact of the selected variables on long-term SR maintenance. At 1 year, SR was present in 63.5% of patients. Left atrium area (LAar) > 28 cm (P < 0.02) and FS value >26% (P < 0.05), both measured at baseline, were significantly associated with SR maintenance after 1 year. Patients with large LAar values (>28 cm2) presented a significant decrease (31.45 ± 3.07 cm2 vs 28.94 ± 3.81 cm2; P < 0.008) during 30 days following SR maintenance. In patients with LAar >28 cm2 we noted an atrial decrease of 2.57 ± 3.2 cm2 (P < 0.004) during 30 days following SR restoration, which turned out to be an independent factor related to SR presence at 1 year of follow-up (relative risk 1.83; 95% confidence interval: 1.03–2.95; P < 0.01). Of all the considered variables only LA area and FS value seem to be relatively reliable predictors of SR sustainability at 1 year after an effective cardioversion of persistent AF.

Abdominal Aortic Doppler Waveform in Patients with Aorto-iliac Disease

OBJECTIVES The mid-systolic deceleration (notch) in the proximal descending aortic Doppler waveform was reported to be common in patients with aorto-iliac disease. However, evaluation of the descending aorta is limited to echocardiography and may be technically difficult. Therefore, we decided to check whether similar Doppler flow disturbance can be found in abdominal aorta, which is easily evaluated in wider range of patients undergoing general abdominal and vascular ultrasound, as well as echocardiography. METHODS We evaluated 115 consecutive symptomatic patients with severe peripheral artery disease admitted for vascular surgery, and 60 controls. The presence or absence of the mid-systolic deceleration in the Doppler waveform was evaluated retrospectively, by the single echocardiographer blinded to the localisation of the arterial occlusion or stenosis. RESULTS The mid-systolic notch in the proximal abdominal aorta was present in 58 of 71 patients (82%) with significant aorto-iliac disease, seven of 44 (16%) patients with occlusion or significant stenosis distally to the external iliac artery (P < 0.001) and in none of the patients from the control group. Sensitivity, specificity and positive predictive value of the mid-systolic notch in the abdominal aortic Doppler waveform in the detection of aorto-iliac disease in patients with peripheral artery disease were 82%, 84% and 89%, respectively. CONCLUSION The mid-systolic deceleration (notch) in the proximal abdominal Doppler waveform is a simple ultrasonographic marker of significant aorto-iliac disease.

Descending Aortic Doppler Flow Pattern in Patients With Proximal Peripheral Artery Disease

Midsystolic deceleration (notch) in pulmonary pulse-wave (PW) Doppler flow is a common finding in patients with pulmonary embolism. The possible mechanism involves early reflection of pressure wave from proximal embolic sites. The aim of this study was to evaluate with PW Doppler whether occlusion or significant stenosis in the distal aorta or iliac arteries might produce a similar midsystolic notch in descending aortic flow. Echocardiography was performed in 97 consecutive patients with severe peripheral artery disease (PAD) admitted for vascular surgery and in 41 controls. PW Doppler assessment of flow in the proximal descending aorta was recorded from the suprasternal window. After exclusion of 13 patients due to inadequate visualization, atrial fibrillation, or aortic aneurysm, 84 patients were analyzed. Diagnosis of midsystolic notch was made by an experienced echocardiographer blinded to the vascular status of patients. A midsystolic notch in the descending aorta was present in 43 of 49 patients (87.7%) with occlusion or with >70% stenosis in the aortoiliac segment, 6 of 35 (17.1%) patients with occlusion or significant stenosis distal to the external iliac artery, and 0 patient from the control group. Sensitivity of the midsystolic notch in the detection of aortoiliac disease in patients with PAD was 87.7% and specificity was 82.8%. In conclusion, midsystolic deceleration (notch) in the descending aortic Doppler waveform is characteristic for patients with significant proximal PAD. The possible mechanism involves arterial pressure wave reflection from the occlusion or significant stenosis in the aortoiliac segment.

Functional status with rhythm versus rate control strategies for persistent atrial fibrillation

Introduction Recent studies have shown that rhythm control does not provide additional benefit over rate control in terms of morbidity or mortality and is less cost effective in patients with atrial fibrillation (AF). It remains to be determined if any of the treatment strategies should be favored on the basis of the quality of life (QoL) or functional capacity. Objectives This HOT CAFE substudy was conducted to compare the functional status of patients with persistent AF assigned either to rate or rhythm control strategy. Patients and methods We enrolled 205 patients (mean [SD] age, 60.8 [11.2] years) with persistent AF who were randomly assigned either to rate or rhythm control strategies. The New York Heart Association (NYHA) functional classification, intensity of arrhythmia‑related symptoms, exercise tolerance, and QoL were analyzed. Results After a mean (SD) of 1.7 (0.4) years, the NYHA class and QoL improved in both groups. Both strategies lead to improvement in AF‑related symptoms. Treadmill test duration and maximal workload increased over time in both groups. In terms of NYHA class improvement, rhythm control was superior to rate control in patients with AF and hypertension (odds ratio [OR], 1.89; 95% CI, 0.98-3.65; P = 0.055) and in those with moderate HF (OR, 2.04; 95% CI, 1.03-4.06; P = 0.04). When success was considered as left ventricular function improvement, the rhythm‑control strategy also proved to be superior in patients with hypertension (OR, 2.64; 95% CI, 1.21-5.74; P = 0.01) and those with NYHA class II or III (OR, 4.27; 95% CI, 1.25-9.85; P <0.001). Conclusions Rate- and rhythm‑control strategies improved functional status in patients with persistent AF. However, rhythm control might be more appropriate for patients with AF and hypertension and those with moderate HF.