Suwako Fujita

Relation of Aortic Arch Complex Plaques to Risk of Cerebral Infarction in Patients With Aortic Stenosis

Aortic stenosis (AS) and systemic atherosclerosis have been shown to be closely related. We evaluated the prevalence of aortic arch plaques and their possible association with the risk of cerebral infarction in patients with severe AS. Transesophageal echocardiography was performed in 116 patients with severe AS (55 men, mean age 71 ± 7 years, mean aortic valve area 0.68 ± 0.15 cm(2)) who were scheduled for aortic valve replacement. The presence, thickness, and morphology of the aortic arch plaques were evaluated using transesophageal echocardiography. Cerebral infarcts (chronic cerebral infarction and cerebral infarction after cardiac catheterization and aortic valve replacement) were assessed in all patients. Compared to age- and gender-matched control subjects, the patients with severe AS had a significantly greater prevalence of aortic arch plaques (74% vs 41%; p <0.0001) and complex arch plaques such as large plaques (≥4 mm), ulcerated plaques, or mobile plaques (30% vs 10%; p = 0.004). Multivariate logistic analyses showed that the presence of complex arch plaques was independently associated with cerebral infarction in patients with AS after adjusting for traditional atherosclerotic risk factors and coronary artery disease (odds ratio 8.46, 95% confidence interval 2.38 to 30.12; p = 0.001). In conclusion, the results from the present study showed that there is a greater prevalence of aortic arch plaques in patients with AS and that the presence of complex plaques is independently associated with cerebral infarction in these patients. Therefore, the identification of complex arch plaques using transesophageal echocardiography is important for risk stratification of cerebrovascular events in patients with severe AS.

Predictors of silent brain infarction on magnetic resonance imaging in patients with nonvalvular atrial fibrillation: A transesophageal echocardiographic study

BACKGROUND Silent brain infarction (SBI) is often found in patients with atrial fibrillation (AF) and may be related to cognitive decline. We investigated the predictors of SBI on brain magnetic resonance imaging (MRI) using transesophageal echocardiography (TEE) in patients with nonvalvular AF. METHODS The study population consisted of 103 neurologically asymptomatic patients with nonvalvular AF who underwent TEE before transcatheter AF ablation (76 men; mean age 63 ± 10 years). Left atrial (LA) abnormalities such as LA thrombus, spontaneous echo contrast, or abnormal LA appendage emptying velocity (<20 cm/s) and complex plaques in the aortic arch defined as large plaques ≥4 mm thickness, ulcerated plaques, or mobile plaques were evaluated by TEE. All patients were screened for SBI by brain MRI. RESULTS Of 103 patients, 31 (30%) showed SBI on brain MRI. Most lesions were multiple (61%) and small (<15 mm) in diameter (84%). Patients with SBI had a higher prevalence of LA abnormalities (45% vs 14%; P < .001) and complex arch plaques (45% vs 7%; P < .001) compared with those without SBI. In a multivariate logistic regression analysis including age and CHADS2 score ≥2, LA abnormalities (odds ratio 4.13; 95% CI 1.34-12.72; P = .014) and complex arch plaques (odds ratio 4.82; 95% CI 1.23-18.92; P = .024) were independent predictors of SBI. CONCLUSIONS Left atrial abnormalities and complex arch plaques detected by TEE were closely associated with the presence of SBI on brain MRI, suggesting that microembolization of small thrombi derived from the fibrillating LA or advanced aortic atherosclerotic lesions may be important causes of SBI in patients with nonvalvular AF.

Rapid and Accurate Assessment of Aortic Arch Atherosclerosis Using Simultaneous Multi-Plane Imaging by Transesophageal Echocardiography

Transesophageal echocardiography (TEE) is widely used for the evaluation of aortic arch atherosclerosis which carries an increased risk of ischemic stroke. We investigated the feasibility of simultaneous multi-plane imaging by real-time 3-D TEE for the assessment of aortic arch plaques. In 152 patients, we assessed aortic arch plaques and measured their maximum thickness by both conventional TEE imaging and multi-plane TEE imaging. There was excellent correlation and good agreement between the two methods in the measurement of the maximum thickness of arch plaques (r = 0.95, mean difference, -0.1 ± 0.5 mm). The mean image acquisition time required for aortic arch assessment by multi-plane imaging was significantly shorter than that required for conventional imaging in all patients (p < 0.001), especially those with complex plaques. These findings suggest that simultaneous multi-plane TEE imaging enables rapid and accurate evaluation of arch plaques and is therefore a useful tool for the assessment of aortic arch plaques in the clinical setting.

Relationship between CHADS2 Score and Complex Aortic Plaques by Transesophageal Echocardiography in Patients with Nonvalvular Atrial Fibrillation

The CHADS2 score is widely used for risk stratification of thromboembolism in patients with non-valvular atrial fibrillation (NVAF). Although the correlation of CHADS2 score with left atrial (LA) abnormality as detected by transesophageal echocardiography (TEE) has been reported in previous studies, the relationship between CHADS2 score and complex aortic plaque, which is also a significant risk factor for thromboembolism, has not been fully investigated. We assessed aortic plaques by TEE in 150 patients age ≥ 55 y with NVAF. The prevalence of complex aortic plaques increased along with increases in CHADS2 score (p = 0.001). In a multivariate analysis that included atherosclerotic risk factors and LA abnormality, a CHADS2 score ≥2 was independently associated with the presence of complex aortic plaques (odds ratio [OR] 3.39; 95% confidence interval [CI], 1.29-8.90). A high CHADS2 score is closely associated with the presence of complex aortic plaques, which explains, in part, the increased risk of thromboembolism in NVAF patients with high CHADS2 score.

Impact of concomitant coronary artery disease on atherosclerotic plaques in the aortic arch in patients with severe aortic stenosis.

Coronary artery disease (CAD) often occurs concurrently in patients with severe aortic stenosis (AS). However, the influence of concomitant CAD on the presence of atherosclerotic complex plaques in the aortic arch, which is associated with increased stroke risk, has not been fully assessed in patients with severe AS.