Abstract 15523: Absence of Chordae Tendineae near Valve Coaptation Leads to Mitral Regurgitation in Lone Atrial Fibrillation

Introduction: Mitral annuloplasty is performed to treat mitral valve regurgitation (MR) in lone atrial fibrillation (AF) patients. The mechanisms of the significant MR in lone AF patients are not known well. We assessed the hypothesis that absence of chordae tendineae near the mitral valve (MV) coaptation could lead to the significant functional MR in the lone AF patients. Methods: We analyzed 64 patients with a history of AF with greater than 50 % of the left ventricular (LV) ejection fraction, and no organic abnormality of MV. Of these 31 has mild or lesser MR (AF Groups) and 33 has moderate or severe MR (AFMR Group). We also analyzed 33 sinus rhythm patients with normal echocardiographic findings (Sinus Group). Parameters concerning to MV morphology were measured with commercial software. Chordae attaching points (CAPs) nearest from the coaptation line were detected on the anterior mitral leaflet (Figure). Ratio of the length from CAP to coaptation line against that from anterior annulus to coaptation line was calculated as CAP-C/An-C ratio. Results: Mitral annular area (P < 0.05), leaflets surface area (P < 0.05), and CAP-C/An-C ratio (P < 0.05) were larger in the AFMR Group as compared with the AF Group (Table). With multivariate analysis, the correlation factor of significant MR in AF patients was increase in the CAP-C/An-C ratio (Odds ratio (per 1 % increase) = 1.70; p <0.05). Conclusion: The absence of chordae tendineae near the coaptation line represented by larger CAP-C/An-C ratio is related to the functional MR in AF patients with normal LV function.

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Left ventricular ejection fraction reduction due to atrial fibrillation: clinical and echocardiographic predictors

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.038 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

E Marcusohn ◽

O Kobo ◽

M Postnikov ◽

D Epstein ◽

Y Agmon ◽

...

Keyword(s):

Atrial Fibrillation ◽

Left Ventricular Ejection Fraction ◽

Ejection Fraction ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Lv Function ◽

Ventricular Ejection Fraction ◽

Prosthetic Valves ◽

Ventricular Response ◽

History Of

Abstract Funding Acknowledgements Type of funding sources: None. Background The diagnosis of atrial fibrillation (AF) induced cardiomyopathy can be challenging. It relies on ruling out other causes of dilated cardiomyopathy, upon recovery of left ventricular ejection fraction (LVEF) following return to sinus rhythm (SR). Aim The aim of this study was to identify clinical and echocardiographic predictors for developing new dilated cardiomyopathy in patients with AF or atrial flutter (AFL). Methods This is a retrospective study conducted in a large tertiary care center. Patients that suffered deterioration of LVEF under 50% during AF demonstrated by pre-cardioversion trans-esophageal echocardiography (TEE) were compared to those with preserved LV function during AF. All patients had documented preserved LVEF at baseline (EF >50%) while in SR. Patients with a previous history of reduced LVEF during SR were excluded. Results From a total of 482 patients included in the final analysis, 80 (17%) patients had reduced LV function and 402 (83%) had preserved LV function during the pre-cardioversion TEE. Patients with reduced LVEF were more likely to be male and with a more rapid ventricular response during AF/AFL. A history of prosthetic valves was also identified as a risk factor for reduced LVEF. Patients with reduced LVEF also had higher incidence of TR and RV dysfunction. Conclusion In "real world" experience, male patients with rapid ventricular response during AF or AFL are more prone to LVEF reduction. Patients with prosthetic valves are also at risk for LVEF reduction during AF/AFL. Lastly, TR and RV dysfunction may indicate relatively long-standing AF with an associated reduction in LVEF.

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Midterm Surgical Outcomes for ALCAPA Repair in Infants and Children

The Thoracic and Cardiovascular Surgeon ◽

10.1055/s-0041-1725978 ◽

2021 ◽

Author(s):

Renjie Hu ◽

Wen Zhang ◽

Xiafeng Yu ◽

Hongbin Zhu ◽

Haibo Zhang ◽

...

Keyword(s):

Coronary Artery ◽

Mitral Valve ◽

Mitral Valve Regurgitation ◽

Left Ventricular ◽

Surgical Correction ◽

Circulatory Support ◽

Lv Function ◽

Coronary Artery Ligation ◽

Artery Ligation

Abstract Background Surgical correction of an anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) has been associated with excellent survival during recent years. The purpose of this study was to evaluate the effectiveness of reimplantation of the coronary artery and to investigate the recovery of postoperative cardiac and mitral valve (MV) function. Methods From 2005 to 2015, 80 patients who had ALCAPA received surgical correction. Among them, 49 were infants. The median patient age was 7.8 months. Operative strategies included reimplantation of the coronary artery in 71 patients, the Takeuchi procedure in another 7 patients, and coronary artery ligation in the remaining 2 patients. Results There were 11 hospital deaths and 2 late deaths. Six patients required intraoperative or postoperative mechanical circulatory support. A significant improvement in the ejection fraction (EF) and shortening fraction (SF) was present in all surviving patients at discharge, at a 3-month follow-up and at a 1-year follow-up. MV function improved gradually after surgical repair with no late secondary intervention. Conclusions The repair of ALCAPA can be accomplished by establishment of a dual-coronary system, which offers an acceptable mortality rate and will rarely require a second surgery. Left ventricular (LV) recovery is a progressive process, especially for infants with impaired LV function. Concomitant MV annuloplasty is safe and reliable and can be performed as necessary in patients with moderate or severe mitral valve regurgitation.

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Left Ventricle Architecture and Valvular Integrity Following Microaxial Mechanical Support: A Two-Year Follow-Up Study

Journal of Clinical Medicine ◽

10.3390/jcm10061273 ◽

2021 ◽

Vol 10 (6) ◽

pp. 1273

Author(s):

Georgios Chatzis ◽

Styliani Syntila ◽

Harald Schuett ◽

Christian Waechter ◽

Holger Ahrens ◽

...

Keyword(s):

Mitral Valve ◽

Structural Integrity ◽

Mitral Valve Regurgitation ◽

Left Ventricular ◽

Circulatory Support ◽

Lv Function ◽

Long Term Effects ◽

And Function

Although the use of microaxilar mechanical circulatory support systems may improve the outcome of patients with cardiogenic shock (CS), little is known about its effect on the long-term structural integrity of left ventricular (LV) valves as well as on the development of LV-architecture. Therefore, we aimed to study the integrity of the LV valves and architecture and function after Impella support. Thus, 84 consecutive patients were monitored over two years having received ImpellaTM CP (n = 24) or 2.5 (n = 60) for refractory CS (n = 62) or for high-risk percutaneous coronary interventions (n = 22) followed by optimal medical treatment. Beside a significant increase in LV ejection fraction after two years (p ≤ 0.03 vs. pre-implantation), we observed a statistically significant decrease in LV dilation (p < 0.001) and severity of mitral valve regurgitation (p = 0.007) in the two-year follow-up period, suggesting an improved LV architecture. Neither the duration of support, nor the size of the Impella device or the indication for its use revealed any devastating impact on aortic or mitral valve integrity. These findings indicate that Impella device is a safe means of support of LV-function without detrimental long-term effects on the structural integrity of LV valves regardless of the size of the device or the indication of support.

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Ventricular-arterial coupling changes as an early predictor of left ventricular remodelling in atrial fibrillation

European Heart Journal ◽

10.1093/eurheartj/ehab724.0102 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

M Gaczol ◽

A Olszanecka ◽

M Rajzer ◽

W Wojciechowska

Keyword(s):

Atrial Fibrillation ◽

Pulse Wave ◽

Global Longitudinal Strain ◽

Systolic Pressure ◽

Left Ventricular ◽

Public Institution ◽

Lv Function ◽

Ventricular Remodelling ◽

Normal Range ◽

History Of

Abstract Objective Atrial fibrillation (AF) can be associated with adverse atrial and ventricular remodelling also in the absence of persistently elevated heart rate. Ventricular–arterial coupling (VAC) plays a pivotal role in cardiac and aortic adaptation to pathophysiological conditions. The aim of this study was to investigate changes in conventional and novel VAC indexes in long lasting paroxysmal AF. Methods Participants with paroxysmal AF, in sinus rhythm on admission, with preserved left ventricle (LV) systolic function and carotid – femoral pulse wave velocity (PWV) within normal range were carefully selected from consecutive patients admitted to University Hospital in Krakow for scheduled AF ablation. We excluded those with established coronary artery disease, moderate or severe heart valves disease, with uncontrolled hypertension or other comorbidities. The anthropometric and demographic data, medical history, and habits were collected using standardized questionnaire. A total of 51 (mean age 57.7 yrs; 37 men) patients underwent simultaneous echocardiographic and arterial data acquisition. End-systolic pressure was determined from central pulse wave analyses. Arterial elastance (Ea) and LV elastance (Ees) were calculated as end-systolic pressure/stroke volume and end-systolic pressure/end-systolic volume. Two-dimensional speckle tracking was used to derive LV global longitudinal strain (GLS), and then PWV to GLS ratio was calculated. Results Patient presented moderate (EHRA class median = 2b) and long-lasting symptoms (median of AF history 3 years). There was an association of Ees (parameter estimate (PE) 0.12; P=0.0004) and VAC (Ea/Ees) (PE=−0.13; P=0.33) with duration of AF history in the univariate linear regression model and this association retain statistically significant in a model including age, sex, history of hypertension and hypercholesterolemia. Longer history of AF was related to lower PWV to GLS ratio, however this association reached statistical significance only among patients with AF lasting more than 3 years (PE=−0.14; P=0.024) and persisted significant after accounting for covariates. Conclusion The relationship between AF and LV dysfunction is complex and potentially bi-directional. Paroxysmal AF however, can contribute to abnormality in heart–vessel coupling, even when LV function remained within the normal range, indicating early stage of ventricular remodelling due to arrythmia. FUNDunding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Collegium Medicum, Jagiellonian University, Krakow

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Takotsubo syndrome after mitral valve surgery: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa327 ◽

2020 ◽

Author(s):

Ana Devesa ◽

Rafael Hernández-Estefanía ◽

José Tuñón ◽

Álvaro Aceña

Keyword(s):

Mitral Valve ◽

Fatal Outcome ◽

Mitral Valve Surgery ◽

Left Ventricular ◽

Valve Surgery ◽

Lv Function ◽

Partial Recovery ◽

Takotsubo Syndrome ◽

Left Circumflex Artery ◽

Coronary Syndrome

Abstract Background Takotsubo syndrome is a frequent entity; however, it has never been described after a mitral valve surgery. Case summary We present the case of a 79-year-old woman, with background of atrial fibrillation and a left atrial appendage closure device, who was admitted for elective mitral valve replacement, because of asymptomatic severe primary mitral regurgitation. Biologic mitral valve was implanted without incidences, but in the postoperative, she developed cardiogenic shock. Electrocardiogram (ECG) showed inverted T waves in precordial leads and an echocardiography showed severe left ventricular (LV) dysfunction with mid to distal diffuse hypokinesis, and better contractility in basal segments. Troponin levels were mildly elevated. With the suspicion of a postoperative acute coronary syndrome, a coronary angiography was performed and showed no significant coronary lesions. The haemodynamic situation was compromised for the next 48 h, in which vasoactive support and intra-aortic balloon counterpulsation were implemented. After 48 h, the haemodynamic situation suddenly improved. The ECG was normalized, and a control echocardiogram showed partial recovery of the LV function with resolution of regional wall motion abnormalities. The patient could be discharged at 1 week. The clinical picture was interpreted as a stress cardiomyopathy after mitral valve surgery. Discussion Takotsubo syndrome is a threatening condition; complications in acute phase could lead to a fatal outcome. Mitral valve surgery has to be considered as a trigger for this entity, after excluding coronary involvement, specially of left circumflex artery.

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Difference of myocardial injury, inflammation and early recurrence after pulmonary vein isolation among laser balloon ablation, radiofrequency catheter ablation and cryoballoon ablation

European Heart Journal ◽

10.1093/ehjci/ehaa946.0574 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M Yano ◽

M Nishino ◽

H Nakamura ◽

Y Matsuhiro ◽

K Yasumoto ◽

...

Keyword(s):

Atrial Fibrillation ◽

Myocardial Injury ◽

Early Recurrence ◽

Left Ventricular ◽

Cryoballoon Ablation ◽

Echocardiographic Parameters ◽

History Of ◽

Hs Crp ◽

Balloon Ablation ◽

Laser Balloon Ablation

Abstract Background Pulmonary vein isolation (PVI) has become well-established as the main therapy for patients with drug-refractory paroxysmal atrial fibrillation (PAF) and various isolation methods including radiofrequency ablation (RFA), cryoballoon ablation (CBA) and laser balloon ablation (LBA) were available. Pathological findings in each ablation methods such as myocardial injury and inflammation are thought to be different. High sensitive cardiac troponin I (hs-TnI), subunit of cardiac troponin complex, is a sensitive and specific marker of myocardium injury. High-sensitive C-reactive protein (hs-CRP) is a biomarker of inflammation and is elevated following cardiomyocyte necrosis. Relationship between myocardial injury and inflammation after ablation using RFA, CBA and LBA and early recurrence of atrial fibrillation (ERAF) remains unclear. Methods We enrolled consecutive PAF patients from Osaka Rosai Atrial Fibrillation (ORAF) registry who underwent PVI from January 2019 to October 2019. We compared the clinical characteristics including age, gender, hypertension, diabetes mellitus, history of heart failure, CHADS2Vasc score, renal function, serum BNP level and echocardiographic parameters including left ventricular dimensions, left atrial diameter (LAD) and left ventricular ejection fraction (LVEF) between RFA, CBA and LBA groups. We investigated the difference of relationship between myocardial injury marker (hs-TnI), inflammation markers (white blood cell change (DWBC) from post to pre PVI, neutrophil-to-lymphocyte ratio change (DNLR) from after to before PVI and hs-CRP) at 36–48 hours after PVI and ERAF (<3 months after PVI) between each group. Results We enrolled 187 consecutive PAF patients who underwent PVI. RFA, CBA and LBA groups comprised 108, 57 and 22 patients, respectively. There were no significant differences of age, gender, hypertension, diabetes mellitus, history of heart failure, CHADS2Vasc score, renal function, serum BNP level and echocardiographic parameters between each group. Serum hs-TnI in RFA group and LBA group were significantly lower than in CBA group (2.643 ng/ml vs 5.240ng/ml, 1.344 ng/ml vs 5.240 ng/ml, p<0.001, p=0.002, respectively, Figure). DWBC was significantly higher in LBA group than CBA group (1157.3/μl vs 418.4/μl, p=0.045). DNLR did not differ between each group. Hs-CRP in RFA group and LBA group were significantly higher than in CBA group (1.881 mg/dl vs 1.186 mg/dl, 2.173 mg/dl vs 1.186 mg/dl, p=0.010, p=0.003, respectively, Figure). Incidence of ERAF was significantly higher in LBA group than RFA group (36.4% vs 16.7%, p=0.035). Incidence of ERAF tended to be higher in LBA group than CBA group (36.4% vs 19.3%, p=0.112). Conclusion LBA may cause less myocardial injury than RFA and CBA, on the contrary LBA may cause more inflammation than CBA. Incidence of ERAF in LBA was highest between each procedure. Inflammation markers and ERAF Funding Acknowledgement Type of funding source: None

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Application of the current HFA-ESC consensus guidelines on diagnosis of heart failure with preserved ejection fraction to a population referred for echocardiography

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeaa356.038 ◽

2021 ◽

Vol 22 (Supplement_1) ◽

Author(s):

K Liang ◽

R Hearse-Morgan ◽

S Fairbairn ◽

Y Ismail ◽

AK Nightingale

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Ejection Fraction ◽

Diastolic Function ◽

Global Longitudinal Strain ◽

Diagnostic Algorithm ◽

Left Ventricular ◽

Lv Function ◽

Preserved Ejection Fraction ◽

Consensus Guidelines

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND The recent Heart Failure Association (HFA) of the European Society of Cardiology (ESC) consensus guidelines on diagnosis of heart failure with preserved ejection fraction (HFpEF) have developed a simple diagnostic algorithm for clinical use. PURPOSE To assess whether echocardiogram (echo) parameters needed to assess diastolic function are routinely collected in patients referred for assessment of heart failure symptoms. METHODS Retrospective analysis of echo referrals in January 2020 were assessed for parameters of diastolic function as per step 2 of the HF-PEFF diagnostic algorithm. Echo images and clinical reports were reviewed. Electronic records were utilised to obtain clinical history, blood results (NT-proBNP) and demographic data. RESULTS 1330 patients underwent an echo in our department during January 2020. 83 patients were referred with symptoms of heart failure without prior history of cardiac disease; 20 patients found to have impaired left ventricular (LV) function were excluded from analysis. Of the 63 patients with possible HFpEF, HF-PEFF score was low in 18, intermediate in 33 and high in 12. Median age was 68 years (range 32 to 97 years); 25% had a BMI >30. There was a high prevalence of hypertension (52%), diabetes (19%) and atrial fibrillation (40%) (cf. Table 1). Body surface area (BSA) was documented in 65% of echo reports. Most echo parameters were recorded with the exception of global longitudinal strain (GLS) and indexed LV mass (cf. image 1). NT-proBNP was recorded in only 20 patients (31.7%). 12 patients with an intermediate HF-PEFF score could have been re-categorised to a high score depending on GLS and NT-proBNP (which were not recorded). CONCLUSION More than three quarters of echoes acquired in our department obtained the relevant parameters to assess diastolic function. The addition of BSA, and inclusion of NT-proBNP, and GLS would have been additive to a third of ‘intermediate’ patients to determine definite HFpEF. Our study demonstrates that the current HFA-ESC diagnostic algorithm and HF-PEFF scoring system are easy to use, highly relevant and applicable to current clinical practice. Age >70 years 29 (46.0%) Obesity (BMI >30) 16 (25.4%) Diabetes 12 (19%) Hypertension 33 (52.4%) Atrial Fibrillation 25 (39.7%) ECG abnormalities 18 (28.5%) Table 1. Prevalence of Clinical Risk Factors Abstract Figure. Image 1. HFPEFF score & echo parameters

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Visualization and Hemo-Dynamic Evaluation of Edge-to-Edge Mitral Valve Repair Within Reanimated Swine Hearts

Journal of Medical Devices ◽

10.1115/1.3136430 ◽

2009 ◽

Vol 3 (2) ◽

Author(s):

M. G. Bateman ◽

J. L. Quill ◽

J. St. Louis ◽

P. A. Iaizzo

Keyword(s):

Mitral Valve ◽

Mitral Valve Repair ◽

Imaging Modality ◽

Systolic Pressure ◽

Left Ventricular ◽

Lv Function ◽

Valve Repair ◽

Regurgitant Fraction ◽

Orifice Area ◽

Leaflet Coaptation

This project aims to investigate the performance of edge-to-edge mitral valve repair (MVR) within reanimated swine hearts. Direct imaging and hemodynamic data of the mitral valve during normal cardiac function (Normal), after an induced prolapse (Prolapse), and post surgical repair (E2E) was obtained. Isolated swine hearts (n=6) were reanimated using a clear Krebs–Henseleit buffer. Mitral prolapse, and regurgitation, in the P2 region was induced by cutting chordae tendinae of the posterior leaflet. An edge-to-edge MVR procedure was performed, suturing the prolapsed P2 region to the A2 region of the anterior leaflet. The mitral valve was imaged using endoscopic cameras in the left atrium and ventricle allowing verification of stitch placement and leaflet coaptation. Analysis of the endoscopic images provided measures of annulus area, orifice area, and regurgitant area. Echocardiography, the standard clinical imaging modality, was used to determine the hemodynamic performance of the valve. Additionally, ECG and left chamber pressures were recorded at a sample rate of 5 kHz. Prolapse of the P2 region was consistently created, and edge-to-edge repair of the mitral leaflet showed full leaflet coaptation. The annulus area of the valve was tracked throughout the procedure and did not show significant variation. The orifice area, defined as the area of the annulus that does not contain leaflets, normalized to the corresponding annulus area for Normal, Prolapse and E2E were: 41±13%, 44±14% and 21±13%, p=0.02. The regurgitant area, normalized to the corresponding annulus area, increased from 2±2% for Normal to 8±3% for the Prolapse and then decreased to 1±1% for the E2E group. The regurgitant fraction, normalized against the maximum observed, for Normal, Prolapse and E2E was 10±6%, 57±26% and 13±13%, p<0.01. Over the course of the experiment the left ventricular (LV) systolic pressure and negative dP/dt reduced from 95 to 54 mm Hg and 743 to 402 mm Hg/s, respectively. Our results show that orifice area was significantly smaller after MVR when compared to Normal and Prolapse periods. There was no significant change in regurgitant area and regurgitant fraction from the Normal to repaired valve as compared to a significant increase in regurgitant area and regurgitant fraction during Prolapse. Low gradients were observed for all three groups, with no indications for symptomatic stenosis. The reduction of LV function was caused by global ischemia and the progressive onset of edema. In this acute assessment of edge-to-edge repair of P2 prolapse, repair does not affect annulus area, decreases orifice area, and successfully eliminates regurgitant area with no evidence of mitral stenosis.

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P1273 Effects of surgical septal myectomy on left ventricular function in patients with hypertrophic obstructive cardiomyopathy

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.723 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

A Furugen ◽

H D Doi ◽

M H Hashimoto ◽

R K Koshima ◽

K M Mitsube

Keyword(s):

Mitral Valve ◽

Diastolic Function ◽

Longitudinal Strain ◽

Function Analysis ◽

Left Ventricular ◽

Volume Index ◽

Lv Function ◽

Septal Myectomy ◽

Concomitant Procedure ◽

Lv Diastolic Function

Abstract Introduction and Purpose Surgical left ventricular (LV) septal myectomy in patients with obstructive hypertrophic cardiomyopathyhas been shown to reduce left ventricular outflow tract (LVOT) gradient and improve symptoms. We investigated changes in strain analysis, LA volume and LV systolic and diastolic function in patients with HOCM after surgical septal myectomy. Methods We enrolled consecutive 30 patients (age 63.7 ± 11.0 years, 47% Female), who underwent surgical LV septal myectomy for HOCM from 2012 to 2019. We evaluated LV dimension, LVOTG, LV-stroke volume, LV in flow pattern (E wave, A wave, Dct), e’(septal and lateral), LA volume, mitral regurgitation (MR), systolic anterior motion of mitral valve (SAM) and Global longitudinal strain. These parameters were evaluated at baseline and after LV myectomy at medium term (at least 6 months after surgery). Results They are followed for a mean of 3.4± 1.9 years after surgery. Eight patients underwent concomitant procedure; mitral valve repair and annuloplasty in 3 patients (10%), Maze surgery in 1 patient, LV aneurysmectomy in 2 patients and aortic valve replacement in 3 patients (10%). Patients with concomitant procedure were excluded from LV function analysis. Postoperative LVOTG were controlled in 10mmHg or less.Global longitudinal strain (GLS) improved but no significant change. Otherwise LA volume index decreased (from 52.5 ± 16.7 to 32.9 ± 14.6 ml/m2, p = 0.01) and LV diastolic function improved with an increase in lateral e" velocity (from 4.5 ± 2.8 to 9.2 ± 3.4 cm/sec, p = 0.001) and improved E/e’ (from 18.9 ± 5.6 to 10.6 ± 5.2, p <0.05). Symptoms of dyspnea, chest oppression and heart failure improved with reduction in the New York Heart Association functional class. Conclusion Excellent relief of LVOT obstruction in HOCM by surgical LV septal myectomy results in decreased LA volume and LV diastolic function with improved symptoms.

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1203Typical atrial flutter is a manifestation of previously silent coronary artery disease

European Heart Journal ◽

10.1093/eurheartj/ehz748.0033 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

L Iden ◽

S Groschke ◽

R Weinert ◽

R Toelg ◽

G Richardt ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cardiovascular Disease ◽

Family History ◽

Atrial Flutter ◽

Smoking Status ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Typical Atrial Flutter ◽

Silent Coronary Artery Disease ◽

History Of

Abstract Background Long-term mortality after ablation of typical atrial flutter has been found to be increased two fold in comparison to atrial fibrillation ablations through a period of five years with unclear mechanism. Methods We analysed 189 consecutive patients who underwent ablation for typical atrial flutter (AFL), in which the incidence of atrial flutter was the first manifestation of cardiac disease. According to clinical standards of our center, the routine recommendation was to evaluate for CAD by invasive angiogram or CT-scan. We compared the AFL patients to 141 patients with paroxysmal atrial fibrillation (AFIB) without known structural heart disease who underwent ablation in the same period and who had routine coronary angiograms performed. Results Out of 189 patients who presented with AFL, coronary status was available in 152 patients (80.4%). Both groups were balanced for mean age (64.9 years in AFL vs. 63.2 years in AFIB; p=0.15), body-mass-index (BMI; 28.8 vs. 28.5 kg/m2; p=0.15), CHA2DS2-VASc-Score (2.20 vs. 2.04; p=0.35), smoking status (22.2% smokers vs. 28.4%; p=0.23) and renal function (GFR >60 ml/min in 96.7% of all patients vs. 95.7%; p=0.76). There were significantly lower values for left-ventricular ejection fraction (52.5% vs. 59.7%; p<0.001), female sex (17.0% vs. 47.5%; p<0.001), hyperlipidemia (37.9% vs. 58.9%; p<0.001) and family history of cardiovascular disease (15.0 vs. 31.9%; p=0.001) in the AFL vs. AFIB cohorts. CAD with stenoses >50% was found in 26.3% of all patients with available coronary status in AFL and in 7.0% in AFIB (p<0.001). CAD with stenoses >75% in 16.4% in AFL whereas only in 1.4% in AFIB (p<0.001). Multivessel disease was detected in 10.5% in AFL and 0.7% in AFIB (p<0.001). After correction for age, LVEF, BMI, CHA2DS2-VASc-Score and it's individual components, smoking status, hyperlipidemia and family history of cardiovascular disease, there was a more than five-fold increase in the likelihood of CAD with stenosis >50% in AFL as compared to AFIB (OR 5.26). A multivariate analysis was performed in the AFL group. Patients with clinically relevant stenoses (>75%) were older (70.6 years vs. 63.8 years; p=0.001), had a higher number of risk factors (3.08 vs. 2.24; p≤0.0016) and a higher CHA2DS2-VASc-Score (3.20 vs 2.00; p<0.0001). With logistic regression, significant CAD could be predicted by higher values for CHA2DS2-VASc-Score with an exponential rise to a pretest-probability of 42.1% at a value of 4 points. Odds ratios of CAD with AFL vs AFIB Discussion This data suggests that typical atrial flutter constitutes a manifestation for previously asymptomatic CAD. Due to the inclusion criteria, CAD has to be considered silent and stable in most of the patients. Therefore, the presence of typical atrial flutter in formerly healthy patients should raise suspicion of otherwise silent CAD and initiate further investigations and risk-stratification with particular emphasis on the individual CHA2DS2-VASc-Scores.

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