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The Use of Transoesophageal Echocardiography to Determine Management in Stroke
S36
Abstracts
ABSTRACTS
by computer-assisted planimetry, was a hypoenhanced region within the infracted segment. Observers were blinded to the biomarker results. Results: 19 patients, age 58 ± 11 years, were studied. The mean infarct size was 19.2 ± 10.3% and MVO was 3.13 ± 3% of LV mass. Patients with MVO (76%) had a higher peak troponin I (p = 0.015), peak CK (p = 0.02) and infarct size (p = 0.025). The correlation between peak troponin elevation and troponin area under the curve (AUC) was stronger for MVO (r = 0.81 and 0.61, respectively) than infarct size (r = 0.64 and r = 0.46). Furthermore, on multivariate stepwise linear regression analysis MVO was the best predictor of peak troponin (p < 0.001), significantly better than infarct size (p = NS). Conclusion: MVO on contrast-enhanced CMR has a better correlation with peak troponin elevation than infarct size. This finding may reflect the presence of more complete myonecrosis in the MVO region of infarction than elsewhere. These findings also confirm the value of CMR in potentially improving clinical risk stratification. doi:10.1016/j.hlc.2008.05.083 83 Serial Doppler Echocardiography and Tissue Doppler Imaging Measurements can Accurately Detect Elevated Directly Measured Left Atrial Pressure in Chronic Heart Failure Jay Ritzema 1,∗ , Mark Richards 1 , Ian Crozier 1 , Nicola Gardiner 1 , Iain Melton 1 , Robert Doughty 4 , Neal Eigler 2 , James Whiting 2 , William T. Abraham 3 , Richard Troughton 1 1 Christchurch
Hospital, Christchurch, New Zealand; of California, Los Angeles, United States; 3 Ohio State University, Columbus, United States; 4 Auckland City Hospital, Auckland, New Zealand 2 University
Objectives: We determined whether serial measurements of conventional and newer Doppler indices including the ratio of early diastolic transmitral and annular velocities (E/E ) can detect elevated directly measured left atrial pressure (LAP) in ambulant subjects with chronic heart failure. Methods: 13 patients with NYHA II–IV (aged 76 ± 7 years, median LV ejection fraction 30%, range 11–56) heart failure and a permanently implanted direct LAP monitoring device underwent serial echocardiography. Simultaneous mean LAP and Doppler mitral inflow, pulmonary venous inflow and mitral annular tissue Doppler imaging (TDI) velocity variables were obtained during a median of 4 (range 1–7) regular follow-up visits during the year following device implantation. Results: 55 simultaneous echocardiographic studies and LAP measurements were undertaken. Device-LAP ranged from 3.2 to 38.8 mmHg at the time of echocardiography. Septal and lateral E/E had the best receiver-operating characteristic (ROC) curves to detect an LAP ≥ 16 mmHg across all echocardiographic studies (area under the curve 0.89 and 0.9 respectively). The areas under the respective
Heart, Lung and Circulation 2008;17S:S1–S209
ROC curves were 0.83 (mitral E velocity), 0.83 (mitral E to A ratio) and 0.77 (pulmonary venous D velocity) by comparison. E/E medial of >13 and E/E lateral >10 had a 91 and 81% sensitivity and a 73 and 80% specificity, respectively, for the detection of LAP ≥ 16 mmHg. Conclusion: Serial measurements of mitral inflow and mitral annular TDI velocities can reliably detect raised directly measured LAP in ambulant subjects with chronic heart failure. doi:10.1016/j.hlc.2008.05.084 84 The Use of Transoesophageal Echocardiography to Determine Management in Stroke Tanya Stewart ∗ , Keyvan Karimi Galougahi, Jessica Stewart, Chris Choong, Geoff Tofler Royal North Shore Hospital, Sydney, NSW, Australia Introduction: Investigation for cause of stroke is a common indication for transoesophageal echocardiogram (TOE). Although an abnormality is frequently found, it remains uncertain how frequently the findings alter management. Also, the role of transthoracic echocardiogram (TTE) prior to TOE is unclear. We sought to determine the use of TTE prior to TOE, the outcome of the TOE, and the impact this had on management. Methods: We retrospectively reviewed the records and echocardiography results of 100 consecutive patients who underwent TOE for any reason at a tertiary hospital. In 35%, the indication was source of stroke. Among these, we determined if they had a TTE prior to their TOE, clinical risk factors for stroke, the results of the TOE, and its affect on management. Results: Only 28% of those referred for stroke assessment had a TTE performed. The mean age was 64.6 years (range 17–90) and 49% were women. 80% had ≥2 known risk factors for stroke and 17% were in atrial fibrillation. The TOE showed an abnormality in 63% of patients; 37% aortic atheroma; 17% PFO; 14% spontaneous echo contrast; and 6% left atrial appendage thrombus. Of those with an abnormal TOE, in only one patient (3%) was management altered based on the TOE findings. This was the commencement of anticoagulation in a patient found to have a PFO and atrial septal aneurysm. Conclusion: Only one quarter of patients undergoing TOE for investigation of stroke had a TTE prior to TOE. A large proportion of the referred patients had known risk factors for stroke, including 17% with AF. In this series of stroke patients an abnormal TOE, although common, rarely altered management. doi:10.1016/j.hlc.2008.05.085
Abstracts
ABSTRACTS
by computer-assisted planimetry, was a hypoenhanced region within the infracted segment. Observers were blinded to the biomarker results. Results: 19 patients, age 58 ± 11 years, were studied. The mean infarct size was 19.2 ± 10.3% and MVO was 3.13 ± 3% of LV mass. Patients with MVO (76%) had a higher peak troponin I (p = 0.015), peak CK (p = 0.02) and infarct size (p = 0.025). The correlation between peak troponin elevation and troponin area under the curve (AUC) was stronger for MVO (r = 0.81 and 0.61, respectively) than infarct size (r = 0.64 and r = 0.46). Furthermore, on multivariate stepwise linear regression analysis MVO was the best predictor of peak troponin (p < 0.001), significantly better than infarct size (p = NS). Conclusion: MVO on contrast-enhanced CMR has a better correlation with peak troponin elevation than infarct size. This finding may reflect the presence of more complete myonecrosis in the MVO region of infarction than elsewhere. These findings also confirm the value of CMR in potentially improving clinical risk stratification. doi:10.1016/j.hlc.2008.05.083 83 Serial Doppler Echocardiography and Tissue Doppler Imaging Measurements can Accurately Detect Elevated Directly Measured Left Atrial Pressure in Chronic Heart Failure Jay Ritzema 1,∗ , Mark Richards 1 , Ian Crozier 1 , Nicola Gardiner 1 , Iain Melton 1 , Robert Doughty 4 , Neal Eigler 2 , James Whiting 2 , William T. Abraham 3 , Richard Troughton 1 1 Christchurch
Hospital, Christchurch, New Zealand; of California, Los Angeles, United States; 3 Ohio State University, Columbus, United States; 4 Auckland City Hospital, Auckland, New Zealand 2 University
Objectives: We determined whether serial measurements of conventional and newer Doppler indices including the ratio of early diastolic transmitral and annular velocities (E/E ) can detect elevated directly measured left atrial pressure (LAP) in ambulant subjects with chronic heart failure. Methods: 13 patients with NYHA II–IV (aged 76 ± 7 years, median LV ejection fraction 30%, range 11–56) heart failure and a permanently implanted direct LAP monitoring device underwent serial echocardiography. Simultaneous mean LAP and Doppler mitral inflow, pulmonary venous inflow and mitral annular tissue Doppler imaging (TDI) velocity variables were obtained during a median of 4 (range 1–7) regular follow-up visits during the year following device implantation. Results: 55 simultaneous echocardiographic studies and LAP measurements were undertaken. Device-LAP ranged from 3.2 to 38.8 mmHg at the time of echocardiography. Septal and lateral E/E had the best receiver-operating characteristic (ROC) curves to detect an LAP ≥ 16 mmHg across all echocardiographic studies (area under the curve 0.89 and 0.9 respectively). The areas under the respective
Heart, Lung and Circulation 2008;17S:S1–S209
ROC curves were 0.83 (mitral E velocity), 0.83 (mitral E to A ratio) and 0.77 (pulmonary venous D velocity) by comparison. E/E medial of >13 and E/E lateral >10 had a 91 and 81% sensitivity and a 73 and 80% specificity, respectively, for the detection of LAP ≥ 16 mmHg. Conclusion: Serial measurements of mitral inflow and mitral annular TDI velocities can reliably detect raised directly measured LAP in ambulant subjects with chronic heart failure. doi:10.1016/j.hlc.2008.05.084 84 The Use of Transoesophageal Echocardiography to Determine Management in Stroke Tanya Stewart ∗ , Keyvan Karimi Galougahi, Jessica Stewart, Chris Choong, Geoff Tofler Royal North Shore Hospital, Sydney, NSW, Australia Introduction: Investigation for cause of stroke is a common indication for transoesophageal echocardiogram (TOE). Although an abnormality is frequently found, it remains uncertain how frequently the findings alter management. Also, the role of transthoracic echocardiogram (TTE) prior to TOE is unclear. We sought to determine the use of TTE prior to TOE, the outcome of the TOE, and the impact this had on management. Methods: We retrospectively reviewed the records and echocardiography results of 100 consecutive patients who underwent TOE for any reason at a tertiary hospital. In 35%, the indication was source of stroke. Among these, we determined if they had a TTE prior to their TOE, clinical risk factors for stroke, the results of the TOE, and its affect on management. Results: Only 28% of those referred for stroke assessment had a TTE performed. The mean age was 64.6 years (range 17–90) and 49% were women. 80% had ≥2 known risk factors for stroke and 17% were in atrial fibrillation. The TOE showed an abnormality in 63% of patients; 37% aortic atheroma; 17% PFO; 14% spontaneous echo contrast; and 6% left atrial appendage thrombus. Of those with an abnormal TOE, in only one patient (3%) was management altered based on the TOE findings. This was the commencement of anticoagulation in a patient found to have a PFO and atrial septal aneurysm. Conclusion: Only one quarter of patients undergoing TOE for investigation of stroke had a TTE prior to TOE. A large proportion of the referred patients had known risk factors for stroke, including 17% with AF. In this series of stroke patients an abnormal TOE, although common, rarely altered management. doi:10.1016/j.hlc.2008.05.085