Haematologic determinants of left atrial spontaneous echo contrast in mitral stenosis

Severe Spontaneous Echocardiographic Contrast in a Patient With Normal Heart and Chronic Lymphocytic Lymphoma

•SEC can occur in a structurally and functionally normal heart. •SEC formation has a stoichiometric relationship between hematocrit and fibrinogen levels. •SEC may be underappreciated in hematologic malignancies after chemotherapy initiation.

Whole blood viscosity in the evaluation of thrombogenic milieu in mitral stenosis

Aim: We aimed to assess the association of whole blood with thromboembolic milieu in significant mitral stenosis patients. Methodology & results: We included 122 patients and classified patients into two groups as having thrombogenic milieu, thrombogenic milieu (+), otherwise patients without thrombogenic milieu, thrombogenic milieu (-). Whole blood viscosity (WBV) in both shear rates were higher in thrombogenic milieu (+) group comparing with thrombogenic milieu (-). WBV at high shear rate and WBV at low shear rate parameters were moderately correlated with grade of spontaneous echo contrast. Adjusted with other parameters, WBV parameters at both shear rates were associated with presence of thrombogenic milieu. Discussion & conclusion: We found that extrapolated WBV at both shear rates was significantly associated with the thrombogenic milieu in mitral stenosis. This easily available parameter may provide additional perspective about thrombogenic diathesis.

Relationship between presence of spontaneous echo contrast and platelet-to-lymphocyte ratio in patients with mitral stenosis

BACKGROUND

Left atrial spontaneous echo contrast (SEC) is an existence of smoke-like echoes with a typical swirling motion of blood in left atrial cavity or appendage, and it is known to be a marker of prothrombotic state. Previous studies have revealed that there is an association between prothrombotic state and the platelet-to-lymphocyte ratio (PLR). Thus, we aimed to investigate the association between the presence of SEC and PLR in patients with mitral stenosis (MS).

METHODS

A total of 306 consecutive patients with MS were enrolled in the study. Transoesophageal echocardiography was made to assess the SEC for all patients. Recruited patients were divided into two groups according to the formation of SEC in the left atrium. Complete blood counting parameters, biochemical tests and high-sensitive C-reactive protein (Hs-CRP) levels were measured.

RESULTS

There were 182 patients (mean age 42.7 ± 11.9 and 78% female) in the SEC (-) group, and 124 patients (mean age 45.3 ± 10.5 and 68% female) in the SEC (+) group. Hs-CRP levels (3.9 ± 1.9 vs 5.1 ± 3.6, P < 0.001) were significantly different between the two groups. PLR (143.4 ± 77.7 vs 180.6 ± 108.7, P < 0.001) was significantly higher in the SEC (+) group. ROC curve analysis, PRL ≥123 had 71% sensitivity and 52% specificity in predicting SEC in patients with MS.

CONCLUSION

Platelet-to-lymphocyte ratio is an inexpensive and easily calculated biomarker, which is useful to predict left atrial SEC in patients with mitral stenosis.

Prediction of New-Onset and Recurrent Atrial Fibrillation by Complete Blood Count Tests: A Comprehensive Systematic Review with Meta-Analysis

Background

Atrial fibrillation (AF) is one of the most critical and frequent arrhythmias precipitating morbidities and mortalities. The complete blood count (CBC) test is an important blood test in clinical practice and is routinely used in the workup of cardiovascular diseases. This systematic review with meta-analysis aimed to determine the strength of evidence for evaluating the association of hematological parameters in the CBC test with new-onset and recurrent AF.

Material/Methods

We conducted a meta-analysis of observational studies evaluating hematologic parameters in patients with new-onset AF and recurrent AF. A comprehensive subgroup analysis was performed to explore potential sources of heterogeneity.

Results

The literature search of all major databases retrieved 2150 studies. After screening, 70 studies were analyzed in the meta-analysis on new-onset AF and 23 studies on recurrent AF. Pooled analysis on new-onset AF showed platelet count (PC) (weighted mean difference (WMD)=WMD of −26.39×10⁹/L and p<0.001), mean platelet volume (MPV) (WMD=0.42 FL and p<0.001), white blood cell (WBC) (WMD=−0.005×10⁹/L and p=0.83), neutrophil to lymphocyte ratio (NLR) (WMD=0.89 and p<0.001), and red blood cell distribution width (RDW) (WMD=0.61% and p<0.001) as associated factors. Pooled analysis on recurrent AF revealed PC (WMD=−2.71×10⁹/L and p=0.59), WBC (WMD=0.20×10⁹/L (95% CI: 0.08 to 0.32; p=0.002), NLR (WMD=0.37 and p<0.001), and RDW (WMD=0.28% and p<0.001).

Conclusions

Hematological parameters have significant ability to predict occurrence and recurrence of AF. Therefore, emphasizing the potential predictive role of hematological parameters for new-onset and recurrent AF, we recommend adding the CBC test to the diagnostic modalities of AF in clinical practice.

The association between mean platelet volume and spontaneous echocardiographic contrast or left atrial thrombus in patients with mitral stenosis

Objective:

Although the role of platelet activation has been debated in patients with mitral stenosis (MS) and spontaneous echocardiographic contrast (SEC), data on differences in mean platelet volume (MPV) according to the presence of SEC/left atrial thrombus and the rhythm status are lacking. In this study, MPV was analyzed in patients with MS according to the presence of SEC/left atrial thrombus.

Methods:

Between January 2005 and March 2014, 188 symptomatic patients having moderate or severe MS (mean age, 45.0±11.7 years; female, 81.4%) with favorable valve morphology for percutaneous mitral balloon valvuloplasty (PMBV) and underwent a transesophageal echocardiogram to assess the eligibility for PMBV were retrospectively enrolled in the study. The relation between MPV and echocardiographic thromboembolic risk factors were evaluated. Independent predictors of SEC/left atrial thrombus presence were determined by multiple logistic regression analyses.

Results:

Among all patients, MPV did not differ according to the rhythm status or the presence of SEC/left atrial thrombus (p>0.05). Also, MPV did not vary according to the gender and presence of prior stroke in both atrial fibrillation and sinus rhythm groups (p>0.05). In correlation analysis, MPV did not show any significant correlation with the echocardiographic thrombus predictors (p>0.05).

Conclusion:

Using MPV with echocardiographic and clinical thrombus risk determinants for predicting individual thromboembolism risk in MS is debatable according to our results.

Association of Left Atrial Spontaneous Echo Contrast to Uric Acid in Patients with Mitral Stenosis

OBJECTIVES

Spontaneous echo contrast (SEC) is the presence of smoke-like echoes with a characteristic swirling motion of the blood in echocardiography. Previous clinical studies have shown that SEC is a risk factor for left atrial thrombus formation and a predictor of potential systemic embolism originating from the heart. There is an association between uric acid and prothrombotic state. Therefore, we aimed to investigate the role of uric acid in SEC in patients with mitral stenosis (MS).

METHODS

A total of 85 consecutive patients with MS were enrolled in the study. Patients were divided into two groups according to whether SEC was present in the left atrium.

RESULTS

There were 41 patients (mean age 46.4 ± 11.4 and 68% female) in the SEC(-) group and 44 patients (mean age 45.7 ± 7.2 and 64% female) in the SEC(+) group. High sensitive C-reactive protein (hs-CRP) levels were significantly higher in the SEC(+) group than in the SEC(-) group (9.5 ± 4.2 vs. 4.7 ± 2.2 mg/L, P < 0.001). Uric acid was also significantly higher in the SEC (+) group (6.3 ± 1.4 vs. 4.5 ± 1.3 mg/dL, P < 0.001). In receiver operating characteristics curve analysis, uric acid >5.2 mg/dL had a 73% sensitivity and 76% specificity in predicting SEC in patients with MS. At multivariate analysis, uric acid (OR 3.919, 95% CI 1.911-8.035; P < 0.002) was an independent risk factor for SEC in patients with MS.

CONCLUSION

Uric acid is independently associated with SEC in patients with MS. Our findings suggest that this inexpensive, universally available marker may be a useful biomarker for the stratification of risk in patients with MS.

Transesophageal echocardiography for cardiac thromboembolic risk assessment in patients with severe, symptomatic aortic valve stenosis referred for potential transcatheter aortic valve implantation

Stroke is a devastating complication after transcatheter aortic valve implantation (TAVI) and might partially be related to cardiac embolization. The aim of this single-center prospective study was to determine the incidence of intracardiac thrombi and left atrial spontaneous echo contrast (SEC), both known predictors of cardiac embolic stroke, in patients referred for potential TAVI. One hundred four consecutive patients with severe symptomatic aortic valve stenosis and at high or very high risk for surgery were included and underwent transesophageal echocardiography. In 11 patients (10.6%), intracardiac thrombi were detected, and 25 patients (24%) showed dense grade 2 SEC. Atrial fibrillation (p <0.0001), diastolic dysfunction (p = 0.0005), and atrial size (p = 0.0038) were related to the presence of intracardiac thrombus and/or dense SEC on multivariate analysis. In conclusion, the incidence of intracardiac thrombi and dense SEC in (very) high-risk patients with severe aortic valve stenosis referred for potential TAVI is high and can accurately be detected using transesophageal echocardiography. Systematic thromboembolic evaluation using transesophageal echocardiography is thus recommended in patients referred for TAVI.

Relation of left atrial spontaneous echocardiographic contrast in patients with mitral stenosis to inflammatory markers

Spontaneous echocardiographic contrast (SEC) is the presence of smoke-like echoes with a characteristic swirling motion of blood in echocardiography. Previous clinical studies have demonstrated that SEC is a risk factor for left atrial thrombus formation and an important indicator of potential systemic embolism originated from heart. An established relation exists between the inflammatory status and the prothrombotic state. Therefore, we investigated the role of inflammatory status on SEC in patients with mitral stenosis (MS). A total of 62 consecutive patients with MS who undergoing mitral balloon valvuloplasty were enrolled in the present study. The patients were divided into 2 groups according to the formation of SEC in the left atrium. Of the 62 patients, 32 (mean age 45 ± 12 years; 75% women) were in the SEC-negative group and 30 patients (mean age 45 ± 11 years; 63% women) were in the SEC-positive group. The high-sensitive C-reactive protein levels were significantly greater in the SEC-positive group than in the SEC-negative group (3.9 ± 2.2 vs 10.6 ± 6.3, p = 0.024). The neutrophil levels (64.6 ± 9.4 vs 72.6 ± 8.6) were significantly greater in the SEC-positive group, and the lymphocyte levels (24.4 ± 6.9 vs 18.3 ± 6.0) were significantly greater in the SEC-negative group (p = 0.001 for each). The neutrophil/lymphocyte (N/L) ratio was also significantly greater in the SEC-positive group (3.0 ± 1.8 vs 4.5 ± 1.8, p = 0.003). In the receiver operating characteristics curve analysis, a N/L ratio > 3.1 mg/dl had a 80% sensitivity and 72% specificity in predicting SEC in patients with MS. On multivariate analysis, high-sensitive C-reactive protein (odds ratio [OR] 1.235, 95% confidence interval [CI] 1.040 to 1.466; p = 0.016), N/L ratio (OR 1.461, 95% CI 0.977 to 2.184; p = 0.02), left atrial volume (OR 3.012, 95% CI 1.501 to 5.611; p = 0.001), and mitral valve area (OR 0.135, 95% CI 0.020 to 0.503; p = 0.017) were independent risk factors of SEC in patients with MS. In conclusion, the high-sensitive C-reactive protein and N/L ratio were independently associated with SEC in patients with MS.

Relationship between platelet indices and spontaneous echo contrast in patients with mitral stenosis

AIMS

To determine the association of platelet indices with spontaneous echo contrast (SEC) in patients with mitral stenosis.

METHODS AND RESULTS

A total of 232 consecutive patients with mitral stenosis who undergoing mitral balloon valvuloplasty were enrolled to the study. Patients were divided into two groups according to the formation of SEC in the left atrium. Group 1: mitral stenosis complicated with SEC; Group 2: mitral stenosis without SEC. Transthoracic echocardiography and transoesophageal echocardiography were performed for each patient. Complete blood counting parameters were measured and all routine biochemical tests were performed. There were 133 patients (mean age 42 ± 11 and 74% female) in the SEC(-) group and 99 patients (mean age 45 ± 10 and 64% female) in the SEC(+) group. Plateletcrit (0.25 ± 0.06 vs. 0.27 ± 0.07, P = 0.043) and mean platelet volume (MPV) levels (9.4 ± 1.1 vs. 10.4 ± 1.2, P < 0.001) were significantly higher in the SEC(+) group. When we divided the SEC(+) patients into four subgroups according to previously reported criteria, MPV levels increased to correlate with the degree of SEC (P < 0.001). At multivariate analysis, MPV levels [odds ratio (OR) 2.365, 95% confidence interval (CI) 1.720-3.251; P < 0.001] and PCT levels (OR 2.699, 95% CI 1.584-4.598; P= 0.033) are independent risk factors of SEC in patients with mitral stenosis.

CONCLUSION

In patients with mitral stenosis, cheaply and easily measurable platelet indices including MPV and PCT levels are associated with the presence of SEC and are independent risk factors of SEC.

Increased mean platelet volume in rheumatic mitral stenosis: a possible factor for thromboembolic events

BACKGROUNDS

Systemic embolism is an important complication in patients with rheumatic mitral stenosis (RMS). The mean platelet volume (MPV) is considered a marker and determinant of platelet function since larger platelets are hemostatically more reactive than platelets of normal size, increasing the propensity to thrombosis. The aim of this study was to investigate MPV in patients with RMS and healthy control subjects.

METHODS

We selected 30 consecutive patients with RMS and 31 consecutive healthy age- and sex-matched control subjects. All subjects were in sinus rhythm. We measured MPV in a blood sample collected in EDTA.

RESULTS

Demographic data of the RMS (mean age: 39.5+/-9.9 years, 22 [71%] female) and control groups (mean age: 39.2+/-9.3 years, 20 [67%] female) were similar. The MPV was significantly higher in patients with RMS 8.8 (8.2-11.3) fl than control subjects 8.1 (7.1-9.3) (P<0.001).

CONCLUSION

Elevated MPV might be considered as a marker of increased thromboembolic risk in patients with RMS. We suggest that patients with high MPV values might benefit from antiplatelet therapy.

The relationship between spontaneous echocontrast, transesophageal echocardiographic parameters, and blood hemoglobin levels

BACKGROUND

Spontaneous echocontrast (SEC) or "smoke" is an intracavitary echocardiographic finding seen in situations of stasis or low blood flow. Increased hematocrit and fibrinogen levels have been associated with SEC in prior studies. Whether low hemoglobin (Hb) levels are an independent predictor of lower prevalence of SEC is a question that remains unanswered.

METHODS

A total of 266 transesophageal echocardiographic (TEE) studies were reviewed. Hb levels within 1 month from the TEE study were used as the baseline Hb before the study (75% had Hb on the same day of the TEE study). Clinical characteristics and demographics, and all relevant TEE variables including left atrial (LA) size, LA appendage emptying velocity (LAAEV), and presence or absence of SEC, were obtained using electronic patient information system search of TEE reports. Multivariate regression analysis was performed to identify the independent predictors of SEC.

RESULTS

Two groups were analyzed SEC (n = 45) or no SEC (n = 221). Only 7 patients had both LA and right atrial SEC. On univariate analysis, male sex, greater age, prior coronary artery bypass grafting, low ejection fraction (<50%), atrial fibrillation, renal failure, aortic atheroma, dilated LA, and decreased LAAEV (<40 cm/s) predicted SEC whereas low Hb levels were significantly associated with a lower prevalence of SEC (P = .01). However, after adjusting for clinical and echocardiographic variables, low Hb levels did not independently predict absence of SEC. Low LAAEV (P < .001), dilated LA (P = .001), and prior statin therapy (P = .001) were the most powerful independent predictors of SEC.

CONCLUSION

A low Hb level is not associated with a lower prevalence of SEC when controlled for clinical and echocardiographic variables. Our study confirms the importance of LAAEV and dilated LA in determining presence of SEC, but also raises interesting questions of the relationship between statins and SEC that warrant further study.

Spontaneous echoes due to hypoalbuminemia

We found spontaneous echoes in two teenagers with nephrotic syndrome and profound hypoalbuminemia, both having normal cardiac structure, function and output. The phenomenon disappeared after the level of albumin normalized. In one patient, all spontaneous echoes disappeared following convalescence, the level of albumin in the serum then being documented at normal levels. The second patient, who presented with profound hypoalbuminemia, was infused with human albumin because of oliguria, following which the spontaneous echoes disappeared.