Cardiac imaging in
new guidelines and
recommendations
on…
…atrial fibrillation and
source of embolism
Paolo Colonna, MD FESC
Cardiology Hospital,
Policlinico of Bari
august 2010
august 2010
july 2010
Why new recommendations for atrial
fibrillation and source of embolism ?
• Diagnosis of embolism is mainly echo
• New technologies (second Ha, deformation,
contrast, 3D, etc) + TE echo
• Novel and controversial “etiological”
therapies for stroke (thrombolysis, closures,
ablations, etc)
• Changes in stroke population (↑ age and
heart failure, ↓ rheumatic heart disease)
Origin of Stroke
Stroke Registry- St Louis University
1986
Unknown
1992
21% Cardiac
Unknown
26%
53%
Atheroscl.
15%
2% Lacunar
9%
Others
Prior to TEE
Cardiac
29%
Others
3%
4%
Lacunar
37%
Atheroscl.
After TEE
Gomez CR, Echocardiography ‘93
TOAST classification:
ASCO classification. Amarenco P,
A-S-C-O phenotypes:
Cerebrovasc Dis 2009;27:502-508
• A for atherosclerosis,
• S for small vessel disease,
• C for cardiac source,
• O for other cause.
Causality levels:
• 1: definitely a potential cause of the index
stroke
• 2: causality uncertain
• 3: unlikely a direct cause of the index stroke
(but disease is present)
• 0: absence of disease
Clinical findings indicating
cardioembolic stroke mechanism
• Abrupt onset of stroke symptoms, (e.g.
AF without preceding TIA / stroke)
• Striking stroke severity, old age
(NIH-Stroke Scale ≥10; age ≥70 years)
• Previous infarctions in various arterial
distributions:
– Multiplicity in space (= infarct in both anterior
and posterior circulation, or bilateral L+R)
– Multiplicity in time (= infarct of different age)
EAE recommendations, EJE 2010
Imaging findings indicating
cardioembolic stroke mechanism
• Other signs of systemic
thromboembolism (e.g. edge-shaped
infarctions of kidney or spleen; Osler
splits; Blue toe-syndrome)
• Territorial distribution of the infarcts
• Hyperdense MCA sign (as long as
without severe ipsilateral internal
carotid stenosis)
EAE recommendations, EJE 2010
Territorial distribution
Probable Cardioembolic:
A) cortex,
B) subcortical ‘large
lenticulostriate infarct’
Unprobable:
C) lacunar infarctions
(subcortical)
Low flow infarct:
interterritorial…
D up) subcortical
D down) cortical
EAE recommendations, EJE 2010
hyperdense
middle cerebral
artery (MCA) sign
bilateral old infarcts in right
middle cerebral artery and
left anterior cerebral artery
distribution in AF pts
EAE recommendations, EJE 2010
(a) Mitral stenosis;
(b) Prosthetic heart valve;
(c) Myocardial infarction within the past 4 weeks;
(d) Mural thrombus in left cavities;
(e) Left ventricular aneurysm;
(f) History or permanent AF or flutter;
(g) Sick sinus syndrome;
(h) Dilated cardiomyopathy;
Level of causality 1
(i) Ejection fraction <35%;
(certain)
(j) Endocarditis;
(k) Intracardiac mass;
(l) PFO plus in situ thrombosis;
(m) PFO + PE or DVT preceding the stroke
a)
b)
c)
d)
e)
Level of causality 2
(uncertain)
PFO and ASA;
PFO + DVT or PE (but not preceding the stroke);
Spontaneous echo contrast;
Apical LV akinesia + ↓ ejection fraction (35-50%);
Only suggested: history of myocardial infarction or
palpitation and multiple brain infarcts;
f) Only suggested: abdominal CT/MRI presence of
systemic infarction (e.g. kidney, splenic) or lower
limb embolism (in addition to the index stroke)
•
Level of causality 3
(unlikely)
PFO, ASA, valvular strands,
mitral annulus calcification, calcified aortic valve,
nonapical LV akinesia
Multiplane TEE to detect effectiveness of
selective pulmonary rt-PA thrombolysis in
pulmonary embolism and PFO
Colonna, JASE 1997
Paradoxical embolism thrombus
in transit through a PFO
Srivastava, NEJM 97
Diagnosis and management of
entrapped embolus through a PFO
Aboyans, EJCTS 98
exhaustive review of the
medical literature of this rare
finding (43 cases):
Morphology of PFO in asymptomatic
versus symptomatic (stroke or TIA) pts
Goel, AJC ‘09
Morphology of PFO in asymptomatic
versus symptomatic (stroke or TIA) pts
Goel, AJC ‘09
PFOs in pts with cryptogenic CVAs: - larger,
- longer tunnels,
- more frequently associated with atrial septal aneurysms
Morphology of PFO in asymptomatic
versus symptomatic (stroke or TIA) pts
Goel, AJC ‘09
Linkage PFO / arterial embolism
EAE recommendations, EJE 2010
• Paradoxical embolism through PFO rare, escept
in acute pulmonary embolism (↑Right atrium pr)
• In the absence of ↑Right atrium pressure,
do not suspect causality for PFO, except if:
– young age
– association ASA + PFO
– large right → left shunt
• TOE echo + contrasti gold standard for PFO
evaluation, but also TT echo (good quality)
• Use Valsalva or vigorous cough (TOE and TT )
• Evaluate: color Doppler, n° bubbles, size defect
Echo in AFib / embolic risk
EAE recommendations, EJE 2010
Indication of TTecho in AFib for:
• diagnosis of cardiac underlying disease
(ischemic, valvular, DCM, LV dysfunction)
• choose of management and drugs strategy, prior
to arrhythmia conversion
• indication, guidance and follow up of
interventional procedures (ablation, LA
appendage closure)
Addition of TOecho for:
• giudance of TOE/shortened cardioversion
• complex cases (embolic recurrences in AC, etc)
• additional information on embolic risk
(not indicated as a routine exam!)
As alternative to 3 weeks of OAT, the TEE guided
cardioversion is recommended to exclude LA or
appendage thrombi. Class I LOE B
august 2010
Cardiac imaging and independent risk
factors for stroke:
• TTE: moderate to severe LV systolic
dysfunction
• TOE: LA thrombus, complex aortic
plaques, spontaneous echo-contrast,
and low LAA velocities
Echocardiography in atrial fib:
information for clinical decisions
EAE recommendations, EJE ‘10
• Thrombi
• Spontaneous echocontrast
• LA appendage velocities
Atrio auricular
function
• LV function and thrombi
• Patent foramen ovale
• Complex aortic plaques
Only with TOE
TEE correlates of thromboembolism in
high-risk patients with nonvalvular AF
The SPAF3 Investigators Committee on Echocardiography
Ann Intern Med 1998
.
Importance of LAA flow as a predictor
of thromboembolism in patients with AF
Clinical risk
factors
Echographic
risk factors
Kamp EHJ 99
Prevalence and clinical impact of LA
thrombi /echocontrast in AF and low
CHADS2 score
Kleeman et al. EJE ‘08
Pathophysiologic cascade for
stroke in AF pts
Clinical risk factors
(age, hypertension, etc.)
Long lasting AF /
Asympt. recurrences
(LV diastolic dysf.)
Atrio / auricular
= Low LAA velocity
structural remodeling
(LAA dysfunction)
Contrast / thrombi
in the LAA
Khan, Int J Card '03
de Luca, Int J Card '05
Colonna, JCM '06
Stroke
Analysis of pts undergoing
cardioversion (in ReLY trial)
Stroke / embolism at 30 days
Nagarakanti, Circ 2011
1,2
Warfarin
1
D110 mg
0,8
0,6
D110 mg
Warfarin
D150 mg
0,4
0,2
0
D150 mg
TOE prior cardioversion
NO TOE prior
cardioversion
Chads Embolic
risk
Vasc
>4
> 4% Dab 150
2-3
2-3% Dab 150 110>150? None/110
0-1
< 1% Dab 110 110/None
<1%
110/150?
3%
Dab 110
None
>10%Bleeding
risk
>3 Hasbled
0-1
2
In doubts… help from echocardiography
Echocardiography in stroke
and thromboembolism
• useful to identify difficult etiologies
(masses, endocardites, PFO, thrombi, etc)
• study all patients with A Fib for
stratification (some of them with TOE)
• play “early” to win the championship
for Napoli … in
bocca al lupo
Embolic risk stratification of AF
pts for the “wise cardiologist”
1. Calculate %/y embolic risk with
CHA2DS2VASc
2. Calculate %/y bleeding risk with
HAS-BLED
3. In the balance of difficult pts use
echo risk factors (atrial appendage,
aorta, LV function)
4. All evaluations more important for
new anticoagulants (usage / dosage)
L’ecocardiografia nello stroke
e nel tromboembolismo:
• identificare le cause anche quando
nascoste
• agire presto, ma nei casi difficili non
demordere …anche tardi può essere utile
per vincere la partita
ieri sera…
Cagliari Napoli 0-1
Lavezzi al 95’
Imaging findings indicating
cardioembolic stroke mechanism
• Other signs of systemic thromboembolism
(e.g. edge-shaped infarctions of kidney or
spleen; Osler splits; Blue toe-syndrome)
• Territorial distribution of the infarcts
• Hyperdense MCA sign (as long as without
severe ipsilateral internal carotid stenosis)
• Rapid recanalization of occluded major
brain artery (to be evaluated by repetitive
neurovascular ultrasound)
EAE recommendations, EJE 2010
“At present, closure of patent
foramen ovale appears to be
reasonable if” :
Alp N, Heart 01, mod.
• Pt < 60 y with cryptogenetic stroke
• Multiple clinical events
• Multiple infarcts at CT scan
Clinical
• Valsalva manouver preceding the stroke
• Wide PFO (numbers of bubble + dimensions)
• Coexistence of atrial septal aneurysm
• Deep venous thrombosis
Echo
Stroke mechanisms
hypothesis in PFO
• Origin from deep vein thrombosis
(demonstrated in 5-10%)
• Thrombosis in the aneurysm or in
the “tunnel”
• Increase of atrial arrhythmias
• Hypercoagulation state associated
Plaques in thoracic aorta
Grade I: normal
Grade IV: plaque >4mm
Grade II: thickening
Grade V: ulcers or mobility
Grade III: plaque < 4mm
Katz et al JACC ‘92
Actual Source Echocardiographic Findings
LV thrombus
Apical aneurysm, presence of thrombus,
dilated CM, hypertrabeculation / noncompaction
LA thrombus
Thrombus in LAA, spontaneous echo contrast,
LAA emptying velocity, mitral stenosis, interatrial
septal low aneurysm
3
Pelvic veins or ASD, atrial septal aneurysm, PFO
LL thrombus
1
Native valves
Vegetation, tumor, MVP, mitral annular
calcification, sclerotic aortic valve
Prosthetic
valves
Cardiac tumor
Thrombus, vegetation
Aorta
Complex aortic plaque, atheroma
LA myxoma, papillary fibroelastoma
2
L’ecocardiografia nel
tromboembolismo arterioso:
dalle Guidelines dell’EAE
Paolo Colonna, MD FESC
Cardiologia Osp. - Policlinico di Bari
Perché nuove raccomandazioni su
ecocardiografia e fonti emboliche ?
• Diagnostica embolismo è soprattutto eco
• Nuove tecnologie (seconda armonica,
deformation, contrasto, 3D, etc.) + ecoTE
• Nuove e controverse terapie “eziologiche”
per stroke (trombolisi, chiusure, ablazioni, et.)
• Cambio popolazione con stroke (↑ età e
scompenso, ↓ reumatismo)
Eco e diagnosi di endocardite:
• Criteri maggiori per diagnosi (3 eco): vegetazioni,
ascessi, mobilizzazione di protesi valvolari
• Indicato EcoTT precoce in tutti i sospetti clinici
• EcoTE se: ecoTT neg. + alto sospetto clinico,
protesi valvolari, scarsa qualità ecoTT
• Ripetere ecoTT / TE a 7-10 gg se persiste sospetto
Eco per predire il rischio di embolizzazione di EI:
• Rischio correlato a dimensioni e mobilità:
aumentato se vegetazioni grandi (>10 mm),
particolarmente se mobili e grandi (>15 mm)
• Massimo rischio nei primi giorni dopo inizio
antibiotico; decresce dopo 2 settimane
EAE recommendations, EJE 2010
Ecocardiografia per FA / rischio embolico
EAE recommendations, EJE 2010
EcoTT indicato in FA per:
• valutare patologia di base (eziologia ischemica,
valvolare, CMP, disfunzione VS)
• scegliere strategia e farmaco prima di
cardioversione aritmia
• indicazione, guida e follow up procedure
interventistiche (ablazione, chiusura auricola)
Aggiungere ecoTE per:
• guidare strategia abbreviata con ecoTE
• casi complessi (ricorrenze emboliche in AC, etc)
• informazioni aggiuntive su rischio embolico
Associazione PFO / embolia arteriosa
EAE recommendations, EJE 2010
• Embolia paradossa attraverso PFO rara, eccetto
che in emb polmonare acuta (↑press in AD)
• In assenza di ↑PAD no causalità PFO, eccetto :
– età giovane
– associazione ASA + PFO
– ampio shunt dx → sin
• EcoTE gold standard for PFO evaluation;
anche eco TT (se di buona qualità)
• In ecoTE e TT Valsalva o vigorosi colpi tosse
• Valutare: color Doppler, n° bolle (pochi cicli dopo
comparsa in AD)
Bleeding / embolism balance
for Dabigatran dosage
Embolism
> 3% Dab 150
?
Dab 110
2%
?
?
Dab 110
1%
?
Dab 110
Dab 110
1%
2%
>3% Bleeding
In doubt… help from echocardiography