Hematologic correlates of spontaneous echo contrast in patients with atrial fibrillation and implications for thromboembolic risk

doi:10.1016/0002-9149(94)90932-6

The American Journal of Cardiology

Volume 73, Issue 9, 1 April 1994, Pages 672-676

https://doi.org/10.1016/0002-9149(94)90932-6 Get rights and content

Abstract

Spontaneous echo contrast has been observed in conditions of low blood flow velocity, such as rheumatic mitral stenosis and & trial fibrillation (AF). The phenomenon has been attributed to increased echogenicity due to aggregation of blood cells at low shear rates. The aim of this study was to determine whether abnormalities of blood composition also might contribute to spontaneous echo contrast formation by promoting cellular aggregation. Transesophageal echo-cardiography was performed in 185 patients with AF (31 with valvular and 154 with nonvalvular AF). The left atrium was examined for thrombus and spontaneous echo contrast, which was graded from 0 (nil) to 4+ (severe) by 2 independent observers. Forty milliliters of venous blood was obtained from each patient for hematologic analysis. Spontaneous echo contrast was observed in 46% of patients (74% with valvular and 41% with nonvalvular AF). In linear regression analysis, positive correlations were found between grade of spontaneous echo contrast and erythrocyte sedimentation rate (p < 0.001), lowshear blood viscosity (p < 0.001) and anticardiolipin antibody (p = 0.02) in the total study population, and in patients with nonvalvular AF. Spontaneous echo contrast correlated with mitral valve area (p < 0.01) and gradient (p = 0.03), but not with hematologic parameters in patients with valvular AF. Left atrial thrombus was present in 6 patients, all of whom had spontaneous echo contrast. Age (p < 0.01), spontaneous echo contrast (p = 0.03) and the fibrinogen concentration (p = 0.03) correlated with previous embolic events. These results suggest that, in addition to flow disturbance associated with structural carrdiac abnormalities and AF, blood composition may also be important in spontaneous echo contrast formation, particularly in patients with nonvalvular AF. The association between spontaneous echo contrast and both the erythrocyte sedimentation rate and low-shear blood viscosity supports a role for red cell aggregation in the pathogenesis of this phenomenon.

References (28)

S. Beppu et al.
Smoke-like echo in the left atrial cavity in mitral valve disease: its features and significance
J Am Coll Cardiol
(1985)
W.G. Daniel et al.
Left atrial spontaneous echo contrast in mitral valve disease: an indicator for an increased thromboembolic risk
J Am Coll Cardiol
(1988)
R. Castello et al.
Prevalence and clinical implications of atrial spontaneous contrast in patients undergoing transesophageal echocardiography
Am J Cardiol
(1990)
I.W. Black et al.
Left atrial spontaneous echo contrast: a clinical and echocardiographic analysis
J Am Coll Cardiol
(1991)
X.-F. Wang et al.
The relationship between intracardiovascular smoke-like echo and erythrocyte rouleaux formation
Am Heart J
(1992)
A. Merino et al.
Echogenic “smoke” is produced by an interaction of erythrocytes and plasma proteins modulated by shear forces
J Am Coll Cardiol
(1992)
I.W. Black et al.
Hematologic correlates of left atrial spontaneous echo contrast and thromboemholism in nonvalvular atrial fibrillation
J Am Coll Cardiol
(1993)
H. Feigenbaum
Coronary artery disease
F.L. Mikell et al.
Regional stasis of blood in the dysfunctional left ventricle: echocardiographic detection and differentiation from early thrombosis
Circulation
(1982)
R. Virchow
Metastatical dyscrasiae

R. Castello et al.

Spontaneous echocardiographic contrast in the descending aorta

Am Heart J

(1990)

D.J. Sahn et al.

Recommendations regarding quantitation in M-mode echocardiography: results of a survey of echocardiographic measurements

Circulation

(1978)

B. Sigel et al.

Ultrasonography of blood during stasis and coagulation

Invest Radiol

(1981)

B. Sigel et al.

Effect of plasma proteins and temperature on echogenicity of blood

Invest Radiol

(1982)

Cited by (109)

Association of spontaneous echo contrast with Systemic Immune Inflammation Index in patients with mitral stenosis
2022, Revista Portuguesa de Cardiologia
Spontaneous echo contrast (SEC) is the appearance of swirling, smoke-like echoes in the left atrium (LA) and is accepted as an independent predictor of thromboembolic risk. There is an established relationship between the inflammatory state and the prothrombotic state. Therefore, we investigated the relationship between the Systemic Immune Inflammation Index (SII), a new inflammation parameter introduced recently, and SEC in patients with mitral stenosis (MS).
A total of 262 patients who underwent percutaneous mitral valvuloplasty (PMBV) for MS were included in this study. The patients were divided into two groups: patients with MS complicated by SEC and patients with MS without SEC, based on whether SEC occurred in the LA.
There were 79 patients (mean age 47.1 ± 6.6, 30.3% male gender) in the SEC (+) group, while there were 183 patients (mean age 46.4 ± 8.6, 29.5% male gender) in the SEC (-) group. In multivariate analysis, high levels of SII were an independent risk factor for SEC in patients with MS (OR: 1.001, 95% confidence interval (CI): 1.000-1.001, p<0.001) together with high levels of C-reactive protein (OR: 1.145, 95% CI: 1.027-1.277, p=0.014). The receiver operating characteristics (ROC) curve analysis showed that at a cutoff value of 547.6 for SII to predict SEC with 74.6% sensitivity and 77.6% specificity (area under ROC curve=0.736 (95% CI: 0.668-0.805), p<0.001).
Our study showed that the SII levels were independently associated with SEC in patients with MS.
O contraste espontâneo (CE) consiste no aparecimento de ecos em espiral semelhantes ao fumo de tabaco na aurícula esquerda sendo aceite como um fator preditivo independente de risco tromboembólico. Existe uma relação estabelecida entre o estado inflamatório e o estado protrombótico. Portanto, analisámos a relação entre Índice de Inflamação Imunológica Sistémica, (IIIS), um novo parâmetro recentemente introduzido e o CE em doentes com estenose mitral (EM).
Foram incluídos neste estudo 262 doentes, submetidos a valvuloplastia mitral percutânea (VMP) por EM. Os doentes foram divididos em dois grupos: em doentes com EM complicada por CE e em doentes com EM sem CE, com base na ocorrência de CE na aurícula esquerda.
Foram estudados 79 doentes (idade média 47,1 ± 6,6, 30,3% do sexo masculino) no grupo CE (+) e 183 doentes (idade média 46,4 ± 8,6, 29,5% do sexo masculino) no grupo CE (-). Na análise multivariada, níveis elevados de IIIS constituíram um fator de risco independente de CE em doentes com EM (OR: 1,001, intervalo de confiança 95% (IC): 1,000-1,001, p<0,001) juntamente com níveis elevados de PCR (OR: 1,145, IC 95%: 1,027-1,277, p=0,014). A análise da curva das características de funcionamento do recetor (ROC) mostrou que com um valor cut-off de 547,6 para IIIS é fator preditivo de CE com 74,6% de sensibilidade e 77,6% de especificidade (área sob curva ROC=0,736 (IC 95%: 0,668-0,805), p<0,001).
O nosso estudo mostrou que os níveis de IIIS associam-se independentemente a CE em doentes com EM.
Precision Medicine Approaches to Cardiac Arrhythmias: JACC Focus Seminar 4/5
2021, Journal of the American College of Cardiology
In the initial 3 papers in this Focus Seminar series, the fundamentals and key concepts of precision medicine were reviewed, followed by a focus on precision medicine in the context of vascular disease and cardiomyopathy. For the remaining 2 papers, we focus on precision medicine in the context of arrhythmias. Specifically, in this fourth paper we focus on long QT syndrome, Brugada syndrome, and atrial fibrillation. The final (fifth) paper will deal with catecholaminergic polymorphic ventricular tachycardia. These arrhythmias represent a spectrum of disease ranging from common to relatively rare, with very different genetic and environmental causative factors, and with differing clinical manifestations that range from almost no consequences to lethality in childhood or adolescence if untreated. Accordingly, the emerging precision medicine approaches to these arrhythmias vary significantly, but several common themes include increased use of genetic testing, avoidance of triggers, and personalized risk stratification to guide the use of arrhythmia-specific therapies.
A novel risk score for predicting left atrial and left atrial appendage thrombogenic milieu in patients with non-valvular atrial fibrillation
2020, Thrombosis Research
Citation Excerpt :
Sludge was defined as a dynamic gelatinous, precipitous echodensity, without a discrete mass throughout the cardiac cycle [3]. SEC was defined as smoke-like echoes, swirling pattern, detectable constantly throughout the cardiac cycle and was classified from 1 to 4 based using a set of criteria by Fatkin et al. [11] All TEE images were reviewed by 2 experienced observers blinded to other clinical data.
Although the CHADS2 and CHA2DS2-VASc scoring systems are commonly used as measures of thromboembolic risk in patients with nonvalvular atrial fibrillation (NVAF), data are inconsistent as to their value in predicting the presence of left atrial (LA) and/or left atrial appendage (LAA) thrombogenic milieu (TM). The present study aimed to establish a novel risk score to assess the risk of LA and/or LAATM in NVAF patients.
This is a retrospective case-control study that included 125 consecutive patients with NVAF plus TM, as evidenced by transesophageal echocardiography (TEE) during a period from1 January 2010 to 1 February 2017. The controls were 1098 NVAF patients without TM during the same period. Risk factors for LA and/or LAATM were identified using univariable analysis and multivariable logistic regression. The risk score model was developed based on 10-fold validation and multiple regression. Risk model performance was evaluated using receiver operating characteristic (ROC) curves. Net reclassification improvement (NRI) was used for the comparison of C-statistics. The AUCs were compared using the Z test.
Among all 1223 NVAF patients, 125 (10.22%) patients had LA and/or LAATM. A score system (0−12) was developed based on the following 6 independent variables identified by 10-fold validation with sequential methods. Different points were assigned for each variable, according to multivariable regression using relative coefficients (coefficient of the index risk factor divided by the lowest coefficient among the 6 risk factors; rounded to closest integer): 1 for blood type A and N-terminal B-type natriuretic peptide (NT-proBNP) ≥864.85 pg/mL; 2 for LAD ≥43.5 mm and age ≥ 73.5 years old; 3 for previous heart failure and previous stroke or TIA. The present risk score system had a sensitivity of 58.3%, specificity of 91.4 and accuracy of 81.6%. The area under the ROC curve (AUC) was 0.832, (95% CI: 0.784–0.881; P < 0.001). The negative predictive value (NPV) was 92% when we set the cut-off point at 4; when the cut-off point was set at 8, the positive predictive value (PPV) was 85.7%. Compared with CHADS2 and CHA2DS2-VASc score, the present novel risk score has better predictive power [net reclassification improvement (NRI) +96.3% and +66.2%, respectively; all P < 0.001].
This study developed a novel risk score to help predicting LA and/or LAATM in NVAF patients, which had higher accuracy than CHADS2 and CHA2DS2-VASc score system.
ABO blood groups: A risk factor for left atrial and left atrial appendage thrombogenic milieu in patients with non-valvular atrial fibrillation
2017, Thrombosis Research
Previous studies have identified ABO blood groups as predictors of thromboembolic diseases. In patients with atrial fibrillation (AF), however, potential association between ABO blood groups and the risk of left atrial (LA) and/or left atrial appendage (LAA) thrombogenic milieu (TM) has not been established.
This is a retrospective case-control study that included 125 consecutive patients with non-valvular atrial fibrillation (NVAF) plus TM, as evidenced by transesophageal echocardiography (TEE) during a period from1 January 2010 to 31 December 2016. The controls were selected randomly from 1072 NVAF without TM at a 1:2 ratio. Potential association between ABO blood groups and TM was analyzed using multivariate logistic regression analysis.
The risk of TM was higher in patients with blood group A (33.6% vs. 20.2% in non-A blood groups, P = 0.005). After adjusting for age, sex, oral anticoagulant use, AF type and duration, and relevant functional measures (e.g., NT-pro BNP level, left atrium diameter, and left ventricular ejection fraction), blood group A remained associated with an increased risk of TM (OR = 2.99, 95% CI 1.4–6.388, P = 0.005).
Blood group A is an independent risk factor for TM in NVAF patients.
Association between the N-terminal plasma brain natriuretic peptide levels or elevated left ventricular filling pressure and thromboembolic risk in patients with non-valvular atrial fibrillation
2016, Journal of Cardiology
We aimed to investigate the role of brain natriuretic peptide (BNP) levels and left ventricular (LV) filling pressures in thromboembolic risk in patients with non-valvular atrial fibrillation (AF).
Among 327 patients with non-valvular AF, the ratio of peak early filling velocity to mitral annulus velocity (E/Ea) and N-terminal proBNP (NT-proBNP) was compared according to the presence of left atrial appendage (LAA) dysfunction [presence of spontaneous echo contrast (SEC) ≥ grade 3 and/or reduced LAA emptying flow velocity <20 cm/s].
Compared to patients without LAA dysfunction, patients with LAA dysfunction presented with significantly higher CHADS₂ scores (1.24 ± 1.14 vs. 1.68 ± 1.31, p = 0.005), high-sensitivity C-reactive protein (0.36 ± 1.18 mg/dl vs. 0.66 ± 1.32 mg/dl, p = 0.043), and NT-proBNP (765.3 ± 2534.8 pg/ml vs. 2266.9 ± 6117.4 pg/ml, p = 0.002). Furthermore, patients with LAA dysfunction showed significantly higher left atrial volume index (LAVI, 25.1 ± 10.9 vs. 43.1 ± 22.1, p < 0.001) and E/Ea (10.8 ± 7.27 vs. 7.97 ± 2.50 mg/dl, p < 0.001). Plasma log NT-proBNP levels were significantly correlated with the presence of SEC (r = 0.276, p < 0.001), LAA emptying flow velocity (r = −0.492, p < 0.001), LAVI (r = 0.405, p < 0.001), and E/Ea (r = 0.353, p < 0.001). Binary logistic regression analysis showed that high NT-proBNP level >249.7 pg/ml (odds ratio, OR 6.79, 95% confidence interval, CI 3.16–15.55, p < 0.001) and E/Ea >10 (OR 4.41, 95% CI 2.39–8.15, p < 0.001) were independent predictors of LAA dysfunction after adjustment of known thromboembolic risk factors.
Elevated plasma NT-proBNP concentrations and LV filling pressures represented by LAA dysfunction may be reliable surrogate markers for predicting thromboembolic risk in patients with AF.
Impact of Diastolic Function Parameters on the Risk for Left Atrial Appendage Thrombus in Patients with Nonvalvular Atrial Fibrillation: A Prospective Study
2016, Journal of the American Society of Echocardiography
In patients with nonvalvular atrial fibrillation (NVAF), the impact of left ventricular diastolic function on the risk for left atrial appendage (LAA) thrombus has not been prospectively studied.
At two academic medical centers, patients with NVAF were prospectively enrolled to undergo investigational transthoracic echocardiography immediately before clinically indicated transesophageal echocardiography. Mitral inflow E velocity and tissue Doppler septal and lateral mitral annulus velocities (e′) were measured, and E/e′ ratios were calculated.
Among 266 subjects (mean age, 65 years; 32% women), 17 (6.4%) had LAA thrombus. Patients with LAA thrombus had a higher mean CHA₂DS₂-VASc score (4.6 ± 1.7 vs 3.0 ± 1.8, P < .001), a higher mean lateral E/e′ ratio (19.4 ± 10.1 vs 10.2 ± 5.6, P < .001), and a lower mean lateral e′ velocity (7.0 ± 3.2 vs 10.4 ± 3.7 cm/sec, P = .001). There was a good discriminative capacity for E/e′ (area under the curve, 0.83; P < .001) and e′ velocity (area under the curve, 0.76; P = .001). None of the patients with normal E/e′ ratios or normal e′ velocities had LAA thrombus. Both E/e′ (odds ratio, 1.13 per point; 95% CI, 1.06-1.20; P < .001) and e′ velocity (odds ratio, 0.76 per 1 cm/sec; 95% CI, 0.63-0.92; P = .005) provided independent and incremental predictive value beyond the CHA₂DS₂-VASc score; however, E/e′ provided greater incremental value than e′ velocity (P = .036). Analyses using septal and averaged E/e′ and septal e′ velocity yielded similar results. Diastolic function parameters were also associated with the presence and intensity of left atrial spontaneous echo contrast, a precursor of LAA thrombus.
This prospective and concomitant evaluation of diastolic function and LAA thrombus in patients with NVAF demonstrates that E/e′ ratio and e′ velocity are associated with LAA thrombus, independent of CHA₂DS₂-VASc score, and may play a role in identifying patients at low risk for LAA thrombus. These data suggest that diastolic function assessment may improve stroke prediction in patients with NVAF.

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^∗∗: Dr. Fatkin is supported by a Postgraduate Medical Research Scholarship from the National Health and Medical Research Council of Australia

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Hematologic correlates of spontaneous echo contrast in patients with atrial fibrillation and implications for thromboembolic risk

Abstract

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

J Am Coll Cardiol

Coronary artery disease

Regional stasis of blood in the dysfunctional left ventricle: echocardiographic detection and differentiation from early thrombosis

Circulation

Metastatical dyscrasiae

Spontaneous echocardiographic contrast in the descending aorta

Am Heart J

Recommendations regarding quantitation in M-mode echocardiography: results of a survey of echocardiographic measurements

Circulation

Ultrasonography of blood during stasis and coagulation

Invest Radiol

Effect of plasma proteins and temperature on echogenicity of blood

Invest Radiol