paolo colonna, md fesc cardiology hospital, policlinico of bari

Cardiac imaging in new guidelines and recommendations

on…

…atrial fibrillation and source of embolism

Paolo Colonna, MD FESCCardiology 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 echoDiagnosis of embolism is mainly echo• New technologies (second Ha, deformation, New technologies (second Ha, deformation,

contrast, 3D, etc) + TE echocontrast, 3D, etc) + TE echo• Novel and controversial “etiological” Novel and controversial “etiological”

therapies for stroke (thrombolysis, closures, therapies for stroke (thrombolysis, closures, ablations, etc)ablations, etc)

• Changes in stroke population (Changes in stroke population (↑↑ age and age and heart failure, heart failure, ↓↓ rheumatic heart disease)rheumatic heart disease)

15%

2%

9%

21%

Prior to TEE After TEE

Origin of Stroke Stroke Registry- St Louis University

Gomez CR, Echocardiography ‘93

Others

Lacunar

Atheroscl.

CardiacUnknown CardiacUnknown

Atheroscl.

Others

Lacunar

1986 1992

53%

37%

4%

29%3%

26%

TOAST classification:

A-S-C-O phenotypesA-S-C-O phenotypes: : • AA for atherosclerosis, for atherosclerosis, • SS for small vessel disease, for small vessel disease, • CC for cardiac source, for cardiac source, • OO for other cause. for other cause.

Causality levelsCausality levels: : • 1: definitely a potential cause of the 1: definitely a potential cause of the index index

strokestroke• 2: causality uncertain 2: causality uncertain • 3: unlikely a direct cause of the index stroke 3: unlikely a direct cause of the index stroke

(but disease is present)(but disease is present)• 0: absence of disease0: absence of disease

ASCO classification. Amarenco P, Cerebrovasc Dis 2009;27:502-508

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 2010EAE recommendations, EJE 2010

Imaging findings indicating cardioembolic stroke mechanism

• Other signs of systemic Other signs of systemic thromboembolism (e.g. edge-shaped thromboembolism (e.g. edge-shaped infarctions of kidney or spleen; Osler infarctions of kidney or spleen; Osler splits; Blue toe-syndrome)splits; Blue toe-syndrome)

• TerritorialTerritorial distribution of the infarcts distribution of the infarcts• Hyperdense MCA sign (as long as Hyperdense MCA sign (as long as

withoutwithout severe ipsilateral internal carotid severe ipsilateral internal carotid stenosis)stenosis)


Territorial distributionTerritorial distribution

Probable CardioembolicProbable Cardioembolic: : A) cortex, A) cortex, B) subcortical ‘large B) subcortical ‘large lenticulostriate infarct’lenticulostriate infarct’

UnprobableUnprobable::C) lacunar infarctionsC) lacunar infarctions(subcortical)(subcortical)

Low flow infarctLow flow infarct::interterritorial…interterritorial…D up) subcorticalD up) subcorticalD down) corticalD down) cortical


hyperdense middle cerebral artery (MCA) sign

bilateral old infarcts in right middle cerebral artery and left anterior cerebral artery distribution in AF pts

(a) Mitral stenosis;(a) Mitral stenosis;(b) Prosthetic heart valve;(b) Prosthetic heart valve;(c) Myocardial infarction within the past 4 weeks;(c) Myocardial infarction within the past 4 weeks;(d) Mural thrombus in left cavities;(d) Mural thrombus in left cavities;(e) Left ventricular aneurysm;(e) Left ventricular aneurysm;(f) History or permanent AF or flutter;(f) History or permanent AF or flutter;(g) Sick sinus syndrome;(g) Sick sinus syndrome;(h) Dilated cardiomyopathy;(h) Dilated cardiomyopathy;(i) Ejection fraction <35%;(i) Ejection fraction <35%;(j) Endocarditis;(j) Endocarditis;(k) Intracardiac mass;(k) Intracardiac mass;(l) PFO plus in situ thrombosis;(l) PFO plus in situ thrombosis;(m) PFO + PE or DVT (m) PFO + PE or DVT precedingpreceding the stroke the stroke

Level of causality 1 Level of causality 1 (certain) (certain)

a) PFO and ASA;b) PFO + DVT or PE (but not preceding the stroke);c) Spontaneous echo contrast;d) Apical LV akinesia + ↓ ejection fraction (35-50%);e) 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)

• PFO, ASA, valvular strands, mitral annulus calcification, calcified aortic valve, nonapical LV akinesia

Level of causality 3 Level of causality 3 (unlikely)(unlikely)

Level of causality 2 (uncertain)

Multiplane TEE to detect effectiveness of Multiplane TEE to detect effectiveness of selective pulmonary rt-PA thrombolysis in selective pulmonary rt-PA thrombolysis in

pulmonary embolism and PFOpulmonary embolism and PFO Colonna, JASE 1997Colonna, JASE 1997

Paradoxical embolism thrombus in Paradoxical embolism thrombus in transit through a PFOtransit through a PFO

Srivastava, NEJM 97Srivastava, NEJM 97

Diagnosis and management of Diagnosis and management of entrapped embolus through a PFOentrapped embolus through a PFO

Aboyans, EJCTS 98Aboyans, EJCTS 98

exhaustive review of the exhaustive review of the medical literature of this rare medical literature of this rare finding (43 cases):finding (43 cases):

Morphology of PFO in asymptomatic Morphology of PFO in asymptomatic versus symptomatic (stroke or TIA) ptsversus symptomatic (stroke or TIA) pts

Goel, AJC ‘09Goel, AJC ‘09



PFOs in pts with cryptogenic CVAsPFOs in pts with cryptogenic CVAs: - larger, : - larger, - longer tunnels, - longer tunnels, - more frequently associated with atrial septal aneurysms- more frequently associated with atrial septal aneurysms

Linkage PFO / arterial embolism

• Paradoxical embolism through PFO Paradoxical embolism through PFO rarerare, escept in , escept in acute pulmonary embolism (acute pulmonary embolism (↑Right atrium ↑Right atrium pr)pr)

• In the absence of In the absence of ↑Right atrium ↑Right atrium pressure, pressure, do not suspect causality for PFO, except if: do not suspect causality for PFO, except if: – young ageyoung age– association ASA + PFOassociation ASA + PFO– large right large right → → left shunt left shunt

• TOE echo + contrasti gold standard for PFO TOE echo + contrasti gold standard for PFO evaluation, but also TT echo (good quality)evaluation, but also TT echo (good quality)

• Use Valsalva or vigorous cough (TOE and TT )Use Valsalva or vigorous cough (TOE and TT )• Evaluate: color Doppler, n° bubbles, size defectEvaluate: color Doppler, n° bubbles, size defect


Echo in AFib / embolic riskEcho in AFib / embolic risk

Indication of TTecho in AFib for:Indication of TTecho in AFib for:• diagnosis of cardiac underlying disease (ischemic, diagnosis of cardiac underlying disease (ischemic,

valvular, DCM, LV dysfunction)valvular, DCM, LV dysfunction)• choose of management and drugs strategy, prior to choose of management and drugs strategy, prior to

arrhythmia conversionarrhythmia conversion• indication, guidance and follow up of interventional indication, guidance and follow up of interventional

procedures (ablation, LA appendage closure)procedures (ablation, LA appendage closure)Addition of TOecho for:Addition of TOecho for:• giudance of TOE/shortened cardioversiongiudance of TOE/shortened cardioversion• complex cases (embolic recurrences in AC, etc)complex cases (embolic recurrences in AC, etc)• additional information on embolic riskadditional information on embolic risk

(not indicated as a routine exam!)(not indicated as a routine exam!)


As alternative to 3 weeks of OAT, the TEE guided As alternative to 3 weeks of OAT, the TEE guided cardioversion is recommended to exclude LA or cardioversion is recommended to exclude LA or appendage thrombi. appendage thrombi. Class I LOE BClass 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

• ThrombiThrombi

• Spontaneous echocontrastSpontaneous echocontrast

• LA appendage velocitiesLA appendage velocities

• LV function and thrombiLV function and thrombi

• Patent foramen ovalePatent foramen ovale

• Complex aortic plaquesComplex aortic plaques

Atrio auricular Atrio auricular

functionfunction

Echocardiography in atrial fib: Echocardiography in atrial fib: information for clinical decisionsinformation for clinical decisions

EAE recommendations, EJE ‘10EAE recommendations, EJE ‘10

Only with TOEOnly with TOE

TEE correlates of thromboembolism in high-risk patients with nonvalvular AF

The SPAF3 Investigators Committee on EchocardiographyAnn Intern Med 1998 .

Importance of LAA flow as a predictor of thromboembolism in patients with AF

Kamp EHJ 99

Clinical riskClinical riskfactorsfactors

EchographicEchographicrisk factorsrisk factors

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 Clinical risk factors (age, hypertension, etc.)(age, hypertension, etc.)

(LV diastolic dysf.)(LV diastolic dysf.)

Long lasting AF /Long lasting AF /Asympt. recurrencesAsympt. recurrences

Atrio / auricular Atrio / auricular structural remodelingstructural remodeling = Low LAA velocity= Low LAA velocity

((LAA LAA dysfunction))

Contrast / thrombi Contrast / thrombi in the LAAin the LAA

StrokeStrokeKhan, Int J Card '03Khan, Int J Card '03de Luca, Int J Card '05de Luca, Int J Card '05Colonna, JCM '06Colonna, JCM '06

Analysis of pts undergoing Analysis of pts undergoing cardioversion (in ReLY trial) cardioversion (in ReLY trial)

Nagarakanti, Circ 2011Nagarakanti, Circ 2011

D110 mg

D150 mg

Warfarin

D110 mg

D150 mgWarfarin

0

0,2

0,4

0,6

0,8

1

1,2

Stro

ke /

embo

lism

at 3

0 da

ys

TOE prior cardioversion NO TOE priorcardioversion

BleedingBleedingriskrisk

Dab 150Dab 150 110/150?110/150? Dab 110Dab 110

Dab 150Dab 150 110>150?110>150? None/110None/110

Dab 110Dab 110 110/None110/None NoneNone

In doubts… help from echocardiographyIn doubts… help from echocardiography

Embolic Embolic riskrisk

>> 4% 4%

2-3%2-3%

<< 1% 1%

<<1%1% 3% 3% >>10%10%

ChadsChadsVascVasc>> 4 4

2-32-3

0-10-1

HasbledHasbled0-10-1 2 2 >>3 3

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 Embolic risk stratification of AF pts for the “wise cardiologist”pts for the “wise cardiologist”

1.1. Calculate %/y embolic risk with Calculate %/y embolic risk with CHACHA22DSDS22VAScVASc

2.2. Calculate %/y bleeding risk with Calculate %/y bleeding risk with HAS-BLEDHAS-BLED

3.3. In the balance of difficult pts In the balance of difficult pts use echo risk use echo risk factorsfactors (atrial appendage, aorta, LV (atrial appendage, aorta, LV function)function)

4.4. All evaluations more important for new All evaluations more important for new anticoagulants (usage / dosage)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 0-1Lavezzi al 95’

Imaging findings indicating cardioembolic stroke mechanism

• Other signs of systemic thromboembolism (e.g. Other signs of systemic thromboembolism (e.g. edge-shaped infarctions of kidney or spleen; Osler edge-shaped infarctions of kidney or spleen; Osler splits; Blue toe-syndrome)splits; Blue toe-syndrome)

• Territorial distribution of the infarcts Territorial distribution of the infarcts • Hyperdense MCA sign (as long as Hyperdense MCA sign (as long as withoutwithout severe severe

ipsilateral internal carotid stenosis)ipsilateral internal carotid stenosis)• Rapid recanalization of occluded major brain artery Rapid recanalization of occluded major brain artery

(to be evaluated by repetitive neurovascular (to be evaluated by repetitive neurovascular ultrasound)ultrasound)


“At present, closure of patent foramen ovale appears to be reasonable if” :

• Pt < 60 y with cryptogenetic stroke• Multiple clinical events• Multiple infarcts at CT scan• Valsalva manouver preceding the stroke• Wide PFO (numbers of bubble + dimensions)• Coexistence of atrial septal aneurysm• Deep venous thrombosis

Alp N, Heart 01, mod.

Clinical

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

Grade I: normal Grade IV: plaque >4mmGrade II: thickening Grade V: ulcers or mobilityGrade III: plaque < 4mm

Plaques in thoracic aorta

Katz et al JACC ‘92

Actual Source Echocardiographic FindingsLV thrombus Apical aneurysm, presence of thrombus,

dilated CM, hypertrabeculation / noncompactionLA thrombus Thrombus in LAA, spontaneous echo contrast,

LAA emptying velocity, mitral stenosis, interatrial septal low aneurysm

Pelvic veins or LL thrombus

ASD, atrial septal aneurysm, PFO

Native valves Vegetation, tumor, MVP, mitral annular calcification, sclerotic aortic valve

Prosthetic valves

Thrombus, vegetation

Cardiac tumor LA myxoma, papillary fibroelastoma

Aorta Complex aortic plaque, atheroma

1

2

3

L’ecocardiografia nel tromboembolismo arterioso:

dalle Guidelines dell’EAE

Paolo Colonna, MD FESCCardiologia Osp. - Policlinico di Bari

Perché nuove raccomandazioni su ecocardiografia e fonti emboliche ?

• Diagnostica embolismo è soprattutto eco Diagnostica embolismo è soprattutto eco • Nuove tecnologie (seconda armonica, Nuove tecnologie (seconda armonica,

deformation, contrasto, 3D, etc.) + ecoTE deformation, contrasto, 3D, etc.) + ecoTE • Nuove e controverse terapie “eziologiche” per Nuove e controverse terapie “eziologiche” per

stroke (trombolisi, chiusure, ablazioni, et.)stroke (trombolisi, chiusure, ablazioni, et.)• Cambio popolazione con stroke (Cambio popolazione con stroke (↑↑ età e età e

scompenso, scompenso, ↓↓ reumatismo)reumatismo)

Eco e diagnosi di endocardite:Eco e diagnosi di endocardite:• Criteri maggiori per diagnosi (3 eco): vegetazioni, ascessi, Criteri maggiori per diagnosi (3 eco): vegetazioni, ascessi,

mobilizzazione di protesi valvolarimobilizzazione di protesi valvolari• Indicato EcoTT Indicato EcoTT precoceprecoce in tutti i sospetti clinici in tutti i sospetti clinici• EcoTEEcoTE se: ecoTT neg. + alto sospetto clinico, protesi valvolari, se: ecoTT neg. + alto sospetto clinico, protesi valvolari,

scarsa qualità ecoTTscarsa qualità ecoTT• Ripetere ecoTT / TE a 7-10 gg se persiste sospettoRipetere ecoTT / TE a 7-10 gg se persiste sospetto

Eco per predire il rischio di embolizzazione di EI:Eco per predire il rischio di embolizzazione di EI:• Rischio correlato a dimensioni e mobilità: aumentato se vegetazioni Rischio correlato a dimensioni e mobilità: aumentato se vegetazioni

grandi (>10 mm), particolarmente se mobili e grandi (>15 mm)grandi (>10 mm), particolarmente se mobili e grandi (>15 mm)• Massimo rischio nei primi giorni dopo inizio antibiotico; decresce Massimo rischio nei primi giorni dopo inizio antibiotico; decresce

dopo 2 settimanedopo 2 settimane


Ecocardiografia per FA / rischio embolico

EcoTT indicato in FA per:EcoTT indicato in FA per:• valutare patologia di base (eziologia ischemica, valvolare, valutare patologia di base (eziologia ischemica, valvolare,

CMP, disfunzione VS)CMP, disfunzione VS)• scegliere strategia e farmaco prima di cardioversione scegliere strategia e farmaco prima di cardioversione

aritmia aritmia • indicazione, guida e follow up procedure interventistiche indicazione, guida e follow up procedure interventistiche

(ablazione, chiusura auricola)(ablazione, chiusura auricola)Aggiungere ecoTE per:Aggiungere ecoTE per:• guidare strategia abbreviata con ecoTEguidare strategia abbreviata con ecoTE• casi complessi (ricorrenze emboliche in AC, etc)casi complessi (ricorrenze emboliche in AC, etc)• informazioni aggiuntive su rischio embolicoinformazioni aggiuntive su rischio embolico


Associazione PFO / embolia arteriosa

• Embolia paradossa attraverso PFO Embolia paradossa attraverso PFO rararara, eccetto che in , eccetto che in emb polmonare acuta (emb polmonare acuta (↑↑press in AD)press in AD)

• In assenza di In assenza di ↑↑PAD no causalità PFO, eccetto : PAD no causalità PFO, eccetto : – età giovaneetà giovane– associazione ASA + PFOassociazione ASA + PFO– ampio shunt dx ampio shunt dx → → sinsin

• EcoTE gold standard for PFO evaluation; EcoTE gold standard for PFO evaluation; anche eco TT (se di buona qualità)anche eco TT (se di buona qualità)

• In ecoTE e TT Valsalva o vigorosi colpi tosse In ecoTE e TT Valsalva o vigorosi colpi tosse • Valutare: color Doppler, n° bolle (pochi cicli dopo Valutare: color Doppler, n° bolle (pochi cicli dopo

comparsa in AD)comparsa in AD)


Bleeding / embolism balance for Dabigatran dosage

Bleeding

Dab 150 ? Dab 110

? ? Dab 110

? Dab 110 Dab 110

In doubt… help from echocardiography

Embolism

> 3%

2%

1%

1% 2% >3%

paolo colonna, md fesc cardiology hospital, policlinico of bari

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