Significantly Elevated C-Reactive Protein Levels After Epicardial Clipping of the Left Atrial Appendage.

PubMed

Verberkmoes, Niels J; Akca, Ferdi; Vandevenne, Ann-Sofie; Jacobs, Luuk; Soliman Hamad, Mohamed A; van Straten, Albert H M

Besides mechanical and anatomical changes of the left atrium, epicardial closure of the left atrial appendage has also possible homeostatic effects. The aim of this study was to assess whether epicardial clipping of the left atrial appendage has different biochemical effects compared with complete removal of the left atrial appendage. Eighty-two patients were included and underwent a totally thoracoscopic AF ablation procedure. As part of the procedure, the left atrial appendage was excluded with an epicardial clip (n = 57) or the left atrial appendage was fully amputated with an endoscopic vascular stapler (n = 25). From all patients' preprocedural and postprocedural blood pressure, electrolytes and inflammatory parameters were collected. The mean age and left atrial volume index were comparable between the epicardial clip and stapler group (64 ± 8 years vs. 60 ± 9 years, P = non-significant; 44 ± 15 mL/m vs. 40 ± 13 mL/m, P = non-significant). Patients receiving left atrial appendage clipping had significantly elevated C-reactive protein levels compared with patients who had left atrial appendage stapling at the second, third, and fourth postoperative day (225 ± 84 mg/L vs. 149 ± 76 mg/L, P = 0.002, 244 ± 78 vs. 167 ± 76, P = 0.004, 190 ± 74 vs. 105 ± 48, P < 0.001, respectively). Patients had a significant decrease in sodium levels, systolic, and diastolic blood pressure at 24 and 72 hours after left atrial appendage closure. However, this was comparable for both the left atrial appendage clipping and stapling group. Increased activation of the inflammatory response was observed after left atrial appendage clipping compared with left atrial appendage stapling. Furthermore, a significant decrease in blood pressure was observed after surgical removal of the left atrial appendage. Whether the inflammatory response affects the outcome of arrhythmia surgery needs to be further evaluated.

Effect of left ventricular diastolic dysfunction on left atrial appendage function and thrombotic potential in nonvalvular atrial fibrillation.

PubMed

Demirçelik, Muhammed Bora; Çetin, Mustafa; Çiçekcioğlu, Hülya; Uçar, Özgül; Duran, Mustafa

2014-05-01

We aimed to investigate effects of left ventricular diastolic dysfunction on left atrial appendage functions, spontaneous echo contrast and thrombus formation in patients with nonvalvular atrial fibrillation. In 58 patients with chronic nonvalvular atrial fibrilation and preserved left ventricular systolic function, left atrial appendage functions, left atrial spontaneous echo contrast grading and left ventricular diastolic functions were evaluated using transthoracic and transoesophageal echocardiogram. Patients divided in two groups: Group D (n=30): Patients with diastolic dysfunction, Group N (n=28): Patients without diastolic dysfunction. Categorical variables in two groups were evaluated with Pearson's chi-square or Fisher's exact test. The significance of the lineer correlation between the degree of spontaneous echo contrast (SEC) and clinical measurements was evaluated with Spearman's correlation analysis. Peak pulmonary vein D velocity of the Group D was significantly higher than the Group N (p=0.006). However, left atrial appendage emptying velocity, left atrial appendage lateral wall velocity, peak pulmonary vein S, pulmonary vein S/D ratio were found to be significantly lower in Group D (p=0.028, p<0.001, p<0.001; p<0.001). Statistically significant negative correlation was found between SEC in left atrium and left atrial appendage emptying, filling, pulmonary vein S/D levels and lateral wall velocities respectively (r=-0.438, r=-0.328, r=-0.233, r=-0.447). Left atrial appendage emptying, filling, pulmonary vein S/D levels and lateral wall velocities were significantly lower in SEC 2-3-4 than SEC 1 (p=0.003, p=0.029, p<0.001, p=0.002). In patients with nonvalvular atrial fibrillation and preserved left ventricular ejection fraction, left atrial appendage functions are decreased in patients with left ventricular diastolic dysfunction. Left ventricular diastolic dysfunction may constitute a potential risk for formation of thrombus and stroke.

Left Atrial 4D Blood Flow Dynamics and Hemostasis following Electrical Cardioversion of Atrial Fibrillation.

PubMed

Cibis, Merih; Lindahl, Tomas L; Ebbers, Tino; Karlsson, Lars O; Carlhäll, Carl-Johan

2017-01-01

Background: Electrical cardioversion in patients with atrial fibrillation is followed by a transiently impaired atrial mechanical function, termed atrial stunning. During atrial stunning, a retained risk of left atrial thrombus formation exists, which may be attributed to abnormal left atrial blood flow patterns. 4D Flow cardiovascular magnetic resonance (CMR) enables blood flow assessment from the entire three-dimensional atrial volume throughout the cardiac cycle. We sought to investigate left atrial 4D blood flow patterns and hemostasis during left atrial stunning and after left atrial mechanical function was restored. Methods: 4D Flow and morphological CMR data as well as blood samples were collected in fourteen patients at two time-points: 2-3 h (Time-1) and 4 weeks (Time-2) following cardioversion. The volume of blood stasis and duration of blood stasis were calculated. In addition, hemostasis markers were analyzed. Results: From Time-1 to Time-2: Heart rate decreased (61 ± 7 vs. 56 ± 8 bpm, p = 0.01); Maximum change in left atrial volume increased (8 ± 4 vs. 22 ± 15%, p = 0.009); The duration of stasis (68 ± 11 vs. 57 ± 8%, p = 0.002) and the volume of stasis (14 ± 9 vs. 9 ± 7%, p = 0.04) decreased; Thrombin-antithrombin complex (TAT) decreased (5.2 ± 3.3 vs. 3.3 ± 2.2 μg/L, p = 0.008). A significant correlation was found between TAT and the volume of stasis ( r 2 = 0.69, p < 0.001) at Time-1 and between TAT and the duration of stasis ( r 2 = 0.34, p = 0.04) at Time-2. Conclusion: In this longitudinal study, left atrial multidimensional blood flow was altered and blood stasis was elevated during left atrial stunning compared to the restored left atrial mechanical function. The coagulability of blood was also elevated during atrial stunning. The association between blood stasis and hypercoagulability proposes that assessment of left atrial 4D flow can add to the pathophysiological understanding of thrombus formation during atrial fibrillation related atrial stunning.

Mid-Term Results of Surgical Treatment of Atrial Fibrillation in Valvular Heart Disease Assesed by Speckle Tracking Echocardiography

PubMed Central

Lorenzo, Natalia; Mendez, Irene; Taibo, Mikel; Martinis, Gianfranco; Badia, Sara; Reyes, Guillermo; Aguilar, Rio

2018-01-01

Background Atrial fibrillation frequently affects patients with valvular heart disease. Ablation of atrial fibrillation during valvular surgery is an alternative for restoring sinus rhythm. Objectives This study aimed to evaluate mid-term results of successful atrial fibrillation surgical ablation during valvular heart disease surgery, to explore left atrium post-ablation mechanics and to identify predictors of recurrence. Methods Fifty-three consecutive candidates were included. Eligibility criteria for ablation included persistent atrial fibrillation <10 years and left atrium diameter < 6.0 cm. Three months after surgery, echocardiogram, 24-hour Holter monitoring and electrocardiograms were performed in all candidates who maintained sinus rhythm (44 patients). Echo-study included left atrial deformation parameters (strain and strain rate), using 2-dimensional speckle-tracking echocardiography. Simultaneously, 30 healthy individuals (controls) were analyzed with the same protocol for left atrial performance. Significance was considered with a P value of < 0.05. Results After a mean follow up of 17 ± 2 months, 13 new post-operative cases of recurrent atrial fibrillation were identified. A total of 1,245 left atrial segments were analysed. Left atrium was severely dilated in the post-surgery group and, mechanical properties of left atrium did not recover after surgery when compared with normal values. Left atrial volume (≥ 64 mL/m2) was the only independent predictor of atrial fibrillation recurrence (p = 0.03). Conclusions Left atrial volume was larger in patients with atrial fibrillation recurrence and emerges as the main predictor of recurrences, thereby improving the selection of candidates for this therapy; however, no differences were found regarding myocardial deformation parameters. Despite electrical maintenance of sinus rhythm, left atrium mechanics did not recover after atrial fibrillation ablation performed during valvular heart disease surgery. PMID:29561964

Atrial Electromechanical Properties in Inflammatory Bowel Disease.

PubMed

Efe, Tolga Han; Cimen, Tolga; Ertem, Ahmet Goktug; Coskun, Yusuf; Bilgin, Murat; Sahan, Haluk Furkan; Pamukcu, Hilal Erken; Yayla, Cagri; Sunman, Hamza; Yuksel, Ilhami; Yeter, Ekrem

2016-09-01

There is much evidence linking inflammation to the initiation and continuation of atrial fibrillation (AF). Inflammatory bowel diseases (IBD), including ulcerative colitis (UC) and Crohn's disease (CD), are chronic systemic inflammatory disorders. Atrial electromechanical delay (EMD) has been known as an early marker of AF. The objectives of this study were to evaluate the atrial electromechanical properties in patients with IBD. Fifty-two patients with IBD and 26 healthy controls were recruited in the study. Twenty-five of patients with IBD were on active period, and the remaining 27 were on remission period. Atrial electromechanical properties were measured by using transthoracic echocardiography and tissue Doppler imaging and simultaneous surface ECG recording. Interatrial EMD, left intraatrial EMD, and right intraatrial EMD were calculated. Patients on activation with IBD had significantly prolonged left and right intraatrial EMDs and interatrial EMD compared to patients on remission (P = 0.048, P = 0.036, P < 0.001, respectively) and healthy controls (P < 0.001, for all comparisons). Left and right intraatrial EMDs and interatrial EMD were also found to be higher when patients on remission with IBD compared with healthy controls. No statistical difference was observed between UC and CD in terms of inter- and intraatrial EMDs. Atrial electromechanical conduction is prolonged in IBD, and exposure to chronic inflammation may lead to structural and electrophysiological changes in the atrial tissue that causes slow conduction. Measurement of atrial EMD parameters might be used to predict the risk for the development of AF in patients with IBD. © 2016, Wiley Periodicals, Inc.

Role of Left Ventricular Diastolic Dysfunction in Predicting Atrial Fibrillation Recurrence after Successful Electrical Cardioversion

PubMed Central

Melduni, Rowlens M.; Cullen, Michael W.

2013-01-01

The role of left ventricular (LV) diastolic dysfunction in predicting atrial fibrillation (AF) recurrence after successful electrical cardioversion is largely unknown. Studies suggest that there may be a link between abnormal LV compliance and the initial development, and recurrence of AF after electrical cardioversion. Although direct-current cardioversion (DCCV) is a well-established and highly effective method to convert AF to sinus rhythm, it offers little else beyond immediate rate control because it does not address the underlying cause of AF. Preservation of sinus rhythm after successful cardioversion still remains a challenge for clinicians. Despite the use of antiarrhythmic drugs and serial cardioversions, the rate of AF recurrence remains high in the first year. Current evidence suggests that diastolic dysfunction, which is associated with atrial volume and pressure overload, may be a mechanism underlying the perpetuating cycle of AF recurrence following successful electrical cardioversion. Diastolic dysfunction is considered to be a defect in the ability of the myofibrils, which have shortened against a load in systole to eject blood into the high-pressure aorta, to rapidly or completely return to their resting length. Consequently, LV filling is impaired and the non-compliant left ventricle is unable to fill at low pressures. As a result, left atrial and pulmonary vein pressure rises, and electrical and structural remodeling of the atrial myocardium ensues, creating a vulnerable substrate for AF. In this article, we review the current evidence highlighting the association of LV diastolic dysfunction with AF recurrence after successful electrical cardioversion and provide an approach to the management of LV diastolic dysfunction to prevent AF recurrence. PMID:23525127

Left Atrial Enlargement in Young High-Level Endurance Athletes - Another Sign of Athlete's Heart?

PubMed

Król, Wojciech; Jędrzejewska, Ilona; Konopka, Marcin; Burkhard-Jagodzińska, Krystyna; Klusiewicz, Andrzej; Pokrywka, Andrzej; Chwalbińska, Jolanta; Sitkowski, Dariusz; Dłużniewski, Mirosław; Mamcarz, Artur; Braksator, Wojciech

2016-12-01

Enlargement of the left atrium is perceived as a part of athlete's heart syndrome, despite the lack of evidence. So far, left atrial size has not been assessed in the context of exercise capacity. The hypothesis of the present study was that LA enlargement in athletes was physiological and fitness-related condition. In addition, we tried to assess the feasibility and normal values of left atrial strain parameters and their relationship with other signs of athlete's heart. The study group consisted of 114 international-level rowers (17.5 ± 1.5 years old; 46.5% women). All participants underwent a cardio-pulmonary exercise test and resting transthoracic echocardiography. Beside standard echocardiographic measurements, two dimensional speckle tracking echocardiography was used to assess average peak atrial longitudinal strain, peak atrial contraction strain and early left atrial diastolic longitudinal strain. Mild, moderate and severe left atrial enlargement was present in 27.2°%, 11.4% and 4.4% athletes, respectively. There were no significant differences between subgroups with different range of left atrial enlargement in any of echocardiographic parameters of the left ventricle diastolic function, filling pressure or hypertrophy. A significant correlation was found between the left atrial volume index and maximal aerobic capacity (R > 0.3; p < 0.001). Left atrial strain parameters were independent of atrial size, left ventricle hypertrophy and left ventricle filling pressure. Decreased peak atrial longitudinal strain was observed in 4 individuals (3.5%). We concluded that LA enlargement was common in healthy, young athletes participating in endurance sport disciplines with a high level of static exertion and was strictly correlated with exercise capacity, therefore, could be perceived as another sign of athlete's heart.

CT derived left atrial size identifies left heart disease in suspected pulmonary hypertension: Derivation and validation of predictive thresholds.

PubMed

Currie, Benjamin J; Johns, Chris; Chin, Matthew; Charalampopolous, Thanos; Elliot, Charlie A; Garg, Pankaj; Rajaram, Smitha; Hill, Catherine; Wild, Jim W; Condliffe, Robin A; Kiely, David G; Swift, Andy J

2018-06-01

Patients with pulmonary hypertension due to left heart disease (PH-LHD) have overlapping clinical features with pulmonary arterial hypertension making diagnosis reliant on right heart catheterization (RHC). This study aimed to investigate computed tomography pulmonary angiography (CTPA) derived cardiopulmonary structural metrics, in comparison to magnetic resonance imaging (MRI) for the diagnosis of left heart disease in patients with suspected pulmonary hypertension. Patients with suspected pulmonary hypertension who underwent CTPA, MRI and RHC were identified. Measurements of the cardiac chambers and vessels were recorded from CTPA and MRI. The diagnostic thresholds of individual measurements to detect elevated pulmonary arterial wedge pressure (PAWP) were identified in a derivation cohort (n = 235). Individual CT and MRI derived metrics were tested in validation cohort (n = 211). 446 patients, of which 88 had left heart disease. Left atrial area was a strong predictor of elevated PAWP>15 mm Hg and PAWP>18 mm Hg, area under curve (AUC) 0.854, and AUC 0.873 respectively. Similar accuracy was also identified for MRI derived LA volume, AUC 0.852 and AUC 0.878 for PAWP > 15 and 18 mm Hg, respectively. Left atrial area of 26.8 cm 2 and 30.0 cm 2 were optimal specific thresholds for identification of PAWP > 15 and 18 mm Hg, had sensitivity of 60%/53% and specificity 89%/94%, respectively in a validation cohort. CTPA and MRI derived left atrial size identifies left heart disease in suspected pulmonary hypertension with high specificity. The proposed diagnostic thresholds for elevated left atrial area on routine CTPA may be a useful to indicate the diagnosis of left heart disease in suspected pulmonary hypertension. Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.

Left Atrial Size and Left Ventricular End-Systolic Dimension Predict the Progression of Paroxysmal Atrial Fibrillation After Catheter Ablation.

PubMed

Liao, Ying-Chieh; Liao, Jo-Nan; Lo, Li-Wei; Lin, Yenn-Jiang; Chang, Shih-Lin; Hu, Yu-Feng; Chao, Tze-Fan; Chung, Fa-Po; Tuan, Ta-Chuan; Te, Abigail Louise D; Walia, Rohit; Yamada, Shinya; Lin, Chung-Hsing; Lin, Chin-Yu; Chang, Yao-Ting; Allamsetty, Suresh; Yu, Wen-Chung; Huang, Jing-Long; Wu, Tsu-Juey; Chen, Shih-Ann

2017-01-01

Although rare, some paroxysmal atrial fibrillations (AF) still progress despite radiofrequency (RF) ablation. In the study, we evaluated the long-term efficacy of RF ablation and the predictors of AF progression. A total of 589 paroxysmal AF patients (404 men and 185 women; aged 54 ± 12 years) who received 3-dimensional mapping and ablation were enrolled. Their clinical parameters and electrophysiological characteristics were collected. They were divided into Group 1 (N = 13, with AF progression) and Group 2 (N = 576, no AF progression). AF progression was defined as recurrence of persistent AF. Group 1 patients had larger left atrial (LA) diameter, larger left ventricle (LV) end-systolic and end-diastolic diameters, poorer LV systolic function, and more amiodarone use at baseline. After 1.2 ± 0.5 procedures, 123 (21%) patients experienced recurrence during 56 ± 29 months' follow-up. In the multivariate analysis, LA diameter (P = 0.018, HR = 1.12, 95% CI = 1.02-1.24) and LV end-systolic diameter (P = 0.005, HR = 1.10, 95% CI = 1.03-1.17) independently predicted AF progression. LA diameter >43 mm and LV end-systolic diameter >31 mm were the best cut-off values for predicting AF progression by ROC analysis. AF progression rate achieved 19% if they had both larger LA diameter (>43 mm) and LV end-systolic diameter (>31 mm). RF ablation prevents the progression of paroxysmal AF effectively, except in patients with increased LA diameter and LV end-systolic diameter on echocardiogram, suggesting more aggressive rhythm control therapies should be considered in these patients. © 2016 Wiley Periodicals, Inc.

Is HATCH score a reliable predictor of atrial fibrillation after cavotricuspid isthmus ablation for typical atrial flutter?

PubMed

García-Seara, Javier; Gude Sampedro, Francisco; Martínez Sande, Jose L; Fernández López, Xesus Alberte; Rodríguez Mañero, Moisés; González Melchor, Laila; Alvarez Alvarez, Belén; Iglesias Alvarez, Diego; González Juanatey, José Ramón

2016-09-01

We determined the effectiveness of the HATCH score in patients with typical atrial flutter (AFl) undergoing cavotricuspid isthmus (CTI) ablation to predict long-term atrial fibrillation (AF). We conducted an observational retrospective single-center cohort study including all patients admitted to our hospital for a CTI ablation between 1998 and 2010. The patients were divided into four categories: 1) new-onset AF (no prior AF and AF during follow-up (FU)); 2) old AF (prior AF and no AF during FU); 3) prior and post AF (AF prior and post CTI ablation); and 4) no AF. Four hundred and eight patients were included. In patients without prior AF, the hazard ratio (HR) for new-onset AF during FU was 0.98 (CI 95%: 0.65-1.50; p = 0.95) and 1.00 (CI 95%: 0.57-1.77; p = 0.98) for HATCH ≥ 2 and HATCH ≥ 3, respectively. In patients with prior AF, the HR for AF was 1.41 (CI 95%: 0.87-2.28; p = 0.17) and 1.79 (CI 95%: 0.96-3.35; p = 0.06), for HATCH ≥ 2 and HATCH ≥ 3, respectively. Left atrial enlargement was positively correlated with the occurrence of AF during FU, especially in the subgroup without prior AF, which had a HR of 2.44 (CI 95%: 1.35-4.40; p = 0.003), a HR of 2.88 (CI 95%: 1.36-6.10; p = 0.006) and a HR of 3.68 (CI 95%: 1.71-7.94; p = 0.001), for slight, moderate and severely dilated left atrial dimension, respectively, compared with a normal value. HATCH score did not predict AF in patients with typical AFl who underwent CTI ablation. Basal left atrium dimension could help predict new-onset AF.

Measurement of funny current (I(f)) channel mRNA in human atrial tissue: correlation with left atrial filling pressure and atrial fibrillation.

PubMed

Lai, L P; Su, M J; Lin, J L; Tsai, C H; Lin, F Y; Chen, Y S; Hwang, J J; Huang, S K; Tseng, Y Z; Lien, W P

1999-07-01

The funny current (I(f)) contributes to phase IV spontaneous depolarization in cardiac pacemaker tissue. Enhanced I(f) activity in myocardial tissue may lead to increased automaticity and therefore tachyarrhythmia. We measured the amount of I(f) activity in the messenger ribonucleic acid (mRNA) in human atrial tissue and correlated the mRNA amount to left atrial filling pressure and atrial fibrillation (AF). A total of 34 patients undergoing open heart surgery were included (15 men and 19 women, aged 55+/-10 years). Atrial tissue was obtained from the right atrial free wall, the right atrial appendage, the left atrial free wall, and the left atrial appendage, respectively. The mRNA amount of the I(f) channel was measured by reverse transcription polymerase chain reaction and was normalized to the mRNA levels of glyceraldehyde 3-phosphate dehydrogenase. We found that the I(f) channel mRNA was present at all the atrial sampling sites. A higher left atrial filling pressure, an indicator of congestive heart failure, was associated with a higher I(f) mRNA level (r2 = 0.446, P < 0.01 by linear regression). We also found that the mRNA amount was significantly higher in patients with AF than in patients without AF (1.68+/-0.49 vs 1.27+/-0.43; P < 0.05). Age, sex, right atrial filling pressure, left atrial dimension, and left ventricular ejection fraction had no significant effect on the mRNA level. The mRNA of the I(f) channel is present in the free-wall area and appendage area from both atria. Increased left atrial filling pressure and clinical AF are associated with increased I(f) mRNA level.

Speckle tracking analysis: a new tool for left atrial function analysis in systemic hypertension: an overview.

PubMed

Cameli, Matteo; Ciccone, Marco M; Maiello, Maria; Modesti, Pietro A; Muiesan, Maria L; Scicchitano, Pietro; Novo, Salvatore; Palmiero, Pasquale; Saba, Pier S; Pedrinelli, Roberto

2016-05-01

Speckle tracking echocardiography (STE) is an imaging technique applied to the analysis of left atrial function. STE provides a non-Doppler, angle-independent and objective quantification of left atrial myocardial deformation. Data regarding feasibility, accuracy and clinical applications of left atrial strain are rapidly gathering. This review describes the fundamental concepts of left atrial STE, illustrates its pathophysiological background and discusses its emerging role in systemic arterial hypertension.

A novel atrial volume reduction technique to enhance the Cox maze procedure: initial results.

PubMed

Marui, Akira; Nishina, Takeshi; Tambara, Keiichi; Saji, Yoshiaki; Shimamoto, Takeshi; Nishioka, Masahiko; Ikeda, Tadashi; Komeda, Masashi

2006-11-01

Large left atrial diameter is reported to be a predictor for recurrent atrial fibrillation after the Cox maze procedure, and left atrial diameter by itself influences the chance of sinus rhythm recovery, as well as maintenance of sinus rhythm. However, additional cut-and-sew procedures to decrease left atrial diameter extend operative time and can cause bleeding. Thus we developed a no-bleeding, faster, and therefore less invasive left atrial volume reduction technique to enhance the Cox maze procedure. The modified Cox maze III procedure with cryoablation or the left atrial maze procedure in association with mitral valve surgery was performed in 80 patients with atrial fibrillation and enlarged left atria (> or =60 mm). Among them, 44 patients had the concomitant volume reduction technique (VR group); continuous horizontal mattress sutures for left atrial plication were placed on the left atrial wall along the pulmonary vein isolation line. Cryoablation was applied to the suture line so that the plicated left atrium is anatomically and electrically isolated. Another 36 patients did not have the volume reduction technique (control group). The VR group had preoperative left atrial diameters similar to those of the control group (67.1 +/- 7.8 vs 64.5 +/- 6.7 mm) and a longer preoperative duration of atrial fibrillation (14.1 +/- 5.4 vs 9.5 +/- 5.1 years, P < .05) but had smaller postoperative left atrial diameters (47.6 +/- 6.3 vs 62.1 +/- 7.9 mm, P < .01). There were no differences in mean crossclamp/bypass time and chest tube drainage for 12 hours between the groups. Twelve months after surgical intervention, the sinus rhythm recovery rate of the VR group was better than that of the control group (90% vs 69%, P < .05). Even in patients with long-standing atrial fibrillation and an enlarged left atrium, maze procedures concomitant with the novel left atrial volume reduction technique improved the sinus rhythm recovery rate without increasing complications. Although further study with a larger number of patients and a longer follow-up period is needed, this safe and thus far potent technique that catheter-based ablation cannot copy might extend indication of the Cox maze procedure for patients with tough atrial fibrillation.

Epinephrine and left atrial and left ventricular diastolic function decrease in normal subjects.

PubMed

Fuenmayor, Abdel J; Solórzano, Moisés I; Gómez, Luisangelly

2016-10-01

We assessed the effect of epinephrine over left atrial and left ventricular diastolic function in subjects without structural heart disease. Twenty-seven, 34.6±17.2year-old patients without structural heart disease were included. Intravenous epinephrine (50 to 100ng/kg/min) was infused. Left atrial and ventricular functions were evaluated by means of echocardiography before and during the epinephrine infusion. No complications were observed. Significant increases in heart rate and systolic blood pressure were recorded. Both left atrial (minimal and maximal) volumes increased but increase in the minimal volume was more pronounced, and the ejection fraction diminished. Left atrial expansion index decreased and the fraction of left ventricular inflow volume resulting from atrial contraction increased. Two patients displayed abnormal left ventricular diastolic function. During epinephrine infusion, E/A and e' decreased, and isovolumetric relaxation time increased. In this group of young adults without structural heart disease, epinephrine infusion was safe, did not produce any complications, and induced a small but significant decrease in left atrial function and left ventricular diastolic function. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Stiff Left Atrial Syndrome: A Complication Undergoing Radiofrequency Catheter Ablation for Atrial Fibrillation.

PubMed

Yang, Yufan; Liu, Qiming; Wu, Zhihong; Li, Xuping; Xiao, Yichao; Tu, Tao; Zhou, Shenghua

2016-07-01

Radiofrequency catheter ablation for atrial fibrillation is an effective approach for treating atrial fibrillation. Its complications have attracted much attention, of which the stiff left atrial syndrome is a recently discovered complication that has not been completely understood. This study aims to investigate the concept, pathologic basis, clinical characteristics, predictors, and treatment protocols of the stiff left atrial syndrome after radiofrequency ablation for atrial fibrillation. © 2016 Wiley Periodicals, Inc.

Physiological variation in left atrial transverse orientation does not influence orthogonal P-wave morphology.

PubMed

Petersson, Richard; Mosén, Henrik; Steding-Ehrenborg, Katarina; Carlson, Jonas; Faxén, Lisa; Mohtadi, Alan; Platonov, Pyotr G; Holmqvist, Fredrik

2017-03-01

It has previously been demonstrated that orthogonal P-wave morphology in healthy athletes does not depend on atrial size, but the possible impact of left atrial orientation on P-wave morphology remains unknown. In this study, we investigated if left atrial transverse orientation affects P-wave morphology in different populations. Forty-seven patients with atrial fibrillation, 21 patients with arrhythmogenic right ventricular cardiomyopathy, 67 healthy athletes, and 56 healthy volunteers were included. All underwent cardiac magnetic resonance imaging or computed tomography and the orientation of the left atrium was determined. All had 12-lead electrocardiographic recordings, which were transformed into orthogonal leads and orthogonal P-wave morphology was obtained. The median left atrial transverse orientation was 87 (83, 91) degrees (lower and upper quartiles) in the total study population. There was no difference in left atrial transverse orientation between individuals with different orthogonal P-wave morphologies. The physiological variation in left atrial orientation was small within as well as between the different populations. There was no difference in left atrial transverse orientation between subjects with type 1 and type 2 P-wave morphology, implying that in this setting the P-wave morphology was more dependent on atrial conduction than orientation. © 2016 Wiley Periodicals, Inc.

Effect of pilsicainide on dominant frequency in the right and left atria and pulmonary veins during atrial fibrillation: association with its atrial fibrillation terminating effect.

PubMed

Horiuchi, Daisuke; Iwasa, Atsushi; Sasaki, Kenichi; Owada, Shingen; Kimura, Masaomi; Sasaki, Shingo; Okumura, Ken

2009-04-17

Dominant frequency reflects the peak cycle length of atrial fibrillation. In 34 patients with atrial fibrillation, bipolar electrograms were recorded from multiple atrial sites and pulmonary veins and the effect of pilsicainide, class Ic antiarrhythmic drug, on dominant frequency was examined. At baseline, mean dominant frequencies (Hz) in the right and left atria, coronary sinus and right and left superior pulmonary veins were 5.87 +/- 0.76, 6.08 +/- 0.60, 5.65 +/- 0.95, 6.12 +/- 0.88 and 6.59 +/- 0.89, respectively (P < 0.05, left superior pulmonary vein vs right atrium and coronary sinus). After pilsicainide (1.0 mg/kg/5 min), dominant frequency decreased at all sites in all patients. Atrial fibrillation was terminated at 5.9 +/- 2.2 min in 16 patients (Group A) with a decrease in the average of mean dominant frequencies at all sites from 5.80 +/- 0.72 to 3.57 +/- 0.63 Hz, was converted to atrial flutter at 7.3 +/- 1.4 min in 5 (Group B) with a decrease in the average dominant frequency from 5.83 +/- 0.48 to 3.08 +/- 0.19 Hz, and was not terminated in the other 13 (Group C) despite the average dominant frequency decrease from 6.59 +/- 0.76 to 4.42 +/- 0.52 Hz. In 14 of the 21 Groups A and B patients (67%), mean dominant frequencies at all recording sites were < 4.0 after pilsicainide, while they were < 4.0 in 1 of the 13 Group C patients (8%, P < 0.01). In conclusion, the degree of dominant frequency decrease by pilsicainide is closely related to its atrial fibrillation terminating effect: When dominant frequency in the atria decreases to < 4.0 Hz, atrial fibrillation is terminated with 93% positive and 63% negative predictive values.

Concomitant surgical closure of left atrial appendage: A systematic review and meta-analysis.

PubMed

Ando, Masahiko; Funamoto, Masaki; Cameron, Duke E; Sundt, Thoralf M

2018-03-12

Although percutaneous closure of the left atrial appendage is supported as a potential alternative to lifelong anticoagulation in patients with atrial fibrillation, comprehensive evidence on surgical left atrial appendage closure in heart surgery is limited. We conducted a meta-analysis of studies comparing patients who underwent open cardiac surgery with or without left atrial appendage closure. A literature search was performed on PubMed, Embase, and Cochrane Trials databases. Outcomes of interest were 30-day/in-hospital mortality and cerebrovascular accident. I 2 statistics were used to evaluate heterogeneity, and publication bias was evaluated by Begg's and Egger's tests. We reviewed 1284 articles and selected for main analysis 7 articles including 3897 patients (1963 in the left atrial appendage closure group and 1934 in the non-left atrial appendage closure group). Among the 7 studies, 3 were randomized-controlled studies, 3 were propensity-matched studies, and 1 was a case-matching study. At 30-day/in-hospital follow-up, left atrial appendage closure was significantly associated with decreased risk of mortality and cerebrovascular accident (odds ratio, 0.384, 95% confidence interval, 0.233-0.631 for mortality, and odds ratio, 0.622, 95% confidence interval, 0.388-0.998 for cerebrovascular accident). Stratified analysis demonstrated that this association was more prominent in preoperative atrial fibrillation strata. Concomitant surgical left atrial appendage closure should be considered at the time of open cardiac surgery, particularly among those in atrial fibrillation preoperatively. The benefit of left atrial appendage closure for patients not in atrial fibrillation and for those undergoing nonvalvular surgery is still unclear. Further prospective investigations are indicated. Copyright © 2018. Published by Elsevier Inc.

Anatomy of the left atrium for interventional electrophysiologists.

PubMed

Ho, Siew Yen; McCarthy, Karen P

2010-05-01

Increasingly, interventional procedures require accessing the left atrium from the inside of the heart as well as from the pericardial space. The right phrenic nerve running along the fibrous pericardium is close to the atrial insertion of the right superior pulmonary vein while the left phrenic nerve passes over the left atrial appendage. Posteriorly, the esophagus descends adjacent to the fibrous pericardium covering the posterior and postero-inferior walls of the left atrium. The component parts of the left atrium are reviewed with emphasis on the structure of the atrial septum, the left atrial ridge, the mitral isthmus, and the left atrial walls. Although the atrial walls are mainly smooth, pits and crevices are common in the region of the mitral isthmus and the vicinity of the os of the atrial appendage. The muscular rim around the valve of the oval fossa delimits the extent of the true atrial septum. Interatrial muscular connections exist at the septum, along Bachmann's bundle and also at the muscular sleeves of the coronary sinus and pulmonary veins. Anatomical features relevant to interventional electrophysiologists are highlighted.

Mapping of the left-sided phrenic nerve course in patients undergoing left atrial catheter ablations.

PubMed

Huemer, Martin; Wutzler, Alexander; Parwani, Abdul S; Attanasio, Philipp; Haverkamp, Wilhelm; Boldt, Leif-Hendrik

2014-09-01

Catheter ablation of atrial fibrillation has been associated with left-sided phrenic nerve palsy. Knowledge of the individual left phrenic nerve course therefore is essential to prevent nerve injury. The aim of this study was to test the feasibility of an intraprocedural pace mapping and reconstruction of the left phrenic nerve course and to characterize which anatomical areas are affected. In patients undergoing left atrial catheter ablation, a three-dimensional map of the left atrial anatomical structures was created. The left-sided phrenic nerve course was determined by high-output pace mapping and reconstructed in the map. In this study, 40 patients with atrial fibrillation or atrial tachycardias were included. Left phrenic nerve capture was observed in 23 (57.5%) patients. Phrenic nerve was captured in 22 (55%) patients inside the left atrial appendage, in 22 (55%) in distal parts, in 21 (53%) in medial parts, and in two (5%) in ostial parts of the appendage. In three (7.5%) patients, capture was found in the distal coronary sinus and in one (2.5%) patient in the left atrium near the left atrial appendage ostium. Ablation target was changed due to direct spatial relationship to the phrenic nerve in three (7.5%) patients. No phrenic nerve palsy was observed. Left-sided phrenic nerve capture was found inside and around the left atrial appendage in the majority of patients and additionally in the distal coronary sinus. Phrenic nerve mapping and reconstruction can easily be performed and should be considered prior catheter ablations in potential affected areas. ©2014 Wiley Periodicals, Inc.

Impaired left atrial function predicts inappropriate shocks in primary prevention implantable cardioverter-defibrillator candidates.

PubMed

Tao, Susumu; Ashikaga, Hiroshi; Ciuffo, Luisa A; Yoneyama, Kihei; Lima, Joao A C; Frank, Terry F; Weiss, Robert G; Tomaselli, Gordon F; Wu, Katherine C

2017-07-01

Inappropriate implantable cardioverter-defibrillator (ICD) shocks, commonly caused by atrial fibrillation (AF), are associated with an increased mortality. Because impaired left atrial (LA) function predicts development of AF, we hypothesized that impaired LA function predicts inappropriate shocks beyond a history of AF. We prospectively analyzed the association between LA function and incident inappropriate shocks in primary prevention ICD candidates. In the Prospective Observational Study of ICD (PROSE-ICD), we assessed LA function using tissue-tracking cardiac magnetic resonance (CMR) prior to ICD implantation. A total of 162 patients (113 males, age 56 ± 15 years) were included. During the mean follow-up of 4.0 ± 2.9 years, 26 patients (16%) experienced inappropriate shocks due to AF (n = 19; 73%), supraventricular tachycardia (n = 5; 19%), and abnormal sensing (n = 2; 8%). In univariable analyses, inappropriate shocks were associated with AF history prior to ICD implantation, age below 70 years, QRS duration less than 120 milliseconds, larger LA minimum volume, lower LA stroke volume, lower LA emptying fraction, impaired LA maximum and preatrial contraction strains (S max and S preA ), and impaired LA strain rate during left ventricular systole and atrial contraction (SR s and SR a ). In multivariable analysis, impaired S max (hazard ratio [HR]: 0.96, P = 0.044), S preA (HR: 0.94, P = 0.030), and SR a (HR: 0.25, P < 0.001) were independently associated with inappropriate shocks. The receiver-operating characteristics curve showed that SR a improved the predictive value beyond the patient demographics including AF history (P = 0.033). Impaired LA function assessed by tissue-tracking CMR is an independent predictor of inappropriate shocks in primary prevention ICD candidates beyond AF history. © 2017 Wiley Periodicals, Inc.

Imaging of thrombi and assessment of left atrial appendage function: a prospective study comparing transthoracic and transoesophageal echocardiography

PubMed Central

Omran, H; Jung, W; Rabahieh, R; Wirtz, P; Becher, H; Illien, S; Schimpf, R; Luderitz, B

1999-01-01

Objective—To compare the value of current transthoracic echocardiographic systems and transoesophageal echocardiography for assessing left atrial appendage function and imaging thrombi.
Design—Single blind prospective study. Patients were first investigated by transthoracic echocardiography and thereafter by a second investigator using transoesophageal echocardiography. The feasibility of imaging the left atrial appendage, recording its velocities, and identifying thrombi within the appendage were determined by both methods.
Patients—117 consecutive patients with a stroke or transient neurological deficit.
Setting—Tertiary cardiac and neurological care centre.
Results—Imaging of the complete appendage was feasible in 75% of the patients by transthoracic echocardiography and in 95% by transoesophageal echocardiography. Both methods were concordant for the detection of thrombi in 10 cases. Transoesophageal echocardiography revealed two additional thrombi. In one of these patients, transthoracic echocardiography was not feasible and in the other the thrombus had been missed by transthoracic examination. In patients with adequate transthoracic echogenicity, the specificity and sensitivity of detecting left atrial appendage thrombi were 100% and 91%, respectively. Recording of left atrial appendage velocities by transthoracic echocardiography was feasible in 69% of cases. None of the patients with a velocity > 0.3 m/s had left atrial appendage thrombi. In the one patient in whom transthoracic echocardiographic evaluation missed a left atrial appendage thrombus, the peak emptying velocity of the left atrial appendage was 0.25 m/s.
Conclusions—A new generation echocardiographic system allows for the transthoracic detection of left atrial appendage thrombi and accurate determination of left atrial appendage function in most patients with a neurological deficit.

 Keywords: echocardiography; left atrial appendage thrombi; stroke; thromboembolism PMID:9922358

[Left versus bi-atrial radiofrequency ablation in the treatment of atrial fibrillation].

PubMed

Wang, Jian-Gang; Meng, Xu; Li, Hui

2008-11-25

To evaluate the effectiveness of radiofrequency modified maze operation for the treatment of atrial fibrillation (AF) and compare the results of the left versus bi-atrial procedures. 305 patients of organic heart disease combined with AF, 117 males and 188 females, aged (53 +/- 10), that underwent cardiac valve operation (n = 293) and/or coronary artery bypass graft surgery (n = 14), received concomitant atrial fibrillation, bi-atrial (n = 160) or left atrial (n = 145) with a mean duration of (36 +/- 43) months. Follow-up was conducted for (28 +/- 5) (3 - 42) months. Thirteen patients (4.3%) died postoperatively: 7 died of multisystem and organ failure, 3 of low cardiac output, 1 of rupture of left ventricle, 1 of arrhythmia, and 1 of sudden death. During the follow-up, 1 patient died of heart failure, 1 of encephalorrhagia and 1 of unknown reason in the bi-atrial group. At the end of the procedure 223 patients (73.1%) had sinus rhythm, with a sinus rhythm rate of 66.9% (107/160) in the bi-atrial group, significant lower than that in the left atrial group (80.0%, 116/145, P < 0.05). At late follow-up, 215 of the 266 patients (80.8%) were in stable sinus rhythm. Sinus rhythm rate of the bi-atrial group was 80.0%, not significantly different from that of the left atrial group (81.9%, P > 0.05). The Kaplan-Meier survival analysis showed there was no significant difference in the AF rhythm rate between these 2 groups (P = 0.33). Logistic regression analysis showed that the left atrial diameter of >/= 80 mm was an independent predictor of AF recurrence. Both the left and bi-atrial procedures are successful in terms of restoring sinus rhythm. Left atrial ablation in severe cases and where the incision of right atrium is not needed is a reasonable choice.

Left atrial strain predicts hemodynamic parameters in cardiovascular patients.

PubMed

Hewing, Bernd; Theres, Lena; Spethmann, Sebastian; Stangl, Karl; Dreger, Henryk; Knebel, Fabian

2017-08-01

We aimed to evaluate the predictive value of left atrial (LA) reservoir, conduit, and contractile function parameters as assessed by speckle tracking echocardiography (STE) for invasively measured hemodynamic parameters in a patient cohort with myocardial and valvular diseases. Sixty-nine patients undergoing invasive hemodynamic assessment were enrolled into the study. Invasive hemodynamic parameters were obtained by left and right heart catheterization. Transthoracic echocardiography assessment of LA reservoir, conduit, and contractile function was performed by STE. Forty-nine patients had sinus rhythm (SR) and 20 patients had permanent atrial fibrillation (AF). AF patients had significantly reduced LA reservoir function compared to SR patients. In patients with SR, LA reservoir, conduit, and contractile function inversely correlated with pulmonary capillary wedge pressure (PCWP), left ventricular end-diastolic pressure, and mean pulmonary artery pressure (PAP), and showed a moderate association with cardiac index. In AF patients, there were no significant correlations between LA reservoir function and invasively obtained hemodynamic parameters. In SR patients, LA contractile function with a cutoff value of 16.0% had the highest diagnostic accuracy (area under the curve, AUC: 0.895) to predict PCWP ≥18 mm Hg compared to the weaker diagnostic accuracy of average E/E' ratio with an AUC of 0.786 at a cutoff value of 14.3. In multivariate analysis, LA contractile function remained significantly associated with PCWP ≥18 mm Hg. In a cohort of patients with a broad spectrum of cardiovascular diseases LA strain shows a valuable prediction of hemodynamic parameters, specifically LV filling pressures, in the presence of SR. © 2017, Wiley Periodicals, Inc.

Survival after extreme left atrial hypertension and pulmonary hemorrhage in an infant supported with extracorporeal membrane oxygenation for refractory atrial flutter.

PubMed

Cisco, Michael J; Asija, Ritu; Dubin, Anne M; Perry, Stanton B; Hanley, Frank L; Roth, Stephen J

2011-05-01

We report here the survival of an infant who developed extreme left atrial hypertension and severe pulmonary hemorrhage while supported with extracorporeal membrane oxygenation for refractory atrial flutter. The patient recovered after decompression of the left heart and catheter ablation of the atrioventricular node. Lucile Packard Children's Hospital (Stanford, CA). Chart review. Recovery of lung function is possible despite systemic-level left atrial pressure resulting in pulmonary hemorrhage and complete solidification of lung parenchyma on gross inspection. Resolution of pulmonary hemorrhage despite anticoagulation while on extracorporeal membrane oxygenation can occur after relief of left atrial hypertension.

Effects of novel oral anticoagulants on left atrial and left atrial appendage thrombi: an appraisal.

PubMed

Marsico, Fabio; Cecere, Milena; Parente, Antonio; Paolillo, Stefania; de Martino, Fabiana; Dellegrottaglie, Santo; Trimarco, Bruno; Perrone Filardi, Pasquale

2017-02-01

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and predisposes to an increased risk of thromboembolic events. Patients affected by AF exhibit an increased risk of stroke compared with those in sinus rhythm, with the most common location of thrombi in the left atrial appendage. Until 2009, warfarin and other vitamin K antagonists were the only class of oral anticoagulants available. More recently, dabigatran, rivaroxaban, apixaban, and edoxaban have been approved by regulatory authorities for prevention of stroke in patients with non-valvular AF. Few data are available about the efficacy of novel oral anticoagulants for the treatment of left atrial and left atrial appendage thrombosis. Aim of this review is to summarize available evidence regarding the effectiveness of novel oral anticoagulants on left atrial appendage thrombosis.

Atorvastatin can ameliorate left atrial stunning induced by radiofrequency ablation for atrial fibrillation.

PubMed

Xie, Ruiqin; Yang, Yingtao; Cui, Wei; Yin, Hongning; Zheng, Hongmei; Zhang, Jidong; You, Ling

2017-09-01

The objective of this study was to study the functional changes of the left atrium after radiofrequency ablation treatment for atrial fibrillation and the therapeutic effect of atorvastatin. Fifty-eight patients undergoing radiofrequency ablation for atrial fibrillation were randomly divided into non-atorvastatin group and atorvastatin group. Patients in the atorvastatin group were treated with atorvastatin 20 mg p.o. per night in addition to the conventional treatment of atrial fibrillation; patients in the non-atorvastatin group received conventional treatment of atrial fibrillation only. Echocardiography was performed before radiofrequency ablation operation and 1 week, 2 weeks, 3 weeks, and 4 weeks after operation. Two-dimensional ultrasound speckle tracking imaging system was used to measure the structural indexes of the left atrium. Results indicated that there was no significant change for indexes representing the structural status of the left atrium within a month after radiofrequency ablation (P > 0.05); however, there were significant changes for indexes representing the functional status of the left atrium. There were also significant changes in indexes reflecting left atrial strain status: the S and SRs of atorvastatin group were higher than those of non-atorvastatin group (P < 0.05). In summary, atorvastatin could improve left atrial function and shorten the duration of atrial stunning after radiofrequency ablation of atrial fibrillation.

The effects of the Cox maze procedure on atrial function

PubMed Central

Voeller, Rochus K.; Zierer, Andreas; Lall, Shelly C.; Sakamoto, Shun–ichiro; Chang, Nai–Lun; Schuessler, Richard B.; Moon, Marc R.; Damiano, Ralph J.

2010-01-01

Objective The effects of the Cox maze procedure on atrial function remain poorly defined. The purpose of this study was to investigate the effects of a modified Cox maze procedure on left and right atrial function in a porcine model. Methods After cardiac magnetic resonance imaging, 6 pigs underwent pericardiotomy (sham group), and 6 pigs underwent a modified Cox maze procedure (maze group) with bipolar radiofrequency ablation. The maze group had preablation and immediate postablation left and right atrial pressure–volume relations measured with conductance catheters. All pigs survived for 30 days. Magnetic resonance imaging was then repeated for both groups, and conductance catheter measurements were repeated for the right atrium in the maze group. Results Both groups had significantly higher left atrial volumes postoperatively. Magnetic resonance imaging–derived reservoir and booster pump functional parameters were reduced postoperatively for both groups, but there was no difference in these parameters between the groups. The maze group had significantly higher reduction in the medial and lateral left atrial wall contraction postoperatively. There was no change in immediate left atrial elastance or in the early and 30-day right atrial elastance after the Cox maze procedure. Although the initial left atrial stiffness increased after ablation, right atrial diastolic stiffness did not change initially or at 30 days. Conclusions Performing a pericardiotomy alone had a significant effect on atrial function that can be quantified by means of magnetic resonance imaging. The effects of the Cox maze procedure on left atrial function could only be detected by analyzing segmental wall motion. Understanding the precise physiologic effects of the Cox maze procedure on atrial function will help in developing less-damaging lesion sets for the surgical treatment of atrial fibrillation. PMID:19026812

Cardiac Cycle Dependent Left Atrial Dynamics: Implications for Catheter Ablation of Atrial Fibrillation

PubMed Central

Patel, Amit R.; Fatemi, Omid; Norton, Patrick T.; West, J. Jason; Helms, Adam S.; Kramer, Christopher M.; Ferguson, John D.

2008-01-01

Background Left atrial volume (LAV) determines prognosis and response to therapy in atrial fibrillation. Integration of electro-anatomical maps with 3D-images rendered from CT and MRI is used to facilitate atrial fibrillation ablation. Objectives We measured LAV changes and regional motion during the cardiac cycle that might affect the accuracy of image integration and determined their relationship to standard LAV measurements. Methods MRI was performed in thirty patients with paroxysmal atrial fibrillation. Left atrial time-volume curves were generated and used to divide the left atrial function (LAEF) into pumping (PEF) and conduit (CEF) fractions and to determine the maximum LAV (LAMAX) and the pre-atrial contraction volume (PACV). LAV was measured using an MRI angiogram and traditional geometric models from echocardiography (area-length and ellipsoid). The in-plane displacement of the pulmonary veins, anterior left atrium, mitral annulus, and left atrial appendage was measured. Results LAMAX was 107±36ml and occurred at 42±5% of the RR interval. PACV was 86 ±34ml and occurred at 81±4% of the RR interval. LAEF was 45±10% and PEF was 31±10%. LAV measurements made from the MRI angiogram, area-length and ellipsoid models underestimated LAMAX by 21±25ml, 16±26ml, and 35±22ml, respectively. The anterior LA, mitral annulus, and left atrial appendage were significantly displaced during the cardiac cycle (8.8±2.0mm, 13.2±3.8mm, and 10.2±3.4mm, respectively); the pulmonary veins were not. Conclusions LAV changes significantly during the cardiac cycle and substantial regional variation in left atrial motion exists. Standard measurements of left atrial volume significantly underestimate LAMAX when compared to the gold standard measure of 3D-volumetrics. PMID:18486563

Noninvasive assessment of left atrial maximum dP/dt by a combination of transmitral and pulmonary venous flow.

PubMed

Nakatani, S; Garcia, M J; Firstenberg, M S; Rodriguez, L; Grimm, R A; Greenberg, N L; McCarthy, P M; Vandervoort, P M; Thomas, J D

1999-09-01

The study assessed whether hemodynamic parameters of left atrial (LA) systolic function could be estimated noninvasively using Doppler echocardiography. Left atrial systolic function is an important aspect of cardiac function. Doppler echocardiography can measure changes in LA volume, but has not been shown to relate to hemodynamic parameters such as the maximal value of the first derivative of the pressure (LA dP/dt(max)). Eighteen patients in sinus rhythm were studied immediately before and after open heart surgery using simultaneous LA pressure measurements and intraoperative transesophageal echocardiography. Left atrial pressure was measured with a micromanometer catheter, and LA dP/dt(max) during atrial contraction was obtained. Transmitral and pulmonary venous flow were recorded by pulsed Doppler echocardiography. Peak velocity, and mean acceleration and deceleration, and the time-velocity integral of each flow during atrial contraction was measured. The initial eight patients served as the study group to derive a multilinear regression equation to estimate LA dP/dt(max) from Doppler parameters, and the latter 10 patients served as the test group to validate the equation. A previously validated numeric model was used to confirm these results. In the study group, LA dP/dt(max) showed a linear relation with LA pressure before atrial contraction (r = 0.80, p < 0.005), confirming the presence of the Frank-Starling mechanism in the LA. Among transmitral flow parameters, mean acceleration showed the strongest correlation with LA dP/dt(max) (r = 0.78, p < 0.001). Among pulmonary venous flow parameters, no single parameter was sufficient to estimate LA dP/dt(max) with an r2 > 0.30. By stepwise and multiple linear regression analysis, LA dP/dt(max) was best described as follows: LA dP/dt(max) = 0.1 M-AC +/- 1.8 P-V - 4.1; r = 0.88, p < 0.0001, where M-AC is the mean acceleration of transmitral flow and P-V is the peak velocity of pulmonary venous flow during atrial contraction. This equation was tested in the latter 10 patients of the test group. Predicted and measured LA dP/dt(max) correlated well (r = 0.90, p < 0.0001). Numerical simulation verified that this relationship held across a wide range of atrial elastance, ventricular relaxation and systolic function, with LA dP/dt(max) predicted by the above equation with r = 0.94. A combination of transmitral and pulmonary venous flow parameters can provide a hemodynamic assessment of LA systolic function.

Noninvasive assessment of left atrial maximum dP/dt by a combination of transmitral and pulmonary venous flow

NASA Technical Reports Server (NTRS)

Nakatani, S.; Garcia, M. J.; Firstenberg, M. S.; Rodriguez, L.; Grimm, R. A.; Greenberg, N. L.; McCarthy, P. M.; Vandervoort, P. M.; Thomas, J. D.

1999-01-01

OBJECTIVES: The study assessed whether hemodynamic parameters of left atrial (LA) systolic function could be estimated noninvasively using Doppler echocardiography. BACKGROUND: Left atrial systolic function is an important aspect of cardiac function. Doppler echocardiography can measure changes in LA volume, but has not been shown to relate to hemodynamic parameters such as the maximal value of the first derivative of the pressure (LA dP/dt(max)). METHODS: Eighteen patients in sinus rhythm were studied immediately before and after open heart surgery using simultaneous LA pressure measurements and intraoperative transesophageal echocardiography. Left atrial pressure was measured with a micromanometer catheter, and LA dP/dt(max) during atrial contraction was obtained. Transmitral and pulmonary venous flow were recorded by pulsed Doppler echocardiography. Peak velocity, and mean acceleration and deceleration, and the time-velocity integral of each flow during atrial contraction was measured. The initial eight patients served as the study group to derive a multilinear regression equation to estimate LA dP/dt(max) from Doppler parameters, and the latter 10 patients served as the test group to validate the equation. A previously validated numeric model was used to confirm these results. RESULTS: In the study group, LA dP/dt(max) showed a linear relation with LA pressure before atrial contraction (r = 0.80, p < 0.005), confirming the presence of the Frank-Starling mechanism in the LA. Among transmitral flow parameters, mean acceleration showed the strongest correlation with LA dP/dt(max) (r = 0.78, p < 0.001). Among pulmonary venous flow parameters, no single parameter was sufficient to estimate LA dP/dt(max) with an r2 > 0.30. By stepwise and multiple linear regression analysis, LA dP/dt(max) was best described as follows: LA dP/dt(max) = 0.1 M-AC +/- 1.8 P-V - 4.1; r = 0.88, p < 0.0001, where M-AC is the mean acceleration of transmitral flow and P-V is the peak velocity of pulmonary venous flow during atrial contraction. This equation was tested in the latter 10 patients of the test group. Predicted and measured LA dP/dt(max) correlated well (r = 0.90, p < 0.0001). Numerical simulation verified that this relationship held across a wide range of atrial elastance, ventricular relaxation and systolic function, with LA dP/dt(max) predicted by the above equation with r = 0.94. CONCLUSIONS: A combination of transmitral and pulmonary venous flow parameters can provide a hemodynamic assessment of LA systolic function.

Isovolumic relaxation time varies predictably with its time constant and aortic and left atrial pressures: implications for the noninvasive evaluation of ventricular relaxation.

PubMed

Thomas, J D; Flachskampf, F A; Chen, C; Guererro, J L; Picard, M H; Levine, R A; Weyman, A E

1992-11-01

The isovolumic relaxation time (IVRT) is an important noninvasive index of left ventricular diastolic function. Despite its widespread use, however, the IVRT has not been related analytically to invasive parameters of ventricular function. Establishing such a relationship would make the IVRT more useful by itself and perhaps allow it to be combined more precisely with other noninvasive parameters of ventricular filling. The purpose of this study was to validate such a quantitative relationship. Assuming isovolumic relaxation to be a monoexponential decay of ventricular pressure (pv) to a zero-pressure asymptote, it was postulated that the time interval from aortic valve closure (when pv = p(o)) until mitral valve opening (when pv = left atrial pressure, pA) would be given analytically by IVRT = tau[log(p(o))-log(pA)], where tau is the time constant of isovolumic relaxation and log is to the base e. To test this hypothesis we analyzed data from six canine experiments in which ventricular preload and afterload were controlled nonpharmacologically. In addition, tau was adjusted with the use of beta-adrenergic blockade and calcium infusion, as well as with hypothermia. In each experiment data were collected before and after the surgical formation of mitral stenosis, performed to permit the study of a wide range of left atrial pressures. High-fidelity left atrial, left ventricular, and aortic root pressures were digitized, the IVRT was measured from the aortic dicrotic notch until the left atrioventricular pressure crossover point, and tau was calculated by nonlinear least-squares regression.(ABSTRACT TRUNCATED AT 250 WORDS)

Anatomic relationship between left coronary artery and left atrium in patients undergoing atrial fibrillation ablation.

PubMed

Anselmino, Matteo; Torri, Federica; Ferraris, Federico; Calò, Leonardo; Castagno, Davide; Gili, Sebastiano; Rovera, Chiara; Giustetto, Carla; Gaita, Fiorenzo

2017-07-01

Atrial fibrillation transcatheter ablation (TCA) is, within available atrial fibrillation rhythm control strategies, one of the most effective. To potentially improve ablation outcome in case of recurrent atrial fibrillation after a first procedure or in presence of structural myocardial disease, isolation of the pulmonary veins may be associated with extensive lesions within the left atrium. To avoid rare, but potentially life-threatening, complications, thorough knowledge and assessment of left atrium anatomy and its relation to structures in close proximity are, therefore, mandatory. Aim of the present study is to describe, by cardiac computed tomography, the anatomic relationship between aortic root, left coronary artery and left atrium in patients undergoing atrial fibrillation TCA. The cardiac computed tomography scan of 21 patients affected by atrial fibrillation was elaborated to segment left atrium, aortic root and left coronary artery from the surrounding structures and the following distances measured: left atrium and aortic root; left atrium roof and aortic root; left main coronary artery and left atrium; circumflex artery and left atrium appendage; and circumflex artery and mitral valve annulus. Above all, the median distance between left atrium and aortic root (1.9, 1.5-2.1 mm), and between circumflex artery and left atrium appendage ostium (3.0, 2.1-3.4 mm) were minimal (≤3 mm). None of measured distances significantly varied between patients presenting paroxysmal versus persistent atrial fibrillation. The anatomic relationship between left atrium and coronary arteries is extremely relevant when performing atrial fibrillation TCA by extensive lesions. Therefore, at least in the latter case, preablation imaging should be recommended to avoid rare, but potentially life-threatening, complications with the aim of an as well tolerated as possible procedure.

Atrial conduction times and left atrial mechanical functions and their relation with diastolic function in prediabetic patients.

PubMed

Gudul, Naile Eris; Karabag, Turgut; Sayin, Muhammet Rasit; Bayraktaroglu, Taner; Aydin, Mustafa

2017-03-01

The aim of this study was to investigate atrial conduction times and left atrial mechanical functions, the noninvasive predictors of atrial fibrillation, in prediabetic patients with impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). Study included 59 patients (23 males, 36 females; mean age 52.5 ± 10.6 years) diagnosed with IFG or IGT by the American Diabetes Association criteria, and 43 healthy adults (22 males, 21 females; mean age 48.5 ± 12.1 years). Conventional and tissue Doppler echocardiography were performed. The electromechanical delay parameters were measured from the onset of the P wave on the surface electrocardiogram to the onset of the atrial systolic wave on tissue Doppler imaging from septum, lateral, and right ventricular annuli. The left atrial volumes were calculated by the disk method. Left atrial mechanical functions were calculated. The mitral E/A and E'/A' ratios measured from the lateral and septal annuli were significantly lower in the prediabetics compared to the controls. The interatrial and left atrial electromechanical delay were significantly longer in prediabetic group compared to the controls. Left atrial active emptying volume (LAAEV) and fraction (LAAEF) were significantly higher in the prediabetics than the controls. LAAEV and LAAEF were significantly correlated with E/A, lateral and septal E'/A'. In the prediabetic patients, the atrial conduction times and P wave dispersion on surface electrocardiographic were longer before the development of overt diabetes. In addition, the left atrial mechanical functions were impaired secondary to a deterioration in the diastolic functions in the prediabetic patients.

Mitochondrial apoptotic pathway activation in the atria of heart failure patients due to mitral and tricuspid regurgitation.

PubMed

Chang, Jen-Ping; Chen, Mien-Cheng; Liu, Wen-Hao; Lin, Yu-Sheng; Huang, Yao-Kuang; Pan, Kuo-Li; Ho, Wan-Chun; Fang, Chih-Yuan; Chen, Chien-Jen; Chen, Huang-Chung

2015-08-01

Apoptosis occurs in atrial cardiomyocytes in mitral and tricuspid valve disease. The purpose of this study was to examine the respective roles of the mitochondrial and tumor necrosis factor-α receptor associated death domain (TRADD)-mediated death receptor pathways for apoptosis in the atrial cardiomyocytes of heart failure patients due to severe mitral and moderate-to-severe tricuspid regurgitation. This study comprised eighteen patients (7 patients with persistent atrial fibrillation and 11 in sinus rhythm). Atrial appendage tissues were obtained during surgery. Three purchased normal human left atrial tissues served as normal controls. Moderately-to-severely myolytic cardiomyocytes comprised 59.7±22.1% of the cardiomyocytes in the right atria and 52.4±12.9% of the cardiomyocytes in the left atria of mitral and tricuspid regurgitation patients with atrial fibrillation group and comprised 58.4±24.8% of the cardiomyocytes in the right atria of mitral and tricuspid regurgitation patients with sinus rhythm. In contrast, no myolysis was observed in the normal human adult left atrial tissue samples. Immunohistochemical analysis showed expression of cleaved caspase-9, an effector of the mitochondrial pathways, in the majority of right atrial cardiomyocytes (87.3±10.0%) of mitral and tricuspid regurgitation patients with sinus rhythm, and right atrial cardiomyocytes (90.6±31.4%) and left atrial cardiomyocytes (70.7±22.0%) of mitral and tricuspid regurgitation patients with atrial fibrillation. In contrast, only 5.7% of cardiomyocytes of the normal left atrial tissues showed strongly positive expression of cleaved caspase-9. Of note, none of the atrial cardiomyocytes in right atrial tissue in sinus rhythm and in the fibrillating right and left atria of mitral and tricuspid regurgitation patients, and in the normal human adult left atrial tissue samples showed cleaved caspase-8 expression, which is a downstream effector of TRADD of the death receptor pathway. Immunoblotting of atrial extracts showed that there was enhanced expression of cytosolic cytochrome c, an effector of the mitochondrial pathways, but no expression of membrane TRADD and cytosolic caspase-8 in the right atrial tissue of mitral and tricuspid regurgitation patients with sinus rhythm, and right atrial and left atrial tissues of mitral and tricuspid regurgitation patients with atrial fibrillation. Taken together, this study showed that mitochondrial pathway for apoptosis was activated in the right atria in sinus rhythm and in the left and right atria in atrial fibrillation of heart failure patients due to mitral and tricuspid regurgitation, and this mitochondrial pathway activation may contribute to atrial contractile dysfunction and enlargement in this clinical setting. Copyright © 2015. Published by Elsevier Inc.

Identification of Left Atrial Appendage Thrombi in Patients With Persistent and Long-Standing Persistent Atrial Fibrillation Using Intra-Cardiac Echocardiography and Cardiac Computed Tomography.

PubMed

Ikegami, Yukinori; Tanimoto, Kojiro; Inagawa, Kohei; Shiraishi, Yasuyuki; Fuse, Jun; Sakamoto, Munehisa; Momiyama, Yukihiko; Takatsuki, Seiji

2017-12-25

Intracardiac echocardiography (ICE) and cardiac computed tomography (CCT), in addition to standard transesophageal echocardiography (TEE), have been used to identify left atrial (LA) thrombi prior to ablation for atrial fibrillation (AF). The clinical advantages of this, however, remain unclear. This study therefore investigated the advantages of additional pre-procedural LA appendage (LAA) thrombus evaluation using ICE and the clinical value of CCT in persistent and long-standing persistent AF.Methods and Results:We analyzed data from 108 consecutive patients with persistent and long-standing persistent AF who were scheduled to undergo AF ablation. TEE was performed within 24 h prior to ablation. ICE was performed for 97 patients in whom a thrombus was not detected on TEE. CCT was performed in 95 patients. Thrombus or sludge was detected on TEE in 11 patients (10.3%), for whom ablation was cancelled. Four additional patients were diagnosed with LAA thrombus on ICE. When TEE and ICE were used as the reference for thrombus detection, the sensitivity, specificity, positive predictive value, and negative predictive value of CCT for identifying contrast defects in the LAA were 100%, 81.0%, 40.7%, and 100%, respectively. ICE combined with TEE increased the detection rate of LAA thrombi in patients with persistent and long-standing persistent AF. Moreover, CCT had high sensitivity and negative predictive value for LAA thrombus detection.

Incisional left atrial isolation for ablation of atrial fibrillation in mitral valve surgery.

PubMed

Graffigna, Angelo; Branzoli, Stefano; Sinelli, Stefano; Vigano, Mario

2009-01-01

The renewed interest in surgical techniques for atrial fibrillation (AF) limited to the left atrium has risen the importance of the original technique of left atrial isolation by means of surgical incision. Transmurality of lesions and cost containment are strong elements to be appreciated in this technique.

The Left Atrial Appendage Revised

PubMed Central

Evora, Paulo Roberto Barbosa; Menardi, Antonio Carlos; Celotto, Andrea Carla; Albuquerque, Agnes Afrodite S.; Chagas, Hannah Miranda Araujo; Rodrigues, Alfredo José

2017-01-01

Nonvalvular atrial fibrillation is associated with a 4- to 5-fold strokes increase and may be responsible for 15% to 20% of all strokes in the elderly. In this scenario, the left atrial appendage thrombus would be the associated with 90% of cases. The use of anticoagulants, percutaneous devices, and the left atrial appendage surgical exclusion is still an open discussion. For left atrial appendage procedures, relevant anatomic spatial relationships have to be emphasized, besides the chance of the normal physiological functioning would be eliminated with the proceedings. There are evidences that the left atrial appendage closure during routine cardiac surgery is significantly associated with an increased risk of early postoperative atrial fibrillation. Therefore, the purpose of this review is to focus basic aspects for continuous medical education. In summary, the rationale of this text is to emphasize anatomical and pharmacological aspects involved in the simple surgical exclusion of left atrial appendage under cardiopulmonary bypass. There are several operative techniques, but to conclude this revision it will present one of them based on the discussed basic sciences. PMID:29267615

Efficacy of catheter ablation of atrial fibrillation beyond HATCH score.

PubMed

Tang, Ri-Bo; Dong, Jian-Zeng; Long, De-Yong; Yu, Rong-Hui; Ning, Man; Jiang, Chen-Xi; Sang, Cai-Hua; Liu, Xiao-Hui; Ma, Chang-Sheng

2012-10-01

HATCH score is an established predictor of progression from paroxysmal to persistent atrial fibrillation (AF). The purpose of this study was to determine if HATCH score could predict recurrence after catheter ablation of AF. The data of 488 consecutive paroxysmal AF patients who underwent an index circumferential pulmonary veins (PV) ablation were retrospectively analyzed. Of these patients, 250 (51.2%) patients had HATCH score = 0, 185 (37.9%) patients had HATCH score = 1, and 53 (10.9%) patients had HATCH score ≥ 2 (28 patients had HATCH score = 2, 23 patients had HATCH score = 3, and 2 patients had HATCH score = 4). The patients with HATCH score ≥ 2 had significantly larger left atrium size, the largest left ventricular end systolic diameter, and the lowest ejection fraction. After a mean follow-up of (823 ± 532) days, the recurrence rates were 36.4%, 37.8% and 28.3% from the HATCH score = 0, HATCH score = 1 to HATCH score ≥ 2 categories (P = 0.498). Univariate analysis revealed that left atrium size, body mass index, and failure of PV isolation were predictors of AF recurrence. After adjustment for body mass index, left atrial size and PV isolation, the HATCH score was not an independent predictor of recurrence (HR = 0.92, 95% confidence interval = 0.76 - 1.12, P = 0.406) in multivariate analysis. HATCH score has no value in prediction of AF recurrence after catheter ablation.

Orthogonal P-wave morphology is affected by intra-atrial pressures.

PubMed

Petersson, Richard; Smith, J Gustav; Larsson, David A; Reitan, Öyvind; Carlson, Jonas; Platonov, Pyotr; Holmqvist, Fredrik

2017-12-06

It has previously been shown that the morphology of the P-wave neither depends on atrial size in healthy subjects with physiologically enlarged atria nor on the physiological anatomical variation in transverse orientation of the left atrium. The present study aimed to investigate if different pressures in the left and right atrium are associated with different P-wave morphologies. 38 patients with isolated, increased left atrial pressure, 51 patients with isolated, increased right atrial pressure and 76 patients with biatrially increased pressure were studied. All had undergone right heart catheterization and had 12-lead electrocardiographic recordings, which were transformed into vectorcardiograms for detailed P-wave morphology analysis. Normal P-wave morphology (type 1) was more common in patients with isolated increased pressure in the right atrium while abnormal P-wave morphology (type 2) was more common in the groups with increased left atrial pressure (P = 0.032). Moreover, patients with increased left atrial pressure, either isolated or in conjunction with increased right atrial pressure, had significantly more often a P-wave morphology with a positive deflection in the sagittal plane (P = 0.004). Isolated elevated right atrial pressure was associated with normal P-wave morphology while left-sided atrial pressure elevation, either isolated or in combination with right atrial pressure elevation, was associated with abnormal P-wave morphology.

Left Atrial Appendage Eccentricity and Irregularity Are Associated With Residual Leaks After Percutaneous Closure.

PubMed

Rajwani, Adil; Shirazi, Masoumeh G; Disney, Patrick J S; Wong, Dennis T L; Teo, Karen S L; Delacroix, Sinny; Chokka, Ramesh G; Young, Glenn D; Worthley, Stephen G

2015-12-01

Predictors of residual leak following percutaneous LAA closure were evaluated. Left atrial appendage (LAA) closure aims to exclude this structure from the circulation, typically using a circular occluder. A noncircular orifice is frequently encountered however, and fibrous remodeling of the LAA in atrial fibrillation may restrict orifice deformation. Noncircularity may thus be implicated in the occurrence of residual leak despite an appropriately oversized device. Pre-procedural multislice computerized tomography was used to quantify LAA orifice eccentricity and irregularity. Univariate predictors of residual leak were identified with respect to the orifice, device, and relevant clinical variables, with the nature of any correlations then further evaluated. Eccentricity and irregularity indexes of the orifice in 31 individuals were correlated with residual leak even where the device was appropriately oversized. An eccentricity index of 0.15 predicted a residual leak with 85% sensitivity and 59% specificity. An irregularity index of 0.05 predicted a significant residual leak ≥3 mm with 100% sensitivity and 86% specificity. Orifice size, device size, degree of device oversize, left atrial volume, and pulmonary artery pressure were not predictors of residual leak. Eccentricity and irregularity of the LAA orifice are implicated in residual leak after percutaneous closure even where there is appropriate device over-size. Irregularity index in particular is a novel predictor of residual leak, supporting a closer consideration of orifice morphology before closure. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Exploring Regulatory Mechanisms of Atrial Myocyte Hypertrophy of Mitral Regurgitation through Gene Expression Profiling Analysis: Role of NFAT in Cardiac Hypertrophy

PubMed Central

Chang, Tzu-Hao; Chen, Mien-Cheng; Chang, Jen-Ping; Huang, Hsien-Da; Ho, Wan-Chun; Lin, Yu-Sheng; Pan, Kuo-Li; Huang, Yao-Kuang; Liu, Wen-Hao; Wu, Chia-Chen

2016-01-01

Background Left atrial enlargement in mitral regurgitation (MR) predicts a poor prognosis. The regulatory mechanisms of atrial myocyte hypertrophy of MR patients remain unknown. Methods and Results This study comprised 14 patients with MR, 7 patients with aortic valve disease (AVD), and 6 purchased samples from normal subjects (NC). We used microarrays, enrichment analysis and quantitative RT-PCR to study the gene expression profiles in the left atria. Microarray results showed that 112 genes were differentially up-regulated and 132 genes were differentially down-regulated in the left atria between MR patients and NC. Enrichment analysis of differentially expressed genes demonstrated that “NFAT in cardiac hypertrophy” pathway was not only one of the significant associated canonical pathways, but also the only one predicted with a non-zero score of 1.34 (i.e. activated) through Ingenuity Pathway Analysis molecule activity predictor. Ingenuity Pathway Analysis Global Molecular Network analysis exhibited that the highest score network also showed high association with cardiac related pathways and functions. Therefore, 5 NFAT associated genes (PPP3R1, PPP3CB, CAMK1, MEF2C, PLCE1) were studies for validation. The mRNA expressions of PPP3CB and MEF2C were significantly up-regulated, and CAMK1 and PPP3R1 were significantly down-regulated in MR patients compared to NC. Moreover, MR patients had significantly increased mRNA levels of PPP3CB, MEF2C and PLCE1 compared to AVD patients. The atrial myocyte size of MR patients significantly exceeded that of the AVD patients and NC. Conclusions Differentially expressed genes in the “NFAT in cardiac hypertrophy” pathway may play a critical role in the atrial myocyte hypertrophy of MR patients. PMID:27907007

Left atrial pressure pattern without a-wave in sinus rhythm after cardioversion affects the outcomes after catheter ablation for atrial fibrillation.

PubMed

Kishima, Hideyuki; Mine, Takanao; Takahashi, Satoshi; Ashida, Kenki; Ishihara, Masaharu; Masuyama, Tohru

2018-04-24

The a-wave in left atrial pressure (LAP) is often not observed after cardioversion (CV). We hypothesized that repeated atrial fibrillation (AF) occurs in patients who do not show a-wave pattern after CV. We investigated the impact of "LAP pattern without a-wave" on the outcome after catheter ablation (CA) for AF. We studied 100 patients (64 males, age 66 ± 8 years, 42 with non-paroxysmal AF) who underwent CA for AF. Sustained- or induced-AF were terminated with internal CV, and LAP was measured during sinus rhythm (SR) after CV. LAP pattern without a-wave was defined as absence of a-wave (the "a-wave" was defined as a protruding part by 0.2 mmHg or more from the baseline) in LAP wave form. AF was terminated with CV in all patients. Recurrent AF was detected in 35/100 (35%) during the follow-up period (13.1 ± 7.8 month). Univariate analysis revealed higher prevalence of LAP pattern without a-wave (71 vs. 17%, P < 0.0001), larger left atrial volume, elevated E wave, and decreased deceleration time as significant variables. On multivariate analysis, LAP pattern without a-wave was only independently associated with recurrent AF (P = 0.0014, OR 9.865, 95% CI 2.327-54.861). Moreover, patients with LAP pattern without a-wave had a higher risk of recurrent AF than patients with a-wave (25/36 patients, 69 vs. 10/64 patients, 16%, log-rank P < 0.0001). Left atrial pressure pattern without a-wave in sinus rhythm after cardioversion could predict recurrence after catheter ablation for AF.

Left atrial accessory appendages, diverticula, and left-sided septal pouch in multi-slice computed tomography. Association with atrial fibrillation and cerebrovascular accidents.

PubMed

Hołda, Mateusz K; Koziej, Mateusz; Wszołek, Karolina; Pawlik, Wiesław; Krawczyk-Ożóg, Agata; Sorysz, Danuta; Łoboda, Piotr; Kuźma, Katarzyna; Kuniewicz, Marcin; Lelakowski, Jacek; Dudek, Dariusz; Klimek-Piotrowska, Wiesława

2017-10-01

The aim of this study is to provide a morphometric description of the left-sided septal pouch (LSSP), left atrial accessory appendages, and diverticula using cardiac multi-slice computed tomography (MSCT) and to compare results between patient subgroups. Two hundred and ninety four patients (42.9% females) with a mean of 69.4±13.1years of age were investigated using MSCT. The presence of the LSSP, left atrial accessory appendages, and diverticula was evaluated. Multiple logistic regression analysis was performed to check whether the presence of additional left atrial structures is associated with increased risk of atrial fibrillation and cerebrovascular accidents. At least one additional left atrial structure was present in 51.7% of patients. A single LSSP, left atrial diverticulum, and accessory appendage were present in 35.7%, 16.0%, and 4.1% of patients, respectively. After adjusting for other risk factors via multiple logistic regression, patients with LSSP are more likely to have atrial fibrillation (OR=2.00, 95% CI=1.14-3.48, p=0.01). The presence of a LSSP was found to be associated with an increased risk of transient ischemic attack using multiple logistic regression analysis after adjustment for other risk factors (OR=3.88, 95% CI=1.10-13.69, p=0.03). In conclusion LSSPs, accessory appendages, and diverticula are highly prevalent anatomic structures within the left atrium, which could be easily identified by MSCT. The presence of LSSP is associated with increased risk for atrial fibrillation and transient ischemic attack. Copyright © 2017 Elsevier B.V. All rights reserved.

Real-time dominant frequency mapping and ablation of dominant frequency sites in atrial fibrillation with left-to-right frequency gradients predicts long-term maintenance of sinus rhythm.

PubMed

Atienza, Felipe; Almendral, Jesús; Jalife, José; Zlochiver, Sharon; Ploutz-Snyder, Robert; Torrecilla, Esteban G; Arenal, Angel; Kalifa, Jérôme; Fernández-Avilés, Francisco; Berenfeld, Omer

2009-01-01

Spectral analysis identifies localized sites of high-frequency activity during atrial fibrillation (AF). This study sought to determine the effectiveness of using real-time dominant frequency (DF) mapping for radiofrequency ablation of maximal DF (DFmax) sites and elimination of left-to-right frequency gradients in the long-term maintenance of sinus rhythm (SR) in AF patients. DF mapping was performed in 50 patients during ongoing AF (32 paroxysmal, 18 persistent), acquiring a mean of 117 +/- 38 points. Ablation was performed targeting DFmax sites, followed by circumferential pulmonary vein isolation. Ablation significantly reduced DFs (Hz) in the LA (7.9 +/- 1.4 vs. 5.7 +/- 1.3, P <.001), coronary sinus (CS) (5.7 +/- 1.1 vs. 5.3 +/- 1.2, P = .006), and RA (6.3 +/- 1.4 vs. 5.4 +/- 1.3, P <.001) abolishing baseline left-to-right atrial DF gradient (1.7 +/- 1.7 vs. 0.2 +/- 0.9; P <.001). Only a significant reduction in DFs in all chambers with a loss of the left-to-right atrial gradient after ablation was associated with a higher probability of long-term SR maintenance in both paroxysmal and persistent AF patients. After a mean follow-up of 9.3 +/- 5.4 months, 88% of paroxysmal and 56% of persistent AF patients were free of AF (P = .02). Ablation of DFmax sites was associated with a higher probability of remaining both free of arrhythmias (78% vs. 20%; P = .001) and free of AF (88% vs. 30%; P <.001). Radiofrequency ablation leading to elimination of LA-to-RA frequency gradients predicts long-term SR maintenance in AF patients.

The role of the atrial electromechanical delay in predicting atrial fibrillation in beta-thalassemia major patients.

PubMed

Rago, Anna; Russo, Vincenzo; Papa, Andrea Antonio; Ciardiello, Carmine; Pannone, Bruno; Mayer, Maria Carolina; Cimmino, Giovanni; Nigro, Gerardo

2017-03-01

Paroxysmal atrial tachyarrhythmias frequently occur in beta-thalassemia major (β-TM) patients. The aim of the current study was to evaluate the atrial electromechanical delay (AEMD) in a large β-TM population with normal cardiac function and its relationship to atrial fibrillation (AF) onset. Eighty β-TM patients (44 men, 36 women), with a mean age of 36.2 ± 11.1 years, and 80 healthy subjects used as controls, matched for age and gender, were studied for the occurrence of AF during a 5-year follow-up, through 30-day external loop recorder (ELR) monitoring performed every 6 months. Intra-AEMD and inter-AEMD of both atria were measured through tissue Doppler echocardiography. P-wave dispersion (PD) was carefully measured using 12-lead electrocardiogram (ECG). Compared to the healthy control group, the β-TM patients showed a statistically significant increase in inter-AEMD, intra-left AEMD, maximum P-wave duration, and PD. Dividing the β-TM group into two subgroups (patients with or without AF), the inter-AEMD, intra-left AEMD, maximum P-wave duration, and PD were significantly higher in the subgroup with AF compared to the subgroup without AF. There were significant good correlations of intra-left AEMD and inter-AEMD with PD. A cut-off value of 40.1 ms for intra-left AEMD had a sensitivity of 76.2% and a specificity of 97.5% in identifying β-TM patients with AF risk. A cut-off value of 44.8 ms for inter-AEMD had a sensitivity of 81.2% and a specificity of 98.7% in identifying this category of patients. Our results showed that the echocardiographic atrial electromechanical delay indices (intra-left and inter-AEMD) and the PD were significantly increased in β-TM subjects with normal cardiac function. PD and AEMD represent non-invasive, inexpensive, useful, and simple parameters to assess the AF risk in β-TM patients.

[Quantitative Measurements on the Blood Flow Fields of Left Atrial Appendage using Vector Flow Mapping in Patients with Nonvalvular Atrial Fibrillation].

PubMed

Cai, Yu-Yan; Wei, Xin; Zhang, Xiao-Ling; Liu, Gu-Yue; Li, Xi; Tang, Hong

2018-01-01

To quantify the hemodynamic characteristics of patients with nonvalvular atrial fibrillation. Twenty patients with paroxysmal atrial fibrillation and 15 patients with persistent atrial fibrillation enrolled in this study,while 12 patients with sinus rhythms served as controls. The hemodynamic characteristics of the patients in left atrial appendage were measured by transesophageal echocardiography (TEE) and vector flow mapping (VFM) using indicators such as vectors,vortex and energy loss (EL). ① Significant differences appeared between the patients with atrial fibrillation and the controls in heart rate,size of left atrium,size of left atrial appendage (LAA),and velocities of LAA filling and emptying. ② Regular vectors in LAA in early systole and late diastole were found in the patients with paroxysmal atrial fibrillation and the controls; whereas,irregular vectors with direction alternating were visualized in the whole cardiac cycle in the patients with persistent atrial fibrillation. ③ Small vortexes were observed at the opening of the left atrial appendage in late diastole in the patients with paroxysmal atrial fibrillation and the controls. ④ Peak EL values occurred in early systole and late diastole in the patients with paroxysmal atrial fibrillation and the controls. But the patients with persistent atrial fibrillation had increased EL values over the whole cardiac cycle. VFM can visualize and quantify the hemodynamics of LAA in patients with different heart rhythms. It may provide a new method for assessing atrial fibrillation. CopyrightCopyright© by Editorial Board of Journal of Sichuan University (Medical Science Edition).

Pulmonary venous flow determinants of left atrial pressure under different loading conditions in a chronic animal model with mitral regurgitation

NASA Technical Reports Server (NTRS)

Yang, Hua; Jones, Michael; Shiota, Takahiro; Qin, Jian Xin; Kim, Yong Jin; Popovic, Zoran B.; Pu, Min; Greenberg, Neil L.; Cardon, Lisa A.; Eto, Yoko;

Diagnostic accuracy of electrocardiographic P wave related parameters in the assessment of left atrial size in dogs with degenerative mitral valve disease.

PubMed

Soto-Bustos, Ángel; Caro-Vadillo, Alicia; Martínez-DE-Merlo, Elena; Alonso-Alegre, Elisa González

2017-10-07

The purpose of this research was to compare the accuracy of newly described P wave-related parameters (P wave area, Macruz index and mean electrical axis) with classical P wave-related parameters (voltage and duration of P wave) for the assessment of left atrial (LA) size in dogs with degenerative mitral valve disease. One hundred forty-six dogs (37 healthy control dogs and 109 dogs with degenerative mitral valve disease) were prospectively studied. Two-dimensional echocardiography examinations and a 6-lead ECG were performed prospectively in all dogs. Echocardiography parameters, including determination of the ratios LA diameter/aortic root diameter and LA area/aortic root area, were compared to P wave-related parameters: P wave area, Macruz index, mean electrical axis voltage and duration of P wave. The results showed that P wave-related parameters (classical and newly described) had low sensitivity (range=52.3 to 77%; median=60%) and low to moderate specificity (range=47.2 to 82.5%; median 56.3%) for the prediction of left atrial enlargement. The areas under the curve of P wave-related parameters were moderate to low due to poor sensitivity. In conclusion, newly P wave-related parameters do not increase the diagnostic capacity of ECG as a predictor of left atrial enlargement in dogs with degenerative mitral valve disease.

Diagnostic accuracy of electrocardiographic P wave related parameters in the assessment of left atrial size in dogs with degenerative mitral valve disease

PubMed Central

SOTO-BUSTOS, Ángel; CARO-VADILLO, Alicia; MARTÍNEZ-DE-MERLO, Elena; ALONSO-ALEGRE, Elisa González

2017-01-01

The purpose of this research was to compare the accuracy of newly described P wave-related parameters (P wave area, Macruz index and mean electrical axis) with classical P wave-related parameters (voltage and duration of P wave) for the assessment of left atrial (LA) size in dogs with degenerative mitral valve disease. One hundred forty-six dogs (37 healthy control dogs and 109 dogs with degenerative mitral valve disease) were prospectively studied. Two-dimensional echocardiography examinations and a 6-lead ECG were performed prospectively in all dogs. Echocardiography parameters, including determination of the ratios LA diameter/aortic root diameter and LA area/aortic root area, were compared to P wave-related parameters: P wave area, Macruz index, mean electrical axis voltage and duration of P wave. The results showed that P wave-related parameters (classical and newly described) had low sensitivity (range=52.3 to 77%; median=60%) and low to moderate specificity (range=47.2 to 82.5%; median 56.3%) for the prediction of left atrial enlargement. The areas under the curve of P wave-related parameters were moderate to low due to poor sensitivity. In conclusion, newly P wave-related parameters do not increase the diagnostic capacity of ECG as a predictor of left atrial enlargement in dogs with degenerative mitral valve disease. PMID:28845021

Percutaneous closure of atrial septal defects leads to normalisation of atrial and ventricular volumes

PubMed Central

Teo, Karen SL; Dundon, Benjamin K; Molaee, Payman; Williams, Kerry F; Carbone, Angelo; Brown, Michael A; Worthley, Matthew I; Disney, Patrick J; Sanders, Prashanthan; Worthley, Stephen G

2008-01-01

Background Percutaneous closure of atrial septal defects (ASDs) should potentially reduce right heart volumes by removing left-to-right shunting. Due to ventricular interdependence, this may be associated with impaired left ventricular filling and potentially function. Furthermore, atrial changes post-ASD closure have been poorly understood and may be important for understanding risk of atrial arrhythmia post-ASD closure. Cardiovascular magnetic resonance (CMR) is an accurate and reproducible imaging modality for the assessment of cardiac function and volumes. We assessed cardiac volumes pre- and post-percutaneous ASD closure using CMR. Methods Consecutive patients (n = 23) underwent CMR pre- and 6 months post-ASD closure. Steady state free precession cine CMR was performed using contiguous slices in both short and long axis views through the ASD. Data was collected for assessment of left and right atrial, ventricular end diastolic volumes (EDV) and end systolic volumes (ESV). Data is presented as mean ± SD, volumes as mL, and paired t-testing performed between groups. Statistical significance was taken as p < 0.05. Results There was a significant reduction in right ventricular volumes at 6 months post-ASD closure (RVEDV: 208.7 ± 76.7 vs. 140.6 ± 60.4 mL, p < 0.0001) and RVEF was significantly increased (RVEF 35.5 ± 15.5 vs. 42.0 ± 15.2%, p = 0.025). There was a significant increase in the left ventricular volumes (LVEDV 84.8 ± 32.3 vs. 106.3 ± 38.1 mL, p = 0.003 and LVESV 37.4 ± 20.9 vs. 46.8 ± 18.5 mL, p = 0.016). However, there was no significant difference in LVEF and LV mass post-ASD closure. There was a significant reduction in right atrial volumes at 6 months post-ASD closure (pre-closure 110.5 ± 55.7 vs. post-closure 90.7 ± 69.3 mL, p = 0.019). Although there was a trend to a decrease in left atrial volumes post-ASD closure, this was not statistically significant (84.5 ± 34.8 mL to 81.8 ± 44.2 mL, p = NS). Conclusion ASD closure leads to normalisation of ventricular volumes and also a reduction in right atrial volume. Further follow-up is required to assess how this predicts outcomes such as risk of atrial arrhythmias after such procedures. PMID:19040763

Association Between Left Atrial Compression And Atrial Fibrillation: A Case Presentation And A Short Review Of Literature.

PubMed

Ahmed, Niloy; Carlos, Morales-Mangual; Moshe, Gunsburg; Yitzhak, Rosen

2016-01-01

This case report describes a patient who developed palpitations and chest pain and was found to be in atrial fibrillation, which was likely due to the presence of an extra-cardiac mass. This was compressing the left atrium. The mass was related to small cell carcinoma, which decreased significantly in size after chemotherapy. Resolution of the atrial fibrillation correlated temporally with reduction in the size of the mass and alleviation of the left atrial compression.

Assessment of left atrial mechanical functions and atrial electromechanical delay in Juvenile idiopathic arthritis by tissue Doppler echocardiography.

PubMed

El Eraky, Azza Z; Handoka, Nesrin M; Ghaly, Mona Sayed; Nasef, Samah Ismail; Eldahshan, Nahed A; Ibrahim, Ahmed M; Shalaby, Sherein

2016-11-24

Juvenile idiopathic arthritis (JIA) is a systemic chronic inflammatory disease. Studies using tissue Doppler imaging (TDI) for the evaluation of cardiac functions of children with JIA are limited. Thus, this study was conducted to evaluate Left ventricular function, left atrial mechanical functions and atrial electromechanical delay in JIA. This study was carried out as a across sectional study. A total of 34 patients with active JIA and 34 controls were included. Atrial electromechanical delay and left atrial (LA) mechanical functions in addition to systolic and diastolic left ventricular (LV) functions were measured by using conventional echocardiography and TDI. Assessment of disease activity was done using Juvenile arthritis disease activity score (JADAS-27). JIA patients had abnormal atrial electromechanical coupling as established from prolonged lateral mitral annulus (PA lateral), septal mitral annulus (PA septum), inter-atrial and intra-atrial electromechanical delays compared with healthy controls. Left ventricular filling abnormalities were found characterized by a reduced E/A ratio (1.07 ± 0.56 vs. 1.48 ± 0.16, p = 0.01). E/Em was significantly higher in patients with JIA (7.58 ± 1.79 vs. 4.74 ± 1.45, p = 0.003) denoting impaired diastolic function. Left atrial mechanical functions assessment showed significantly decreased LA passive emptying fraction, increased LA active emptying fraction and LA total emptying volume in JIA patients (p = 0.01, p = 0.01, p = 0.03 respectively). Atrial electromechanical coupling intervals, and LA mechanical functions were impaired which can be considered as an early form of subclinical cardiac involvement in JIA patients. Significant diastolic functional abnormalities exist in JIA.

Left atriotomy versus right atriotomy trans-septal approach for left atrial myxoma.

PubMed

Hatemi, A C; Gürsoy, M; Tongut, A; Kiliçkesmez, K; Karaoğlu, K; Küçükoğlu, S; Kansiz, E

2010-01-01

The biatrial approach has been the classic means of access for left atrial myxoma resection. Increased surgical experience led cardiac surgeons to favour the uniatrial approach to reduce incisions and achieve adequate exposure. In this study, two unilateral surgical approaches were compared in 18 consecutive left atrial myxoma cases. Patients were divided into two groups according to the surgical approach: left atriotomy (group 1, n = 9) and right atriotomy trans-septal approach (group 2, n = 9). Comparison criteria included pre- and post-operative functional capacity, cardiac rhythm, left ventricular ejection fraction, pulmonary artery pressure, left atrial dimensions, cardiopulmonary bypass time, aortic cross-clamp time, drainage over 48 h post-operatively, units of blood transfused, extubation time and length of stay in the intensive care unit and hospital. No significant between-group difference was observed in any criteria except aortic cross-clamp time, which was significantly longer in group 2 than in group 1. No recurrence of myxoma occurred in either group for the 15 patients followed up. Right atrial trans-septal incision appears to be as safe and effective as the left atriotomy approach for left atrial myxoma resection.

Prognostication of valvular aortic stenosis using tissue Doppler echocardiography: underappreciated importance of late diastolic mitral annular velocity.

PubMed

Poh, Kian-Keong; Chan, Mark Yan-Yee; Yang, Hong; Yong, Quek-Wei; Chan, Yiong-Huak; Ling, Lieng H

2008-05-01

Intact left atrial booster pump function helps maintain cardiac compensation in patients with aortic valve stenosis (AS). Because late diastolic mitral annular (A') velocity reflects left atrial systolic function, we hypothesized that A' velocity correlates with plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) level and clinical outcome in AS. We prospectively enrolled 53 consecutive patients (median age 74 years) with variable degrees of AS, in sinus rhythm, and left ventricular ejection fraction greater than 50%. Indices of valvular stenosis, left ventricular diastolic dysfunction, and mitral annular motion were correlated with plasma NT-proBNP and a composite clinical end point comprising cardiac death and symptom-driven aortic valve replacement. Tissue Doppler echocardiographic parameters, including early diastolic (E') velocity and A' velocity and ratio of early diastolic transmitral (E) to E' velocity (E/E') at the annular septum correlated better with NT-proBNP levels than body surface area-indexed aortic valve area. Eighteen patients had the composite end point, which was univariately predicted by body surface area-indexed aortic valve area, NT-proBNP, and all tissue Doppler echocardiographic indices. This outcome was most strongly predicted by the combination of septal A' velocity and E/E' ratio in bivariate Cox modeling. Septal annular A' velocity less than 9.6 cm/s was associated with significantly reduced event-free survival (Kaplan Meier log rank = 27.3, P < .0001) and predicted the end point with a sensitivity, specificity, and accuracy of 94%, 80%, and 85%, respectively. In patients with AS and normal ejection fraction, annular tissue Doppler echocardiographic indices may better reflect the physiologic consequences of afterload burden on the left ventricle than body surface area-indexed aortic valve area. Lower A' velocity is a predictor of cardiac death and need for valve surgery, suggesting an important role for compensatory left atrial booster pump function.

Evaluation of atrial electromechanical delay and left atrial mechanical function in patients with obstructive sleep apnea : Cardiac involvement in patients with OSA.

PubMed

Karabag, Turgut; Aydin, Mustafa; Altin, Remzi; Dogan, Sait M; Cil, Cem; Buyukuysal, Cagatay; Sayin, Muhammet R

2012-07-01

The aim of this study was to evaluate atrial electromechanical delay measured by tissue Doppler imaging and left atrial mechanical function in patients with obstructive sleep apnea (OSA). Fourty-seven moderate-to-severe OSA patients who were newly diagnosed by polysomnography (Apnea-hypopnea index ≥ 15 events/h, 32 males, mean age 49.4 ± 11.5) and 30 patients who had no OSA in polysomnography (Apnea-hypopnea index < 5 events/h, 21 males, mean age 45.4 ± 9.1) were included in the study. Using tissue Doppler, diastolic functions, atrial electromechanical coupling were measured from the lateral mitral, septal, and tricuspid annulus. Inter, intra, and left atrial electromechanical delay were calculated (lateral-tricuspid, septum-tricuspid, lateral-septal). Left atrial volumes (maximal, minimal, and presystolic) were measured by the method of discs in the apical four-chamber view and were indexed to body surface area. Mechanical function parameters of the left atrium were also calculated. Interatrial, intraatrial, and left atrial electromechanical delays were significantly higher in the OSA group compared to the control group. Passive emptying fraction was significantly decreased, volume at the beginning of atrial systole and active emptying volume were significantly increased in OSA patients compared to the controls. The apnea-hypopnea index was significantly associated with interatrial and intraatrial electromechanical delay, passive emptying fraction, and conduit volume. Electromechanical delay was markedly prolonged and left atrial electromechanical function was impaired in untreated OSA patients. These impairments worsen with increasing severity of OSA.

The Left Atrio-Vertebral Ratio: a new simple means for assessing left atrial enlargement on Computed Tomography.

PubMed

Montillet, Marie; Baqué-Juston, Marie; Tasu, Jean-Pierre; Bertrand, Sandra; Berthier, Frédéric; Zarqane, Naïma; Brunner, Philippe

2018-03-01

The purpose of this study is to describe a new method to quickly estimate left atrial enlargement (LAE) on Computed Tomography. Left atrial (LA) volume was assessed with a 3D-threshold Hounsfield unit detection technique, including left atrial appendage and excluding pulmonary venous confluence, in 201 patients with ECG-gated 128-slice dual-source CT and indexed to body surface area. LA and vertebral axial diameter and area were measured at the bottom level of the right inferior pulmonary vein ostium. Ratio of LA diameter and surface on vertebra (LAVD and LAVA) were compared to LA volume. In accordance with the literature, a cutoff value of 78 ml/m 2 was chosen for maximal normal LA volume. 18% of LA was enlarged. The best cutoff values for LAE assessment were 2.5 for LAVD (AUC: 0.65; 95% CI: 0.58-0.73; sensitivity: 57%; specificity: 71%), and 3 for LAVA (AUC: 0.78; 95% CI: 0.72-0.84; sensitivity: 67%; specificity: 79%), with higher accuracy for LAVA (P=0.015). Inter-observer and intra-observer variability were either good or excellent for LAVD and LAVA (respective intraclass coefficients: 0.792 and 0.910; 0.912 and 0.937). A left atrium area superior to three times the vertebral area indicates LAE with high specificity. • Left atrial enlargement is a frequent condition associated with poor cardiac outcome. • Left atrial enlargement is highly time-consuming to diagnose on CT. • The left atrio-vertebral ratio quickly assesses left atrial enlargement. • A left atrial area > three times vertebral area is highly specific.

Comparison of left atrial size and function in hypertrophic cardiomyopathy and in Fabry disease with left ventricular hypertrophy.

PubMed

Saccheri, María Cristina; Cianciulli, Tomás Francisco; Challapa Licidio, Wilde; Lax, Jorge A; Beck, Martín A; Morita, Luis A; Gagliardi, Juan A

2018-05-01

Fabry disease (FD) and hypertrophic cardiomyopathy (HCM) are two diseases with a different pathophysiology, both cause left ventricular hypertrophy (LVH) and myocardial fibrosis. Although remodeling and systolic dysfunction of the left atrium (LA) are associated with atrial fibrillation and stroke in HCM, changes in the size and function of the LA have not been well studied in FD with LVH. The following groups were studied prospectively, and their respective findings compared: 19 patients with non-obstructive HCM (Group I), 20 patients with a diagnosis of Fabry cardiomyopathy (Group II), and 20 normal subjects matched for sex and age (Group III). Left ventricular mass index was measured using Devereux' formula, left atrial volume with Simpson's biplane method and left atrial mechanical function, including strain and strain rate, was measured using the speckle tracking technique. Strain and strain rate of the reservoir were measured during the three phases: reservoir (SR S), passive conduit (SR E) and atrial contraction (SR A). Patients with HCM had a larger left atrial volume than patients with FD (48.16 ± 14.3 mL/m 2 vs 38.9 ± 14.9 mL/m 2 respectively, P < .001), but in both disorders there was a severe decrease in left atrial function: reservoir strain in the apical four-chamber view: 17.47% in HCM vs 22.5% in FD, P = .24), strain rate in the apical chamber view: SR A: -0.80/seconds in HCM vs -1.04/seconds in FD (P = .88), SR S: 0.69/seconds in HCM vs 0.93 in FD (P = .12), SR E: -0.80 seconds in HCM vs -0.97/seconds in FD (P = .18). In this echocardiographic study we used speckle tracking to assess left atrial mechanical function and showed that FD is associated to an atrial cardiomyopathy, affecting the three phasic functions of the LA. Although in patients with HCM left atrial volume is larger than in patients with FD, both disorders exhibit severe decrease in left atrial function. These findings should be considered, given the potentially serious complications that can occur with the two diseases. © 2018 Wiley Periodicals, Inc.

Echocardiographic predictors of atrial fibrillation recurrence after catheter ablation: A literature review.

PubMed

Liżewska-Springer, Aleksandra; Dąbrowska-Kugacka, Alicja; Lewicka, Ewa; Drelich, Łukasz; Królak, Tomasz; Raczak, Grzegorz

2018-06-20

Catheter ablation (CA) is a well-known treatment option for patients with symptomatic drug-resistant atrial fibrillation (AF). Multiple factors have been identified to determine AF recurrence after CA, however their predictive value is rather small. Identification of novel predictors of CA outcome is therefore of primary importance to reduce health costs and improve long-term results of this intervention. The recurrence of AF following CA is related to the severity of left ventricular (LV) dysfunction, extend of atrial dilatation and fibrosis. The aim of this paper was to present and discuss the latest studies on utility of echocardiographic parameters in terms of CA effectiveness in patients with paroxysmal and persistent AF. PubMed, Google Scholar, EBSCO databases were searched for studies reporting echocardiographic preprocedural predictors of AF recurrence after CA. LV systolic and diastolic function, as well as atrial size, strain and dyssynchrony were taken into consideration. Twenty one full-text articles were analyzed, including three meta-analyses. Several echocardiographic parameters have been reported to determine a risk of AF recurrence after CA. There are conventional methods that measure left atrial (LA) size and volume, LV ejection fraction, parameters assessing LV diastolic dysfunction, and methods using more innovative technologies based on speckle tracking echocardiography (STE) to determine LA synchrony and strain. Each of these parameters has its own predictive value. Regarding CA effectiveness, every patient has to be evaluated individually to estimate the risk of AF recurrence, optimally using a combination of several echocardiographic parameters.

Noninvasive estimation of left atrial pressure in patients with congestive heart failure and mitral regurgitation by Doppler echocardiography.

PubMed

Gorcsan, J; Snow, F R; Paulsen, W; Nixon, J V

1991-03-01

A completely noninvasive method for estimating left atrial pressure in patients with congestive heart failure and mitral regurgitation has been devised with the use of continuous-wave Doppler echocardiography and brachial sphygmomanometry. Of 46 patients studied with mitral regurgitation, 35 (76%) had jets with distinct Doppler spectral envelopes recorded. The peak ventriculoatrial gradient was obtained by measuring peak mitral regurgitant velocity in systole and using the modified Bernoulli equation. This gradient was then subtracted from peak brachial systolic blood pressure, an estimate of left ventricular systolic pressure, to yield left atrial pressure (left atrial pressure = systolic blood pressure - mitral regurgitant pressure gradient). Noninvasive estimates of left atrial pressure from 35 patients were plotted against simultaneous recordings of mean pulmonary capillary wedge pressure resulting in the correlation y = 0.88x + 3.3, r = 0.88, standard error of estimate = +/- 4 mm Hg (p less than 0.001). Therefore, continuous-wave Doppler echocardiography and sphygmomanometry may be used in selected patients with congestive heart failure and mitral regurgitation for noninvasive estimation of left atrial pressure.

Left atrial booster function in valvular heart disease.

PubMed

Heidenreich, F P; Shaver, J A; Thompson, M E; Leonard, J J

1970-09-01

This study was designed to assess atrial booster pump action in valvular heart disease and to dissect booster pump from reservoir-conduit functions. In five patients with aortic stenosis and six with mitral stenosis, sequential atrioventricular (A-V) pacing was instituted during the course of diagnostic cardiac catheterization. Continuous recording of valvular gradient allowed estimation of flow for each cardiac cycle by transposition of the Gorlin formula. Left ventricular ejection time and left ventricular stroke work in aortic stenosis or left ventricular mean systolic pressure in mitral stenosis were also determined. Control observations were recorded during sequential A-V pacing with well-timed atrial systole. Cardiac cycles were then produced with no atrial contraction but undisturbed atrial reservoir function by intermittently interrupting the atrial pacing stimulus during sequential A-V pacing. This intervention significantly reduced valvular gradient, flow, left ventricular ejection time, and left ventricular mean systolic pressure or stroke work. Cardiac cycles were then produced with atrial booster action eliminated by instituting synchronous A-V pacing. The resultant simultaneous contraction of the atrium and ventricle not only eliminated effective atrial systole but also placed atrial systole during the normal period of atrial reservoir function. This also significantly reduced all the hemodynamic measurements. However, comparison of the magnitude of change from these two different pacing interventions showed no greater impairment of hemodynamic state when both booster pump action and reservoir function were impaired than when booster pump action alone was impaired. The study confirms the potential benefit of well placed atrial booster pump action in valvular heart disease in man.

Atrial function as a guide to timing of intervention in mitral valve prolapse with mitral regurgitation.

PubMed

Ring, Liam; Rana, Bushra S; Wells, Francis C; Kydd, Anna C; Dutka, David P

2014-03-01

The purpose of this study was to determine the clinical utility of left atrial (LA) functional indexes in patients with mitral valve prolapse (MVP) and mitral regurgitation (MR). Timing of surgery for MVP remains challenging. We hypothesized that assessment of LA function may provide diagnostic utility in these patients. We studied 192 consecutive patients in sinus rhythm with MVP, classified into 3 groups: moderate or less MR (MOD group, n = 54); severe MR without surgical indication (SEV group, n = 52); and severe MR with ≥1 surgical indication (SURG group, n = 86). Comparison was made with 50 control patients. Using 2D speckle imaging, average peak contractile, conduit, and reservoir atrial strain was recorded. Using Simpson's method we recorded maximal left atrial volume (LAVmax) and minimal left atrial volume (LAVmin), from which the total left atrial emptying fraction (TLAEF) was derived: (LAVmax-LAVmin)/LAVmax × 100%. TLAEF was similar in the MOD and control groups (61% vs. 57%; p = NS), was reduced in the SEV group (55%; p < 0.001 vs. control group), and markedly lower in the SURG group (40%; p < 0.001 vs. other groups). Reservoir strain demonstrated a similar pattern. Contractile strain was similarly reduced in the MOD and SEV groups (MOD 15%; SEV 14%; p = NS; both p < 0.05 vs. control group 20%) and further reduced in the SURG group (8%; p < 0.001 vs. other groups). By multivariate analysis, TLAEF (odds ratio [OR]: 0.78; p < 0.001), reservoir strain (OR: 0.91; p = 0.028), and contractile strain (OR: 0.86; p = 0.021) were independent predictors of severe MR requiring surgery. Using receiver-operating characteristic analysis, TLAEF <50% demonstrated 91% sensitivity and 92% specificity for predicting MVP with surgical indication (area under the curve: 0.96; p < 0.001). We report the changes in left atrial function in humans with MVP and the relationship of LA dysfunction to clinical indications for mitral valve surgery. We propose that the findings support the utility of quantitative assessment of atrial function by echocardiography as an additional tool to guide the optimum timing of surgery for MVP. Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

A Simple Score That Predicts Paroxysmal Atrial Fibrillation on Outpatient Cardiac Monitoring after Embolic Stroke of Unknown Source.

PubMed

Ricci, Brittany; Chang, Andrew D; Hemendinger, Morgan; Dakay, Katarina; Cutting, Shawna; Burton, Tina; Mac Grory, Brian; Narwal, Priya; Song, Christopher; Chu, Antony; Mehanna, Emile; McTaggart, Ryan; Jayaraman, Mahesh; Furie, Karen; Yaghi, Shadi

2018-06-01

Occult paroxysmal atrial fibrillation (AF) is detected in 16%-30% of patients with embolic stroke of unknown source (ESUS). The identification of AF predictors on outpatient cardiac monitoring can help guide clinicians decide on a duration or method of cardiac monitoring after ESUS. We included all patients with ESUS who underwent an inpatient diagnostic evaluation and outpatient cardiac monitoring between January 1, 2013, and December 31, 2016. Patients were divided into 2 groups based on detection of AF or atrial flutter during monitoring. We compared demographic data, clinical risk factors, and cardiac biomarkers between the 2 groups. Multivariable logistic regression was used to determine predictors of AF. We identified 296 consecutive patients during the study period; 38 (12.8%) patients had AF detected on outpatient cardiac monitoring. In a multivariable regression analysis, advanced age (ages 65-74: odds ratio [OR] 2.36, 95% confidence interval [CI] .85-6.52; ages 75 or older: OR 4.08, 95% CI 1.58-10.52) and moderate-to-severe left atrial enlargement (OR 4.66, 95% CI 1.79-12.12) were predictors of AF on outpatient monitoring. We developed the Brown ESUS-AF score: age (65-74 years: 1 point, 75 years or older: 2 points) and left atrial enlargement (moderate or severe: 2 points) with good prediction of AF (area under the curve .725) and was internally validated using bootstrapping. The percentage of patients with AF detected in each score category were as follows: 0: 4.2%; 1: 14.8%; 2: 20.8%; 3: 22.2%; 4: 55.6%. The Brown ESUS-AF score predicts AF on prolonged outpatient monitoring after ESUS. More studies are needed to externally validate our findings. Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.

[Prophylaxis of thromboembolism in atrial fibrillation: new oral anticoagulants and left atrial appendage closure].

PubMed

Zeus, Tobias; Kelm, Malte; Bode, Christoph

2015-08-01

Thrombo-embolic prophylaxis is a key element within the therapy of atrial fibrillation/atrial flutter. Besides new oral anticoagulants the concept of left atrial appendage occlusion has approved to be a good alternative option, especially in patients with increased risk of bleeding. © Georg Thieme Verlag KG Stuttgart · New York.

[Echocardiographic diagnosis of atrial thrombosis].

PubMed

Pinto Tortolero, R; Vargas Barrón, J; Rodas, M A; Díaz de la Vega, V; Horwitz, S

1982-01-01

Seventy patients with rheumatic mitral disease were studied by M-Mode and 2D echocardiography in order to detect left atrial thrombosis before surgery. Thrombosis were suspected by the observation of abnormal echoes in the left atrium. During surgery 17 (24%) patients had atrial thrombosis. It had been suspected by echocardiography in 12 (sensitivity 70%). In 53 patients thrombosis were not found during surgery; in 46 the echo had been also negative (specificity 86%). There was a false positive detection of thrombosis by echo in 7 patients (14%) and false negativity in 5 (30%). Patients with atrial thrombosis had atrial fibrilation in 91% of cases; and the most frequent valvular disease was mitral stenosis. There was not a direct relationship among existence of left atrial thrombosis and the anteroposterior diameter of the left atrium as measured by echo. We conclude that echocardiography has good specificity to rule out atrial thrombosis and moderate sensitivity to detect it in rheumatic mitral disease.

Clinical implications of atrial isomerism.

PubMed Central

Chiu, I S; How, S W; Wang, J K; Wu, M H; Chu, S H; Lue, H C; Hung, C R

1988-01-01

Right atrial isomerism or left atrial isomerism is frequently diagnosed as situs ambiguous without further discrimination of the specific morbid anatomy. Thirty six cases of right atrial isomerism and seven cases of left atrial isomerism were collected from the records and pathological museum at the National Taiwan University Hospital. There was a necropsy report for 18 cases. In all patients one or more of the following conditions was met: (a) isomeric bronchial anatomy, (b) echocardiographic and angiocardiographic evidence of isomerism, and (c) surgical or necropsy evidence of abnormal atrial anatomy. An anomalous pulmonary venous connection was present in 55% of patients with right atrial isomerism; in left atrial isomerism one case (14%) had a partial anomalous pulmonary venous connection. Forty per cent of cases of anomalous pulmonary venous connection with right atrial isomerism had obstruction. Six (86%) of seven cases with left atrial isomerism had an ambiguous biventricular atrioventricular connection. In contrast, univentricular atrioventricular connection (26 of 36, 72%) was significantly more common in right atrial isomerism. A common atrioventricular valve was the most frequent mode of connection in both forms. Two discrete atrioventricular valves were significantly more common in left atrial isomerism. Atrioventricular valve regurgitation was detected in 14 cases. Double outlet right ventricle was the most common type of ventriculoarterial connection. The most commonly cited causes of death after either palliative or definitive operation were undetected anomalous pulmonary venous connection, pulmonary venous stricture, and uncorrected atrioventricular valve or aortic regurgitation complicated by abnormal coagulation. Although the prognosis is poor, successful operation depends on knowledge of the precise anatomical arrangement associated with atrial isomerism. Images Fig 1 Fig 2 Fig 3 PMID:3408620

Monophasic Synovial Sarcoma Presenting as Mitral Valve Obstruction

PubMed Central

Chokesuwattanaskul, Warangkana; Terrell, Jason; Jenkins, Leigh Ann

2010-01-01

We report the case of a 26-year-old man who experienced progressive left-sided chest pain and 2 episodes of near-syncope. Studies revealed a 15-cm mass in the upper left lung, a 10-cm mass in the medial base of the left lung, and a 5-cm left atrial mass that involved the left lung, infiltrated the left pulmonary vein, and prolapsed into the mitral valve, causing intermittent obstruction. The patient underwent surgical excision of the left atrial tumor. Pathologic evaluation confirmed the diagnosis of monophasic synovial sarcoma. To our knowledge, this is only the 3rd report of left atrial invasion and resultant mitral valve obstruction from a synovial sarcoma that infiltrated the pulmonary vein. We believe that this is the 1st documented case of a metastatic left atrial synovial sarcoma in monophasic form. PMID:20844626

Left Atrial Appendage Closure for Stroke Prevention: Devices, Techniques, and Efficacy.

PubMed

Iskandar, Sandia; Vacek, James; Lavu, Madhav; Lakkireddy, Dhanunjaya

2016-05-01

Left atrial appendage closure can be performed either surgically or percutaneously. Surgical approaches include direct suture, excision and suture, stapling, and clipping. Percutaneous approaches include endocardial, epicardial, and hybrid endocardial-epicardial techniques. Left atrial appendage anatomy is highly variable and complex; therefore, preprocedural imaging is crucial to determine device selection and sizing, which contribute to procedural success and reduction of complications. Currently, the WATCHMAN is the only device that is approved for left atrial appendage closure in the United States. Copyright © 2016 Elsevier Inc. All rights reserved.

Effect of mitral regurgitation on cerebrovascular accidents in patients with atrial fibrillation and left atrial thrombus.

PubMed

Nair, Chandra K; Aronow, Wilbert S; Shen, Xuedong; Anand, Kishlay; Holmberg, Mark J; Esterbrooks, Dennis J

2009-11-01

The effect of mitral regurgitation (MR) on the incidence of new cerebrovascular accidents (CVA) and mortality in patients with atrial fibrillation (AF) and left atrial thrombus (LAT) is unknown. To investigate the effect of MR in patients with AF and LAT on new CVA and mortality. Eighty nine consecutive patients, mean age 71 years, with AF and LAT documented by transesophageal echocardiography were investigated to determine the prevalence and severity of MR and the association of the severity of MR with new cerebrovascular accidents (CVA) and mortality at 34-mo follow-up. Of 89 patients, 1 + MR was present in 23 patients (26%), 2 + MR in 44 patients (50%), 3 + MR in 17 patients (19%), and 4 + MR in 3 patients (4%). Mean follow-up was 34 +/- 28 mo. The Cox proportional hazards model showed that the severity of increased MR did not significantly increase new CVA or mortality at 34-mo follow-up. The only variable predictive of mortality was left ventricular ejection fraction (LVEF), and with every unit increase in LVEF, the risk decreased by 3%. MR occurred in 87 of 89 patients (98%) with AF and LAT. There was no association between the severity of MR and the incidence of CVA or mortality.

Pulmonary hypertension due to left heart disease causes intrapulmonary venous arterialization in rats.

PubMed

Fujimoto, Yoshitaka; Urashima, Takashi; Kawachi, Fumie; Akaike, Toru; Kusakari, Yoichiro; Ida, Hiroyuki; Minamisawa, Susumu

2017-11-01

A rat model of left atrial stenosis-associated pulmonary hypertension due to left heart diseases was prepared to elucidate its mechanism. Five-week-old Sprague-Dawley rats were randomly divided into 2 groups: left atrial stenosis and sham-operated control. Echocardiography was performed 2, 4, 6, and 10 weeks after surgery, and cardiac catheterization and organ excision were subsequently performed at 10 weeks after surgery. Left ventricular inflow velocity, measured by echocardiography, significantly increased in the left atrial stenosis group compared with that in the sham-operated control group (2.2 m/s, interquartile range [IQR], 1.9-2.2 and 1.1 m/s, IQR, 1.1-1.2, P < .01), and the right ventricular pressure-to-left ventricular systolic pressure ratio significantly increased in the left atrial stenosis group compared with the sham-operated control group (0.52, IQR, 0.54-0.60 and 0.22, IQR, 0.15-0.27, P < .01). The right ventricular weight divided by body weight was significantly greater in the left atrial stenosis group than in the sham-operated control group (0.54 mg/g, IQR, 0.50-0.59 and 0.39 mg/g, IQR, 0.38-0.43, P < .01). Histologic examination revealed medial hypertrophy of the pulmonary vein was thickened by 1.6 times in the left atrial stenosis group compared with the sham-operated control group. DNA microarray analysis and real-time polymerase chain reaction revealed that transforming growth factor-β mRNA was significantly elevated in the left atrial stenosis group. The protein levels of transforming growth factor-β and endothelin-1 were increased in the lung of the left atrial stenosis group by Western blot analyses. We successfully established a novel, feasible rat model of pulmonary hypertension due to left heart diseases by generating left atrial stenosis. Although pulmonary hypertension was moderate, the pulmonary hypertension due to left heart diseases model rats demonstrated characteristic intrapulmonary venous arterialization and should be used to further investigate the mechanism of pulmonary hypertension due to left heart diseases. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Clinical Features and Surgical Results of Right Atrial Myxoma.

PubMed

Li, Han; Guo, Hongwei; Xiong, Hui; Xu, Jianping; Wang, Wei; Hu, Shengshou

2016-01-01

We retrospectively analyzed 367 patients receiving surgical resection of cardiac myxomas in our center over six years, and analyzed the incidence and surgical results of 28 cases of right atrial myxomas. We also compared the age, gender, and attached sites between left atrial myxoma and right atrial myxoma. Between January 2007 and December 2012, 28 patients with right atrial myxomas underwent surgical resection. There were 16 males and 12 females. The mean age was 47.77 ± 13.20 years (range: 8.00-79.00 years). Associated cardiac lesions included moderate and severe tricuspid regurgitation in four, coronary atherosclerotic heart disease in five, and pulmonary embolism in one. Twenty-seven patients (96.43%) were followed from 26 to 94 months (mean 55.78 ± 21.10 months). There was no early death after operation. The incidence of right atrial myxomas among sporadic cardiac myxomas was 7.89%. One patient died of lung cancer 34 months after myxoma resection. Two patients underwent coronary artery stent implantation due to coronary atherosclerotic heart disease during the follow-up period. One patient underwent myxoma resection due to recurrence in the left atrium four years after the first operation. There was no significant difference in the age between left atrial myxoma and right atrial myxoma (p > 0.05). There was a significant difference in the gender between left atrial myxomas and right atrial myxomas (p < 0.05). The most common attached sites of left atrial myxomas and right atrial myxomas are the atrial septum. Surgical resection of the right atrial myxoma results in good clinical outcomes and a decreased incidence of recurrence. © 2015 Wiley Periodicals, Inc.

Left Atrial Anatomy in Patients Undergoing Ablation for Atrial Fibrillation.

PubMed

Krum, David; Hare, John; Gilbert, Carol; Choudhuri, Indrajit; Mori, Naoyo; Sra, Jasbir

2013-01-01

Background: Left atrial anatomy is highly variable, asymmetric, irregular and three-dimensionally unique. This variability can affect the outcome of atrial ablation. A catalog of anatomic varieties may aid patient selection and ablation approach and provide better tools for left atrial ablation. Methods: We analyzed computed tomography scans from 514 patients undergoing left atrial ablation. Images were processed on Advantage Windows with CardEP™ software (GE Healthcare, Waukesha, WI). Measurements of pulmonary vein (PV) ostial size along the long and short axes were made using double oblique cuts, and area of the ostia was calculated. Results: Patients with 2 left (LPV) and 2 right PVs (RPV) (62.6%), 2 LPVs and 3 RPVs (17.3%) and 1 LPV and 2 RPVs (14.2%) made up the three most common variants. In the 2-LPV/2-RPV anatomy, the ostial size and area of the RPVs were larger than their corresponding LPVs (p<0.001), and the ostial size and area of the superior PVs were larger than their corresponding inferior PVs (p<0.001). In the 2-LPV/3-RPV anatomy, the total area of the RPVs was larger than the total area of the LPVs (p<0.001). In the 1-LPV/2-RPV anatomy, the ostial size of the left common PV was larger than either right PV (p<0.007). However, the total area of the RPVs was larger than the area of the left common PV (p<0.002). The left common PV was also larger than any of the left veins in any of the other anatomies. The total PV area between the three most common anatomies was not significantly different. Conclusions: More than 37% of patients have a left atrial anatomy other than 2 left and 2 right PVs. This data may help in designing approaches for left atrial ablation, tailoring the procedure to individual patients and improving ablation tools.

[Right atrial appendage thrombosis during atrial fibrillation: an element to look for].

PubMed

Barbati, Giovanni; De Domenico, Renato; Rossi, Stefania; Vecchiato, Elena; Zeppellini, Roberto

2017-03-01

Oral anticoagulant therapy (OAT) is a mainstay of atrial fibrillation (AF) pharmacological treatment. Left atrial appendage closure is a possible treatment, when feasible, in patients with intracerebral hemorrhage during OAT. We report a case of right atrial appendage thrombosis in a patient with chronic AF admitted for syncope due to diuretic-induced orthostatic hypotension. Two years previously, he had undergone left atrial appendage closure with the Amplatzer Cardiac Plug device because of intracerebral hemorrhage during OAT. After neurological consult, OAT was resumed with apixaban 5 mg twice daily, and transesophageal echocardiography performed two months later showed complete resolution of the right atrial appendage thrombosis. This particular case underlines the importance of searching for a possible right atrial appendage thrombosis in patients affected by AF, and suggests that left atrial appendage closure in AF patients not suitable for OAT does not fully eliminate the risk of thromboembolism.

[The prediction of atrial fibrillation recurrence after electrical cardioversion with the chemoreflex sensitivity].

PubMed

Budeus, M; Hennersdorf, M; Perings, C; Strauer, B E

2004-04-01

Patients with paroxysmal atrial fibrillation have a lower chemoreflex sensitivity (CHRS) which is characterized as an autonomic dysfunction. Because of this observation we examined the theory of an autonomic dysfunction as the reason for the reccurrence of atrial fibrilation after electrical cardioversion. We measured the CHRS among 43 patients 24 h after successful electrical cardioversion and the patients were controlled for at least 6 months. During the six months of follow-up a recurrence was observed in 18 patients with a mean of 8.3 days. There was no difference in organic heart disease or in the use of drugs. Left atrial diameter was not significantly larger in patients with a recurrence. Patients with a recurrence have a significantly lower CHRS than patients with sinus rhythm (2.41 +/- 1.82 vs 5.62 +/- 3.02 ms/mmHg, p < 0.04). The diagnostic value of a CHRS below 3.0 ms/mmHg achieved a specificity of 68%, a sensitivity of 67%, a positive and negative predictive value of 60% and 74%. An analysis of CHRS seems to be an appropriate method to predict a recurrence of atrial fibrillation. The predictive power of the method has to be examined by prospective investigations of a larger patient population and a longer follow-up. Patients with paroxysmal atrial fibrillation have a lower chemoreflex sensitivity (CHRS) which is characterized as an autonomic dysfunction. Because of this observation we examined the theory of an autonomic dysfunction as the reason for the recurrence of atrial fibrillation after electrical cardioversion.

Evaluation of left atrial function in patients with iron-deficiency anemia by two-dimensional speckle tracking echocardiography.

PubMed

Shen, Jiaqi; Zhou, Qiao; Liu, Yue; Luo, Runlan; Tan, Bijun; Li, Guangsen

2016-08-23

Iron-deficiency anemia (IDA) is a global health problem and a common medical condition that can be seen in everyday clinical practice. And two-dimensional speckle tracking echocardiography (2D-STE) has been reported very useful in evaluating left atrial (LA) function, as well as left ventricular (LV) function. The aim of our study is to evaluate the LA function in patients with IDA by 2D-STE. 65 patients with IDA were selected. This group of patients was then divided into two groups according to the degree of hemoglobin: group B (Hb > 90 g/L) and group C (Hb60 ~ 90 g/L). Another 30 healthy people were also selected as control group A. Conventional echocardiography parameters, such as left atrial diameter (LAD), peak E and A of mitralis (E, A), E/A, end-diastolic thickness of ventricular septum (IVST d), end-diastolic thickness of LV posterior wall (PWTd) and left ventricular end-diastolic dimension (LVDd) were obtained from these three groups. Left atrial minimum volume (LAVmin), left atrial pre-atrial contraction volume (LAVp) and left atrial maximum volume (LAVmax) were measured by Simpson's rule, whereas left atrial active ejection fraction (LAAEF) and left atrial passive ejection fraction (LAPEF) were obtained from calculation. Two-dimensional images were acquired from apical four-chamber view and two-chamber view to store images for offline analysis. The global peak atrial longitudinal strain and strain rate of systolic LV (GLSs, GLSRs) as well as early and late diastolic LV strain rate (GLSRe, GLSRa) curves of LA were acquired in each LA segment from basal segment to top segment of LA by 2D-STE. Compared with group A, there were no differences between group B and group A (all P > 0.05). The LAAEF and GLSRa were significantly higher in group C compared with those of group A and group B (all P < 0.01). The LAPEF, GLSs, GLSRs and GLSRe were significantly lower in group C compared with those of group A and group B (all P < 0.01). 2D-STE could evaluate the LA function in patients with IDA.

Biomarkers of Atrial Cardiopathy and Atrial Fibrillation Detection on Mobile Outpatient Continuous Telemetry After Embolic Stroke of Undetermined Source.

PubMed

Sebasigari, Denise; Merkler, Alexander; Guo, Yang; Gialdini, Gino; Kummer, Benjamin; Hemendinger, Morgan; Song, Christopher; Chu, Antony; Cutting, Shawna; Silver, Brian; Elkind, Mitchell S V; Kamel, Hooman; Furie, Karen L; Yaghi, Shadi

2017-06-01

Biomarkers of atrial dysfunction or "cardiopathy" are associated with embolic stroke risk. However, it is unclear if this risk is mediated by undiagnosed paroxysmal atrial fibrillation or flutter (AF). We aim to determine whether atrial cardiopathy biomarkers predict AF on continuous heart-rhythm monitoring after embolic stroke of undetermined source (ESUS). This was a single-center retrospective study including all patients with ESUS undergoing 30 days of ambulatory heart-rhythm monitoring to look for AF between January 1, 2013 and December 31, 2015. We reviewed medical records for clinical, radiographic, and cardiac variables. The primary outcome was a new diagnosis of AF detected during heart-rhythm monitoring. The primary predictors were atrial biomarkers: left atrial diameter on echocardiography, P-wave terminal force in electrocardiogram (ECG) lead V1, and P wave - R wave (PR) interval on ECG. A multiple logistic regression model was used to assess the relationship between atrial biomarkers and AF detection. Among 196 eligible patients, 23 (11.7%) were diagnosed with AF. In unadjusted analyses, patients with AF were older (72.4 years versus 61.4 years, P < .001) and had larger left atrial diameter (39.2 mm versus 35.7 mm, P = .03). In a multivariable model, the only predictor of AF was age ≥ 60 years (odds ratio, 3.0; 95% CI, 1.06-8.5; P = .04). Atrial biomarkers were weakly associated with AF after ESUS. This suggests that previously reported associations between these markers and stroke may reflect independent cardiac pathways leading to stroke. Prospective studies are needed to investigate these mechanisms. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Biatrial reduction plasty with reef imbricate technique as an adjunct to maze procedure for permanent atrial fibrillation associated with giant left atria.

PubMed

Wang, William; Guo, L Ray; Martland, Anne Marie; Feng, Xiao-Dong; Ma, Jie; Feng, Xi Qing

2010-04-01

Success of the modified maze procedure after valvular operation with giant atria and permanent atrial fibrillation (AF) remains suboptimal. We report an aggressive approach for these patients utilizing biatrial reduction plasty with a reef imbricate suture technique concomitantly with valvular and maze procedure for AF. From January 1999 to December 2006, 122 consecutive Chinese patients with permanent AF and biatrial enlargement who required mitral valve+/-tricuspid valve (TV) surgery underwent aggressive left atrial reduction combined with radiofrequency bipolar full maze procedure. Left atrial dimensions were measured by TTE or TEE. There were 71 women (58.1%) and 51 men (41.9%) and their mean age was 45+/-9.5 years. Mean duration of AF was 48.4+/-21.4 months. All patients underwent left atrial reduction plasty with reef imbricate suture technique and full maze procedure. Their preoperative left atria measured 64+/-12 mm in the enlarged left atria (ELA) group and 86+/-17 mm in the giant left atria (GLA). Mitral valve replacement (MVR) combined with TV repair was performed in 102 patients (83%) while 21 patients underwent MVRs combined with aortic valve replacements (17%). Sixty-six (54%) patients required additional procedures and 61 (50%) of the patients also underwent left atrial appendage clot evacuation. Postoperative left atrial size was reduced to 49+/-8 mm (ELA) and 51+/-11 mm (GLA), respectively (P<0.05). Ninety-three of 122 (76%) patients were restored in normal sinus rhythm after one year clinical follow-up. Aggressive biatrial reduction plasty combined with full maze procedure is an effective treatment for patients with permanent AF undergoing concomitant valvular surgery. Further studies utilizing the reef imbricate suture technique for atrial reduction need to subsequently be evaluated.

Dabigatran exhibits low intensity of left atrial spontaneous echo contrast in patients with nonvalvular atrial fibrillation as compared with warfarin.

PubMed

Watanabe, Tetsuya; Shinoda, Yukinori; Ikeoka, Kuniyasu; Inui, Hirooki; Fukuoka, Hidetada; Sunaga, Akihiro; Kanda, Takashi; Uematsu, Masaaki; Hoshida, Shiro

2017-03-01

The presence of spontaneous echo contrast (SEC) in the left atrium has been reported to be an independent predictor of thromboembolic risk in patients with atrial fibrillation (AF). Dabigatran was associated with lower rates of stroke and systemic embolism as compared with warfarin when administered at a higher dose. Between July 2011 and October 2015, nonvalvular AF patients treated with warfarin or dabigatran who had transesophageal echocardiography prior to ablation therapy for AF were enrolled. The intensity of SEC was classified into four grades, from 0 to 3. Univariate and multivariate analysis was performed to analyze factors associated with SEC. Sixty-five patients were on dabigatran and 65 were on warfarin, with the prothrombin time in therapeutic range. There were no significant differences in the age, CHADS2 score, left atrial dimension, and left atrial appendage flow between the two groups. However, there were more grade 2 or higher patients with left atrial SEC in the warfarin group (n = 20) than in the dabigatran group (n = 2) (p < 0.001). When multivariate regression analysis was performed, grade 2 or higher left atrial SEC was independently associated with no dabigatran usage in addition to high brain natriuretic peptide level and high incidence of diabetes mellitus or persistent AF. Thus, dabigatran exhibited low intensity of left atrial SEC in nonvalvular AF patients as compared with warfarin.

[The effect of atrial pacing on left ventricular diastolic function and BNP levels in patients with DDD pacemaker].

PubMed

Apali, Zeynep; Bayata, Serdar; Yeşil, Murat; Arikan, Erdinç; Postaci, Nursen

2010-08-01

We aimed to investigate the effect of atrial pacing on left ventricular diastolic function and brain natriuretic peptide (BNP) levels in patients with DDD pacemaker. Thirty patients with complete atrio-ventricular (AV) block and DDD pacemaker were included. All patients had normal left ventricular systolic function. Echocardiographic diastolic function parameters (transmitral and tissue Doppler velocities during early (E and E') and late (A and A') filling) and NT-pro-BNP levels were evaluated prospectively during atrial sensing and pacing periods. Echocardiographic data were compared with paired sample t test and NT-pro-BNP levels were compared with Wilcoxon test. Echocardiographic E/A, E'/A', E/E' ratios were calculated as 0.72+/-0.34, 0.61+/-0.21 and 8.76+/-2.58 during atrial sensing period. Same parameters were found as 0.71+/-0.23, 0.64+/-0.16 and 8.93+/-3.16 respectively during atrial pacing period. Echocardiographic left ventricular diastolic function parameters were not significantly different during atrial pacing and atrial sensing periods. Median plasma NT-pro-BNP levels were measured as 142 pg/ml (min-max 47-563 pg/ml) and 147 pg/ml (min-max 33-1035 pg/ml) during atrial sensing and pacing periods respectively. These levels were not significantly different (p=0.86). The result of this study has shown that, atrial pacing has not any additional detrimental effect on left ventricular diastolic function parameters in paced patients with normal left ventricular systolic function.

A low-dose, dual-phase cardiovascular CT protocol to assess left atrial appendage anatomy and exclude thrombus prior to left atrial intervention.

PubMed

Lazoura, Olga; Ismail, Tevfik F; Pavitt, Christopher; Lindsay, Alistair; Sriharan, Mona; Rubens, Michael; Padley, Simon; Duncan, Alison; Wong, Tom; Nicol, Edward

2016-02-01

Assessment of the left atrial appendage (LAA) for thrombus and anatomy is important prior to atrial fibrillation (AF) ablation and LAA exclusion. The use of cardiovascular CT (CCT) to detect LAA thrombus has been limited by the high incidence of pseudothrombus on single-pass studies. We evaluated the diagnostic accuracy of a two-phase protocol incorporating a limited low-dose delayed contrast-enhanced examination of the LAA, compared with a single-pass study for LAA morphological assessment, and transesophageal echocardiography (TEE) for the exclusion of thrombus. Consecutive patients (n = 122) undergoing left atrial interventions for AF were assessed. All had a two-phase CCT protocol (first-past scan plus a limited, 60-s delayed scan of the LAA) and TEE. Sensitivity, specificity, diagnostic accuracy, positive (PPV) and negative predictive values (NPV) were calculated for the detection of true thrombus on first-pass and delayed scans, using TEE as the gold standard. Overall, 20/122 (16.4 %) patients had filling defects on the first-pass study. All affected the full delineation of the LAA morphology; 17/20 (85 %) were confirmed as pseudo-filling defects. Three (15 %) were seen on late-pass and confirmed as true thrombi on TEE; a significant improvement in diagnostic performance relative to a single-pass scan (McNemar Chi-square 17, p < 0.001). The sensitivity, specificity, diagnostic accuracy, PPV and NPV was 100, 85.7, 86.1, 15.0 and 100 % respectively for first-pass scans, and 100 % for all parameters for the delayed scans. The median (range) additional radiation dose for the delayed scan was 0.4 (0.2-0.6) mSv. A low-dose delayed scan significantly improves the identification of true LAA anatomy and thrombus in patients undergoing LA intervention.

Growth differentiation factor 15 is associated with left atrial/left atrial appendage thrombus in patients with nonvalvular atrial fibrillation.

PubMed

Hu, Xiao Feng; Zhan, Rui; Xu, Shanhu; Wang, Junjun; Wu, Jiong; Liu, Xiaoli; Li, Yaguo; Chen, Linhui

2018-01-01

There is evidence suggesting that growth differentiation factor 15 (GDF-15) appears to be associated with stroke in patients with atrial fibrillation (AF). AF-related thromboembolic stroke is predominantly attributed to the thrombus from the left atrium (LA) or left atrial appendage (LAA). GDF-15 is related to LA/LAA thrombus in nonvalvular AF (NVAF) patients. A total of 894 patients with NVAF without anticoagulation therapy were included in this study. All patients routinely underwent transesophageal echocardiography for detection of LA/LAA thrombus. GDF-15 was measured by enzyme-linked immunosorbent assay. Logistic regression models were used to test for association. LA/LAA thrombus was detected by transesophageal echocardiography in 69 (7.72%) patients with AF. The GDF-15 levels in the patients with LA/LAA thrombus were significantly higher than those without LA/LAA thrombus (log 10 GDF-15: 2.989 ± 0.023 ng/L vs 2.831 ± 0.007 ng/L; P < 0.001). Logistic regression analysis showed that GDF-15 was an independent risk factor for LA/LAA thrombus (odds ratio [per quarter]: 1.799, 95% confidence interval: 1.381-2.344, P < 0.001) after adjusting for potential clinical risk factors. The optimal cutoff point for GDF-15 predicting LA/LAA thrombus was 809.9 ng/L (sensitivity, 75.3%; specificity, 61.5%), determined by ROC curve. The area under the curve was 0.709 (95% confidence interval: 0.644-0.770, P < 0.001). Elevated GDF-15 indicated a significantly increased risk for LA/LAA thrombus in NVAF patients. Thus, GDF-15 might be a potentially useful adjunct in discriminating LA/LAA thrombus in NVAF patients. © 2018 Wiley Periodicals, Inc.

Left Atrial Mechanical Functions in Professional Soccer Players: A Pilot Study

ERIC Educational Resources Information Center

Kartal, Alper; Güngör, Hasan; Kartal, Resat; Ergin, Esin

2017-01-01

Long-term regular exercise is associated with physiologic and morphologic alterations in the heart chambers. The aim of this study to evaluate left atrium (LA) phasic functions in professional football players and compare with control subjects. Left atrial volume was calculated at end-systole (Vmax), end-diastole and pre-atrial contraction by…

Impact of preoperative atrial fibrillation on mortality and cardiovascular outcomes of mechanical mitral valve replacement for rheumatic mitral valve disease.

PubMed

Wang, Bin; Xu, Zhi-yun; Han, Lin; Zhang, Guan-xin; Lu, Fang-lin; Song, Zhi-gang

2013-03-01

The prognostic significance of preoperative atrial fibrillation on mitral valve replacement remains unclear. The aim of this study was to explore the effects of the presence of preoperative atrial fibrillation on mortality and cardiovascular outcomes of mitral valve replacement for rheumatic valve disease. A retrospective analysis was performed on a total of 793 patients who underwent mitral valve replacement with or without tricuspid valve repair in our hospital. The patients selected were divided into two groups according to preoperative rhythm status. Patients with preoperative atrial fibrillation were assigned to the AF group, while patients in preoperative sinus rhythm were assigned to the SR group. Postoperative follow-up was performed by outpatient visits, as well as by telephone and written correspondence. Data gathered included survivorship, postoperative complications, left ventricular function and tricuspid regurgitation. For patients with atrial fibrillation vs those in sinus rhythm, there was no difference in postoperative mortality and morbidity. Follow-up was a mean of 8.6 ± 2.4 years. For patients with preoperative atrial fibrillation, 10-year survival from a Kaplan-Meier curve was 88.7%, compared with 96.6% in patients with preoperative sinus rhythm (P = 0.002). Multivariate analysis identified low left ventricular ejection fraction, older age, large left atrium and preoperative atrial fibrillation as significant adverse predictors for overall survival. Freedom from thromboembolism complications at 13 years was lower for patients with preoperative atrial fibrillation without maze procedure and left atrial appendage ligation, compared with that for patients with preoperative sinus rhythm without maze procedure and left atrial appendage ligation, and patients with concomitant maze procedure and left atrial appendage ligation (76.3 vs 94.8 vs 94.0%, respectively; P = 0.001). On echocardiography, the proportion of patients with significant tricuspid regurgitation was 38.7% (atrial fibrillation patients) vs 25.4% (patients in sinus rhythm; P < 0.001). Left ventricular ejection fraction measured 5 years after surgery increased by an average of 1.2% in the AF group, while it increased by 5.3% in the SR group (P = 0.028). Preoperative atrial fibrillation is a risk factor for long-term mortality, thromboembolism complications and tricuspid regurgitation, and it also has an adverse effect on the degree of improvement when considering left ventricular function.

Septum primum atrial septal defect in an infant with hypoplastic left heart syndrome.

PubMed

Loar, Robert W; Burkhart, Harold M; Taggart, Nathaniel W

2014-08-01

Hypoplastic left heart syndrome (HLHS) is a form of congenital heart disease characterized by severe underdevelopment of the left heart, leading to inadequate systemic blood flow. Several different atrial septal morphologies are observed in HLHS, most commonly a secundum atrial septal defect, patent foramen ovale, intact septum, and leftward displacement of the superior attachment of the septum primum. It has been postulated that atrial septal development is associated with the development of the left heart. We present a case of a newborn infant with HLHS and the unusual finding of a primum ASD.

Predicting Peri-Device Leakage of Left Atrial Appendage Device Closure Using Novel Three-Dimensional Geometric CT Analysis.

PubMed

Chung, Hyemoon; Jeon, Byunghwan; Chang, Hyuk-Jae; Han, Dongjin; Shim, Hackjoon; Cho, In Jeong; Shim, Chi Young; Hong, Geu-Ru; Kim, Jung-Sun; Jang, Yangsoo; Chung, Namsik

2015-12-01

After left atrial appendage (LAA) device closure, peri-device leakage into the LAA persists due to incomplete occlusion. We hypothesized that pre-procedural three-dimensional (3D) geometric analysis of the interatrial septum (IAS) and LAA orifice can predict this leakage. We investigated the predictive parameters of LAA device closure obtained from baseline cardiac computerized tomography (CT) using a novel 3D analysis system. We conducted a retrospective study of 22 patients who underwent LAA device closure. We defined peri-device leakage as the presence of a Doppler signal inside the LAA after device deployment (group 2, n = 5) compared with patients without peri-device leakage (group 1, n = 17). Conventional parameters were measured by cardiac CT. Angles θ and φ were defined between the IAS plane and the line, linking the LAA orifice center and foramen ovale. Group 2 exhibited significantly better left atrial (LA) function than group 1 (p = 0.031). Pre-procedural θ was also larger in this group (41.9° vs. 52.3°, p = 0.019). The LAA cauliflower-type morphology was more common in group 2. Overall, the patients' LA reserve significantly decreased after the procedure (21.7 mm(3) vs. 17.8 mm(3), p = 0.035). However, we observed no significant interval changes in pre- and post-procedural values of θ and φ in either group (all p > 0.05). Angles between the IAS and LAA orifice might be a novel anatomical parameter for predicting peri-device leakage after LAA device closure. In addition, 3D CT analysis of the LA and LAA orifice could be used to identify clinically favorable candidates for LAA device closure.

Assessment of the effect of left atrial cryoablation enhanced by ganglionated plexi ablation in the treatment of atrial fibrillation in patients undergoing open heart surgery.

PubMed

Bárta, Jiří; Brát, Radim

2017-08-17

The aim of our study was to investigate, whether enhancement of left atrial cryoablation by ablation of the autonomic nervous system of left atrium leads to influencing the outcomes of surgical treatment of atrial fibrillation in patients with structural heart disease undergoing open-heart surgery. The observed patient file consisted of 100 patients, who have undergone a combined open-heart surgery at our department between July 2012 and December 2014. The patients were indicated for the surgical procedure due to structural heart disease, and suffered from paroxysmal, persistent, or long-standing persistent atrial fibrillation. In all cases, left atrial cryoablation was performed in the extent of isolation of pulmonary veins, box lesion, connecting lesion with mitral annulus, amputation of the left atrial appendage and connecting lesion of the appendage base with left pulmonary veins. Furthermore, 35 of the patients underwent mapping and radiofrequency ablation of ganglionated plexi, together with discision and ablation of the ligament of Marshall (Group GP). A control group was consisted of 65 patients without ganglionated plexi intervention (Group LA). The main primary outcome was establishment and duration of sinus rhythm in the course of one-year follow-up. Evaluation of the number of patients with a normal sinus rhythm in per cent has shown comparable values in both groups (Group GP - 93.75%, Group LA - 86.67%, p = 0.485); comparable results were also observed in patients with normal sinus rhythm without anti-arrhythmic treatment in the 12th month (Group GP - 50%, Group LA - 47%, p = 0.306). We have not observed any relation between the recurrence of atrial fibrillation and the presence of a mitral valve surgery, or between the presence of a mitral and tricuspid valves surgery and between the left atrial diameter > 50 mm. Enhancement of left atrial cryoablation by gangionated plexi ablation did not influence the outcomes of surgical ablation due to atrial fibrillation in our population in the course of 12-month follow-up. The study was approved retrospectively by the Ethics Committee of the University Hospital Ostrava ( reference number 867/2016).

Early Efficacy Analysis of Biatrial Ablation versus Left and Simplified Right Atrial Ablation for Atrial Fibrillation Treatment in Patients with Rheumatic Heart Disease.

PubMed

Liu, Hong; Chen, Lin; Xiao, Yingbin; Ma, Ruiyan; Hao, Jia; Chen, Baicheng; Qin, Chuan; Cheng, Wei

2015-08-01

Atrial fibrillation (AF) is the most common sustained arrhythmia. About 60% of patients with rheumatic heart disease have persistent AF. A total of 197 patients underwent valve replacement concomitant bipolar radiofrequency ablation (BRFA). Patients were divided into the biatrial ablation group and the simplified right atrial ablation group. In biatrial ablation group, the patients underwent a complete left and right atrial ablation. In simplified right atrial ablation group, the patients underwent a complete left atrial ablation and a simplified right atrial ablation. The conversion of sinus rhythm (SR) was high in both groups during the follow-up period. In the simplified right atrial ablation group, SR conversion rate was 88.29% at discharge. At six months and 12 months after surgery, 87.39% of patients and 86.49% of patients were in SR free of antiarrhythmic drugs, respectively. While in the biatrial ablation group, SA conversion rate was 89.53% at discharge. Percentage of patients in SR free of antiarrhythmic drugs was 88.37% and 88.37% at six months and 12 months after surgery, respectively. Echocardiography showed left atrial diameter decreased significantly after the surgery in the two groups. The ejection fraction and fractional shortening were improved significantly, without significant differences between the two groups. The results suggest that the concomitant left atrial and simplified right atrial BRFA for AF in patients undergoing valve replacement can achieve similar early efficiency as biatrial ablation. Copyright © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.

Impact of stepwise ablation on the biatrial substrate in patients with persistent atrial fibrillation and heart failure.

PubMed

Jones, David G; Haldar, Shouvik K; Jarman, Julian W E; Johar, Sofian; Hussain, Wajid; Markides, Vias; Wong, Tom

2013-08-01

Ablation of persistent atrial fibrillation can be challenging, often involving not only pulmonary vein isolation (PVI) but also additional linear lesions and ablation of complex fractionated electrograms (CFE). We examined the impact of stepwise ablation on a human model of advanced atrial substrate of persistent atrial fibrillation in heart failure. In 30 patients with persistent atrial fibrillation and left ventricular ejection fraction ≤35%, high-density CFE maps were recorded biatrially at baseline, in the left atrium (LA) after PVI and linear lesions (roof and mitral isthmus), and biatrially after LA CFE ablation. Surface area of CFE (mean cycle length ≤120 ms) remote to PVI and linear lesions, defined as CFE area, was reduced after PVI (18.3±12.03 to 10.2±7.1 cm(2); P<0.001) and again after linear lesions (7.7±6.5 cm(2); P=0.006). Complete mitral isthmus block predicted greater CFE reduction (P=0.02). Right atrial CFE area was reduced by LA ablation, from 25.9±14.1 to 12.9±11.8 cm(2) (P<0.001). Estimated 1-year arrhythmia-free survival was 72% after a single procedure. Incomplete linear lesion block was an independent predictor of arrhythmia recurrence (hazard ratio, 4.69; 95% confidence interval, 1.05-21.06; P=0.04). Remote LA CFE area was progressively reduced following PVI and linear lesions, and LA ablation reduced right atrial CFE area. Reduction of CFE area at sites remote from ablation would suggest either regression of the advanced atrial substrate or that these CFE were functional phenomena. Nevertheless, in an advanced atrial fibrillation substrate, linear lesions after PVI diminished the target area for CFE ablation, and complete lesions resulted in a favorable clinical outcome.

Left atrial function measured by cardiac magnetic resonance imaging in patients with heart failure: clinical associations and prognostic value.

PubMed

Pellicori, Pierpaolo; Zhang, Jufen; Lukaschuk, Elena; Joseph, Anil C; Bourantas, Christos V; Loh, Huan; Bragadeesh, Thanjavur; Clark, Andrew L; Cleland, John G F

2015-03-21

Left atrial (LA) volume is an important marker of cardiac dysfunction and cardiovascular outcome in heart failure (HF), but LA function is rarely measured. Left atrial emptying function (LAEF), its clinical associations and prognostic value was studied in outpatients referred with suspected HF who were in sinus rhythm and had cardiac magnetic resonance imaging (CMRI). Heart failure was defined as relevant symptoms and signs with either a left ventricular ejection fraction (LVEF) <50% or amino-terminal pro-B-type natriuretic peptide (NTproBNP) >400 pg/mL (or >125 pg/mL if taking loop diuretics). Of 982 patients, 664 fulfilled the HF criteria and were in sinus rhythm. The median (interquartile range, IQR) LAEF was 42 (31-51)% and 55 (48-61)% in patients with and without HF (P < 0.001). Patients with HF in the lowest quartile of LAEF (23%; IQR: 17-28%) had lower LV and right ventricular (RV) EF, and greater LV and RV mass and higher plasma NTproBNP than those in the highest quartile of LAEF (56%; IQR: 53-61%). Log[LAEF] and log[NTproBNP] were inversely correlated (r = -0.410, P < 0.001). During a median follow-up of 883 (IQR: 469-1626) days, 394 (59%) patients with HF died or were admitted with HF and 101 (15%) developed atrial fibrillation (AF). In a multivariable Cox model, increasing LAEF, but not LVEF, was independently associated with survival (HR for 10% change: 0.81 (95%CI: 0.73-0.90), P = <0.001). Increasing age and decreasing LAEF predicted incident AF. In patients with HF, LAEF predicts adverse outcome independently of other measures of cardiac dysfunction. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.

Global longitudinal strain in patients with suspected heart failure and a normal ejection fraction: does it improve diagnosis and risk stratification?

PubMed

Pellicori, Pierpaolo; Kallvikbacka-Bennett, Anna; Khaleva, Olga; Carubelli, Valentina; Costanzo, Pierluigi; Castiello, Teresa; Wong, Kenneth; Zhang, Jufen; Cleland, John G F; Clark, Andrew L

2014-01-01

Many patients have clinical, structural or bio-marker evidence of heart failure (HF) but a normal left ventricular ejection fraction (LVEF; HeFNEF). Measurement of global longitudinal strain (GLS) may add diagnostic and prognostic information. Patients with symptoms suggesting heart failure and LVEF ≥50% were studied: 76 had no substantial cardiac dysfunction (left atrial diameter (LAD) <40 mm and amino-terminal pro-brain natriuretic peptide (NTproBNP) <400 ng/l); 99 had "possible HeFNEF" (LAD ≥40 mm or NTproBNP ≥400 ng/l); and 138 had "definite HeFNEF" (LAD ≥40 mm and NTproBNP ≥400 ng/L). Mean LVEF was 58% in each subgroup. Patients with definite HeFNEF were older, more likely to have atrial fibrillation, had more symptoms and signs of fluid retention, were more likely to have right ventricular dysfunction and had higher pulmonary pressures than other groups. Mean GLS (SD) was less negative in patients with definite HeFNEF (-13.6 (3.0)% vs. possible HeFNEF: -15.2 (3.1)% vs. no substantial cardiac dysfunction: -15.9 (2.4)%; p < 0.001). GLS was -19.1 (2.1)% in 20 controls. During a median follow up of 647 days, cardiovascular death or an unplanned hospitalisation for heart failure occurred in 62 patients. In univariable analysis, GLS but not LVEF predicted events. However, in a multi-variable analysis, only urea, NTproBNP, left atrial volume, inferior vena cava diameter and atrial fibrillation independently predicted adverse outcome. GLS is abnormal in patients who have other evidence of HeFNEF, is associated with a worse prognosis in this population but is not a powerful independent predictor of outcome.

Left atrial strain and strain rate in patients with paroxysmal and persistent atrial fibrillation: relationship to left atrial structural remodeling detected by delayed-enhancement MRI.

PubMed

Kuppahally, Suman S; Akoum, Nazem; Burgon, Nathan S; Badger, Troy J; Kholmovski, Eugene G; Vijayakumar, Sathya; Rao, Swati N; Blauer, Joshua; Fish, Eric N; Dibella, Edward V R; Macleod, Rob S; McGann, Christopher; Litwin, Sheldon E; Marrouche, Nassir F

2010-05-01

Atrial fibrillation (AF) is a progressive condition that begins with hemodynamic and/or structural changes in the left atrium (LA) and evolves through paroxysmal and persistent stages. Because of limitations with current noninvasive imaging techniques, the relationship between LA structure and function is not well understood. Sixty-five patients (age, 61.2+/-14.2 years; 67% men) with paroxysmal (44%) or persistent (56%) AF underwent 3D delayed-enhancement MRI. Segmentation of the LA wall was performed and degree of enhancement (fibrosis) was determined using a semiautomated quantification algorithm. Two-dimensional echocardiography and longitudinal LA strain and strain rate during ventricular systole with velocity vector imaging were obtained. Mean fibrosis was 17.8+/-14.5%. Log-transformed fibrosis values correlated inversely with LA midlateral strain (r=-0.5, P=0.003) and strain rate (r=-0.4, P<0.005). Patients with persistent AF as compared with paroxysmal AF had more fibrosis (22+/-17% versus 14+/-9%, P=0.04) and lower midseptal (27+/-14% versus 38+/-16%, P=0.01) and midlateral (35+/-16% versus 45+/-14% P=0.03) strains. Multivariable stepwise regression showed that midlateral strain (r=-0.5, P=0.006) and strain rate (r=-0.4, P=0.01) inversely predicted the extent of fibrosis independent of other echocardiographic parameters and the rhythm during imaging. LA wall fibrosis by delayed-enhancement MRI is inversely related to LA strain and strain rate, and these are related to the AF burden. Echocardiographic assessment of LA structural and functional remodeling is quick and feasible and may be helpful in predicting outcomes in AF.

Randomized, double-blind trial of simultaneous right and left atrial epicardial pacing for prevention of post-open heart surgery atrial fibrillation.

PubMed

Daoud, E G; Dabir, R; Archambeau, M; Morady, F; Strickberger, S A

2000-08-15

The purpose of this study was to assess simultaneous right and left atrial pacing as prophylaxis for postoperative atrial fibrillation. In a double-blind, randomized fashion, 118 patients who underwent open heart surgery were assigned to right atrial pacing at 45 bpm (RA-AAI; n=39), right atrial triggered pacing at a rate of >/=85 bpm (RA-AAT; n=38), or simultaneous right and left atrial triggered pacing at a rate of >/=85 bpm (Bi-AAT; n=41). Holter monitoring was performed for 4. 8+/-1.4 days after surgery to assess for episodes of atrial fibrillation lasting >5 minutes. The prevalence of postoperative atrial fibrillation was significantly less in the patients randomized to biatrial AAT pacing when compared with the other 2 pacing regimens (P=0.02). An episode of atrial fibrillation occurred in 4 (10%) of 41 patients in the Bi-AAT group compared with 11 (28%) of 39 patients in the RA-AAI group (P=0.03 versus Bi-AAT) and 12 (32%) of 38 patients in the RA-AAT group (P=0.01 versus Bi-AAT). There was no difference in the occurrence of atrial fibrillation between the right atrial AAI and AAT groups (P=0.8). There was no significant difference among the 3 groups with regard to the number of postoperative hospital days (7.3+/-4.2 days), morbidity (5.1%), or mortality rate (2.5%). Simultaneous right and left atrial triggered pacing is well tolerated and significantly reduces the prevalence of post-open heart surgery atrial fibrillation.

Left Atrial Wall Dissection: A Rare Sequela of Native-Valve Endocarditis

PubMed Central

Isbitan, Ahmad; Roushdy, Alaa; Shamoon, Fayez

2015-01-01

Left atrial wall dissection is a rare condition; most cases are iatrogenic after mitral valve surgery. A few have been reported as sequelae of blunt chest trauma, acute myocardial infarction, and invasive cardiac procedures. On occasion, infective endocarditis causes left atrial wall dissection. We report a highly unusual case in which a 41-year-old man presented with native mitral valve infective endocarditis that had caused left atrial free-wall dissection. Although our patient died within an hour of presentation, we obtained what we consider to be a definitive diagnosis of a rare sequela, documented by transthoracic and transesophageal echocardiography. PMID:25873836

Left Atrial Size, Chemosensitivity, and Central Sleep Apnea in Heart Failure

PubMed Central

Calvin, Andrew D.; Somers, Virend K.; Johnson, Bruce D.; Scott, Christopher G.

2014-01-01

BACKGROUND: Central sleep apnea (CSA) is common among patients with heart failure (HF) and is promoted by elevated CO2 chemosensitivity. Left atrial size is a marker of the hemodynamic severity of HF. The aim of this study was to determine if left atrial size predicts chemosensitivity to CO2 and CSA in patients with HF. METHODS: Patients with HF with left ventricular ejection fraction ≤ 35% underwent polysomnography for detection of CSA, echocardiography, and measurement of CO2 chemosensitivity. CSA was defined as an apnea-hypopnea index (AHI) ≥ 15/h with ≥ 50% central apneic events. The relation of clinical and echocardiographic parameters to chemosensitivity and CSA were evaluated by linear regression, estimation of ORs, and receiver operator characteristics. RESULTS: Of 46 subjects without OSA who had complete data for analysis, 25 had CSA. The only parameter that significantly correlated with chemosensitivity was left atrial volume index (LAVI) (r = 0.40, P < .01). LAVI was greater in those with CSA than those without CSA (59.2 mL/m2 vs 36.4 mL/m2, P < .001) and significantly correlated with log-transformed AHI (r = 0.46, P = .001). LAVI was the best predictor of CSA (area under the curve = 0.83). A LAVI ≤ 33 mL/m2 was associated with 22% risk for CSA, while LAVI ≥ 53 mL/m2 was associated with 92% risk for CSA. CONCLUSIONS: Increased LAVI is associated with heightened CO2 chemosensitivity and greater frequency of CSA. LAVI may be useful to guide referral for polysomnography for detection of CSA in patients with HF. PMID:24522490

[Electrophysiological findings and ablation strategies in patients with atrial tachyarrhythmias after left atrial circumferential ablation in the treatment of atrial fibrillation].

PubMed

Chen, Ming-long; Yang, Bing; Xu, Dong-jie; Zou, Jian-gang; Shan, Qi-jun; Chen, Chun; Chen, Hong-wu; Li, Wen-qi; Cao, Ke-jiang

2007-02-01

To report the electrophysiological findings and the ablation strategies in patients with atrial tachyarrhythmias (ATAs) or atrial fibrillation (AF) recurrence after left atrial circumferential ablation (LACA) in the treatment of AF. 91 patients with AF had LACA procedure from April 2004 to May 2006, 19 of which accepted the second ablation procedure due to ATAs or AF recurrence. In all the 19 patients [17 male, 2 female, age 25 - 65 (53 +/- 12) years], 11 presented with paroxysmal AF before the first ablation procedure, 2 with persistent AF and 6 with permanent AF. Pulmonary vein potentials (PVP) were investigated in both sides in all the patients. Delayed PVP was identified inside the left circular line in 5 patients, in the right in 1 and both in 2 during sinus rhythm. "Gap" conduction was found and successfully closed guided by circular mapping catheter. In 3 cases, irregular left atrial tachycardia was caused by fibrillation rhythm inside the left ring via decremental "gap" conduction. Reisolation was done successfully again guided by 3-D mapping and made the left atrium in sinus rhythm but the fibrillation rhythm was still inside the left ring. Pulmonary vein tachycardia with 1:1 conduction to the left atrium presented in one case and reisolation stopped the tachycardia. No PVP was discovered in both sides in 4 patients but other tachycardias could be induced, including two right atrial scar related tachycardias, two supraventricular tachycardias mediated by concealed accessory pathway, one cavo-tricuspid isthmus dependent atrial flutter and one focal atrial tachycardia near the coronary sinus ostium. All the tachycardias in these 4 patients were successfully ablated with the help of routine and 3-D mapping techniques. In the rest 3, which were in AF rhythm, LACA was successfully done again. After a mean follow-up of 4 - 26 (11.5 +/- 8.5) months, 16 patients were symptom free without anti-arrhythmic drug therapy; 1 of them had frequent palpitation attack with Holter recording of atrial premature contractions; 2 of them with permanent AF became paroxysmal in one, and still in AF in the other. Reconduction between the left atrium and the pulmonary veins is the dominant factor for post-LACA ATAs and AF recurrence. Other forms of atrial tachycardias or supraventricular tachycardias may coexist with AF or sometimes trigger AF. LACA can not sufficiently modify AF substrate in some permanent AF patients.

Left atrial isolation associated with mitral valve operations.

PubMed

Graffigna, A; Pagani, F; Minzioni, G; Salerno, J; Viganò, M

1992-12-01

Surgical isolation of the left atrium was performed for the treatment of chronic atrial fibrillation secondary to valvular disease in 100 patients who underwent mitral valve operations. From May 1989 to September 1991, 62 patients underwent mitral valve operations (group I); 19, mitral valve operations and DeVega tricuspid annuloplasty (group II); 15, mitral and aortic operations (group III); and 4, mitral and aortic operations and DeVega tricuspid annuloplasty (group IV). Left atrial isolation was performed, prolonging the usual left paraseptal atriotomy toward the left fibrous trigone anteriorly and the posteromedial commissure posteriorly. The incision was conducted a few millimeters apart from the mitral valve annulus, and cryolesions were placed at the edges to ensure complete electrophysiological isolation of the left atrium. Operative mortality accounted for 3 patients (3%). In 79 patients (81.4%) sinus rhythm recovered and persisted until discharge from the hospital. No differences were found between the groups (group I, 80.7%; group II, 68.5%; group III, 86.7%; group IV, 75%; p = not significant). Three late deaths (3.1%) were registered. Long-term results show persistence of sinus rhythm in 71% of group I, 61.2% of group II, 85.8% of group III, and 100% of group IV. The unique risk factor for late recurrence of atrial fibrillation was found to be preoperative atrial fibrillation longer than 6 months. Due to the satisfactory success rate in recovering sinus rhythm, we suggest performing left atrial isolation in patients with chronic atrial fibrillation undergoing valvular operations.

Changes in left atrial deformation in hypertrophic cardiomyopathy: Evaluation by vector velocity imaging

PubMed Central

Badran, Hala Mahfouz; Soltan, Ghada; Hassan, Hesham; Nazmy, Ahmed; Faheem, Naglaa; Saadan, Haythem; Yacoub, Magdi H.

2012-01-01

Abstract: Objectives: Hypertrophic cardiomyopathy (HCM) represents a generalized myopathic process affecting both ventricular and atrial myocardium. We assessed the global and regional left atrial (LA) function and its relation to left ventricular (LV) mechanics and clinical status in patients with HCM using Vector Velocity Imaging (VVI). Methods: VVI of the LA and LV was acquired from apical four- and two-chamber views of 108 HCM patients (age 40 ± 19years, 56.5% men) and 33 healthy subjects, all had normal LV systolic function. The LA subendocardium was traced to obtain atrial volumes, ejection fraction, velocities, and strain (ϵ)/strain rate (SR) measurements. Results: Left atrial reservoir (ϵsys,SRsys) and conduit (early diastolic SRe) function were significantly reduced in HCM compared to controls (P < .0001). Left atrial deformation directly correlated to LVϵsys, SRsys and negatively correlated to age, NYHA class, left ventricular outflow tract (LVOT) gradient, left ventricular mass index (LVMI), LA volume index and severity of mitral regurge (P < 0.001). Receiver operating characterist was constructed to explore the cutoff value of LA deformation in differentiation of LA dysfunction; ϵsys < 40% was 75% sensitive, 50% specific, SRsys < 1.7s− 1 was 70% sensitive, 61% specific, SRe> − 1.8s− 1 was 81% sensitive and 30% specific, SRa> − 1.5s− 1 was 73% sensitive and 40% specific. By multivariate analysis global LVϵsys and LV septal thickness are independent predictors for LAϵsys, while end systolic diameter is the only independent predictor for SRsys, P < .001. Conclusion: Left atrial reservoir and conduit function as measured by VVI were significantly impaired while contractile function was preserved among HCM patients. Left atrial deformation was greatly influenced by LV mechanics and correlated to severity of phenotype. PMID:24688992

ABO blood groups: A risk factor for left atrial and left atrial appendage thrombogenic milieu in patients with non-valvular atrial fibrillation.

PubMed

Fu, Yuan; Li, Kuibao; Yang, Xinchun

2017-08-01

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. Copyright © 2017 Elsevier Ltd. All rights reserved.

Value of local electrogram characteristics predicting successful catheter ablation of left-versus right-sided accessory atrioventricular pathways by radiofrequency current.

PubMed

Lin, J L; Schie, J T; Tseng, C D; Chen, W J; Cheng, T F; Tsou, S S; Chen, J J; Tseng, Y Z; Lien, W P

1995-01-01

Despite similar guidance by local electrogram criteria, catheter ablation of right-sided accessory atrioventricular (AV) pathways by radiofrequency current has been less effective than that of left-sided ones. In order to elucidate the possible diversities in local electrosignal criteria, we systematically analyzed the morphological and timing characteristics of 215 bipolar local electrograms from catheter ablation sites of 65 left-sided accessory AV pathways and of 356 from those of 37 right-sided ones in 92 consecutive patients with Wolff-Parkinson-White syndrome or AV reentrant tachycardia incorporating concealed accessory AV pathways. After stepwise multivariate analysis, we selected the presence of a possible accessory pathway potential, local ventricular activation preceding QRS complex for 20 ms or more during ventricular insertion mapping, and the local retrograde ventriculoatrial (VA) continuity, local retrograde VA interval < or = 50 ms, electrogram stability (left-sided targets only), retrograde accessory pathway potential (right-sided targets only) during atrial insertion mapping, as independent local electrogram predictors for successful ablation of left- and right-sided accessory AV pathways. Combination of all local electrogram predictors could have moderate chance of success (80 and 51%) for the ventricular and atrial insertion ablation of left-sided accessory AV pathways, but only low probability of success (40% in ventricular insertion ablation) or very low sensitivity (12.5% in atrial insertion ablation) for right-sided ones. In conclusion, with the present approach, successful catheter ablation of right-sided accessory AV pathways, compared to left-sided ones, still necessitate a breakthrough in the precision mapping and the efficiency of energy delivery.

Percutaneous closure of the left atrial appendage in patients with diabetes mellitus.

PubMed

Azizy, Obayda; Rammos, Christos; Lehmann, Nils; Rassaf, Tienush; Kälsch, Hagen

2017-09-01

Left atrial appendage closure is a preventive treatment of atrial fibrillation-related thrombo-embolism. Patients with diabetes mellitus have increased risk for a negative outcome in percutaneous cardiac interventions. We assessed whether percutaneous left atrial appendage closure is safe and effective in patients with diabetes mellitus. We included 78 patients (mean age of 74.4 ± 8.3 years) with indication for left atrial appendage closure in an open-label observational single-centre study. Patients with diabetes mellitus ( n = 31) were at higher thrombo-embolic and bleeding risk (CHA 2 DS 2 -VASc: 4.5 ± 0.9, HAS-BLED: 4.7 ± 0.7) compared to patients without diabetes mellitus ( n = 47, CHA 2 DS 2 -VASc: 3.5 ± 1.0, HAS-BLED: 4.1 ± 0.8; p < 0.001 for both). Pre- and periprocedural risk was elevated in patients with diabetes mellitus (Euro II-Score: 6.6 ± 3.7 vs 3.9 ± 1.9, p < 0.01; Society of Thoracic Surgeons (STS)-Score: 4.0 ± 2.5 vs 2.6 ± 1.2, p < 0.01). Procedural success was similar. Periprocedural major adverse cardiac and cerebrovascular events occurred in one patient from the control group (2.1%), whereas patients with diabetes mellitus had no events ( p = 0.672). Follow-up of 6 months revealed no bleeding complication in both groups. No stroke occurred in follow-up, and left atrial appendage flow velocity reduction (55.6 ± 38.6 vs 51.4 ± 19.1 cm/s, p = 0.474) and rate of postinterventional leakage in the left atrial appendage were comparable (0% vs 2.1%, p = 0.672). Despite patients with diabetes mellitus are high-risk patients, the outcome of percutaneous left atrial appendage closure is similar to patients without diabetes mellitus.

Larger late sodium current density as well as greater sensitivities to ATX II and ranolazine in rabbit left atrial than left ventricular myocytes.

PubMed

Luo, Antao; Ma, Jihua; Song, Yejia; Qian, Chunping; Wu, Ying; Zhang, Peihua; Wang, Leilei; Fu, Chen; Cao, Zhenzhen; Shryock, John C

2014-02-01

An increase of cardiac late sodium current (INa.L) is arrhythmogenic in atrial and ventricular tissues, but the densities of INa.L and thus the potential relative contributions of this current to sodium ion (Na(+)) influx and arrhythmogenesis in atria and ventricles are unclear. In this study, whole-cell and cell-attached patch-clamp techniques were used to measure INa.L in rabbit left atrial and ventricular myocytes under identical conditions. The density of INa.L was 67% greater in left atrial (0.50 ± 0.09 pA/pF, n = 20) than in left ventricular cells (0.30 ± 0.07 pA/pF, n = 27, P < 0.01) when elicited by step pulses from -120 to -20 mV at a rate of 0.2 Hz. Similar results were obtained using step pulses from -90 to -20 mV. Anemone toxin II (ATX II) increased INa.L with an EC50 value of 14 ± 2 nM and a Hill slope of 1.4 ± 0.1 (n = 9) in atrial myocytes and with an EC50 of 21 ± 5 nM and a Hill slope of 1.2 ± 0.1 (n = 12) in ventricular myocytes. Na(+) channel open probability (but not mean open time) was greater in atrial than in ventricular cells in the absence and presence of ATX II. The INa.L inhibitor ranolazine (3, 6, and 9 μM) reduced INa.L more in atrial than ventricular myocytes in the presence of 40 nM ATX II. In summary, rabbit left atrial myocytes have a greater density of INa.L and higher sensitivities to ATX II and ranolazine than rabbit left ventricular myocytes.

Cardiac structure and function predicts functional decline in the oldest old.

PubMed

Leibowitz, David; Jacobs, Jeremy M; Lande-Stessman, Irit; Gilon, Dan; Stessman, Jochanan

2018-02-01

Background This study examined the association between cardiac structure and function and the deterioration in activities of daily living (ADLs) in an age-homogenous, community-dwelling population of patients born in 1920-1921 over a five-year follow-up period. Design Longitudinal cohort study. Methods Patients were recruited from the Jerusalem Longitudinal Cohort Study, which has followed an age-homogenous cohort of Jerusalem residents born in 1920-1921. Patients underwent home echocardiography and were followed up for five years. Dependence was defined as needing assistance with one or more basic ADL. Standard echocardiographic assessment of cardiac structure and function, including systolic and diastolic function, was performed. Reassessment of ADLs was performed at the five-year follow-up. Results A total of 459 patients were included in the study. Of these, 362 (79%) showed a deterioration in at least one ADL at follow-up. Patients with functional deterioration had a significantly higher left ventricular mass index and left atrial volume with a lower ejection fraction. There was no significant difference between the diastolic parameters the groups in examined. When the data were examined categorically, a significantly larger percentage of patients with functional decline had an abnormal left ventricular ejection fraction and left ventricular hypertrophy. The association between left ventricular mass index and functional decline remained significant in all multivariate models. Conclusions In this cohort of the oldest old, an elevated left ventricular mass index, higher left atrial volumes and systolic, but not diastolic dysfunction, were predictive of functional disability.

Left atrial concomitant surgical ablation for treatment of atrial fibrillation in cardiac surgery: A meta-analysis of randomized controlled trials

PubMed Central

Wang, Chunguo; Ye, Minhua; Lin, Jiang; Jin, Jiang; Hu, Quanteng; Zhu, Chengchu; Chen, Baofu

2018-01-01

Introduction Surgical ablation is a generally established treatment for patients with atrial fibrillation undergoing concomitant cardiac surgery. Left atrial (LA) lesion set for ablation is a simplified procedure suggested to reduce the surgery time and morbidity after procedure. The present meta-analysis aims to explore the outcomes of left atrial lesion set versus no ablative treatment in patients with AF undergoing cardiac surgery. Methods A literature research was performed in six database from their inception to July 2017, identifying all relevant randomized controlled trials (RCTs) comparing left atrial lesion set versus no ablative treatment in AF patient undergoing cardiac surgery. Data were extracted and analyzed according to predefined clinical endpoints. Results Eleven relevant RCTs were included for analysis in the present study. The prevalence of sinus rhythm in ablation group was significantly higher at discharge, 6-month and 1-year follow-up period. The morbidity including 30 day mortality, late all-cause mortality, reoperation for bleeding, permanent pacemaker implantation and neurological events were of no significant difference between two groups. Conclusions The result of our meta-analysis demonstrates that left atrial lesion set is an effective and safe surgical ablation strategy for AF patients undergoing concomitant cardiac surgery. PMID:29360851

The Electrophysiologic Effects of Acute Mitral Regurgitation in a Canine Model.

PubMed

Lawrance, Christopher P; Henn, Matthew C; Miller, Jacob R; Kopek, Michael A; Zhang, Andrew J; Schuessler, Richard B; Damiano, Ralph J

2017-04-01

Atrial fibrillation (AF) occurs in 30% of patients with mitral regurgitation referred for surgical intervention. However, the underlying mechanisms in this population are poorly understood. This study examined the effects of acute left atrial volume overload on atrial electrophysiology and the inducibility of AF. Ten canines underwent insertion of an atrioventricular shunt between the left ventricle and left atrium. Shunt and aortic flows were calculated, and the shunt was titrated to a shunt fraction to 40% to 50% of cardiac output. An epicardial plaque with 250 bipolar electrodes was used to determine activation and refractory periods. Biatrial pressures and volumes, conduction times, and atrial fibrillation inducibility were recorded. Data were collected at baseline and 20 minutes after shunt opening and closure. Mean shunt flow was 1.3 ± 0.5 L/min with a shunt fraction of 43% ± 6% simulating moderate to severe mitral regurgitation. Compared with baseline, left atrial volumes and maximum pressures increased by 27% and 29%, respectively, after shunt opening. Biatrial effective refractory periods did not change significantly after shunt opening or closure. Conduction times increased by 9% with shunt opening and returned to baseline after closure. AF duration or inducibility did not change with shunt opening. This canine model of mitral regurgitation demonstrated that acute left atrial volume overload did not increase the inducibility of atrial arrhythmias in contrast with experimental and clinical findings of chronic left atrial volume overload. This suggests that the substrates for AF in patients with mitral regurgitation are a result of chronic remodeling. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Efficacy of anticoagulation in resolving left atrial and left atrial appendage thrombi: A transesophageal echocardiographic study

NASA Technical Reports Server (NTRS)

Jaber, W. A.; Prior, D. L.; Thamilarasan, M.; Grimm, R. A.; Thomas, J. D.; Klein, A. L.; Asher, C. R.

2000-01-01

BACKGROUND: Transesophageal echocardiography (TEE) is the gold standard for evaluation of the left atrium and the left atrial appendage (LAA) for the presence of thrombi. Anticoagulation is conventionally used for patients with atrial fibrillation to prevent embolization of atrial thrombi. The mechanism of benefit and effectiveness of thrombi resolution with anticoagulation is not well defined. METHODS AND RESULTS: We used a TEE database of 9058 consecutive studies performed between January 1996 and November 1998 to identify all patients with thrombi reported in the left atrium and/or LAA. One hundred seventy-four patients with thrombi in the left atrial cavity (LAC) and LAA were identified (1.9% of transesophageal studies performed). The incidence of LAA thrombi was 6.6 times higher than LAC thrombi (151 vs 23, respectively). Almost all LAC thrombi were visualized on transthoracic echocardiography (90.5%). Mitral valve pathology was associated with LAC location of thrombi (P <.0001), whereas atrial fibrillation or flutter was present in most patients with LAA location of thrombi. Anticoagulation of 47 +/- 18 days was associated with thrombus resolution in 80.1% of the patients on follow-up TEE. Further anticoagulation resulted in limited additional benefit. CONCLUSIONS: LAC thrombi are rare and are usually associated with mitral valve pathology. Transthoracic echocardiography is effective in identifying these thrombi. LAA thrombi occur predominantly in patients with atrial fibrillation or flutter. Short-term anticoagulation achieves a high rate of resolution of LAA and LAC thrombi but does not obviate the need for follow-up TEE.

Atrial Electromechanical Properties in Coeliac Disease.

PubMed

Efe, Tolga Han; Ertem, Ahmet Goktug; Coskun, Yusuf; Bilgin, Murat; Algul, Engin; Beton, Osman; Asarcikli, Lale Dinc; Erat, Mehmet; Ayturk, Mehmet; Yuksel, Ilhami; Yeter, Ekrem

2016-02-01

Coeliac disease (CD) is an autoimmune and inflammatory disorder of the small intestine. There is reasonable evidence linking inflammation to the initiation and continuation of atrial fibrillation (AF) in inflammatory conditions. Atrial electro-mechanic delay (EMD) was suggested as an early marker of AF in previous studies. The objectives of this study were to evaluate atrial electromechanical properties measured by tissue Doppler imaging and simultaneous electrocardiography (ECG) tracing in patients with CD. Thirty-nine patients with coeliac disease (CD), and 26 healthy volunteers, matched for age and sex, were enrolled in the study. Atrial electromechanical properties were measured by using transthoracic echocardiography and surface ECG. Interatrial electro-mechanic delay (EMD), left intraatrial EMD, right intratrial EMD were calculated. There was no difference between CD patients and healthy volunteers in terms of basal characteristics. Patients with CD had significantly prolonged left and right intraatrial EMDs, and interatrial EMD compared to healthy controls (p= 0.03, p= 0.02, p<0.0001, respectively). Interatrial EMD was positively correlated with age, disease duration, anti-gliadin IgG, anti-endomysium and disease status. In multiple linear regression, interatrial EMD was independently associated with disease duration, anti-endomysium and disease status after adjusting for age and sex. In the present study, atrial EMDs were found significantly higher in patients with CD compared with healthy individuals. Measurement of atrial EMD parameters might be used to predict the risk of development of AF in patients with CD. Copyright © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.

Comparison of left and right atrial volume by echocardiography versus cardiac magnetic resonance imaging using the area-length method.

PubMed

Whitlock, Matthew; Garg, Anuj; Gelow, Jill; Jacobson, Timothy; Broberg, Craig

2010-11-01

Increased atrial volumes predict adverse cardiovascular events. Accordingly, accurate measurement of atrial size has become increasingly important in clinical practice. The area-length method is commonly used to estimate the volume. Disagreements between atrial volumes using echocardiography and other imaging modalities have been found. It is unclear whether this has resulted from differences in the measurement method or discrepancies among imaging modalities. We compared the right atrial (RA) and left atrial (LA) volume estimates using the area-length method for transthoracic echocardiography and cardiovascular magnetic resonance (CMR) imaging. Patients undergoing echocardiography and CMR imaging within 1 month were identified retrospectively. For both modalities, the RA and LA long-axis dimension and area were measured using standard 2- and 4-chamber views, and the volume was calculated using the area-length method for both atria. The echocardiographic and CMR values were compared using the Bland-Altman method. A total of 85 patients and 18 controls were included in the present study. The atrial volumes estimated using the area-length method were significantly smaller when measured using echocardiography than when measured using CMR imaging (LA volume 35 ± 20 vs 49 ± 30 ml/m², p <0.001, and RA volume 32 ± 23 vs 43 ± 29 ml/m², p = 0.012). The mean difference (CMR imaging minus echocardiography) was 14 ± 14 ml/m² for the LA and 10 ± 16 ml/m² for the RA volume. Similar results were found in the healthy controls. No significant intra- or interobserver variability was found within each modality. In conclusion, echocardiography consistently underestimated the atrial volumes compared to CMR imaging using the area-length method. Copyright © 2010 Elsevier Inc. All rights reserved.

Paroxysmal postprandial atrial fibrilation suppressed by laparoscopic repair of a giant paraesophageal hernia compressing the left atrium.

PubMed

Cristian, Daniel A; Constantin, Alin S; Barbu, Mariana; Spătaru, Dan; Burcoș, Traean; Grama, Florin A

2015-03-01

We present the case of a patient with a giant paraesophageal hernia associated with paroxysmal postprandial atrial fibrillation that was suppressed after surgery. The imaging investigations showed the intrathoracic displacement of a large part of the stomach, which pushed the left atrial wall causing atrial fibrillation. The laparoscopic surgical repair acted as sole treatment for this condition.

Percutaneous left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation and contraindication for anticoagulation.

PubMed

Grosset-Janin, D; Barth, E; Bertrand, B; Detante, O

2015-05-01

Stroke, as the third cause of death in developed countries, is a public health issue. Atrial fibrillation is an important cause of ischemic stroke and its prevention is efficient with oral anticoagulation. However, oral anticoagulation can be contraindicated because of hemorrhagic risk related to these treatments. Percutaneous left atrial appendage occlusion is a new alternative of oral anticoagulation for patients with atrial fibrillation and high risk of cardio-embolic stroke but contraindicated for oral anticoagulation. We describe in this paper the procedure of left atrial appendage occlusion with the Amplatzer cardiac plug device, used in our center in Grenoble university hospital, for the first three patients who have been treated with this device. These three patients (one man and two women) have all atrial fibrillation with neurological complication of this arrhythmia, as ischemic stroke. Oral anticoagulation is indicated to prevent another ischemic stroke. However, they all have a high risk of cerebral bleeding for different reasons (cavernomatosis, history of intracerebral hemorrhage and aneurysm of the polygon of Willis). Consequently, they have a high risk of cardio-embolic complication but contraindication for oral anticoagulation. They have been treated by left atrial appendage occlusion with Amplatzer cardiac plug device by percutaneous and trans-septal access. Then, they have been followed by neurologist and cardiologist, with clinical and paraclinical evaluation by echocardiography. Our three first patients have been successfully implanted, without periprocedural complication. No latest adverse event was observed, and particularly no cardiac or neurologic adverse event. The technique of left atrial appendage occlusion is a very interesting and promising technique for ischemic stroke prevention in patient with high risk of cardio-embolic complication because of atrial fibrillation, but high risk of bleeding and contraindication for oral anticoagulation. Because of frequency of both atrial fibrillation and contraindication for oral anticoagulation, occlusion of the left atrial appendage should become an interesting alternative for many patients. However, it remains an invasive procedure and efficacy and indications need to be evaluated in further clinical trials. Risk/benefit ratio must be carefully assessed and compared to that of the new anticoagulant drugs. Copyright © 2015. Published by Elsevier Masson SAS.

Left atrial function after Cox's maze operation concomitant with mitral valve operation.

PubMed

Itoh, T; Okamoto, H; Nimi, T; Morita, S; Sawazaki, M; Ogawa, Y; Asakura, T; Yasuura, K; Abe, T; Murase, M

1995-08-01

This study examined whether the atrial fibrillation that commonly occurs in patients with a mitral valve operation could be eliminated by a concomitant maze operation. Left atrial function after Cox's maze operation performed concomitantly with a mitral valve operation was evaluated in 10 patients ranging in age from 38 to 67 years (mean age, 54 years). Seven patients who had had coronary artery bypass grafting served as the control group. Using transthoracic echocardiography, the ratio between the peak speed of the early filling wave and that of the atrial contraction wave (A/E ratio) and the atrial filling fraction (AFF) were determined from transmitral flow measurements. These two indices have been considered to represent the contribution of left atrial active contraction to ventricular filling. The A/E ratio and the AFF were significantly lower in the maze group (0.35 +/- 0.17 versus 0.97 +/- 0.28 [p < 0.01] and 17.6% +/- 8.8% versus 36.8% +/- 6.4% [p < 0.01], respectively). The A/E ratio and the AFF correlated inversely with age (r = -0.72, p < 0.05 and r = 0.76, p < 0.05, respectively) in the maze group. In an angiographic study, the mean left atrial maximal volume index in the maze group was approximately three times larger than that in the control group (117.5 +/- 24.3 mL/m2 versus 35.3 +/- 6.6 mL/m2 [p < 0.01]). The left atrial active emptying volume index was significantly smaller in patients in the maze group (7.2 +/- 2.5 mL/m2 versus 13.1 +/- 4.6 mL/m2 [p < 0.01]). After the maze procedure performed concomitantly with a mitral valve operation in patients with a dilated left atrium, left atrial contraction is detectable but incomplete in the elderly.

Laser Atrial Septostomy: An Engineering Problem

NASA Astrophysics Data System (ADS)

Ben-Shachar, Giora; Cohen, Mark H.; Riemenschneider, Thomas A.; Beder, Stanley D.

1987-04-01

The purpose of this study was to develop a reproducible method for atrial septostomy in live animals, which would be independent of both atrial septal thickness and left atrial size. Seven mongrel dogs monitored electrocardiographically were anesthetized and instrumented with systemic and pulmonary arterial lines. A modified Mullin's transseptal sheath was advanced under fluoroscopic control to interrogate the left atrium and atrial septum. A 400 micron regular quartz or a laser heated metallic tip fiber was passed through the sheath up to the atrial septum. Lasing of the atrial septum was done with an Argon laser at power output of 5 watts. In three dogs, an atrial septosomy catheter was passed to the left atrium through the laser atrial septostomy and balloon atrial septostomy was performed. The laser atrial septostomy measured 3 x 5 mm in diameter. This interatrial communication could be enlarged with a balloon septostomy to over one cm in diameter. Hemodynamic and electrocardiographic monitoring were stable during the procedure. Engineering problems included: 1) radioluscency of the laser fibers thus preventing fluoroscopic localization of the fiber course; and 2) the inability to increase lateral vaporization of the atrial septum. It is concluded that further changes in the lasing fibers need to be made before the method can be considered for clinical use.

Association of Left Atrial Enlargement with Cortical Infarction in Subjects with Patent Foramen Ovale.

PubMed

Lee, Mi Ji; Park, Sung-Ji; Yoon, Chang Hyo; Hwang, Ji-Won; Ryoo, Sookyung; Kim, Suk Jae; Kim, Gyeong-Moon; Chung, Chin-Sang; Lee, Kwang Ho; Bang, Oh Young

2016-09-01

Left atrial dysfunction has been reported in patients with patent foramen ovale (PFO). Here we investigated the role of left atrial dysfunction in the development of embolic stroke in patients with PFO. We identified consecutive patients with embolic stroke of undetermined sources except for PFO (PFO+ESUS). Healthy subjects with PFO served as controls (PFO+control). A stratified analysis by 10-year age group and an age- and sex- matching analysis were performed to compare echocardiographic markers between groups. In the PFO+ESUS group, infarct patterns of PFO-related stroke were determined (cortical vs. cortico-subcortical) and analyzed in correlation with left atrial function parameters. A total of 118 patients and 231 controls were included. The left atrial volume indices (LAVIs) of the PFO+ESUS patients were higher than those of the PFO+controls in age groups of 40-49, 50-59, and 60-69 years ( P <0.001, P =0.003, and P =0.027, respectively), and in the age- and sex-matched analysis ( P =0.001). In the PFO+ESUS patients, a higher (>28 mL/m 2 ) LAVI was more associated with the cortical infarct pattern ( P =0.043 for an acute infarction and P =0.024 for a chronic infarction, both adjusted for age and shunt amount). The degree of right-to-left shunting was not associated with infarct patterns, but with the posterior location of acute infarcts ( P =0.028). Left atrial enlargement was associated with embolic stroke in subjects with PFO. Left atrial physiology might contribute to the development of PFO-related stroke and need to be taken into consideration for optimal prevention of PFO-related stroke.

Acute effects of unilateral temporary stellate ganglion block on human atrial electrophysiological properties and atrial fibrillation inducibility.

PubMed

Leftheriotis, Dionyssios; Flevari, Panayota; Kossyvakis, Charalampos; Katsaras, Dimitrios; Batistaki, Chrysanthi; Arvaniti, Chrysa; Giannopoulos, Georgios; Deftereos, Spyridon; Kostopanagiotou, Georgia; Lekakis, John

2016-11-01

In experimental models, stellate ganglion block (SGB) reduces the induction of atrial fibrillation (AF), while data in humans are limited. The aim of this study was to assess the effect of unilateral SGB on atrial electrophysiological properties and AF induction in patients with paroxysmal AF. Thirty-six patients with paroxysmal AF were randomized in a 2:1 order to temporary, transcutaneous, pharmaceutical SGB with lidocaine or placebo before pulmonary vein isolation. Lidocaine was 1:1 randomly infused to the right or left ganglion. Before and after randomization, atrial effective refractory period (ERP) of each atrium, difference between right and left atrial ERP, intra- and interatrial conduction time, AF inducibility, and AF duration were assessed. After SGB, right atrial ERP was prolonged from a median (1st-3rd quartile) of 240 (220-268) ms to 260 (240-300) ms (P < .01) and left atrial ERP from 235 (220-260) ms to 245 (240-280) ms (P < .01). AF was induced by atrial pacing in all 24 patients before SGB, but only in 13 patients (54%) after the intervention (P < .01). AF duration was shorter after SGB: 1.5 (0.0-5.8) minutes from 5.5 (3.0-12.0) minutes (P < .01). Intra- and interatrial conduction time was not significantly prolonged. No significant differences were observed between right and left SGB. No changes were observed in the placebo group. Unilateral temporary SGB prolonged atrial ERP, reduced AF inducibility, and decreased AF duration. An equivalent effect of right and left SGB on both atria was observed. These findings may have a clinical implication in the prevention of drug refractory and postsurgery AF and deserve further clinical investigation. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.

[Left atrial electric isolation in the treatment of atrial fibrillation secondary to rheumatic valvular disease].

PubMed

Graffigna, A; Pagani, F; Minzioni, G; Salerno, J; Viganò, M

1992-08-01

Surgical isolation of the left atrium was performed for the treatment of chronic atrial fibrillation secondary to valvular disease in 100 patients who underwent valve surgery. From May 1989 to September 1991, 62 patients underwent mitral valve surgery (Group I), 19 underwent mitral valve surgery and DeVega tricuspid annuloplasty (Group II), 15 underwent mitral and aortic surgery (Group III), and 4 patients underwent mitral and aortic surgery and DeVega tricuspid annuloplasty (Group IV). Left atrial isolation was performed prolonging the usual left paraseptal atriotomy towards the left fibrous trigone anteriorly, and the postero-medial commissure posteriorly. The incision was conducted a few millimeters apart from the mitral valve annulus, and cryolesion were placed at the edges to ensure complete electrophysiological isolation of the left atrium. Operative mortality accounted for 3 cases (3%). In 79 patients (81.4%) sinus rhythm recovered and persisted until discharge from the hospital. No differences were found between the groups (Group I: 80.7%; Group II: 68.5%; Group III 86.7%, Group IV 75% - p = N.S.). Three cases of late mortality (3.1%) were registered. long-term results showed persistence of SR in 71% of Group I, 61.2% of Group II, 85.8% of Group III, and 100% of Group IV. The unique risk factor for late recurrency of atrial fibrillation was found to be a duration of preoperative AF longer than 6 months. Due to the high success rate in recovering the sinus rhythm, we suggest left atrial isolation in patients with chronic atrial fibrillation undergoing valvular surgery.

Clinical and electrocardiographic characteristics for prediction of new-onset atrial fibrillation in asymptomatic patients with atrial premature complexes.

PubMed

Im, Sung Il; Park, Dong Hyun; Kim, Bong Joon; Cho, Kyoung Im; Kim, Hyun Su; Heo, Jung Ho

2018-06-01

Identification of precursors of atrial fibrillation (AF) may lead to early detection and prevent associated morbidity and mortality. Atrial premature complexes (APCs) are commonly seen in healthy subjects. However, there was limited data about the clinical and electrocardiographic (ECG) characteristics for prediction of new-onset AF in asymptomatic patients with APCs in the long-term follow up. The Kosin University (No. 2014-02-04) 24-h holter monitoring, echocardiography, ECG database were reviewed from 2008 to 2016 to identify new- onset AF in patients with APCs. We analyzed demographic and clinical features and the nature of the APCs by ECG according to new-onset AF in those patients. Among 652 patients who underwent 24-h holter monitoring, 226 (34.4%) patients had new-onset AF. There was no difference of the baseline characteristics between new-onset AF group and non-AF group. In univariate analysis, hypertension (HTN), renal failure (CRF), high APC burdens, fastest APC running heart rate (HR), minimal HR, left ventricular ejection fraction (LVEF), left atrial volume index, peak mitral flow velocity of the early rapid filling wave and tricuspid regurgitation grade were significantly associated with new-onset AF. In multivariate analysis, higher APCs burden ( P  = 0.047), higher fastest APCs running HR ( P  = 0.034) and lower minimal HR ( P  = 0.025) were independent risk factors for new-onset AF in asymptomatic patients with APCs. Higher APCs burden, higher fastest APCs running HR and lower minimal HR were associated with new-onset AF in asymptomatic patients with APCs in the long-term follow up.

Does the STAF score help detect paroxysmal atrial fibrillation in acute stroke patients?

PubMed

Horstmann, S; Rizos, T; Güntner, J; Hug, A; Jenetzky, E; Krumsdorf, U; Veltkamp, R

2013-01-01

Detecting paroxysmal atrial fibrillation (pAF) soon after acute cerebral ischaemia has a major impact on secondary stroke prevention. Recently, the STAF score, a composite of clinical and instrumental findings, was introduced to identify stroke patients at risk of pAF. We aimed to validate this score in an independent study population. Consecutive patients admitted to our stroke unit with acute ischaemic stroke were prospectively enrolled. The diagnostic work-up included neuroimaging, neuroultrasound, baseline 12-channel electrocardiogram (ECG), 24-h Holter ECG, continuous ECG monitoring, and echocardiography. Presence of AF was documented according to the medical history of each patient and after review of 12-lead ECG, 24-h Holter ECG, or continuous ECG monitoring performed during the stay on the ward. Additionally, a telephone follow-up visit was conducted for each patient after 3 months to inquire about newly diagnosed AF. Items for each patient-age, baseline NIHSS, left atrial dilatation, and stroke etiology according to the TOAST criteria - were assessed to calculate the STAF score. Overall, 584 patients were enrolled in our analysis. AF was documented in 183 (31.3%) patients. In multivariable analysis, age, NIHSS, left atrial dilatation, and absence of vascular etiology were independent predictors for AF. The logistic AF-prediction model of the STAF score revealed fair classification accuracy in receiver operating characteristic curve analysis with an area under the curve of 0.84. STAF scores of ≥5 had a sensitivity of 79% and a specificity of 74% for predicting AF. The value of the STAF score for predicting the risk of pAF in stroke patients is limited. © 2012 The Author(s) European Journal of Neurology © 2012 EFNS.

Echocardiographic diagnosis of left ventricular-right atrial communication (Gerbode-type defect) in an adult with chronic renal failure: a case report.

PubMed

Eroglu, Serpil; Sade, Elif; Bozbas, Huseyin; Pirat, Bahar; Yildirir, Aylin; Muderrisoglu, Haldun

2008-03-01

Left ventricular-right atrial communication, known as a Gerbode-type defect, is a rare form of ventricular septal defect. It is usually congenital, but rarely acquired. Clinical presentation is associated with the volume of the shunt. Transthoracic echocardiography is the most useful diagnostic method. We present a 63-year-old man with chronic renal failure and left ventricular-right atrial shunt.

Global left atrial failure in heart failure.

PubMed

Triposkiadis, Filippos; Pieske, Burkert; Butler, Javed; Parissis, John; Giamouzis, Gregory; Skoularigis, John; Brutsaert, Dirk; Boudoulas, Harisios

2016-11-01

The left atrium plays an important role in the maintenance of cardiovascular and neurohumoral homeostasis in heart failure. However, with progressive left ventricular dysfunction, left atrial (LA) dilation and mechanical failure develop, which frequently culminate in atrial fibrillation. Moreover, LA mechanical failure is accompanied by LA endocrine failure [deficient atrial natriuretic peptide (ANP) processing-synthesis/development of ANP resistance) and LA regulatory failure (dominance of sympathetic nervous system excitatory mechanisms, excessive vasopressin release) contributing to neurohumoral overactivity, vasoconstriction, and volume overload (global LA failure). The purpose of the present review is to describe the characteristics and emphasize the clinical significance of global LA failure in patients with heart failure. © 2016 The Authors. European Journal of Heart Failure © 2016 European Society of Cardiology.

Surgical management of the left superior vena cava draining into the left atrium: a novel off-pump technique using the left atrial appendage

PubMed Central

Boutayeb, Alaae; Marmade, Lahcen; Bensouda, Adil; Moughil, Said

2012-01-01

The left superior vena cava is the most common congenital venous anomaly in the chest; however, its drainage into the left atrium is exceptional. The aim of the paper is to describe our novel technique to connect the left superior vena cava to the right cavities using the left atrial appendage, without cardiopulmonary bypass. PMID:22802356

Assessment of left atrial appendage function by transthoracic pulsed Doppler echocardiography: Comparing against transesophageal interrogation and predicting echocardiographic risk factors for stroke.

PubMed

Wai, Shin Hnin; Kyu, Kyu; Galupo, Mary Joyce; Songco, Geronica G; Kong, William K F; Lee, Chi Hang; Yeo, Tiong Cheng; Poh, Kian Keong

2017-10-01

Transesophageal echocardiographic (TEE) findings of left atrial appendage (LAA) thrombus, spontaneous echo contrast (SEC), and LAA dysfunction are established risk factors of cardioembolic stroke. The semi-invasive nature of TEE limits its utility as a routine risk stratification tool. We aim to correlate TEE and transthoracic echocardiography (TTE) pulsed Doppler measurements of LAA flow velocities and use TTE measurements to predict TEE findings. We prospectively measured pulsed Doppler LAA flow velocities in 103 consecutive patients on TEE and TTE. There was a strong correlation between TEE and TTE LAA emptying velocity (LAA E) (r = .88, P < .001) and a moderate correlation between LAA filling velocities (r = .50, P < .001). TTE LAA E predicted the presence of thrombus or SEC independent of atrial fibrillation (AF). To predict the presence of thrombus or SEC, the optimal TTE LAA E cutoff was ≤30 cm/s in all patients (75% sensitive, 90% specific) and ≤31 cm/s in AF patients (80% sensitive, 79% specific). To predict LAA dysfunction (TEE E ≤ 20 cm/s), the optimal TTE LAA E cutoff was ≤27 cm/s (100% sensitive, 89% specific in all patients and 100% sensitive, 74% specific in AF patients). TTE assessment of LAA function is feasible and correlates well with the more invasive TEE method. It predicts the presence of thrombus, SEC, and LAA dysfunction on TEE. TTE LAA assessment has incremental value in thromboembolic risk stratification and should be utilized more frequently. © 2017, Wiley Periodicals, Inc.

The Value of 3D Printing Models of Left Atrial Appendage Using Real-Time 3D Transesophageal Echocardiographic Data in Left Atrial Appendage Occlusion: Applications toward an Era of Truly Personalized Medicine.

PubMed

Liu, Peng; Liu, Rijing; Zhang, Yan; Liu, Yingfeng; Tang, Xiaoming; Cheng, Yanzhen

The objective of this study was to assess the clinical feasibility of generating 3D printing models of left atrial appendage (LAA) using real-time 3D transesophageal echocardiogram (TEE) data for preoperative reference of LAA occlusion. Percutaneous LAA occlusion can effectively prevent patients with atrial fibrillation from stroke. However, the anatomical structure of LAA is so complicated that adequate information of its structure is essential for successful LAA occlusion. Emerging 3D printing technology has the demonstrated potential to structure more accurately than conventional imaging modalities by creating tangible patient-specific models. Typically, 3D printing data sets are acquired from CT and MRI, which may involve intravenous contrast, sedation, and ionizing radiation. It has been reported that 3D models of LAA were successfully created by the data acquired from CT. However, 3D printing of the LAA using real-time 3D TEE data has not yet been explored. Acquisition of 3D transesophageal echocardiographic data from 8 patients with atrial fibrillation was performed using the Philips EPIQ7 ultrasound system. Raw echocardiographic image data were opened in Philips QLAB and converted to 'Cartesian DICOM' format and imported into Mimics® software to create 3D models of LAA, which were printed using a rubber-like material. The printed 3D models were then used for preoperative reference and procedural simulation in LAA occlusion. We successfully printed LAAs of 8 patients. Each LAA costs approximately CNY 800-1,000 and the total process takes 16-17 h. Seven of the 8 Watchman devices predicted by preprocedural 2D TEE images were of the same sizes as those placed in the real operation. Interestingly, 3D printing models were highly reflective of the shape and size of LAAs, and all device sizes predicted by the 3D printing model were fully consistent with those placed in the real operation. Also, the 3D printed model could predict operating difficulty and the presence of a peridevice leak. 3D printing of the LAA using real-time 3D transesophageal echocardiographic data has a perfect and rapid application in LAA occlusion to assist with physician planning and decision making. © 2016 S. Karger AG, Basel.

Pulmonary vein activity does not predict the outcome of catheter ablation for persistent atrial fibrillation: A long-term multicenter prospective study.

PubMed

Prabhu, Sandeep; Kalla, Manish; Peck, Kah Y; Voskoboinik, Aleksandr; McLellan, Alex J A; Pathik, Bupesh; Nalliah, Chrishan J; Wong, Geoff R; Sugumar, Hariharan; Azzopardi, Sonia M; Lee, Geoffrey; Ling, Liang-Han; Kalman, Jonathan M; Kistler, Peter M

2018-03-02

Pulmonary vein (PV) isolation (PVI) remains the cornerstone of catheter ablation (CA) in persistent atrial fibrillation (AF) (PeAF), although less successful than for paroxysmal AF. Whether rapid or fibrillatory (PV AF) PV firing may identify patients with PeAF more likely to benefit from a PV-based ablation approach is unclear. The purpose of this study was to determine the relationship between the PV cycle length (PVCL) and the PV AF outcome after CA. Before ablation, the multipolar catheter was placed in each PV and the left atrial appendage (LAA) for 100 consecutive cycles. The presence of PV AF, the average PVCL of all 4 veins (PV 4VAverage ), the fastest vein average (PV FVAverage ), the fastest cycle length (PV Fast ) both individually and relative to the average LAA cycle length were calculated. The ablation strategy included PVI and posterior wall isolation with a minimum of 12 months follow-up. A total of 123 patients underwent CA (age 62 ± 9.1 years; CHA 2 DS 2 -VASC score 1.6 ± 1.1; left ventricular ejection fraction 48% ± 13%; left atrial area 31 ± 8.7 cm 2 ; AF duration 16 ± 17 months). PVI was achieved in 100% of patients. Multiprocedure success (MPS; freedom from AF/atrial tachycardia episodes lasting >30 seconds) was achieved in 76% of patients at 24 ± 8.1 months of follow-up after 1.2 ± 0.4 procedures. PV activity was not associated with MPS either absolutely (PV 4VAverage [MPS no vs yes: 178 ± 27 ms vs 177 ± 24 ms; P = .92], PV FVAverage [P = .69], or PV Fast [P = .82]) or as a ratio relative to the LAA cycle length (PV 4VAverage /LAA 1.05 ± 0.11 vs 1.06 ± 0.21; P = .87). The presence of PV AF (31% vs 47%; P = .13) did not predict MPS. The rapidity of PV firing or presence of fibrillation within the PV was not predictive of outcome of CA for PeAF. PV activity does not identify patients most likely to benefit from a PV-based ablation strategy. Copyright © 2018 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

The Effect of Atrial Fibrillation Ablation Techniques on P Wave Duration and P Wave Dispersion.

PubMed

Furniss, Guy O; Panagopoulos, Dimitrios; Kanoun, Sadeek; Davies, Edward J; Tomlinson, David R; Haywood, Guy A

2018-02-14

A reduction in surface electrocardiogram (ECG) P wave duration and dispersion is associated with improved outcomes in atrial fibrillation ablation. We investigated the effects of different ablation strategies on P wave duration and dispersion, hypothesising that extensive left atrial (LA) ablation with left atrial posterior wall isolation would give a greater reduction in P wave duration than more limited ablation techniques. A retrospective analysis of ECGs from patients who have undergone atrial fibrillation (AF) ablation was performed and pre-procedural sinus rhythm ECGs were compared with the post procedure ECGs. Maximal P wave duration was measured in leads I or II, minimum P wave duration in any lead and values were calculated for P wave duration and dispersion. Left atrial dimensions and medications at the time of ECG were documented. Ablation strategies compared were; pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) and the persistent AF (PsAF) ablation strategies of pulmonary vein isolation plus additional linear lesions (Lines), left atrial posterior wall isolation via catheter (PWI) and left atrial posterior wall isolation via staged surgical and catheter ablation (Hybrid). Sixty-nine patients' ECGs were analysed: 19 PVI, 21 Lines, 14 PWI, 15 Hybrid. Little correlation was seen between pre-procedure left atrial size and P wave duration (r=0.24) but LA size and P wave duration was larger in PsAF patients. A significant difference was seen in P wave reduction driven by Hybrid AF ablation (p<0.005) and Lines (<0.02). There was no difference amongst P wave dispersion between groups but the largest reduction was seen in the Hybrid ablation group. P wave duration increased with duration of continuous atrial fibrillation. Hybrid AF ablation significantly reduced P wave duration and dispersion compared to other ablation strategies including posterior wall isolation via catheter despite this being the same lesion set. Copyright © 2018 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.

Evaluating the Atrial Myopathy Underlying Atrial Fibrillation: Identifying the Arrhythmogenic and Thrombogenic Substrate

PubMed Central

Goldberger, Jeffrey J.; Arora, Rishi; Green, David; Greenland, Philip; Lee, Daniel C.; Lloyd-Jones, Donald M.; Markl, Michael; Ng, Jason; Shah, Sanjiv J.

2015-01-01

Atrial disease or myopathy forms the substrate for atrial fibrillation (AF) and underlies the potential for atrial thrombus formation and subsequent stroke. Current diagnostic approaches in patients with AF focus on identifying clinical predictors with evaluation of left atrial size by echocardiography serving as the sole measure specifically evaluating the atrium. Although the atrial substrate underlying AF is likely developing for years prior to the onset of AF, there is no current evaluation to identify the pre-clinical atrial myopathy. Atrial fibrosis is one component of the atrial substrate that has garnered recent attention based on newer MRI techniques that have been applied to visualize atrial fibrosis in humans with prognostic implications regarding success of treatment. Advanced ECG signal processing, echocardiographic techniques, and MRI imaging of fibrosis and flow provide up-to-date approaches to evaluate the atrial myopathy underlying AF. While thromboembolic risk is currently defined by clinical scores, their predictive value is mediocre. Evaluation of stasis via imaging and biomarkers associated with thrombogenesis may provide enhanced approaches to assess risk for stroke in patients with AF. Better delineation of the atrial myopathy that serves as the substrate for AF and thromboembolic complications might improve treatment outcomes. Furthermore, better delineation of the pathophysiologic mechanisms underlying the development of the atrial substrate for AF, particularly in its earlier stages, could help identify blood and imaging biomarkers that could be useful to assess risk for developing new onset AF and suggest specific pathways that could be targeted for prevention. PMID:26216085

Relation of female sex to left atrial diameter and cardiovascular death in atrial fibrillation: The AFFIRM Trial.

PubMed

Proietti, Marco; Raparelli, Valeria; Basili, Stefania; Olshansky, Brian; Lip, Gregory Y H

2016-03-15

Female sex is associated with thromboembolism related to atrial fibrillation (AF). Left atrial (LA) diameter independently predicted incident cardiovascular (CV) major events in the general population. In AF patients, LA enlargement is associated to AF occurrence and recurrence. No data have previously been reported on the relationship between LA enlargement, sex and CV death in AF patients. All patients enrolled in the AFFIRM Trial with available data about LA dimension were included in this post-hoc analysis. Of the 2615 eligible for the present analysis, LA enlargement was recorded in 67.0%, more commonly in women than in men (p=0.032). Patients with LA enlargement had higher body mass index (BMI), and were more frequently hypertensive, diabetic, and diagnosed with a structural heart disease, prior coronary artery disease (CAD) and heart failure (HF). BMI, left ventricular mass, female sex and mitral valve insufficiency (p<0.001) were associated with LA enlargement. AF female patients with LA enlargement had a higher risk for CV death (p=0.011). LA diameter showed a significant association with CV death (p<0.001). Cox regression analysis demonstrated that LA diameter was an independent predictor of CV death in female AF patients (p=0.003). LA diameter enlargement is associated with female sex, and carries a higher risk for CV death, particularly in females. LA diameter was an independent predictor of CV death in female AF patients. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

[Plasma cardiac natriuretic peptide as a biological marker of recurrence of atrial fibrillation in elderly people].

PubMed

Mabuchi, N; Tsutamoto, T; Maeda, K; Masahiko, K

2000-07-01

We designed this study to evaluate the relationship between plasma atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) levels and recurrence of atrial fibrillation (AF) after direct current cardioversion (DC) and the differences with aging. Fifty patients with mild congestive heart failure (CHF) undergoing elective DC of AF were included in this study (New York Heart Association (NYHA) functional class II: n = 42, III = 8). Patients who failed to show restoration of sinus rhythm or those with mitral valve stenosis were excluded. Before successful DC, we measured plasma levels of ANP and BNP and evaluated left atrial dimension (LAD), left ventricular end-diastolic dimension (LVDd), and left ventricular ejection fraction (EF) by echocardiography. Twenty-one patients had recurrence of AF within 2 months after DC (average 9.05 days). We followed up the other 29 patients for 580.5 days. By Cox stepwise multivariate analysis, history of AF (p = 0.007), low plasma levels of ANP (p = 0.003), and high plasma levels of BNP (p = 0.0003) were found to be independent predictors of recurrent AF. High plasma BNP levels indicating ventricular dysfunction and low plasma ANP levels may be due to atrial histological change such as fibrosis. In these patients, plasma ratios of ANP and BNP (ANP/BNP) less than 0.43 were predictive factors for AF recurrence (sensitivity 70%, specificity 62%), especially in patients who were older than 70 years (sensitivity 100%, specificity 80%). Relatively low plasma ANP level compared to BNP is an independent risk factor of AF recurrence in patients with CHF, especially in elderly patients, suggesting that plasma cardiac natriuretic peptides are important biochemical markers of AF recurrence in elderly patients with CHF.

Cardiac troponin I: prothrombotic risk marker in non-valvular atrial fibrillation.

PubMed

Providência, Rui; Paiva, Luís; Faustino, Ana; Botelho, Ana; Trigo, Joana; Casalta-Lopes, João; Nascimento, José; Leitão-Marques, António Manuel

2013-08-10

Evidence of a link between small rises in cardiac troponin I (cTnI) and an increased risk of thromboembolic events (TE) in atrial fibrillation (AF) is currently scarce. We aimed to assess the relation between cTnI and findings of an increased thromboembolic risk in patients with non-valvular AF using transesophageal echocardiography. We have included 245 patients performing transthoracic and transesophageal echocardiogram, alongside with laboratory assessment (including cTnI) in a cross-sectional survey. Changes associated to TE were sought on transesophageal echocardiogram: left atrial or left atrial appendage thrombus, dense spontaneous echocardiographic contrast, low flow velocities in the left atrial appendage and protuberant aortic plaques. Comparisons were performed according to the baseline concentration of cTnI, regarding the prevalence of these changes. We have added cTnI to CHADS2 and CHA2DS2-VASc scores in order to assess its capability to refine risk stratification using transesophageal markers as surrogate endpoints and assessed it by means of ROC-curve analysis and Net Reclassification Improvement (NRI). A direct relation between rising concentrations of cTnI and a higher prevalence of transesophageal echocardiogram changes was found. Furthermore, the addition of cTnI to CHADS2 and CHA2DS2-VASc scores improved their ability to predict changes associated to TE on transesophageal echocardiography both through ROC-curve analysis and NRI. cTnI seems to be associated to thromboembolic risk in patients with AF. The possible role of cTnI in the refinement of risk stratification schemes needs to be tested in further prospective studies using clinical endpoints. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Coherex WAVECREST I Left Atrial Appendage Occlusion Study

ClinicalTrials.gov

2015-01-13

Non-valvular Paroxysmal, Persistent, or Permanent Atrial Fibrillation; LAA Anatomy Amenable to Treatment by Percutaneous Technique; Anticoagulation Indication for Potential Thrombus Formation in the Left Atrium

Intermittent changing axis deviation with intermittent left anterior hemiblock during atrial flutter with subclinical hyperthyroidism.

PubMed

Patanè, Salvatore; Marte, Filippo

2009-06-26

Subclinical hyperthyroidism is an increasingly recognized entity that is defined as a normal serum free thyroxine and free triiodothyronine levels with a thyroid-stimulating hormone level suppressed below the normal range and usually undetectable. It has been reported that subclinical hyperthyroidism is not associated with CHD or mortality from cardiovascular causes but it is usually associated with a higher heart rate and a higher risk of supraventricular arrhythmias including atrial fibrillation and atrial flutter. Intermittent changing axis deviation during atrial fibrillation has also rarely been reported. We present a case of intermittent changing axis deviation with intermittent left anterior hemiblock in a 59-year-old Italian man with atrial flutter and subclinical hyperthyroidism. To our knowledge, this is the first report of intermittent changing axis deviation with intermittent left anterior hemiblock in a patient with atrial flutter.

78 FR 67365 - Circulatory System Devices Panel of the Medical Devices Advisory Committee; Notice of Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2013-11-12

... reduce the risk of life-threatening bleeding events in patients with non-valvular atrial fibrillation who... premarket approval application regarding the Boston Scientific WATCHMAN Left Atrial Appendage (LAA) Closure... placed in the left atrial appendage. This device is intended to prevent thrombus embolization from the...

Assessment of left atrial volume and function: a comparative study between echocardiography, magnetic resonance imaging and multi slice computed tomography.

PubMed

Kühl, J Tobias; Lønborg, Jacob; Fuchs, Andreas; Andersen, Mads J; Vejlstrup, Niels; Kelbæk, Henning; Engstrøm, Thomas; Møller, Jacob E; Kofoed, Klaus F

2012-06-01

Measurement of left atrial (LA) maximal volume (LA(max)) using two-dimensional transthoracic echocardiography (TTE) provides prognostic information in several cardiac diseases. However, the relationship between LA(max) and LA function is poorly understood and TTE is less well suited for measuring dynamic LA volume changes. Conversely, cardiac magnetic resonance imaging (CMR) and multi-slice computed tomography (MSCT) appears more appropriate for such measures. We sought to determine the relationship between LA size assessed with TTE and LA size and function assessed with CMR and MSCT. Fifty-four patients were examined 3 months post myocardial infarction with echocardiography, CMR and MSCT. Left atrial volumes and LA reservoir function were assessed by TTE. LA time-volume curves were determined and LA reservoir function (cyclic change and fractional change), passive emptying function (reservoir volume) and pump function (left atrial ejection fraction-LAEF) were derived using CMR and MSCT. Left atrial fractional change and left atrial ejection fraction (LAEF) determined with CMR and MSCT were unrelated to LA(max) enlargement by echocardiography (P = NS). There was an overall good agreement between CMR and MSCT, with a small to moderate bias in LA(max) (4.9 ± 10.4 ml), CC (3.1 ± 9.1 ml) and reservoir volume (3.4 ± 9.1 ml). TTE underestimates LA(max) with up to 32% compared with CMR and MSCT (P < 0.001). Left atrial function assessed with MSCT and CMR as LA fractional change and LAEF is not significantly related to LA(max) measured by TTE. TTE systematically underestimated LA volumes, whereas there are good agreements between MSCT and CMR for volumetric and functional properties.

Plasmacytoid lymphoma within a left atrial myxoma: a rare coincidental dual pathology.

PubMed

White, Ralph W; Hirst, Natalie A; Edward, Sara; Nair, Unnikrishnan R

2010-01-01

Primary malignant cardiac neoplasms are extremely rare. The occurrence of a malignant lymphoid tumour within a left atrial myxoma is highly atypical, with only one such case previously reported. Here, we describe a patient who presented with symptoms and signs of a left atrial myxoma. Subsequent specimen histology demonstrated the presence of lymphoma within the myxoma. We discuss the importance of histological diagnosis in order to best direct treatment and prognosis of such cases.

Echocardiographic reference ranges for normal left atrial function parameters: results from the EACVI NORRE study.

PubMed

Sugimoto, Tadafumi; Robinet, Sébastien; Dulgheru, Raluca; Bernard, Anne; Ilardi, Federica; Contu, Laura; Addetia, Karima; Caballero, Luis; Kacharava, George; Athanassopoulos, George D; Barone, Daniele; Baroni, Monica; Cardim, Nuno; Hagendorff, Andreas; Hristova, Krasimira; Lopez, Teresa; de la Morena, Gonzalo; Popescu, Bogdan A; Penicka, Martin; Ozyigit, Tolga; Rodrigo Carbonero, Jose David; van de Veire, Nico; Von Bardeleben, Ralph Stephan; Vinereanu, Dragos; Zamorano, Jose Luis; Go, Yun Yun; Marchetta, Stella; Nchimi, Alain; Rosca, Monica; Calin, Andreea; Moonen, Marie; Cimino, Sara; Magne, Julien; Cosyns, Bernard; Galli, Elena; Donal, Erwan; Habib, Gilbert; Esposito, Roberta; Galderisi, Maurizio; Badano, Luigi P; Lang, Roberto M; Lancellotti, Patrizio

2018-06-01

To obtain the normal ranges for echocardiographic measurements of left atrial (LA) function from a large group of healthy volunteers accounting for age and gender. A total of 371 (median age 45 years) healthy subjects were enrolled at 22 collaborating institutions collaborating in the Normal Reference Ranges for Echocardiography (NORRE) study of the European Association of Cardiovascular Imaging (EACVI). Left atrial data sets were analysed with a vendor-independent software (VIS) package allowing homogeneous measurements irrespective of the echocardiographic equipment used to acquire data sets. The lowest expected values of LA function were 26.1%, 48.7%, and 41.4% for left atrial strain (LAS), 2D left atrial emptying fraction (LAEF), and 3D LAEF (reservoir function); 7.7%, 24.2%, and -0.53/s for LAS-active, LAEF-active, and LA strain rate during LA contraction (SRa) (pump function) and 12.0% and 21.6% for LAS-passive and LAEF-passive (conduit function). Left atrial reservoir and conduit function were decreased with age while pump function was increased. All indices of reservoir function and all LA strains had no difference in both gender and vendor. However, inter-vendor differences were observed in LA SRa despite the use of VIS. The NORRE study provides contemporary, applicable echocardiographic reference ranges for LA function. Our data highlight the importance of age-specific reference values for LA functions.

Prognostic value of trans-thoracic echocardiography in patients with acute stroke and atrial fibrillation: findings from the RAF study.

PubMed

Paciaroni, Maurizio; Agnelli, Giancarlo; Falocci, Nicola; Caso, Valeria; Becattini, Cecilia; Marcheselli, Simona; Rueckert, Christina; Pezzini, Alessandro; Poli, Loris; Padovani, Alessandro; Csiba, Laszló; Szabó, Lilla; Sohn, Sung-Il; Tassinari, Tiziana; Abdul-Rahim, Azmil H; Michel, Patrik; Cordier, Maria; Vanacker, Peter; Remillard, Suzette; Alberti, Andrea; Venti, Michele; Acciarresi, Monica; D'Amore, Cataldo; Mosconi, Maria Giulia; Scoditti, Umberto; Denti, Licia; Orlandi, Giovanni; Chiti, Alberto; Gialdini, Gino; Bovi, Paolo; Carletti, Monica; Rigatelli, Alberto; Putaala, Jukka; Tatlisumak, Turgut; Masotti, Luca; Lorenzini, Gianni; Tassi, Rossana; Guideri, Francesca; Martini, Giuseppe; Tsivgoulis, Georgios; Vadikolias, Kostantinos; Liantinioti, Chrissoula; Corea, Francesco; Del Sette, Massimo; Ageno, Walter; De Lodovici, Maria Luisa; Bono, Giorgio; Baldi, Antonio; D'Anna, Sebastiano; Sacco, Simona; Carolei, Antonio; Tiseo, Cindy; Imberti, Davide; Zabzuni, Dorjan; Doronin, Boris; Volodina, Vera; Consoli, Domenico; Galati, Franco; Pieroni, Alessio; Toni, Danilo; Monaco, Serena; Baronello, Mario Maimone; Barlinn, Kristian; Pallesen, Lars-Peder; Kepplinger, Jessica; Bodechtel, Ulf; Gerber, Johannes; Deleu, Dirk; Melikyan, Gayane; Ibrahim, Faisal; Akhtar, Naveed; Lees, Kennedy R

2016-02-01

Anticoagulant therapy is recommended for the secondary prevention of stroke in patients with atrial fibrillation (AF). T he identification of patients at high risk for early recurrence, which are potential candidates to prompt anticoagulation, is crucial to justify the risk of bleeding associated with early anticoagulant treatment. The aim of this study was to evaluate in patients with acute ischemic stroke and AF the association between findings at trans-thoracic echocardiography (TTE) and 90 days recurrence. In consecutive patients with acute ischemic stroke and AF, TTE was performed within 7 days from hospital admission. Study outcomes were recurrent ischemic cerebrovascular events (stroke or TIA) and systemic embolism. 854 patients (mean age 76.3 ± 9.5 years) underwent a TTE evaluation; 63 patients (7.4%) had at least a study outcome event. Left atrial thrombosis was present in 11 patients (1.3%) among whom 1 had recurrent ischemic event. Left atrial enlargement was present in 548 patients (64.2%) among whom 51 (9.3%) had recurrent ischemic events. The recurrence rate in the 197 patients with severe left atrial enlargement was 11.7%. On multivariate analysis, the presence of atrial enlargement (OR 2.13; 95% CI 1.06-4.29, p = 0.033) and CHA2DS2-VASc score (OR 1.22; 95% CI 1.04-1.45, p = 0.018, for each point increase) were correlated with ischemic recurrences. In patients with AF-associated acute stroke, left atrial enlargement is an independent marker of recurrent stroke and systemic embolism. The risk of recurrence is accounted for by severe atrial enlargement. TTE-detected left atrial thrombosis is relatively uncommon.

Wellens' syndrome and other electrocardiographic changes in a patient with a left anterior descending artery subocclusion associated with a left main coronary artery subocclusion.

PubMed

Patanè, Salvatore; Marte, Filippo

2011-09-01

Changing axis deviation has been reported also during atrial fibrillation or atrial flutter. Changing axis deviation has been also reported during acute myocardial infarction associated with atrial fibrillation too or at the end of atrial fibrillation during acute myocardial infarction. Patients with unstable angina have a higher incidence of left main coronary artery (LMCA) and proximal left anterior descending (LAD) coronary artery disease compared to patients with stable angina pectoris. In 1982, Wellens and colleagues described two electrocardiographic patterns that were predictive of critical narrowing of the proximal LAD artery, and were subsequently termed Wellens' syndrome. The criteria were: a) prior history of chest pain, b) little or no cardiac enzyme elevation, c) no pathologic precordial ST segment elevation, d) no loss of precordial R waves, and e) biphasic T waves in leads V2 and V3, or asymmetric, often deeply inverted T waves in leads V2 and V3. The ECG changes are best recognized outside the episode of anginal pain. Lead aVR and lead v1 ST segment elevation, during chest pain, has been reported in patients with LMCA disease with ST segment depression in leads V3, V4 and V5 (with maximal depression in V4).We present a case of changing axis deviation in a 37-year-old Italian man with a LAD coronary artery subocclusion associated with a LMCA subocclusion. This case focuses attention on the importance of the recognition of the patterns suspected for LAD coronary artery disease or for LMCA disease. Copyright © 2009 Elsevier Ireland Ltd. All rights reserved.

Assessment of Left Atrial Deformation and Function by 2-Dimensional Speckle Tracking Echocardiography in Healthy Dogs and Dogs With Myxomatous Mitral Valve Disease.

PubMed

Baron Toaldo, M; Romito, G; Guglielmini, C; Diana, A; Pelle, N G; Contiero, B; Cipone, M

2017-05-01

The assessment of left atrial (LA) function by 2-dimensional speckle tracking echocardiography (STE) holds important clinical implications in human medicine. Few similar data are available in dogs. To assess LA function by STE in dogs with and without myxomatous mitral valve disease (MMVD), analyzing LA areas, systolic function, and strain. One hundred and fifty dogs were divided according to the American College of Veterinary Internal Medicine classification of heart failure: 23 dogs in class A, 52 in class B1, 36 in class B2, and 39 in class C + D. Prospective observational study. Conventional morphologic and Doppler variables, LA areas, and STE-based LA strain analysis were performed in all dogs and results were compared among groups. Correlation analysis was carried out between LA STE variables and other echocardiographic variables. Variability study showed good reproducibility for all the tested variables (coefficient of variation <16%). Left atrial areas, fractional area change, peak atrial longitudinal strain (PALS), peak atrial contraction strain, and contraction strain index (CSI) differed significantly between groups B2 and C + D and all the other groups (overall P < .001), whereas only PALS differed between groups B1 and A (P = .01). Left atrial areas increased with progression of the disease, whereas LA functional parameters decreased. Only CSI increased nonsignificantly from group A to group B1 and then progressively decreased. Thirty-one significant correlations (P < .001, r > .3) were found between conventional left heart echocardiographic variables and LA areas and strain variables. Left atrial STE analysis provides useful information on atrial function in the dog, highlighting a progressive decline in atrial function with worsening of MMVD. Copyright © 2017 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals, Inc. on behalf of the American College of Veterinary Internal Medicine.

Validation of semi-automatic segmentation of the left atrium

NASA Astrophysics Data System (ADS)

Rettmann, M. E.; Holmes, D. R., III; Camp, J. J.; Packer, D. L.; Robb, R. A.

2008-03-01

Catheter ablation therapy has become increasingly popular for the treatment of left atrial fibrillation. The effect of this treatment on left atrial morphology, however, has not yet been completely quantified. Initial studies have indicated a decrease in left atrial size with a concomitant decrease in pulmonary vein diameter. In order to effectively study if catheter based therapies affect left atrial geometry, robust segmentations with minimal user interaction are required. In this work, we validate a method to semi-automatically segment the left atrium from computed-tomography scans. The first step of the technique utilizes seeded region growing to extract the entire blood pool including the four chambers of the heart, the pulmonary veins, aorta, superior vena cava, inferior vena cava, and other surrounding structures. Next, the left atrium and pulmonary veins are separated from the rest of the blood pool using an algorithm that searches for thin connections between user defined points in the volumetric data or on a surface rendering. Finally, pulmonary veins are separated from the left atrium using a three dimensional tracing tool. A single user segmented three datasets three times using both the semi-automatic technique as well as manual tracing. The user interaction time for the semi-automatic technique was approximately forty-five minutes per dataset and the manual tracing required between four and eight hours per dataset depending on the number of slices. A truth model was generated using a simple voting scheme on the repeated manual segmentations. A second user segmented each of the nine datasets using the semi-automatic technique only. Several metrics were computed to assess the agreement between the semi-automatic technique and the truth model including percent differences in left atrial volume, DICE overlap, and mean distance between the boundaries of the segmented left atria. Overall, the semi-automatic approach was demonstrated to be repeatable within and between raters, and accurate when compared to the truth model. Finally, we generated a visualization to assess the spatial variability in the segmentation errors between the semi-automatic approach and the truth model. The visualization demonstrates the highest errors occur at the boundaries between the left atium and pulmonary veins as well as the left atrium and left atrial appendage. In conclusion, we describe a semi-automatic approach for left atrial segmentation that demonstrates repeatability and accuracy, with the advantage of significant time reduction in user interaction time.

Hypertension and atrial fibrillation: epidemiology, pathophysiology and therapeutic implications.

PubMed

Lau, Y-F; Yiu, K-H; Siu, C-W; Tse, H-F

2012-10-01

Hypertension is one of the most important risk factors associated with atrial fibrillation (AF) and increased the risk of cardiovascular events in patients with AF. However, the pathophysiological link between hypertension and AF is unclear. Nevertheless, this can be explained by the hemodynamic changes of the left atrium secondary to long standing hypertension, resulting in elevated left atrium pressure and subsequently left atrial enlargement. Moreover, the activation of renin-angiotensin-aldosterone system (RAAS) activation in patients with hypertension induces left atrial fibrosis and conduction block in the left atrium, resulting in the development of AF. Accordingly, recent studies have shown that effective blockage of RAAS by angiotensin converting enzyme inhibitors or angiotensin receptor antagonist may be effective in both primary and secondary prevention of AF in patients with hypertension, although with controversies. In addition, optimal antithrombotic therapy, blood pressure control as well as rate control for AF are key to the management of patients with AF.

Clinical impact of quantitative left atrial vortex flow analysis in patients with atrial fibrillation: a comparison with invasive left atrial voltage mapping.

PubMed

Lee, Jung Myung; Hong, Geu-Ru; Pak, Hui-Nam; Shim, Chi Young; Houle, Helene; Vannan, Mani A; Kim, Minji; Chung, Namsik

2015-08-01

Recently, left atrial (LA) vortex flow analysis using contrast transesophageal echocardiography (TEE) has been shown to be feasible and has demonstrated significant differences in vortex flow morphology and pulsatility between normal subjects and patients with atrial fibrillation (AF). However, the relationship between LA vortex flow and electrophysiological properties and the clinical significance of LA vortex flow are unknown. The aims of this study were (1) to compare LA vortex flow parameters with LA voltage and (2) to assess the predictive value of LA vortex flow parameters for the recurrence of AF after radiofrequency catheter ablation (RFCA). Thirty-nine patients with symptomatic non-valvular AF underwent contrast TEE before undergoing RFCA for AF. Quantitative LA vortex flow parameters were analyzed by Omega flow (Siemens Medical Solution, Mountain View, CA, USA). The morphology and pulsatility of LA vortex flow were compared with electrophysiologic parameters that were measured invasively. Hemodynamic, electrophysiological, and vortex flow parameters were compared between patients with and without early recurrence of AF after RFCA. Morphologic parameters, including LA vortex depth, length, width, and sphericity index were not associated with LA voltage or hemodynamic parameters. The relative strength (RS), which represents the pulsatility power of LA, was positively correlated with LA voltage (R = 0.53, p = 0.01) and LA appendage flow velocity (R = 0.73, p < 0.001) and negatively correlated with LA volume index (R = -0.56, p < 0.001). Patients with recurrent AF after RFCA showed significantly lower RS (1.7 ± 0.2 vs 1.9 ± 0.4, p = 0.048) and LA voltage (0.9 ± 0.7 vs 1.7 ± 0.8, p = 0.004) than patients without AF recurrence. In the relatively small LA dimension group (LA volume index ≤ 33 ml/m(2)), RS was significantly lower (2.1 ± 0.3 vs 1.7 ± 0.1, p = 0.029) in patients with the recurrent AF. Quantitative LA vortex flow analysis, especially RS, correlated well with LA voltage. Decreased pulsatility strength in the LA was associated with recurrent AF. LA vortex may have incremental value in predicting the recurrence of AF.

The association between acute mental stress and abnormal left atrial electrophysiology.

PubMed

O'Neal, Wesley T; Hammadah, Muhammad; Sandesara, Pratik B; Almuwaqqat, Zakaria; Samman-Tahhan, Ayman; Gafeer, Mohamad M; Abdelhadi, Naser; Wilmot, Kobina; Al Mheid, Ibhar; Bremner, Douglas J; Kutner, Michael; Soliman, Elsayed Z; Shah, Amit J; Quyyumi, Arshed A; Vaccarino, Viola

2017-10-01

Acute stress may trigger atrial fibrillation (AF), but the underlying mechanisms are unclear. We examined if acute mental stress results in abnormal left atrial electrophysiology as detected by more negative deflection of P-wave terminal force in lead V 1 (PTFV 1 ), a well-known marker of AF risk. We examined this hypothesis in 422 patients (mean age = 56 ± 10 years; 61% men; 44% white) with stable coronary heart disease who underwent mental (speech task) stress testing. PTFV 1 was defined as the duration (milliseconds) times the value of the depth (μV) of the downward deflection (terminal portion) of the P-wave in lead V 1 measured on digital electrocardiograms (ECG). Electrocardiographic left atrial abnormality was defined as PTFV 1 ≤ -4000 μV*ms. Mean PTFV 1 values during stress and recovery were compared with rest. The percentage of participants who developed left atrial abnormality during stress and recovery was compared with the percentage at rest. Compared with rest, PTFV 1 became more negative during mental stress (mean change =  -348, 95% CI = [-515, -182]; P < 0.001) and no change was observed at recovery (mean change = 12, 95%CI = [-148, 172]; P = 0.89). A larger percentage of participants showed left atrial abnormality on ECGs obtained at stress (n = 163, 39%) and recovery (n = 142, 34%) compared with rest (n = 127, 30%). Acute mental stress alters left atrial electrophysiology, suggesting that stressful situations promote adverse transient electrical changes to provide the necessary substrate for AF. © 2017 Wiley Periodicals, Inc.

Association Between Local Bipolar Voltage and Conduction Gap Along the Left Atrial Linear Ablation Lesion in Patients With Atrial Fibrillation.

PubMed

Masuda, Masaharu; Fujita, Masashi; Iida, Osamu; Okamoto, Shin; Ishihara, Takayuki; Nanto, Kiyonori; Kanda, Takashi; Sunaga, Akihiro; Tsujimura, Takuya; Matsuda, Yasuhiro; Mano, Toshiaki

2017-08-01

A bipolar voltage reflects a thick musculature where formation of a transmural lesion may be hard to achieve. The purpose of this study was to explore the association between local bipolar voltage and conduction gap in patients with persistent atrial fibrillation (AF) who underwent atrial roof or septal linear ablation. This prospective observational study included 42 and 36 consecutive patients with persistent AF who underwent roof or septal linear ablations, respectively. After pulmonary vein isolation, left atrial linear ablations were performed, and conduction gap sites were identified and ablated after first-touch radiofrequency application. Conduction gap(s) after the first-touch roof and septal linear ablation were observed in 13 (32%) and 19 patients (53%), respectively. Roof and septal area voltages were higher in patients with conduction gap(s) than in those without (roof, 1.23 ± 0.77 vs 0.73 ± 0.42 mV, p = 0.010; septal, 0.96 ± 0.43 vs 0.54 ± 0.18 mV, p = 0.001). Trisected regional analyses revealed that the voltage was higher at the region with a conduction gap than at the region without. Complete conduction block across the roof and septal lines was not achieved in 3 (7%) and 6 patients (17%), respectively. Patients in whom a linear conduction block could not be achieved demonstrated higher ablation area voltage than those with a successful conduction block (roof, 1.91 ± 0.74 vs 0.81 ± 0.51 mV, p = 0.001; septal, 1.15 ± 0.56 vs 0.69 ± 0.31 mV, p = 0.006). In conclusion, a high regional bipolar voltage predicts failure to achieve conduction block after left atrial roof or septal linear ablation. In addition, the conduction gap was located at the preserved voltage area. Copyright © 2017 Elsevier Inc. All rights reserved.

Angiotensin converting enzyme 2 activity and human atrial fibrillation: increased plasma angiotensin converting enzyme 2 activity is associated with atrial fibrillation and more advanced left atrial structural remodelling.

PubMed

Walters, Tomos E; Kalman, Jonathan M; Patel, Sheila K; Mearns, Megan; Velkoska, Elena; Burrell, Louise M

2017-08-01

Angiotensin converting enzyme 2 (ACE2) is an integral membrane protein whose main action is to degrade angiotensin II. Plasma ACE2 activity is increased in various cardiovascular diseases. We aimed to determine the relationship between plasma ACE2 activity and human atrial fibrillation (AF), and in particular its relationship to left atrial (LA) structural remodelling. One hundred and three participants from a tertiary arrhythmia centre, including 58 with paroxysmal AF (PAF), 20 with persistent AF (PersAF), and 25 controls, underwent clinical evaluation, echocardiographic analysis, and measurement of plasma ACE2 activity. A subgroup of 20 participants underwent invasive LA electroanatomic mapping. Plasma ACE2 activity levels were increased in AF [control 13.3 (9.5-22.3) pmol/min/mL; PAF 16.9 (9.7-27.3) pmol/min/mL; PersAF 22.8 (13.7-33.4) pmol/min/mL, P = 0.006]. Elevated plasma ACE2 was associated with older age, male gender, hypertension and vascular disease, elevated left ventricular (LV) mass, impaired LV diastolic function and advanced atrial disease (P < 0.05 for all). Independent predictors of elevated plasma ACE2 activity were AF (P = 0.04) and vascular disease (P < 0.01). There was a significant relationship between elevated ACE2 activity and low mean LA bipolar voltage (adjusted R2 = 0.22, P = 0.03), a high proportion of complex fractionated electrograms (R2 = 0.32, P = 0.009) and a long LA activation time (R2 = 0.20, P = 0.04). Plasma ACE2 activity is elevated in human AF. Both AF and vascular disease predict elevated plasma ACE2 activity, and elevated plasma ACE2 is significantly associated with more advanced LA structural remodelling. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.

Renal function decline predicted by left atrial expansion index in non-diabetic cohort with preserved systolic heart function.

PubMed

Hsiao, Shih-Hung; Chiou, Kuan-Rau

2017-05-01

Since natriuretic peptide and troponin are associated with renal prognosis and left atrial (LA) parameters are indicators of subclinical cardiovascular abnormalities, this study investigated whether LA expansion index can predict renal decline. This study analysed 733 (69% male) non-diabetic patients with sinus rhythm, preserved systolic function, and estimated glomerular filtration rate (eGFR) higher than 60 mL/min/1.73 m2. In all patients, echocardiograms were performed and LA expansion index was calculated. Renal function was evaluated annually. The endpoint was a downhill trend in renal function with a final eGFR of <60 mL/min/1.73 m2. Rapid renal decline was defined as an annual decline in eGFR >3 mL/min/1.73 m2. The median follow-up time was 5.2 years, and 57 patients (7.8%) had renal function declines (19 had rapid renal declines, and 38 had incidental renal dysfunction). Events were associated with left ventricular mass index, LA expansion index, and heart failure during the follow-up period. The hazard ratio was 1.426 (95% confidence interval, 1.276-1.671; P < 0.0001) per 10% decrease in LA expansion index and was independently associated with an increased event rate. Compared with the highest quartile for the LA expansion index, the lowest quartile had a 9.7-fold risk of renal function decline in the unadjusted model and a 6.9-fold risk after adjusting for left ventricular mass index and heart failure during the follow-up period. Left atrial expansion index is a useful early indicator of renal function decline and may enable the possibility of early intervention to prevent renal function from worsening. NCT01171040. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.

[Impact of CHA2DS2 VASc score on substrate for persistent atrial fibrillation and outcome post catheter ablation of atrial fibrillation].

PubMed

Ribo, Tang; Jianzeng, Dong; Xiaohui, Liu; Meisheng, Shang; Ronghui, Yu; Deyong, Long; Xin, Du; Junping, Kang; Jiahui, Wu; Man, Ning; Caihua, Sang; Chenxi, Jiang; Rong, Bai; Songnan, Li; Yan, Yao; Songnan, Wen; Changsheng, Ma

2015-08-01

To explore if CHA2DS2 VASc score can predict substrate for persistent atrial fibrillation ( AF) and outcome post catheter ablation of AF. From January 2011 to December 2012,116 patients underwent catheter ablation of persistent AF in our department and were enrolled in this study. CHA2DS2VASc score was calculated as follows: two points were assigned for a history of stroke or transient ischemic attack and age ≥ 75 and 1 point each was assigned for age ≥ 65, a history of hypertension, diabetes,recent cardiac failure, vessel disease, female. Left atrial geometry ( LA) was reconstructed with a 3.5 mm tip ablation catheter with fill-in threshold 10 in CARTO system. The mapping catheter was stabled at each endocardial location for at least 3 seconds for recording. The electrogram recordings at each endocardial location were analyzed with a custom software embedded in the CARTO mapping system. Interval confidence level (ICL) was used to characterize complex fractionated atrial electrograms (CFAEs) . As the default setting of the software, ICL more than or equal to 7 was considered sites with a highly repetitive CFAEs complex. CFAEs index was defined as the fraction of area of ICL more than or equal to 7 to the left atrial surface. The CFAEs index and outcome of catheter ablation among different CHA2DS2VASc groups were compared. Of the 116 patients, CHA2DS2VASc was 0 in 33 patients, 1 in 31 patients and ≥ 2 in 52 patients. Left atrial surface ((121.2 ± 18.9) cm2, (133.6 ± 23.8) cm2, (133.9 ± 16.1) cm2, P = 0.008), left atrial volume ((103.6 ± 24.8) ml, (118.3 ± 27.8) ml, (120.9 ± 20.9) ml, P = 0.005) and CFAEs index (44.6% ± 22.4%, 54.2% ± 22.2%, 58.7% ± 23.1%, P = 0.023) increased in proportion with increasing CHA2DS2VASc. ICLmax, ICLmin and CFAEs spatial distribution were similar among the three groups. During the mean follow-up of (13 ± 8) months, the recurrence rate were 36.4%, 35.5%, 55.8% among the three groups (P = 0.025). A high CHA2DS2VASc score is associated with extensive AF substrate and higher recurrence rate post catheter ablation of persistent AF.

Left atrial ejection force predicts the outcome after catheter ablation for paroxysmal atrial fibrillation.

PubMed

Kishima, Hideyuki; Mine, Takanao; Takahashi, Satoshi; Ashida, Kenki; Ishihara, Masaharu; Masuyama, Tohru

2018-02-01

Left atrium (LA) systolic dysfunction is observed in the early stages of atrial fibrillation (AF) prior to LA anatomical change. We investigated whether LA systolic dysfunction predicts recurrent AF after catheter ablation (CA) in patients with paroxysmal AF. We studied 106 patients who underwent CA for paroxysmal AF. LA systolic function was assessed with the LA emptying volume = Maximum LA volume (LAV max ) - Minimum LA volume (LAV min ), LA emptying fraction = [(LAV max - LAV min )/LAV max ] × 100, and LA ejection force calculated with Manning's method [LA ejection force = (0.5 × ρ × mitral valve area × A 2 )], where ρ is the blood density and A is the late-diastolic mitral inflow velocity. Recurrent AF was detected in 35/106 (33%) during 14.6 ± 9.1 months. Univariate analysis revealed reduced LA ejection force, decreased LA emptying fraction, larger LA diameter, and elevated brain natriuretic peptide as significant variables. On multivariate analysis, reduced LA ejection force and larger LA diameter were independently associated with recurrent AF. Moreover, patients with reduced LA ejection force and larger LA diameter had a higher risk of recurrent AF than preserved LA ejection force (log-rank P = 0.0004). Reduced LA ejection force and larger LA diameter were associated with poor outcome after CA for paroxysmal AF, and could be a new index to predict recurrent AF. © 2017 Wiley Periodicals, Inc.

Investigating relationships between left atrial volume, symmetry, and sphericity

NASA Astrophysics Data System (ADS)

Menon, Prahlad G.; Nedios, Sotiris; Hindricks, Gerhard; Bollmann, Andreas

2016-03-01

Catheter ablation is a safe and effective therapy for drug-refractory patients symptomatic of atrial fibrillation (AF), with up to 80% of patients experiencing long-term arrhythmia-free survival. However, up to 20-40% of patients require more than one procedure in order to become arrhythmia-free. Therefore, appropriate patient selection is paramount to the effective implementation and long-term success of ablation therapy for patients with atrial fibrillation (AF). In this study, as a precursor to evaluating clinical significance of specific LA shape metrics as pre-procedural predictors of AF recurrence following ablative pulmonary vein isolation therapy, we report on a computational geometric analysis in a pilot cohort evaluating relationships between various patient-specific metrics of LA shape which might have such predictive value. This study specifically is focused on establishing the relationship between LA volume and sphericity, using a novel methodology for computing atrial sphericity based on regional shape.

Effect of preload reduction by hemodialysis on left atrial volume and echocardiographic Doppler parameters in patients with end-stage renal disease.

PubMed

Barberato, Silvio H; Mantilla, Diego E V; Misocami, M Arcio; Gonçalves, Simone M; Bignelli, Alexandre T; Riella, Miguel C; Pecoits-Filho, Roberto

2004-11-01

Left atrial (LA) volume has been proposed as a less preload-dependent parameter of diastolic function than Doppler mitral inflow. We hypothesize that in the absence of mitral regurgitation and atrial fibrilation, LA enlargement could be a more practical (and relatively preload-independent) method for the evaluation of left ventricular diastolic function. The aim of the present study was to determine the effects of preload reduction by hemodialysis on LA volume.

Sensitivity analysis of geometrical parameters to study haemodynamics and thrombus formation in the left atrial appendage.

PubMed

García-Isla, Guadalupe; Olivares, Andy Luis; Silva, Etelvino; Nuñez-Garcia, Marta; Butakoff, Constantine; Sanchez-Quintana, Damian; G Morales, Hernán; Freixa, Xavier; Noailly, Jérôme; De Potter, Tom; Camara, Oscar

2018-05-08

The left atrial appendage (LAA) is a complex and heterogeneous protruding structure of the left atrium (LA). In atrial fibrillation patients, it is the location where 90% of the thrombi are formed. However, the role of the LAA in thrombus formation is not fully known yet. The main goal of this work is to perform a sensitivity analysis to identify the most relevant LA and LAA morphological parameters in atrial blood flow dynamics. Simulations were run on synthetic ellipsoidal left atria models where different parameters were individually studied: pulmonary veins and mitral valve dimensions; LAA shape; and LA volume. Our computational analysis confirmed the relation between large LAA ostia, low blood flow velocities and thrombus formation. Additionally, we found that pulmonary vein configuration exerted a critical influence on LAA blood flow patterns. These findings contribute to a better understanding of the LAA and to support clinical decisions for atrial fibrillation patients. Copyright © 2018 John Wiley & Sons, Ltd.

Left atrial physiology and pathophysiology: Role of deformation imaging

PubMed Central

Kowallick, Johannes Tammo; Lotz, Joachim; Hasenfuß, Gerd; Schuster, Andreas

2015-01-01

The left atrium (LA) acts as a modulator of left ventricular (LV) filling. Although there is considerable evidence to support the use of LA maximum and minimum volumes for disease prediction, theoretical considerations and a growing body of literature suggest to focus on the quantification of the three basic LA functions: (1) Reservoir function: collection of pulmonary venous return during LV systole; (2) Conduit function: passage of blood to the left ventricle during early LV diastole; and (3) Contractile booster pump function (augmentation of ventricular filling during late LV diastole. Tremendous advances in our ability to non-invasively characterize all three elements of atrial function include speckle tracking echocardiography (STE), and more recently cardiovascular magnetic resonance myocardial feature tracking (CMR-FT). Corresponding imaging biomarkers are increasingly recognized to have incremental roles in determining prognosis and risk stratification in cardiac dysfunction of different origins. The current editorial introduces the role of STE and CMR-FT for the functional assessment of LA deformation as determined by strain and strain rate imaging and provides an outlook of how this exciting field may develop in the future. PMID:26131333

Obese Hypertensive Men Have Lower Circulating Proatrial Natriuretic Peptide Concentrations Despite Greater Left Atrial Size.

PubMed

Asferg, Camilla L; Andersen, Ulrik B; Linneberg, Allan; Goetze, Jens P; Jeppesen, Jørgen L

2018-05-07

Obese persons have lower circulating natriuretic peptide (NP) concentrations. It has been proposed that this natriuretic handicap plays a role in obesity-related hypertension. In contrast, hypertensive patients with left atrial enlargement have higher circulating NP concentrations. On this background, we investigated whether obese hypertensive men could have lower circulating NP concentrations despite evidence of pressure-induced greater left atrial size. We examined 98 obese men (body mass index [BMI] ≥ 30.0 kg/m2) and 27 lean normotensive men (BMI 20.0-24.9 kg/m2). All men were healthy, medication free, with normal left ventricular ejection fraction. We measured blood pressure using 24-hour ambulatory blood pressure (ABP) recordings. Hypertension was defined as 24-hour ABP ≥ 130/80 mm Hg, and normotension was defined as 24-hour ABP < 130/80 mm Hg. We determined left atrial size using echocardiography, and we measured fasting serum concentrations of midregional proatrial NP (MR-proANP). Of the 98 obese men, 62 had hypertension and 36 were normotensive. The obese hypertensive men had greater left atrial size (mean ± SD: 28.7 ± 6.0 ml/m2) compared with the lean normotensive men (23.5 ± 4.5 ml/m2) and the obese normotensive men (22.7 ± 5.1 ml/m2), P < 0.01. Nevertheless, despite evidence of pressure-induced greater left atrial size, the obese hypertensive men had lower serum MR-proANP concentrations (median [interquartile range]: 48.5 [37.0-64.7] pmol/l) compared with the lean normotensive men (69.3 [54.3-82.9] pmol/l), P < 0.01, whereas the obese normotensive men had serum MR-proANP concentrations in between the 2 other groups (54.1 [43.6-62.9] pmol/l). Despite greater left atrial size, obese hypertensive men have lower circulating MR-proANP concentrations compared with lean normotensive men.

Time of Occurrence and Duration of Atrial Fibrillation Following Coronary Artery Bypass Grafting.

PubMed

Avdic, Sevleta; Osmanovic, Enes; Kadric, Nedzad; Mujanovic, Emir; Ibisevic, Merima; Avdic, Azra

2016-04-01

Dilatation of the left atrium and left ventricular diastolic dysfunction (DDLV) according to recent studies has significance in the occurrence of postoperative atrial fibrillation (AF), stroke and death. Authors of some studies found no relationship between these parameters and atrial fibrillation. this study is to determine the time of occurrence and duration of atrial fibrillation in patients after surgical revascularization (CABG) due to the presence of left ventricular diastolic dysfunction and left atrium dilatation and identify the most significant predictors of incident AF. Prospective study included 116 patients undergoing surgical myocardial revascularization followed from admission to discharge. The study was conducted at the Special Hospital "Heart Center BH" Tuzla for a period of one year (March 2011/2012 g.). For all patients was performed preoperative ultrasound examination, especially parameters of diastolic function of the left ventricle and left atrium volume index (LAVi), as the best parameter sized left atrium, and the postoperative occurrence of certain AF and day occurrence, duration in hours, the number of attacks. To assess whether an event occurred or not was used logistic regression, and the effect of time on the event of interest is analyzed by Cox 's regression hazard parallel. 75.9 % of patients had DDLV, and 91.4 % were hypertensives, 12.9 % from the previous stroke (ICV) and 42.2 % diabetics (DM), 14 % with COPD. The average age of patients was 61.41 ± 4.69 years. In both groups was 32.8 % women and 67.2 % men. LAVi preoperative values were significantly higher as DDLV greater degree. In patients with DDLV and higher values LAVi risk of AF is higher, the greater the length of AF and significantly higher number of attacks FA. Early occurrence of atrial fibrillation and its longer duration in function with increasing LAVi a marked increase in the value LAVi have the greatest hazard for the early appearance of atrial fibrillation. As a result of analysis of the most significant predictors of AF are DDLV and LAVi. Postoperative atrial fibrillation occurs earlier and lasts longer in patients with DDLV and elevated left atrial volume index especially LAV > 36ml/m(2). LAVi has the best explanation of the function of hazard occurrence of atrial fibrillation after CABG.

[Structural and functional changes of myocardium in Chernobyl disaster clean-up workers with atrial fibrillation].

PubMed

Khomaziuk, I M; Habulavichene, Zh M; Khomaziuk, V A

2011-01-01

Particularities and clinical importance of the structural and functional changes of myocardium were estimated in Chernobyl disaster clean-up workers with atrial fibrillation (AF). We examined 122 men with AF, which was associated with ischemic heart disease and arterial hypertension. Paroxysmal AF was diagnosed in 42 patients, 80 patients had permanent AE Control group comprised 80 men without AF. Echocardiography and Doppler studies were performed using ultrasound scanner Aloka SSD-630 (Japan). Significant structural and functional changes of the heart were revealed already in paroxysmal AF and became more pronounced in permanent AF. Increased left atrial size, its ratio to left ventricular end diastolic diameter, diastolic dysfunction were important echocardiographic predictors of AF. Heart walls thickening was accompanied by disorders of myocardial relaxation, increase in myocardial mass led to ischemia, and together they promoted overload, dysfunction of atrium and development of AF. Obligatory echocardiographic examination of the Chernobyl disaster clean-up workers with ischemic heart disease and arterial hypertension is necessary for predicting AF early, ordering adequate therapy in proper time and improving prognosis.

Echocardiographic Parameters and Survival in Chagas Heart Disease with Severe Systolic Dysfunction

PubMed Central

Rassi, Daniela do Carmo; Vieira, Marcelo Luiz Campos; Arruda, Ana Lúcia Martins; Hotta, Viviane Tiemi; Furtado, Rogério Gomes; Rassi, Danilo Teixeira; Rassi, Salvador

2014-01-01

Background Echocardiography provides important information on the cardiac evaluation of patients with heart failure. The identification of echocardiographic parameters in severe Chagas heart disease would help implement treatment and assess prognosis. Objective To correlate echocardiographic parameters with the endpoint cardiovascular mortality in patients with ejection fraction < 35%. Methods Study with retrospective analysis of pre-specified echocardiographic parameters prospectively collected from 60 patients included in the Multicenter Randomized Trial of Cell Therapy in Patients with Heart Diseases (Estudo Multicêntrico Randomizado de Terapia Celular em Cardiopatias) - Chagas heart disease arm. The following parameters were collected: left ventricular systolic and diastolic diameters and volumes; ejection fraction; left atrial diameter; left atrial volume; indexed left atrial volume; systolic pulmonary artery pressure; integral of the aortic flow velocity; myocardial performance index; rate of increase of left ventricular pressure; isovolumic relaxation time; E, A, Em, Am and Sm wave velocities; E wave deceleration time; E/A and E/Em ratios; and mitral regurgitation. Results In the mean 24.18-month follow-up, 27 patients died. The mean ejection fraction was 26.6 ± 5.34%. In the multivariate analysis, the parameters ejection fraction (HR = 1.114; p = 0.3704), indexed left atrial volume (HR = 1.033; p < 0.0001) and E/Em ratio (HR = 0.95; p = 0.1261) were excluded. The indexed left atrial volume was an independent predictor in relation to the endpoint, and values > 70.71 mL/m2 were associated with a significant increase in mortality (log rank p < 0.0001). Conclusion The indexed left atrial volume was the only independent predictor of mortality in this population of Chagasic patients with severe systolic dysfunction. PMID:24553982

Echocardiographic parameters and survival in Chagas heart disease with severe systolic dysfunction.

PubMed

Rassi, Daniela do Carmo; Vieira, Marcelo Luiz Campos; Arruda, Ana Lúcia Martins; Hotta, Viviane Tiemi; Furtado, Rogério Gomes; Rassi, Danilo Teixeira; Rassi, Salvador

2014-03-01

Echocardiography provides important information on the cardiac evaluation of patients with heart failure. The identification of echocardiographic parameters in severe Chagas heart disease would help implement treatment and assess prognosis. To correlate echocardiographic parameters with the endpoint cardiovascular mortality in patients with ejection fraction < 35%. Study with retrospective analysis of pre-specified echocardiographic parameters prospectively collected from 60 patients included in the Multicenter Randomized Trial of Cell Therapy in Patients with Heart Diseases (Estudo Multicêntrico Randomizado de Terapia Celular em Cardiopatias) - Chagas heart disease arm. The following parameters were collected: left ventricular systolic and diastolic diameters and volumes; ejection fraction; left atrial diameter; left atrial volume; indexed left atrial volume; systolic pulmonary artery pressure; integral of the aortic flow velocity; myocardial performance index; rate of increase of left ventricular pressure; isovolumic relaxation time; E, A, Em, Am and Sm wave velocities; E wave deceleration time; E/A and E/Em ratios; and mitral regurgitation. In the mean 24.18-month follow-up, 27 patients died. The mean ejection fraction was 26.6 ± 5.34%. In the multivariate analysis, the parameters ejection fraction (HR = 1.114; p = 0.3704), indexed left atrial volume (HR = 1.033; p < 0.0001) and E/Em ratio (HR = 0.95; p = 0.1261) were excluded. The indexed left atrial volume was an independent predictor in relation to the endpoint, and values > 70.71 mL/m2 were associated with a significant increase in mortality (log rank p < 0.0001). The indexed left atrial volume was the only independent predictor of mortality in this population of Chagasic patients with severe systolic dysfunction.

Recovery of atrial function after atrial compartment operation for chronic atrial fibrillation in mitral valve disease.

PubMed

Shyu, K G; Cheng, J J; Chen, J J; Lin, J L; Lin, F Y; Tseng, Y Z; Kuan, P; Lien, W P

1994-08-01

We prospectively studied the recovery of atrial function after atrial compartment operation and mitral valve surgery in patients with chronic atrial fibrillation caused by mitral valve disease. Chronic atrial fibrillation is the most common arrhythmia in mitral valve disease. This arrhythmia is associated with excessive morbidity and mortality. Mitral valve surgery alone rarely eliminates it. Twenty-two patients underwent mitral valve surgery and a new surgical method, atrial compartment operation. Doppler echocardiography was performed in all patients before operation and at 1 week and 2 and 6 months after operation in the successful cardioversion group. Peak early diastolic (E) and atrial (A) filling velocities, peak A/E velocity ratio and A/E integral ratio of the mitral and tricuspid valves were measured. Sinus rhythm was restored immediately after operation in 91% of patients and was maintained for > 1 week in 15 (68%) of 22 patients and > 6 months in 14 (64%) of 22. Eleven of 15 patients had left atrial paralysis (A/E integral ratio 0) at 1 week and 6 of 14 patients at 2 months. Nine of 15 patients had right atrial paralysis (A/E integral ratio 0) at 1 week and 1 of 14 patients at 2 months. Both left and right atrial contractile function (presence of an A wave on Doppler findings) was detected at 6 months in 14 patients. Mean (+/- SD) peak atrial filling velocity of the mitral valve was 15 +/- 26 cm/s at 1 week, 38 +/- 39 cm/s at 2 months and 93 +/- 32 cm/s at 6 months (p < 0.001). Mean peak atrial filling velocity of the tricuspid valve was 14 +/- 19 cm/s at 1 week, 33 +/- 19 cm/s at 2 months and 50 +/- 19 cm/s at 6 months (p < 0.001). Peak early diastolic and atrial filling velocities, peak A/E velocity ratio and A/E integral ratio of the mitral and tricuspid valves increased significantly from 1 week to 6 months. Chronic atrial fibrillation in mitral valve disease can often be eliminated by atrial compartment operation. No surgical mortality or significant complications were encountered. Both left and right atrial function, as manifested by Doppler findings, recover after compartment operation and improve over time. The mechanical function of the right atrium recovers earlier than that of the left.

Left atrial isomerism in the adolescence: report of two cases.

PubMed

Liu, C Y; Chiu, I S; Chen, J J; Hung, C R; Lien, W P

1991-01-01

Atrial isomerism is very rare in adolescence. Two cases of left atrial isomerism are reported here in 2 females, aged 21 and 19 years. They had presented with cyanosis and dyspnea since childhood. High kilovoltage filter films showed a bilateral morphologically left bronchus. Cardiac catheterization in Case 1 revealed normal pulmonary artery pressure, severe subvalvular pulmonic stenosis, a double outlet right ventricle, a significant oxygen step-up at the atrial level and moderate systemic oxygen desaturation; while Case 2 disclosed pulmonary hypertension and mild systemic oxygen desaturation. Both cases had the following anatomical features: ipsilateral connection of pulmonary veins to the bilateral morphological left atrium; interrupted inferior vena cave with azygos or hemiazygos continuation; total anomalous hepatic venous return to the right-sided atrium; complete atrioventricular canal. The diagnoses were confirmed in both cases at surgical correction.

A Review of the Relevant Embryology, Pathohistology, and Anatomy of the Left Atrial Appendage for the Invasive Cardiac Electrophysiologist

PubMed Central

DeSimone, Christopher V.; Gaba, Prakriti; Tri, Jason; Syed, Faisal; Noheria, Amit; Asirvatham, Samuel J.

2016-01-01

The three-dimensional morphology of the left atrial appendage provides the substrate for thrombus generation, and is a harbinger for embolic material due to its direct connection to the left-sided circulation. Appreciating the development of the appendage from mesodermal layer to its adult form provides the basis to improve exclusion from the atrial circulation, and thereby can lead to a significant reduction in stroke risk. This process also provides insight into the role of the left atrial appendage as an endocrine organ, its involvement in fluid homeostasis, and its connection to the autonomic nervous system. Knowledge of the surrounding structural arrangement is critical to identify landmarks from both an endocardial and epicardial perspective to improve targeted device placement. Furthermore, correlation of the left atrial appendage body, neck, and ostium to the surrounding anatomy can also improve both procedural efficacy and safety. In addition, a working knowledge of the regional anatomy adds a prudent degree of awareness for procedural complications, and allows for early identification and timely intervention as these situations arise. A detailed understanding of the left atrial appendage embryology, histology, and gross anatomy is imperative to identify the correct device and approach for each individual patient. In addition, this increased awareness can identify areas that are in need of further innovation, and thus provide the ability to adapt and refine existing technologies to overcome pitfalls currently facing catheter-based approaches. PMID:27087889

Atrial Function after the Atrial Switch Operation for Transposition of the Great Arteries: Comparison with Arterial Switch and Normals by Cardiovascular Magnetic Resonance.

PubMed

Franzoso, Francesca D; Wohlmuth, Christoph; Greutmann, Matthias; Kellenberger, Christian J; Oxenius, Angela; Voser, Eva M; Valsangiacomo Buechel, Emanuela R

2016-09-01

The atria serve as reservoir, conduit, and active pump for ventricular filling. The performance of the atrial baffles after atrial switch repair for transposition of the great arteries may be abnormal and impact the function of the systemic right ventricle. We sought to assess atrial function in patients after atrial repair in comparison to patients after arterial switch repair (ASO) and to controls. Using magnetic resonance imaging, atrial volumes and functional parameters were measured in 17 patients after atrial switch repair, 9 patients after ASO and 10 healthy subjects. After the atrial switch operation, the maximum volume of the pulmonary venous atrium was significantly enlarged, but not of the systemic venous atrium. In both patients groups, independently from the surgical technique used, the minimum atrial volumes were elevated, which resulted in a decreased total empting fraction compared with controls (P < .01). The passive empting volume was diminished for right atrium, but elevated for left atrium after atrial switch and normal for left atrium after ASO; however, the passive empting fraction was diminished for both right atrium and left atrium after both operations (P < .01). The active empting volume was the most affected parameter in both atria and both groups and active empting fractions were highly significantly reduced compared with controls. Atrial function is abnormal in all patients, after atrial switch and ASO repair. The cyclic volume changes, that is, atrial filling and empting, are reduced when compared with normal subjects. Thus, the atria have lost part of their capacity to convert continuous venous flow into a pulsatile ventricular filling. The function of the pulmonary venous atrium, acting as preload for the systemic right ventricle, after atrial switch is altered the most. © 2015 Wiley Periodicals, Inc.

Surgery for atrial fibrillation.

PubMed

Viganò, M; Graffigna, A; Ressia, L; Minzioni, G; Pagani, F; Aiello, M; Gazzoli, F

1996-01-01

The mechanisms of atrial fibrillation arc multiple reentry circuits spinning around the atrial surface, and these baffle any attempt to direct surgical interruption. The purpose of this article is to report the surgical experience in the treatment of isolated and concomitant atrial fibrillation at the Cardiac Surgical Institute of the University of Pavia. In cases of atrial fibrillation secondary to mitral/valve disease, surgical isolation of the left atrium at the time of mitral valve surgery can prevent atrial fibrillation from involving the right atrium, which can exert its diastolic pump function on the right ventricle. Left atrial isolation was performed on 205 patients at the time of mitral valve surgery. Atrial partitioning ("maze operation") creates straight and blind atrial alleys so that non-recentry circuits can take place. Five patients underwent this procedure. In eight-cases of atrial fibrillation secondary to atrial septal defect, the adult patients with atrial septal defect and chronic or paroxysmal atrial fibrillation underwent surgical isolation of the right atrium associated which surgical correction of the defect, in order to let sinus rhythm govern the left atrium and the ventricles. "Lone" atrial fibrillation occurs in hearts with no detectable organic disease. Bi-atrial isolation with creation of an atrial septal internodal "corridor" was performed on 14 patients. In cases of atrial fibrillation secondary to mitral valve disease, left atrial isolation was performed on 205 patients at the time of mitral valve surgery with an overall sinus rhythm recovery of 44%. In the same period, sinus rhythm was recovered and persisted in only 19% of 252 patients who underwent mitral valve replacement along (P < 0.001). Sinus rhythm was less likely to recover in patients with right atriomegaly requiring tricuspid valve annuloplasty: 59% vs 84% (P < 0.001). Restoration of the right atrial function raised the cardiac index from 2.25 +/- 0.55 1/min per m2 during atrial fibrillation to 2.54 +/- 0.58 1/min per m2, with a mean percentage increase in cardiac index of 13.5% (P < 0.00018). Atrial partitioning ("maze operation") was performed on five patients with an immediate sinus rhythm recovery of 100%, but with two patients requiring pacemaker implant. Seven out of eight patients (87.5%), with atrial fibrillation secondary to atrial septal defect, who underwent surgical isolation of the right atrium at the time of surgery were free from atrial fibrillation and without medications. 2-52 months after operation. Thirteen of 14 patients with "lone" atrial fibrillation who underwent corridor procedure remained in sinus rhythm with a sinus rhythm recovery rate of 92%. Different surgical options can be chosen for different cases of atrial fibrillation, according to the underlying cardiac disease.

Transcatheter closure of the left atrial appendage: initial experience with the WATCHMAN device

PubMed Central

Ding, Jiandong; Zhu, Jian; Lu, Jing; Ding, Xiuxia; Zhang, Xiaoli; Lu, Wenbin; Ao, Mingqiang; Ma, Genshan

2015-01-01

Background: Atrial fibrillation (AF) is the most commonly encountered clinical arrhythmia, accounting for approximately one third of hospitalizations for cardiac rhythm disturbance. In patients with non-valvular AF, approximately 90% of thrombi are thought to arise from the left atrial appendage (LAA). Anticoagulation with warfarin has been the mainstay of therapy to reduce stroke risk in these patients; however, it is not without its complications including bleeding and drug interactions. Percutaneous left atrial appendage closure can be an alternative to warfarin treatment in patients with AF at high risk for thromboembolic events and/or bleeding complications. Methods: Patients with atrial fibrillation and CHADSVASc score ≥ 2, not eligible for anticoagulation, were submitted to left atrial appendage closure using the WATCHMAN device. The procedure was performed under general anaesthesia, and was guided by fluoroscopy and transoesophageal echocardiography. Results: Percutaneous LAA closure with the WATCHMAN device was performed in all patients. At 45-day follow-up no recurrent major adverse events and especially no thromboembolic events occurred. Conclusions: Transcatheter closure of the LAA with the WATCHMAN device is generally safe and feasible. Long-term follow-up will further reveal the risk and benefits of this therapy. PMID:26629008

The effects of hypoxemia on myocardial blood flow during exercise.

PubMed

Paridon, S M; Bricker, J T; Dreyer, W J; Reardon, M; Smith, E O; Porter, C B; Michael, L; Fisher, D J

1989-03-01

We evaluated the adequacy of regional and transmural blood flow during exercise and rapid pacing after 1 wk of hypoxemia. Seven mature mongrel dogs were made hypoxemic (mean O2 saturation = 72.4%) by anastomosis of left pulmonary artery to left atrial appendage. Catheters were placed in the left atrium, right atrium, pulmonary artery, and aorta. Atrial and ventricular pacing wires were placed. An aortic flow probe was placed to measure cardiac output. Ten nonshunted dogs, similarly instrumented, served as controls. Recovery time was approximately 1 wk. Cardiac output, mean aortic pressure, and oxygen saturation were measured at rest, with ventricular pacing, atrial pacing, and with treadmill exercise. Ventricular and atrial pace and exercise were at a heart rate of 200. Right ventricular free wall, left ventricular free wall, and septal blood flow were measured with radionuclide-labeled microspheres. Cardiac output, left atrial blood pressure, and aortic blood pressure were similar between the two groups of dogs in all testing states. Myocardial blood flow was significantly higher in the right and left ventricular free wall in the hypoxemic animals during resting and exercise testing states. Myocardial oxygen delivery was similar between the two groups of animals. Pacing resulted in an increase in myocardial blood flow in the control animals but not the hypoxemic animals.(ABSTRACT TRUNCATED AT 250 WORDS)

F-amplitude, left atrial appendage velocity, and thromboembolic risk in nonrheumatic atrial fibrillation. Stroke Prevention in Atrial Fibrillation Investigators.

PubMed

Blackshear, J L; Safford, R E; Pearce, L A

1996-04-01

Reduced left atrial appendage velocity (LAAV) has been identified as a marker for thromboembolism in patients with atrial fibrillation. It was postulated that electrocardiographic (ECG) F-wave amplitude would correlate with LAAV, and inversely with the risk of thromboembolism in patients with atrial fibrillation. In all, 53 patients with nonrheumatic (NRAF) and 7 patients with rheumatic (RAF) atrial fibrillation underwent assessment of maximum LAAV, which was correlated to the maximum ECG F-wave voltage from lead V1 (F(max)). In 450 NRAF patients on neither aspirin nor warfarin, the relationship between F(max) and thromboembolic risk was assessed over an average follow-up of 1.3 years. F(max) did not correlate with LAAV (r = 0.2, p = 0.07). Patients with intermittent atrial fibrillation (n = 123) had smaller F(max) amplitude than patients with constant atrial fibrillation (n = 327) (mean 0.73 vs. 0.88 mV-1, p = 0.001). F(max) amplitude was not related to a history of hypertension, systolic blood pressure, duration of NRAF, abnormal transthoracic echocardiographic left ventricular (LV) systolic function or left atrial (LA) diameter. There was a strong trend for increased LV mass being related to smaller F(max) amplitude after adjusting for body surface area (p = 0.06). F(max) amplitude was not correlated with risk of embolic events, including only those events presumed by a panel of case-blinded neurologists to be cardioembolic. F(max) amplitude in NRAF is smaller in patients with intermittent versus constant AF. It does not correlate with LAAV, LA size, increased LV mass, or systolic dysfunction, hypertension, or risk of embolism. Therefore, F(max) amplitude may not be used as a surrogate for LAAV, or as a measure of thromboembolic risk in NRAF.

[Left atrial function and left atrial appendage flow velocity in hypertrophic cardiomyopathy: comparison of patients with and without paroxysmal atrial fibrillation].

PubMed

Akasaka, K; Kawashima, E; Shiokoshi, T; Ishii, Y; Hasebe, N; Kikuchi, K

1998-07-01

The involvement of left atrial (LA) appendage flow velocity in reduced left atrial function was investigated in 24 patients with hypertrophic cardiomyopathy, who retained sinus rhythm at the examination. Patients were divided into 11 with a history of paroxysmal atrial fibrillation [PAf(+)] and 13 without such history [PAf(-)]. Transthoracic echocardiography was performed to evaluate LA fractional shortening (LA%FS) and mean velocity of circumferential LA fiber shortening (LAmVcf), as contractile functions of the left atrium at the phase of active atrial contraction. Transesophageal echocardiographic Doppler examination was performed in all patients to measure the LA appendage velocity. In all patients, significant positive correlations were observed between the LA appendage velocity and LA%FS (r = 0.50, p < 0.05) or LAmVcf (r = 0.82, p < 0.001). LAmVcf and LA appendage velocity in patients with paroxysmal fibrillation were significantly lower than in those without (0.84 +/- 0.15 vs 1.28 +/- 0.37 circ/sec, 44 +/- 12 vs 65 +/- 20 cm/sec, both p < 0.01), whereas LA diameter was greater in the former compared to the latter (45 +/- 5 vs 38 +/- 5 mm, p < 0.01). LAmVcf and LA appendage velocity were low in four patients with cerebral infarction or transient cerebral ischemic attack (LAmVcf < 1.0 circ/sec, LA appendage velocity < or = 40 cm/sec). Importantly, all these patients had a history of paroxysmal fibrillation. These results indicate that there is a close relationship between LA appendage velocity and LA contractile function in patients with hypertrophic cardiomyopathy with paroxysmal atrial fibrilation, and these patients have potential risk of cerebral infarction.

[Morphological and electrophysiological changes of the heart atria in necropsy patients with atrial fibrillation - a pilot study].

PubMed

Matějková, Adéla; Steiner, Ivo

2014-01-01

Atrial fibrillation (AF), the most common supraventricular tachycardia, has a morphological base, so called remodelation of atrial myocardium, with its abnormal conduction pattern as a consequence. The remodelation regards electrical, contractile, and structural properties. In this pilot study we attempted to find relations between the myocardial morphological (scarring, amyloidosis, left atrial enlargement) and electrophysiological (ECG characteristics of the P-wave) changes in patients with AF. We examined 40 hearts of necropsy patients - 20 with a history of AF and 20 with no history of AF. Grossly, the heart weight and the size of the left atrium (LA) were evaluated. Histologically, 7 standard sites from the atria were examined. In each specimen, the degree of myocardial scarring and of deposition of isolated atrial amyloid (IAA) were assessed. We failed to show any significant difference in the P-wave pattern between patients with and without AF. Morphologically, however, there were several differences - the patients with AF had significantly heavier hearts, larger left atria, more severely scarred myocardium of the LA and the atrial septum, and more severe deposition of IAA in both atria in comparison to the control group of patients with sinus rhythm. The left atrial distribution of both fibrosis and amyloidosis was irregular. In patients with AF the former was most pronounced in the LA ceiling while the latter in the LA anterior wall. The entire series showed more marked amyloidosis in the left than in the right atrium. An interesting finding was the universal absence of IAA in the sinoatrial node. The knowledge of distribution of atrial myocardial structural changes could be utilized by pathologists in taking specimens for histology and also by cardiologists in targeting the radiofrequency ablation therapy.

Early Changes in Atrial Electromechanical Coupling in Patients with Hypertension: Assessment by Tissue Doppler Imaging.

PubMed

Avci, Burcak Kilickiran; Gulmez, Oyku; Donmez, Guclu; Pehlivanoglu, Seckin

2016-06-05

Hypertension (HT) is associated with atrial electrophysiological abnormalities. Echocardiographic pulsed wave tissue Doppler imaging (TDI) is one of the noninvasive methods for evaluation of atrial electromechanical properties. The aims of our study were to investigate the early changes in atrial electromechanical conduction in patients with HT and to assess the parameters that affect atrial electromechanical conduction. Seventy-six patients with HT (41 males, mean age 52.6 ± 9.0 years) and 41 controls (22 males, mean age 49.8 ± 7.9 years) were included in the study. Atrial electromechanical coupling at the right (PRA), left (PLA), interatrial septum (PIS) were measured with TDI. Intra- (right: PIS-PRA, left: PLA-PIS) and inter-atrial (PLA-PRA) electromechanical delays were calculated. Maximum P-wave duration (Pmax) was calculated from 12-lead electrocardiogram. Atrial electromechanical coupling at PLA (76.6 ± 14.1 ms vs. 82.9 ± 15.8 ms, P = 0.036), left intra-atrial (10.9 ± 5.0 ms vs. 14.0 ± 9.7 ms, P = 0.023), right intra-atrial (10.6 ± 7.8 ms vs. 14.5 ± 10.1 ms, P = 0.035), and interatrial electromechanical (21.4 ± 9.8 ms vs. 28.3 ± 12.7 ms, P = 0.003) delays were significantly longer in patients with HT. The linear regression analysis showed that left ventricular (LV) mass index and Pmax were significantly associated with PLA (P = 0.001 and P = 0.002, respectively), and the LV mass index was the only related factor for interatrial delay (P = 0.001). Intra- and interatrial electromechanical delay, PLA were significantly prolonged in hypertensive patients. LV mass index and Pmax were significantly associated with PLA, and the LV mass index was the only related factor for interatrial delay. The atrial TDI can be a valuable method to assess the early changes of atrial electromechanical conduction properties in those patients.

Early Changes in Atrial Electromechanical Coupling in Patients with Hypertension: Assessment by Tissue Doppler Imaging

PubMed Central

Avci, Burcak Kilickiran; Gulmez, Oyku; Donmez, Guclu; Pehlivanoglu, Seckin

2016-01-01

Background: Hypertension (HT) is associated with atrial electrophysiological abnormalities. Echocardiographic pulsed wave tissue Doppler imaging (TDI) is one of the noninvasive methods for evaluation of atrial electromechanical properties. The aims of our study were to investigate the early changes in atrial electromechanical conduction in patients with HT and to assess the parameters that affect atrial electromechanical conduction. Methods: Seventy-six patients with HT (41 males, mean age 52.6 ± 9.0 years) and 41 controls (22 males, mean age 49.8 ± 7.9 years) were included in the study. Atrial electromechanical coupling at the right (PRA), left (PLA), interatrial septum (PIS) were measured with TDI. Intra- (right: PIS-PRA, left: PLA-PIS) and inter-atrial (PLA-PRA) electromechanical delays were calculated. Maximum P-wave duration (Pmax) was calculated from 12-lead electrocardiogram. Results: Atrial electromechanical coupling at PLA (76.6 ± 14.1 ms vs. 82.9 ± 15.8 ms, P = 0.036), left intra-atrial (10.9 ± 5.0 ms vs. 14.0 ± 9.7 ms, P = 0.023), right intra-atrial (10.6 ± 7.8 ms vs. 14.5 ± 10.1 ms, P = 0.035), and interatrial electromechanical (21.4 ± 9.8 ms vs. 28.3 ± 12.7 ms, P = 0.003) delays were significantly longer in patients with HT. The linear regression analysis showed that left ventricular (LV) mass index and Pmax were significantly associated with PLA (P = 0.001 and P = 0.002, respectively), and the LV mass index was the only related factor for interatrial delay (P = 0.001). Conclusions: Intra- and interatrial electromechanical delay, PLA were significantly prolonged in hypertensive patients. LV mass index and Pmax were significantly associated with PLA, and the LV mass index was the only related factor for interatrial delay. The atrial TDI can be a valuable method to assess the early changes of atrial electromechanical conduction properties in those patients. PMID:27231168

New echocardiographic techniques for evaluation of left atrial mechanics.

PubMed

Todaro, Maria Chiara; Choudhuri, Indrajit; Belohlavek, Marek; Jahangir, Arshad; Carerj, Scipione; Oreto, Lilia; Khandheria, Bijoy K

2012-12-01

Until recently the left atrium had been subordinate to the left ventricle, but cardiologists now recognize that left atrial (LA) function is indispensable to normal circulatory performance. Transthoracic two-dimensional (2D) and Doppler echocardiography can elucidate parameters of LA function non-invasively. Yet, with the advent of 2D speckle-tracking echocardiography, we are able to detect early LA dysfunction even before structural changes occur. This is pivotal in some common disease states, such as atrial fibrillation, hypertension, and heart failure, in which LA deformation parameters can influence clinical management. However, a unique standardized technique to investigate LA deformation needs to be validated.

Substrate characteristics and ablation outcome of left atrial tachycardia in rheumatic mitral valve disease.

PubMed

Chen, Hongwu; Yang, Bing; Ju, Weizhu; Zhang, Fengxiang; Yang, Gang; Gu, Kai; Li, Mingfang; Liu, Hailei; Wang, Zidun; Cao, Kejiang; Chen, Minglong

2017-08-01

Right atrial tachycardia (AT) is a common arrhythmia postsurgical valve replacement in patients with rheumatic heart disease (RHD). However, the substrate and the mechanism of left AT in such patients and the ablation efficacy is less known. Twenty-seven RHD patients with AT were enrolled in this study; nine of them (33%) had left AT. Five and four patients had left AT during the first and second procedure, respectively. A spontaneous scar in the left posterior wall was identified in all patients, and obvious anterior scar in three patients. Dual-roof-dependent AT was found in three patients and macroreentry AT surrounding right pulmonary vein was identified in one patient, two of whom had left anterior scar. Three patients had AT circuit going around the mitral annulus, one of whom had left anterior scar. Entrainment pacing at different sites confirmed the mechanism of these macroreentries. Two patients had a focal origin, one was localized in posterior wall at the edge of the scar and the other one was originated from the left septum with normal voltage. After a mean follow-up of 27.4 ± 7.9 months, the left AT group had a similar recurrence rate compared with the right AT group alone (67% vs 56%, P = 0.58). In the left AT group, 11% of patients had AT recurrence and 56% of patients developed atrial fibrillation. Left atrial AT can occur in RHD patients postmitral valve replacement. Catheter ablation is feasible with high acute success rate. The incidence of late development atrial fibrillation is considerable after successful ablation. © 2017 Wiley Periodicals, Inc.

Neural mechanisms in body fluid homeostasis.

PubMed

DiBona, G F

1986-12-01

Under steady-state conditions, urinary sodium excretion matches dietary sodium intake. Because extracellular fluid osmolality is tightly regulated, the quantity of sodium in the extracellular fluid determines the volume of this compartment. The left atrial volume receptor mechanism is an example of a neural mechanism of volume regulation. The left atrial mechanoreceptor, which functions as a sensor in the low-pressure vascular system, is located in the left atrial wall, which has a well-defined compliance relating intravascular volume to filling pressure. The left atrial mechanoreceptor responds to changes in wall left atrial tension by discharging into afferent vagal fibers. These fibers have suitable central nervous system representation whose related efferent neurohumoral mechanisms regulate thirst, renal excretion of water and sodium, and redistribution of the extracellular fluid volume. Efferent renal sympathetic nerve activity undergoes appropriate changes to facilitate renal sodium excretion during sodium surfeit and to facilitate renal sodium conservation during sodium deficit. By interacting with other important determinants of renal sodium excretion (e.g., renal arterial pressure), changes in efferent renal sympathetic nerve activity can significantly modulate the final renal sodium excretion response with important consequences in pathophysiological states (e.g., hypertension, edema-forming states).

Effect of irbesartan on development of atrial fibrosis and atrial fibrillation in a canine atrial tachycardia model with left ventricular dysfunction, association with p53.

PubMed

Kataoka, Naoya; Nishida, Kunihiro; Kinoshita, Koshi; Sakamoto, Tamotsu; Nakatani, Yosuke; Tsujino, Yasushi; Mizumaki, Koichi; Inoue, Hiroshi; Kinugawa, Koichiro

2016-12-01

Effects of an angiotensin II receptor blocker, irbesartan (IRB), on the development of atrial fibrosis and atrial fibrillation (AF) were assessed in a canine model of atrial tachycardia remodeling (ATR) with left ventricular dysfunction, together with its possible association with involvement of p53. Atrial tachypacing (400 bpm for 4 weeks) was used to induce ATR in beagles treated with placebo (ATR-dogs, n = 6) or irbesartan (IRB-dogs, n = 5). Non-paced sham dogs served as control (Control-dogs, n = 4). ATR- and IRB-dogs developed tachycardia-induced left ventricular dysfunction. Atrial effective refractory period (AERP) shortened (83 ± 5 ms, p < 0.05), inter-atrial conduction time prolonged (72 ± 2 ms, p < 0.05), and AF duration increased (29 ± 5 s, p < 0.05 vs. baseline) after 4 weeks in ATR-dogs. ATR-dogs also had a larger area of atrial fibrous tissue (5.2 ± 0.5 %, p < 0.05 vs. Control). All these changes, except for AERP, were attenuated in IRB-dogs (92 ± 3 ms, 56 ± 3 ms, 9 ± 5 s, and 2.5 ± 0.7 %, respectively; p < 0.05 vs. ATR for each). In ATR-dogs, p53 expression in the left atrium decreased by 42 % compared with Control-dogs (p < 0.05); however, it was highly expressed in IRB-dogs (+89 % vs. ATR). Transforming growth factor (TGF)-β1 expression was enhanced in ATR-dogs (p < 0.05 vs. Control) but reduced in IRB-dogs (p < 0.05 vs. ATR). Irbesartan suppresses atrial fibrosis and AF development in a canine ATR model with left ventricular dysfunction in association with p53.

Isolation of the posterior left atrium for patients with persistent atrial fibrillation: routine adenosine challenge for dormant posterior left atrial conduction improves long-term outcome.

PubMed

McLellan, Alex J A; Prabhu, Sandeep; Voskoboinik, Alex; Wong, Michael C G; Walters, Tomos E; Pathik, Bhupesh; Morris, Gwilym M; Nisbet, Ashley; Lee, Geoffrey; Morton, Joseph B; Kalman, Jonathan M; Kistler, Peter M

2017-12-01

Catheter ablation to achieve posterior left atrial wall (PW) isolation may be performed as an adjunct to pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (AF). We aimed to determine whether routine adenosine challenge for dormant posterior wall conduction improved long-term outcome. A total of 161 patients with persistent AF (mean age 59 ± 9 years, AF duration 6 ± 5 years) underwent catheter ablation involving circumferential PVI followed by PW isolation. Posterior left atrial wall isolation was performed with a roof and inferior wall line with the endpoint of bidirectional block. In 54 patients, adenosine 15 mg was sequentially administered to assess reconnection of the pulmonary veins and PW. Sites of transient reconnection were ablated and adenosine was repeated until no further reconnection was present. Holter monitoring was performed at 6 and 12 months to assess for arrhythmia recurrence. Posterior left atrial wall isolation was successfully achieved in 91% of 161 patients (procedure duration 191 ± 49 min, mean RF time 40 ± 19 min). Adenosine-induced reconnection of the PW was demonstrated in 17%. The single procedure freedom from recurrent atrial arrhythmia was superior in the adenosine challenge group (65%) vs. no adenosine challenge (40%, P < 0.01) at a mean follow-up of 19 ± 8 months. After multiple procedures, there was significantly improved freedom from AF between patients with vs. without adenosine PW challenge (85 vs. 65%, P = 0.01). Posterior left atrial wall isolation in addition to PVI is a readily achievable ablation strategy in patients with persistent AF. Routine adenosine challenge for dormant posterior wall conduction was associated with an improvement in the success of catheter ablation for persistent AF. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions please email: journals.permissions@oup.com.

Stand alone totally endoscopic epimyocardial ablation in patients with persistent atrial fibrillation and significant atrial dilatation.

PubMed

Wagner, Florian Mathias; Pecha, Simon; Conradi, Lenard; Reichenspurner, Hermann

2015-05-01

To analyze safety and efficacy of surgical totally endoscopic epimyocardial ablation in patients (pts) turned down for interventional catheter therapy due to long-standing persistent atrial fibrillation (pAF) combined with significant atrial dilatation (> 5 cm). Since December 2010, 15 pts were referred for surgical ablation due to persistent AF combined with biatrial dilatation (left atrium [LA] 5.0 ± 0.6 cm). Mean age was 52 ± 6 years, body mass index (BMI) 38 ± 6, duration of AF 2.8 ± 1.2 years, left ventricular end diastolic diameter (LVEDD) 5.8 cm ± 0.6 cm. Ablation was performed via a bilateral endoscopic approach using bipolar RF energy application. Monitoring was achieved by an event recorder (Reveal XT Medtronic, Inc., Minneapolis, MN, USA) or repeated 24-hours Holter electrocardiogram. All pts successfully received bilateral pulmonary vein isolation + box lesion + trigonal lesion + left atrial appendage resection. Mean duration of procedure was 235 ± 70 minutes. There was no intraoperative complication; however, one patient had persistent left phrenic nerve palsy. Mean hospital stay was 4 ± 2 days, mean follow-up time was 21 ± 11 months. Incidence of sinus rhythm (SR) was 67, 73, and 80% at discharge, three months, and 12 months follow-up. Mean LA diameter was reduced from 58.1 mm ± 6.0 mm preoperative to 49.7 mm ± 5.4 mm (p = 0.004) at 12 months follow-up. Incidence of SR was 86% at latest follow-up (mean time 21 months). All pts currently in SR (13/15 = 86%) are of class I or III antiarrhythmic drugs. Totally endoscopic left atrial ablation including left atrial resection can safely be performed. It achieved excellent rates of SR restoration in patients with long-standing persistent AF combined with significant atrial dilatation. © 2015 Wiley Periodicals, Inc.

Atrial myocardial nox2 containing NADPH oxidase activity contribution to oxidative stress in mitral regurgitation: potential mechanism for atrial remodeling.

PubMed

Chang, Jen-Ping; Chen, Mien-Cheng; Liu, Wen-Hao; Yang, Cheng-Hsu; Chen, Chien-Jen; Chen, Yung-Lung; Pan, Kuo-Li; Tsai, Tzu-Hsien; Chang, Hsueh-Wen

2011-01-01

Oxidative stress is linked with several cardiovascular diseases. However, the NADPH oxidase activity in severe mitral regurgitation patients with and without atrial fibrillation has not yet been explored. This study involved 16 adult patients (eight patients with persistent atrial fibrillation and eight with sinus rhythm) with severe mitral and moderate-to-severe tricuspid regurgitation and five control patients without mitral and tricuspid disease. Atrial tissues of the right and left atrial appendages were obtained during surgery. Superoxide anion production was measured by lucigenin-enhanced chemiluminescence, and the expression of nox2 containing NADPH oxidase mRNA was measured by quantitative real-time RT-PCR. Additionally, immunohistochemical study was performed. NADPH-stimulated superoxide release was significantly higher than basal superoxide production from right [5671.9±3498.7 vs. 232.7±70.0 relative light units per second per milligram of protein (RLU s(-1) mg protein(-1)), P=.008) and left atrial homogenates (6475.1±1890.8 vs. 229.0±79.6 RLU s(-1) mg protein(-1), P=.008) in atrial fibrillation patients. The NADPH-stimulated superoxide release from right atrial homogenates was also significantly higher than basal superoxide production in sinus patients (6809.1±1327.1 vs. 244.2±65.5 RLU s(-1) mg protein(-1), P=.008). Additionally, there was a borderline significant correlation between NADPH-stimulated superoxide production from left atrial homogenates and left atrial sizes (r=0.683, P=.062) in atrial fibrillation patients. Membrane-bound nox2 containing NADPH oxidase mRNA expression was increased and was similar in both the atrial fibrillation patients and sinus patients. The NADPH-stimulated superoxide production in right atrial homogenates in control atrial samples was 1863.7±137.2 RLU s(-1) mg protein(-1). Immunohistochemical study demonstrated increased expression of nox2 in myocytes with moderate-to-severe myolysis and hypertrophy. Results of this study demonstrate that membrane-bound nox2 containing NADPH oxidase activity and expression in the atrial myocardium is increased in patients with severe mitral regurgitation, possibly contributing to atrial remodeling in this clinical setting. Copyright © 2011 Elsevier Inc. All rights reserved.

Patient-specific analysis of blood stasis in the left atrium

NASA Astrophysics Data System (ADS)

Flores, Oscar; Gonzalo, Alejandro; Garcia-Villalba, Manuel; Rossini, Lorenzo; Hsiao, Albert; McVeigh, Elliot; Kahn, Andrew M.; Del Alamo, Juan C.

2016-11-01

Atrial fibrillation (AF) is a common arrhythmia in which the left atrium (LA) beats rapidly and irregularly. Patients with AF are at increased risk of thromboembolic events (TE), particularly stroke. Anticoagulant therapy can reduce the risk of TE in AF, but it can also increase the risks of adverse events such as internal bleeding. The current lack of tools to predict each patient's risk of LA thrombogenesis makes it difficult to decide whether to anticoagulate patients with AF. The aim of this work is to evaluate blood stasis in patient-specific models of the LA, because stasis is a known thrombogenesis risk factor. To achieve our aim, we performed direct numerical simulations of left atrial flow using an immersed boundary solver developed at the UC3M, coupled to a 0D model for the pulmonary circulation. The LA geometry is obtained from time-resolved CT scans and the parameters of the 0D model are found by fitting pulmonary vein flow data obtained by 4D phase contrast MRI. Blood stasis is evaluated from the flow data by computing blood residence time together with other kinematic indices of the velocity field (e.g. strain and kinetic energy). We focus on the flow in the left atrial appendage, including a sensitivity analysis of the effect of the parameters of the 0D model. Funded by the Spanish MECD, the Clinical and Translational Research Institute at UCSD and the American Heart Association.

Effects of Prolonged Spaceflight on Atrial Size, Atrial Electrophysiology, and Risk of Atrial Fibrillation.

PubMed

Khine, Htet W; Steding-Ehrenborg, Katarina; Hastings, Jeffrey L; Kowal, Jamie; Daniels, James D; Page, Richard L; Goldberger, Jeffery J; Ng, Jason; Adams-Huet, Beverley; Bungo, Michael W; Levine, Benjamin D

2018-05-01

The prevalence of atrial fibrillation (AF) in active astronauts is ≈5%, similar to the general population but at a younger age. Risk factors for AF include left atrial enlargement, increased number of premature atrial complexes, and certain parameters on signal-averaged electrocardiography, such as P-wave duration, root mean square voltage for the terminal 20 ms of the signal-averaged P wave, and P-wave amplitude. We aimed to evaluate changes in atrial structure, supraventricular beats, and atrial electrophysiology to determine whether spaceflight could increase the risk of AF. Thirteen astronauts underwent cardiac magnetic resonance imaging to assess atrial structure and function before and after 6 months in space and high-resolution Holter monitoring for multiple 48-hour time periods before flight, during flight, and on landing day. Left atrial volume transiently increased after 6 months in space (12±18 mL; P =0.03) without changing atrial function. Right atrial size remained unchanged. No changes in supraventricular beats were noted. One astronaut had a large increase in supraventricular ectopic beats but none developed AF. Filtered P-wave duration did not change over time, but root mean square voltage for the terminal 20 ms decreased on all fight days except landing day. No changes in P-wave amplitude were seen in leads II or V 1 except landing day for lead V 1 . Six months of spaceflight may be sufficient to cause transient changes in left atrial structure and atrial electrophysiology that increase the risk of AF. However, there was no definite evidence of increased supraventricular arrhythmias and no identified episodes of AF. © 2018 American Heart Association, Inc.

Updating a preoperative surface model with information from real-time tracked 2D ultrasound using a Poisson surface reconstruction algorithm

NASA Astrophysics Data System (ADS)

Sun, Deyu; Rettmann, Maryam E.; Holmes, David R.; Linte, Cristian A.; Packer, Douglas; Robb, Richard A.

2014-03-01

In this work, we propose a method for intraoperative reconstruction of a left atrial surface model for the application of cardiac ablation therapy. In this approach, the intraoperative point cloud is acquired by a tracked, 2D freehand intra-cardiac echocardiography device, which is registered and merged with a preoperative, high resolution left atrial surface model built from computed tomography data. For the surface reconstruction, we introduce a novel method to estimate the normal vector of the point cloud from the preoperative left atrial model, which is required for the Poisson Equation Reconstruction algorithm. In the current work, the algorithm is evaluated using a preoperative surface model from patient computed tomography data and simulated intraoperative ultrasound data. Factors such as intraoperative deformation of the left atrium, proportion of the left atrial surface sampled by the ultrasound, sampling resolution, sampling noise, and registration error were considered through a series of simulation experiments.

Quality of life assessment in the randomized PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) trial of patients at risk for stroke with nonvalvular atrial fibrillation.

PubMed

Alli, Oluseun; Doshi, Shepal; Kar, Saibal; Reddy, Vivek; Sievert, Horst; Mullin, Chris; Swarup, Vijay; Whisenant, Brian; Holmes, David

2013-04-30

This study sought to assess quality of life parameters in a subset of patients enrolled in the PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) trial. The PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) trial demonstrated that in patients with nonvalvular atrial fibrillation (AF) and CHADS2 (congestive heart failure, hypertension, age, diabetes mellitus, and prior stroke, transient ischemic attack, or thromboembolism) score ≥1, a left atrial appendage closure device is noninferior to long-term warfarin for stroke prevention. Given this equivalency, quality of life (QOL) indicators are an important metric for evaluating these 2 different strategies. QOL using the Short-Form 12 Health Survey, version 2, measurement tool was obtained at baseline and 12 months in a subset of 547 patients in the PROTECT AF trial (361 device and 186 warfarin patients). The analysis cohort consisted of patients for whom either paired quality of life data were available after 12 months of follow-up or for patients who died. With the device, the total physical score improved in 34.9% and was unchanged in 29.9% versus warfarin in whom 24.7% were improved and 31.7% were unchanged (p = 0.01). Mental health improvement occurred in 33.0% of the device group versus 22.6% in the warfarin group (p = 0.06). There was a significant improvement in QOL in patients randomized to device for total physical score, physical function, and in physical role limitation compared to control. There were significant differences in the change in total physical score among warfarin naive and not-warfarin naive subgroups in the device group compared to control, but larger gains were seen with the warfarin naive subgroup with a 12-month change of 1.3 ± 8.8 versus -3.6 ± 6.7 (p = 0.0004) device compared to warfarin. Patients with nonvalvular AF at risk for stroke treated with left atrial appendage closure have favorable QOL changes at 12 months versus patients treated with warfarin. (WATCHMAN Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation [WATCHMAN PROTECT]; NCT00129545). Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Left-to-right atrial inward rectifier potassium current gradients in patients with paroxysmal versus chronic atrial fibrillation.

PubMed

Voigt, Niels; Trausch, Anne; Knaut, Michael; Matschke, Klaus; Varró, András; Van Wagoner, David R; Nattel, Stanley; Ravens, Ursula; Dobrev, Dobromir

2010-10-01

Recent evidence suggests that atrial fibrillation (AF) is maintained by high-frequency reentrant sources with a left-to-right-dominant frequency gradient, particularly in patients with paroxysmal AF (pAF). Unequal left-to-right distribution of inward rectifier K(+) currents has been suggested to underlie this dominant frequency gradient, but this hypothesis has never been tested in humans. Currents were measured with whole-cell voltage-clamp in cardiomyocytes from right atrial (RA) and left (LA) atrial appendages of patients in sinus rhythm (SR) and patients with AF undergoing cardiac surgery. Western blot was used to quantify protein expression of I(K1) (Kir2.1 and Kir2.3) and I(K,ACh) (Kir3.1 and Kir3.4) subunits. Basal current was ≈2-fold larger in chronic AF (cAF) versus SR patients, without RA-LA differences. In pAF, basal current was ≈2-fold larger in LA versus RA, indicating a left-to-right atrial gradient. In both atria, Kir2.1 expression was ≈2-fold greater in cAF but comparable in pAF versus SR. Kir2.3 levels were unchanged in cAF and RA-pAF but showed a 51% decrease in LA-pAF. In SR, carbachol-activated (2 μmol/L) I(K,ACh) was 70% larger in RA versus LA. This right-to-left atrial gradient was decreased in pAF and cAF caused by reduced I(K,ACh) in RA only. Similarly, in SR, Kir3.1 and Kir3.4 proteins were greater in RA versus LA and decreased in RA of pAF and cAF. Kir3.1 and Kir3.4 expression was unchanged in LA of pAF and cAF. Our results support the hypothesis that a left-to-right gradient in inward rectifier background current contributes to high-frequency sources in LA that maintain pAF. These findings have potentially important implications for development of atrial-selective therapeutic approaches.

Left-to-Right Atrial Inward Rectifier Potassium Current Gradients in Patients With Paroxysmal Versus Chronic Atrial Fibrillation

PubMed Central

Voigt, Niels; Trausch, Anne; Knaut, Michael; Matschke, Klaus; Varró, András; Van Wagoner, David R.; Nattel, Stanley; Ravens, Ursula; Dobrev, Dobromir

2018-01-01

Background Recent evidence suggests that atrial fibrillation (AF) is maintained by high-frequency reentrant sources with a left-to-right–dominant frequency gradient, particularly in patients with paroxysmal AF (pAF). Unequal left-to-right distribution of inward rectifier K+ currents has been suggested to underlie this dominant frequency gradient, but this hypothesis has never been tested in humans. Methods and Results Currents were measured with whole-cell voltage-clamp in cardiomyocytes from right atrial (RA) and left (LA) atrial appendages of patients in sinus rhythm (SR) and patients with AF undergoing cardiac surgery. Western blot was used to quantify protein expression of IK1 (Kir2.1 and Kir2.3) and IK,ACh (Kir3.1 and Kir3.4) subunits. Basal current was ≈2-fold larger in chronic AF (cAF) versus SR patients, without RA-LA differences. In pAF, basal current was ≈2-fold larger in LA versus RA, indicating a left-to-right atrial gradient. In both atria, Kir2.1 expression was ≈2-fold greater in cAF but comparable in pAF versus SR. Kir2.3 levels were unchanged in cAF and RA-pAF but showed a 51% decrease in LA-pAF. In SR, carbachol-activated (2 μmol/L) IK,ACh was 70% larger in RA versus LA. This right-to-left atrial gradient was decreased in pAF and cAF caused by reduced IK,ACh in RA only. Similarly, in SR, Kir3.1 and Kir3.4 proteins were greater in RA versus LA and decreased in RA of pAF and cAF. Kir3.1 and Kir3.4 expression was unchanged in LA of pAF and cAF. Conclusions Our results support the hypothesis that a left-to-right gradient in inward rectifier background current contributes to high-frequency sources in LA that maintain pAF. These findings have potentially important implications for development of atrial-selective therapeutic approaches. PMID:20657029

Limited left atrial surgical ablation effectively treats atrial fibrillation but decreases left atrial function.

PubMed

Compier, Marieke G; Tops, Laurens F; Braun, Jerry; Zeppenfeld, Katja; Klautz, Robert J; Schalij, Martin J; Trines, Serge A

2017-04-01

Limited left atrial (LA) surgical ablation with bipolar radiofrequency is considered to be an effective procedure for treatment of atrial fibrillation (AF). We studied whether limited LA surgical ablation concomitant to cardiac surgery is able to maintain LA function. Thirty-six consecutive patients (age 66 ± 12 years, 53% male, 78% persistent AF) scheduled for valve surgery and/or coronary revascularization and concomitant LA surgical ablation were included. Epicardial pulmonary vein isolation (PVI) and additional endo-epicardial lines were performed using bipolar radiofrequency. An age- and gender-matched control group (n = 36, age 66 ± 9 years, 69% male, 81% paroxysmal AF) was selected from patients undergoing concomitant epicardial PVI only. Left atrial dimensions and function were assessed on two-dimensional echocardiography preoperatively and at 3- and 12-month follow-up. Sinus rhythm (SR) maintenance was 67% for limited LA ablation and 81% for PVI at 1-year follow-up (P = 0.18). Left atrial volume decreased from 72 ± 21 to 50 ± 14 mL (31%, P < 0.01) after limited LA ablation and from 65 ± 23 to 56 ± 20 mL (14%, P < 0.01) after PVI. Atrial transport function was restored in 54% of patients in SR after limited LA ablation compared with 100% of patients in SR after PVI. Atrial strain and contraction parameters (LA ejection fraction, A-wave velocity, reservoir function, and strain rate) significantly decreased after limited LA ablation. After PVI, strain and contraction parameters remained unchanged. Even limited LA ablation decreased LA volume, contraction, transport function, and compliance, indicating both reverse remodelling combined with significant functional deterioration. In contrast, surgical PVI decreased LA volume while function remained unchanged. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.

Thrombophilia-Related Complications in the Treatment of a Left Atrial Appendage Thrombus: A Case Report

PubMed Central

Parato, Vito Maurizio; Scarano, Michele; Labanti, Benedetto

2014-01-01

Trans-esophageal echocardiography (TEE) revealed a left atrial appendage (LAA) thrombus in an 84-year-old woman with nonvalvular atrial fibrillation not known before our evaluation. In her medical history, there were hypertension, dyslipidemia and a previous pulmonary embolism. She was taking warfarin at time of our evaluation and presented signs and symptoms of heart failure. Together with heart failure treatment, intravenous anticoagulation with unfractionated heparin was initiated. Treatment was complicated by additional right lower limb embolic event and the LAA thrombus remained unchanged. Testing revealed heterozygosity for both the factor V Leiden and the methylenetetrahydrofolate reductase C677T mutations inducing resistance to activated protein C. The patient refused transcatheter closure of the left atrial appendage. PMID:28465906

Hybrid procedures for an infant with hypoplastic left heart syndrome with intact atrial septum.

PubMed

Suzuki, Shoji; Kise, Hiroaki; Kaga, Shigeaki; Hoshiai, Minako; Koizumi, Keiichi; Hasebe, Yohei; Motohashi, Shinya; Matsumoto, Masahiko

2015-08-01

A boy, prenatally diagnosed as hypoplastic left heart syndrome (HLHS) with intact atrial septum (IAS) was successfully treated by hybrid procedures. He underwent emergent catheter atrial septostomy and stent insertion in the atrial septum on Day 1 and then underwent bilateral pulmonary artery banding, ductal stent insertion, modified Norwood operation, bidirectional Glenn's operation and finally Fontan type operation at 2 years of age. Considering the presence of decompression pathway from the left atrium in HLHS with IAS, we should organize a treatment team for collaborative work and plan an appropriate treatment strategy before delivery. Although his clinical course has been uneventful until now, closer medical observation is warranted because he may have coexisting pulmonary disease.

Three-dimensional atrial wall thickness maps to inform catheter ablation procedures for atrial fibrillation.

PubMed

Bishop, Martin; Rajani, Ronak; Plank, Gernot; Gaddum, Nicholas; Carr-White, Gerry; Wright, Matt; O'Neill, Mark; Niederer, Steven

2016-03-01

Transmural lesion formation is critical to success in atrial fibrillation ablation and is dependent on left atrial wall thickness (LAWT). Pre- and peri-procedural planning may benefit from LAWT measurements. To calculate the LAWT, the Laplace equation was solved over a finite element mesh of the left atrium derived from the segmented computed tomographic angiography (CTA) dataset. Local LAWT was then calculated from the length of field lines derived from the Laplace solution that spanned the wall from the endocardium or epicardium. The method was validated on an atrium phantom and retrospectively applied to 10 patients who underwent routine coronary CTA for standard clinical indications at our institute. The Laplace wall thickness algorithm was validated on the left atrium phantom. Wall thickness measurements had errors of <0.2 mm for thicknesses of 0.5-5.0 mm that are attributed to image resolution and segmentation artefacts. Left atrial wall thickness measurements were performed on 10 patients. Successful comprehensive LAWT maps were generated in all patients from the coronary CTA images. Mean LAWT measurements ranged from 0.6 to 1.0 mm and showed significant inter and intra patient variability. Left atrial wall thickness can be measured robustly and efficiently across the whole left atrium using a solution of the Laplace equation over a finite element mesh of the left atrium. Further studies are indicated to determine whether the integration of LAWT maps into pre-existing 3D anatomical mapping systems may provide important anatomical information for guiding radiofrequency ablation. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.

Masked hypertension and cardiac remodeling in middle-aged endurance athletes.

PubMed

Trachsel, Lukas D; Carlen, Frederik; Brugger, Nicolas; Seiler, Christian; Wilhelm, Matthias

2015-06-01

Extensive endurance training and arterial hypertension are established risk factors for atrial fibrillation. We aimed to assess the proportion of masked hypertension in endurance athletes and the impact on cardiac remodeling, mechanics, and supraventricular tachycardias (SVT). Male participants of a 10-mile race were recruited and included if office blood pressure was normal (<140/90 mmHg). Athletes were stratified into a masked hypertension and normotension group by ambulatory blood pressure. Primary endpoint was diastolic function, expressed as peak early diastolic mitral annulus velocity (E'). Left ventricular global strain, left ventricular mass/volume ratio, left atrial volume index, signal-averaged P-wave duration (SAPWD), and SVT during 24-h Holter monitoring were recorded. From 108 runners recruited, 87 were included in the final analysis. Thirty-three (38%) had masked hypertension. The mean age was 42 ± 8 years. Groups did not differ with respect to age, body composition, cumulative training hours, and 10-mile race time. Athletes with masked hypertension had a lower E' and a higher left ventricular mass/volume ratio. Left ventricular global strain, left atrial volume index, SAPWD, and SVT showed no significant differences between the groups. In multiple linear regression analysis, masked hypertension was independently associated with E' (beta = -0.270, P = 0.004) and left ventricular mass/volume ratio (beta = 0.206, P = 0.049). Cumulative training hours was the only independent predictor for left atrial volume index (beta = 0.474, P < 0.001) and SAPWD (beta = 0.481, P < 0.001). In our study, a relevant proportion of middle-aged athletes had masked hypertension, associated with a lower diastolic function and a higher left ventricular mass/volume ratio, but unrelated to left ventricular systolic function, atrial remodeling, or SVT.

Left Atrial Appendage Exclusion for Atrial Fibrillation

PubMed Central

Syed, Faisal F.; DeSimone, Christopher V.; Friedman, Paul A.; Asirvatham, Samuel J.

2015-01-01

SYNOPSIS Percutaneous left atrial appendage (LAA) closure is increasingly being used as a treatment strategy to prevent stroke in patients with atrial fibrillation (AF) who have contraindications to anticoagulants. A number of approaches and devices have been developed in the last few years, each with their own unique set of advantages and disadvantages. We review the published studies on surgical and percutaneous approaches to LAA closure; focusing on stroke mechanisms in AF, LAA structure and function relevant to stroke prevention, practical differences in procedural approach, and clinical considerations surrounding management. PMID:25443240

Atrial electromechanical coupling intervals in pregnant subjects.

PubMed

Altun, Burak; Tasolar, Hakan; Gazï, Emïne; Gungor, Aysenur Cakir; Uysal, Ahmet; Temïz, Ahmet; Barutcu, Ahmet; Acar, Gurkan; Colkesen, Yucel; Ozturk, Ufuk; Akkoy, Murat

2014-01-01

The aim of this study was to evaluate atrial conduction abnormalities obtained by tissue Doppler imaging (TDI) and electrocardiogram analysis in pregnant subjects. A total of 30 pregnant subjects (28 ± 4 years) and 30 controls (28 ± 3 years) were included. Systolic and diastolic left ventricular (LV) function was measured using conventional echocardiography and TDI. Inter-atrial, intraatrial and intra-left atrial electromechanical coupling (PA) intervals were measured with TDI. P-wave dispersion (PD) was calculated from a 12-lead electrocardiogram. Atrial electromechanical coupling at the septal and left lateral mitral annulus (PA septal, PA lateral) was significantly prolonged in pregnant subjects (62.1 ± 2.7 vs 55.3 ±3.2 ms, p < 0.001; 45.7 ± 2.5 vs 43.1 ± 2.7 ms, p < 0.001, respectively). Inter-atrial (PA lateral - PA tricuspid), intra-atrial (PA septum - PA tricuspid) and intra-left atrial (PA lateral - PA septum) electromechanical coupling intervals, maximum P-wave (Pmax) duration and PD were significantly longer in the pregnant subjects (26.4 ± 4.0 vs 20.2 ± 3.6 ms, p < 0.001; 10.0 ± 2.0 vs 8.0 ± 2.6 ms, p = 0.002; 16.4 ± 3.3 vs 12.2 ± 3.0 ms, p < 0.001; 103.1 ± 5.4 vs 96.8 ± 7.4 ms, p ± 0.001; 50.7 ± 6.8 vs 41.6 ± 5.5 ms, p < 0.001, respectively). We found a significant positive correlation between inter-atrial and intraleft atrial electromechanical coupling intervals and Pmax (r = 0.282, p = 0.029, r = 0.378, p = 0.003, respectively). This study showed that atrial electromechanical coupling intervals and PD, which are predictors of AF, were longer in pregnant subjects and this may cause an increased risk of AF in pregnancy.

A quantitative comparison of transesophageal and epicardial color Doppler echocardiography in the intraoperative assessment of mitral regurgitation.

PubMed

Kleinman, J P; Czer, L S; DeRobertis, M; Chaux, A; Maurer, G

1989-11-15

Epicardial and transesophageal color Doppler echocardiography are both widely used for the intraoperative assessment of mitral regurgitation (MR); however, it has not been established whether grading of regurgitation is comparable when evaluated by these 2 techniques. MR jet size was quantitatively compared in 29 hemodynamically and temporally matched open-chest epicardial and transesophageal color Doppler echocardiography studies from 22 patients (18 with native and 4 with porcine mitral valves) scheduled to undergo mitral valve repair or replacement. Jet area, jet length and left atrial area were analyzed. Comparison of jet area measurements as assessed by epicardial and transesophageal color flow mapping revealed an excellent correlation between the techniques (r = 0.95, p less than 0.001). Epicardial and transesophageal jet length measurements were also similar (r = 0.77, p less than 0.001). Left atrial area could not be measured in 18 transesophageal studies (62%) due to foreshortening, and in 5 epicardial studies (17%) due to poor image resolution. Acoustic interference with left atrial and color flow mapping signals was noted in all patients with mitral valve prostheses when imaged by epicardial echocardiography, but this did not occur with transesophageal imaging. Thus, in patients undergoing valve repair or replacement, transesophageal and epicardial color flow mapping provide similar quantitative assessment of MR jet size. Jet area to left atrial area ratios have limited applicability in transesophageal color flow mapping, due to foreshortening of the left atrial borders in transesophageal views. Transesophageal color flow mapping may be especially useful in assessing dysfunctional mitral prostheses due to the lack of left atrial acoustic interference.

Left atrial appendage dimensions predict the risk of stroke/TIA in patients with atrial fibrillation.

PubMed

Beinart, Roy; Heist, E Kevin; Newell, John B; Holmvang, Godtfred; Ruskin, Jeremy N; Mansour, Moussa

2011-01-01

Risk of Stroke/TIA in Patients With Atrial Fibrillation. Most strokes in patients with atrial fibrillation (AF) arise from thrombus formation in left atrial appendage (LAA). Our aim was to identify LAA features associated with a higher stroke risk in patients with AF using magnetic resonance imaging and angiography (MRI/MRA). The study included 144 patients with nonvalvular AF who were not receiving warfarin and who underwent MRI/MRA prior to catheter ablation for AF. LAA volume, LAA depth, short and long axes of LAA neck, and numbers of lobes were measured. Of the 144 patients, 18 had a prior stroke or transient ischemic attack (TIA) (13 and 5, respectively). Compared with patients who had no history of stroke/TIA, these patients were older, had higher prevalence of hypertension and hyperlipidemia and had higher LAA volume (22.9 ± 9.6 cm(3) vs. 14.5 ± 7.1 cm(3) , P < 0.001). Their LAA depth (3.76 ± 0.9 cm vs. 3.21 ± 0.8 cm, P = 0.006) and the long and short axes of the LAA neck (3.12 ± 0.7 cm vs. 2.08 ± 0.7 cm, P < 0.001; 2.06 ± 0.5 cm vs. 1.37 ± 0.4 cm, P < 0.001, respectively) were larger. Using stepwise logistic regression model, the only statistically significant multivariable predictors of events were age (OR = 1.21 per year, 95% CI 1.06-1.38, P = 0.004), aspirin use (OR = 0.039, 95% CI 0.005-0.28, P = 0.001), and LAA neck dimensions (short axis × long axis) (OR = 3.59 per cm(2) , 95% CI 1.93-6.69, P < 0.001). LAA dimensions predict strokes/TIAs in patients with AF. LAA assessment by MRI/MRA can potentially be used as an adjunctive tool for risk stratification for embolic events in AF patients. © 2010 Wiley Periodicals, Inc.

Association of Left Atrial Function Index With Late Atrial Fibrillation Recurrence after Catheter Ablation.

PubMed

Sardana, Mayank; Ogunsua, Adedotun A; Spring, Matthew; Shaikh, Amir; Asamoah, Owusu; Stokken, Glenn; Browning, Clifford; Ennis, Cynthia; Donahue, J Kevin; Rosenthal, Lawrence S; Floyd, Kevin C; Aurigemma, Gerard P; Parikh, Nisha I; McManus, David D

2016-12-01

Although catheter ablation (CA) for atrial fibrillation (AF) is commonly used to improve symptoms, AF recurrence is common and new tools are needed to better inform patient selection for CA. Left atrial function index (LAFI), an echocardiographic measure of atrial mechanical function, has shown promise as a noninvasive predictor of AF. We hypothesized that LAFI would relate to AF recurrence after CA. All AF patients undergoing index CA were enrolled in a prospective institutional AF Treatment Registry between 2011 and 2014. LAFI was measured post hoc from pre-ablation clinical echocardiographic images in 168 participants. Participants were mostly male (33% female), middle-aged (60 ± 10 years), obese and had paroxysmal AF (64%). Mean LAFI was 25.9 ± 17.6. Over 12 months of follow-up, 78 participants (46%) experienced a late AF recurrence. In logistic regression analyses adjusting for factors known to be associated with AF, lower LAFI remained associated with AF recurrence after CA [OR 0.04 (0.01-0.67), P = 0.02]. LAFI discriminated AF recurrence after CA slightly better than CHADS2 (C-statistic 0.60 LAFI, 0.57 CHADS2). For participants with persistent AF, LAFI performed significantly better than CHADS2 score (C statistic = 0.79 LAFI, 0.56 CHADS2, P = 0.02). LAFI, an echocardiographic measure of atrial function, is associated with AF recurrence after CA and has improved ability to discriminate AF recurrence as compared to the CHADS-2 score, especially among persistent AF patients. Since LAFI can be calculated using standard 2D echocardiographic images, it may be a helpful tool for predicting AF recurrence. © 2016 Wiley Periodicals, Inc.

Assessment of the atrial electromechanical properties of patients with human immunodeficiency virus.

PubMed

Ertem, Ahmet G; Yayla, Çağrı; Açar, Burak; Ünal, Sefa; Erdol, Mehmet A; Sonmezer, Meliha Ç; Kaya Kiliç, Esra; Ataman Hatipoglu, Çiğdem; Gokaslan, Serkan; Kafes, Habibe; Akboga, Mehmet K; Aladag, Pelin; Demirtas, Koray; Tulek, Necla; Erdinç, Fatma S; Aydogdu, Sinan

The relationship between atrial fibrillation and human immunodeficiency virus (HIV) infection was evaluated. Electro-echocardiographic methods can be used to predict the development of atrial fibrillation (AF). In this study, we aimed to investigate the atrial electromechanical delay (AEMD) parameters of HIV (+) patients. Forty-two HIV (+) patients and 40 HIV (-) healthy volunteers were prospectively enrolled in this study. The electromechanical properties of the subjects' atria were evaluated with tissue Doppler imaging. The left-AEMD, right-AEMD and inter-AEMD were increased in the HIV (+) patients relative to the controls (p=0.003, p<0.001, and p<0.001, respectively). The CD4 count was inversely correlated with the inter-AEMD (r=-0.428, p<0.001). The CD4 count was an independent predictor of the inter-AEMD (β=0.523, p=0.007). Our study demonstrated that both the inter- and intra-atrial electromechanical delays were prolonged in the patients with HIV. This non-invasive and simple technique may provide significant contributions to the assessment of the risk of atrial arrhythmia in patients with HIV. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

Hyperthyroidism and atrial myxoma--an intriguing cardio-endocrine association.

PubMed

Kumar, Gautam; Chow, John T; Klarich, Kyle W; Dean, Diana S

2007-12-01

A 65-year-old woman presented with dyspnea and bilateral leg edema for 1 week, worsening fatigue for 1 month, and a 7-lb weight loss over the last summer. She was clinically and biochemically hyperthyroid. Echocardiography revealed a left atrial myxoma measuring 6.2 x 3.3 cm protruding into the mitral orifice and left ventricle during diastole. She was treated for Graves' disease with Iodine-131. Six weeks later, her left atrial myxoma measuring 10.1 x 6.2 x 2.4 cm was resected. She became euthyroid before surgery and then biochemically hypothyroid 6 weeks after radioiodine treatment, for which she subsequently required thyroxine replacement. Atrial myxomas are the most common primary cardiac neoplasms. At least 5% to 10% can be attributed to Carney's complex. More than two-thirds of patients with Carney's complex develop one or more cardiac myxomas. Although atrial myxomas in Carney's complex are histologically indistinguishable from the sporadic form, their clinical presentation and course is distinct. This is the first case of newly diagnosed Graves' disease that has been reported in association with an atrial myxoma. The features discussed in this article help differentiate between syndromic and sporadic atrial myxomas.

Left Atrial Myxoma Hypervascularized from the Right Coronary Artery: An Interesting Cath Lab Finding.

PubMed

Oliveira, Marcos Danillo Peixoto; Tamazato, Adriano Ossuna; de Fazzio, Fernando Roberto; Kajita, Luiz J; Ribeiro, Expedito E; Lemos, Pedro Alves

2016-01-01

Primary cardiac tumors are rare and approximately half of them are atrial myxomas. They rarely remain asymptomatic, especially if large. The imaging of a myxoma by contrast dye during coronary angiography is an infrequent sign, which clarifies the vascular supply of the tumor. We report herein an interesting and rare case of a left atrial myxoma hypervascularized from the right coronary artery.

Alterations in atrial electrophysiology and tissue structure in a canine model of chronic atrial dilatation due to mitral regurgitation.

PubMed

Verheule, Sander; Wilson, Emily; Everett, Thomas; Shanbhag, Sujata; Golden, Catherine; Olgin, Jeffrey

2003-05-27

Clinically, chronic atrial dilatation is associated with an increased incidence of atrial fibrillation (AF), but the underlying mechanism is not clear. We have investigated atrial electrophysiology and tissue structure in a canine model of chronic atrial dilatation due to mitral regurgitation (MR). Thirteen control and 19 MR dogs (1 month after partial mitral valve avulsion) were studied. Dogs in the MR group were monitored using echocardiography and Holter recording. In open-chest follow-up experiments, electrode arrays were placed on the atria to investigate conduction patterns, effective refractory periods, and inducibility of AF. Alterations in tissue structure and ultrastructure were assessed in atrial tissue samples. At follow-up, left atrial length in MR dogs was 4.09+/-0.45 cm, compared with 3.25+/-0.28 at baseline (P<0.01), corresponding to a volume of 205+/-61% of baseline. At follow-up, no differences in atrial conduction pattern and conduction velocities were noted between control and MR dogs. Effective refractory periods were increased homogeneously throughout the left and right atrium. Sustained AF (>1 hour) was inducible in 10 of 19 MR dogs and none of 13 control dogs (P<0.01). In the dilated MR left atrium, areas of increased interstitial fibrosis and chronic inflammation were accompanied by increased glycogen ultrastructurally. Chronic atrial dilatation in the absence of overt heart failure leads to an increased vulnerability to AF that is not based on a decrease in wavelength.

HATCH score in the prediction of new-onset atrial fibrillation after catheter ablation of typical atrial flutter.

PubMed

Chen, Ke; Bai, Rong; Deng, Wenning; Gao, Chuanyu; Zhang, Jing; Wang, Xianqing; Wang, Shunbao; Fu, Haixia; Zhao, Yonghui; Zhang, Jiaying; Dong, Jianzeng; Ma, Changsheng

2015-07-01

New-onset atrial fibrillation (AF) is not uncommon after ablation of typical atrial flutter (AFL); however, limited data are available for a risk prediction model for the future occurrence of AF in patients with typical AFL undergoing successful catheter ablation. This study aimed to determine whether the HATCH score (which is based on hypertension, age ≥75 years, transient ischemic attack or stroke, chronic obstructive pulmonary disease, and heart failure) is useful for risk prediction of subsequent AF after ablation of typical AFL. A total of 216 consecutive patients presenting with typical AFL and no history of AF who underwent successful catheter ablation were enrolled in the study. The clinical endpoint was occurrence of new-onset AF during follow-up after ablation. During a follow-up period of 29.1 ± 18.3 months, 85 patients (39%) experienced at least 1 episode of AF. Multivariate Cox regression analysis demonstrated that the HATCH score (hazard ratio 1.784; 95% confidence interval 1.352-2.324; P < .001) and left atrial diameter (hazard ratio 1.270; 95% confidence interval 1.115-1.426; P < .001) were independently associated with new-onset AF after typical AFL ablation. The area under the receiver operator characteristic curve based on the HATCH score for prediction of new-onset AF was 0.743. The HATCH score could be used to stratify the patients into 2 groups with different incidences of new-onset AF (69% vs 27%, P < .001) at a cutoff value of 2. The HATCH score is a useful predictor of new-onset AF after typical AFL ablation. Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

P1033Echocardiographic predictive model of new-onset postoperative atrial fibrillation after abdominal surgery.

PubMed

Demirevska, L; Gotchev, D

2016-12-01

and purpose: Postoperative atrial fibrillation (POAF) is a frequent complication post high-risk abdominal surgery in elderly patients. This study aimed to develop a predictive model of POAF based on preoperative transthoracic echocardiography (TTE) findings in these patients. We conducted a prospective study of 300 consecutive patients, age ≥ 65 years (mean age 72±6 years, 61% men), who underwent high-risk abdominal surgery under general anesthesia. Preoperative TTE was performed in all patients, including tissue Doppler imaging (TDI). We measured the time interval between the onset of the P-wave on ECG and a point of the peak-A wave on TDI from the lateral mitral annulus (PA lateral) and septal mitral annulus (PA septal). Left atrial (LA) dyssynchrony was measured by subtracting the PA septal from PA lateral. Right ventricular systolic pressure was estimated by using the tricuspid regurgitation jet (TRJ) Doppler velocity method. The primary endpoint was the occurance of new-onset POAF. Thirty-seven (12%) patients developed POAF. Multiple echocardiographic parameters were measured and tested in different combinations. The final model included the following variables with cutoff points predictive of POAF: PA lateral > 139 ms (69% sensitivity, 92% specificity), LA dyssynchrony > 35 ms (78% sensitivity, 89% specificity), and TRJ Doppler velocity >2.6 m/s (89% sensitivity, 64% specificity). A value of 0 was assigned when the result was below the cutoff point and a value of 1 if above the cutoff point. Coding of these three variables in the following order: PA lateral- TRJ Doppler- left atrial dyssynchrony can predict the probability of POAF. The model showed a postive predictive value of 79% and a negative predictive value of 95%. A model using three echocardiographic variables: PA lateral, LA dyssynchrony and TRJ Doppler velocity, can predict the incidence of POAF after high-risk abdominal surgery. The model can be used preoperatively to identify high-risk patients that would need aggressive prophylactic treatment. PA lateral >139 ms-TRJ Doppler velocity >2.6 m/s-LA dyssynchrony >35 msProbability of POAF0- 0- 0; 0- 1- 0No0- 0- 1; 0- 1- 1; 1- 0- 0; 1- 0- 1; 1- 1- 0; 1- 1- 1Yes. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: Journals.permissions@oup.com.

Inadvertent transarterial insertion of atrial and ventricular defibrillator leads.

PubMed

Issa, Ziad F; Rumman, Syeda S; Mullin, James C

2009-01-01

Inadvertent placement of pacemaker and implantable cardioverter-defibrillator (ICD) leads in the left ventricle (LV) is a rare but well-recognized complication of device implantation [1]. We report a case of inadvertent transarterial implantation of dual-chamber ICD leads; the ventricular lead positioned in the LV and the atrial lead positioned in the aortic root. The tip of the atrial lead migrated across the aortic wall and captured the epicardial surface of the left atrium. The diagnosis was made 5 years after the implantation procedure with no apparent adverse events directly related to left heart lead placement.

Effects of heart rate on experimentally produced mitral regurgitation in dogs.

PubMed

Yoran, C; Yellin, E L; Hori, M; Tsujioka, K; Laniado, S; Sonnenblick, E H; Frater, R W

1983-12-01

The effects of increasing heart rate (HR) on the hemodynamics of acute mitral regurgitation (MR) were studied in 8 open-chest dogs. Filling volume, regurgitant volume and stroke volume were calculated from electromagnetic probe measurements of mitral and aortic flows. The left atrial-left ventricular systolic pressure gradient was measured with micromanometers. The calculated effective mitral regurgitant orifice area varied from 10 to 128 mm2, with a consequent regurgitant fraction (regurgitant volume/filling volume) of 24 to 62%. After crushing the sinus node, HR was increased stepwise from 90 to 180 beats/min by atrial pacing while maintaining aortic pressure constant. With increasing HR, filling volume, stroke volume, regurgitant volume and regurgitant time decreased; total cardiac output, forward cardiac output, regurgitant output, systolic pressure gradient, regurgitant fraction and the regurgitant orifice did not change; left ventricular end-diastolic pressure decreased; and left atrial v-wave amplitude increased. These results indicate that in acute experimental MR with a wide spectrum of incompetence, the relative distribution of forward and regurgitant flows did not change with large increases in HR. At rates greater than 150 beats/min the atrial contraction occurs early and increases the amplitude of the left atrial v wave. This may contribute to the severity of pulmonary congestion in patients with MR.

Patients With Undetermined Stroke Have Increased Atrial Fibrosis: A Cardiac Magnetic Resonance Imaging Study.

PubMed

Fonseca, Ana Catarina; Alves, Pedro; Inácio, Nuno; Marto, João Pedro; Viana-Baptista, Miguel; Pinho-E-Melo, Teresa; Ferro, José M; Almeida, Ana G

2018-03-01

Some patients with ischemic strokes that are currently classified as having an undetermined cause may have structural or functional changes of the left atrium (LA) and left atrial appendage, which increase their risk of thromboembolism. We compared the LA and left atrial appendage of patients with different ischemic stroke causes using cardiac magnetic resonance imaging. We prospectively included a consecutive sample of ischemic stroke patients. Patients with structural changes on echocardiography currently considered as causal for stroke in the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification were excluded. A 3-T cardiac magnetic resonance imaging was performed. One hundred and eleven patients were evaluated. Patients with an undetermined cause had a higher percentage of LA fibrosis ( P =0.03) than patients with other stroke causes and lower, although not statistically significant, values of LA ejection fraction. Patients with atrial fibrillation and undetermined stroke cause showed a similar value of atrial fibrosis. The LA phenotype that was found in patients with undetermined cause supports the hypothesis that an atrial disease may be associated with stroke. © 2018 American Heart Association, Inc.

Percutaneous Occlusion of the Left Atrial Appendage with the Watchman Device in an Active Duty Sailor with Atrial Fibrillation and Recurrent Thromboembolism Despite Appropriate Use of Oral Anticoagulation.

PubMed

Cox, Justin M; Choi, Anthony J; Oakley, Luke S; Francisco, Gregory M; Nayak, Keshav R

2018-05-23

Atrial fibrillation is the most common significant cardiac arrhythmia and is associated with a five-fold increased risk of stroke from thromboembolism. Over 94% of these emboli arise from the left atrial appendage. Systemic embolic phenomena are rare, accounting for less than 1 out of 10 of all embolic events, but have a similar prevention strategy. Anticoagulation significantly reduces the risk of these events, and thus forms the cornerstone of therapy for most patients with atrial fibrillation. Left atrial appendage occlusion with the Watchman device is a recently approved alternative for stroke prevention in selected patients. We present a case of an active duty U.S. Navy sailor at low risk for thromboembolism who nonetheless suffered recurrent thromboembolic events despite appropriate anticoagulation, and thus underwent Watchman implantation. The therapy in this case will ideally provide a lifetime of protection from recurrent systemic embolization while allowing the patient to continue his active duty military career without restriction due to oral anticoagulation.

Atrial development in the human heart: an immunohistochemical study with emphasis on the role of mesenchymal tissues

NASA Technical Reports Server (NTRS)

Wessels, A.; Anderson, R. H.; Markwald, R. R.; Webb, S.; Brown, N. A.; Viragh, S.; Moorman, A. F.; Lamers, W. H.

2000-01-01

The development of the atrial chambers in the human heart was investigated immunohistochemically using a set of previously described antibodies. This set included the monoclonal antibody 249-9G9, which enabled us to discriminate the endocardial cushion-derived mesenchymal tissues from those derived from extracardiac splanchnic mesoderm, and a monoclonal antibody recognizing the B isoform of creatine kinase, which allowed us to distinguish the right atrial myocardium from the left. The expression patterns obtained with these antibodies, combined with additional histological information derived from the serial sections, permitted us to describe in detail the morphogenetic events involved in the development of the primary atrial septum (septum primum) and the pulmonary vein in human embryos from Carnegie stage 14 onward. The level of expression of creatine kinase B (CK-B) was found to be consistently higher in the left atrial myocardium than in the right, with a sharp boundary between high and low expression located between the primary septum and the left venous valve indicating that the primary septum is part of the left atrial gene-expression domain. This expression pattern of CK-B is reminiscent of that of the homeobox gene Pitx2, which has recently been shown to be important for atrial septation in the mouse. This study also demonstrates a poorly appreciated role of the dorsal mesocardium in cardiac development. From the earliest stage investigated onward, the mesenchyme of the dorsal mesocardium protrudes into the dorsal wall of the primary atrial segment. This dorsal mesenchymal protrusion is continuous with a mesenchymal cap on the leading edge of the primary atrial septum. Neither the mesenchymal tissues of the dorsal protrusion nor the mesenchymal cap on the edge of the primary septum expressed the endocardial tissue antigen recognized by 249-9G9 at any of the stages investigated. The developing pulmonary vein uses the dorsal mesocardium as a conduit to reach the primary atrial segment. Initially, the pulmonary pit, which will becomes the portal of entry for the pulmonary vein, is located along the midline, flanked by two myocardial ridges. As development progresses, tissue remodeling results in the incorporation of the portal of entry of the pulmonary vein in left atrial myocardium, which is recognized because of its high level of creatine. Closure of the primary atrial foramen by the primary atrial septum occurs as a consequence of the fusion of these mesenchymal structures. Copyright 2000 Wiley-Liss, Inc.

Aneurysm of the Left Atrial Appendage

PubMed Central

Victor, Solomon; Nayak, Vijaya M.

2001-01-01

A 43-year-old woman underwent excision of an aneurysm of the left atrial appendage, which had been causing cerebrovascular embolic episodes. We attribute the aneurysm to congenital dysplasia of the musculi pectinati in the left atrial appendage and of the bands of atrial muscle from which they arise. In Appendix I, we draw attention to the morphologically similar arrangements of inner and outer bands that emanate from a common transverse interatrial band and yield morphologically similar medial, descending, and ascending palm-leaf arrangements of musculi pectinati. In addition, we observe that the strap-like arrangements of musculi in both atria connect the outer band with the para-annular segment of the inner band. In Appendix II, we briefly review the literature concerning musculi pectinati and related bands. PMID:11453121

Experimental myocardial infarction

PubMed Central

Kumar, Raj; Joison, Julio; Gilmour, David P.; Molokhia, Farouk A.; Pegg, C. A. S.; Hood, William B.

1971-01-01

The hemodynamic effects of tachycardia induced by atrial pacing were investigated in left ventricular failure of acute and healing experimental myocardial infarction in 20 intact, conscious dogs. Myocardial infarction was produced by gradual inflation of a balloon cuff device implanted around the left anterior descending coronary artery 10-15 days prior to the study. 1 hr after acute myocardial infarction, atrial pacing at a rate of 180 beats/min decreased left ventricular end-diastolic pressure from 19 to 8 mm Hg and left atrial pressure from 17 to 12 mm Hg, without change in cardiac output. In the healing phase of myocardial infarction 1 wk later, atrial pacing decreased left ventricular end-diastolic pressure from 17 to 9 mm Hg and increased the cardiac output by 37%. This was accompanied by evidence of peripheral vasodilation. In two dogs with healing anterior wall myocardial infarction, left ventricular failure was enhanced by partial occlusion of the circumflex coronary artery. Both the dogs developed pulmonary edema. Pacing improved left ventricular performance and relieved pulmonary edema in both animals. In six animals propranolol was given after acute infarction, and left ventricular function deteriorated further. However the pacing-induced augmentation of cardiac function was unaltered and, hence, is not mediated by sympathetics. The results show that the spontaneous heart rate in left ventricular failure of experimental canine myocardial infarction may be less than optimal and that maximal cardiac function may be achieved at higher heart rates. Images PMID:4395910

Cost effectiveness of left atrial appendage closure with the Watchman device for atrial fibrillation patients with absolute contraindications to warfarin

PubMed Central

Reddy, Vivek Y.; Akehurst, Ronald L.; Armstrong, Shannon O.; Amorosi, Stacey L.; Brereton, Nic; Hertz, Deanna S.; Holmes, David R.

2016-01-01

Abstract Aims Atrial fibrillation (AF) patients with contraindications to oral anticoagulation have had few options for stroke prevention. Recently, a novel oral anticoagulant, apixaban, and percutaneous left atrial appendage closure (LAAC) have emerged as safe and effective therapies for stroke risk reduction in these patients. This analysis assessed the cost effectiveness of LAAC with the Watchman device relative to apixaban and aspirin therapy in patients with non-valvular AF and contraindications to warfarin therapy. Methods and results A cost-effectiveness model was constructed using data from three studies on stroke prevention in patients with contraindications: the ASAP study evaluating the Watchman device, the ACTIVE A trial of aspirin and clopidogrel, and the AVERROES trial evaluating apixaban. The cost-effectiveness analysis was conducted from a German healthcare payer perspective over a 20-year time horizon. Left atrial appendage closure yielded more quality-adjusted life years (QALYs) than aspirin and apixaban by 2 and 4 years, respectively. At 5 years, LAAC was cost effective compared with aspirin with an incremental cost-effectiveness ratio (ICER) of €16 971. Left atrial appendage closure was cost effective compared with apixaban at 7 years with an ICER of €9040. Left atrial appendage closure was cost saving and more effective than aspirin and apixaban at 8 years and remained so throughout the 20-year time horizon. Conclusions This analysis demonstrates that LAAC with the Watchman device is a cost-effective and cost-saving solution for stroke risk reduction in patients with non-valvular AF who are at risk for stroke but have contraindications to warfarin. PMID:26838691

Acute myocardial infarction with changing axis deviation.

PubMed

Patanè, Salvatore; Marte, Filippo

2011-07-01

Changing axis deviation has been rarely reported also during atrial fibrillation or atrial flutter. Changing axis deviation has been rarely reported also during acute myocardial infarction associated with atrial fibrillation. Isolated left posterior hemiblock is a very rare finding but the evidence of transient right axis deviation with a left posterior hemiblock pattern has been reported during acute anterior myocardial infarction as related with significant right coronary artery obstruction and collateral circulation between the left coronary system and the posterior descending artery. Left anterior hemiblock development during acute inferior myocardial infarction can be an indicator of left anterior descending coronary artery lesions, multivessel coronary artery disease, and impaired left ventricular systolic function. We present a case of changing axis deviation in a 62-year-old Italian man with acute myocardial infarction. Also this case focuses attention on changing axis deviation during acute myocardial infarction. Copyright © 2009 Elsevier Ireland Ltd. All rights reserved.

Association of pulse pressure with new-onset atrial fibrillation in patients with hypertension and left ventricular hypertrophy: the Losartan Intervention For Endpoint (LIFE) reduction in hypertension study.

PubMed

Larstorp, Anne Cecilie K; Ariansen, Inger; Gjesdal, Knut; Olsen, Michael H; Ibsen, Hans; Devereux, Richard B; Okin, Peter M; Dahlöf, Björn; Kjeldsen, Sverre E; Wachtell, Kristian

2012-08-01

Previous studies have found pulse pressure (PP), a marker of arterial stiffness, to be an independent predictor of atrial fibrillation (AF) in general and hypertensive populations. We examined whether PP predicted new-onset AF in comparison with other blood pressure components in the Losartan Intervention For Endpoint reduction in hypertension study, a double-blind, randomized (losartan versus atenolol), parallel-group study, including 9193 patients with hypertension and electrocardiographic left ventricular hypertrophy. In 8810 patients with neither a history of AF nor AF at baseline, Minnesota coding of electrocardiograms confirmed new-onset AF in 353 patients (4.0%) during mean 4.9 years of follow-up. In multivariate Cox regression analyses, baseline and in-treatment PP and baseline and in-treatment systolic blood pressure predicted new-onset AF, independent of baseline age, height, weight, and Framingham Risk Score; sex, race, and treatment allocation; and in-treatment heart rate and Cornell product. PP was the strongest single blood pressure predictor of new-onset AF determined by the decrease in the -2 Log likelihood statistic, in comparison with systolic blood pressure, diastolic blood pressure, and mean arterial pressure. When evaluated in the same model, the predictive effect of systolic and diastolic blood pressures together was similar to that of PP. In this population of patients with hypertension and left ventricular hypertrophy, PP was the strongest single blood pressure predictor of new-onset AF, independent of other risk factors.

Treatment of hypertension with perindopril reduces plasma atrial natriuretic peptide levels, left ventricular mass, and improves echocardiographic parameters of diastolic function

NASA Technical Reports Server (NTRS)

Yalcin, F.; Aksoy, F. G.; Muderrisoglu, H.; Sabah, I.; Garcia, M. J.; Thomas, J. D.

2000-01-01

BACKGROUND: Hypertension is a major independent risk factor for cardiac deaths, and diastolic dysfunction is a usual finding during the course of this disease. HYPOTHESIS: This study was designed to investigate the effects of chronic therapy with perindopril on left ventricular (LV) mass, left atrial size, diastolic function, and plasma level of atrial natriuretic peptide (ANP) in patients with hypertension. METHODS: Twenty four patients who had not been previously taking any antihypertensive medication and without prior history of angina pectoris, myocardial infarction, congestive heart failure, dysrhythmias, valvular heart disease, or systemic illnesses received 4-8 mg/day of perindopril orally. Echocardiographic studies were acquired at baseline and 6 months after the initiation of therapy. RESULTS: Systolic and diastolic blood pressure decreased from 174 +/- 19.7 and 107.5 +/- 7.8 mmHg to 134 +/- 10.6 and 82 +/- 6.7 mmHg, respectively (p < 0.001). Left ventricular mass decreased from 252.4 +/- 8.3 to 205.7 +/- 7.08 g and left atrial volume from 20.4 +/- 5.1 to 17.6 +/- 5.2 ml, respectively (p < 0.001). Transmitral Doppler early and atrial filling velocity ratio (E/A) increased from 0.69 +/- 0.06 to 0.92 +/- 0.05 m/s and plasma ANP level decreased from 71.9 +/- 11.7 to 35.3 +/- 7.8 pg/ml (p < 0.001). Reduction of LV mass correlated positively with a reduction in ANP levels (r = 0.66, p < 0.0005). CONCLUSIONS: Perindopril caused a significant reduction of LV mass, left atrial volume, and plasma ANP levels, as well as improvement in Doppler parameters of LV filling in this group of patients with hypertension.

Localizing Circuits of Atrial Macro-Reentry Using ECG Planes of Coherent Atrial Activation

PubMed Central

Kahn, Andrew M.; Krummen, David E.; Feld, Gregory K.; Narayan, Sanjiv M.

2007-01-01

Background The complexity of ablation for atrial macro-reentry (AFL) varies significantly depending upon the circuit location. Presently, surface ECG analysis poorly separates left from right atypical AFL and from some cases of typical AFL, delaying diagnosis until invasive study. Objective To differentiate and localize the intra-atrial circuits of left atypical AFL, right atypical, and typical AFL using quantitative ECG analysis. Methods We studied 66 patients (54 M, age 59±14 years) with typical (n=35), reverse typical (n=4) and atypical (n=27) AFL. For each, we generated filtered atrial waveforms from ECG leads V5 (X-axis), aVF (Y) and V1 (Z) by correlating a 120 ms F-wave sample to successive ECG regions. Atrial spatial loops were plotted for 3 orthogonal planes (frontal, XY=V5/aVF; sagittal, YZ=aVF/V1; axial, XZ=V5/V1), then cross-correlated to measure spatial regularity (‘coherence’: range −1 to 1). Results Mean coherence was greatest in the XY plane (p<10−3 vs XZ or YZ). Atypical AFL showed lower coherence than typical AFL in XY (p<10−3), YZ (p<10−6) and XZ (p<10−5) planes. Atypical left AFL could be separated from atypical right AFL by lower XY coherence (p=0.02); for this plane coherence < 0.69 detected atypical left AFL with 84% specificity and 75% sensitivity. F-wave amplitude did not separate typical, atypical right or atypical left AFL (p=NS). Conclusions Atypical AFL shows lower spatial coherence than typical AFL, particularly in sagittal and axial planes. Coherence in the Cartesian frontal plane separated left and right atypical AFL. Such analyses may be used to plan ablation strategy from the bedside. PMID:17399632

Left atrial appendage myxofibrosarcoma: A rare masquerader of myxoma and thrombus-"all that glitters is not gold".

PubMed

Khan, Muhammad Shoaib; Reddy, Sahadev; Lombardi, Richard; Isabel, Pitti; Mcgregor, Walter E; Tang, Bang; Gabriel, George; Biederman, Robert W

2018-02-01

Left atrial appendage mass can occasionally pose a serious challenge to physicians to identify the nature of the mass with the aid of imaging techniques. We present a case of 67-year-old man, who was evaluated for suspected left atria myxoma. Transesophageal echocardiography revealed a heterogeneous density originating from left atrial appendage, thought to be most consistent with a myxoma. Cardiac magnetic resonance imaging, uncharacteristically, gave an equivocal picture, suggesting the mass to be a myxoma on initial imaging and a thrombus with evidence of liquefaction necrosis following postcontrast enhancement. Surprisingly, histopathology of the mass following its surgical excision yielded a rare diagnosis of myxofibrosarcoma. © 2017, Wiley Periodicals, Inc.

Non-invasive identification of stable rotors and focal sources for human atrial fibrillation: mechanistic classification of atrial fibrillation from the electrocardiogram.

PubMed

Jones, Aled R; Krummen, David E; Narayan, Sanjiv M

2013-09-01

To develop electrocardiogram (ECG) tools to quantify the number of sources for atrial fibrillation (AF), i.e. spatially stable rotors and focal impulses, and whether they lie in right or left atrium. Intracardiac mapping has recently shown that paroxysmal and persistent AF is sustained by rotors or focal sources that are stable in location and thus targets for limited ablation [focal impulse and rotor modulation (FIRM)] to eliminate AF. Importantly, the numbers and locations of concurrent sources determine both the complexity of AF and the approach for ablation. In 36 AF patients (n = 29 persistent, 63 ± 9 years) in the CONventional ablation with or without Focal Impulse and Rotor Modulation (CONFIRM) trial, we developed phase lock (PL) to quantify spatial repeatability of ECG 'F-waves' between leads over time. Phase lock spectrally quantifies the angle θ between F-wave voltages in planes formed by ECG leads I, aVF, and V1 at successive points in time. We compared PL with ECG spectral dominant frequency (DF) and organizational index (OI) to characterize stable rotors and focal sources validated by intracardiac FIRM mapping. Focal impulse and rotor modulation ablation alone at ≤3 sources acutely terminated and rendered AF non-inducible or substantially slowed AF in 31 of 36 patients. Receiver operating characteristics of PL for this endpoint had area under the curve (AUC) = 0.72, and the optimum cut-point (PL = 0.09) had 74% sensitivity, 92% positive predictive value (PPV). Receiver operating characteristics areas for OI and DF were 0.50 and 0.58, respectively. Left (n = 28) or right (n = 3) atrial sources were localized by PL with AUC = 0.85, sensitivity 100%, PPV 30%, and negative predictive value 100%. Spectral DF provided AUC = 0.79. Notably, PL did not comigrate with diagnosis of paroxysmal or persistent AF (P = NS), unlike ECG DF. The novel metric of ECG PL identifies patients with fewer (≤3) or greater numbers of stable rotors/focal sources for AF, validated by intracardiac FIRM mapping, and localized them to right or left atria. These data open the possibility of using 12-lead ECG analyses to classify AF mechanistically and plan procedures for right- or left-sided FIRM ablation.

Cor triatriatum sinister identified after new onset atrial fibrillation in an elderly man.

PubMed

Zepeda, Ignacio A; Morcos, Peter; Castellanos, Luis R

2014-01-01

A 73-year-old man with new onset atrial fibrillation with rapid ventricular response underwent transthoracic echocardiography that revealed an echogenic linear structure along the left atrium, suggestive of cor triatriatum sinister (CTS). CTS was confirmed with transesophageal echocardiography which demonstrated a proximal accessory atrium receiving pulmonary venous flow separated from a distal true atrium by a fibromuscular membrane with a large fenestration allowing flow between the chambers. In CTS, the left atrium is divided into proximal and distal chambers by a fenestrated fibromuscular septum. This cardiac anomaly accounts for 0.1% of cases of congenital heart disease and rarely presents in adults. CTS is primarily diagnosed with echocardiography and is associated with left atrial enlargement and development of atrial fibrillation. Treatment options depend on size of the communication between proximal and distal chambers, the gradient across the membrane, and the position of pulmonary veins. In some instances, surgical resection of the membrane that divides the left atrium is warranted.

Cor Triatriatum Sinister Identified after New Onset Atrial Fibrillation in an Elderly Man

PubMed Central

Zepeda, Ignacio A.; Morcos, Peter; Castellanos, Luis R.

2014-01-01

A 73-year-old man with new onset atrial fibrillation with rapid ventricular response underwent transthoracic echocardiography that revealed an echogenic linear structure along the left atrium, suggestive of cor triatriatum sinister (CTS). CTS was confirmed with transesophageal echocardiography which demonstrated a proximal accessory atrium receiving pulmonary venous flow separated from a distal true atrium by a fibromuscular membrane with a large fenestration allowing flow between the chambers. In CTS, the left atrium is divided into proximal and distal chambers by a fenestrated fibromuscular septum. This cardiac anomaly accounts for 0.1% of cases of congenital heart disease and rarely presents in adults. CTS is primarily diagnosed with echocardiography and is associated with left atrial enlargement and development of atrial fibrillation. Treatment options depend on size of the communication between proximal and distal chambers, the gradient across the membrane, and the position of pulmonary veins. In some instances, surgical resection of the membrane that divides the left atrium is warranted. PMID:25614746

Remote magnetic navigation for accurate, real-time catheter positioning and ablation in cardiac electrophysiology procedures.

PubMed

Filgueiras-Rama, David; Estrada, Alejandro; Shachar, Josh; Castrejón, Sergio; Doiny, David; Ortega, Marta; Gang, Eli; Merino, José L

2013-04-21

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac substrates such as left atrial flutter. This protocol describes all the clinical and invasive interventional steps performed during a human electrophysiological study and ablation to assess the accuracy, safety and real-time navigation of the Catheter Guidance, Control and Imaging (CGCI) system. Patients who underwent ablation of a right or left atrium flutter substrate were included. Specifically, data from three left atrial flutter and two counterclockwise right atrial flutter procedures are shown in this report. One representative left atrial flutter procedure is shown in the movie. This system is based on eight coil-core electromagnets, which generate a dynamic magnetic field focused on the heart. Remote navigation by rapid changes (msec) in the magnetic field magnitude and a very flexible magnetized catheter allow real-time closed-loop integration and accurate, stable positioning and ablation of the arrhythmogenic substrate.

Remote Magnetic Navigation for Accurate, Real-time Catheter Positioning and Ablation in Cardiac Electrophysiology Procedures

PubMed Central

Filgueiras-Rama, David; Estrada, Alejandro; Shachar, Josh; Castrejón, Sergio; Doiny, David; Ortega, Marta; Gang, Eli; Merino, José L.

2013-01-01

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac substrates such as left atrial flutter. This protocol describes all the clinical and invasive interventional steps performed during a human electrophysiological study and ablation to assess the accuracy, safety and real-time navigation of the Catheter Guidance, Control and Imaging (CGCI) system. Patients who underwent ablation of a right or left atrium flutter substrate were included. Specifically, data from three left atrial flutter and two counterclockwise right atrial flutter procedures are shown in this report. One representative left atrial flutter procedure is shown in the movie. This system is based on eight coil-core electromagnets, which generate a dynamic magnetic field focused on the heart. Remote navigation by rapid changes (msec) in the magnetic field magnitude and a very flexible magnetized catheter allow real-time closed-loop integration and accurate, stable positioning and ablation of the arrhythmogenic substrate. PMID:23628883

[Measurement of left atrial and ventricular volumes in real-time 3D echocardiography. Validation by nuclear magnetic resonance

NASA Technical Reports Server (NTRS)

Bauer, F.; Shiota, T.; Qin, J. X.; White, R. D.; Thomas, J. D.

2001-01-01

The measurement of the left ventricular ejection fraction is important for the evaluation of cardiomyopathy and depends on the measurement of left ventricular volumes. There are no existing conventional echocardiographic means of measuring the true left atrial and ventricular volumes without mathematical approximations. The aim of this study was to test anew real time 3-dimensional echocardiographic system of calculating left atrial and ventricular volumes in 40 patients after in vitro validation. The volumes of the left atrium and ventricle acquired from real time 3-D echocardiography in the apical view, were calculated in 7 sections parallel to the surface of the probe and compared with atrial (10 patients) and ventricular (30 patients) volumes calculated by nuclear magnetic resonance with the simpson method and with volumes of water in balloons placed in a cistern. Linear regression analysis showed an excellent correlation between the real volume of water in the balloons and volumes given in real time 3-dimensional echocardiography (y = 0.94x + 5.5, r = 0.99, p < 0.001, D = -10 +/- 4.5 ml). A good correlation was observed between real time 3-dimensional echocardiography and nuclear magnetic resonance for the measurement of left atrial and ventricular volumes (y = 0.95x - 10, r = 0.91, p < 0.001, D = -14.8 +/- 19.5 ml and y = 0.87x + 10, r = 0.98, P < 0.001, D = -8.3 +/- 18.7 ml, respectively. The authors conclude that real time three-dimensional echocardiography allows accurate measurement of left heart volumes underlying the clinical potential of this new 3-D method.

Left atrial volume index as a predictor for persistent left ventricular dysfunction after aortic valve surgery in patients with chronic aortic regurgitation: the role of early postoperative echocardiography.

PubMed

Cho, In-Jeong; Chang, Hyuk-Jae; Hong, Geu-Ru; Heo, Ran; Sung, Ji Min; Lee, Sang-Eun; Chang, Byung-Chul; Shim, Chi Young; Ha, Jong-Won; Chung, Namsik

2015-06-01

This study aimed to explore whether echocardiographic measurements during the early postoperative period can predict persistent left ventricular systolic dysfunction (LVSD) after aortic valve surgery in patients with chronic aortic regurgitation (AR). We prospectively recruited 54 patients (59 ± 12 years) with isolated chronic severe AR who subsequently underwent aortic valve surgery. Standard transthoracic echocardiography was performed before the operation, during the early postoperative period (≤2 weeks), and then 1 year after the surgery. Twelve patients with preoperative LVSD demonstrated LVSD at early after the surgery. Of the 42 patients without LVSD at preoperative echocardiography, 15 patients (36%) developed early postoperative LVSD after surgical correction. All 27 patients without LVSD at early postoperative echocardiography maintained LV function at 1 year after surgery. In the other 27 patients with postoperative LVSD, 17 patients recovered from LVSD and 10 patients did not at 1 year after surgery. Multiple logistic analysis demonstrated that postoperative left atrial volume index (LAVI) was the only independent predictor for persistent LVSD at 1 year after surgery in patients with postoperative LVSD (OR 1.180, 95% CI, 1.003-1.390, P = 0.046). The optimal LAVI cutoff value (>34.9 mL/m(2) ) had a sensitivity of 80% and a specificity of 88% for the prediction of persistent LVSD. Prevalence of early postoperative LVSD was relatively high, even in the patients without LVSD at preoperative echocardiography. Postoperative LAVI could be useful to predict persistent LVSD after aortic valve surgery in patients with early postoperative LVSD. © 2014, Wiley Periodicals, Inc.

Characteristics of Left Atrial Deformation Parameters and Their Prognostic Impact in Patients with Pathological Left Ventricular Hypertrophy: Analysis by Speckle Tracking Echocardiography.

PubMed

Iio, Chiharuko; Inoue, Katsuji; Nishimura, Kazuhisa; Fujii, Akira; Nagai, Takayuki; Suzuki, Jun; Okura, Takafumi; Higaki, Jitsuo; Ogimoto, Akiyoshi

2015-12-01

The pathological process of left ventricular (LV) hypertrophy is associated with left atrial (LA) remodeling. This study was aimed to evaluate the prognostic value of LA strain parameters in patients with pathological LV hypertrophy. This study included 95 patients with hypertensive heart disease (HHD: n = 24), hypertrophic cardiomyopathy (HCM: n = 56), cardiac amyloidosis (CA: n = 15), and control subjects (n = 20). We used two-dimensional speckle tracking echocardiography (STE) to analyze LA global strain. LA electromechanical conduction time (EMT) at the septal (EMT-septal) and lateral wall (EMT-lateral), and their time difference (EMT-diff) were calculated. The incidence of cardiac death and heart failure hospitalization was defined as major cardiac events and that of atrial fibrillation as secondary outcome. Left atrial volume index was increased and LA booster strain was decreased in the HCM and CA groups compared with the HHD group. EMT-lateral was increased in the diseased groups compared with the control. EMT-diff was prolonged in the CA group compared with the HCM group. During the follow-up period (mean 3.4 years), major cardiac events and atrial fibrillation occurred in 17 and 13 patients, respectively. The occurrence of atrial fibrillation was associated with CA etiology, E/e', LA volume index, LAa, and EMT-lateral. The incidence of major cardiac events was independently correlated with LA volume index and EMT-diff in multivariate analysis. This study suggested that the EMT-diff could discriminate patients with a high risk of cardiac events among patients with pathological LV hypertrophy. © 2015, Wiley Periodicals, Inc.

Pulmonary hypertension in dogs with mitral regurgitation attributable to myxomatous valve disease.

PubMed

Chiavegato, David; Borgarelli, Michele; D'Agnolo, Gino; Santilli, Roberto A

2009-01-01

Pulmonary hypertension has been associated with mitral insufficiency caused by chronic degenerative valve disease in dogs. Our aim was to search for associations between left atrial to aortic root ratio, end-systolic and end-diastolic volume indices, and changes in the right ventricular to right atrial pressure gradient as estimated by the peak velocity of tricuspid regurgitation in dogs with chronic degenerative valve disease and different classes of heart failure. Dogs, for which follow-up was available were evaluated for changes in the right ventricular to right atrial systolic pressure gradient over time. Three hundred and forty-four dogs were studied; 51 in the International Small Animal Cardiac Health Council class la, 75 in class 1b, 113 in class 2, 97 in class 3a, and 8 in class 3b. The mean values for right ventricular to right atrial systolic pressure gradient, end-systolic volume index, end-diastolic volume index, and left atrial to aortic ratio were 49.2 +/- 17.1 mmHg, 149.12 +/- 60.8 and 37.7 +/- 21.6 ml/m2, and 1.9 +/- 0.5, respectively. A weak positive correlation was found between the right ventricular to right atrial systolic pressure gradient and the left atrial to aorta ratio (r = 0.242, P < 0.0001), end-diastolic volume index (r = 0.242, P < 0.0001), and end-systolic volume index (r = 0.129, P < 0.001). Follow up was available for 49 dogs. Of these, 18 had an increased, 12 a decreased, and 19 a stable right ventricular to right atrial systolic pressure gradient despite therapy. The equivalence point between the sensitivity and specificity curves of about 80% in the coincident point corresponded to a right ventricular to right atrial systolic pressure gradient of 48 mmHg. Our results suggest an association between the progressive nature of chronic degenerative mitral valve disease and pulmonary hypertension. It is of clinical interest that, with a right ventricular to right atrial systolic pressure gradient pressure gradient at or above 48 mmHg, pulmonary hypertension does not appear to improve despite therapy targeted at lowering the left atrial load.

Rescue pulmonary vein isolation for hemodynamically unstable atrial fibrillation storm in a patient with an acute extensive myocardial infarction.

PubMed

Morishima, Itsuro; Sone, Takahito; Tsuboi, Hideyuki; Mukawa, Hiroaki

2012-11-26

New-onset atrial fibrillation in patients hospitalized for an acute myocardial infarction often leads to hemodynamic deterioration and has serious adverse prognostic implications; mortality is particularly high in patients with congestive heart failure and/or a reduced left ventricular ejection fraction. The mechanism of atrial fibrillation in the context of an acute myocardial infarction has not been well characterized and an effective treatment other than optimal medical therapy and mechanical hemodynamic support are expected. A 71 year-old male with an acute myocardial infarction due to an occlusion of the left main coronary artery was treated with percutaneous coronary intervention. He had developed severe congestive heart failure with a left ventricular ejection fraction of 34%. The systemic circulation was maintained with an intraaortic balloon pump, continuous hemodiafiltration, and mechanical ventilation until atrial fibrillation occurred on day 3 which immediately led to cardiogenic shock. Because atrial fibrillation was refractory to intravenous amiodarone, beta-blockers, and a total of 15 electrical cardioversions, the patient underwent emergent radiofrequency catheter ablation on day 4. Soon after electrical cardioversion, ectopies from the right superior pulmonary vein triggered the initiation of atrial fibrillation. The right pulmonary veins were isolated during atrial fibrillation. Again, atrial fibrillation was electrically cardioverted, then, sinus rhythm was restored. Subsequently, the left pulmonary veins were isolated. The stabilization of the hemodynamics was successfully achieved with an increase in the blood pressure and urine volume. Hemodiafiltration and amiodarone were discontinued. The patient had been free from atrial fibrillation recurrence until he suddenly died due to ventricular fibrillation on day 9. To the best of our knowledge, this is the first report of pulmonary vein isolation for a rescue purpose applied in a patient with hemodymically unstable atrial fibrillation complicated with an acute myocardial infarction. This case demonstrates that ectopic activity in the pulmonary veins may be responsible for triggering atrial fibrillation in the critical setting of an acute myocardial infarction and thus pulmonary vein isolation could be an effective therapeutic option.

Atrial Fibrillation in Heart Failure With Preserved Ejection Fraction: Association With Exercise Capacity, Left Ventricular Filling Pressures, Natriuretic Peptides, and Left Atrial Volume.

PubMed

Lam, Carolyn S P; Rienstra, Michiel; Tay, Wan Ting; Liu, Licette C Y; Hummel, Yoran M; van der Meer, Peter; de Boer, Rudolf A; Van Gelder, Isabelle C; van Veldhuisen, Dirk J; Voors, Adriaan A; Hoendermis, Elke S

2017-02-01

This study sought to study the association of atrial fibrillation (AF) with exercise capacity, left ventricular filling pressure, natriuretic peptides, and left atrial size in heart failure with preserved ejection fraction (HFpEF). The diagnosis of HFpEF in patients with AF remains a challenge because both contribute to impaired exercise capacity, and increased natriuretic peptides and left atrial volume. We studied 94 patients with symptomatic heart failure and left ventricular ejection fractions ≥45% using treadmill cardiopulmonary exercise testing and right- and/or left-sided cardiac catheterization with simultaneous echocardiography. During catheterization, 62 patients were in sinus rhythm, and 32 patients had AF. There were no significant differences in age, sex, body size, comorbidities, or medications between groups; however, patients with AF had lower peak oxygen consumption (VO 2 ) compared with those with sinus rhythm (10.8 ± 3.1 ml/min/kg vs. 13.5 ± 3.8 ml/min/kg; p = 0.002). Median (25th to 75th percentile) N-terminal pro-B-type natriuretic peptide (NT-proBNP) was higher in AF versus sinus rhythm (1,689; 851 to 2,637 pg/ml vs. 490; 272 to 1,019 pg/ml; p < 0.0001). Left atrial volume index (LAVI) was higher in AF than sinus rhythm (57.8 ± 17.0 ml/m 2 vs. 42.5 ± 15.1 ml/m 2 ; p = 0.001). Invasive hemodynamics showed higher mean pulmonary capillary wedge pressure (PCWP) (19.9 ± 3.7 vs. 15.2 ± 6.8) in AF versus sinus rhythm (all p < 0.001), with a trend toward higher left ventricular end-diastolic pressure (17.7 ± 3.0 mm Hg vs. 15.7 ± 6.9 mm Hg; p = 0.06). After adjusting for clinical covariates and mean PCWP, AF remained associated with reduced peak VO 2 increased log NT-proBNP, and enlarged LAVI (all p ≤0.005). AF is independently associated with greater exertional intolerance, natriuretic peptide elevation, and left atrial remodeling in HFpEF. These data support the application of different thresholds of NT-proBNP and LAVI for the diagnosis of HFpEF in the presence of AF versus the absence of AF. Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Postoperative pulmonary hypertensive crisis caused by inverted left atrial appendage after cardiopulmonary bypass surgery for congenital heart disease in a neonate.

PubMed

Zhao, Qifeng; Hu, Xingti

2013-09-01

Postoperative pulmonary hypertensive crisis (PHC) caused by an inverted left atrial appendage (ILAA) is a rare complication following cardiac surgery. We present a case of 23 day-old male infant who developed postoperative PHC attacks after undergoing cardiopulmonary bypass (CPB) surgery for repair of the coactation of aorta. A hyperechogenic left atrial mass was detected via bedside transthoracic echocardiography (TTE), which was identified as an ILAA and corrected following repeat surgery. In this case, both the negative pressure in vent catheter and the long left atrial appendage (LAA) with a narrow base led to an irreversible ILAA. As in this neonate, ILAA had significant influence on the left atrial volume and caused PHC since the ILAA was located on the mitral valve orifice and interfered with the blood flow through the valve. Therefore, we recommend that the vent catheter should be turned off before removing to avoid this potential complication. Additionally, LAA should be carefully inspected after CPB surgery, and intra-operative and post-operative transoesophageal echocardiography (TEE) should be performed to detect ILAA intraoperatively so as to avoid the reoperation. When an ILAA is diagnosed postoperatively, whether conservative treatment or surgery will depend on the balance of benefit and risk for a particular patient. Crown Copyright © 2013. Published by Elsevier B.V. All rights reserved.

4D flow MRI assessment of right atrial flow patterns in the normal heart – influence of caval vein arrangement and implications for the patent foramen ovale

PubMed Central

Parikh, Jehill D.; Kakarla, Jayant; Keavney, Bernard; O’Sullivan, John J.; Ford, Gary A.; Blamire, Andrew M.; Hollingsworth, Kieren G.

2017-01-01

Aim To investigate atrial flow patterns in the normal adult heart, to explore whether caval vein arrangement and patency of the foramen ovale (PFO) may be associated with flow pattern. Materials and Methods Time-resolved, three-dimensional velocity encoded magnetic resonance imaging (4D flow) was employed to assess atrial flow patterns in thirteen healthy subjects (6 male, 40 years, range 25–50) and thirteen subjects (6 male, 40 years, range 21–50) with cryptogenic stroke and patent foramen ovale (CS-PFO). Right atrial flow was defined as vortical, helico-vortical, helical and multiple vortices. Time-averaged and peak systolic and diastolic flows in the caval and pulmonary veins and their anatomical arrangement were compared. Results A spectrum of right atrial flow was observed across the four defined categories. The right atrial flow patterns were strongly associated with the relative position of the caval veins. Right atrial flow patterns other than vortical were more common (p = 0.015) and the separation between the superior and inferior vena cava greater (10±5mm versus 3±3mm, p = 0.002) in the CS-PFO group. In the left atrium all subjects except one had counter-clockwise vortical flow. Vortex size varied and was associated with left lower pulmonary vein flow (systolic r = 0.61, p = 0.001, diastolic r = 0.63 p = 0.002). A diastolic vortex was less common and time-averaged left atrial velocity was greater in the CS-PFO group (17±2cm/sec versus 15±1, p = 0.048). One CS-PFO subject demonstrated vortical retrograde flow in the descending aortic arch; all other subjects had laminar descending aortic flow. Conclusion Right atrial flow patterns in the normal heart are heterogeneous and are associated with the relative position of the caval veins. Patterns, other than ‘typical’ vortical flow, are more prevalent in the right atrium of those with cryptogenic stroke in the context of PFO. Left atrial flow patterns are more homogenous in normal hearts and show a relationship with flow arising from the left pulmonary veins. PMID:28282389

Heart Transplant in Patient With Isolated Left Superior Vena Cava by Atrial Appendage Rotation.

PubMed

Reyes, Karl M; Gupta, Dipankar; Fricker, Frederick Jay; Cooke, Susan; Bleiweis, Mark S

2018-06-01

Orthotopic heart transplantation in patients with an isolated persistent left superior vena cava is extremely rare, and the anastomotic connection between a right-sided donor superior vena cava and left-sided recipient superior vena cava can be challenging to perform. We present a novel technique used in an infant female, using the left atrial appendage to extend the superior vena cava anastomosis. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Successful Repair of Hypoplastic Left Heart Syndrome With Intact Atrial Septum, Congenital Diaphragm Hernia, and Anomalous Origin of Coronary Artery: Defying the Odds.

PubMed

Sathanandam, Shyam; Kumar, T K Susheel; Feliz, Alexander; Knott-Craig, Christopher J

2016-07-01

We report a case of an infant who was postnatally diagnosed with hypoplastic left heart syndrome and an intact atrial septum who underwent emergent atrial decompression followed by the Norwood operation. She was also found to have a congenital diaphragmatic hernia on the left side and a congenital eventration of the right diaphragm, both requiring surgical repair. She was later found to have an anomalous origin of the left circumflex coronary artery from the right pulmonary artery that was ligated at the time of the bilateral bidirectional Glenn operation. She is currently thriving at home, defying all odds. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

The left atrial catheter: its uses and complications.

PubMed

Leitman, B S; Naidich, D P; McGuinness, G; McCauley, D I

1992-11-01

The authors describe the radiographic appearance of the left atrial catheter, a widely used postsurgical intracardiac device. Recognition of the characteristic appearance of this catheter should be of value in detection of potential complications, including line fracture with resultant retention and/or embolization, infection, prosthetic valve dysfunction, and even cardiac tamponade.

Rivaroxaban as an effective alternative to warfarin in a patient with atrial fibrillation, thrombophilia, and left atrial appendage thrombus: a case report.

PubMed

Scarano, Michele; Casale, Matteo; Mantini, Cesare; Imbalzano, Egidio; Consorti, Cristiana; Clemente, Daniela; Dattilo, Giuseppe

2017-04-09

Atrial fibrillation is the most common cardiac arrhythmia. It is responsible for up to 20% of all ischemic strokes. Rate control and anticoagulation are crucial for atrial fibrillation management and stroke prevention. We present the case of an 84-year-old Italian woman with a left atrial appendage thrombus that developed despite her use of anticoagulant therapy with warfarin for a previous pulmonary embolism. She had atrial fibrillation and heterozygosity for both factor V Leiden and methylenetetrahydrofolate reductase C677T mutation, thus creating resistance to activated protein C. Anticoagulant therapy was switched to heparin for 1 week and then to rivaroxaban. After 3 months of rivaroxaban use, the thrombus disappeared. This case raises the issue of the ineffectiveness of warfarin therapy in complex cases involving particular thrombophilic conditions and the possibility of using rivaroxaban as a safe and effective alternative.

Prognostic implications of atrial fibrillation in patients undergoing myocardial perfusion single-photon emission computed tomography.

PubMed

Abidov, Aiden; Hachamovitch, Rory; Rozanski, Alan; Hayes, Sean W; Santos, Marcia M; Sciammarella, Maria G; Cohen, Ishac; Gerlach, James; Friedman, John D; Germano, Guido; Berman, Daniel S

2004-09-01

The aim of this research was to determine whether presence of atrial fibrillation (AF) provides incremental prognostic information relative to myocardial perfusion single-photon emission computed tomography (MPS) with respect to risk of cardiac death (CD). The prognostic significance of AF in patients undergoing MPS is not known. A total of 16,048 consecutive patients undergoing MPS were followed-up for a mean of 2.21 +/- 1.15 years for the development of CD. Of those, 384 patients (2.4%) had AF. Cox proportional hazards method was used to compare clinical and perfusion data for the prediction of CD in patients with and without AF. Atrial fibrillation was a significant predictor of CD in patients with normal (1.6% per year vs. 0.4% per year in non-AF patients), mildly abnormal (6.3% per year vs. 1.2% per year), and severely abnormal MPS (6.4% per year vs. 3.7% per year) (p < 0.001 for all). By multivariable analysis, AF patients had worse survival (p = 0.001) even after adjustment for the variables most predictive of CD: age, diabetes, shortness of breath, use of vasodilator stress, rest heart rate, and the nuclear variables. In the 4,239 patients with left ventricular ejection fraction evaluated by gated MPS, AF demonstrated incremental prognostic value not only over clinical and nuclear variables, but also over left ventricular ejection in predicting CD (p = 0.014). The presence of AF independently increases the risk of cardiac events over perfusion and function variables in patients undergoing MPS. Patients with AF have a high risk of CD, even when MPS is only mildly abnormal. Whether patients with AF and mildly abnormal MPS constitute a group more deserving of early referral to cardiac catheterization is a question warranting further study.

Presumptive partial atrial standstill secondary to atrial cardiomyopathy in a Greyhound.

PubMed

Wesselowski, S; Abbott, J; Borgarelli, M; Tursi, M

2017-06-01

Persistent atrial standstill is a rare arrhythmia in both human and veterinary patients. In recent decades, cases of partial atrial standstill have been recognized in humans. We describe a case of presumptive partial atrial standstill in a Greyhound, in which there was disparate left and right atrial electromechanical function and rapid progression to congestive heart failure over the span of fourteen weeks. An atrial cardiomyopathy characterized by severe, diffuse, fibrofatty replacement of the atrial myocardium was identified histologically. Copyright © 2017 Elsevier B.V. All rights reserved.

Evaluation of atrial electromechanical conduction delay in case of hemodynamically insignificant rheumatic heart disease: A tissue Doppler study.

PubMed

Cagdas, Metin; Velibey, Yalcin; Guvenc, Tolga Sinan; Gungor, Baris; Guzelburc, Ozge; Calik, Nazmi; Ugur, Murat; Tekkesin, Ahmet Ilker; Gurkan, Kadir; Eren, Mehmet

2015-01-01

Atrial electromechanical delay (AEMD) that reflects delayed conduction may show us the clinical reflection of pathological changes in the atria. The main objective of the present study is to investigate AEMD in patients who had previous rheumatic carditis but without hemodynamically significant valvular disease. A total of 40 patients, previously diagnosed as rheumatic carditis but without significant valvular stenosis/regurgitation and atrial enlargement; and 39 age- and-sex matched controls were enrolled for the present study. Parameters of AEMD (lateral mitral annulus electromechanical delay, septal mitral annulus electromechanical delay and lateral tricuspid annulus electromechanical delay) were measured with tissue Doppler echocardiography and left intra-atrial and inter-atrial conduction times were calculated accordingly. A 24h ambulatory Holter monitoring was used in both groups to detect atrial fibrillation episodes and quantify atrial extrasystoles. Parameters of AEMD, including left intra-atrial and inter-atrial conduction times of subjects in the study group were longer compared to the control group (23.7 ± 7.0 vs. 18.3 ± 6.2). Increased AEMD is observed in patients with previous rheumatic carditis and no significant valvular stenosis/regurgitation and atrial enlargement, which may partly explain the increased incidence of atrial fibrillation observed in these patients.

Effect of the Size of the Left Atrium on Sustained Sinus Rhythm in Patients Undergoing Mitral Valve Surgery and Concomitant Bipolar Radiofrequency Ablation for Atrial Fibrillation.

PubMed

Avdagić, Harun; Sijerčić Avdagić, Selma; Pirić Avdagić, Melika; Antonič, Miha

2017-12-01

Atrial fibrillation is associated with systemic embolization and complications due to anticoagulant therapy. Radiofrequency ablation has been established as an effective and safe method for the treatment of atrial fibrillation. The aim of this study was to evaluate the effect of the size of the left atrium on the outcome of surgical radiofrequency ablation. Forty patients scheduled for elective mitral valve surgery and radiofrequency ablation were enrolled in the study. Group 1 consisted of patients with a left atrium diameter ≤5 cm and group 2 of patients with left atrium diameter >5 cm. The primary endpoint of the study was stable sinus rhythm 6 months postoperatively. At 6 months postoperatively, sinus rhythm was present in significantly more group 1 patients as compared with group 2 patients, i.e. 15 (75%) vs. 8 (40%), p=0.025. Multivariate analysis proved the size of the left atrium to be an independent predictor of the radiofrequency ablation outcome. Accordingly, the size of the left atrium was demonstrated to be an important predictor of the outcome of radiofrequency ablation for atrial fibrillation. A lower cut-off value of surgical reduction of the atria than previously reported should be considered in order to improve the radiofrequency ablation outcome.

Changes in the mRNA levels of delayed rectifier potassium channels in human atrial fibrillation.

PubMed

Lai, L P; Su, M J; Lin, J L; Lin, F Y; Tsai, C H; Chen, Y S; Tseng, Y Z; Lien, W P; Huang, S K

1999-01-01

We measured mRNA levels of delayed rectifier potassium channels in human atrial tissue to investigate the mechanism of the shortening of the atrial effective refractory period and the loss of rate-adaptive shortening of the atrial effective refractory period in human atrial fibrillation. A total of 34 patients undergoing open heart surgery were included. Atrial tissue was obtained from the right atrial free wall, right atrial appendage, left atrial free wall and left atrial appendage, respectively. The mRNA amounts of KVLQT1 (IKs), minK (beta-subunit of IKs), HERG (IKr), and KV1.5 (IKur) were measured by reverse transcription-polymerase chain reaction and normalized to the mRNA amount of GAPDH. We found that the mRNA levels of KV1.5, HERG and KVLQT1 were all significantly decreased in patients with persistent atrial fibrillation for more than 3 months. In contrast, the mRNA level of minK was significantly increased in patients with persistent atrial fibrillation for more than 3 months. We further showed that these changes were independent of the underlying cardiac disease, atrial filling pressure, gender and age. We also found that there was no spatial dispersion of mRNA levels among the four atrial sampling sites. Because the decrease in potassium currents results in a prolonged action potential, the shortening of the atrial effective refractory period in atrial fibrillation should be attributed to other factors. However, the decrease in IKs might contribute, at least in part, to the loss of rate-adaptive shortening of the atrial refractory period.

Cardiac structure and function in relation to cardiovascular risk factors in Chinese

PubMed Central

2012-01-01

Background Cardiac structure and function are well-studied in Western countries. However, epidemiological data is still scarce in China. Methods Our study was conducted in the framework of cardiovascular health examinations for the current and retired employees of a factory and their family members. According to the American Society of Echocardiography recommendations, we performed echocardiography to evaluate cardiac structure and function, including left atrial volume, left ventricular hypertrophy and diastolic dysfunction. Results The 843 participants (43.0 years) included 288 (34.2%) women, and 191 (22.7%) hypertensive patients, of whom 82 (42.9%) took antihypertensive drugs. The prevalence of left atrial enlargement, left ventricular hypertrophy and concentric remodeling was 2.4%, 5.0% and 12.7%, respectively. The prevalence of mild and moderate-to-severe left ventricular diastolic dysfunction was 14.2% and 3.3%, respectively. The prevalence of these cardiac abnormalities significantly (P ≤ 0.002) increased with age, except for the moderate-to-severe left ventricular diastolic dysfunction. After adjustment for age, gender, body height and body weight, left atrial enlargement was associated with plasma glucose (P = 0.009), and left ventricular hypertrophy and diastolic dysfunction were significantly associated with systolic and diastolic blood pressure (P ≤ 0.03), respectively. Conclusions The prevalence of cardiac structural and functional abnormalities increased with age in this Chinese population. Current drinking and plasma glucose had an impact on left atrial enlargement, whereas systolic and diastolic blood pressures were major correlates for left ventricular hypertrophy and diastolic dysfunction, respectively. PMID:23035836

Shortness of breath in clinical practice: A case for left atrial function and exercise stress testing for a comprehensive diastolic heart failure workup

PubMed Central

Iyngkaran, Pupalan; Anavekar, Nagesh S; Neil, Christopher; Thomas, Liza; Hare, David L

2017-01-01

The symptom cluster of shortness of breath (SOB) contributes significantly to the outpatient workload of cardiology services. The workup of these patients includes blood chemistry and biomarkers, imaging and functional testing of the heart and lungs. A diagnosis of diastolic heart failure is inferred through the exclusion of systolic abnormalities, a normal pulmonary function test and normal hemoglobin, coupled with diastolic abnormalities on echocardiography. Differentiating confounders such as obesity or deconditioning in a patient with diastolic abnormalities is difficult. While the most recent guidelines provide more avenues for diagnosis, such as incorporating the left atrial size, little emphasis is given to understanding left atrial function, which contributes to at least 25% of diastolic left ventricular filling; additionally, exercise stress testing to elicit symptoms and test the dynamics of diastolic parameters, especially when access to the “gold standard” invasive tests is lacking, presents clinical translational gaps. It is thus important in diastolic heart failure work up to understand left atrial mechanics and the role of exercise testing to build a comprehensive argument for the diagnosis of diastolic heart failure in a patient presenting with SOB. PMID:29354484

Roles of Transesophageal Echocardiography and Cardiac Computed Tomography for Evaluation of Left Atrial Thrombus and Associated Pathology: A Review and Critical Analysis.

PubMed

Pathan, Faraz; Hecht, Harvey; Narula, Jagat; Marwick, Thomas H

2018-04-01

Evaluation of the left atrium and left atrial appendage for the presence of thrombus prior to cardioversion and pulmonary vein isolation, and of the entire heart for embolic sources in the setting of cryptogenic stroke, has long been standard medical care. Guidelines have uniformly recommended transesophageal echocardiography (TEE) to accomplish these goals. In recent years, computed tomographic angiography has demonstrated diagnostic accuracy similar to that of TEE for the detection of thrombus. Analysis of the pertinent data and relative merits of the 2 technologies leads to the conclusions that: 1) both modalities have some unique, nonoverlapping capabilities that may dictate their use in specific situations; 2) computed tomographic angiography is a reasonable alternative to TEE when the primary aim is to exclude left atrial and left atrial appendage thrombus and in patients in whom the risks associated with TEE outweigh the benefits; and 3) both options should be discussed with the patient in the setting of shared decision making. Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

High incidence of echocardiographic abnormalities of the interatrial septum in patients undergoing ablation for atrial fibrillation.

PubMed

Schernthaner, Christiana; Danmayr, Franz; Daburger, Apollonia; Eichinger, Jörg; Hammerer, Matthias; Strohmer, Bernhard

2013-04-01

Atrial fibrosis or fatty deposition is known to increase the propensity for the development of atrial fibrillation (AF). Apart from the pulmonic veins, the interatrial septum (IAS) might play a role in the maintenance of AF. In contrast to left atrial anatomy and adjacent veins, the IAS cannot be visualized in detail with computed tomography. Thus, preprocedural transesophageal echocardiography (TEE) may provide important morphologic information beyond exclusion from atrial thrombi. The study comprised 108 consecutive patients (mean age 60 ± 11 years; 98 men). AF was paroxysmal in 91 (84%) and persistent in 17 (16%) patients. We investigated the morphological characteristics of the IAS by TEE in patients who underwent radiofrequency ablation of AF. The IAS was structurally abnormal in 46 (43%) patients, showing the following echocardiograhic findings: atrial septal hypermobility or aneurysm (n = 27) associated with a patent foramen ovale (PFO) (n = 11) or with a small atrial septal defect (ASD) (n = 2), a septal flap associated with a PFO or an ASD (n = 8), and an abnormally thickened IAS (n = 12). A thrombus in the left atrial appendage was discovered in only 2 (2%) patients. A structurally abnormal IAS was diagnosed in nearly half of the patients undergoing ablation therapy for AF. The information obtained by TEE is mandatory to exclude left atrial thrombi prior the ablation procedure. Moreover, detailed knowledge of morphologic characteristics of the IAS facilitates an optimized and safe performance of the transseptal puncture using long sheaths with large diameters. © 2012, Wiley Periodicals, Inc.

Plasma cardiac troponin I concentration and cardiac death in cats with hypertrophic cardiomyopathy.

PubMed

Borgeat, K; Sherwood, K; Payne, J R; Luis Fuentes, V; Connolly, D J

2014-01-01

The use of cardiac biomarkers to assist in the diagnosis of occult and symptomatic hypertrophic cardiomyopathy (HCM) in cats has been established. There is limited data describing their prognostic utility in cats with HCM. Circulating concentrations of N-terminal B-type natriuretic peptide (NTproBNP) and cardiac troponin I (cTnI) predict cardiac death in cats with HCM. Forty-one cats diagnosed with HCM at a veterinary teaching hospital, between February 2010 and May 2011. Prospective investigational study. Plasma samples were collected from cats diagnosed with HCM and concentrations of NTproBNP and cTnI were analyzed at a commercial laboratory. Echocardiographic measurements from the day of blood sampling were recorded. Long-term outcome data were obtained. Associations with time to cardiac death were analyzed using Cox proportional hazards models. When controlling for the presence/absence of heart failure and echocardiographic measures of left atrial size and function, cTnI > 0.7 ng/mL was independently associated with time to cardiac death. In univariable analysis, NTproBNP > 250 pmol/L was associated with cardiac death (P = .023), but this did not remain significant (P = .951) when controlling for the effect of clinical signs or left atrial size/function. Plasma concentration of cTnI (cutoff >0.7 ng/mL) is a predictor of cardiac death in cats with HCM that is independent of the presence of heart failure or left atrial dilatation. Copyright © 2014 by the American College of Veterinary Internal Medicine.

Role of atrial endothelial cells in the development of atrial fibrosis and fibrillation in response to pressure overload.

PubMed

Kume, Osamu; Teshima, Yasushi; Abe, Ichitaro; Ikebe, Yuki; Oniki, Takahiro; Kondo, Hidekazu; Saito, Shotaro; Fukui, Akira; Yufu, Kunio; Miura, Masahiro; Shimada, Tatsuo; Takahashi, Naohiko

Monocyte chemoattractant protein-1 (MCP-1)-mediated inflammatory mechanisms have been shown to play a crucial role in atrial fibrosis induced by pressure overload. In the present study, we investigated whether left atrial endothelial cells would quickly respond structurally and functionally to pressure overload to trigger atrial fibrosis and fibrillation. Six-week-old male Sprague-Dawley rats underwent suprarenal abdominal aortic constriction (AAC) or a sham operation. By day 3 after surgery, macrophages were observed to infiltrate into the endocardium. The expression of MCP-1 and E-selectin in atrial endothelium and the expression of intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and ED1 in left atrial tissue were enhanced. Atrial endothelial cells were irregularly hypertrophied with the disarrangement of lines of cells by scanning electron microscopy. Various-sized gap formations appeared along the border in atrial endothelial cells, and several macrophages were located just in the endothelial gap. Along with the development of heterogeneous interstitial fibrosis, interatrial conduction time was prolonged and the inducibility of atrial fibrillation by programmed extrastimuli was increased in the AAC rats compared to the sham-operated rats. Atrial endothelium responds rapidly to pressure overload by expressing adhesion molecules and MCP-1, which induce macrophage infiltration into the atrial tissues. These processes could be an initial step in the development of atrial remodeling for atrial fibrillation. Copyright © 2016 Elsevier Inc. All rights reserved.

Renal clearance studies of effect of left atrial distension in the dog.

NASA Technical Reports Server (NTRS)

Kinney, M. J.; Discala, V. A.

1972-01-01

Investigation of the water diuresis of left atrial distension in 16 dogs on the basis of clearance studies employing hydration, chronic and acute salt loading, deoxycorticosterone (DOCA) in excess, and distal tubular nephron blockade with diuretics. The diuresis was found in hydrated and salt-loaded dogs and was independent of DOCA and presumed renin depletion. It was not found in five dogs after distal tubular blockade. No significant reproducible saluresis was ever documented. The water diuresis was always stopped by exogenous vasopressin (seven dogs). Antidiuretic hormone inhibition with distal tubular nephron water permeability changes appears to be the sole mechanism of the diuresis of left atrial distension in the dog.

Pulmonary artery perforation by plug anchoring system after percutaneous closure of left appendage.

PubMed

Bianchi, Giacomo; Solinas, Marco; Gasbarri, Tommaso; Bevilacqua, Stefano; Tiwari, Kaushal Kishore; Berti, Sergio; Glauber, Mattia

2013-07-01

Patients receiving oral anticoagulant therapy for atrial fibrillation who are at high risk of bleeding are increasingly referred for percutaneous left atrial appendage exclusion. Although effective, this procedure is not free from risk. We report a case of pericardial tamponade due to pulmonary artery tear caused by a trespassing anchoring hook of an AGA plug. Intraoperatively, no actual bleeding was found from the left appendage, a proof of its complete occlusion by the device. The patient underwent successful surgical repair and radio-frequency ablation of atrial fibrillation was performed by pulmonary veins encircling. Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

[Tetralogy of Fallot associated with left atrial isomerism].

PubMed

Ferrín, L M; Atik, E; Aiello, V; Marcial, M B; Ebaid, M

1996-10-01

The association of tetralogy of Fallot with atrial isomerism has been rarely reported. Eight cases (five with left isomerism and three with right isomerism) are known. This paper reports two other cases of tetralogy of Fallot with left atrial isomerism. The syndrome's defects were disguised and without clinical expression because of the presence of the right ventricular outlet obstruction of tetralogy of Fallot. These diagnostic elements, not recognized in one of the patients previous to surgical correction of tetralogy of Fallot, were present: junctional rhythm, bronchial isomerism, partial anomalous pulmonary vein connection, agenesy of inferior vena cava and abdominal heterotaxy; their identification previous to surgical correction of tetralogy of Fallot, is necessary for an adequate surgical management.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chen, Xiao-Qing; Zhang, Dao-Liang; Zhang, Ming-Jian

Aims: Atrial fibroblasts and macrophages have long been thought to participate in atrial fibrillation (AF). However, which specific mediator may regulate the interaction between them remains unclear. Methods and results: We provided the evidence for the involvement of Toll/IL-1 receptor domain-containing adaptor inducing IFN-β (TRIF), an important inflammation-related molecule, in the pathophysiology of AF. Patients with AF showed higher levels of angiotensin II (AngII) and TRIF expression and larger number of macrophages infiltration in left atria appendage than individuals with sinus rhythm (SR). In the cell study, AngII induced chemokines expressions in mouse atrial fibroblasts and AngII-stimulated atrial fibroblasts inducedmore » the chemotaxis of macrophages, which were reduced by losartan and TRIF siRNA. Meanwhile, AngII-stimulated atrial fibroblasts proliferation was enhanced by macrophages. Conclusions: Our data demonstrated that TRIF may be a crucial factor promoting the interaction between atrial fibroblasts and macrophages, leading to atrial fibrosis. - Highlights: • Compared with SR, AF showed higher TRIF expression in left atrial appendage. • TRIF siRNA reversed macrophage chemotaxis induced by AngII-treated fibroblast. • TRIF siRNA reversed chemokines expressions induced by AngII in fibroblast. • AngII-stimulated atrial fibroblast proliferation was enhanced by macrophage.« less

Left atrial structure and function in atrial fibrillation: ENGAGE AF-TIMI 48

PubMed Central

Gupta, Deepak K.; Shah, Amil M.; Giugliano, Robert P.; Ruff, Christian T.; Antman, Elliott M.; Grip, Laura T.; Deenadayalu, Naveen; Hoffman, Elaine; Patel, Indravadan; Shi, Minggao; Mercuri, Michele; Mitrovic, Veselin; Braunwald, Eugene; Solomon, Scott D.

2014-01-01

Aims The complex relationship between left atrial (LA) structure and function, electrical burden of atrial fibrillation (AF) and stroke risk is not well understood. We aimed to describe LA structure and function in AF. Methods and results Left atrial structure and function was assessed in 971 subjects enrolled in the echocardiographic substudy of ENGAGE AF-TIMI 48. Left atrial size, emptying fraction (LAEF), and contractile function were compared across AF types (paroxysmal, persistent, or permanent) and CHADS2 scores as an estimate of stroke risk. The majority of AF patients (55%) had both LA enlargement and reduced LAEF, with an inverse relationship between LA size and LAEF (R = −0.57, P < 0.001). With an increasing electrical burden of AF and higher CHADS2 scores, LA size increased and LAEF declined. Moreover, 19% of AF subjects had impaired LAEF despite normal LA size, and LA contractile dysfunction was present even among the subset of AF subjects in sinus rhythm at the time of echocardiography. Conclusions In a contemporary AF population, LA structure and function were increasingly abnormal with a greater electrical burden of AF and higher stroke risk estimated by the CHADS2 score. Moreover, LA dysfunction was present despite normal LA size and sinus rhythm, suggesting that the assessment of LA function may add important incremental information in the evaluation of AF patients. Clinical Trial Registration: http://www.clinicaltrials.gov; ID = NCT00781391. PMID:24302269

Left atrial appendage obliteration in atrial fibrillation patients undergoing bioprosthetic mitral valve replacement.

PubMed

Min, X P; Zhu, T Y; Han, J; Li, Y; Meng, X

2016-02-01

Left atrial appendage (LAA) obliteration is a proven stroke-preventive measure for patients with nonvalvular atrial fibrillation (AF). However, the efficacy of LAA obliteration for patients with AF after bioprosthetic mitral valve replacement (MVR) remains unclear. This study aimed to estimate the efficacy of LAA obliteration in preventing embolism and to investigate the predictors of thromboembolism after bioprosthetic MVR. We retrospectively studied 173 AF subjects with bioprosthetic MVR; among them, 81 subjects underwent LAA obliteration using an endocardial running suture method. The main outcome measure was the occurrence of thrombosis events (TEs). The mean follow-up time was 40 ± 17 months. AF rhythm was observed in 136 patients postoperatively. The incidence rate of TEs was 13.97 % for postoperative AF subjects; a dilated left atrium (LA; > 49.5 mm) was identified as an independent risk factor of TEs (OR = 10.619, 95 % CI = 2.754-40.94, p = 0.001). For postoperative AF patients with or without LAA, the incidence rate of TEs was 15.8 % (9/57) and 12.7 % (10/79; p = 0.603), respectively. The incidence rate of TEs was 2.7 % (1/36) and 4.2 % (2/48) for the subgroup patients with a left atrial diameter of < 49.5 mm, and 38.1 % (8/21) and 25.8 % (8/31) for those with a left atrial diameter of > 49.5 mm (p = 0.346). Surgical LAA obliteration in patients with valvular AF undergoing bioprosthetic MVR did not reduce TEs, even when the CHA2DS2-VASc score (a score for estimating the risk of stroke in AF) was ≥ 2 points.

Reflex tracheal contraction during pulmonary venous congestion in the dog.

PubMed Central

Kappagoda, C T; Man, G C; Ravi, K; Teo, K K

1988-01-01

1. The effect of pulmonary venous congestion on tracheal tone was studied in dogs anaesthetized with alpha-chloralose. Pulmonary venous congestion was produced by partial obstruction of the mitral valve to increase left atrial pressure by 10 mmHg. Tracheal tone was measured in vivo by an isometric force displacement method. 2. Tracheal tone increased by 6.3 +/- 0.3 g from a control level of 91.6 +/- 2.8 g when left atrial pressure was increased by 10.5 +/- 0.3 mmHg. This response was abolished by cooling the cervical vagi to 8 degrees C at a point caudal to the origin of the superior laryngeal nerves. Also, sectioning the superior laryngeal nerves abolished this increase in tracheal tone. 3. Afferent activity recorded from rapidly adapting receptors of the airways increased significantly during pulmonary venous congestion. This increase in activity was abolished by cooling the vagi caudal to the recording site to 8-9 degrees C. 4. Administration of propranolol (0.5 mg/kg) failed to abolish this increase in tracheal tone while atropine (3 mg/kg) did so. 5. Stimulation of left atrial receptors without an increase in left atrial pressure and stimulation of right atrial receptors with and without increases in right atrial pressure did not cause any change in tracheal tone. 6. It is suggested that pulmonary venous congestion is associated with a reflex increase in tracheal tone, the afferent limb of which is formed by pulmonary receptors discharging into myelinated fibres in the cervical vagi and the efferent limb by parasympathetic cholinergic fibres in the superior laryngeal nerves. The afferent receptors are likely to be the rapidly adapting receptors. This reflex may be of importance in the development of the respiratory symptoms associated with left ventricular failure. PMID:3236242

Cardiac autotransplantation for the treatment of permanent atrial fibrillation combined with mitral valve disease.

PubMed

Troise, Giovanni; Brunelli, Federico; Cirillo, Marco; Amaducci, Andrea; Mhagna, Zen; Tomba, Margherita Dalla; Tasca, Giordano; Quaini, Eugenio

2003-01-01

The results of current surgical options for the treatment of permanent atrial fibrillation associated with mitral valve surgery are widely different, particularly for extremely dilated left atria. The aim of this study is to assess the efficacy of cardiac autotransplantation in restoring a normal sinus rhythm via a consistent reduction in the left atrium volume associated with a complete isolation of the pulmonary veins. From April 2000 to April 2002, 28 patients (men/women, 5/23) underwent cardiac autotransplantation for the treatment of mitral disease and concomitant permanent atrial fibrillation (>1 year). A modified surgical technique derived from bicaval heart transplantation procedures maintained the connection of the right atrium with the inferior vena cava in all but 3 cases. In 2 patients, the mitral valve was repaired, and it was replaced in 26 patients. Associated procedures were 6 aortic valve replacements, 2 tricuspid valve annuloplasties, and 2 coronary revascularizations. No hospital deaths were recorded, but 1 patient died of pneumonia 3 months postoperatively. At a mean follow-up period of 17.2 +/- 6.7 months (range, 6-30 months), 24 patients (88.9%) were in sinus rhythm, and 3 (11.1%) were in atrial fibrillation. The Santa Cruz Score was 0 for 3 patients, 2 for 1 patient, and 4 for the remaining 23 patients (85.2%). The mean left atrial diameter decreased from 65.4 +/- 17.1 mm (range, 50-130 mm) before the operation to 48.4 +/- 5.6 mm (range, 37-78 mm) postoperatively (P <.001), and the mean left atrial volume decreased from 119 +/- 70.5 mL (range, 60-426 mL) to 69.1 +/- 35.1 mL (range, 31-226 mL) (P <.0001). Cardiac autotransplantation is a safe and effective surgical option for the treatment of permanent atrial fibrillation in patients with long-lasting mitral valve disease and severe enlargement of the left atrium.

Comparison of Pulmonary Venous and Left Atrial Remodeling in Patients With Atrial Fibrillation With Hypertrophic Cardiomyopathy Versus With Hypertensive Heart Disease.

PubMed

Yoshida, Kentaro; Hasebe, Hideyuki; Tsumagari, Yasuaki; Tsuneoka, Hidekazu; Ebine, Mari; Uehara, Yoshiko; Seo, Yoshihiro; Aonuma, Kazutaka; Takeyasu, Noriyuki

2017-04-15

Left ventricular diastolic dysfunction in hypertrophic cardiomyopathy (HC) increases susceptibility to atrial fibrillation. Although phenotypical characteristics of the hypertrophied left ventricle are clear, left atrial (LA) and pulmonary venous (PV) remodeling has rarely been investigated. This study aimed to identify differences in LA and PV remodeling between HC and hypertensive heart disease (HHD) using 3-dimensional computed tomography. Included were 33 consecutive patients with HC, 25 with HHD, and 29 without any co-morbidities who were referred for catheter ablation of atrial fibrillation. Pre-ablation plasma atrial and brain natriuretic peptide levels, post-ablation troponin T level, and LA pressure were measured, and LA and PV diameters were determined 3 dimensionally. LA transverse diameter in the control group was smaller than that in the HHD or HC group (55 ± 6 vs 63 ± 9 vs 65 ± 12 mm, p = 0.0003). PV diameter in all 4 PVs was greatest in the HC group and second greatest in the HHD group (21.0 ± 3.1 vs 23.8 ± 2.8 vs 26.8 ± 4.1 mm, p <0.0001 for left superior PV). Differences in PV size between the HHD and HC groups were enhanced by indexing to the body surface area (12.4 ± 1.9 vs 13.1 ± 1.4 vs 16.1 ± 3.3 mm/m 2 , p <0.0001). The PV/LA diameter ratio was greater in the HC than in the other groups (0.38 ± 0.06 vs 0.38 ± 0.05 vs 0.42 ± 0.07, p = 0.01). Atrial natriuretic peptide, brain natriuretic peptide, troponin T levels, and LA pressure were highest in the HC group (all p <0.05). In conclusion, the stiff LA caused from atrial hypertrophy may account for higher levels of biomarkers, higher LA pressure, and PV-dominant remodeling in HC. Copyright © 2017 Elsevier Inc. All rights reserved.

Temporary atrial epicardial pacing as prophylaxis against atrial fibrillation after heart surgery: a meta-analysis.

PubMed

Daoud, Emile G; Snow, Rick; Hummel, John D; Kalbfleisch, Steven J; Weiss, Raul; Augostini, Ralph

2003-02-01

Recent studies have reported the use of temporary epicardial atrial pacing as prophylaxis for postoperative atrial fibrillation (AF). The aim of this study was to assess the effect of pacing therapies for prevention of postoperative AF using meta-analysis. Using a computerized MEDLINE search, eight pacing prophylaxis trials with 776 patients were included in the meta-analysis. Trials compared control patients to patients randomized to right atrial, left atrial, or biatrial pacing used in conjunction with either fixed high-rate pacing or overdrive pacing. Overdrive biatrial pacing (OR 2.6, CI 1.4-4.8), overdrive right atrial pacing (OR 1.8, CI 1.1-2.7), and fixed high-rate biatrial pacing (OR 2.5, CI 1.3-5.1) demonstrated a significant antiarrhythmic effect for prevention of AF after open heart surgery. Furthermore, studies investigating overdrive left atrial pacing and fixed high-rate right atrial pacing have been underpowered to assess efficacy. Biatrial overdrive and fixed high-rate pacing and right atrial fixed high-rate pacing reduced the risk of new-onset AF after open heart surgery, and the relative risk reduction is approximately 2.5-fold. These results imply that various pacing algorithms are useful as a nonpharmacologic method to prevent postoperative AF.

Toward standardized mapping for left atrial analysis and cardiac ablation guidance

NASA Astrophysics Data System (ADS)

Rettmann, M. E.; Holmes, D. R.; Linte, C. A.; Packer, D. L.; Robb, R. A.

2014-03-01

In catheter-based cardiac ablation, the pulmonary vein ostia are important landmarks for guiding the ablation procedure, and for this reason, have been the focus of many studies quantifying their size, structure, and variability. Analysis of pulmonary vein structure, however, has been limited by the lack of a standardized reference space for population based studies. Standardized maps are important tools for characterizing anatomic variability across subjects with the goal of separating normal inter-subject variability from abnormal variability associated with disease. In this work, we describe a novel technique for computing flat maps of left atrial anatomy in a standardized space. A flat map of left atrial anatomy is created by casting a single ray through the volume and systematically rotating the camera viewpoint to obtain the entire field of view. The technique is validated by assessing preservation of relative surface areas and distances between the original 3D geometry and the flat map geometry. The proposed methodology is demonstrated on 10 subjects which are subsequently combined to form a probabilistic map of anatomic location for each of the pulmonary vein ostia and the boundary of the left atrial appendage. The probabilistic map demonstrates that the location of the inferior ostia have higher variability than the superior ostia and the variability of the left atrial appendage is similar to the superior pulmonary veins. This technique could also have potential application in mapping electrophysiology data, radio-frequency ablation burns, or treatment planning in cardiac ablation therapy.

Luminal esophageal temperature monitoring with a deflectable esophageal temperature probe and intracardiac echocardiography may reduce esophageal injury during atrial fibrillation ablation procedures: results of a pilot study.

PubMed

Leite, Luiz R; Santos, Simone N; Maia, Henrique; Henz, Benhur D; Giuseppin, Fábio; Oliverira, Anderson; Zanatta, André R; Peres, Ayrton K; Novakoski, Clarissa; Barreto, Jose R; Vassalo, Fabrício; d'Avila, Andre; Singh, Sheldon M

2011-04-01

Luminal esophageal temperature (LET) monitoring is one strategy to minimize esophageal injury during atrial fibrillation ablation procedures. However, esophageal ulceration and fistulas have been reported despite adequate LET monitoring. The objective of this study was to assess a novel approach to LET monitoring with a deflectable LET probe on the rate of esophageal injury in patients undergoing atrial fibrillation ablation. Forty-five consecutive patients undergoing an atrial fibrillation ablation procedure followed by esophageal endoscopy were included in this prospective observational pilot study. LET monitoring was performed with a 7F deflectable ablation catheter that was positioned as close as possible to the site of left atrial ablation using the deflectable component of the catheter guided by visualization of its position on intracardiac echocardiography. Ablation in the posterior left atrial was limited to 25 W and terminated when the LET increased 2°C from baseline. Endoscopy was performed 1 to 2 days after the procedure. All patients had at least 1 LET elevation >2°C necessitating cessation of ablation. Deflection of the LET probe was needed to accurately measure LET in 5% of patients when ablating near the left pulmonary veins, whereas deflection of the LET probe was necessary in 88% of patients when ablating near the right pulmonary veins. The average maximum increase in LET was 2.5±1.5°C. No patients had esophageal thermal injury on follow-up endoscopy. A strategy of optimal LET probe placement using a deflectable LET probe and intracardiac echocardiography guidance, combined with cessation of radiofrequency ablation with a 2°C rise in LET, may reduce esophageal thermal injury during left atrial ablation procedures.

Cardiac function adaptations in hibernating grizzly bears (Ursus arctos horribilis).

PubMed

Nelson, O Lynne; Robbins, Charles T

2010-03-01

Research on the cardiovascular physiology of hibernating mammals may provide insight into evolutionary adaptations; however, anesthesia used to handle wild animals may affect the cardiovascular parameters of interest. To overcome these potential biases, we investigated the functional cardiac phenotype of the hibernating grizzly bear (Ursus arctos horribilis) during the active, transitional and hibernating phases over a 4 year period in conscious rather than anesthetized bears. The bears were captive born and serially studied from the age of 5 months to 4 years. Heart rate was significantly different from active (82.6 +/- 7.7 beats/min) to hibernating states (17.8 +/- 2.8 beats/min). There was no difference from the active to the hibernating state in diastolic and stroke volume parameters or in left atrial area. Left ventricular volume:mass was significantly increased during hibernation indicating decreased ventricular mass. Ejection fraction of the left ventricle was not different between active and hibernating states. In contrast, total left atrial emptying fraction was significantly reduced during hibernation (17.8 +/- 2.8%) as compared to the active state (40.8 +/- 1.9%). Reduced atrial chamber function was also supported by reduced atrial contraction blood flow velocities and atrial contraction ejection fraction during hibernation; 7.1 +/- 2.8% as compared to 20.7 +/- 3% during the active state. Changes in the diastolic cardiac filling cycle, especially atrial chamber contribution to ventricular filling, appear to be the most prominent macroscopic functional change during hibernation. Thus, we propose that these changes in atrial chamber function constitute a major adaptation during hibernation which allows the myocardium to conserve energy, avoid chamber dilation and remain healthy during a period of extremely low heart rates. These findings will aid in rational approaches to identifying underlying molecular mechanisms.

Does permanent atrial fibrillation modify response to cardiac resynchronization therapy in heart failure patients?

PubMed

Abreu, Ana; Oliveira, Mário; Silva Cunha, Pedro; Santa Clara, Helena; Portugal, Guilherme; Gonçalves Rodrigues, Inês; Santos, Vanessa; Morais, Luís; Selas, Mafalda; Soares, Rui; Branco, Luísa; Ferreira, Rui; Mota Carmo, Miguel

2017-10-01

The benefits of cardiac resynchronization therapy (CRT) documented in heart failure (HF) may be influenced by atrial fibrillation (AF). We aimed to compare CRT response in patients in AF and in sinus rhythm (SR). We prospectively studied 101 HF patients treated by CRT. Rates of clinical, echocardiographic and functional response, baseline NYHA class and variation, left ventricular ejection fraction, volumes and mass, atrial volumes, cardiopulmonary exercise test (CPET) duration (CPET dur), peak oxygen consumption (VO 2 max) and ventilatory efficiency (VE/VCO 2 slope) were compared between AF and SR patients, before and at three and six months after implantation of a CRT device. All patients achieved ≥95% biventricular pacing, and 5.7% underwent atrioventricular junction ablation. Patients were divided into AF (n=35) and SR (n=66) groups; AF patients were older, with larger atrial volumes and lower CPET dur and VO 2 max before CRT. The percentages of clinical and echocardiographic responders were similar in the two groups, but there were more functional responders in the AF group (71% vs. 39% in SR patients; p=0.012). In SR patients, left atrial volume and left ventricular mass were significantly reduced (p=0.015 and p=0.021, respectively), whereas in AF patients, CPET dur (p=0.003) and VO 2 max (p=0.001; 0.083 age-adjusted) showed larger increases. Clinical and echocardiographic response rates were similar in SR and AF patients, with a better functional response in AF. Improvement in left ventricular function and volumes occurred in both groups, but left ventricular mass reduction and left atrial reverse remodeling were seen exclusively in SR patients (ClinicalTrials.gov identifier: NCT02413151; FCT code: PTDC/DES/120249/2010). Copyright © 2017 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.

Left atrial appendage resection can be performed minimally invasively with good clinical and echocardiographic outcomes without any severe risk.

PubMed

Inoue, Takafumi; Suematsu, Yoshihiro

2018-01-22

The adverse effects of left atrial appendage (LAA) closure have not yet been evaluated. This study aimed to prove the safety and low invasiveness of LAA resection through our thoracoscopic stand-alone left atrial appendectomy experience. Eighty-seven patients [mean age 68 ± 9 years, 68 men (78%), mean congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke or transient ischaemic attack to thromboembolism, vascular disease, age 65-74 years and sex category (CHA2DS2-VASc) score 2.9 ± 1.6 points] who had undergone thoracoscopic left atrial appendectomy were selected. The operative and clinical data (left atrial diameter, left ventricular diameter of systole/diastole, ejection fraction, brain natriuretic peptide and human atrial natriuretic peptide) were evaluated. All procedures were performed without cardiopulmonary bypass or cardiac arrest. The LAA was resected with an endoscopic linear cutter device. Except for 1 case with severe pleural adhesion, all operations were performed thoracoscopically. The preoperative and postoperative data are as follows: left atrial diameter 43 ± 5 mm and 43 ± 5 mm (P = 0.8); left ventricular diameter of systole/diastole 50 ± 5/35 ± 6 mm and 48 ± 5/34 ± 6 mm (P < 0.01); ejection fraction 57 ± 10% and 56 ± 10% (P = 0.11); brain natriuretic peptide 97 ± 77 pg/ml and 72 ± 65 pg/ml (P < 0.01) and human atrial natriuretic peptide 73 ± 64 pg/ml and 96 ± 67 pg/ml (P = 0.03), respectively. The mean volume of bleeding in the operation was very small (<10 ml). The mean length of postoperative in-hospital stay was 3.8 ± 1.8 days. All the patients were discharged while maintaining their preoperative activities of daily living without major complications. No thrombus or residual stumps were detected during the 3-month postoperative computed tomography follow-up. The perioperative heart function did not change significantly in this study. Bleeding with resection was minimal, and no rebleeding events occurred. LAA resection did not affect negatively on the cardiac function and did not increase the risk of bleeding risk. © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

76 FR 9018 - National Center for Health Statistics (NCHS), Classifications and Public Health Data Standards...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-02-16

...: Acute kidney injury Acute interstitial pneumonia (re-presentation) Atrial fibrillation Highly calcified... encephalomyelitis Acute necrotizing hemorrhagic encephalopathy Atrial fibrillation and flutter Benign shuddering... resurfacing Lead extraction Left atrial appendage exclusion femoral/epicardial access Neuroflow endovascular...

Association of Fibroblast Growth Factor 23 With Atrial Fibrillation in Chronic Kidney Disease, From the Chronic Renal Insufficiency Cohort Study

PubMed Central

Mehta, Rupal; Cai, Xuan; Lee, Jungwha; Scialla, Julia J.; Bansal, Nisha; Sondheimer, James H.; Chen, Jing; Hamm, L. Lee; Ricardo, Ana C.; Navaneethan, Sankar D.; Deo, Rajat; Rahman, Mahboob; Feldman, Harold I.; Go, Alan S.; Isakova, Tamara; Wolf, Myles

2016-01-01

Importance Levels of fibroblast growth factor 23 (FGF23) are elevated in chronic kidney disease (CKD) and strongly associated with left ventricular hypertrophy, heart failure, and death. Whether FGF23 is an independent risk factor for atrial fibrillation in CKD is unknown. Objective To investigate the association of FGF23 with atrial fibrillation in CKD. Design, Setting, and Participants Prospective cohort study of 3876 individuals with mild to severe CKD who enrolled in the Chronic Renal Insufficiency Cohort Study between June 19, 2003, and September 3, 2008, and were followed up through March 31, 2013. Exposures Baseline plasma FGF23 levels. Main Outcomes and Measures Prevalent and incident atrial fibrillation. Results The study cohort comprised 3876 participants. Their mean (SD) age was 57.7 (11.0) years, and 44.8% (1736 of 3876) were female. Elevated FGF23 levels were independently associated with increased odds of prevalent atrial fibrillation (n = 660) after adjustment for cardiovascular and CKD-specific factors (odds ratio of highest vs lowest FGF23 quartile, 2.30; 95% CI, 1.69-3.13; P < .001 for linear trend across quartiles). During a median follow-up of 7.6 years (interquartile range, 6.3-8.6 years), 247 of the 3216 participants who were at risk developed incident atrial fibrillation (11.9 events per 1000 person-years). In fully adjusted models, elevated FGF23 was independently associated with increased risk of incident atrial fibrillation after adjustment for demographic, cardiovascular, and CKD-specific factors, and other markers of mineral metabolism (hazard ratio of highest vs lowest FGF23 quartile, 1.59; 95% CI, 1.00-2.53; P = .02 for linear trend across quartiles). The results were unchanged when further adjusted for ejection fraction, but individual adjustments for left ventricular mass index, left atrial area, and interim heart failure events partially attenuated the association of elevated FGF23 with incident atrial fibrillation. Conclusions and Relevance Elevated FGF23 is independently associated with prevalent and incident atrial fibrillation in patients with mild to severe CKD. The effect may be partially mediated through a diastolic dysfunction pathway that includes left ventricular hypertrophy, atrial enlargement, and heart failure events. PMID:27434583

Predictors of arrhythmia recurrence after balloon cryoablation of atrial fibrillation: the value of CAAP-AF risk scoring system.

PubMed

Sanhoury, Mohamed; Moltrasio, Massimo; Tundo, Fabrizio; Riva, Stefania; Dello Russo, Antonio; Casella, Michela; Tondo, Claudio; Fassini, Gaetano

2017-08-01

In the present study, we aimed to test the value of CAAP-AF score for prediction of atrial fibrillation (AF) recurrence at follow-up in a group of our patients treated by balloon cryoablation. A total of 283 symptomatic drug-refractory AF patients [261 (92%) with paroxysmal AF] who underwent pulmonary vein isolation (PVI) with second-generation cryoballoon between April 2012 and October 2016 were included. The CAAP-AF score was calculated for every patient. A total of 283 patients [68 female (20%), mean age 59.8 ± 11.4 years] were included in the present analysis. Eighty-nine patients (31%) had hypertension and 13 (4%) had coronary artery disease. The mean left atrial diameter and left ventricular ejection fraction were 40.6 ± 7.0 mm and 60.0 ± 9.1%, respectively. The mean CHA 2 DS 2 -VASc score was 1.2 ± 1.1, and mean number of prior failed antiarrhythmic drugs was 1.4 ± 0.8. At 18 ± 6 months follow-up, 25 patients (8.87%) developed AF recurrence. The recurrence rate was as follows: 3.17% (score 0-3), 8.47% (score 4), 16.28% (score 5), 6.67% (score 6), 23.08% (score 7), and 36.36% (score ≥8). The recurrence rate was 4.86% at a score <5 and 16.49% at a value ≥5; a score cutoff ≥5 predicted AF recurrence with a sensitivity 64% and specificity 68%. The present analysis suggests the usefulness of CAAP-AF scoring system, with its simple and easily obtained six clinical variables, to predict AF recurrence after PVI by means of second-generation cryoballoon. A score value ≥5 predicted AF recurrence with a sensitivity 64% and specificity 68%.

Interatrial block and interatrial septal thickness in patients with paroxysmal atrial fibrillation undergoing catheter ablation: Long-term follow-up study.

PubMed

Gul, Enes E; Pal, Raveen; Caldwell, Jane; Boles, Usama; Hopman, Wilma; Glover, Benedict; Michael, Kevin A; Redfearn, Damian; Simpson, Chris; Abdollah, Hoshiar; Baranchuk, Adrian

2017-07-01

Interatrial block (IAB) is a strong predictor of recurrence of atrial fibrillation (AF). IAB is a conduction delay through the Bachman region, which is located in the upper region of the interatrial space. During IAB, the impulse travels from the right atrium to the interatrial septum (IAS) and coronary sinus to finally reach the left atrium in a caudocranial direction. No relation between the presence of IAB and IAS thickness has been established yet. To determine whether a correlation exists between the degree of IAB and the thickness of the IAS and to determine whether IAS thickness predicts AF recurrence. Sixty-two patients with diagnosis of paroxysmal AF undergoing catheter ablation were enrolled. IAB was defined as P-wave duration ≥120 ms. IAS thickness was measured by cardiac computed tomography. Among 62 patients with paroxysmal AF, 45 patients (72%) were diagnosed with IAB. Advanced IAB was diagnosed in 24 patients (39%). Forty-seven patients were male. During a mean follow-up period of 49.8 ± 22 months (range 12-60 months), 32 patients (51%) developed AF recurrence. IAS thickness was similar in patients with and without IAB (4.5 ± 2.0 mm vs. 4.0 ± 1.4 mm; p = .45) and did not predict AF. Left atrial size was significantly enlarged in patients with IAB (40.9 ± 5.7 mm vs. 37.2 ± 4.0 mm; p = .03). Advanced IAB predicted AF recurrence after the ablation (OR: 3.34, CI: 1.12-9.93; p = .03). IAS thickness was not significantly correlated to IAB and did not predict AF recurrence. IAB as previously demonstrated was an independent predictor of AF recurrence. © 2016 Wiley Periodicals, Inc.

The relationship between atrial electromechanical delay and left atrial mechanical function in stroke patients

PubMed Central

Akıl, Mehmet Ata; Akıl, Eşref; Bilik, Mehmet Zihni; Oylumlu, Mustafa; Acet, Halit; Yıldız, Abdülkadir; Akyüz, Abdurrahman; Ertaş, Faruk; Toprak, Nizamettin

2015-01-01

Objective: The aim of this study was to evaluate the relationship between atrial electromechanical delay (EMD) measured with tissue Doppler imaging (TDI) and left atrial (LA) mechanical functions in patients with ischemic stroke and compare them with healthy controls. Methods: Thirty patients with ischemic stroke were enrolled into this cross-sectional, observational study. The control group consisted of 35 age- and gender-matched apparently healthy individuals patients. Acute cerebral infarcts of probable embolic origin were diagnosed via imaging and were confirmed by a neurologist. Echocardiographically, time intervals from the beginning of P wave to beginning of A wave from the lateral and septal mitral and right ventricular tricuspid annuli in TDI were recorded. The differences between these intervals gave the mechanical delays (inter- and intra-atrial). Left atrial (LA) volumes were measured using the biplane area-length method, and LA mechanical function parameters were calculated. Statistical analysis was performed using student’s t-test, chi-squared test, and Pearson’s test. Results: The laboratory and clinical characteristics were similar in the two groups. Increased left atrial EMD (21.36±10.38 ms versus 11.74±6.06 ms, p<0.001), right atrial EMD (13.66±8.62 ms versus 9.66±6.81 ms, p=0.040), and interatrial EMD (35.03±9.95 ms versus 21.40±8.47 ms, p<0.001) were observed in stroke patients as compared to controls. Active LA emptying volume and fraction and passive LA emptying volumes and fraction were similar between controls and stroke patients. Total LA emptying volumes were significantly increased in stroke patients as compared to healthy controls (33.19±11.99 mL/m2 versus 27.48±7.08 mL/m2, p=0.021). Conclusion: According to the results of our study, interatrial electromechanical delay may be a new predictor for ischemic stroke. PMID:25537998

Prevalence of atrial arrhythmias in arrhythmogenic right ventricular dysplasia/cardiomyopathy.

PubMed

Camm, Christian F; James, Cynthia A; Tichnell, Crystal; Murray, Brittney; Bhonsale, Aditya; te Riele, Anneline S J M; Judge, Daniel P; Tandri, Harikrishna; Calkins, Hugh

2013-11-01

Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is an inherited cardiomyopathy, characterized by right ventricular dysfunction and ventricular arrhythmias. Limited information is available concerning atrial arrhythmias in ARVD/C. The purpose of this study was to characterize spontaneous atrial arrhythmias in a large registry population of ARVD/C patients. Patients (n = 248) from the Johns Hopkins ARVD/C registry who met the diagnostic criteria and had undertaken genotype analysis were included. Medical records of each were reviewed to ascertain incidence and characteristics of atrial arrhythmia episodes. Detailed demographic, phenotypic, and structural information was obtained from registry data. Thirty-five patients with ARVD/C (14%) experienced one or more types of atrial arrhythmia during median follow-up of 5.78 (interquartile range 8.52) years. Atrial fibrillation was the most common atrial arrhythmia, occurring in 80% of ARVD/C patients with atrial arrhythmias. Patients developed atrial arrhythmias at a mean age of 43.0 ± 14.0 years. Atrial arrhythmia patients obtained a total of 22 inappropriate implantable cardioverter-defibrillator shocks during follow-up. Older age at last follow-up (P <.001) and male gender (P = .044) were associated with atrial arrhythmia development. Patients with atrial arrhythmias had a higher occurrence of death (P = .028), heart failure (P <.001), and left atrial enlargement on echocardiography (P = .004). Atrial arrhythmias are common in ARVD/C and present at a younger age than in the general population. They are associated with male gender, increasing age, and left atrial enlargement. Atrial arrhythmias are clinically important as they are associated with inappropriate implantable cardioverter-defibrillator shocks and increased risk of both death and heart failure. © 2013 Heart Rhythm Society. All rights reserved.

Long-term biatrial recordings in post-operative atrial fibrillation.

PubMed

Masè, M; Graffigna, A; Sinelli, S; Pallaoro, G; Nollo, G; Ravelli, F

2010-01-01

Although atrial fibrillation (AF) is a common complication of cardiac surgery, its pathophysiology remains unclear. The study of post-operative AF demands for the recording of cardiac electrical activity in correspondence of AF onset and progression. Long-term recordings in post-surgery patients could provide this information, but, to date, have been limited to surface signals, which precludes a characterization of the arrhythmic triggers and substrate. In this study we demonstrate the feasibility of a continuous long-term recording of atrial electrical activities from the right and left atria in post-surgery patients. Local atrial epicardial electrograms are acquired by positioning temporary pacing wires in the right and left atria at the end of the intervention, while three day recordings are obtained by a digital holter recorder, adapted to epicardial signal features. The capability of the system to map local atrial activity and the possibility to obtain quantitative information on atrial rate and synchronization from the processed epicardial signals are proven in representative examples. The quantitative description of local atrial properties opens new perspective in the investigation of post-surgery AF.

Morphological considerations pertaining to recognition of atrial isomerism. Consequences for sequential chamber localisation.

PubMed Central

Macartney, F J; Zuberbuhler, J R; Anderson, R H

1980-01-01

The atrial morphology and venous connections were assessed "blind" in 51 necropsy specimens from patients with visceral heterotaxy. This was compared with bronchial morphology as established by dissection. Six specimens were found to have both atria and bronchi in situs solitus or inversus, and were rejected. In the remainder, atrial isomerism was diagnosed, though this required minor revision of the atrial assessment in two patients. Thirty-four patients had isomeric right atria and bronchi, while 11 had isomeric left atria and bronchi. In seven cases, splenic status was unknown, but in seven of the remaining 38 (18.4%) atrial isomerism was not associated with either asplenia or polysplenia. Nevertheless, right isomerism was strongly associated with total anomalous pulmonary venous drainage (as is asplenia) and left isomerism was likewise associated with interruption of the inferior vena cava (as is polysplenia). Bilateral superior venae cavae and hepatic veins, and absence of the coronary sinus, were frequent in both forms of isomerism (as they are in asplenia and polysplenia). These findings suggest that atrial situs can be defined as solitus inversus, right isomerism, and left isomerism. This determination of atrial situs is quite independent of any other abnormalities of visceral situs. The high incidence of anomalies of both venous return and common atrium resulted in presumed complete mixing of blood at atrial level in all but one patient (97.8%), making the haemodynamic connection between atria and ventricles almost always ambiguous. To describe this anatomical connection as ambiguous when there are two ventricles present is therefore no more than recognition of anatomical and haemodynamic reality. Images PMID:7459148

Regional distribution of T-tubule density in left and right atria in dogs.

PubMed

Arora, Rishi; Aistrup, Gary L; Supple, Stephen; Frank, Caleb; Singh, Jasleen; Tai, Shannon; Zhao, Anne; Chicos, Laura; Marszalec, William; Guo, Ang; Song, Long-Sheng; Wasserstrom, J Andrew

2017-02-01

The peculiarities of transverse tubule (T-tubule) morphology and distribution in the atrium-and how they contribute to excitation-contraction coupling-are just beginning to be understood. The objectives of this study were to determine T-tubule density in the intact, live right and left atria in a large animal and to determine intraregional differences in T-tubule organization within each atrium. Using confocal microscopy, T-tubules were imaged in both atria in intact, Langendorf-perfused normal dog hearts loaded with di-4-ANEPPS. T-tubules were imaged in large populations of myocytes from the endocardial surface of each atrium. Computerized data analysis was performed using a new MatLab (Mathworks, Natick, MA) routine, AutoTT. There was a large percentage of myocytes that had no T-tubules in both atria with a higher percentage in the right atrium (25.1%) than in the left atrium (12.5%) (P < .02). The density of transverse and longitudinal T-tubule elements was low in cells that did contain T-tubules, but there were no significant differences in density between the left atrial appendage, the pulmonary vein-posterior left atrium, the right atrial appendage, and the right atrial free wall. In contrast, there were significant differences in sarcomere spacing and cell width between different regions of the atria. There is a sparse T-tubule network in atrial myocytes throughout both dog atria, with significant numbers of myocytes in both atria-the right atrium more so than the left atrium-having no T-tubules at all. These regional differences in T-tubule distribution, along with differences in cell width and sarcomere spacing, may have implications for the emergence of substrate for atrial fibrillation. Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Mitral stenosis in 15 dogs.

PubMed

Lehmkuhl, L B; Ware, W A; Bonagura, J D

1994-01-01

Mitral stenosis was diagnosed in 15 young to middle-aged dogs. There were 5 Newfoundlands and 4 bull terriers affected, suggesting a breed predisposition for this disorder. Clinical signs included cough, dyspnea, exercise intolerance, and syncope. Soft left apical diastolic murmurs were heard only in 4 dogs, whereas 8 dogs had systolic murmurs characteristic of mitral regurgitation. Left atrial enlargement was the most prominent radiographic feature. Left-sided congestive heart failure was detected by radiographs in 11 dogs within 1 year of diagnosis. Electrocardiographic abnormalities varied among dogs and included atrial and ventricular enlargement, as well as atrial and ventricular arrhythmias. Abnormalities on M-mode and two-dimensional echocardiograms included abnormal diastolic motion of the mitral valve characterized by decreased leaflet separation, valve doming, concordant motion of the parietal mitral valve leaflet, and a decreased E-to-F slope. Increased mitral valve inflow velocities and prolonged pressure half-times were detected by Doppler echocardiography. Cardiac catheterization, performed in 8 dogs, documented a diastolic pressure gradient between the left atrial, pulmonary capillary wedge, or pulmonary artery diastolic pressures and the left ventricular diastolic pressure. Necropsy showed mitral stenosis caused by thickened, fused mitral valve leaflets in 5 dogs and a supramitral ring in another dog. The outcome in affected dogs was poor; 9 of 15 dogs were euthanatized or died by 2 1/2 years of age.

Congenital left atrial appendage aneurysm

PubMed Central

Wang, Bin; Li, He; Zhang, Li; He, Lin; Zhang, Jing; Liu, Cong; Wang, Jing; Lv, Qing; Shang, Xiaoke; Liu, Jinping; Xie, Mingxing

2018-01-01

Abstract Rationale: Left atrial appendage aneurysms (LAAA) are rare. Patients with LAAA are often diagnosed incidentally or after cardiac tachyarrhythmia or systemic thromboembolism happen. Early diagnosis and surgical resection is of utmost importance to prevent hazardous adverse events. Patient concerns: We present a case of 46-year-old man with congenital LAAA. The individual in this manuscript has given written informed consent to publish these case details. Diagnoses: Imaging studies, such as echocardiography, cardiovascular computed tomography (CT) and magnetic resonance imaging (MRI), demonstrated the large cavity arising from the left atrial appendage. The diagnosis of LAAA was confirmed. Interventions: The patient underwent an aneurysmectomy without any complications. Outcomes: TTE confirmed the disappearance of the LAAA from the left parasternal short-axis view of the aortic root postoperatively. The patient remained asymptomatic without any adverse events at his 3-month follow-up visits. Lessons: The associated high risk of life-threatening complications and the relative ease of surgical removal suggest that prompt evaluation should be considered in patients with lesions adjacent to the left heart border. PMID:29480827

Right atrial volume by cardiovascular magnetic resonance predicts mortality in patients with heart failure with reduced ejection fraction

PubMed Central

Ivanov, Alexander; Mohamed, Ambreen; Asfour, Ahmed; Ho, Jean; Khan, Saadat A.; Chen, Onn; Klem, Igor; Ramasubbu, Kumudha; Brener, Sorin J.; Heitner, John F.

2017-01-01

Background Right Atrial Volume Index (RAVI) measured by echocardiography is an independent predictor of morbidity in patients with heart failure (HF) with reduced ejection fraction (HFrEF). The aim of this study is to evaluate the predictive value of RAVI assessed by cardiac magnetic resonance (CMR) for all-cause mortality in patients with HFrEF and to assess its additive contribution to the validated Meta-Analysis Global Group in Chronic heart failure (MAGGIC) score. Methods and results We identified 243 patients (mean age 60 ± 15; 33% women) with left ventricular ejection fraction (LVEF) ≤ 35% measured by CMR. Right atrial volume was calculated based on area in two- and four -chamber views using validated equation, followed by indexing to body surface area. MAGGIC score was calculated using online calculator. During mean period of 2.4 years 33 patients (14%) died. The mean RAVI was 53 ± 26 ml/m2; significantly larger in patients with than without an event (78.7±29 ml/m2 vs. 48±22 ml/m2, p<0.001). RAVI (per ml/m2) was an independent predictor of mortality [HR = 1.03 (1.01–1.04), p = 0.001]. RAVI has a greater discriminatory ability than LVEF, left atrial volume index and right ventricular ejection fraction (RVEF) (C-statistic 0.8±0.08 vs 0.55±0.1, 0.62±0.11, 0.68±0.11, respectively, all p<0.02). The addition of RAVI to the MAGGIC score significantly improves risk stratification (integrated discrimination improvement 13%, and category-free net reclassification improvement 73%, both p<0.001). Conclusion RAVI by CMR is an independent predictor of mortality in patients with HFrEF. The addition of RAVI to MAGGIC score improves mortality risk stratification. PMID:28369148

Brain Abscess Associated with Isolated Left Superior Vena Cava Draining into the Left Atrium in the Absence of Coronary Sinus and Atrial Septal Defect

DOE Office of Scientific and Technical Information (OSTI.GOV)

Erol, Ilknur; Cetin, I. Ilker; Alehan, Fuesun

A previously healthy 12-year-old girl presented with severe headache for 2 weeks. On physical examination, there was finger clubbing without apparent cyanosis. Neurological examination revealed only papiledema without focal neurologic signs. Cerebral magnetic resonance imaging showed the characteristic features of brain abscess in the left frontal lobe. Cardiologic workup to exclude a right-to-left shunt showed an abnormality of the systemic venous drainage: presence of isolated left superior vena cava draining into the left atrium in the absence of coronary sinus and atrial septal defect. This anomaly is rare, because only a few other cases have been reported.

Successful surgical treatment of left atrioesophageal fistula following atrial ablation.

PubMed

Takahashi, Toru; Mohara, Jun; Ogawa, Hiroomi; Igarashi, Takamichi; Motegi, Yoko

2018-01-23

A 69-year-old male had catheter-based ablation for atrial fibrillation. He was admitted with high fever and had neurological disorder; he was diagnosed with atrioesophageal fistula by CT scan. Intraoperative findings showed that the fistula existed adjacent to the left lower pulmonary vein with a vegetation. The esophageal fistula was repaired, and the left atrial fistula was closed. A nasogastric tube tip was placed in the esophagus for decompression and advanced into the stomach for nutritional support. After vomiting, the patient showed loss of consciousness and left hemiplegia. CT scan revealed a micro-air embolism to the brain. The nasogastric tube tip was pulled back into the esophagus. Gastrointestinal fiberscopy showed a pinhole at the fistula, and a percutaneous endoscopic gastrostomy was made. After conservative treatment, the esophageal fistula was closed and mediastinitis was improved. He was discharged with a little neurological deficit.

Cor triatriatum or divided atriums: which approach provides the better understanding?

PubMed

Bharucha, Tara; Spicer, Diane E; Mohun, Timothy J; Black, David; Henry, G William; Anderson, Robert H

2015-02-01

It is frequent, in the current era, to encounter congenital cardiac malformations described in terms of "cor triatriatum". But can hearts be truly found with three atrial chambers? The morphological method, emphasised by Van Praagh et al, states that structures within the heart should be defined on the basis of their most constant components. In the atrial chambers, it is the appendages that are the most constant components, and to the best of our knowledge, hearts can only possess two appendages, which can be of either right or left morphology. The hearts described on the basis of "cor triatriatum", nonetheless, can also be analysed on the basis of division of either the morphologically right or the morphologically left atriums. In this review, we provide a description of cardiac embryology, showing how each of the atrial chambers possesses part of the embryological body, along with an appendage, a vestibule, a venous component, and a septum that separates them. We then show how it is, indeed, the case that the hearts described in terms of "cor triatriatum" can be readily understood on the basis of division of these atrial components. In the right atrium, it is the venous valves that divide the chamber. In the left atrium, it is harder to provide an explanation for the shelf that produces atrial division. We also contrast the classic examples of the divided atrial chambers with the vestibular shelf that produces supravalvar stenosis in the morphologically left atrium, showing that this form of obstruction needs to be distinguished from the fibrous shelves producing intravalvar obstruction.

Dissection of the atrial wall after mitral valve replacement.

PubMed Central

Lukács, L; Kassai, I; Lengyel, M

1996-01-01

We describe an unusual sequela of mitral valve replacement in a 50-year-old woman who had undergone a closed mitral commissurotomy in 1975. She was admitted to our hospital because of mitral restenosis in November 1993, at which time her mitral valve was replaced with a mechanical prosthesis. On the 8th postoperative day, the patient developed symptoms of heart failure; transesophageal echocardiography revealed dissection and rupture of the left atrial wall. At prompt reoperation, we found an interlayer dissection and rupture of the atrial wall into the left atrium. We repaired the ruptured atrial wall with a prosthetic patch. The postoperative course was uneventful, and postoperative transesophageal echocardiography showed normal prosthetic valve function and no dissection. Images PMID:8680278

Early signs that predict later haemodynamically significant patent ductus arteriosus.

PubMed

Engür, Defne; Deveci, Murat; Türkmen, Münevver K

2016-03-01

Our aim was to determine the optimal cut-off values, sensitivity, specificity, and diagnostic power of 12 echocardiographic parameters on the second day of life to predict subsequent ductal patency. We evaluated preterm infants, born at ⩽32 weeks of gestation, starting on their second day of life, and they were evaluated every other day until ductal closure or until there were clinical signs of re-opening. We measured transductal diameter; pulmonary arterial diastolic flow; retrograde aortic diastolic flow; pulsatility index of the left pulmonary artery and descending aorta; left atrium and ventricle/aortic root ratio; left ventricular output; left ventricular flow velocity time integral; mitral early/late diastolic flow; and superior caval vein diameter and flow as well as performed receiver operating curve analysis. Transductal diameter (>1.5 mm); pulmonary arterial diastolic flow (>25.6 cm/second); presence of retrograde aortic diastolic flow; ductal diameter by body weight (>1.07 mm/kg); left pulmonary arterial pulsatility index (⩽0.71); and left ventricle to aortic root ratio (>2.2) displayed high sensitivity and specificity (p0.9). Parameters with moderate sensitivity and specificity were as follows: left atrial to aortic root ratio; left ventricular output; left ventricular flow velocity time integral; and mitral early/late diastolic flow ratio (p0.05) had low diagnostic value. Left pulmonary arterial pulsatility index, left ventricle/aortic root ratio, and ductal diameter by body weight are useful adjuncts offering a broader outlook for predicting ductal patency.

Assessment of atrial electromechanical delay in children with acute rheumatic fever.

PubMed

Ciftel, Murat; Turan, Ozlem; Simşek, Ayşe; Kardelen, Fırat; Akçurin, Gayaz; Ertuğ, Halil

2014-02-01

There may be an increase in the risk of atrial arrhythmia due to left atrial enlargement and the influence on conduction system in acute rheumatic fever. The aim of this study is to investigate atrial electromechanical delay and P-wave dispersion in patients with acute rheumatic fever. A total of 48 patients diagnosed with acute rheumatic fever and 40 volunteers of similar age, sex, and body mass index were included in the study. The study groups were compared for M-mode echocardiographic parameters, interatrial electromechanical delay, intra-atrial electromechanical delay, and P-wave dispersion. Maximum P-wave duration, P-wave dispersion, and interatrial electromechanical delay were significantly higher in patients with acute rheumatic fever compared with the control group (p < 0.001). However, there was no difference in terms of intra-atrial electromechanical delay (p > 0.05). For patients with acute rheumatic fever, a positive correlation was identified between the left atrium diameter and the P-wave dispersion and interatrial electromechanical delay (r = 0.524 and p < 0.001, and r = 0.351 and p = 0.014, respectively). Furthermore, an important correlation was also identified between the P-wave dispersion and the interatrial electromechanical delay (r = 0.494 and p < 0.001). This study shows the prolongation of P-wave dispersion and interatrial electromechanical delay in acute rheumatic fever. Left atrial enlargement can be one of the underlying reasons for the increase in P-wave dispersion and interatrial electromechanical delay.

Left atrial enlargement increases the risk of major adverse cardiac events independent of coronary vasodilator capacity.

PubMed

Koh, Angela S; Murthy, Venkatesh L; Sitek, Arkadiusz; Gayed, Peter; Bruyere, John; Wu, Justina; Di Carli, Marcelo F; Dorbala, Sharmila

2015-09-01

Longstanding uncontrolled atherogenic risk factors may contribute to left atrial (LA) hypertension, LA enlargement (LAE) and coronary vascular dysfunction. Together they may better identify risk of major adverse cardiac events (MACE). The aim of this study was to test the hypothesis that chronic LA hypertension as assessed by LAE modifies the relationship between coronary vascular function and MACE. In 508 unselected subjects with a normal clinical (82)Rb PET/CT, ejection fraction ≥40 %, no prior coronary artery disease, valve disease or atrial fibrillation, LAE was determined based on LA volumes estimated from the hybrid perfusion and CT transmission scan images and indexed to body surface area. Absolute myocardial blood flow and global coronary flow reserve (CFR) were calculated. Subjects were systematically followed-up for the primary end-point - MACE - a composite of all-cause death, myocardial infarction, hospitalization for heart failure, stroke, coronary artery disease progression or revascularization. During a median follow-up of 862 days, 65 of the subjects experienced a composite event. Compared with subjects with normal LA size, subjects with LAE showed significantly lower CFR (2.25 ± 0.83 vs. 1.95 ± 0.80, p = 0.01). LAE independently and incrementally predicted MACE even after accounting for clinical risk factors, medication use, stress left ventricular ejection fraction, stress left ventricular end-diastolic volume index and CFR (chi-squared statistic increased from 30.9 to 48.3; p = 0.001). Among subjects with normal CFR, those with LAE had significantly worse event-free survival (risk adjusted HR 5.4, 95 % CI 2.3 - 12.8, p < 0.0001). LAE and reduced CFR are related but distinct cardiovascular adaptations to atherogenic risk factors. LAE is a risk marker for MACE independent of clinical factors and left ventricular volumes; individuals with LAE may be at risk of MACE despite normal coronary vascular function.

Down-regulation of L-type calcium channel and sarcoplasmic reticular Ca(2+)-ATPase mRNA in human atrial fibrillation without significant change in the mRNA of ryanodine receptor, calsequestrin and phospholamban: an insight into the mechanism of atrial electrical remodeling.

PubMed

Lai, L P; Su, M J; Lin, J L; Lin, F Y; Tsai, C H; Chen, Y S; Huang, S K; Tseng, Y Z; Lien, W P

1999-04-01

We investigated the gene expression of calcium-handling genes including L-type calcium channel, sarcoplasmic reticular calcium adenosine triphosphatase (Ca(2+)-ATPase), ryanodine receptor, calsequestrin and phospholamban in human atrial fibrillation. Recent studies have demonstrated that atrial electrical remodeling in atrial fibrillation is associated with intracellular calcium overload. However, the changes of calcium-handling proteins remain unclear. A total of 34 patients undergoing open heart surgery were included. Atrial tissue was obtained from the right atrial free wall, right atrial appendage, left atrial free wall and left atrial appendage, respectively. The messenger ribonucleic acid (mRNA) amount of the genes was measured by reverse transcription-polymerase chain reaction and normalized to the mRNA levels of glyceraldehyde 3-phosphate dehydrogenase. The mRNA of L-type calcium channel and of Ca(2+)-ATPase was significantly decreased in patients with persistent atrial fibrillation for more than 3 months (0.36+/-0.26 vs. 0.90+/-0.88 for L-type calcium channel; 0.69+/-0.42 vs. 1.21+/-0.68 for Ca(2+)-ATPase; both p < 0.05, all data in arbitrary unit). We further demonstrated that there was no spatial dispersion of the gene expression among the four atrial tissue sampling sites. Age, gender and underlying cardiac disease had no significant effects on the gene expression. In contrast, the mRNA levels of ryanodine receptor, calsequestrin and phospholamban showed no significant change in atrial fibrillation. L-type calcium channel and the sarcoplasmic reticular Ca(2+)-ATPase gene were down-regulated in atrial fibrillation. These changes may be a consequence of, as well as a contributory factor for, atrial fibrillation.

Different effects of prolonged exercise on the right and left ventricles.

PubMed

Douglas, P S; O'Toole, M L; Hiller, W D; Reichek, N

1990-01-01

To examine the functional consequences of the greater increase in right ventricular work with exercise, the effects of prolonged exercise on the right and left heart chambers were compared in 41 athletes before, at the finish (13 min) and after recovery (28 h) from the Hawaii Ironman Triathlon (3.9 km swim, 180.2 km bike ride, 42.2 km run). Two-dimensional and Doppler echocardiograms were analyzed for left and right atrial and ventricular areas at end-diastole and end-systole, right and left ventricular inflow velocities and mitral and tricuspid regurgitation. After exercise, left ventricular and left and right atrial sizes were reduced, whereas right ventricular size increased (diastole: 21.4 to 24.2 cm2; systole: 15.8 to 18.2 cm2; p less than 0.01). The emptying fraction of all chambers was unchanged. Left but not right ventricular inflow showed an increase in peak velocity of rapid filling, whereas both atrial systolic velocities increased (26 to 38 cm/s tricuspid; 38 to 54 cm/s mitral; both p less than 0.01). Overall, the right ventricular early to atrial velocity ratio was reduced after exercise (1.56 to 1.17; p less than 0.05) and the left ventricular pattern was unchanged. The prevalence of tricuspid regurgitation was statistically unchanged (86% to 52%), although that of mitral regurgitation was greatly reduced (76% to 0%). Changes in all variables returned toward prerace values during recovery. Thus, in highly trained athletes, prolonged exercise causes differing responses of the right and left ventricles. These differences may be due to changes in right ventricular function, shape or compliance.

Effect of atrial systole on canine and porcine coronary blood flow.

PubMed

Bellamy, R F

1981-09-01

A feature of phasic coronary flow patterns recorded in conscious chronically instrumented dogs is the atrial cove--a transient depression of arterial flow that occurs during atrial systole. The association between the hemodynamic effects of atrial systole and the atrial cove was studied in anesthetized dogs and pigs with complete heart block. Many atrial coves are available for study in these preparations because atrial activity continues unabated during the diastolic ventricular arrest that follows cessation of electrical pacing. The effect of atrial systole is to translate the pressure-flow relation found during diastole to a higher intercept pressure without change in slope. The increase in the intercept pressure equals the increase in intramyocardial pressure measured with microtransducers embedded in the left ventricular wall. The decrement in flow during the atrial cove is a direct function of the change in intramyocardial pressure and an inverse function of coronary vascular resistance. Each atrial systole is associated with a forward flow transient in the coronary veins, the peak of which occurs at the same instant as does the nadir of atrial flow. These data suggest that the coronary vessels are acting as collapsible tubes and that the waterfall model of the coronary circulation is applicable. The following sequence is proposed to account for the atrial cove. Atrial systole ejects a bolus of blood into the left ventricle increasing both ventricular cavity and intramyocardial pressures. The increase in intramyocardial pressure raises the back pressure opposing coronary flow, reducing the arterial perfusion pressure gradient and causing flow to fall.

Usefulness of radionuclide angiocardiography in predicting stenotic mitral orifice area

DOE Office of Scientific and Technical Information (OSTI.GOV)

Burns, R.J.; Armitage, D.L.; Fountas, P.N.

1986-12-01

Fifteen patients with pure mitral stenosis (MS) underwent high-temporal-resolution radionuclide angiocardiography for calculation of the ratio of peak left ventricular (LV) filling rate divided by mean LV filling rate (filling ratio). Whereas LV filling normally occurs in 3 phases, in MS it is more uniform. Thus, in 13 patients the filling ratio was below the normal range of 2.21 to 2.88 (p less than 0.001). In 11 patients in atrial fibrillation, filling ratio divided by mean cardiac cycle length and by LV ejection fraction provided good correlation (r = 0.85) with modified Gorlin formula derived mitral area and excellent correlationmore » with echocardiographic mitral area (r = 0.95). Significant MS can be detected using radionuclide angiocardiography to calculate filling ratio. In the absence of the confounding influence of atrial systole calculation of 0.14 (filling ratio divided by cardiac cycle length divided by LV ejection fraction) + 0.40 cm2 enables accurate prediction of mitral area (+/- 4%). Our data support the contention that the modified Gorlin formula, based on steady-state hemodynamics, provides less certain estimates of mitral area for patients with MS and atrial fibrillation, in whom echocardiography and radionuclide angiocardiography may be more accurate.« less

En face view of the mitral valve: definition and acquisition.

PubMed

Mahmood, Feroze; Warraich, Haider Javed; Shahul, Sajid; Qazi, Aisha; Swaminathan, Madhav; Mackensen, G Burkhard; Panzica, Peter; Maslow, Andrew

2012-10-01

A 3-dimensional echocardiographic view of the mitral valve, called the "en face" or "surgical view," presents a view of the mitral valve similar to that seen by the surgeon from a left atrial perspective. Although the anatomical landmarks of this view are well defined, no comprehensive echocardiographic definition has been presented. After reviewing the literature, we provide a definition of the left atrial and left ventricular en face views of the mitral valve. Techniques used to acquire this view are also discussed.

Rotational Angiography Based Three-Dimensional Left Atrial Reconstruction: A New Approach for Transseptal Puncture.

PubMed

Koektuerk, Buelent; Yorgun, Hikmet; Koektuerk, Oezlem; Turan, Cem H; Gorr, Eduard; Horlitz, Marc; Turan, Ramazan G

2016-02-01

Rotational angiography is a well-known method for the three-dimensional (3-D) reconstruction of left atrium and pulmonary veins during left-sided atrial arrhythmia ablation procedures. In our study, we aimed to review our experience in transseptal puncture (TSP) using 3-D rotational angiography. We included a total of 271 patients who underwent atrial fibrillation ablation using cryoballoon. Rotational angiography was performed to get the three-dimensional left atrial and pulmonary vein reconstructions using cardiac C-arm computed tomography. The image reconstruction was made using the DynaCT Cardiac software (Siemens, Erlangen, Germany). The mean age of the study population was 61 ± 10 years. The indications for left atrial arrhythmia ablation were paroxysmal AF in 140 patients (52%) and persistent AF patients in 131 (48%) patients. The success rate of TSP using only rotational guidance was (264/271 patients, 97.4%). In the remaining seven patients, transesophageal guidance was used after the initial attempt due to thick interatrial septum in five patients and difficult TSP due to abnormal anatomy and mild pericardial effusion in the remaining two patients. Mean fluoroscopy dosage of the rotational angiography was 4896.4 ± 825.3 μGym(2). The mean time beginning from femoral vein puncture to TSP was 12.3 ± 5.5 min. TSP guided by rotational angiography is a safe and effective method. Our results indicate that integration of rotational angiographic images into the real-time fluoroscopy can guide the TSP during the procedure. © 2015 John Wiley & Sons Ltd.

Assessment of atrial electromechanical delay and influential factors in patients with obstructive sleep apnea.

PubMed

Yagmur, Julide; Yetkin, Ozkan; Cansel, Mehmet; Acikgoz, Nusret; Ermis, Necip; Karakus, Yasin; Tasolar, Hakan

2012-03-01

The interaction between moderate-to-severe obstructive sleep apnea (OSA) and cardiac arrhythmias, especially atrial fibrillation (AF), is well known. We aimed to determine whether atrial electromechanical parameters assessed by tissue Doppler imaging (TDI) would be affected in moderate-to-severe OSA, and detect the influential factors of atrial electromechanical parameters in these patients. Interatrial and intra-atrial electromechanical delay was measured by TDI in patients with moderate-to-severe OSA (n = 64) and control subjects (n = 39). P-wave dispersion (PWD) was calculated on the 12-lead ECG. Interatrial and intra-atrial electromechanical delay was significantly higher in the OSA group when compared with the controls (52.26 ± 12.9 vs 29.61 ± 11.26, P < 0.0001 and 18.90 ± 8.13 vs 8.71 ± 5.46, P < 0.0001; respectively). PWD was higher in the OSA group (46.09 ± 13.40 ms vs 34.10 ± 10.75 ms, P < 0.0001). Interatrial electromechanical delay had a positive correlation with PWD (r = 0.490, P < 0.0001), left atrial (LA) diameter (r = 0.383, P = 0.002), LA volume index (r = 0.354, P = 0.004), and apnea-hypopnea index (r = 0.365, P = 0.003). In addition, interatrial electromechanical delay was negatively correlated with the magnitude of the lowest oxygen saturation percentage (r = -0.498, P < 0.0001). This study showed that interatrial and intra-atrial electromechanical delay and PWD were prolonged in patients with moderate-to-severe OSA. LA dilatation, hypoxemia, and the severity of the disease may contribute a prolongation in interatrial electromechanical delay via atrial structural and electrical alterations, which may predict the risk of future AF development in patients with moderate-to-severe OSA.

Night-time heart rate nondipping: clinical and prognostic significance in the general population.

PubMed

Cuspidi, Cesare; Facchetti, Rita; Bombelli, Michele; Sala, Carla; Tadic, Marijana; Grassi, Guido; Mancia, Giuseppe

2018-06-01

Studies addressing the association between a reduced drop of heart rate (HR) at night with subclinical organ damage and cardiovascular events in the general population are scanty. We evaluated this issue in individuals enrolled in the Pressioni Monitorate E Loro Associazioni study. At entry, 2021 individuals underwent diagnostic tests including laboratory investigations, 24-h ambulatory blood pressure (BP) monitoring and echocardiography. Participants were followed from the initial medical visit for a time interval of 148 ± 27 months. To explore the association of circadian HR rhythm and outcomes, participants were classified in the primary analysis according to quartiles of nocturnal HR decrease. In secondary analyses, the population was also classified according nondipping nocturnal HR (defined as a drop in average HR at night lower than 10% compared with day-time values) and next in four categories: first, BP/HR dipper, second, BP/HR nondipper, third, HR dipper/BP nondipper, fourth, HR nondipper/BP dipper). A flattened circadian HR rhythm (i.e. lowest quartile of night-time HR dip) was independently associated with left atrial enlargement, but not to left ventricular hypertrophy; moreover, it was predictive of fatal and nonfatal cardiovascular events, independently of several confounders (hazard ratio 1.8, confidence interval: 1.13-2.86, P < 0.01 vs. highest quartile). A blunted dipping of nocturnal HR is associated with preclinical cardiac damage in terms of left atrial enlargement and is predictive cardiovascular morbidity and mortality in the general population.

Echocardiographic Evaluation of Left Atrial Mechanics: Function, History, Novel Techniques, Advantages, and Pitfalls.

PubMed

Leischik, Roman; Littwitz, Henning; Dworrak, Birgit; Garg, Pankaj; Zhu, Meihua; Sahn, David J; Horlitz, Marc

2015-01-01

Left atrial (LA) functional analysis has an established role in assessing left ventricular diastolic function. The current standard echocardiographic parameters used to study left ventricular diastolic function include pulsed-wave Doppler mitral inflow analysis, tissue Doppler imaging measurements, and LA dimension estimation. However, the above-mentioned parameters do not directly quantify LA performance. Deformation studies using strain and strain-rate imaging to assess LA function were validated in previous research, but this technique is not currently used in routine clinical practice. This review discusses the history, importance, and pitfalls of strain technology for the analysis of LA mechanics.

Functional β2-adrenoceptors in rat left atria: effect of foot-shock stress.

PubMed

Moura, André Luiz de; Hyslop, Stephen; Grassi-Kassisse, Dora M; Spadari, Regina C

2017-09-01

Altered sensitivity to the chronotropic effect of catecholamines and a reduction in the β 1 /β 2 -adrenoceptor ratio have previously been reported in right atria of stressed rats, human failing heart, and aging. In this report, we investigated whether left atrial inotropism was affected by foot-shock stress. Male rats were submitted to 3 foot-shock sessions and the left atrial inotropic response, adenylyl cyclase activity, and β-adrenoceptor expression were investigated. Left atria of stressed rats were supersensitive to isoprenaline when compared with control rats and this effect was abolished by ICI118,551, a selective β 2 -receptor antagonist. Schild plot slopes for the antagonism between CGP20712A (a selective β 1 -receptor antagonist) and isoprenaline differed from unity in atria of stressed but not control rats. Atrial sensitivity to norepinephrine, as well as basal and forskolin- or isoprenaline-stimulated adenylyl cyclase activities were not altered by stress. The effect of isoprenaline on adenylyl cyclase stimulation was partially blocked by ICI118,551 in atrial membranes of stressed rats. These findings indicate that foot-shock stress equally affects inotropism and chronotropism and that β 2 -adrenoceptor upregulation contributes to the enhanced inotropic response to isoprenaline.

Biatrial or left atrial drainage of the right superior vena cava: anatomic, morphogenetic, and surgical considerations--report of three new cases and literature review.

PubMed

Van Praagh, S; Geva, T; Lock, J E; Nido, P J; Vance, M S; Van Praagh, R

2003-01-01

Since the posterior wall of the right superior vena cava (RSVC) is contiguous with the anterior wall of the right upper pulmonary veins, a localized defect in this common wall may create a cavopulmonary venous confluence without eliminating the normal connection of the same right pulmonary veins with the left atrium (LA). Through this defect, blood of the unroofed right pulmonary veins will drain into the RSVC and right atrium (RA), and blood from the RSVC may shunt into the right pulmonary veins and LA. Hemodynamically, the RSVC will become biatrial. If the RSVC blood flows preferentially into the LA, its right atrial orifice will become stenotic or even atretic. If atretic, the normally positioned RSVC will drain entirely into the LA. In this report, we present the clinical and anatomical findings of two postmortem cases with biatrial drainage of the RSVC. We also document the clinical, echocardiographic, angiocardiographic, and surgical data of a living patient with left atrial drainage of the RSVC and tetralogy of Fallot with pulmonary atresia. The relevant literature and surgical treatment are reviewed, and the morphogenesis of the biatrial and left atrial RSVC is considered.

Atrial contribution to ventricular filling in mitral stenosis.

PubMed

Meisner, J S; Keren, G; Pajaro, O E; Mani, A; Strom, J A; Frater, R W; Laniado, S; Yellin, E L

1991-10-01

The importance of the contribution of atrial systole to ventricular filling in mitral stenosis is controversial. The cause of reduced cardiac output following the onset of atrial fibrillation may be due to an increased heart rate, a loss of booster pump function, or both. We studied the atrial contribution to filling under a variety of conditions by combining noninvasive studies of patients with computer modeling. Thirty patients in sinus rhythm with mild-to-severe stenosis were studied with two-dimensional and Doppler echocardiography for measurement of mitral flow velocity and mitral valve area (MVA). The mean +/- SD atrial contribution to left ventricular filling volume was 18 +/- 10% and varied inversely with mitral resistance. Patients with mild mitral stenosis (MVA, 1.8 +/- 0.7 cm2) and severe mitral stenosis (MVA, 0.9 +/- 0.2 cm2) had atrial contributions of 29 +/- 4% and 9 +/- 5%, respectively. The pathophysiological mechanisms responsible for these trends were further investigated by the computer model. In modeled severe mitral stenosis, increasing heart rate from 75 to 150 beats/min caused an increase of 5.2 mm Hg in mean left atrial pressure, whereas loss of atrial contraction at a heart rate of 150 beats/min caused only a 1.3 mm Hg increase. The atrial booster pump contributes less to ventricular filling in mitral stenosis than in the normal heart, and the loss of atrial pump function is less important than the effect of increasing heart rate as the cause of decompensation during atrial fibrillation.

Left cardiac isomerism in the Sonic hedgehog null mouse.

PubMed

Hildreth, Victoria; Webb, Sandra; Chaudhry, Bill; Peat, Jonathan D; Phillips, Helen M; Brown, Nigel; Anderson, Robert H; Henderson, Deborah J

2009-06-01

Sonic hedgehog (Shh) is a secreted morphogen necessary for the production of sidedness in the developing embryo. In this study, we describe the morphology of the atrial chambers and atrioventricular junctions of the Shh null mouse heart. We demonstrate that the essential phenotypic feature is isomerism of the left atrial appendages, in combination with an atrioventricular septal defect and a common atrioventricular junction. These malformations are known to be frequent in humans with left isomerism. To confirm the presence of left isomerism, we show that Pitx2c, a recognized determinant of morphological leftness, is expressed in the Shh null mutants on both the right and left sides of the inflow region, and on both sides of the solitary arterial trunk exiting from the heart. It has been established that derivatives of the second heart field expressing Isl1 are asymmetrically distributed in the developing normal heart. We now show that this population is reduced in the hearts from the Shh null mutants, likely contributing to the defects. To distinguish the consequences of reduced contributions from the second heart field from those of left-right patterning disturbance, we disrupted the movement of second heart field cells into the heart by expressing dominant-negative Rho kinase in the population of cells expressing Isl1. This resulted in absence of the vestibular spine, and presence of atrioventricular septal defects closely resembling those seen in the hearts from the Shh null mutants. The primary atrial septum, however, was well formed, and there was no evidence of isomerism of the atrial appendages, suggesting that these features do not relate to disruption of the contributions made by the second heart field. We demonstrate, therefore, that the Shh null mouse is a model of isomerism of the left atrial appendages, and show that the recognized associated malformations found at the venous pole of the heart in the setting of left isomerism are likely to arise from the loss of the effects of Shh in the establishment of laterality, combined with a reduced contribution made by cells derived from the second heart field.

Effect of pulmonary vein isolation on the left-to-right atrial dominant frequency gradient in human atrial fibrillation.

PubMed

Lazar, Sorin; Dixit, Sanjay; Callans, David J; Lin, David; Marchlinski, Francis E; Gerstenfeld, Edward P

2006-08-01

We previously demonstrated the existence of a left-to-right atrial dominant frequency gradient during paroxysmal but not persistent atrial fibrillation (AF) in humans. One possible mechanism of the left-to-right dominant frequency gradient involves the role of the pulmonary veins (PVs) in AF maintenance. The purpose of this study was to examine the effect of PV isolation on the dominant frequency gradient and outcome after PV isolation. Patients with either paroxysmal or persistent AF were studied. Recordings were made from catheters in the coronary sinus (CS), posterior right atrium (RA), and posterior left atrium (LA) during AF before and after PV isolation. Mean left-to-right dominant frequency gradient was measured before and after segmental PV isolation. Patients were followed for AF recurrence after PV isolation. Twenty-seven patients with paroxysmal (n = 15) or persistent (n = 12) AF were studied. In the paroxysmal group, baseline dominant frequency was greatest in the posterior LA with a significant left-to-right atrial dominant frequency gradient (posterior LA = 6.2 +/- 0.9 Hz, CS = 5.8 +/- 0.8 Hz, posterior RA = 5.4 +/- 0.9 Hz; P <.001). After PV isolation, there was no regional difference in dominant frequency (5.9 +/- 0.7 Hz vs 5.7 +/- 0.6 Hz vs 5.7 +/- 0.7 Hz, respectively; P = NS). In the persistent AF group, there was no overall difference in dominant frequency among sites before or after PV isolation (P = NS); however, patients with long-term freedom from AF after PV isolation had a higher left-to-right dominant frequency gradient compared with patients with recurrent AF (0.4 vs 0.1 Hz; P <.05). PV isolation results in a loss in the left-to-right dominant frequency gradient in patients with paroxysmal AF. This finding supports the critical role of PVs in the maintenance of ongoing paroxysmal AF. Patients with persistent AF and a baseline left-to-right dominant frequency gradient have a better success rate with PV isolation alone compared with patients without a dominant frequency gradient.

Unusual presentation of total anomalous systemic venous connection.

PubMed

Vaidyanathan, Swaminathan; Kothandam, Sivakumar; Kumar, Rajesh; Pradhan, Priya M; Agarwal, Ravi

2017-07-01

A 9-year-old girl who presented with dyspnea on exertion was diagnosed with total anomalous systemic venous connection to the left atrium (both venae cavae), no left superior vena cava, and a moderate-sized atrial septal defect with severe pulmonary arterial hypertension and ectopic atrial rhythm. She underwent septation of the common atrium using autologous pericardium, thereby rerouting the superior vena cava, inferior vena cava, and coronary sinus to the right atrium. Her postoperative course was uneventful. This case is reported for its rarity of presentation with severe pulmonary arterial hypertension and ectopic atrial rhythm.

Differences in Characteristics, Left Atrial Reverse Remodeling, and Functional Outcomes after Mitral Valve Replacement in Patients with Low-Gradient Very Severe Mitral Stenosis.

PubMed

Cho, In-Jeong; Hong, Geu-Ru; Lee, Seung Hyun; Lee, Sak; Chang, Byung-Chul; Shim, Chi Young; Chang, Hyuk-Jae; Ha, Jong-Won; Shin, Gil Ja; Chung, Namsik

2016-08-01

The discrepancy between planimetered mitral valve area (MVA) and mean diastolic pressure gradient (MDPG) has not been studied extensively in patients with mitral stenosis. The purpose of the present study was to investigate differences in characteristics and outcomes after mitral valve replacement (MVR) between low- and high-MDPG groups in patients with very severe mitral stenosis (VSMS). The hypothesis was that the low-MDPG group would have different characteristics and would be associated with poor clinical outcomes after MVR. In total, 140 patients who underwent isolated MVR because of pure VSMS (planimetered MVA ≤ 1.0 cm(2)) were retrospectively reviewed, and follow-up echocardiography was performed for ≥12 months after MVR. Patients were divided into two groups according to preoperative MDPG (low gradient [LG], <10 mm Hg; high gradient [HG], ≥10 mm Hg). Strain and strain rate analysis was performed using speckle-tracking echocardiography of the left ventricle before MVR in a subgroup of 56 patients. There were 82 patients (59%) in the LG group and 58 patients (41%) in the HG group. The LG group was older and demonstrated a higher prevalence of female gender, diabetes mellitus, and atrial fibrillation (P < .05 for all). When comparing the LG and HG groups, the left atrial volume index was larger (105.1 ± 51.9 vs 87.8 ± 42.9 mL/m(2), P < .001), and strain rate during isovolumic relaxation of the left ventricle was lower (0.17 ± 0.08 vs 0.29 ± 0.09 sec(-1), P < .001) in the LG group. After MVR, the percentage left atrial volume index reduction after MVR was significantly smaller in the LG group (-29.9 ± 15.1% vs -43.5 ± 16.4%, P < .001). Persistent symptoms after MVR were more common in the LG group compared with the HG group (P = .004), even though preoperative functional class was similar between the groups. Compared with those with HG VSMS, patients with LG VSMS were older, more often female, and more frequently had diabetes mellitus and atrial fibrillation. They also had greater impairment of isovolumic relaxation, less favorable left atrial reverse remodeling, and a greater risk for persistent symptoms after MVR. These data might suggest other concurrent mechanisms for left atrial enlargement and symptom development in LG VSMS, such as atrial fibrillation and diastolic dysfunction, as well as valvular stenosis. Copyright © 2016 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

Safety of percutaneous left atrial appendage closure: results from the Watchman Left Atrial Appendage System for Embolic Protection in Patients with AF (PROTECT AF) clinical trial and the Continued Access Registry.

PubMed

Reddy, Vivek Y; Holmes, David; Doshi, Shephal K; Neuzil, Petr; Kar, Saibal

2011-02-01

The Watchman Left Atrial Appendage System for Embolic Protection in Patients With AF (PROTECT AF) randomized trial compared left atrial appendage closure against warfarin in atrial fibrillation (AF) patients with CHADS₂ ≥1. Although the study met the primary efficacy end point of being noninferior to warfarin therapy for the prevention of stroke/systemic embolism/cardiovascular death, there was a significantly higher risk of complications, predominantly pericardial effusion and procedural stroke related to air embolism. Here, we report the influence of experience on the safety of percutaneous left atrial appendage closure. The study cohort for this analysis included patients in the PROTECT AF trial who underwent attempted device left atrial appendage closure (n=542 patients) and those from a subsequent nonrandomized registry of patients undergoing Watchman implantation (Continued Access Protocol [CAP] Registry; n=460 patients). The safety end point included bleeding- and procedure-related events (pericardial effusion, stroke, device embolization). There was a significant decline in the rate of procedure- or device-related safety events within 7 days of the procedure across the 2 studies, with 7.7% and 3.7% of patients, respectively, experiencing events (P=0.007), and between the first and second halves of PROTECT AF and CAP, with 10.0%, 5.5%, and 3.7% of patients, respectively, experiencing events (P=0.006). The rate of serious pericardial effusion within 7 days of implantation, which had made up >50% of the safety events in PROTECT AF, was lower in the CAP Registry (5.0% versus 2.2%, respectively; P=0.019). There was a similar experience-related improvement in procedure-related stroke (0.9% versus 0%, respectively; P=0.039). Finally, the functional impact of these safety events, as defined by significant disability or death, was statistically superior in the Watchman group compared with the warfarin group in PROTECT AF. This remained true whether significance was defined as a change in the modified Rankin score of ≥1, ≥2, or ≥3 (1.8 versus 4.3 events per 100 patient-years; relative risk, 0.43; 95% confidence interval, 0.24 to 0.82; 1.5 versus 3.7 events per 100 patient-years; relative risk, 0.41; 95% confidence interval, 0.22 to 0.82; and 1.4 versus 3.3 events per 100 patient-years; relative risk, 0.43; 95% confidence interval, 0.22 to 0.88, respectively). As with all interventional procedures, there is a significant improvement in the safety of Watchman left atrial appendage closure with increased operator experience. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique identifier: NCT00129545.

Transcatheter closure of left ventricle to right atrial communication using cera duct occluder.

PubMed

Ganesan, Gnanavelu; Paul, G Justin; Mahadevan, Vaikom S

Left ventricle-right atrial communication could be congenital (Gerbode defect) or acquired as a complication of surgery or infective endocarditis and leads to volume overloading of pulmonary circulation. Two types, direct and indirect types are known depending on the involvement of septal tricuspid leaflet. Transcatheter closure of this defect is feasible and appears an attractive alternative to surgical management. Various devices like Amplatzer duct occluder I, II, Muscular ventricular septal defect device etc. have been used to close this defect. We report two patients, a preteen boy with direct left ventricle-right atrial communication as post operative complication and an adult female with indirect communication who underwent transcatheter closure with Cera duct occluder (Lifetech Scientific (Shenzhen), China). Copyright © 2017. Published by Elsevier B.V.

Impact of Ischemic and Valvular Heart Disease on Atrial Excitation:A High-Resolution Epicardial Mapping Study.

PubMed

Mouws, Elisabeth M J P; Lanters, Eva A H; Teuwen, Christophe P; van der Does, Lisette J M E; Kik, Charles; Knops, Paul; Yaksh, Ameeta; Bekkers, Jos A; Bogers, Ad J J C; de Groot, Natasja M S

2018-03-08

The influence of underlying heart disease or presence of atrial fibrillation (AF) on atrial excitation during sinus rhythm (SR) is unknown. We investigated atrial activation patterns and total activation times of the entire atrial epicardial surface during SR in patients with ischemic and/or valvular heart disease with or without AF. Intraoperative epicardial mapping (N=128/192 electrodes, interelectrode distances: 2 mm) of the right atrium, Bachmann's bundle (BB), left atrioventricular groove, and pulmonary vein area was performed during SR in 253 patients (186 male [74%], age 66±11 years) with ischemic heart disease (N=132, 52%) or ischemic valvular heart disease (N=121, 48%). As expected, SR origin was located at the superior intercaval region of the right atrium in 232 patients (92%). BB activation occurred via 1 wavefront from right-to-left (N=163, 64%), from the central part (N=18, 7%), or via multiple wavefronts (N=72, 28%). Left atrioventricular groove activation occurred via (1) BB: N=108, 43%; (2) pulmonary vein area: N=9, 3%; or (3) BB and pulmonary vein area: N=136, 54%; depending on which route had the shortest interatrial conduction time ( P <0.001). Ischemic valvular heart disease patients more often had central BB activation and left atrioventricular groove activation via pulmonary vein area compared with ischemic heart disease patients (N=16 [13%] versus N=2 [2%]; P =0.009 and N=86 [71%] versus N=59 [45%]; P <0.001, respectively). Total activation times were longer in patients with AF (AF: 136±20 [92-186] ms; no AF: 114±17 [74-156] ms; P <0.001), because of prolongation of right atrium ( P =0.018) and BB conduction times ( P <0.001). Atrial excitation during SR is affected by underlying heart disease and AF, resulting in alternative routes for BB and left atrioventricular groove activation and prolongation of total activation times. Knowledge of atrial excitation patterns during SR and its electropathological variations, as demonstrated in this study, is essential to further unravel the pathogenesis of AF. © 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Assessment of left atrial mechanical function and synchrony in paroxysmal atrial fibrillation with two-dimensional speckle tracking echocardiography.

PubMed

Shang, Zhijuan; Su, Dechun; Cong, Tao; Sun, Yinghui; Liu, Yan; Chen, Na; Yang, Jun

2017-02-01

The aim of this study was to investigate left atrial (LA) function and synchrony in paroxysmal atrial fibrillation (PAF) patients using two-dimensional speckle tracking echocardiography (STE). Forty-five PAF patients and 30 healthy controls were enrolled. LA peak ventricular systolic longitudinal strain (LA S -S ) and strain rate (LA SR -S ) and left atrial longitudinal strain (LA S -A ) and strain rate (LA SR -A ) during late diastole were determined using STE, and the standard deviation of the time to peak (TPSD) of the regional strains was calculated to quantify LA dyssynchrony. TPSD during ventricular systole and late diastole were named SDs and SDa, respectively. Left atrial peak longitudinal strain during ventricular systole (LA S -S ) (29.34±8.57 vs 36.73±6.13), LA SR -S (1.27±0.311 vs 1.57±0.25), LA S -A (13.11±4.91 vs 17.86±3.57), and LA SR -A (-1.51±0.58 vs -1.90±0.30) were reduced in the PAF group compared with the controls (P<.05 for all). SDs (8.11±3.00% vs 4.67±1.48%) and SDa (5.57±2.26% vs 3.11±1.13%) were greater in PAF patients than in the controls (P<.05 for both). Furthermore, PAF patients with normal LA sizes exhibited lower LA S -S (P<.05), LA SR -S (P<.05), LA S -A (P<.05), and LA SR -A (P<.05) values and increased SDs (P<.05) and SDa (P<.05) values compared with the controls. Multivariate regression confirmed that SDs and SDa were powerful parameters for differentiating PAF patients from controls (SDs: sensitivity, 83%; specificity, 72%; SDa: sensitivity, 81%; specificity, 76%). Left atrial (LA) dysfunction and dyssynchrony in PAF patients can be detected with STE even in the absence of LA enlargement. STE-derived SDs and SDa were powerful parameters for identifying PAF patients. © 2017, Wiley Periodicals, Inc.

Frequent premature atrial contractions impair left atrial contractile function and promote adverse left atrial remodeling.

PubMed

John, Anub G; Hirsch, Glenn A; Stoddard, Marcus F

2018-06-10

This study assessed if frequent premature atrial contractions (PACs) were associated with decreased left atrial (LA) strain and adverse remodeling. Left atrial dysfunction and enlargement increases risk of stroke. If frequent PACs cause LA dysfunction and remodeling, PAC suppressive therapy may be beneficial. Inclusion criteria were age ≥18 years and sinus rhythm. Exclusion criteria were atrial fibrillation or any etiology for LA enlargement. Hundred and thirty-two patients with frequent PACs (≥100/24 hours) by Holter were matched to controls. Speckle tracking strain of the left atrium was performed from the 4-chamber view. Strain measurements were LA peak contractile, reservoir and conduit strain and strain rates. In the frequent PAC vs control group, PACs were more frequent (1959 ± 3796 vs 28 ± 25/24 hours, P < .0001). LA peak contractile strain was reduced in the group with frequent PACs vs controls (-7.85 ± 4.12% vs -9.33 ± 4.45%, P = .006). LA peak late negative contractile strain rate was less negative in the frequent PAC vs control group (-0.63 ± 0.27 s -1 vs -0.69 ± 0.32 s -1 , P = .051). LA reservoir and conduit strain and strain rates did not differ. LA volume index (LAVI) was larger in the frequent PAC vs control group (26.6 ± 7.8 vs 24.6 ± 8.8 mL/m 2 , P < .05). Frequent PACs were an independent predictor of reduced LA peak contractile strain and reduced LA peak late negative contractile strain rate. Patients with frequent PACs have reduced LA peak contractile strain and strain rates and larger LAVI compared to controls. Frequent PACs are an independent predictor of reduced LA peak contractile strain and strain rate. These findings support the hypothesis that frequent PACs impair LA contractile function and promote adverse LA remodeling. © 2018 Wiley Periodicals, Inc.

Left atrial function to identify patients with atrial fibrillation at high risk of stroke: new insights from a large registry.

PubMed

Leung, Melissa; van Rosendael, Philippe J; Abou, Rachid; Ajmone Marsan, Nina; Leung, Dominic Y; Delgado, Victoria; Bax, Jeroen J

2018-04-21

Atrial fibrillation (AF) is an independent risk factor for ischaemic stroke. The CHA2DS2-VASc is the most widely used risk stratification model; however, echocardiographic refinement may be useful, particularly in low risk AF patients. The present study examined the association between advanced echocardiographic parameters and ischaemic stroke, independent of CHA2DS2-VASc score. One thousand, three hundred and sixty-one patients (mean age 65±12 years, 74% males) with first diagnosis of AF and baseline transthoracic echocardiogram were followed by chart review for the occurrence of stroke over a mean of 7.9 years. Left atrial (LA) volumes, LA reservoir strain, P-wave to A' duration on tissue Doppler imaging (PA-TDI, reflecting total atrial conduction time), and left ventricular (LV) global longitudinal strain (GLS) were evaluated in patients with and without stroke. The independent association of these echocardiographic parameters with the occurrence of ischaemic stroke was evaluated with Cox proportional hazard models. One-hundred patients (7%) developed an ischaemic stroke, representing an annualized stroke rate of 0.9%. The incident stroke rate in the year following the first diagnosis of AF was 2.6% in the entire population and higher than the remainder of the follow-up period. Left atrial reservoir (14.5% vs. 18.9%, P = 0.005) and conduit strains were reduced (10.5% vs. 13.5%, P = 0.013), and PA-TDI lengthened (166 ms vs. 141 ms, P < 0.001) in the stroke compared with non-stroke group, despite similar LV dimensions, LV ejection fraction, GLS, and LA volumes. Left atrial reservoir strain and PA-TDI were independently associated with risk of stroke in a model including CHA2DS2-VASc score, age, and anticoagulant use. The assessment of LA reservoir strain and PA-TDI on echocardiography after initial CHA2DS2-VASc scoring provides additional risk stratification for stroke and may be useful to guide decisions regarding anticoagulation for patients upon first diagnosis of AF.

Characterization and autoradiographic localization of beta-adrenoceptor subtypes in human cardiac tissues.

PubMed Central

Buxton, B. F.; Jones, C. R.; Molenaar, P.; Summers, R. J.

1987-01-01

1 Receptor autoradiography using (-)-[125I]-cyanopindolol (CYP) was used to study the distribution of beta-adrenoceptor subtypes in human right atrial appendage, left atrial free wall, left ventricular papillary muscle and pericardium. 2 The binding of (-)-[125I]-CYP to slide-mounted tissue sections of human right atrial appendage was time-dependent (K1 = 4.11 +/- 1.01 X 10(8) M-1 min-1, K-1 = 1.47 +/- 0.25 X 10(-3) min-1, n = 3), saturable (42.02 +/- 2.96 pM, n = 4) and stereoselective with respect to the optical isomers of propranolol (pKD (-):8.97 +/- 0.02, (+):6.88 +/- 0.06, n = 3). 3 The proportions of beta-adrenoceptor subtypes were determined in slide-mounted tissue sections using the antagonists CGP 20712A (beta 1-selective) and ICI 118,551 (beta 2-selective). In right atrial appendage and left ventricular papillary muscle 40% (34-45%) of the beta-adrenoceptors were of the beta 2-subtype. 4 Images from X-ray film and nuclear emulsion coated coverslips exposed to (-)-[125I]-CYP-labelled sections showed an even distribution of beta-adrenoceptor subtypes over the myocardium of the right atrial appendage, left ventricular papillary muscle and left atrial free wall. Sections of pericardium exhibited predominantly beta 2-adrenoceptors. beta 2-Adrenoceptors were localized to the intimal surface of coronary arteries. 5 The selective beta 1-adrenoceptor agonist RO363 and beta 2-selective agonist procaterol produced concentration-dependent inotropic responses in right atrial appendage strips. Responses to RO363 were antagonized by CGP 20712A (pKB = 9.29) suggesting an interaction with beta 1-adrenoceptors. Responses to procaterol were antagonized by ICI 118,551 (pKB = 9.06) suggesting an interaction at beta 2-adrenoceptors. 6 The finding that a significant proportion of human myocardial adrenoceptors are of the beta 2-subtype has important clinical implications for the involvement of these receptors in the control of heart rate and force, and the autoradiographic evidence suggests other roles in the coronary vasculature and pericardium. Images Figure 5 Figure 6 PMID:2823947

Age, Sex, and Blood Pressure-Related Influences on Reference Values of Left Atrial Deformation and Mechanics From a Large-Scale Asian Population.

PubMed

Liao, Jo-Nan; Chao, Tze-Fan; Kuo, Jen-Yuan; Sung, Kuo-Tzu; Tsai, Jui-Peng; Lo, Chi-In; Lai, Yau-Huei; Su, Cheng-Huang; Hung, Chung-Lieh; Yeh, Hung-I; Chen, Shih-Ann

2017-10-01

Left atrial (LA) function is tightly linked to several cardiovascular diseases and confers key prognostic information. Speckle tracking-based deformation as a feasible and sensitive LA mechanical assessment has proven its clinical significance beyond volume measures; however, the reference values remain largely unknown. We studied 4042 participants undergoing annual cardiovascular survey. Among them, 2812 healthy participants (65% men; mean age, 47.4±9.9 years) were eligible for speckle tracking analysis. Peak atrial longitudinal systolic strain and strain rate (SR) at systolic (SRs), early diastolic (SRe), and late diastolic atrial contraction phases (SRa) were analyzed by dedicated software (EchoPAC, GE) and compared in terms of age, sex, and blood pressure. Overall, women demonstrated higher peak atrial longitudinal systolic strain (39.34±7.99% versus 37.95±7.96%; P<0.001) and showed age-dependent more pronounced peak atrial longitudinal systolic strain functional decay than those of men (P value for interaction, <0.05), with men showing higher SRs and SRa, although lower SRe (all P<0.001). Both increasing age and higher blood pressure were independently associated with deteriorated peak atrial longitudinal systolic strain, SRs, and SRe, although augmented LA SRa, even after accounting for baseline clinical covariates in multivariable models that incorporated LA volume, NT-proBNP (N-terminal pro-B-type natriuretic peptide), or left ventricular E/e' (all P<0.001). Our findings suggest LA mechanical functional decays in association with increasing age and higher blood pressure, which seem to be compensated for by augmentation of atrial pump function. We have also provided age- and sex-stratified reference values for strain and SR based on a large-scale Asian population. © 2017 American Heart Association, Inc.

Sinus venosus syndrome: atrial septal defect or anomalous venous connection? A multiplane transoesophageal approach.

PubMed

Oliver, J M; Gallego, P; Gonzalez, A; Dominguez, F J; Aroca, A; Mesa, J M

2002-12-01

To discuss the anatomical features of sinus venosus atrial defect on the basis of a comprehensive transoesophageal echocardiography (TOE) examination and its relation to surgical data. 24 patients (13 men, 11 women, mean (SD) age 37 (17) years, range 17-73 years) with a posterior interatrial communication closely related to the entrance of the superior (SVC) or inferior vena cava (IVC) who underwent TOE before surgical repair. Records of these patients were retrospectively reviewed and compared with surgical assessments. In 13 patients, TOE showed a deficiency in the extraseptal wall that normally separates the left atrium and right upper pulmonary vein from the SVC and right atrium. This deficiency unroofed the right upper pulmonary vein, compelling it to drain into the SVC, which overrode the intact atrial septum. In three patients, TOE examination showed a defect in the wall of the IVC, which continued directly into the posterior border of the left atrium. Thus, the intact muscular border of the atrial septum was overridden by the mouth of the IVC, which presented a biatrial connection. In the remaining eight patients, the defect was located in the muscular posterior border of the fossa ovalis. A residuum of atrial septum was visualised in the superior margin of the defect. Neither caval vein overriding nor anomalous pulmonary vein drainage was present. Sinus venosus syndrome should be regarded as an anomalous venous connection with an interatrial communication outside the confines of the atrial septum, in the unfolding wall that normally separates the left atrium from either caval vein. It results in overriding of the caval veins across the intact atrial septum and partial pulmonary vein anomalous drainage. It should be differentiated from posterior atrial septal defect without overriding or anomalous venous connections.

Sinus venosus syndrome: atrial septal defect or anomalous venous connection? A multiplane transoesophageal approach

PubMed Central

Oliver, J M; Gallego, P; Gonzalez, A; Dominguez, F J; Aroca, A; Mesa, J M

2002-01-01

Objective: To discuss the anatomical features of sinus venosus atrial defect on the basis of a comprehensive transoesophageal echocardiography (TOE) examination and its relation to surgical data. Methods: 24 patients (13 men, 11 women, mean (SD) age 37 (17) years, range 17–73 years) with a posterior interatrial communication closely related to the entrance of the superior (SVC) or inferior vena cava (IVC) who underwent TOE before surgical repair. Records of these patients were retrospectively reviewed and compared with surgical assessments. Results: In 13 patients, TOE showed a deficiency in the extraseptal wall that normally separates the left atrium and right upper pulmonary vein from the SVC and right atrium. This deficiency unroofed the right upper pulmonary vein, compelling it to drain into the SVC, which overrode the intact atrial septum. In three patients, TOE examination showed a defect in the wall of the IVC, which continued directly into the posterior border of the left atrium. Thus, the intact muscular border of the atrial septum was overridden by the mouth of the IVC, which presented a biatrial connection. In the remaining eight patients, the defect was located in the muscular posterior border of the fossa ovalis. A residuum of atrial septum was visualised in the superior margin of the defect. Neither caval vein overriding nor anomalous pulmonary vein drainage was present. Conclusions: Sinus venosus syndrome should be regarded as an anomalous venous connection with an interatrial communication outside the confines of the atrial septum, in the unfolding wall that normally separates the left atrium from either caval vein. It results in overriding of the caval veins across the intact atrial septum and partial pulmonary vein anomalous drainage. It should be differentiated from posterior atrial septal defect without overriding or anomalous venous connections. PMID:12433899

Hemodynamics of a functional centrifugal-flow total artificial heart with functional atrial contraction in goats.

PubMed

Shiga, Takuya; Shiraishi, Yasuyuki; Sano, Kyosuke; Taira, Yasunori; Tsuboko, Yusuke; Yamada, Akihiro; Miura, Hidekazu; Katahira, Shintaro; Akiyama, Masatoshi; Saiki, Yoshikatsu; Yambe, Tomoyuki

2016-03-01

Implantation of a total artificial heart (TAH) is one of the therapeutic options for the treatment of patients with end-stage biventricular heart failure. There is no report on the hemodynamics of the functional centrifugal-flow TAH with functional atrial contraction (fCFTAH). We evaluated the effects of pulsatile flow by atrial contraction in acute animal models. The goats received fCFTAH that we created from two centrifugal-flow ventricular assist devices. Some hemodynamic parameters maintained acceptable levels: heart rate 115.5 ± 26.3 bpm, aortic pressure 83.5 ± 10.1 mmHg, left atrial pressure 18.0 ± 5.9 mmHg, pulmonary pressure 28.5 ± 9.7 mmHg, right atrial pressure 13.6 ± 5.2 mmHg, pump flow 4.0 ± 1.1 L/min (left) 3.9 ± 1.1 L/min (right), and cardiac index 2.13 ± 0.14 L/min/m(2). fCFTAH with atrial contraction was able to maintain the TAH circulation by forming a pulsatile flow in acute animal experiments. Taking the left and right flow rate balance using the low internal pressure loss of the VAD pumps may be easier than by other pumps having considerable internal pressure loss. We showed that the remnant atrial contraction effected the flow rate change of the centrifugal pump, and the atrial contraction waves reflected the heart rate. These results indicate that remnant atria had the possibility to preserve autonomic function in fCFTAH. We may control fCFTAH by reflecting the autonomic function, which is estimated with the flow rate change of the centrifugal pump.

Left atrial appendage function in prediction of paroxysmal atrial fibrilation in patients with untreated hypertension.

PubMed

Tenekecioglu, Erhan; Agca, Fahriye Vatansever; Karaagac, Kemal; Ozluk, Ozlem Arican; Peker, Tezcan; Kuzeytemiz, Mustafa; Senturk, Muhammed; Yılmaz, Mustafa

2014-01-01

Abstract The onset of AF results in a significant increase in mortality rates and morbidity in hypertensive patients and this rhythm disorder exposes patients to a significantly increased risk of cerebral or peripheral embolisms. Tissue Doppler imaging was found to be useful in early detection of myocardial dysfunction in several diseases. It was shown that tissue Doppler analysis of the walls of the left atrial appendage (LAA) can give accurate information about the function of the LAA in hypertensive patients. In this study, we aimed to investigate and identify the specific predictive parameters for the onset of AF in patients with hypertension with tissue Doppler imaging of LAA. We studied age and sex matched 57 untreated hypertensive patients with paroxysmal atrial fibrillation (PAF) and 27 untreated hypertensive subjects without PAF. With transthoracic echocardiography, diastolic mitral A-velocity and LA maximal volume index which reflects reservoir function of left atrium was measured, with transesophageal echocardiography, LAA emptying velocity (LAA-PW D2) and tissue Doppler contracting velocity of LAA (LAA-TDI-D2) were measured. LA maximal volume index of the groups (22.28 ± 3.59 mL/m(2) in Group 1 versus 20.37 ± 3.97 mL/m(2) in Group 2, p = 0.07) and diastolic mitral A-velocity [0.93 (0.59-1.84) m/s in patients with PAF versus 0.90 (0.62-1.76) m/s in patients without PAF, p = 0.26] was not significantly different between study groups, during TEE, LAA-PW D2 (0.31 ± 0.04 m/s in Group 1 versus 0.33 ± 0.03 m/s in Group 2, p = 0.034) and LAA-TDI-D2 (0.18 ± 0.04 m/s in Group 1 versus 0.21 ± 0.05 m/s in Group 2, p = 0.014) were significantly decreased in Group 1. In this study, we found that in hypertensive PAF patients despite normal global LA functions, LAA contracting function was deteriorated. Tissue Doppler analysis of LAA is clinically usefull approach to detect the risk of developing PAF in hypertensives.

ASSESSMENT OF DIASTOLIC DYSFUNCTION, ARTERIAL STIFFNESS, AND CAROTID INTIMA-MEDIA THICKNESS IN PATIENTS WITH ACROMEGALY.

PubMed

Cansu, Güven Barış; Yılmaz, Nusret; Yanıkoğlu, Atakan; Özdem, Sebahat; Yıldırım, Aytül Belgi; Süleymanlar, Gültekin; Altunbaş, Hasan Ali

2017-05-01

Early diagnosis and treatment of cardiovascular diseases, the most frequent cause of morbidity and mortality in acromegaly, may be an efficient approach to extending the lifespan of affected patients. Therefore, it is crucial to determine any cardiovascular diseases in the subclinical period. The study objectives were to determine markers of subclinical atherosclerosis and asses heart structure and function. This was a cross-sectional, single-center study of 53 patients with acromegaly and 22 age- and sex-matched healthy individuals. Carotid intima-media thickness (CIMT), pulse-wave velocity (PWV), and echocardiographic data were compared between these groups. CIMT and PWV were higher in the acromegaly group than in the healthy group (P = .008 and P = .002, respectively). Echocardiography showed that left ventricular diastolic dysfunction was present in 11.3% of patients. Left ventricular mass index and left atrial volume index were higher in the patients (P = .016 and P<.001, respectively). No differences in the CIMT, PWV, or echocardiographic measurements were identified between the patients with biochemically controlled and uncontrolled acromegaly and the control group. Our results showed that subclinical atherosclerosis (i.e., CIMT and PWV markers) and heart structure and function were worse in patients with acromegaly than in healthy individuals. Because there were no differences in these parameters between patients with controlled and uncontrolled acromegaly, our results suggest that the structural and functional changes do not reverse with biochemical control. AA = active acromegaly BSA = body surface area CA = biochemically controlled acromegaly CH = concentric hypertrophy CIMT = carotid intima-media thickness DBP = diastolic blood pressure DM = diabetes mellitus ECHO = echocardiography EDV = enddiastolic volume EF = ejection fraction ESV = endsystolic volume GH = growth hormone HC = healthy control HL = hyperlipidemia HT = hypertension IGF-1 = insulin-like growth factor 1 LA = left atrial LAV = left atrial volume LAVI = left atrial volume index LV = left ventricular LVDD = left ventricular diastolic dysfunction LVEF = left ventricular ejection fraction LVH = left ventricular hypertrophy LVMI = left ventricular mass index PWV = pulse-wave velocity RWT = relative wall thickness.

Functional Tricuspid Regurgitation Caused by Chronic Atrial Fibrillation: A Real-Time 3-Dimensional Transesophageal Echocardiography Study.

PubMed

Utsunomiya, Hiroto; Itabashi, Yuji; Mihara, Hirotsugu; Berdejo, Javier; Kobayashi, Sayuki; Siegel, Robert J; Shiota, Takahiro

2017-01-01

Functional tricuspid regurgitation (TR) with a structurally normal tricuspid valve (TV) may occur secondary to chronic atrial fibrillation (AF). However, the clinical and echocardiographic differences according to functional TR subtypes are unclear. Therefore, characterization of functional TR because of chronic AF (AF-TR) remains undetermined. To investigate the prevalence of AF-TR, 437 patients with moderate to severe TR underwent 3-dimensional (3D) transesophageal echocardiography. TR severity was determined by the averaged vena contracta width on apical and parasternal inflow views. The prevalence of AF-TR was 9.2%, whereas that of functional TR because of left-sided heart disease was 45.3%. Clinical features of AF-TR included advanced age, female sex, greater right atrial than left atrial enlargement and lower systolic pulmonary artery pressure compared with left-sided heart disease-TR with sinus rhythm (all P<0.05). In 3D TV assessment, patients with AF-TR had a larger TV annular area with weaker annular contraction (both P<0.001) but a smaller tethering angle (P<0.001) despite a similar leaflet coaptation status compared with patients with left-sided heart disease-TR with sinus rhythm. On multivariable analysis, only the TV annular area in midsystole (coefficient, 0.059; 95% confidence interval, 0.041-0.078 per 100 mm 2 ; P<0.001) was associated with TR severity in AF-TR. The annular area was more closely correlated with the right atrial volume than right ventricular end-systolic volume in AF-TR (P<0.001). AF-TR is not rare and is associated with advanced age and right atrial enlargement. TV deformations and their association with right heart remodeling differ between AF-TR and left-sided heart disease-TR. Our results suggest that in patients with TR secondary to AF, TV annuloplasty should be effective because this entity has annular dilatation without leaflet deformation. © 2017 American Heart Association, Inc.

Trends in hospitalization for atrial fibrillation: epidemiology, cost, and implications for the future.

PubMed

Sheikh, Azfar; Patel, Nileshkumar J; Nalluri, Nikhil; Agnihotri, Kanishk; Spagnola, Jonathan; Patel, Aashay; Asti, Deepak; Kanotra, Ritesh; Khan, Hafiz; Savani, Chirag; Arora, Shilpkumar; Patel, Nilay; Thakkar, Badal; Patel, Neil; Pau, Dhaval; Badheka, Apurva O; Deshmukh, Abhishek; Kowalski, Marcin; Viles-Gonzalez, Juan; Paydak, Hakan

2015-01-01

Atrial fibrillation (AF) is the most prevalent arrhythmia worldwide and the most common arrhythmia leading to hospitalization. Due to a substantial increase in incidence and prevalence of AF over the past few decades, it attributes to an extensive economic and public health burden. The increasing number of hospitalizations, aging population, anticoagulation management, and increasing trend for disposition to a skilled facility are drivers of the increasing cost associated with AF. There has been significant progress in AF management with the release of new oral anticoagulants, use of left atrial catheter ablation, and novel techniques for left atrial appendage closure. In this article, we aim to review the trends in epidemiology, hospitalization, and cost of AF along with its future implications on public health. Published by Elsevier Inc.

"Crosstalk" technique: A comparison between two generations of cryoballoon catheter.

PubMed

Yang, Jian-du; Sun, Qi; Guo, Xiao-Gang; Zhou, Gong-Bu; Liu, Xu; Luo, Bin; Wei, Hui-Qiang; Liang, Jackson J; Ma, Jian

2018-03-30

The "Crosstalk" technique: if pulmonary vein isolation (PVI) of the superior one is not achieved due to a gap in the inferior part, it could be done during inferior vein cryoablation. This maneuver minimizes the total energy delivery time and number of lesions. We aimed to correlate the likelihood of crosstalk phenomenon with certain anatomic characteristics. A total of 676 patients undergoing a first ablation procedure for paroxysmal or persistent atrial fibrillation (470 first-generation cryoballoon [CB] and 206 second-generation CB) between June 2014 and December 2016 were included. "Crosstalk" phenomenon occurred in 32 patients (18 first-generation CB, 14 second-generation CB). Compared to 54 control patients without crosstalk, the angle between left superior pulmonary vein (LSPV) and left atrial (LA) roof-plane, left pulmonary common ostia were significant parameters associated with crosstalk (odds ratio [OR] = 1.20, ±95% confidence interval [CI]: 1.11-1.31, P < 0.001; OR = 5.67, ±95% CI: 1.08-28.69, P = 0.04). As for angle between LSPV and LA roof-plane, the cut-off value was 28.68° with a sensitivity of 72.22%, a specificity of 81.25%, and an area under the receiver operating characteristic curve of 0.87 to predict the possibility of crosstalk technique application to get isolated in LSPV. Among the crosstalk group, there was no statistical difference between first-generation CB and second-generation CB in pulmonary anatomic characteristics. Crosstalk technique can be effective in patients with AF undergoing CB ablation using with both first and second-generation CBs. Anatomic characteristics predictive of crosstalk include a left common ostia and smaller angle between the LSPV and LA roof-plane. © 2018 Wiley Periodicals, Inc.

Hybrid Therapy in the Management of Atrial Fibrillation

PubMed Central

Stárek, Zdeněk; Lehar, František; Jež, Jiří; Wolf, Jiří; Novák, Miroslav

2015-01-01

Atrial fibrillation is the most common sustained arrhythmia. Because of the sub-optimal outcomes and associated risks of medical therapy as well as the recent advances in non-pharmacologic strategies, a multitude of combined (hybrid) algorithms have been introduced that improve efficacy of standalone therapies while maintaining a high safety profile. Antiarrhythmic administration enhances success rate of electrical cardioversion. Catheter ablation of antiarrhythmic drug-induced typical atrial flutter may prevent recurrent atrial fibrillation. Through simple ablation in the right atrium, suppression of atrial fibrillation may be achieved in patients with previously ineffective antiarrhythmic therapy. Efficacy of complex catheter ablation in the left atrium is improved with antiarrhythmic drugs. Catheter ablation followed by permanent pacemaker implantation is an effective and safe treatment option for selected patients. Additional strategies include pacing therapies such as atrial pacing with permanent pacemakers, preventive pacing algorithms, and/or implantable dual-chamber defibrillators are available. Modern hybrid strategies combining both epicardial and endocardial approaches in order to create a complex set of radiofrequency lesions in the left atrium have demonstrated a high rate of success and warrant further research. Hybrid therapy for atrial fibrillation reviews history of development of non-pharmacological treatment strategies and outlines avenues of ongoing research in this field. PMID:25028165

Atrial Function in Patients with Breast Cancer After Treatment with Anthracyclines.

PubMed

Yaylali, Yalin Tolga; Saricopur, Ahmet; Yurtdas, Mustafa; Senol, Hande; Gokoz-Dogu, Gamze

2016-11-01

Atrial electromechanical delay (EMD) is used to predict atrial fibrillation, measured by echocardiography. The aim of this study was to assess atrial EMD and mechanical function after anthracycline-containing chemotherapy. Fifty-three patients with breast cancer (48 ± 8 years old) who received 240 mg/m2of Adriamycin, 2400 mg/m2 of cyclophosphamide, and 960 mg/m2 of paclitaxel were included in this retrospective study, as were 42 healthy subjects (47 ± 9 years old). Echocardiographic measurements were performed 11 ± 7 months (median 9 months) after treatment with anthracyclines. Left intra-atrial EMD (11.4 ± 6.0 vs. 8.1 ± 4.9, p=0.008) and inter-atrial EMD (19.7 ± 7.4 vs. 14.7 ± 6.5, p=0.001) were prolonged; LA passive emptying volume and fraction were decreased (p=0.0001 and p=0.0001); LA active emptying volume and fraction were increased (p=0.0001 and p=0.0001); Mitral A velocity (0.8 ± 0.2 vs. 0.6 ± 0.2, p=0.0001) and mitral E-wave deceleration time (201.2 ± 35.6 vs. 163.7 ± 21.8, p=0.0001) were increased; Mitral E/A ratio (1.0 ± 0.3 vs. 1.3 ± 0.3, p=0.0001) and mitral Em (0.09 ± 0.03 vs. 0.11 ± 0.03, p=0.001) were decreased; Mitral Am (0.11 ± 0.02 vs. 0.09 ± 0.02, p=0.0001) and mitral E/Em ratio (8.8 ± 3.2 vs. 7.6 ± 2.6, p=0.017) were increased in the patients. In patients with breast cancer after anthracycline therapy: Left intra-atrial, inter-atrial electromechanical intervals were prolonged. Diastolic function was impaired. Impaired left ventricular relaxation and left atrial electrical conduction could be contributing to the development of atrial arrhythmias. Atraso eletromecânico atrial (AEA) é utilizado para prever fibrilação atrial, medido pela ecocardiografia. O propósito deste estudo era verificar o AEA e a função mecânica após quimioterapia com antraciclinas. Cinquenta e três pacientes com câncer de mama (48 ± 8 anos) que receberam 240 mg/m2 de adriamicina, 2400 mg/m2 de ciclofosfamida, e 960 mg/m2 de paclitaxel foram incluídas neste estudo retrospectivo, além de 42 indivíduos saudáveis (47 ± 9 anos). Medidas ecocardiográficas foram realizadas por aproximadamente 11 ± 7 meses (média de 9 meses) após tratamento com antraciclinas. AEA esquerdo intra-atrial (11,4 ± 6,0 vs. 8,1 ± 4,9, p=0,008) e AEA interarterial (19,7 ± 7,4 vs. 14,7 ± 6,5, p=0,001) foram prolongados; Volume de esvaziamento passivo e fracionamento de AE diminuíram (p=0,0001 e p=0,0001); Volume de esvaziamento ativo e fracionamento de AE (p=0,0001 e p=0,0001); Tempo de aceleração mitral A (0,8 ± 0,2 vs. 0,6 ± 0,2, p=0,0001) e de desaceleração de onda-E mitral (201,2 ± 35,6 vs. 163,7 ± 21,8, p=0,0001) aumentarão; Razão mitral E/A (1,0 ± 0,3 vs. 1,3 ± 0,3, p=0,0001) e mitral Em (0,09 ± 0,03 vs. 0,11 ± 0,03, p=0,001) diminuíram; Razão mitral Am (0,11 ± 0,02 vs. 0,09 ± 0,02, p=0,0001) e mitral E/Em (8,8 ± 3,2 vs. 7,6 ± 2,6, p=0,017) aumentaram nos pacientes. Em pacientes com câncer de mama após terapia com antraciclina: intervalos eletromecânicos intra-atriais esquerdos, intra-atriais foram prolongados. A função diastólica foi prejudicada. O relaxamento ventricular esquerdo foi prejudicado, e a condução elétrica atrial esquerda pode estar contribuindo para o desenvolvimento de arritmias atriais.

Phosphatidylserine-exposing blood cells and microparticles induce procoagulant activity in non-valvular atrial fibrillation.

PubMed

Wang, Lixiu; Bi, Yayan; Yu, Muxin; Li, Tao; Tong, Dongxia; Yang, Xiaoyan; Zhang, Cong; Guo, Li; Wang, Chunxu; Kou, Yan; Dong, Zengxiang; Novakovic, Valerie A; Tian, Ye; Kou, Junjie; Shammas, Masood A; Shi, Jialan

2018-05-01

The definitive role of phosphatidylserine (PS) in the prothrombotic state of non-valvular atrial fibrillation (NVAF) remains unclear. Our objectives were to study the PS exposure on blood cells and microparticles (MPs) in NVAF, and evaluate their procoagulant activity (PCA). NVAF patients without (n = 60) and with left atrial thrombi (n = 18) and controls (n = 36) were included in our study. Exposed PS was analyzed with flow cytometry and confocal microscopy. PCA was evaluated using clotting time, factor Xa (FXa), thrombin and fibrin formation. PS + blood cells and MPs were significantly higher in NVAF patients without and with left atrial thrombi (both P < 0.01) than in controls. Patients with left atrial thrombi showed increased PS + platelets, neutrophils, erythrocytes and MPs compared with patients without thrombi (all P < 0.05). Moreover, in patients with left atrial thrombi, MPs primarily originated from platelets (56.1%) followed by leukocytes (21.9%, including MPs from neutrophils, monocytes and lymphocytes), erythrocytes (12.2%) and endothelial cells (8.9%). Additionally, PS + blood cells and MPs contributed to markedly shortened coagulation time and dramatically increased FXa/thrombin/fibrin (all P < 0.001) generation in both NVAF groups. Furthermore, blockade of exposed PS on blood cells and MPs with lactadherin inhibited PCA by approximately 80%. Lastly, we found that the amount of PS + platelets and MPs was positively correlated with thrombus diameter (all p < 0.005). Our results suggest that exposed PS on blood cells and MPs play a procoagulant role in NVAF patients. Blockade of PS prior to thrombus formation might be a novel therapeutic approach in these patients. Copyright © 2018 Elsevier B.V. All rights reserved.

[Hyperthyroidism, eosinophilia, and fever in a 64-year-old patient].

PubMed

Tack, C; Stierle, U; Heydrich, D; Petersohn, S; Sievers, H H; Feller, A C; Schneider, B

2012-10-01

We report on a male patient suffering from loss of weight, fatigue, fever, eosinophilia, and hyperthyreoidism. The echocardiogram revealed a left atrial mass originating from the posterior mitral leaflet. In combination with the constitutional symptoms a left atrial myxoma was diagnosed. The tumor was surgically removed. Postoperatively therapy with corticosteroids and thiamazole was stopped. During follow-up, eosinophilia and hyperthyreodism could no longer be detected.

Percutaneous left atrial appendage occlusion – treatment outcomes and 6 months of follow-up – a single-center experience

PubMed Central

Karczewski, Michał; Skowronek, Radomir; Burysz, Marian; Fischer, Marcin; Anisimowicz, Lech; Demkow, Marcin; Konka, Marek; Ogorzeja, Wojciech

2016-01-01

Aim To present the results of treatment and evaluate 6 months of follow-up in a group of patients with non-valvular atrial fibrillation, who underwent the procedure of percutaneous left atrial appendage occlusion (PLAAO). Material and methods Percutaneous left atrial appendage occlusion was performed in 34 patients with non-valvular atrial fibrillation and contraindications for oral anticoagulation therapy. The risk of thromboembolic and bleeding complications was determined based on the CHA2DS2VASc and HAS-BLED scales. The Amplatzer Amulet system from St. Jude Medical was used. On the first postoperative day, all patients were started on double antiplatelet therapy with 75 mg/day of acetylsalicylic acid (ASA) and 75 mg/day of clopidogrel (CLO). On the 30th postoperative day, the efficacy of the antiplatelet therapy was assessed with impedance aggregometry using a Multiplate analyzer (Roche). Echocardiographic examinations were performed intraoperatively and on the first postoperative day; subsequently, follow-up examinations were conducted 1 and 6 months after the implantation. Results In all patients, proper occluder position was observed throughout the follow-up. No leakage or thrombi around the implants were found. No strokes or bleeding complications associated with the antiplatelet therapy were observed. Multiplate assessment of platelet activity was conducted in 20 out of 34 patients. The efficacy of ASA treatment was demonstrated in all patients; no response to clopidogrel treatment was observed in 5 out of 20 patients. One patient suffered from cardiac tamponade, which required the performance of full sternotomy. Local complications (hematomas of the inguinal region) were observed in 3 patients. One of the patients died for reasons unrelated to the procedure. Conclusions Percutaneous left atrial appendage occlusion is an effective procedure in patients with non-valvular atrial fibrillation and contraindications for chronic anticoagulation therapy. Further observation is necessary to evaluate the longterm results. PMID:27516780

A Study on Cerebral Embolism in Mitral Stenosis

PubMed Central

Kwon, Osun; Kim, Myung Hwan; Kim, Kwon Sam; Bae, Jong Hoa; Kim, Myung Shick; Song, Jung Sang

1986-01-01

To evaluate the significance of episodes of cerebral embolism in patients with mitral valve disease in Korea, 128 patients with echocardiographic diagnosis of mitral valve disease were examined. Among these, 82 patients had predominant mitral stenosis. The clinical features of 82 patients with mitral stenosis have been reviewed to elucidate the factors favoring cerebral embolism which occurred in 19 patients, i.e., incidence of 23.2%.Atrial fibrillation was present in 16 of 19 patients with cerebral embolism (84.2%). Cerebral embolic episodes occurred in 16 of 47 patients with atrial fibrillation (34.0%).The mean age (55.3 ± 12.1 years) of patients without cerebral embolism was significantly older than that (43.2 ± 14.6 years) of patients without cerebral embolism (P<0.005).There was no significant relationship between the incidence of embolism and sex, left atrial thrombi, left atrium/aortic root diameter, mitral valvular orifice area, mitral valvular vegetation or calcification, left ventricular enddiastolic dimension or left ventricular posterior wall thickness. Cerebral embolism is common in patients with mitral stenosis in our country. The presence of atrial fibrillation and low cardiac output increase the attack of cerebral emboli whereas the severity of mitral stenosis, as judged by valve area, may not correlate with the occurrence of emboli. The best treatment for cerebral embolism is prevention. Therefore, we believe that more vigorous treatment of patients with mitral valve disease who are old or associated with atrial fibrillation as well as previous embolic history is indicated. PMID:15759378

Bayés syndrome and acute cardioembolic ischemic stroke.

PubMed

Arboix, Adrià; Martí, Lucía; Dorison, Sebastien; Sánchez, María José

2017-03-16

Bayés syndrome is an under-recognized clinical condition characterized by advanced interatrial block. Bayés syndrome is a subclinical disease that manifests electrocardiographically as a prolonged P wave duration > 120 ms with biphasic morphology ± in the inferior leads. The clinical relevance of Bayés syndrome lies in the fact that is a clear arrhythmological syndrome and has a strong association with supraventricular arrhythmias, particularly atypical atrial flutter and atrial fibrillation. Likewise, Bayés syndrome has been recently identified as a novel risk factor for non-lacunar cardioembolic ischemic stroke and vascular dementia. Advanced interatrial block can be a risk for embolic stroke due to its known sequelae of left atrial dilation, left atrial electromechanical dysfunction or atrial tachyarrhythmia (paroxysmal or persistent atrial fibrillation), conditions predisposing to thromboembolism. Bayés syndrome may be responsible for some of the unexplained ischemic strokes and shall be considered and investigated as a possible cause for cryptogenetic stroke. In summary, Bayés syndrome is a poorly recognized cardiac rhythm disorder with important cardiologic and neurologic implications.

Usefulness of the brain natriuretic peptide to atrial natriuretic peptide ratio in determining the severity of mitral regurgitation.

PubMed

Shimamoto, Ken; Kusumoto, Miyako; Sakai, Rieko; Watanabe, Hirota; Ihara, Syunichi; Koike, Natsuka; Kawana, Masatoshi

2007-03-15

Atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) levels were characterized in subjects with mitral regurgitation (MR). Sixty-two cases of moderate or severe chronic MR were studied. The blood levels of neurohormonal factors were stratified by the known MR prognostic factors of New York Heart Association (NYHA) functional class, left ventricular end-diastolic diameters, left ventricular end-systolic diameter (LVDs), ejection fraction (EF), left atrial diameter and presence of atrial fibrillation (AF). ANP levels were higher in NYHA class II and lower in classes I and III/IV (P=0.0206). BNP levels were higher in NYHA class II than class I (P=0.0355). The BNP/ANP ratio was significantly higher in NYHA classes II and III/IV than in class I (P=0.0007). To differentiate between NYHA classes I/II and III/IV, a cut-off BNP/ANP ratio of 2.97 produced a sensitivity of 78% and specificity of 87%. Compared with subjects in sinus rhythm, patients with AF had an enlarged left atrium and lower ANP levels. The BNP/ANP ratio correlated significantly with left atrial diameter, LVDs and EF (r=0.429, P=0.0017; r=0.351, P=0.0117; and r=-0.349, P=0.0122; respectively), and was significantly higher among all the known operative indications for MR tested (LVDs 45 mm or more, EF 60% or less, NYHA class II or greater and AF; P=0.0073, P=0.003, P=0.0102 and P=0.0149, respectively). In chronic MR, levels of ANP and BNP, and the BNP/ANP ratio are potential indicators of disease severity.

Percutaneous transvenous mitral commissurotomy in mitral stenosis and left atrial appendage clot patients in special conditions: Hospital-based study.

PubMed

Rajbhandari, Rajib; Malla, Rabi; Maskey, Arun; Bhatta, Yadav; Limbu, Yubraj; Sharma, Ranjit; Singh, Satish; Adhikari, Chandramani; Mishra, Sundeep

The percutaneous transvenous mitral commissurotomy is an important procedure for the treatment of mitral stenosis. A lot of mitral stenosis cases have left atrial appendage clot which precludes the patient from the benefit of this procedure. The aim of the study was to study the feasibility and safety of the procedure in a patient with appendage clot in the setup of certain urgent conditions. All cases of mitral stenosis with significant dyspnea and mitral valve area <1.5cm 2 with left atrial appendage clot and a condition which would preclude the patient from continuing on anticoagulation and needed urgent intervention were included in the study. From January 2011 to December 2013, twenty patients coming to Shahid Gangalal National Heart Centre, Kathmandu were selected for the procedure with conventional sampling technique. Informed written consent was obtained from the patients explaining all possible complications. The approval of the study was taken from the ethical committee of the hospital. Mean mitral valve area increased from 0.90cm 2 (SD±0.14) to 1.5cm 2 (SD±0.21) (p=0.02). Left atrial mean pressure decreased from mean of 20 to 10mmHg. Subjective improvement was reported in all. All of the patients had fulfilled criteria for successful PTMC. There was no mortality during hospital stay or in one-week follow-up period. There were no neurological complications or any need for emergency surgery. The immediate result of percutaneous transvenous mitral commissurotomy in selected cases of mitral stenosis with left atrial appendage clot is safe and acceptable in certain urgent situations in experienced hands. Copyright © 2016. Published by Elsevier B.V.

Gigantic Thrombus of the Left Atrium in Mitral Stenosis

PubMed Central

Hodzic, Enisa; Granov, Nermir

2017-01-01

Introduction Excess dilatation of the left atrium >65 mm is known in the literature as gigantic atrium. This dilation is most commonly encountered in the mitral insufficiency of rheumatic etiology, but also in severe prolapses of the mitral valve, permanent atrial fibrillation, and at the left right shunt with cardiac insufficiency. Case report In this paper is presented a case study of echocardiographically verified giant thrombus in left atrium in a 50 years old female patient aged 50 hospitalized because of tiredness, choking, heartburn and urinary tract symptoms. The patient had rheumatic fever at age of 18 years. At age of 35, she was diagnosed with mitral stenosis. In permanent atrial fibrillation with anamnestic data on the previous cerebrovascular stroke (CVI) and the repeated transitional ischemic seizures. Echocardiographic examination confirmed severe mitral stenosis with moderate aortic insufficiency and gigantic left atrium (LA) with gigantic thrombus. Invasive diagnostics were indicated and performed, followed by an acute cardiac surgery including left atrial thrombectomy and implantation of the mechanical aortic and mitral valve. The surgical course was without complications. Conclusion On eleven postoperative day, after mobilization, the patient experiences stroke with motor aphasia. She was clinically recovering from stroke consequences, and remains cardiollogically stable. PMID:29416208

Conventional versus 3-D Echocardiography to Predict Arrhythmia Recurrence After Atrial Fibrillation Ablation.

PubMed

Bossard, Matthias; Knecht, Sven; Aeschbacher, Stefanie; Buechel, Ronny R; Hochgruber, Thomas; Zimmermann, Andreas J; Kessel-Schaefer, Arnheid; Stephan, Frank-Peter; Völlmin, Gian; Pradella, Maurice; Sticherling, Christian; Osswald, Stefan; Kaufmann, Beat A; Conen, David; Kühne, Michael

2017-06-01

Arrhythmia recurrence after atrial fibrillation (AF) ablation remains high and requires repeat interventions in a substantial number of patients. We assessed the value of conventional and 3-D echocardiography to predict AF recurrence. Consecutive patients undergoing AF ablation by means of pulmonary vein isolation were included in a prospective registry. Echocardiograms were obtained prior to the ablation procedure, and analyzed offline in a standardized manner, including 3-D left atrial (LA) volumetry and determination of LA function and sphericity. The primary endpoint, AF recurrence (>30 seconds) between 3 to 12 months after AF ablation, was independently adjudicated. We included 276 patients (73% male, mean age 59.9 ± 9.9 years). Paroxysmal and persistent AF were present in 178 (64%) and 98 (36%) patients, respectively. Mean left ventricular ejection fraction and indexed LA volume in 3-D (LAVI) were 52 ± 12% and 42 ± 13 mL/m 2 , respectively. AF recurrence was observed in 110 (40%) patients after a single procedure. Median (interquartile range) time to AF recurrence was 123 (92; 236) days. In multivariable Cox regression models, the only predictors for AF recurrence were the minimal, maximal, and indexed 3-D LA volumes, P = 0.024, P = 0.016, and P = 0.014, respectively. Quartile specific analysis of 3-D LAVI showed an HR of 1.885 (95%CI 1.066-3.334; P for trend = 0.015) for the highest compared to the lowest quartile. Our results show the important role of LA volume for the long-term freedom from arrhythmia after AF ablation. These data also highlight the potential of 3-D echocardiography in this context and may facilitate patient selection for AF ablation. © 2017 Wiley Periodicals, Inc.

Autosomal recessive atrial dilated cardiomyopathy with standstill evolution associated with mutation of Natriuretic Peptide Precursor A.

PubMed

Disertori, Marcello; Quintarelli, Silvia; Grasso, Maurizia; Pilotto, Andrea; Narula, Nupoor; Favalli, Valentina; Canclini, Camilla; Diegoli, Marta; Mazzola, Silvia; Marini, Massimiliano; Del Greco, Maurizio; Bonmassari, Roberto; Masè, Michela; Ravelli, Flavia; Specchia, Claudia; Arbustini, Eloisa

2013-02-01

Atrial dilatation and atrial standstill are etiologically heterogeneous phenotypes with poorly defined nosology. In 1983, we described 8-years follow-up of atrial dilatation with standstill evolution in 8 patients from 3 families. We later identified 5 additional patients with identical phenotypes: 1 member of the largest original family and 4 unrelated to the 3 original families. All families are from the same geographic area in Northeast Italy. We followed up the 13 patients for up to 37 years, extended the clinical investigation and monitoring to living relatives, and investigated the genetic basis of the disease. The disease was characterized by: (1) clinical onset in adulthood; (2) biatrial dilatation up to giant size; (3) early supraventricular arrhythmias with progressive loss of atrial electric activity to atrial standstill; (4) thromboembolic complications; and (5) stable, normal left ventricular function and New York Heart Association functional class during the long-term course of the disease. By linkage analysis, we mapped a locus at 1p36.22 containing the Natriuretic Peptide Precursor A gene. By sequencing Natriuretic Peptide Precursor A, we identified a homozygous missense mutation (p.Arg150Gln) in all living affected individuals of the 6 families. All patients showed low serum levels of atrial natriuretic peptide. Heterozygous mutation carriers were healthy and demonstrated normal levels of atrial natriuretic peptide. Autosomal recessive atrial dilated cardiomyopathy is a rare disease associated with homozygous mutation of the Natriuretic Peptide Precursor A gene and characterized by extreme atrial dilatation with standstill evolution, thromboembolic risk, preserved left ventricular function, and severely decreased levels of atrial natriuretic peptide.

ANMCO/AIAC/SICI-GISE/SIC/SICCH Consensus Document: percutaneous occlusion of the left atrial appendage in non-valvular atrial fibrillation patients: indications, patient selection, staff skills, organisation, and training

PubMed Central

Gulizia, Michele Massimo; Molon, Giulio; Mazzone, Patrizio; Audo, Andrea; Casolo, Giancarlo; Di Lorenzo, Emilio; Portoghese, Michele; Pristipino, Christian; Ricci, Renato Pietro; Themistoclakis, Sakis; Padeletti, Luigi; Tondo, Claudio; Berti, Sergio; Oreglia, Jacopo Andrea; Gerosa, Gino; Zanobini, Marco; Ussia, Gian Paolo; Musumeci, Giuseppe; Romeo, Francesco; Di Bartolomeo, Roberto

2017-01-01

Abstract Atrial fibrillation (AF) is the most common arrhythmia and its prevalence is increasing due to the progressive aging of the population. About 20% of strokes are attributable to AF and AF patients are at five-fold increased risk of stroke. The mainstay of treatment of AF is the prevention of thromboembolic complications with oral anticoagulation therapy. Drug treatment for many years has been based on the use of vitamin K antagonists, but recently newer and safer molecules have been introduced (dabigatran etexilate, rivaroxaban, apixaban, and edoxaban). Despite these advances, many patients still do not receive adequate anticoagulation therapy because of contraindications (relative and absolute) to this treatment. Over the last decade, percutaneous closure of left atrial appendage, main site of thrombus formation during AF, proved effective in reducing thromboembolic complications, thus offering a valid medical treatment especially in patients at increased bleeding risk. The aim of this consensus document is to review the main aspects of left atrial appendage occlusion (selection and multidisciplinary assessment of patients, currently available methods and devices, requirements for centres and operators, associated therapies and follow-up modalities) having as a ground the significant evolution of techniques and the available relevant clinical data. PMID:28751849

The double switch for atrioventricular discordance.

PubMed

Brawn, William J

2005-01-01

Conventional surgery for atrioventricular discordance usually associated with ventricular arterial discordance leaves the morphologic right ventricle in the systemic circulation. Long-term follow-up results with this approach reveal a high incidence of right ventricular failure. The double switch procedure was introduced to restore the morphologic left ventricle to the systemic circulation. This operation is performed in two main ways: the atrial-arterial switch and the atrial switch plus Rastelli procedure. This double switch approach has been successful at least in the medium term in abolishing morphologic right ventricular failure and its associated tricuspid valve regurgitation. In the atrial-arterial switch group, there is an incidence of morphologic left ventricular dysfunction, sometimes associated with neoaortic valve regurgitation, and the minority of cases need aortic valve replacement. The long-term function of the morphologic left ventricle and the aortic valve need careful surveillance in the future. The atrial-Rastelli group of patients has not in the medium term shown evidence of ventricular dysfunction but will require change on a regular basis of their ventricular to pulmonary artery valved conduits.

Atrial Model Development and Prototype Simulations: CRADA Final Report on Tasks 3 and 4

DOE Office of Scientific and Technical Information (OSTI.GOV)

O'Hara, T.; Zhang, X.; Villongco, C.

2016-10-28

The goal of this CRADA was to develop essential tools needed to simulate human atrial electrophysiology in 3-dimensions using an anatomical image-based anatomy and physiologically detailed human cellular model. The atria were modeled as anisotropic, representing the preferentially longitudinal electrical coupling between myocytes. Across the entire anatomy, cellular electrophysiology was heterogeneous, with left and right atrial myocytes defined differently. Left and right cell types for the “control” case of sinus rhythm (SR) was compared with remodeled electrophysiology and calcium cycling characteristics of chronic atrial fibrillation (cAF). The effects of Isoproterenol (ISO), a beta-adrenergic agonist that represents the functional consequences ofmore » PKA phosphorylation of various ion channels and transporters, was also simulated in SR and cAF to represent atrial activity under physical or emotional stress. Results and findings from Tasks 3 & 4 are described. Tasks 3 and 4 are, respectively: Input parameters prepared for a Cardioid simulation; Report including recommendations for additional scenario development and post-processing analytic strategy.« less

Circulating microRNA-1a is a biomarker of Graves' disease patients with atrial fibrillation.

PubMed

Wang, Fang; Zhang, Sheng-Jie; Yao, Xuan; Tian, Dong-Mei; Zhang, Ke-Qin; She, Dun-Min; Guo, Fei-Fan; Zhai, Qi-Wei; Ying, Hao; Xue, Ying

2017-07-01

It has been increasingly suggested that specific microRNAs expression profiles in the circulation and atrial tissue are associated with the susceptibility to atrial fibrillation. Nonetheless, the role of circulating microRNAs in Graves' disease patients with atrial fibrillation has not yet been well described. The objective of the study was to identify the role of circulating microRNAs as specific biomarkers for the diagnosis of Graves' disease with atrial fibrillation. The expression profiles of eight serum microRNAs, which are found to be critical in the pathogenesis of atrial fibrillation, were determined in patients with Graves' disease with or without atrial fibrillation. MicroRNA expression analysis was performed by real-time PCR in normal control subjects (NC; n = 17), patients with Graves' disease without atrial fibrillation (GD; n = 29), patients with Graves' disease with atrial fibrillation (GD + AF; n = 14), and euthyroid patients with atrial fibrillation (AF; n = 22). Three of the eight serum microRNAs,i.e., miR-1a, miR-26a, and miR-133, had significantly different expression profiles among the four groups. Spearman's correlation analysis showed that the relative expression level of miR-1a was positively correlated with free triiodothyronine (FT3) and free thyroxine (FT4), and negatively related to thyroid stimulating hormone. Spearman's correlations analysis also revealed that the level of miR-1a was negatively correlated with a critical echocardiographic parameter (left atrial diameter), which was dramatically increased in GD + AF group compared to GD group. Furthermore, the receiver-operating characteristic curve analysis indicated that, among the eight microRNAs, miR-1a had the largest area under the receiver-operating characteristic curves not only for discriminating between individuals with and without Graves' disease, but also for predicting the presence of atrial fibrillation in patients with Graves' disease. Our findings showed that the levels of serum miR-1a were significantly decreased in GD + AF group compared with GD group, suggesting that serum miR-1a might serve as a novel biomarker for diagnosis of atrial fibrillation in patients with Graves' disease.

Incremental value of right atrial strain for early diagnosis of hemodynamic deterioration in pulmonary hypertension: a new noninvasive tool for a more comprehensive diagnostic paradigma.

PubMed

Piccinino, Cristina; Giubertoni, Ailia; Zanaboni, Jacopo; Gravellone, Miriam; Sola, Daniele; Rosso, Roberta; Ferrarotti, Lorena; Marino, Paolo Nicola

2017-11-01

Increased right atrial size is related to adverse prognosis in pulmonary hypertension. The potential incremental value of right atrial function assessment is still unclear. We tested the relationship between right atrial two-dimensional speckle-tracking echocardiography impairment and hemodynamic, functional and clinical deterioration in patients with pulmonary hypertension. We prospectively evaluated 36 patients (27 female, 9 male; mean age 68 ± 13 years) with suspected pulmonary hypertension undergoing right heart catheterization and 16 matched controls. All patients underwent baseline evaluation by New York Heart Association functional class, 6-min walking test, brain natriuretic peptide (BNP), and standard two-dimensional echocardiography in less than 48 h of right heart catheterization. Right atrial two-dimensional speckle-tracking echocardiography was assessed by averaging all segments in standard four-chamber apical view. Right atrial global integral strain was significantly lower in patients compared with controls (11.40 ± 5.22% vs. 25.72 ± 5.95 P < 0.001). Moreover, right atrial global strain, but not right atrial area or volume, was correlated with invasively measured cardiac index (CI) (r = 0.72; P < 0.0001) and pulmonary vascular resistances in all patients, even though stronger in subjects with precapillary pulmonary hypertension (r = -0.42, P = 0.018; r = -0.54, P = 0.007 respectively; P = 0.007). It was also correlated with New York Heart Association (P = 0.027), BNP (P = 0.002), and 6-min walking test (P = 0.006). After multivariate analysis including right atrial volume, tricuspid annular plane systolic excursion, left atrial strain, and BNP, right atrial global strain showed the strongest correlation with CI. Area under the curve optimal cutoff for predicting CI at least 2.4 l/min/m was 17% (area under the curve: 0.83, sensitivity: 90%, specificity: 54%). Right atrial global strain can identify right atrial functional impairment before structural changes and may be implemented in a comprehensive, noninvasive right heart assessment for diagnosis and follow-up of pulmonary hypertension patients.

Wolff-Parkinson-White syndrome type B and left bundle-branch block: electrophysiologic and radionuclide study

DOE Office of Scientific and Technical Information (OSTI.GOV)

Rakovec, P.; Kranjec, I.; Fettich, J.J.

1985-01-01

Coinciding left bundle-branch block and Wolff-Parkinson-White syndrome type B, a very rare electrocardiographic occurrence, was found in a patient with dilated cardiomyopathy. Electrophysiologic study revealed eccentric retrograde atrial activation during ventricular pacing, suggesting right-sided accessory pathway. At programmed atrial pacing, effective refractory period of the accessory pathway was 310 ms; at shorter pacing coupling intervals, normal atrioventricular conduction with left bundle-branch block was seen. Left bundle-branch block was seen also with His bundle pacing. Radionuclide phase imaging demonstrated right ventricular phase advance and left ventricular phase delay; both right and left ventricular phase images revealed broad phase distribution histograms. Combinedmore » electrophysiologic and radionuclide investigations are useful to disclose complex conduction abnormalities and their mechanical correlates.« less

Dominant frequency increase rate predicts transition from paroxysmal to long-term persistent atrial fibrillation.

PubMed

Martins, Raphael P; Kaur, Kuljeet; Hwang, Elliot; Ramirez, Rafael J; Willis, B Cicero; Filgueiras-Rama, David; Ennis, Steven R; Takemoto, Yoshio; Ponce-Balbuena, Daniela; Zarzoso, Manuel; O'Connell, Ryan P; Musa, Hassan; Guerrero-Serna, Guadalupe; Avula, Uma Mahesh R; Swartz, Michael F; Bhushal, Sandesh; Deo, Makarand; Pandit, Sandeep V; Berenfeld, Omer; Jalife, José

2014-04-08

Little is known about the mechanisms underlying the transition from paroxysmal to persistent atrial fibrillation (AF). In an ovine model of long-standing persistent AF we tested the hypothesis that the rate of electric and structural remodeling, assessed by dominant frequency (DF) changes, determines the time at which AF becomes persistent. Self-sustained AF was induced by atrial tachypacing. Seven sheep were euthanized 11.5±2.3 days after the transition to persistent AF and without reversal to sinus rhythm; 7 sheep were euthanized after 341.3±16.7 days of long-standing persistent AF. Seven sham-operated animals were in sinus rhythm for 1 year. DF was monitored continuously in each group. Real-time polymerase chain reaction, Western blotting, patch clamping, and histological analyses were used to determine the changes in functional ion channel expression and structural remodeling. Atrial dilatation, mitral valve regurgitation, myocyte hypertrophy, and atrial fibrosis occurred progressively and became statistically significant after the transition to persistent AF, with no evidence for left ventricular dysfunction. DF increased progressively during the paroxysmal-to-persistent AF transition and stabilized when AF became persistent. Importantly, the rate of DF increase correlated strongly with the time to persistent AF. Significant action potential duration abbreviation, secondary to functional ion channel protein expression changes (CaV1.2, NaV1.5, and KV4.2 decrease; Kir2.3 increase), was already present at the transition and persisted for 1 year of follow up. In the sheep model of long-standing persistent AF, the rate of DF increase predicts the time at which AF stabilizes and becomes persistent, reflecting changes in action potential duration and densities of sodium, L-type calcium, and inward rectifier currents.

Increased cardiac alpha-myosin heavy chain in left atria and decreased myocardial insulin-like growth factor (Igf-I) expression accompany low heart rate in hibernating grizzly bears.

PubMed

Barrows, N D; Nelson, O L; Robbins, C T; Rourke, B C

2011-01-01

Grizzly bears (Ursus arctos horribilis) tolerate extended periods of extremely low heart rate during hibernation without developing congestive heart failure or cardiac chamber dilation. Left ventricular atrophy and decreased left ventricular compliance have been reported in this species during hibernation. We evaluated the myocardial response to significantly reduced heart rate during hibernation by measuring relative myosin heavy-chain (MyHC) isoform expression and expression of a set of genes important to muscle plasticity and mass regulation in the left atria and left ventricles of active and hibernating bears. We supplemented these data with measurements of systolic and diastolic function via echocardiography in unanesthetized grizzly bears. Atrial strain imaging revealed decreased atrial contractility, decreased expansion/reservoir function (increased atrial stiffness), and decreased passive-filling function (increased ventricular stiffness) in hibernating bears. Relative MyHC-α protein expression increased significantly in the atrium during hibernation. The left ventricle expressed 100% MyHC-β protein in both groups. Insulin-like growth factor (IGF-I) mRNA expression was reduced by ∼50% in both chambers during hibernation, consistent with the ventricular atrophy observed in these bears. Interestingly, mRNA expression of the atrophy-related ubiquitin ligases Muscle Atrophy F-box (MAFBx) and Muscle Ring Finger 1 did not increase, nor did expression of myostatin or hypoxia-inducible factor 1α (HIF-1α). We report atrium-specific decreases of 40% and 50%, respectively, in MAFBx and creatine kinase mRNA expression during hibernation. Decreased creatine kinase expression is consistent with lowered energy requirements and could relate to reduced atrial emptying function during hibernation. Taken together with our hemodynamic assessment, these data suggest a potential downregulation of atrial chamber function during hibernation to prevent fatigue and dilation due to excessive work against an optimally filled ventricle, a response unpredicted by the Frank-Starling mechanism.

A neurosurgical presentation of patent foramen ovale with atrial septal aneurysm

PubMed Central

Walsh, Katie; Kaliaperumal, Chandrasekaran; Wyse, Gerry; Kaar, George

2011-01-01

We describe a case of cerebral abscess in a 53-year-old lady with a background of congenital heart defect. She has an atrial septal defect with atrial septal aneurysm, which remained undiagnosed until this clinical presentation. She presented with a short history of right-sided hemiplaegia and neuroimaging revealed a heterogeneous lesion in the left frontoparietal region. Neuronavigation-guided left frontoparietal craniotomy was performed to debulk the lesion and preoperatively frank pus was drained, which grew Streptococcus constellatus. She was successfully treated with antibiotics for 6 weeks and her clinical condition improved. We believe that the patients’ previous dental extraction has possibly resulted in a paradoxical embolism through the atrial septal defect bypassing the pulmonary circulation. The MRI scan picture was misleading, as it was initially thought to be a high-grade brain tumour. PMID:22689610

Reversible atrial fibrillation following Crotalinae envenomation.

PubMed

Quan, Dan; Zurcher, Kenneth

2017-01-01

Cardiotoxicity is a documented complication of Crotalinae envenomation. Reported cardiac complications following snake envenomation have included acute myocardial infarction, electrocardiogram abnormalities and arrhythmias. Few reports exist describing arrhythmia induced by viper envenomation and to our knowledge none describe arrhythmia induced by Crotalinae envenomation. This report concerns the first known case of atrial fibrillation precipitated by rattlesnake bite. A 73-year-old Caucasian man with a past medical history of hypertension, hyperlipidemia, type 1 diabetes mellitus, and a baseline first-degree atrioventricular block presented to the emergency department following a rattlesnake bite to his left lower leg. He developed pain and swelling in his left leg two-hour post-envenomation and subsequently received four vials of Crotalidae polyvalent immune fab (ovine). At three-hour post-envenomation following transfer to the intensive care unit, an electrocardiogram revealed new-onset atrial fibrillation. An amiodarone drip was started and the patient successfully converted to normal sinus rhythm approximately six hours after he was found to be in atrial fibrillation. A transthoracic echocardiogram revealed mild concentric left ventricular hypertrophy and an ejection fraction of 72%. He was discharged the following day with no hematological abnormalities and a baseline first-degree atrioventricular block. This is the first documented case of reversible atrial fibrillation precipitated by Crotalinae envenomation. In patients with pertinent risk factors for developing atrial fibrillation, physicians should be aware of the potential for this arrhythmia. Direct toxic effects of venom or structural and electrophysiological cardiovascular abnormalities may predispose snakebite patients to arrhythmia, warranting extended and attentive cardiac monitoring.

Transcatheter Interatrial Shunt Device for the Treatment of Heart Failure: Rationale and Design of the Randomized Trial to REDUCE Elevated Left Atrial Pressure in Heart Failure (REDUCE LAP-HF I).

PubMed

Feldman, Ted; Komtebedde, Jan; Burkhoff, Daniel; Massaro, Joseph; Maurer, Mathew S; Leon, Martin B; Kaye, David; Silvestry, Frank E; Cleland, John G F; Kitzman, Dalane; Kubo, Spencer H; Van Veldhuisen, Dirk J; Kleber, Franz; Trochu, Jean-Noël; Auricchio, Angelo; Gustafsson, Finn; Hasenfuβ, Gerd; Ponikowski, Piotr; Filippatos, Gerasimos; Mauri, Laura; Shah, Sanjiv J

2016-07-01

Heart failure with preserved ejection fraction (HFpEF), a major public health problem with high morbidity and mortality rates, remains difficult to manage because of a lack of effective treatment options. Although HFpEF is a heterogeneous clinical syndrome, elevated left atrial pressure-either at rest or with exertion-is a common factor among all forms of HFpEF and one of the primary reasons for dyspnea and exercise intolerance in these patients. On the basis of clinical experience with congenital interatrial shunts in mitral stenosis, it has been hypothesized that the creation of a left-to-right interatrial shunt to decompress the left atrium (without compromising left ventricular filling or forward cardiac output) is a rational, nonpharmacological strategy for alleviating symptoms in patients with HFpEF. A novel transcatheter interatrial shunt device has been developed and evaluated in patients with HFpEF in single-arm, nonblinded clinical trials. These studies have demonstrated the safety and potential efficacy of the device. However, a randomized, placebo-controlled evaluation of the device is required to further evaluate its safety and efficacy in patients with HFpEF. In this article, we give the rationale for a therapeutic transcatheter interatrial shunt device in HFpEF, and we describe the design of REDUCE Elevated Left Atrial Pressure in Heart Failure (REDUCE LAP-HF I), the first randomized controlled trial of a device-based therapy to reduce left atrial pressure in HFpEF. URL: http://www.clinicaltrials.gov. Unique identifier: NCT02600234. © 2016 American Heart Association, Inc.

Efficacy and safety of percutaneous left atrial appendage closure to prevent thromboembolic events in atrial fibrillation patients with high stroke and bleeding risk.

PubMed

Seeger, Julia; Bothner, Carlo; Dahme, Tillman; Gonska, Birgid; Scharnbeck, Dominik; Markovic, Sinisa; Rottbauer, Wolfgang; Wöhrle, Jochen

2016-03-01

The randomized PROTECT AF trial demonstrated non-inferiority of left atrial appendage (LAA) closure to oral anticoagulation with warfarin. Current guidelines give a class IIb recommendation for LAA closure. We evaluated the efficacy and safety of LAA closure in a consecutive series of non-valvular atrial fibrillation patients with contraindications to long-term oral anticoagulation or at high bleeding risk. 101 consecutive non-valvular atrial fibrillation patients (age 74.7 ± 7.5 years) at high risk for stroke (CHA2DS2-VASc Score 4.4 ± 1.6) and high bleeding risk (HAS-BLED Score 4.2 ± 1.3) received LAA closure with either the Watchman closure device (n = 38) or the Amplatzer cardiac plug (n = 63). Dual antiplatelet therapy with aspirin and clopidogrel was recommended for 3-6 months after device implantation, followed by long-term antiplatelet therapy with aspirin. No anticoagulation was given after device implantation. Mean follow-up was 400 days. One patient (1 %) experienced a transient ischemic attack, and two patients (2 %) suffered from ischemic stroke. While on recommended antiplatelet therapy, bleeding occurred in 12/101 patients (12 %). Bleeding was significantly reduced with 3 compared with 6 months dual antiplatelet therapy (3.0 vs. 16.2 %, p < 0.05) while ischemic or thrombotic events were similar. Left atrial appendage closure in patients with non-valvular atrial fibrillation and high risk for stroke and bleeding events effectively prevented stroke and reduced cerebral ischemic events compared to expected stroke rate according to CHA2DS2-VASc Score. Dual antiplatelet therapy for 3 months reduced the rate of bleeding events compared to 6 months therapy with no increase of thrombotic events.

Effect of Body Weight on Echocardiographic Measurements in 19,866 Pure-Bred Cats with or without Heart Disease.

PubMed

Häggström, J; Andersson, Å O; Falk, T; Nilsfors, L; OIsson, U; Kresken, J G; Höglund, K; Rishniw, M; Tidholm, A; Ljungvall, I

2016-09-01

Echocardiography is a cost-efficient method to screen cats for presence of heart disease. Current reference intervals for feline cardiac dimensions do not account for body weight (BW). To study the effect of BW on heart rate (HR), aortic (Ao), left atrial (LA) and ventricular (LV) linear dimensions in cats, and to calculate 95% prediction intervals for these variables in normal adult pure-bred cats. 19 866 pure-bred cats. Clinical data from heart screens conducted between 1999 and 2014 were included. Associations between BW, HR, and cardiac dimensions were assessed using univariate linear models and allometric scaling, including all cats, and only those considered normal, respectively. Prediction intervals were created using 95% confidence intervals obtained from regression curves. Associations between BW and echocardiographic dimensions were best described by allometric scaling, and all dimensions increased with increasing BW (all P<0.001). Strongest associations were found between BW and Ao, LV end diastolic, LA dimensions, and thickness of LV free wall. Weak linear associations were found between BW and HR and left atrial to aortic ratio (LA:Ao), for which HR decreased with increasing BW (P<0.001), and LA:Ao increased with increasing BW (P<0.001). Marginal differences were found for prediction formulas and prediction intervals when the dataset included all cats versus only those considered normal. BW had a clinically relevant effect on echocardiographic dimensions in cats, and BW based 95% prediction intervals may help in screening cats for heart disease. Copyright © 2016 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals, Inc. on behalf of the American College of Veterinary Internal Medicine.

Spatially divergent cardiac responses to nicotinic stimulation of ganglionated plexus neurons in the canine heart.

PubMed

Cardinal, René; Pagé, Pierre; Vermeulen, Michel; Ardell, Jeffrey L; Armour, J Andrew

2009-01-28

Ganglionated plexuses (GPs) are major constituents of the intrinsic cardiac nervous system, the final common integrator of regional cardiac control. We hypothesized that nicotinic stimulation of individual GPs exerts divergent regional influences, affecting atrial as well as ventricular functions. In 22 anesthetized canines, unipolar electrograms were recorded from 127 atrial and 127 ventricular epicardial loci during nicotine injection (100 mcg in 0.1 ml) into either the 1) right atrial (RA), 2) dorsal atrial, 3) left atrial, 4) inferior vena cava-inferior left atrial, 5) right ventricular, 6) ventral septal ventricular or 7) cranial medial ventricular (CMV) GP. In addition to sinus and AV nodal function, neural effects on atrial and ventricular repolarization were identified as changes in the area subtended by unipolar recordings under basal conditions and at maximum neurally-induced effects. Animals were studied with intact AV node or following ablation to achieve ventricular rate control. Atrial rate was affected in response to stimulation of all 7 GPs with an incidence of 50-95% of the animals among the different GPs. AV conduction was affected following stimulation of 6/7 GP with an incidence of 22-75% among GPs. Atrial and ventricular repolarization properties were affected by atrial as well as ventricular GP stimulation. Distinct regional patterns of repolarization changes were identified in response to stimulation of individual GPs. RAGP predominantly affected the RA and posterior right ventricular walls whereas CMVGP elicited biatrial and biventricular repolarization changes. Spatially divergent and overlapping cardiac regions are affected in response to nicotinic stimulation of neurons in individual GPs.

Substance P contributes to rapidly adapting receptor responses to pulmonary venous congestion in rabbits.

PubMed

Bonham, A C; Kott, K S; Ravi, K; Kappagoda, C T; Joad, J P

1996-05-15

1. This study tested the hypothesis that substance P stimulates rapidly adapting receptors (RARs), contributes to the increase in RAR activity produced by mild pulmonary congestion, and evokes an augmented response from RARs when combined with near-threshold levels of pulmonary congestion. 2. RAR activity, peak tracheal pressure, arterial blood pressure and left atrial pressure were measured in paralysed, anaesthetized and ventilated rabbits. Substance P was given i.v. in one-half log incremental doses to a maximum of 3 micrograms kg-1. Mild pulmonary congestion was produced by inflating a balloon in the left atrium to increase left atrial pressure by 5 mmHg. Near-threshold levels of pulmonary congestion were produced by increasing left atrial pressure by 2 mmHg. 3. Substance P produced dose-dependent increases in RAR activity. The highest dose given increased the activity from 1.3 +/- 0.5 to 11.0 +/- 3.1 impulses bin-1. Increases in left atrial pressure of 5 mmHg increased RAR activity from 3.8 +/- 1.4 to 14.7 +/- 3.9 impulses bin-1. Blockade of NK1 receptors with CP 96345 significantly attenuated RAR responses to substance P and to mild pulmonary congestion. 4. Doses of substance P, which alone had no effect, stimulated the RARs when delivered during near-threshold levels of pulmonary congestion. 5. The findings suggest that substance P augments the stimulatory effect of mild pulmonary congestion on RAR activity, most probably by enhancing hydraulically induced microvascular leak.

Steady-state MRA techniques with a blood pool contrast agent improve visualization of pulmonary venous anatomy and left atrial patency compared with time-resolved MRA pre- and postcatheter ablation in atrial fibrillation.

PubMed

Rustogi, Rahul; Galizia, Mauricio; Thakrar, Darshit; Merritt, Bryce; Bi, Xiaoming; Collins, Jeremy; Carr, James C

2015-11-01

To compare steady-state magnetic resonance angiography (SS-MRA), using a blood pool contrast agent, with the established technique of time-resolved MRA (TR-MRA), in pulmonary vein mapping and left atrial patency. Twenty-one patients (12 males, age 58.3 ± 8.4 years; 9 females; 57 ± 10 years) undergoing pulmonary vein mapping were evaluated with TR-MRA (TWIST) and SS-MRA. Orthogonal measurements and areas for four veins per patient per technique were assessed by Friedman's test. Overall intertechnique mean difference for any pulmonary vein orthogonal measurement and area was 0.02 ± 0.34 cm (P = 0.705), and 0.2 ± 0.08 cm(2) (P < 0.001). Interobserver correlation was strong for diameter and area measurements using the three methods with a range of 0.72-0.94, and 0.87-0.97, respectively. Left atrial appendage image quality score for TR-MRA was significantly lower than the other two methods (P < 0.001). Both observers detected more stenosis on inversion recovery (IR)-True FISP compared to TR-MRA and IR-FLASH. SS-MRA with a blood pool agent compared favorably to the established technique of TR-MRA for quantitative assessment of pulmonary venous anatomy. SS-MRA offers greater spatial resolution than TR-MRA with increased confidence for ruling out left atrial appendage filling defect. © 2015 Wiley Periodicals, Inc.

Left Atrial Anatomy Relevant to Catheter Ablation

PubMed Central

Sánchez-Quintana, Damián; Cabrera, José Angel; Saremi, Farhood

2014-01-01

The rapid development of interventional procedures for the treatment of arrhythmias in humans, especially the use of catheter ablation techniques, has renewed interest in cardiac anatomy. Although the substrates of atrial fibrillation (AF), its initiation and maintenance, remain to be fully elucidated, catheter ablation in the left atrium (LA) has become a common therapeutic option for patients with this arrhythmia. Using ablation catheters, various isolation lines and focal targets are created, the majority of which are based on gross anatomical, electroanatomical, and myoarchitectual patterns of the left atrial wall. Our aim was therefore to review the gross morphological and architectural features of the LA and their relations to extracardiac structures. The latter have also become relevant because extracardiac complications of AF ablation can occur, due to injuries to the phrenic and vagal plexus nerves, adjacent coronary arteries, or the esophageal wall causing devastating consequences. PMID:25057427

Anomalous pulmonary venous drainage of right lung to inferior vena cava ("scimitar syndrome"): clinical spectrum in older patients and role of surgery.

PubMed

Honey, M

1977-10-01

Six new cases of the "scimitar syndrome" are described. The anatomical and haemodynamic features of these and other reported cases are reviewed. Within the spectrum of the disorder there is a group of patients in whom the bronchopulmonary manifestations are relatively unimportant. In five of our patients there was a left-to-right shunt exceeding 2:1 and the anomalous pulmonary venous connection was corrected surgically. The presence or absence of an associated atrial septal defect may be difficult to establish but influences the choice of surgical technique. When the atrial septum is intact, the anomalous vein should be reimplanted if possible into the back of the left atrium; otherwise a pericardial or teflon patch can be used to redirect the anomalous venous return through an existing or created atrial septal defect to the left atrium.

Left atrial thrombus as an early consequence of blunt chest trauma

PubMed Central

Mahy, I; Al-Mohammad, A; Cargill, R

1998-01-01

Thromboembolism is rarely considered in discussions of the complications of blunt chest trauma. The few cases of thromboembolism that have been reported in this setting have occurred in association with significant myocardial damage. A previously fit 23 year old woman was admitted to the intensive care unit following a road traffic accident. A day later, left atrial thrombus was demonstrated by transoesophageal echocardiography in the absence of any other evidence of important myocardial injury. Anticoagulation with heparin was cautiously introduced in spite of her extensive injuries, and there were no consequent bleeding complications. At hospital discharge on day 18 she was entirely well. Full anticoagulation with warfarin was continued for a further eight weeks at which time follow up transoesophageal echocardiography showed complete resolution of the thrombus.

 Keywords: blunt chest trauma;  thromboembolism;  left atrial thrombus;  transoesophageal echocardiography PMID:9538317

Remodeling of atrial ATP-sensitive K+ channels in a model of salt-induced elevated blood pressure

PubMed Central

Lader, Joshua M.; Vasquez, Carolina; Bao, Li; Maass, Karen; Qu, Jiaxiang; Kefalogianni, Eirini; Fishman, Glenn I.; Coetzee, William A.

2011-01-01

Hypertension is associated with the development of atrial fibrillation; however, the electrophysiological consequences of this condition remain poorly understood. ATP-sensitive K+ (KATP) channels, which contribute to ventricular arrhythmias, are also expressed in the atria. We hypothesized that salt-induced elevated blood pressure (BP) leads to atrial KATP channel activation and increased arrhythmia inducibility. Elevated BP was induced in mice with a high-salt diet (HS) for 4 wk. High-resolution optical mapping was used to measure atrial arrhythmia inducibility, effective refractory period (ERP), and action potential duration at 90% repolarization (APD90). Excised patch clamping was performed to quantify KATP channel properties and density. KATP channel protein expression was also evaluated. Atrial arrhythmia inducibility was 22% higher in HS hearts compared with control hearts. ERP and APD90 were significantly shorter in the right atrial appendage and left atrial appendage of HS hearts compared with control hearts. Perfusion with 1 μM glibenclamide or 300 μM tolbutamide significantly decreased arrhythmia inducibility and prolonged APD90 in HS hearts compared with untreated HS hearts. KATP channel density was 156% higher in myocytes isolated from HS animals compared with control animals. Sulfonylurea receptor 1 protein expression was increased in the left atrial appendage and right atrial appendage of HS animals (415% and 372% of NS animals, respectively). In conclusion, KATP channel activation provides a mechanistic link between salt-induced elevated BP and increased atrial arrhythmia inducibility. The findings of this study have important implications for the treatment and prevention of atrial arrhythmias in the setting of hypertensive heart disease and may lead to new therapeutic approaches. PMID:21724863

Left atrial appendage closure with the Watchman device in patients with a contraindication for oral anticoagulation: the ASAP study (ASA Plavix Feasibility Study With Watchman Left Atrial Appendage Closure Technology).

PubMed

Reddy, Vivek Y; Möbius-Winkler, Sven; Miller, Marc A; Neuzil, Petr; Schuler, Gerhard; Wiebe, Jens; Sick, Peter; Sievert, Horst

2013-06-25

The purpose of this study was to assess the safety and efficacy of left atrial appendage (LAA) closure in nonvalvular atrial fibrillation (AF) patients ineligible for warfarin therapy. The PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation) trial demonstrated that LAA closure with the Watchman device (Boston Scientific, Natick, Massachusetts) was noninferior to warfarin therapy. However, the PROTECT AF trial only included patients who were candidates for warfarin, and even patients randomly assigned to the LAA closure arm received concomitant warfarin for 6 weeks after Watchman implantation. A multicenter, prospective, nonrandomized study was conducted of LAA closure with the Watchman device in 150 patients with nonvalvular AF and CHADS₂ (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and prior stroke or transient ischemic attack) score ≥1, who were considered ineligible for warfarin. The primary efficacy endpoint was the combined events of ischemic stroke, hemorrhagic stroke, systemic embolism, and cardiovascular/unexplained death. The mean CHADS₂ score and CHA₂DS₂-VASc (CHADS₂ score plus 2 points for age ≥75 years and 1 point for vascular disease, age 65 to 74 years, or female sex) score were 2.8 ± 1.2 and 4.4 ± 1.7, respectively. History of hemorrhagic/bleeding tendencies (93%) was the most common reason for warfarin ineligibility. Mean duration of follow-up was 14.4 ± 8.6 months. Serious procedure- or device-related safety events occurred in 8.7% of patients (13 of 150 patients). All-cause stroke or systemic embolism occurred in 4 patients (2.3% per year): ischemic stroke in 3 patients (1.7% per year) and hemorrhagic stroke in 1 patient (0.6% per year). This ischemic stroke rate was less than that expected (7.3% per year) based on the CHADS₂ scores of the patient cohort. LAA closure with the Watchman device can be safely performed without a warfarin transition, and is a reasonable alternative to consider for patients at high risk for stroke but with contraindications to systemic oral anticoagulation. (ASA Plavix Feasibility Study With Watchman Left Atrial Appendage Closure Technology [ASAP]; NCT00851578). Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Gargantuan left atrium: a sequela of mitral regurgitation and mitral stenosis.

PubMed

Omslaer, Brian T; Biederman, Robert W W

2015-06-01

Cardiac magnetic resonance imaging and echocardiography revealed a gargantuan left atrium measuring 18.9 cm × 15.7 cm × 11.3 cm in a 56-year-old patient diagnosed with severe rheumatic mitral stenosis, severe pulmonary hypertension, and permanent atrial fibrillation. A chest x-ray also revealed a cardiothoracic ratio approaching 1.0 and a transthoracic echocardiogram measured diameters as large as 19.2 cm. The patient then underwent mitral valve replacement and left atrial reduction surgery and has had no further admissions or complications. © 2015, Wiley Periodicals, Inc.

The role of computed tomography in detecting splenic arteriovenous fistula and concomitant atrial myxoma.

PubMed

Rroji, Arben; Bilaj, Fatmir; Qirinxhi, Denis; Vucini, Ortencia; Hasimi, Endri; Goda, Artan

2014-01-01

Female, 45 FINAL DIAGNOSIS: Arterio-venous fistula of the splean Symptoms: Lef-side abdominal pain Medication: - Clinical Procedure: - Specialty: Surgery. Rare disease. Splenic arterial-venous fistula and atrial myxoma are not rare cases but the co-existence of both lesions in the same patient is unpublished so far. A 45- year-old woman presented with vague left flank pain. She was initially scanned by B-dimensional echography, which revealed multiple enlarged hypo-echoic lesions in the splenic hilum. To further characterize the lesion, we performed computed tomography angiography (CTA). CTA showed dilatation of the splenic artery, and aneurismal dilatation of the splenic vein, associated with early opacification of the portal system. CTA showed also an intrasplenic venous aneurism, which was presumed to be the site of fistulous communication. Celiac arteriography confirmed the CTA findings. A left atrial mass was detected by cardiac echography, which was evaluated better by CTA, and was consistent with atrial myxoma. The patient underwent open surgery in different stage with resection of the atrial mass and spleen. The postoperative period was uneventful. This is a unique case in the literature, showing the coexistence of a dual-pathology splenic arterial venous fistula and atrial myxoma.

Spontaneous dissecting aneurysm of the left atrium complicated by cerebral embolism: A report of two cases with review of literature.

PubMed

Mohan, Jagdish C; Shukla, Madhu; Mohan, Vishwas; Sethi, Arvind

2016-09-01

Left atrial dissection is a very uncommon complication of cardiac surgery and usually causes significant hemodynamic compromise. Little is known about spontaneous dissection of the left atrium. Two patients, one middle-aged man and another elderly woman were evaluated following stroke. Routine trans-thoracic echocardiogram showed vertical division of the left atrium with both chambers communicating with each other through an orifice. Detailed trans-oesophageal echocardiographic study revealed dissection of the left atrium producing an additional false chamber (pseudo-aneurysm) placed posterior to the left atrial appendage and above the postero-lateral aspect of mitral annulus. Spontaneous dissection of the left atrium is extremely rare, and there is no report of cerebral embolism associated with it. Review of literature reveals interesting facets of this rare entity. Copyright © 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.

Live 3D TEE demonstrates and guides the management of prosthetic mitral valve obstruction.

PubMed

Chahal, Mangeet; Pandya, Utpal; Adlakha, Satjit; Khouri, Samer J

2011-08-01

A 43-year-old woman, with a remote history of rheumatic mitral stenosis and a St. Jude prosthetic mitral valve replacement, presented with shortness of breath and palpitations, shortly after a long flight. On admission, atrial fibrillation with a rapid ventricular response was noted in the setting of a long history of noncompliance with her anticoagulation. Transesophageal echocardiography (TEE) demonstrated multiple laminated thrombi in the left atrial appendage. Live three-dimensional (3D) TEE confirmed this diagnosis and demonstrated an immobile posterior leaflet of the mitral prosthesis, which had direct implications in her management. She successfully underwent surgery for mitral valve replacement, left atrial appendage ligation, and a Maze procedure on the following day. The multiple thrombi within the atrial appendage were confirmed intraoperatively and pannus formation was determined to be the etiology of the leaflet immobility. © 2011, Wiley Periodicals, Inc.

Metastasis of hepatocellular carcinoma to the heart: unusual patterns in three cases with antemortem diagnosis.

PubMed

Lei, M H; Ko, Y L; Kuan, P; Lien, W P; Chen, D S

1992-04-01

Unusual patterns of cardiac metastasis were noted in three cases of hepatocellular carcinoma (HCC): one patient was noted to have a large right ventricular (RV) tumor mass with intracavitary growth and myocardial invasion; the second had massive pulmonary and left atrial (LA) metastasis; and the third patient had a right atrial tumor mass with concomitant RV and LA involvement. Tumor implantation to the RV without right atrial involvement and extensive myocardial invasion is unusual in HCC. The LA involvement is probably related to tumor growth from the pulmonary veins following massive metastasis to the lung, direct invasion of the atrial septum or tumor implantation via a subclinical right-to-left shunt through the patent foramen ovale. To the best of our knowledge, such unusual intracavitary metastases in HCC have not been reported previously. Cardiac metastasis, without local gross recurrence, may be one of the presentations after lobectomy in patients with HCC.

Left Atrial Appendage Closure in Atrial Fibrillation: A World without Anticoagulation?

PubMed Central

Contractor, Tahmeed; Khasnis, Atul

2011-01-01

Atrial Fibrillation (AF) is a common arrhythmia with an incidence that is as high as 10% in the elderly population. Given the large proportion of strokes caused by AF as well as the associated morbidity and mortality, reducing stroke burden is the most important part of AF management. While warfarin significantly reduces the risk of AF-related stroke, perceived bleeding risks and compliance limit its widespread use in the high-risk AF population. The left atrial appendage is believed to be the “culprit” for thrombogenesis in nonvalvular AF and is a new therapeutic target for stroke prevention. The purpose of this review is to explore the evolving field of percutaneous LAA occlusion. After briefly highlighting the risk of stroke with AF, problems with warfarin, and the role of the LAA in clot formation, this article discusses the feasibility and efficacy of various devices which have been developed for percutaneous LAA occlusion. PMID:21559225

Outcomes and costs of left atrial appendage closure from randomized controlled trial and real-world experience relative to oral anticoagulation

PubMed Central

Panikker, Sandeep; Lord, Joanne; Jarman, Julian W.E.; Armstrong, Shannon; Jones, David G.; Haldar, Shouvik; Butcher, Charles; Khan, Habib; Mantziari, Lilian; Nicol, Edward; Hussain, Wajid; Clague, Jonathan R.; Foran, John P.; Markides, Vias; Wong, Tom

2016-01-01

Aims The aim of this study was to analyse randomized controlled study and real-world outcomes of patients with non-valvular atrial fibrillation (NVAF) undergoing left atrial appendage closure (LAAC) with the Watchman device and to compare costs with available antithrombotic therapies. Methods and results Registry data of LAAC from two centres were prospectively collected from 110 patients with NVAF at risk of stroke, suitable and unsuitable for long-term anticoagulation (age 71.3 ± 9.2 years, CHADS2 2.8 ± 1.2, CHA2DS2-VASc 4.5 ± 1.6, and HAS-BLED 3.8 ± 1.1). Outcomes from PROTECT AF and registry study LAAC were compared with warfarin, dabigatran, rivaroxaban, apixaban, aspirin, and no treatment using a network meta-analysis. Costs were estimated over a 10-year horizon. Uncertainty was assessed using sensitivity analyses. The procedural success rate was 92% (103/112). Follow-up was 24.1 ± 4.6 months, during which annual rates of stroke, major bleeding, and all-cause mortality were 0.9% (2/223 patient-years), 0.9% (2/223 patient-years), and 1.8% (4/223 patient-years), respectively. Anticoagulant therapy was successfully stopped in 91.2% (93/102) of implanted patients by 12 months. Registry study LAAC stroke and major bleeding rates were significantly lower than PROTECT AF results: mean absolute difference of stroke, 0.89% (P = 0.02) and major bleeding, 5.48% (P < 0.001). Left atrial appendage closure achieved cost parity between 4.9 years vs. dabigatran 110 mg and 8.4 years vs. warfarin. At 10 years, LAAC was cost-saving against all therapies (range £1162–£7194). Conclusion Left atrial appendage closure in NVAF in a real-world setting may result in lower stroke and major bleeding rates than reported in LAAC clinical trials. Left atrial appendage closure in both settings achieves cost parity in a relatively short period of time and may offer substantial savings compared with current therapies. Savings are most pronounced among higher risk patients and those unsuitable for anticoagulation. PMID:26935273

Association of left ventricular late gadolinium enhancement with left atrial low voltage areas in patients with atrial fibrillation.

PubMed

Stegmann, Clara; Jahnke, Cosima; Paetsch, Ingo; Hilbert, Sebastian; Arya, Arash; Bollmann, Andreas; Hindricks, Gerhard; Sommer, Philipp

2018-02-06

Presence of late gadolinium enhancement (LGE) is related to adverse cardiovascular outcome. Many patients suffering from atrial fibrillation (AF) undergo cardiovascular magnetic resonance (CMR) imaging prior to ablation. Since quantification of atrial fibrosis still lacks reproducibility, we sought to investigate risk factors for the presence of left ventricular (LV)-LGE and a possible correlation between ventricular fibrosis as defined by positive LGE and pathological atrial voltage maps evaluated by 3D mapping systems. Between May 2015 and January 2017, 241 patients with AF (73% persistent AF, 71% male, mean age 62.8 ± 10.1 years, Redo procedure in 24%, AF history 4.5 ± 5.2 years) underwent CMR including LV LGE prior to pulmonary vein (PV) isolation at Heart Center Leipzig. Depending on CMR results, two groups were separated: 'LV-LGE negative' (Group A, n = 197, 82%) and 'LV-LGE positive' (Group B, n = 44, 18%). To identify low voltage areas (LVA), a 3D electro-anatomic map was created during PV isolation. Multivariate analysis revealed male gender [odds ratio (OR) 7.6, 95% confidence interval (95% CI) 2.4-23.9, P = 0.001] and an increased CHA2DS2VASc Score (OR 1.6, 95% CI 1.2-2.2, P = 0.004) as significantly associated with LV-LGE. Impaired left ventricular ejection fraction, LV dilatation, larger LA size and, enlarged septum diameter occurred significantly more often in the 'LGE positive' group. Low voltage areas were detected in 83 patients overall (34%): Group A: n = 64/197 (33%), Group B: n = 19/44 (43%) (P = 0.177). Male gender and high CHA2DS2VASc Score are significantly associated with presence of LV-LGE, but LV-LGE is not associated with left atrial LVA. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: journals.permissions@oup.com.

Resolution of massive left atrial appendage thrombi with rivaroxaban before balloon mitral commissurotomy in severe mitral stenosis: A case report and literature review.

PubMed

Li, Yuechun; Lin, Jiafeng; Peng, Chen

2016-12-01

Data on nonvitamin K antagonist oral anticoagulant being used for the treatment of LAA thrombi are limited only in nonvalvular atrial fibrillation. There are no data on the antithrombotic efficacy and safety of nonvitamin K antagonist oral anticoagulant in the resolution of left atrial appendage (LAA) thrombi in patients with rheumatic mitral stenosis. A 49-year-old woman with known rheumatic mitral stenosis and atrial fibrillation was referred for percutaneous transvenous mitral commissurotomy because of progressive dyspnea on exertion over a period of 3 months. Transesophageal echocardiography (TEE) demonstrated a large LAA thrombus protruding into left atria cavity before the procedure. Direct factor Xa (FXa) inhibitor rivaroxaban (20 mg/d) was started for the patient. After 3 weeks of rivaroxaban treatment TEE showed a relevantly decreased thrombus size, and a complete thrombus resolution was achieved after 5 weeks of anticoagulant therapy with the FXa inhibitor. To the best of our knowledge, this is the first documented case of large LAA thrombus resolution with nonvitamin K antagonist oral anticoagulant in severe mitral stenosis, and in which percutaneous transvenous mitral commissurotomy was performed subsequently. The report indicated that rivaroxaban could be a therapeutic option for mitral stenosis patients with LAA thrombus. Further study is required before the routine use of rivaroxaban in patients with rheumatic mitral stenosis and atrial fibrillation.

Mechanism of reduction of mitral regurgitation with vasodilator therapy.

PubMed

Yoran, C; Yellin, E L; Becker, R M; Gabbay, S; Frater, R W; Sonnenblick, E H

1979-04-01

Acute mitral regurgitation was produced in six open chest dogs by excising a portion of the anterior valve leaflet. Electromagnetic flow probes were placed in the left atrium around the mitral anulus and in the ascending aorta to determine phasic left ventricular filling volume, regurgitant volume and stroke volume. The systolic pressure gradient was calculated from simultaneously measured high fidelity left atrial and left ventricular pressures. The effective mitral regurgitant orifice area was calculated from Gorlin's hydraulic equation. Infusion of nitroprusside resulted in a significant reduction in mitral regurgitation. No significant change occurred in the systolic pressure gradient between the left ventricle and the left atrium because both peak left ventricular pressure and left atrial pressure were reduced. The reduction of mitral regurgitation was largely due to reduction in the size of the mitral regurgitant orifice. Reduction of ventricular volume rather than the traditional concept of reduction of impedance of left ventricular ejection may explain the effects of vasodilators in reducing mitral regurgitation.

Effects of atorvastatin on atrial remodeling in a rabbit model of atrial fibrillation produced by rapid atrial pacing.

PubMed

Yang, Qian; Qi, Xiaoyong; Dang, Yi; Li, Yingxiao; Song, Xuelian; Hao, Xiao

2016-06-24

Accumulating evidence suggests that myeloperoxidase (MPO) is involved in atrial remodeling of atrial fibrillation (AF). Statins could reduce the MPO levels in patients with cardiovascular diseases. This study evaluated the effects of atorvastatin on MPO level and atrial remodeling in a rabbit model of pacing-induced AF. Eighteen rabbits were randomly divided into sham, control and atorvastatin groups. Rabbits in the control and atorvastatin groups were subjected to rapid atrial pacing (RAP) at 600 bpm for 3 weeks, and treated with placebo or atorvastatin (2.5 mg/kg/d), respectively. Rabbits in the sham group did not receive RAP. After 3 weeks of pacing, atrial structural and functional changes were assessed by echocardiography, atrial effective refractory period (AERP) and AF inducibility were measured by atrial electrophysiological examination, and histological changes were evaluated by Masson trichrome-staining. The L-type calcium channel α1c (Cav1.2), collagen I and III, MPO, matrix metalloproteinase (MMP)-2 and MMP-9 were analyzed by real time polymerase chain reaction and/or western blot. All rabbits were found to have maintained sinus rhythm after 3 weeks of RAP. Atrial burst stimulation induced sustained AF (>30 min) in 5, 4, and no rabbits in the control, atorvastatin, and sham groups, respectively. The AERP shortened and Cav1.2 mRNA level decreased in the control group, but these changes were suppressed in the atorvastatin group. Obvious left atrial enlargement and dysfunction was found in both control and atorvastatin groups. Compared with the control group, these echocardiograhic indices of left atrium did not differ in the atorvastatin group. Prominent atrial fibrosis and increased levels of collagen I and III were observed in the control group but not in the atorvastatin group. The mRNA and protein levels of MPO, MMP-2 and MMP-9 significantly increased in the control group, but these changes were prevented in the atorvastatin group. Treatment with atorvastatin prevented atrial remodeling in a rabbit model of RAP-induced AF. The reduction of levels of atrial MPO, MMP-2 and MMP-9 may contribute to the prevention of atorvastatin on atrial remodeling.

Association of serum chemerin concentrations with the presence of atrial fibrillation.

PubMed

Zhang, Guowei; Xiao, Mochao; Zhang, Lili; Zhao, Yue; Yang, Qinghui

2017-05-01

Objective Chemerin, a newly discovered adipokine, is correlated with hypertension, diabetes and coronary heart disease. The aim of this study is to investigate the association of serum chemerin concentrations with the presence of atrial fibrillation. Methods Serum chemerin concentrations were determined in 256 patients with atrial fibrillation and 146 healthy subjects. Atrial fibrillation patients were then divided into paroxysmal, persistent and permanent atrial fibrillation. Results Serum chemerin concentrations were significantly higher in atrial fibrillation patients compared with healthy controls. In subgroup studies, patients with permanent atrial fibrillation had higher serum chemerin concentrations than those with persistent and paroxysmal atrial fibrillation. Furthermore, significant higher serum chemerin concentrations were observed in persistent atrial fibrillation patients compared with paroxysmal atrial fibrillation subjects. Serum chemerin concentrations were associated with the presence of atrial fibrillation after logistic regression analysis. Pearson correlation analysis revealed a positive relation of serum chemerin concentrations with body mass index, systolic blood pressure, diastolic blood pressure, triglycerides, low-density lipoprotein cholesterol, blood urea nitrogen, creatinine, C-reactive protein and left atrial diameter. Conclusion Serum chemerin concentrations are associated with the presence of atrial fibrillation and atrial remodelling.

Assessment of Device-Related Thrombus and Associated Clinical Outcomes With the WATCHMAN Left Atrial Appendage Closure Device for Embolic Protection in Patients With Atrial Fibrillation (from the PROTECT-AF Trial).

PubMed

Main, Michael L; Fan, Dali; Reddy, Vivek Y; Holmes, David R; Gordon, Nicole T; Coggins, Tina R; House, John A; Liao, Lawrence; Rabineau, Dawn; Latus, George G; Huber, Kenneth C; Sievert, Horst; Wright, Richard F; Doshi, Shephal K; Douglas, Pamela S

2016-04-01

Left atrial appendage closure with the WATCHMAN device is an alternative to anticoagulation for stroke prevention in selected patients with atrial fibrillation (AF). LA device-related thrombus (DRT) is poorly defined and understood. We aimed to (1) develop consensus echocardiographic diagnostic criteria for DRT; (2) estimate the incidence of DRT; and (3) determine clinical event rates in patients with DRT. In phase 1 (training), a training manual was developed and reviewed by 3 echocardiographers with left atrial appendage closure device experience. All available transesophageal (TEE) studies in the WATCHMAN left atrial appendage system for embolic protection in patients with atrial fibrillation (PROTECT-AF) trial patients with suspected DRT were reviewed in 2 subsequent phases. In phase 2 (primary blind read), each reviewer independently scored each study for DRT, and final echo criteria were developed. Unanimously scored studies were considered adjudicated, whereas all others were reevaluated by all reviewers in phase 3 (group adjudication read). DRT was suspected in 35 of 485 patients by the site investigator, the echocardiography core laboratory, or both; 93 of the individual TEE studies were available for review. In phase 2, 3 readers agreed on 67 (72%) of time points. Based on phases 1 and 2, 5 DRT criteria were developed. In phase 3, studies without agreement in phase 2 were adjudicated using these criteria. Overall, at least 1 TEE was DRT positive in 27 (5.7%) PROTECT-AF patients. Stroke, peripheral embolism, or cardiac/unexplained death occurred in subjects with DRT at a rate of 3.4 per 100 patient-years follow-up. In conclusion, DRT were identified on at least 1 TEE in 27 PROTECT-AF patients, indicating a DRT incidence of 5.7%. Primary efficacy events in patients with DRT occurred at a rate of 3.4 per 100 patient-years follow-up, intermediate in frequency between event rates previously reported for the overall device and warfarin arms in PROTECT-AF. Copyright © 2016 Elsevier Inc. All rights reserved.

Association between left atrial function assessed by speckle-tracking echocardiography and the presence of left atrial appendage thrombus in patients with atrial fibrillation.

PubMed

Kupczynska, Karolina; Michalski, Blazej W; Miskowiec, Dawid; Kasprzak, Jaroslaw D; Wejner-Mik, Paulina; Wdowiak-Okrojek, Katarzyna; Lipiec, Piotr

2017-07-01

The aim of the study was to investigate whether the deformation of left atrium (LA) measured by speckle-tracking analysis (STE) is associated with the presence of LA appendage thrombus (LAAT) during non-valvular atrial fibrillation (AF). Eighty-seven patients (mean age 67 years, 59% men) were included to retrospective cross-sectional study. On top of standard echocardiography we assessed: LA longitudinal systolic strain (LS), systolic (LSSR) and early diastolic strain rate (LESR) in four-chamber and twochamber apical views. All patients underwent transesophageal echocardiography disclosing LAAT in 36 (41%) patients. Subgroups with and without thrombi did not differ with regard to clinical characteristics. Univariate factors associated with LAAT were as follows: CH2ADS2-VASc Score, left ventricular ejection fraction (LVEF), LV mass, and STE measurements. In a multivariate model only LVEF (p=0.002), LS (p=0.02), LESR (p=0.008), and LSSR (p=0.045) were independently associated with LAAT presence. Moreover, LVEF and LA STE measurements provided incremental value over the CH2ADS2-VASc Score. Speckle-tracking TTE may be used to describe LA reservoir and conduit function during AF, allowing the identification of patients with higher risk of LAAT and providing incremental value over the CH2ADS2-VASc Score.

Left septal atrial tachycardia after open-heart surgery: relevance to surgical approach, anatomical and electrophysiological characteristics associated with catheter ablation, and procedural outcomes.

PubMed

Adachi, Toru; Yoshida, Kentaro; Takeyasu, Noriyuki; Masuda, Keita; Sekiguchi, Yukio; Sato, Akira; Tada, Hiroshi; Nogami, Akihiko; Aonuma, Kazutaka

2015-02-01

Septal atrial tachycardia (AT) can occur in patients without structural heart disease and in patients with previous catheter ablation of atrial fibrillation. We aimed to assess septal AT that occurs after open-heart surgery. This study comprised 20 consecutive patients undergoing catheter ablation of macroreentrant AT after open-heart surgery. Relevance to surgical approach, mechanisms, anatomic and electrophysiological characteristics, and outcomes were assessed. Septal AT was identified in 7 patients who had all undergone mitral valve surgery. All septal ATs were localized in the left atrial septum, whereas 10 of 13 nonseptal ATs originated from the right atrium. Patients with left septal AT had a thicker fossa ovalis (median, 4.0; 25th-75th percentile, 3.6-4.2 versus 2.3; 1.6-2.6 mm; P=0.006) and broader area of low voltage (<0.3 mV) in the septum than patients with nonseptal AT (82; 76-89 versus 31; 28%-36%; P=0.02). Repeated gradual prolongations of the tachycardia cycle length without change of the septal circuit were observed in all patients with septal AT (70; 63-100 versus 15; 10-40 ms; P=0.0008). Although ablation terminated all ATs, recurrence of targeted ATs was more frequent in patients with left septal AT during 30-month follow-up (71 versus 0%; P=0.001). Left septal AT after open-heart surgery was characterized by a thicker septum, more scar burden in the septum, and repeated prolongations of the tachycardia cycle length during ablation. Such an arrhythmogenic substrate may interfere with transmural lesion formation by ablation and may account for higher likelihood of recurrence of left septal AT. © 2014 American Heart Association, Inc.

Ventricular, but not atrial, M2-muscarinic receptors increase in the canine pacing-overdrive model of heart failure.

PubMed

Wilkinson, M; Giles, A; Armour, J A; Cardinal, R

1996-01-01

To investigate the effects of heart failure induced by chronic rapid ventricular pacing (six weeks) on canine atrial and ventricular muscarinic receptors. Dogs (n = 4) were fitted with a bipolar pacing electrode connected to a Medtronic pacemaker set at 240 stimuli/min. Pacing was maintained for six weeks. Tissue samples obtained from the left atrium and ventral wall of the left ventricle were frozen at -70 degrees C. Control tissue was obtained from normal dogs (n = 6) following anesthesia and thoracotomy. M2-muscarinic receptors were characterized and quantified in tissue micropunches using the hydrophilic ligand [3H] N-methyl-scopolamine (NMS). Cardiac tissue bound [3H] NMS with the specificity of an M2 subtype. Tachycardia-induced heart failure did not affect atrial muscarinic receptors but signify left ventricular myocytes (control 160.0 +/- 10.0 fmol/mg protein versus heart failure 245.0 +/- 25.0 fmol/mg protein; P < 0.01). Canine ventricular muscarinic receptors display a specificity for the M2 subtype. In contrast to previous work, tachycardia-induced heart failure was accompanied by an increase (+ 53%) in ventricular, but not atrial, M2 receptors compared with normal dogs.

Atrial Cardiopathy and Cryptogenic Stroke: A Cross-sectional Pilot Study.

PubMed

Yaghi, Shadi; Boehme, Amelia K; Hazan, Rebecca; Hod, Eldad A; Canaan, Alberto; Andrews, Howard F; Kamel, Hooman; Marshall, Randolph S; Elkind, Mitchell S V

2016-01-01

There is increasing evidence that left atrial dysfunction or cardiopathy is associated with ischemic stroke risk independently of atrial fibrillation. We aimed to determine the prevalence of atrial cardiopathy biomarkers in patients with cryptogenic stroke. We included consecutive patients with ischemic stroke enrolled in the New York Columbia Collaborative Specialized Program of Translational Research in Acute Stroke registry between December 1, 2008, and April 30, 2012. Medical records were reviewed and patients with a diagnosis of cryptogenic stroke were identified. Atrial cardiopathy was defined as at least one of the following: serum N-terminal probrain natriuretic peptide (NT-proBNP) level greater than 250 pg/mL, P-wave terminal force velocity in lead V1 (PTFV1) on electrocardiogram (ECG) greater than 5000 µV⋅ms, or severe left atrial enlargement (LAE) on echocardiogram. We compared clinical, echocardiographic, and radiological characteristics between patients with and without atrial cardiopathy. Among 40 patients with cryptogenic stroke, 63% had at least one of the biomarkers of atrial cardiopathy; 49% had elevated NT-proBNP levels, 20% had evidence of increased PTFV1 on ECG, and 5% had severe LAE. Patients with atrial cardiopathy were more likely to be older (76 versus 62 years, P = .012); have hypertension (96% versus 33%, P < .001), hyperlipidemia (60% versus 27%, P = .05), or coronary heart disease (28% versus 0%, P = .033); and less likely to have a patent foramen ovale (4% versus 40%, P = .007). There is a high prevalence of biomarkers indicative of atrial cardiopathy in patients with cryptogenic stroke. Clinical trials are needed to determine whether these patients may benefit from anticoagulation to prevent stroke. Copyright © 2015 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Differentiation of pre-ablation and post-ablation late gadolinium-enhanced cardiac MRI scans of longstanding persistent atrial fibrillation patients

NASA Astrophysics Data System (ADS)

Yang, Guang; Zhuang, Xiahai; Khan, Habib; Haldar, Shouvik; Nyktari, Eva; Li, Lei; Ye, Xujiong; Slabaugh, Greg; Wong, Tom; Mohiaddin, Raad; Keegan, Jennifer; Firmin, David

2017-03-01

Late Gadolinium-Enhanced Cardiac MRI (LGE CMRI) is an emerging non-invasive technique to image and quantify preablation native and post-ablation atrial scarring. Previous studies have reported that enhanced image intensities of the atrial scarring in the LGE CMRI inversely correlate with the left atrial endocardial voltage invasively obtained by electro-anatomical mapping. However, the reported reproducibility of using LGE CMRI to identify and quantify atrial scarring is variable. This may be due to two reasons: first, delineation of the left atrium (LA) and pulmonary veins (PVs) anatomy generally relies on manual operation that is highly subjective, and this could substantially affect the subsequent atrial scarring segmentation; second, simple intensity based image features may not be good enough to detect subtle changes in atrial scarring. In this study, we hypothesized that texture analysis can provide reliable image features for the LGE CMRI images subject to accurate and objective delineation of the heart anatomy based on a fully-automated whole heart segmentation (WHS) method. We tested the extracted texture features to differentiate between pre-ablation and post-ablation LGE CMRI studies in longstanding persistent atrial fibrillation patients. These patients often have extensive native scarring and differentiation from post-ablation scarring can be difficult. Quantification results showed that our method is capable of solving this classification task, and we can envisage further deployment of this texture analysis based method for other clinical problems using LGE CMRI.

UFO in the Left Atrium: How to Capture Metal Debris Floating in the Left Atrium.

PubMed

Fassini, Gaetano; Moltrasio, Massimo; Conti, Sergio; Biagioli, Viviana; Tondo, Claudio

2016-06-01

Electrophysiology procedures involving left atrium navigation are becoming more frequent, mostly due to the increase of atrial fibrillation ablation. Mapping catheters of different shapes and size as well as dedicated sheaths are mandatory tools for the accomplishment of procedural end point. Therefore, technical issues are expected, usually unrelated to significant risk. However, any accidental intra-atrial device loss of integrity implies a risk of cerebrovascular embolization. The lack of clear evidence on how to manage these events and the need for a quick solution complicate the scenario. We report an empirical solution in the case of debris floating in the left atrium. Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

A hybrid surgical transcatheter strategy for treating severe para-right atrioventricular valvular regurgitation in a patient with left atrial isomerism.

PubMed

Kalantre, Atul; Vettukattil, Joseph; Haw, Marcus; Veldtman, Gruschen R

2007-12-01

Paravalvular leaks are a recognized complication of valve replacement surgery. We report a 47-year-old man with left atrial isomerism, interrupted left sided inferior caval vein with unilateral left sided superior caval vein, a common atrium, and anomalous pulmonary venous connection to the coronary sinus, who had recurrent severe para-right atrioventricular (AV) regurgitation with gross right heart failure following tricuspid valve (TCV) replacement. He underwent a hybrid surgery-transcatheter treatment strategy in the cardiac catheterization laboratory, which led to significant improvement in hemodynamics and symptoms. This to our knowledge is the first reported case of a minimally invasive approach to para-right sided AV valve regurgitation.

Effect of Sleep Apnea and Continuous Positive Airway Pressure on Cardiac Structure and Recurrence of Atrial Fibrillation

PubMed Central

Neilan, Tomas G.; Farhad, Hoshang; Dodson, John A.; Shah, Ravi V.; Abbasi, Siddique A.; Bakker, Jessie P.; Michaud, Gregory F.; van der Geest, Rob; Blankstein, Ron; Steigner, Michael; John, Roy M.; Jerosch‐Herold, Michael; Malhotra, Atul; Kwong, Raymond Y.

2013-01-01

Background Sleep apnea (SA) is associated with an increased risk of atrial fibrillation (AF). We sought to determine the effect of SA on cardiac structure in patients with AF, whether therapy for SA was associated with beneficial cardiac structural remodelling, and whether beneficial cardiac structural remodelling translated into a reduced risk of recurrence of AF after pulmonary venous isolation (PVI). Methods and Results A consecutive group of 720 patients underwent a cardiac magnetic resonance study before PVI. Patients with SA (n=142, 20%) were more likely to be male, diabetic, and hypertensive and have an increased pulmonary artery pressure, right ventricular volume, atrial dimensions, and left ventricular mass. Treated SA was defined as duration of continuous positive airway pressure therapy of >4 hours per night. Treated SA patients (n=71, 50%) were more likely to have paroxysmal AF, a lower blood pressure, lower ventricular mass, and smaller left atrium. During a follow‐up of 42 months, AF recurred in 245 patients. The cumulative incidence of AF recurrence was 51% in patients with SA, 30% in patients without SA, 68% in patients with untreated SA, and 35% in patients with treated SA. In a multivariable model, the presence of SA (hazard ratio 2.79, CI 1.97 to 3.94, P<0.0001) and untreated SA (hazard ratio 1.61, CI 1.35 to 1.92, P<0.0001) were highly associated with AF recurrence. Conclusions Patients with SA have an increased blood pressure, pulmonary artery pressure, right ventricular volume, left atrial size, and left ventricular mass. Therapy with continuous positive airway pressure is associated with lower blood pressure, atrial size, and ventricular mass, and a lower risk of AF recurrence after PVI. PMID:24275628

Spatial Relation Between Left Atrial Anatomical Contact Areas and Circular Activation in Persistent Atrial Fibrillation.

PubMed

Nakahara, Shiro; Yamaguchi, Takanori; Hori, Yuichi; Anjo, Naofumi; Hayashi, Akiko; Kobayashi, Sayuki; Komatsu, Takaaki; Sakai, Yoshihiko; Fukui, Akira; Tsuchiya, Takeshi; Taguchi, Isao

2016-05-01

Atrial low-voltage zones (LVZs) may be related to maintenance of atrial fibrillation (AF). The influence of left atrial (LA) contact areas (CoAs) on reentrant or rotor-like sources maintaining AF has not been investigated. Forty patients with persistent AF (PsAF) were analyzed. Three representative CoA regions in the LA (ascending aorta: anterior wall; descending aorta: left inferior pulmonary vein; and vertebrae: posterior wall) were visualized by enhanced CT. Using circular catheters, the LVZs (<0.5 mV) were assessed after restoration of SR, and local activation mapping and frequency domain analyses were performed after induction of AF. Circular activation during AF was visually defined as sites with ≥2 rotations by serial electrograms encompassing >80% of the mean AF cycle length. A pivot was defined as the core of the localized circular activation. Anterior (39/40 patients, 98%), left pulmonary vein antrum (27/40, 68%), and posterior (19/40, 48%) CoAs were identified, and 80% (68/85) of those sites were overlapped by or close (<3 mm) to LVZs. Thirty-six (90%) patients demonstrated circular activation (3.1±1.7 sites/patients) along with significantly higher organized dominant frequencies (6.3 ± 0.5 Hz, regularity-index: 0.26 [0.23-0.41]) within the LA, and the average electrogram amplitude of those pivots was 0.30 mV (0.18-0.52). Of those sites, 55% (66/120) were located at or close to CoA regions. Catheter ablation including of LVZs neighboring CoAs terminated AF in 9 (23%) patients. External anatomical structures contacting the LA may be related to unique conduction properties in diseased myocardium necessary for PsAF maintenance. © 2016 Wiley Periodicals, Inc.

Can regurgitant flow damage the left atrial endothelium in patients with prosthetic mechanical heart valves?

PubMed

Milo, Simcha; Zarandi, Mehrdad; Gutfinger, Chaim; Gharib, Morteza

2005-05-01

Previous in-vitro studies of mechanical heart valves (MHVs) in the closed position demonstrated the formation of regurgitant flows, with bubbles and jets forming vortices during each systole. The study aim was to determine whether the regurgitant flow observed in patients with MHVs can damage the left atrial endothelium, due to shear stresses exerted on the endothelial layers. This objective has been accomplished by appropriate in-vitro simulation experiments. In these experiments, leakage flow through several commercial MHVs was investigated. The geometry of the set-up closely resembled that of the left atrial anatomy. Water was forced through the slit of a closed MHV and directed toward the hemispherical cup coated with fluorescent paint. The flow field between the valve and the cup was photographed using high-speed videography, from which local velocities were measured, using digital particle imaging velocimetry. Qualitative damage to the surface of the cup was assessed from the amount of fluorescent paint removed from the cup. The experimental results and calculations indicated that flows through the gaps of the closed valves were sufficient to generate strong vortices, with velocities near the atrial wall in the range of 0.5 to 4.0 m/s, depending on the valve. This led to high shear stresses on the left atrial wall, which far exceeded physiologically acceptable levels. The calculated shear stresses exceeded by orders of magnitude the maximum physiologically tolerated stresses. This suggests that shear stresses associated with regurgitant jets in MHVs may damage the endothelial cells, leading to the activation of the inflammatory reaction, enhanced procoagulation, platelet activation and aggregation, and mechanical cell denudation.

Variations in Anticoagulation Practices Following the Maze Procedure.

PubMed

Chung, Jennifer; Sami, Magdi; Albert, Carole; Varennes, Benoit De

2015-01-01

The current real-world anticoagulation practices following left atrial appendectomy in the context of the Maze procedure are unknown. This is a cohort study of all patients who underwent the Maze procedure with amputation of the left atrial appendage from June 2005 to November 2012. Data was prospectively collected at regular intervals with an interview and Holter monitoring. All patients received anticoagulation for 3 months. Those then kept on anticoagulation and those for whom anticoagulation was stopped were compared in terms of death, bleeding and incidence of stroke. In total, there were 113 patients, of whom 66 were treated with anticoagulation (Group A) and 47 were not (Group B). There were no significant baseline differences between the two groups, including the presence of atrial fibrillation (A:19.7%, B:10.6%, p=0.30), CHADS2 score (A:1.41±1.05, B:1.15±1.08, p=0.19), and left atrial size (A:48.3±7.1mm, B:47.6±7.8 mm, p=0.57). There were 275 patient-years of follow-up, with an average of 2.43 years per patient. Only two patients experienced strokes, both in Group A (p=0.27). Of the 5 bleeding events, 4 occurred in the first 3 months while on anticoagulation and the remaining event occurred in Group A at 3 years post-operatively (p=0.10). No standardized approach to anticoagulation after the Maze procedure is apparent in real-world practice in an urban Canadian setting. Patients who undergo the Maze procedure with amputation of the left atrial appendage are at a low risk of stroke, but the optimal anticoagulation strategy requires further investigation.

Left atrial volume and function in dogs with naturally occurring myxomatous mitral valve disease.

PubMed

Höllmer, M; Willesen, J L; Tolver, A; Koch, J

2017-02-01

Myxomatous mitral valve disease (MMVD) induces progressive left atrial (LA) enlargement. The LA modulates left ventricular filling and performance through its reservoir, conduit, and contractile function. Assessment of LA size and function may provide valuable information on the level of cardiac compensation. Left atrial function in dogs with naturally occurring MMVD remains largely unexplored. The objective of this study was to evaluate LA volume and function in dogs with naturally occurring MMVD. This prospective study included 205 client-owned dogs of different breeds, 114 healthy dogs, and 91 dogs with MMVD of different disease severities. Using two-dimensional echocardiography, the biplane area-length method was applied to assess LA volume and calculate volumetric indices of LA reservoir, conduit, and contractile function. Left atrial volume and LA stroke volume increased, whereas LA reservoir and contractile function decreased with increasing disease severity. A maximal LA volume <2.25mL/kg was the optimal cut off identified for excluding congestive heart failure in dogs with chronic MMVD with a sensitivity of 96% and a specificity of 100%. An active LA emptying fraction <24% and/or a LA expansion index <126% were suggestive of congestive heart failure in dogs with chronic MMVD with a sensitivity of 77% and a specificity of 89% and a sensitivity of 82% and a specificity of 82%, respectively. Dogs with MMVD appear to have larger LA volumes with poorer LA function. Deteriorating LA function, characterized by a decreasing reservoir and active contractile function, was evident in dogs with MMVD with increasing disease severity. Copyright © 2016 Elsevier B.V. All rights reserved.

The role of the cardiac nerves in regulation of sodium excretion in conscious dogs.

PubMed

Kaczmarczyk, G; Drake, A; Eisele, R; Mohnhaupt, R; Noble, M I; Simgen, B; Stubbs, J; Reinhardt, H W

1981-05-01

Conscious, chronically instrumented dogs, maintained on a high sodium intake, were used to investigate whether surgical cardiac denervation impairs the natriuresis associated with left atrial pressure increase produced in three ways: during an increase in left atrial pressure by means of a reversible mitral stenosis (protocol 1); after an i.v. saline load (1.0 ml 0.9% saline min-1 . kg-1 over 60 min) (protocol 2); after an oral saline load (14.5 mmol Na . kg-1 given with the food as isotonic solution) (protocol 3). During a reversible mitral stenosis, in intact dogs, urine volume and sodium excretion increased markedly (from 34--145 microliters . min-1 . kg-1 and from 3--12 mumol . min-1 . kg-1); mean arterial pressure increased by an average of 2 kPa (15 mm Hg) and heart rate by 53 b/min; plasma renin activity fell from 0.37--0.21 ng AI . ml-1 . h-1 . Cardiac denervation eliminated these effects of left atrial distension except for a small increase in heart rate (12 b/min). This indicates that the natriuresis and diuresis during left atrial distension resulted from stimulation of receptors located in the left atrium. In contrast, during protocol 2 and 3, the same amounts of sodium and water were excreted in the cardiac denervated dogs as compared to the intact dogs. A comparable decrease in plasma renin activity also was observed. -- Apparently the presence of the cardiac nerves is not a prerequisite for maintenance of sodium and water homeostasis.

Substance P contributes to rapidly adapting receptor responses to pulmonary venous congestion in rabbits.

PubMed Central

Bonham, A C; Kott, K S; Ravi, K; Kappagoda, C T; Joad, J P

1996-01-01

1. This study tested the hypothesis that substance P stimulates rapidly adapting receptors (RARs), contributes to the increase in RAR activity produced by mild pulmonary congestion, and evokes an augmented response from RARs when combined with near-threshold levels of pulmonary congestion. 2. RAR activity, peak tracheal pressure, arterial blood pressure and left atrial pressure were measured in paralysed, anaesthetized and ventilated rabbits. Substance P was given i.v. in one-half log incremental doses to a maximum of 3 micrograms kg-1. Mild pulmonary congestion was produced by inflating a balloon in the left atrium to increase left atrial pressure by 5 mmHg. Near-threshold levels of pulmonary congestion were produced by increasing left atrial pressure by 2 mmHg. 3. Substance P produced dose-dependent increases in RAR activity. The highest dose given increased the activity from 1.3 +/- 0.5 to 11.0 +/- 3.1 impulses bin-1. Increases in left atrial pressure of 5 mmHg increased RAR activity from 3.8 +/- 1.4 to 14.7 +/- 3.9 impulses bin-1. Blockade of NK1 receptors with CP 96345 significantly attenuated RAR responses to substance P and to mild pulmonary congestion. 4. Doses of substance P, which alone had no effect, stimulated the RARs when delivered during near-threshold levels of pulmonary congestion. 5. The findings suggest that substance P augments the stimulatory effect of mild pulmonary congestion on RAR activity, most probably by enhancing hydraulically induced microvascular leak. Images Figure 6 PMID:8735708

d,l-Sotalol reverses abbreviated atrial refractoriness and prevents promotion of atrial fibrillation in a canine model with left ventricular dysfunction induced by atrial tachypacing.

PubMed

Sakamoto, Tamotsu; Fujiki, Akira; Nakatani, Yosuke; Sakabe, Masao; Mizumaki, Koichi; Hashimoto, Norio; Inoue, Hiroshi

2009-10-01

This study evaluated antiarrhythmic effects of d,l-sotalol in a canine atrial fibrillation (AF) model with left ventricular dysfunction. Thirteen beagles (Sotalol group n=7 and Control group n=6) were subjected to atrial tachypacing (ATP) (400 beats/min) with intact atrioventricular conduction for 4 weeks. Oral d,l-sotalol (2 mg/kg) was administered 1 week after starting ATP and continued throughout the experiment. One week after starting ATP, atrial effective refractory periods (AERPs) were shortened in both groups. However, d,l-sotalol treatment gradually prolonged AERP, resulting in a significant prolongation of AERP compared with the Control group at 4 weeks (Control 76 +/-4 and Sotalol 126 +/-5 ms, p<0.01). d,l-Sotalol treatment showed lower AF inducibility and shorter AF duration at 4 weeks. In the control group, expressions of L-type Ca(2+) channel alpha1c and Kv4.3 mRNA were downregulated by 46.2% and 43.0%, respectively, after 4 weeks of ATP; d,l-sotalol treatment did not affect these changes. d,l-Sotalol treatment prolonged AERP, even after atrial electrical remodeling had developed, and prevented AF perpetuation without affecting downregulated expression of L-type Ca(2+) channel alpha1c and Kv4.3 mRNA in an ATP-induced canine AF model.

Increased expression of NF-AT3 and NF-AT4 in the atria correlates with procollagen I carboxyl terminal peptide and TGF-β1 levels in serum of patients with atrial fibrillation.

PubMed

Zhao, Fei; Zhang, ShiJiang; Chen, YiJiang; Gu, WeiDong; Ni, BuQing; Shao, YongFeng; Wu, YanHu; Qin, JianWei

2014-11-25

Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice. Unfortunately, the precise mechanisms and sensitive serum biomarkers of atrial remodeling in AF remain unclear. The aim of this study was to determine whether the expression of the transcription factors NF-AT3 and NF-AT4 correlate with atrial structural remodeling of atrial fibrillation and serum markers for collagen I and III synthesis. Right and left atrial specimens were obtained from 90 patients undergoing valve replacement surgery. The patients were divided into sinus rhythm (n = 30), paroxysmal atrial fibrillation (n = 30), and persistent atrial fibrillation (n = 30) groups. NF-AT3, NF-AT4, and collagen I and III mRNA and protein expression in atria were measured. We also tested the levels of the carboxyl-terminal peptide from pro-collagen I, the N-terminal type I procollagen propeptides, the N-terminal type III procollagen propeptides, and TGF-β1 in serum using an enzyme immunosorbent assay. NF-AT3 and NF-AT4 mRNA and protein expression were increased in the AF groups, especially in the left atrium. NF-AT3 and NF-AT4 expression in the right atrium was increased in the persistent atrial fibrillation group compared the sinus rhythm group with similar valvular disease. In patients with AF, the expression levels of nuclear NF-AT3 and NF-AT4 correlated with those of collagens I and III in the atria and with PICP and TGF-β1 in blood. These data support the hypothesis that nuclear NF-AT3 and NF-AT4 participates in atrial structural remodeling, and that PICP and TGF-β1 levels may be sensitive serum biomarkers to estimate atrial structural remodeling with atrial fibrillation.

Value of Combining Left Atrial Diameter and Amino-terminal Pro-brain Natriuretic Peptide to the CHA2DS2-VASc Score for Predicting Stroke and Death in Patients with Sick Sinus Syndrome after Pacemaker Implantation.

PubMed

Mo, Bin-Feng; Lu, Qiu-Fen; Lu, Shang-Biao; Xie, Yu-Quan; Feng, Xiang-Fei; Li, Yi-Gang

2017-08-20

The CHA2DS2-VASc score is used clinically for stroke risk stratification in patients with atrial fibrillation (AF). We sought to investigate whether the CHA2DS2-VASc score predicts stroke and death in Chinese patients with sick sinus syndrome (SSS) after pacemaker implantation and to evaluate whether the predictive power of the CHA2DS2-VASc score could be improved by combining it with left atrial diameter (LAD) and amino-terminal pro-brain natriuretic peptide (NT-proBNP). A total of 481 consecutive patients with SSS who underwent pacemaker implantation from January 2004 to December 2014 in our department were included. The CHA2DS2-VASc scores were retrospectively calculated according to the hospital medical records before pacemaker implantation. The outcome data (stroke and death) were collected by pacemaker follow-up visits and telephonic follow-up until December 31, 2015. During 2151 person-years of follow-up, 46 patients (9.6%) suffered stroke and 52 (10.8%) died. The CHA2DS2-VASc score showed a significant association with the development of stroke (hazard ratio [HR] 1.45, 95% confidence interval [CI] 1.20-1.75, P< 0.001) and death (HR 1.45, 95% CI 1.22-1.71, P< 0.001). The combination of increased LAD and the CHA2DS2-VASc score improved the predictive power for stroke (C-stat 0.69, 95% CI 0.61-0.77 vs. C-stat 0.66, 95% CI 0.57-0.74, P= 0.013), and the combination of increased NT-proBNP and the CHA2DS2-VASc score improved the predictive power for death (C-stat 0.70, 95% CI 0.64-0.77 vs. C-stat 0.67, 95% CI 0.60--0.75, P= 0.023). CHA2DS2-VASc score is valuable for predicting stroke and death risk in patients with SSS after pacemaker implantation. The addition of LAD and NT-proBNP to the CHA2DS2-VASc score improved its predictive power for stroke and death, respectively, in this patient cohort. Future prospective studies are warranted to validate the benefit of adding LAD and NT-proBNP to the CHA2DS2-VASc score for predicting stroke and death risk in non-AF populations.

Bachmann bundle pacing reduces atrial electromechanical delay in type 1 myotonic dystrophy patients.

PubMed

Russo, Vincenzo; Rago, Anna; Papa, Andrea Antonio; Arena, Giulia; Politano, Luisa; Nigro, Gerardo

2018-04-01

Atrial electromechanical delay (AEMD) is an echocardiographic parameter correlated with the onset of supraventricular arrhythmias in several clinical conditions. Inter-atrial septal pacing in the region of Bachmann's bundle (BB) has been shown to be safe and feasible in myotonic dystrophy type 1 (DM1) patients, with a low rate of sensing and pacing defects. The aim of this study was to assess the impact of temporary BB pacing compared with right atrial appendage (RAA) pacing on AEMD in DM1 patients undergoing pacemaker (PM) implantation for cardiac rhythm abnormalities. The study enrolled 70 consecutive DM1 patients undergoing PM implantation for cardiac rhythm abnormalities in accordance with the current guidelines. Seventy age- and sex-matched non-DM1 patients undergoing dual-chamber PM implantation for cardiac rhythm abnormalities were used as controls. The atrial pacing lead was temporarily positioned in the RAA and on the right side of the inter-atrial septum in the region of Bachmann's bundle. For each site (BB and RAA), temporary atrial pacing in the AAI mode was established at 10 beats per minute above the sinus rate and a detailed trans-thoracic echocardiogram with tissue Doppler (TDI) analysis was recorded after at least 10 min of atrial pacing to evaluate AEMD. Temporary RAA pacing did not show statistically significant differences in inter-AEMD (48.2 ± 17.8 vs 50.5 ± 16.5 ms; P = 0.8), intra-left AEMD (43.3 ± 15.5 vs 44.6 ± 15.8 ms; P = 0.1), or intra-right-AEMD (14.1 ± 4.2 vs 15.4 ± 5.8 ms; P = 0.9), in comparison with sinus rhythm. Temporary BB pacing determined a significantly lower inter-AEMD (36.1 ± 17.1 vs 50.5 ± 16.5 ms; P = 0.001) and intra-left AEMD (32.5 ± 15.2 vs 44.6 ± 15.8 ms; P = 0.001) values in comparison with temporary RAA pacing. No statistically significant difference was found in intra-right AEMD (12.2 ± 4.6 vs 15.4 ± 5.8 ms; P = 0.2). In the control group, neither temporary RAA pacing nor temporary BB pacing showed statistically significant differences in inter-AEMD, intra-left AEMD, or intra-right AEMD values in comparison with sinus rhythm. In DM1 patients undergoing dual-chamber PM implantation, atrial pacing in the Bachmann bundle region is associated with significantly lower echocardiographic indices of atrial electromechanical delay (inter-AEMD and intra-left AEMD) in comparison with RAA pacing.

Intraatrial baffle repair of isolated ventricular inversion with left atrial isomerism.

PubMed

McElhinney, D B; Reddy, V M; Silverman, N H; Hanley, F L

1996-11-01

Isolated ventricular inversion with left atrial isomerism, partial anomalous pulmonary venous connection, and interruption of the inferior vena cava with azygos continuation to a right superior vena cava was diagnosed by echocardiography in a neonate. At 48 days of age, the patient underwent successful anatomic correction with redirection of flow from the superior vena cava and hepatic veins to the left-sided tricuspid valve, and flow from the pulmonary veins to the right-sided mitral valve. In the present report, the surgical techniques of this case are described, along with a survey of the surgical literature covering anatomic repair of isolated ventricular inversion.

Subvalvular pannus and thrombosis in a mitral valve prosthesis.

PubMed

Kim, Gun Ha; Yang, Dong Hyun; Kang, Joon-Won; Kim, Dae-Hee; Jung, Sung-Ho; Lim, Tae-Hwan

2016-01-01

A 69-year-old female underwent cardiac CT to evaluate prosthetic valve (PHV) dysfunction detected on echocardiography. A CT coronal and en face views of the mitral annular plane showed a low-density, mass-like lesion on the left atrial side of the PHV and a high-density, plate-like lesion on the left ventricular side of PHV. A repeat of the mitral valve replacement was performed, and preoperative CT findings of both the thrombus on the left atrial side and pannus formation on the LV side were confirmed in the operative findings. Copyright © 2016 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.

Usefulness of left ventricular speckle tracking echocardiography and novel measures of left atrial structure and function in diagnosing paroxysmal atrial fibrillation in ischemic stroke and transient ischemic attack patients.

PubMed

Skaarup, Kristoffer Grundtvig; Christensen, Hanne; Høst, Nis; Mahmoud, Masti Mahdy; Ovesen, Christian; Olsen, Flemming Javier; Jensen, Jan Skov; Biering-Sørensen, Tor

2017-12-01

Asymptomatic paroxysmal atrial fibrillation (PAF) is often assumed to be the cause of cryptogenic ischemic strokes (IS) and transient ischemic attacks (TIA). We examined the usefulness of measures obtained by 2D speckle tracking echocardiography and novel left atrial measurements, in the diagnosis of PAF in patients with IS and TIA. We retrospectively included 205 patients who after acute IS or TIA underwent an echocardiogram in sinus rhythm. Patients were designated as PAF-patients if they had one or more reported incidents of AF before or after their echocardiographic examination. None of the conventional echocardiographic parameters were significantly associated with PAF. Of the speckle tracking measurements, only early diastolic strain rate (0.7±0.2 s -1 vs. 0.8±0.3 s -1 , p = 0.048) and global longitudinal displacement (GLD) (3.15 ± 1.40 mm vs. 3.87 ± 1.56 mm, p = 0.007) proved significantly different. Of the left atrial parameters both minimal and maximal left atrium volume divided by left ventricular length (min LAV/LVL and max LAV/LVL, respectively) were significantly impaired (min LAV/LVL: 3.7 ± 2.1 cm 2 vs. 2.8 ± 1.11 cm 2 , p = 0.012; max LAV/LVL: 6.6 ± 3.1 cm 2 vs. 5.6 ± 1.7 cm 2 , p = 0.012). GLD, min max LAV/LVL proved significant after adjustment for age, gender, CHA 2 DS 2 -VASc and NIHSS. By combining information regarding age, GLD, min and max LAV/LVL the diagnostic accuracy of PAF improved, resulting in a significantly increased area under the curve (p = 0.037). In patients with IS and TIA GLD, min and max LAV/LVL were independently associated with the presence of PAF.

Pulmonary hypertension due to left heart disease: diagnostic and prognostic value of CT in chronic systolic heart failure.

PubMed

Colin, Geoffrey C; Gerber, Bernhard L; de Meester de Ravenstein, Christophe; Byl, David; Dietz, Anna; Kamga, Michele; Pasquet, Agnes; Vancraeynest, David; Vanoverschelde, Jean-Louis; D'Hondt, Anne-Marie; Ghaye, Benoit; Pouleur, Anne-Catherine

2018-05-14

To evaluate the ability of chest computed tomography (CT) to predict pulmonary hypertension (PH) and outcome in chronic heart failure with reduced ejection fraction (HFrEF). We reviewed 119 consecutive patients with HFrEF by CT, transthoracic echocardiography (TTE) and right heart catheterization (RHC). CT-derived pulmonary artery (PA) diameter and PA to ascending aorta diameter ratio (PA:A ratio), left atrial, right atrial, right ventricular (RV) and left ventricular volumes were correlated with RHC mean pulmonary arterial pressure (mPAP) . Diagnostic accuracy to predict PH and ability to predict primary composite endpoint of all-cause mortality and HF events were evaluated. RV volume was significantly higher in 81 patients with PH compared to 38 patients without PH (133 ml/m 2 vs. 79 ml/m 2 , p < 0.001) and was moderately correlated with mPAP (r=0.55, p < 0.001). Also, RV volume had higher ability to predict PH (area under the curve: 0.88) than PA diameter (0.79), PA:A ratio (0.76) by CT and tricuspid regurgitation gradient (0.83) and RV basal diameter by TTE (0.84, all p < 0.001). During the follow-up period (median: 3.4 years), 51 patients (43%) had HF events or died. After correction for important clinical, TTE and RHC parameters, RV volume (adjusted hazard ratio [HR]: 1.71, 95% CI 1.31-2.23, p < 0.001) and PA diameter (HR: 1.61, 95% CI 1.18-2.22, p = 0.003) were independent predictors of the primary endpoint. In patients with HFrEF, measurement of RV volume and PA diameter on ungated CT are non-invasive markers of PH and may help to predict the patient outcome. • Right ventricular (RV) volume measured by chest CT has good ability to identify pulmonary hypertension (PH) in patients with chronic heart failure (HF) and reduced ejection fraction (HFrEF). • The accuracy of pulmonary artery (PA) diameter and PA to ascending aorta diameter ratio (PA:A ratio) to predict PH was similar to previous studies, however, with lower cut-offs (28.1 mm and 0.92, respectively). • Chest CT-derived PA diameter and RV volume independently predict all-cause mortality and HF events and improve outcome prediction in patients with advanced HFrEF.

Diastolic heart failure associated with hemangiosarcoma infiltrating left ventricular walls in a dog

PubMed Central

Osuga, Tatsuyuki; Nakamura, Kensuke; Morita, Tomoya; Kagawa, Yumiko; Ohta, Hiroshi; Takiguchi, Mitsuyoshi

2017-01-01

A 9-year-old Shetland sheepdog was diagnosed with cardiogenic pulmonary edema. Echocardiography revealed focally thickened left ventricular free wall and interventricular septum and left atrial dilation. Left ventricular systolic function was preserved. Doppler echocardiography of transmitral flow indicated restrictive left ventricular filling. Cardiac histopathology demonstrated hemangiosarcoma infiltrating the left ventricular walls. PMID:29089652

Diastolic heart failure associated with hemangiosarcoma infiltrating left ventricular walls in a dog.

PubMed

Osuga, Tatsuyuki; Nakamura, Kensuke; Morita, Tomoya; Kagawa, Yumiko; Ohta, Hiroshi; Takiguchi, Mitsuyoshi

2017-11-01

A 9-year-old Shetland sheepdog was diagnosed with cardiogenic pulmonary edema. Echocardiography revealed focally thickened left ventricular free wall and interventricular septum and left atrial dilation. Left ventricular systolic function was preserved. Doppler echocardiography of transmitral flow indicated restrictive left ventricular filling. Cardiac histopathology demonstrated hemangiosarcoma infiltrating the left ventricular walls.

[Catheter ablation of ectopic incessant atrial tachycardia using radiofrequency. Reversion of tachycardiomyopathy].

PubMed

de Paola, A A; Mendonça, A; Balbão, C E; Tavora, M Z; da Silva, R M; Hara, V M; Guiguer Júnior, N; Vattimo, A C; Souza, I A; Portugal, O P

1993-10-01

A 8-year-old female patient with refractory incessant atrial tachycardia, very symptomatic and with left ventricular ejection fraction of 0.25. Electrophysiological study and endocardial mapping localized the site of the origin of atrial tachycardia in the superior right atrium. In this site 2 applications of radiofrequency current (25V, 20 and 50 seconds) resulted in termination of the atrial tachycardia. She was discharged off antiarrhythmic drugs and after 2 months ejection fraction was 0.52. She was completely asymptomatic 6 months after ablation procedure.

A flash from the past: a case on long term follow-up of a "corridor" operation.

PubMed

Ricciardi, Danilo; Sarkozy, Andrea; Wauters, Kristel; Brugada, Pedro

2013-01-01

An electrophysiological study in a patient with a previous corridor operation was performed because of syncope. The atrial electrograms showed the persistence of the sinus rhythm in the right atrial corridor despite an organized atrial fibrillation in the left atrium. The first case described of a long term follow-up in a corridor operation, one of the first described surgical approach for the treatment of atrial fibrillation, that gave the beginning to the non-pharmacological approach of this arrhythmia. Copyright © 2013 Elsevier Inc. All rights reserved.

Middle-term results of trans-catheter creation of atrial communication in patients receiving mechanical circulatory support.

PubMed

O'Byrne, Michael L; Glatz, Andrew C; Rossano, Joseph W; Schiavo, Kellie L; Dori, Yoav; Rome, Jonathan J; Gillespie, Matthew J

2015-06-01

To describe our center's middle-term outcomes following trans-catheter creation of atrial communication (ASD) in patients on mechanical circulatory support. Trans-catheter creation of an ASD in patients on mechanical circulatory support is an adjuvant therapy to reduce left atrial pressure and associated morbidity. Data on middle term outcomes following this procedure, specifically in regards to the fate of the ASD, are limited. Retrospective observational study of consecutive children and adults undergoing trans-catheter creation of an atrial septal communication between 1/1/2006 and 5/1/2014, reviewing their baseline characteristics, procedural details, and data from follow-up. Over the study period, 37/227 (16%) subjects undergoing veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) underwent trans-catheter creation of an atrial communication. Mortality on VA-ECMO support in this subgroup was 19%, with an additional 24% transitioning to ventricular assist device. Of the 57% who survived to separation from VA-ECMO, 16/21 (76%) had residual atrial communications. 56% of these underwent closure procedures. Following trans-catheter creation of ASD, a residual ASD is present in the majority of assessable survivors and represents a potential volume overload and/or right to left shunt that may need to be addressed. © 2015 Wiley Periodicals, Inc.

Cost-effectiveness analysis of left atrial appendage occlusion compared with pharmacological strategies for stroke prevention in atrial fibrillation.

PubMed

Lee, Vivian Wing-Yan; Tsai, Ronald Bing-Ching; Chow, Ines Hang-Iao; Yan, Bryan Ping-Yen; Kaya, Mehmet Gungor; Park, Jai-Wun; Lam, Yat-Yin

2016-08-31

Transcatheter left atrial appendage occlusion (LAAO) is a promising therapy for stroke prophylaxis in non-valvular atrial fibrillation (NVAF) but its cost-effectiveness remains understudied. This study evaluated the cost-effectiveness of LAAO for stroke prophylaxis in NVAF. A Markov decision analytic model was used to compare the cost-effectiveness of LAAO with 7 pharmacological strategies: aspirin alone, clopidogrel plus aspirin, warfarin, dabigatran 110 mg, dabigatran 150 mg, apixaban, and rivaroxaban. Outcome measures included quality-adjusted life years (QALYs), lifetime costs and incremental cost-effectiveness ratios (ICERs). Base-case data were derived from ACTIVE, RE-LY, ARISTOTLE, ROCKET-AF, PROTECT-AF and PREVAIL trials. One-way sensitivity analysis varied by CHADS2 score, HAS-BLED score, time horizons, and LAAO costs; and probabilistic sensitivity analysis using 10,000 Monte Carlo simulations was conducted to assess parameter uncertainty. LAAO was considered cost-effective compared with aspirin, clopidogrel plus aspirin, and warfarin, with ICER of US$5,115, $2,447, and $6,298 per QALY gained, respectively. LAAO was dominant (i.e. less costly but more effective) compared to other strategies. Sensitivity analysis demonstrated favorable ICERs of LAAO against other strategies in varied CHADS2 score, HAS-BLED score, time horizons (5 to 15 years) and LAAO costs. LAAO was cost-effective in 86.24 % of 10,000 simulations using a threshold of US$50,000/QALY. Transcatheter LAAO is cost-effective for prevention of stroke in NVAF compared with 7 pharmacological strategies. The transcatheter left atrial appendage occlusion (LAAO) is considered cost-effective against the standard 7 oral pharmacological strategies including acetylsalicylic acid (ASA) alone, clopidogrel plus ASA, warfarin, dabigatran 110 mg, dabigatran 150 mg, apixaban, and rivaroxaban for stroke prophylaxis in non-valvular atrial fibrillation management.

Atrial isomerism: a surgical experience.

PubMed

Sinzobahamvya, N; Arenz, C; Brecher, A M; Urban, A E

1999-06-01

Most publications on atrial isomerism are autopsy or case reports. The authors review 41 consecutive children operated on from 1980 through to 1996 with emphasis on associated cardiac anomalies, surgical procedures and outcome. Left atrial isomerism was present in 23 patients. Interruption of the inferior vena cava (56%), atrio-ventricular septal defect (47%), common atrium (38%) and cor triatriatum sinistrum (30%) were the most common diagnoses. Biventricular repair was achieved in 17 children and total cavo-pulmonary connection in two. Three underwent staged palliation: modified Blalock-Taussig shunt for two and bidirectional Glenn anastomosis for one. The remainder received a cardiac pacemaker. One patient died early after repair. Two underwent reoperation to correct a regurgitant left atrio-ventricular valve: one of these, in another hospital, had peroperative death. Three died later. Actuarial survival rate after repair and total cavo-pulmonary connection that was stabilized after 2 years was 84%. In the 18 children with right atrial isomerism, pulmonary atresia or stenosis predominated (89%) with discordant ventriculo-arterial connection (72%), atrio-ventricular septal defect (72%), 'single' ventricle (55%) and extracardiac total anomalous pulmonary venous drainage (50%). Biventricular repair was achieved in two patients and complete Fontan circulation in eight. The other eight underwent various staged palliative procedures and correction of extracardiac total anomalous pulmonary venous drainage. Five patients died postoperatively: two in our unit after modified Blalock-Taussig shunt and total cavo-pulmonary connection, three in other hospitals after repair (n = 1) and Fontan (n = 2). Five died later. One was lost for review. Survival after repair and Fontan stabilized after 6 months at 49%. In conclusion, the cardiovascular malformations associated with left atrial isomerism can often be successfully corrected. Those accompanying right atrial isomerism usually preclude a biventricular repair, require staged palliation and carry a poor prognosis.

Left atrial thrombus and dense spontaneous echocardiographic contrast in patients on continuous direct oral anticoagulant therapy undergoing catheter ablation of atrial fibrillation: Comparison of dabigatran, rivaroxaban, and apixaban.

PubMed

Wu, Michael; Gabriels, James; Khan, Mohammad; Shaban, Nada; D'Amato, Salvatore; Liu, Christopher F; Markowitz, Steven M; Ip, James E; Thomas, George; Singh, Parmanand; Lerman, Bruce; Patel, Apoor; Cheung, Jim W

2018-04-01

Left atrial thrombus (LAT) and dense spontaneous echocardiographic contrast (SEC) detected by transesophageal echocardiography (TEE) in patients on continuous direct oral anticoagulants (DOAC) therapy before catheter ablation of atrial fibrillation (AF) or atrial flutter (AFL) have been described. We sought to compare rates of TEE-detected LAT and dense SEC among patients taking different DOACs. We evaluated 609 consecutive patients from 3 tertiary hospitals (median age 65 years; interquartile range 58-71 years; 436 (72%) men) who were on ≥4 weeks of continuous DOAC therapy (dabigatran, n = 166 [27%]; rivaroxaban, n = 257 [42%]; or apixaban, n = 186 [31%]) undergoing TEE before catheter ablation of AF/AFL. Demographic, clinical, and TEE data were collected for each patient. Despite ≥4 weeks of continuous DOAC therapy, 17 patients (2.8%) had LAT and 15 patients (2.5%) had dense SEC detected by TEE. The rates of LAT were 3.0%, 3.5%, and 1.6% for patients on dabigatran, rivaroxaban, and apixaban, respectively (P = .482). The rates of dense SEC were 1.2%, 3.5%, and 2.2% for patients on dabigatran, rivaroxaban, and apixaban, respectively (P = .299). Congestive heart failure (odds ratio 4.4; 95% confidence interval 1.6-12; P = .003) and moderate/severe left atrial enlargement (odds ratio 3.1; 95% confidence interval 1.1-8.6; P = .026) were independent predictors of LAT. In this study, ∼3% of patients on continuous DOAC therapy had LAT detected before catheter ablation of AF/AFL. Specific DOAC therapy did not significantly affect the rates of LAT detection. Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Quantification of left and right atrial kinetic energy using four-dimensional intracardiac magnetic resonance imaging flow measurements.

PubMed

Arvidsson, Per M; Töger, Johannes; Heiberg, Einar; Carlsson, Marcus; Arheden, Håkan

2013-05-15

Kinetic energy (KE) of atrial blood has been postulated as a possible contributor to ventricular filling. Therefore, we aimed to quantify the left (LA) and right (RA) atrial blood KE using cardiac magnetic resonance (CMR). Fifteen healthy volunteers underwent CMR at 3 T, including a four-dimensional phase-contrast flow sequence. Mean LA KE was lower than RA KE (1.1 ± 0.1 vs. 1.7 ± 0.1 mJ, P < 0.01). Three KE peaks were seen in both atria: one in ventricular systole, one during early ventricular diastole, and one during atrial contraction. The systolic LA peak was significantly smaller than the RA peak (P < 0.001), and the early diastolic LA peak was larger than the RA peak (P < 0.05). Rotational flow contained 46 ± 7% of total KE and conserved energy better than nonrotational flow did. The KE increase in early diastole was higher in the LA (P < 0.001). Systolic KE correlated with the combination of atrial volume and systolic velocity of the atrioventricular plane displacement (r(2) = 0.57 for LA and r(2) = 0.64 for RA). Early diastolic KE of the LA correlated with left ventricle (LV) mass (r(2) = 0.28), however, no such correlation was found in the right heart. This suggests that LA KE increases during early ventricular diastole due to LV elastic recoil, indicating that LV filling is dependent on diastolic suction. Right ventricle (RV) relaxation does not seem to contribute to atrial KE. Instead, RA KE generated during ventricular systole may be conserved in a hydraulic "flywheel" and transferred to the RV through helical flow, which may contribute to RV filling.

The immunohistochemical evaluation of selected markers in the left atrium of dogs with end-stage dilated cardiomyopathy and myxomatous mitral valve disease - a preliminary study.

PubMed

Janus, Izabela; Kandefer-Gola, Małgorzata; Ciaputa, Rafał; Noszczyk-Nowak, Agnieszka; Pasławska, Urszula; Tursi, Massimiliano; Nowak, Marcin

2016-01-01

Dilated cardiomyopathy (DCM) and myxomatous mitral valve disease (MMVD) are the most common diseases noted in dogs. Although their pathogenesis varies, both include a significant enlargement of the left atrium. The study was carried out on left atrial specimens obtained from 56 dogs, including those from 34 dogs with clinically diagnosed MMVD, 15 dogs with DCM and 7 dogs without heart disease (control group). Dogs in the MMVD and the DCM groups presented with left atrial enlargement and stage D heart failure. The specimens underwent immunohistochemical examination using desmin, vimentin, periostin and caspase-3 antibodies. There were alterations in the expression of the studied proteins in the study groups compared to the control group. The changes included: irregularity of desmin cross-striation and desmosomes, a higher amount of vimentin-positive cells, a change in the periostin expression pattern from cytoplasmic to extracellular, and a lower expression of caspase-3. The alterations were more pronounced in the DCM group than in the MMVD group. During heart failure, the pattern of desmin, vimentin, periostin and caspase-3 expression alters in the left atrium, regardless of the cause. The changes are more pronounced in dogs with DCM than in dogs with MMVD and similar left atrial enlargement, suggesting that volume overload may not be the only cause of myocardial changes in DCM.

Distinct myocardial lineages break atrial symmetry during cardiogenesis in zebrafish

PubMed Central

Stone, Oliver; Arnaout, Rima; Guenther, Stefan; Ahuja, Suchit; Uribe, Verónica; Vanhollebeke, Benoit; Stainier, Didier YR

2018-01-01

The ultimate formation of a four-chambered heart allowing the separation of the pulmonary and systemic circuits was key for the evolutionary success of tetrapods. Complex processes of cell diversification and tissue morphogenesis allow the left and right cardiac compartments to become distinct but remain poorly understood. Here, we describe an unexpected laterality in the single zebrafish atrium analogous to that of the two atria in amniotes, including mammals. This laterality appears to derive from an embryonic antero-posterior asymmetry revealed by the expression of the transcription factor gene meis2b. In adult zebrafish hearts, meis2b expression is restricted to the left side of the atrium where it controls the expression of pitx2c, a regulator of left atrial identity in mammals. Altogether, our studies suggest that the multi-chambered atrium in amniotes arose from a molecular blueprint present before the evolutionary emergence of cardiac septation and provide insights into the establishment of atrial asymmetry. PMID:29762122

Left ventricular obstruction with restrictive inter-atrial communication leads to retardation in fetal lung maturation.

PubMed

Goltz, Diane; Lunkenheimer, Jean-Marc; Abedini, Mojtaba; Herberg, Ulrike; Berg, Christoph; Gembruch, Ulrich; Fischer, Hans-Peter

2015-05-01

Intact atrial septum or highly restrictive inter-atrial communication (I/HRAS) combined with either severe aortic stenosis (SAS) or hypoplastic left heart syndrome (HLHS), respectively, is associated with adverse outcome. This study focusses on changes in alveolo-septal lung parenchyma due to increased left atrial pressure. In a retrospective cross-sectional autoptic study, we investigated fetal/neonatal lung specimens of 18 patients with SAS/HLHS with I/HRAS, 11 patients with SAS/HLHS and unrestrictive inter-atrial communications and 18 controls. Pulmonary maturation was investigated by means of morphometric and immunohistochemical analyses. In a comparison of all three groups, alveolo-capillary membrane maturation was significantly disturbed in I/HRAS fetuses from week 23 of pregnancy on. I/HRAS lungs showed angiomatoid hyper-capillarisation and significantly wider inter-airspace mesenchyme. Differences in width ranged between 34.58 µm (95% CI: 11.41-57.75 µm) and 46.74 µm (95% CI: 13.97-79.50 µm) in the second and third trimesters. In I/HRAS infants with HLHS, inter-airspace mesenchymal diameters steadily normalised with age; however, significant fibroelastosis of alveolar septae developed. Fetal lung maturation with respect to alveolo-capillary membrane formation is severely disordered in patients with SAS/HLHS with I/HRAS. Our findings indicate that, from a morphological point of view, timing of fetal invention in fetuses with I/HRAS should be fixed within the second trimester of pregnancy. © 2015 John Wiley & Sons, Ltd.

Validation of geometric measurements of the left atrium and pulmonary veins for analysis of reverse structural remodeling following ablation therapy

NASA Astrophysics Data System (ADS)

Rettmann, M. E.; Holmes, D. R., III; Gunawan, M. S.; Ge, X.; Karwoski, R. A.; Breen, J. F.; Packer, D. L.; Robb, R. A.

2012-03-01

Geometric analysis of the left atrium and pulmonary veins is important for studying reverse structural remodeling following cardiac ablation therapy. It has been shown that the left atrium decreases in volume and the pulmonary vein ostia decrease in diameter following ablation therapy. Most analysis techniques, however, require laborious manual tracing of image cross-sections. Pulmonary vein diameters are typically measured at the junction between the left atrium and pulmonary veins, called the pulmonary vein ostia, with manually drawn lines on volume renderings or on image cross-sections. In this work, we describe a technique for making semi-automatic measurements of the left atrium and pulmonary vein ostial diameters from high resolution CT scans and multi-phase datasets. The left atrium and pulmonary veins are segmented from a CT volume using a 3D volume approach and cut planes are interactively positioned to separate the pulmonary veins from the body of the left atrium. The cut plane is also used to compute the pulmonary vein ostial diameter. Validation experiments are presented which demonstrate the ability to repeatedly measure left atrial volume and pulmonary vein diameters from high resolution CT scans, as well as the feasibility of this approach for analyzing dynamic, multi-phase datasets. In the high resolution CT scans the left atrial volume measurements show high repeatability with approximately 4% intra-rater repeatability and 8% inter-rater repeatability. Intra- and inter-rater repeatability for pulmonary vein diameter measurements range from approximately 2 to 4 mm. For the multi-phase CT datasets, differences in left atrial volumes between a standard slice-by-slice approach and the proposed 3D volume approach are small, with percent differences on the order of 3% to 6%.

Left ventricular to left atrial communication secondary to a paraaortic abscess: color flow Doppler documentation.

PubMed

Fisher, E A; Estioko, M R; Stern, E H; Goldman, M E

1987-07-01

Aortic root abscess occurs frequently in aortic prosthetic valve infective endocarditis. The present echocardiographic report documents a ruptured abscess that led to a direct communication between the left ventricular outflow tract and the left atrium confirmed by real-time (color flow) Doppler imaging.

Effect of Sex Differences on the Association Between Stroke Risk and Left Atrial Anatomy or Mechanics in Patients With Atrial Fibrillation.

PubMed

Yoshida, Kuniko; Obokata, Masaru; Kurosawa, Koji; Sorimachi, Hidemi; Kurabayashi, Masahiko; Negishi, Kazuaki

2016-10-01

Embolic stroke in atrial fibrillation is more prevalent in women than in men, yet the basis for this difference remains unclear. This study seeks to elucidate whether there are any sex differences in the relationships between stroke risk (CHADS 2 score, CHA 2 DS 2 -VASc score without a sex category, and estimated stroke rate) and left atrial (LA) anatomy or mechanics in patients with atrial fibrillation. LA emptying fraction and global peak atrial longitudinal strain were assessed in 414 subjects with paroxysmal or persistent atrial fibrillation (156 women and 258 men). Linear regression models with an interaction term were performed to test the effect of sex difference on associations between the embolic risk and LA function or anatomy. Sensitivity analyses were performed in 228 age, heart rate, and rhythm-matched subjects (114 women and men). Women were older and had larger LA volumes and lower LA mechanics than men. Significant negative association between the CHADS 2 score and LA emptying fraction was only demonstrated in women with a significant interaction between sexes. Similar significant interactions were found in global peak atrial longitudinal strain but not in LA volume. These findings were corroborated in the comparisons against CHA 2 DS 2 -VASc score without a sex category and the estimated stroke rate. Sensitivity analyses in the matched subgroup also confirmed the robustness of these sex differences in LA emptying fraction, but less so in global peak atrial longitudinal strain. Significant sex interactions on the association between global LA function and risk stratification schemes exist, which may be a reason for the higher prevalence of embolic stroke in women. © 2016 American Heart Association, Inc.

The effect of antithyroid treatment on atrial conduction times in patients with subclinical hyperthyroidism.

PubMed

Nacar, Alper Buğra; Acar, Gürkan; Yorgun, Hikmet; Akçay, Ahmet; Özkaya, Mesut; Canpolat, Uğur; Akkoyun, Murat; Tuncer, Cemal

2012-09-01

Prolonged atrial conduction time measured by tissue Doppler imaging (TDI) has been associated with increased risk of atrial fibrillation. We aimed to evaluate the effect of subclinical hyperthyroidism (SH) and antithyroid treatment on atrial conduction time. A total of 30 patients with SH (26 females; mean age 34.8 ± 8.5 years) and 30 age- and gender-matched controls were included. Using TDI, atrial conduction time was measured from the lateral mitral annulus, septal mitral annulus, and lateral tricuspid annulus. Intra- and interatrial conduction delay were calculated. TDI and thyroid hormone levels were studied at the time of enrollment and after achievement of euthyroid state with propylthiouracil treatment. Patients were followed for 14 ± 3 weeks. Atrial conduction time at the lateral and septal mitral annulus were significantly higher in patients with SH compared to controls. Both inter-, right, and left intraatrial electromechanical delay were prolonged in patients with SH compared to control subjects (21.3 ± 6.1 vs. 13.9 ± 4.3, P < 0.001 and 4.2 ± 3.5 vs. 2.3 ± 1.9, P = 0.014 and 17.1 ± 6.0 vs. 11.6 ± 3.8, P < 0.001, respectively). After achievement of euthyroid state, inter- and left intraatrial electromechanical delay were significantly decreased compared to baseline values and approximated to the values of the control group (P < 0.001). SH is associated with prolonged atrial conduction time. After achievement of euthyroid state, decrement in atrial conduction time may reveal how the antithyroid treatment may prevent the development of atrial fibrillation in these patients. © 2012, Wiley Periodicals, Inc.

Pathophysiologic correlates of thromboembolism in nonvalvular atrial fibrillation: I. Reduced flow velocity in the left atrial appendage (The Stroke Prevention in Atrial Fibrillation [SPAF-III] study).

PubMed

Goldman, M E; Pearce, L A; Hart, R G; Zabalgoitia, M; Asinger, R W; Safford, R; Halperin, J L

1999-12-01

Stroke associated with atrial fibrillation (AF) is mainly due to embolism of thrombus formed during stasis of blood in the left atrial appendage (LAA). Pathophysiologic correlates of appendage flow velocity as assessed by transesophageal echocardiography (TEE) in patients with AF have not been defined. To evaluate the hypothesis that reduced velocity is associated with spontaneous echocardiographic contrast and thrombus in the LAA and with clinical embolic events, we measured LAA flow velocity by TEE in 721 patients with nonvalvular AF entering the Stroke Prevention in Atrial Fibrillation (SPAF-III) study. Patient features, TEE findings, and subsequent cardioembolic events were correlated with velocity by multivariate analysis. Patients in AF during TEE displayed lower peak antegrade (emptying) flow velocity (Anu(p)) than those with intermittent AF in sinus rhythm during TEE (33 cm/s vs 61 cm/s, respectively, P <.0001). Anu(p) < 20 cm/s was associated with dense spontaneous echocardiographic contrast (P <.001), appendage thrombus (P <.01), and subsequent cardioembolic events (P <.01). Independent predictors of Anu(p) < 20 cm/s included age (P =.009), systolic blood pressure (P <.001), sustained AF (P =.01), ischemic heart disease (P =.01), and left atrial area (P =.04). Multivariate analysis found both Anu(p) <20 cm/s (relative risk 2.6, P =.02) and clinical risk factors (relative risk 3.3, P =.002) independently associated with LAA thrombus. LAA Anu(p) is reduced in AF and associated with spontaneous echocardiographic contrast, appendage thrombus, and cardioembolic stroke. Systolic hypertension and aortic atherosclerosis, independent clinical predictors of stroke in patients with AF, also correlated with LAA Anu(p). Our results support the role of reduced LAA Anu(p) in the generation of stasis, thrombus formation, and embolism in patients with AF, although other mechanisms also contribute to stroke.

Left atrial volume assessment in atrial fibrillation using multimodality imaging: a comparison of echocardiography, invasive three-dimensional CARTO and cardiac magnetic resonance imaging.

PubMed

Rabbat, Mark G; Wilber, David; Thomas, Kevin; Malick, Owais; Bashir, Atif; Agrawal, Anoop; Biswas, Santanu; Sanagala, Thriveni; Syed, Mushabbar A

2015-06-01

Left atrial size in atrial fibrillation is a strong predictor of successful ablation and cardiovascular events. Cardiac magnetic resonance multislice method (CMR-MSM) is the current gold standard for left atrial volume (LAV) assessment but is time consuming. We investigated whether LAV with more rapid area-length method by echocardiography (Echo-AL) or cardiac magnetic resonance (CMR-AL) and invasive measurement by 3D-CARTO mapping during ablation correlate with the CMR-MSM. We studied 250 consecutive patients prior to atrial fibrillation ablation. CMR images were acquired on 3T scanner to measure LAV by MSM and biplane area-length method. Standard echocardiography views were used to calculate LAV by biplane area-length method. LAV during ablation was measured by 3D-CARTO mapping. LAV was compared using intra-class correlation (ICC), Pearson's correlation and Bland-Altman plots. CMR-MSM was used as the reference standard. Mean LAV using CMR-MSM was 112.7 ± 36.7 ml. CMR-AL method overestimated LAV by 13.3 ± 21.8 ml (11.2%, p < 0.005) whereas 3D-CARTO and Echo-AL underestimated LAV by 8.3 ± 22.6 and 24.0 ± 27.6 ml respectively (8.7% and 20.0% respectively, p < 0.005). There was no significant difference between paroxysmal and persistent atrial fibrillation. CMR-AL and 3D-CARTO correlated and agreed well with CMR-MSM (r = 0.87 and 0.74, ICC = 0.80 and 0.77 respectively). However, Echo-AL had poor correlation and agreement with CMR-MSM (r = 0.66 and ICC = 0.48). Bland-Altman plots confirmed these findings. CMR-AL method may be used as an alternative to CMR-MSM, as it is non-invasive, rapid, and correlates well with CMR-MSM. LAV by different modalities should not be used interchangeably.

Low Energy Multi-Stage Atrial Defibrillation Therapy Terminates Atrial Fibrillation with Less Energy than a Single Shock

PubMed Central

Li, Wenwen; Janardhan, Ajit H.; Fedorov, Vadim V.; Sha, Qun; Schuessler, Richard B.; Efimov, Igor R.

2011-01-01

Background Implantable device therapy of atrial fibrillation (AF) is limited by pain from high-energy shocks. We developed a low-energy multi-stage defibrillation therapy and tested it in a canine model of AF. Methods and Results AF was induced by burst pacing during vagus nerve stimulation. Our novel defibrillation therapy consisted of three stages: ST1 (1-4 low energy biphasic shocks), ST2 (6-10 ultra-low energy monophasic shocks), and ST3 (anti-tachycardia pacing). Firstly, ST1 testing compared single or multiple monophasic (MP) and biphasic (BP) shocks. Secondly, several multi-stage therapies were tested: ST1 versus ST1+ST3 versus ST1+ST2+ST3. Thirdly, three shock vectors were compared: superior vena cava to distal coronary sinus (SVC>CSd), proximal coronary sinus to left atrial appendage (CSp>LAA) and right atrial appendage to left atrial appendage (RAA>LAA). The atrial defibrillation threshold (DFT) of 1BP shock was less than 1MP shock (0.55 ± 0.1 versus 1.38 ± 0.31 J; p =0.003). 2-3 BP shocks terminated AF with lower peak voltage than 1BP or 1MP shock and with lower atrial DFT than 4 BP shocks. Compared to ST1 therapy alone, ST1+ST3 lowered the atrial DFT moderately (0.51 ± 0.46 versus 0.95 ± 0.32 J; p = 0.036) while a three-stage therapy, ST1+ST2+ST3, dramatically lowered the atrial DFT (0.19 ± 0.12 J versus 0.95 ± 0.32 J for ST1 alone, p=0.0012). Finally, the three-stage therapy ST1+ST2+ST3 was equally effective for all studied vectors. Conclusions Three-stage electrotherapy significantly reduces the AF defibrillation threshold and opens the door to low energy atrial defibrillation at or below the pain threshold. PMID:21980076

Radiofrequency Ablation of Left Atrial Reentrant Tachycardias in Rheumatic Mitral Valve Disease: A Case Series.

PubMed

Prabhu, Mukund A; Thajudeen, Anees; Vk, Ajit Kumar; J, Tharakan; B V, Prasad Srinivas; Namboodiri, Narayanan

2017-01-01

Left atrial (LA) reentrant tachycardias are not uncommon in regions where rheumatic heart disease is prevalent. Some of these arrhythmias may be curable by radiofrequency ablation (RFA). However, there are limited data pertaining to this in existing literature. Three patients who had rheumatic mitral valve disease with past history of surgical-/catheter-based intervention and having no significant residual disease had symptomatic atrial flutter despite optimal medical management. An electrophysiological study confirmed an LA focal/micro-reentrant mechanism in all. There was patchy scarring of the LA, and successful RFA of these arrhythmias could be achieved. The focal nature of the scar in these patients may suggest that the rheumatic involvement of the atrium or the hemodynamic consequence of the vulvar lesion causes nonuniform insult to the atrial tissue and limited scar. At least in some patients with limited scarring, early RFA may help in the maintenance of sinus rhythm. © 2016 Wiley Periodicals, Inc.

Transcatheter closure of a small atrial septal defect with an Amplatzer™ patent foramen ovale occluder in a working dog with cyanosis and exercise intolerance at high altitude.

PubMed

Shelden, A; Wesselowski, S; Gordon, S G; Saunders, A B

2017-12-01

A 6.5-year-old male Border Collie presented for transcatheter closure of an atrial septal defect due to exercise intolerance and cyanosis while working and training at altitude. A small, left-to-right shunting secundum atrial septal defect was confirmed with no evidence of significant right-sided volume overload. Pulmonary hypertension with subsequent right-to-left interatrial shunting occurring during exercise at high altitude was suspected and prompted the closure of the defect due to the dog's continued athletic requirements. The anatomy of the defect prompted use of a patent foramen ovale occluder rather than an atrial septal defect occluder, which was deployed using a combination of fluoroscopic and transesophageal echocardiographic guidance. The owner did not report continued exercise intolerance or cyanosis and the dog's lifestyle and residence at altitude was unchanged. Copyright © 2017 Elsevier B.V. All rights reserved.

Standardization of left atrial, right ventricular, and right atrial deformation imaging using two-dimensional speckle tracking echocardiography: a consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging.

PubMed

Badano, Luigi P; Kolias, Theodore J; Muraru, Denisa; Abraham, Theodore P; Aurigemma, Gerard; Edvardsen, Thor; D'Hooge, Jan; Donal, Erwan; Fraser, Alan G; Marwick, Thomas; Mertens, Luc; Popescu, Bogdan A; Sengupta, Partho P; Lancellotti, Patrizio; Thomas, James D; Voigt, Jens-Uwe

2018-03-27

The EACVI/ASE/Industry Task Force to standardize deformation imaging prepared this consensus document to standardize definitions and techniques for using two-dimensional (2D) speckle tracking echocardiography (STE) to assess left atrial, right ventricular, and right atrial myocardial deformation. This document is intended for both the technical engineering community and the clinical community at large to provide guidance on selecting the functional parameters to measure and how to measure them using 2D STE.This document aims to represent a significant step forward in the collaboration between the scientific societies and the industry since technical specifications of the software packages designed to post-process echocardiographic datasets have been agreed and shared before their actual development. Hopefully, this will lead to more clinically oriented software packages which will be better tailored to clinical needs and will allow industry to save time and resources in their development.

Isolation of canine coronary sinus musculature from the atria by radiofrequency catheter ablation prevents induction of atrial fibrillation.

PubMed

Morita, Hiroshi; Zipes, Douglas P; Morita, Shiho T; Wu, Jiashin

2014-12-01

The junction between the coronary sinus (CS) musculature and both atria contributes to initiation of atrial tachyarrhythmias. The current study investigated the effects of CS isolation from the atria by radiofrequency catheter ablation on the induction and maintenance of atrial fibrillation (AF). Using an optical mapping system, we mapped action potentials at 256 surface sites in 17 isolated and arterially perfused canine atrial tissues containing the entire musculature of the CS, right atrial septum, posterior left atrium, left inferior pulmonary vein, and vein of Marshal. Rapid pacing from each site before and after addition of acetylcholine (0.5 μmol/L) was applied to induce AF. Epicardial radiofrequency catheter ablation at CS-atrial junctions isolated the CS from the atria. Rapid pacing induced sustained AF in all tissues after acetylcholine. Microreentry within the CS drove AF in 88% of preparations. Reentries associated with the vein of Marshall (29%), CS-atrial junctions (53%), right atrium (65%), and pulmonary vein (76%) (frequently with 2-4 simultaneous circuits) were additional drivers of AF. Radiofrequency catheter ablation eliminated AF in 13 tissues before acetylcholine (P<0.01) and in 5 tissues after acetylcholine. Radiofrequency catheter ablation also abbreviated the duration of AF in 12 tissues (P<0.01). CS and its musculature developed unstable reentry and AF, which were prevented by isolation of CS musculature from atrial tissue. The results suggest that CS can be a substrate of recurrent AF in patients after pulmonary vein isolation and that CS isolation might help prevent recurrent AF. © 2014 American Heart Association, Inc.

Left atrial function: evaluation by strain analysis

PubMed Central

Gan, Gary C. H.; Ferkh, Aaisha; Boyd, Anita

2018-01-01

The left atrium has an important role in modulating left ventricular filling and is an important biomarker of cardiovascular disease and adverse cardiovascular outcomes. While previously left atrial (LA) size was utilised, the role of LA function as a biomarker is increasingly being evaluated, both independently and also in combination with LA size. Strain analysis has been utilised for evaluation of LA function and can be measured throughout the cardiac cycle, thereby enabling the evaluation of LA reservoir, conduit and contractile function. Strain evaluates myocardial deformation while strain rate examines the rate of change in strain. This review will focus on the various types of strain analysis for evaluation of LA function, alterations in LA strain in physiological and pathologic states that alter LA function and finally evaluate its utility as a prognostic marker. PMID:29541609

Role of cardiac imaging and three-dimensional printing in percutaneous appendage closure.

PubMed

Iriart, Xavier; Ciobotaru, Vlad; Martin, Claire; Cochet, Hubert; Jalal, Zakaria; Thambo, Jean-Benoit; Quessard, Astrid

2018-06-06

Atrial fibrillation is the most frequent cardiac arrhythmia, affecting up to 13% of people aged>80 years, and is responsible for 15-20% of all ischaemic strokes. Left atrial appendage occlusion devices have been developed as an alternative approach to reduce the risk of stroke in patients for whom oral anticoagulation is contraindicated. The procedure can be technically demanding, and obtaining a complete left atrial appendage occlusion can be challenging. These observations have emphasized the importance of preprocedural planning, to optimize the accuracy and safety of the procedure. In this setting, a multimodality imaging approach, including three-dimensional imaging, is often used for preoperative assessment and procedural guidance. These imaging modalities, including transoesophageal echocardiography and multislice computed tomography, allow acquisition of a three-dimensional dataset that improves understanding of the cardiac anatomy; dedicated postprocessing software integrated into the clinical workflow can be used to generate a stereolithography file, which can be printed in a rubber-like material, seeking to replicate the myocardial tissue characteristics and mechanical properties of the left atrial appendage wall. The role of multimodality imaging and 3D printing technology offers a new field for implantation simulation, which may have a major impact on physician training and technique optimization. Copyright © 2018 Elsevier Masson SAS. All rights reserved.

EWOLUTION: Design of a registry to evaluate real-world clinical outcomes in patients with AF and high stroke risk-treated with the WATCHMAN left atrial appendage closure technology.

PubMed

Boersma, Lucas V A; Schmidt, Boris; Betts, Tim R; Sievert, Horst; Tamburino, Corrado; Teiger, Emmanuel; Stein, Kenneth M; Bergmann, Martin W

2016-09-01

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and the rate of ischemic stroke attributed to non-valvular AF is estimated at 5% per year. Several multi-center studies established left atrial appendage closure as a safe and effective alternative to oral anticoagulation, but there is a need for additional real world data. The purpose of this observational, prospective, single-arm, multicenter clinical study is to compile real-world clinical outcome data for WATCHMAN™ LAA (left atrial appendage) Closure Technology. One thousand subjects at up to 70 institutions in Europe, the Middle East, and Russia will be enrolled. Patients will be followed for 2 years after WATCHMAN implantation, according to standard medical practice. Primary endpoints include procedural and long-term data including stroke/embolism, bleeding, and death. This article presents the background of the LAAC device and describes the design of the study. Results for peri-procedural analyses are expected toward the end of 2015; long-term follow-up data are expected in the latter half of 2017. The EWOLUTION study will formally expand knowledge of LAA closure into a broader real world setting. © 2015 Wiley Periodicals, Inc. © 2015 Wiley Periodicals, Inc.

Outcomes and costs of left atrial appendage closure from randomized controlled trial and real-world experience relative to oral anticoagulation.

PubMed

Panikker, Sandeep; Lord, Joanne; Jarman, Julian W E; Armstrong, Shannon; Jones, David G; Haldar, Shouvik; Butcher, Charles; Khan, Habib; Mantziari, Lilian; Nicol, Edward; Hussain, Wajid; Clague, Jonathan R; Foran, John P; Markides, Vias; Wong, Tom

2016-12-07

The aim of this study was to analyse randomized controlled study and real-world outcomes of patients with non-valvular atrial fibrillation (NVAF) undergoing left atrial appendage closure (LAAC) with the Watchman device and to compare costs with available antithrombotic therapies. Registry data of LAAC from two centres were prospectively collected from 110 patients with NVAF at risk of stroke, suitable and unsuitable for long-term anticoagulation (age 71.3 ± 9.2 years, CHADS 2 2.8 ± 1.2, CHA 2 DS 2 -VASc 4.5 ± 1.6, and HAS-BLED 3.8 ± 1.1). Outcomes from PROTECT AF and registry study LAAC were compared with warfarin, dabigatran, rivaroxaban, apixaban, aspirin, and no treatment using a network meta-analysis. Costs were estimated over a 10-year horizon. Uncertainty was assessed using sensitivity analyses. The procedural success rate was 92% (103/112). Follow-up was 24.1 ± 4.6 months, during which annual rates of stroke, major bleeding, and all-cause mortality were 0.9% (2/223 patient-years), 0.9% (2/223 patient-years), and 1.8% (4/223 patient-years), respectively. Anticoagulant therapy was successfully stopped in 91.2% (93/102) of implanted patients by 12 months. Registry study LAAC stroke and major bleeding rates were significantly lower than PROTECT AF results: mean absolute difference of stroke, 0.89% (P = 0.02) and major bleeding, 5.48% (P < 0.001). Left atrial appendage closure achieved cost parity between 4.9 years vs. dabigatran 110 mg and 8.4 years vs. warfarin. At 10 years, LAAC was cost-saving against all therapies (range £1162-£7194). Left atrial appendage closure in NVAF in a real-world setting may result in lower stroke and major bleeding rates than reported in LAAC clinical trials. Left atrial appendage closure in both settings achieves cost parity in a relatively short period of time and may offer substantial savings compared with current therapies. Savings are most pronounced among higher risk patients and those unsuitable for anticoagulation. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.

Three-dimensional echocardiographic measurements using automated quantification software for big data processing.

PubMed

Feng, Cheng; Chen, Lixin; Li, Jian; Wang, Jiangtao; Dong, Fajin; Xu, Jinfeng

2017-01-01

To compare a full-automated software to quantify 3D transthoracic echocardiography namely, 3DE-HM (three-dimensional echocardiography HeartModel, Philips Healthcare) with the traditional manual quantitative method (3DE-manual) for assessing volumes of left atrial and ventricular volumes, and left ventricular ejection fraction (LVEF). 3D full volume images acquired from 156 subjects were collected and divided into 3 groups, which include 70 normal control cases (Group A), 17 patients with left ventricular remodeling after acute myocardial infarction (AMI) (Group B), and 69 patients with left atrial remodeling secondary to hypertension (Group C). The 3DE-HM method was used to quantify left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), left atrial end-systolic volume (LAESV), and left ventricular ejection fraction (LVEF), respectively. The results were compared with those obtained with the 3DE-manual method for correlation and consistency analyses. The reproducibility of the 3DE-HM method was also evaluated. There was a high correlation between LVEDV, LVESV, LAESV and LVEF values obtained with the 3DE-HM method and those obtained using the 3DE-manual method (r = 0.72 to 0.97). The correlation was strongest for Group B, patients with left ventricular remodeling post-AMI also demonstrated the greatest degree of morphologic changes. There was a significant difference in all parameters measured with the 3DE-HM method in different groups (P < 0.05). The difference in the measurements of LVEDV and LVESV between the two methods was greatest in patients in Group B compared with patients with hypertension-induced left ventricular remodeling (Group C) and in normal controls (Group A) (P < 0.05). Lastly, the difference in the measurement of LAESV between the two methods was greater in patients with hypertension-induced left ventricular remodeling (Group C) than that in the control group (Group A) (P < 0.05). The post-processing time of the 3DE-HM data was significantly shorter than that using the 3DE-manual method (P < 0.05). There was no significant variability in repeated measurements at different time points using the 3DE-HM method either between subjects in different groups or within the same subject. 3DE-HM is a quick and feasible method for left ventricular quantification and is clinically applicable for evaluating patients with left atrial and left ventricular remodeling.

Cardiomyocyte marker expression in dogs with left atrial enlargement due to dilated cardiomyopathy or myxomatous mitral valve disease.

PubMed

Janus, Izabela; Kandefer-Gola, Malgorzata; Ciaputa, Rafal; Noszczyk-Nowak, Agnieszka; Paslawska, Urszula; Tursi, Massimiliano; Nowak, Marcin

2017-01-01

Dilated cardiomyopathy (DCM) and myxomatous mitral valve disease (MMVD) are common heart conditions in dogs. They have different etiology and pathogenesis and although other studies focused on changes in the left ventricles of the affected hearts, the aim of our study was to assess the expressions of some intrinsic proteins in the enlarged left atria. We performed an immunohistochemical analysis of left atrial specimens obtained from 15 dogs with DCM, 35 dogs with MMVD and six control dogs. We assessed the expression of following proteins: SERCA1, SERCA2, sarcomeric actinin, smooth muscle actin, and dystrophin. We noted a higher percentage of SERCA1-positive cells in the MMVD group and lower percentage of dystrophin-positive cells in the DCM group as compared to control group. The expression of other proteins was similar in the hearts of control dogs and dogs with heart diseases. The observed changes in the expression patterns of some proteins in the atria of dogs with DCM and MMVD suggest that atrial enlargement relies not only on volume overload, but also alterations of the intrinsic proteins can contribute to the pathogenesis of dilated cardiomyopathy.

Neonatal piglet model of intraaortic balloon pumping: improved efficacy using echocardiographic timing.

PubMed

Minich, L L; Tani, L Y; Pantalos, G M; Bolland, B L; Knorr, B K; Hawkins, J A

1998-11-01

Pediatric intraaortic balloon pumping (IABP) has met with little success because of technical difficulty in tracking rapid heart rates. This study was designed to evaluate the efficacy of M-mode echocardiography for IABP timing in a neonatal piglet model. Two groups of piglets underwent mitral valve avulsion to create a model of shock. Group 1 (n = 8; mean weight, 7.7+/-1.8 kg) underwent IABP timed with both the ascending aortic pressure and M-mode echocardiogram. Group 2 (n = 6; mean weight, 7.5+/-1.4 kg) underwent two separate periods of IABP: one with echocardiographic timing and the second using standard timing points from the femoral arterial pressure tracing and electrocardiogram. Measurements included ascending aortic flow, left anterior descending arterial flow, ascending aortic pressure, left atrial pressure, and heart rate. Mitral valve avulsion produced a shock model with a significant decrease in mean aortic pressure and aortic flow and a significant increase in left atrial pressure and heart rate. Compared with the shock state, IABP in group 1 animals resulted in a significant increase in aortic flow (353+/-152 versus 454+/-109 mL/min; p < 0.05) and a significant decrease in left atrial pressure (23+/-6 versus 17+/-7 mm Hg; p < 0.05). Group 2 animals with echocardiogram-timed IABP had significantly increased aortic flow (365+/-106 versus 458+/-107 mL/min; p < 0.05) and mean aortic pressure (43+/-11 versus 52+/-8 mm Hg; p < 0.05). However, standard-timed IABP failed to show any improvement. In piglets with rapid heart rates, echocardiogram-timed IABP results in increased aortic flow and pressure and decreased left atrial pressure compared with standard-timed IABP.

The clinical benefit of cardiac resynchronization therapy optimization using a device-based hemodynamic sensor in a patient with dilated cardiomyopathy: a case report.

PubMed

Volpicelli, Mario; Covino, Gregorio; Capogrosso, Paolo

2015-12-19

Results on the evolution of the clinical status of patients undergoing cardiac resynchronization therapy with a defibrillator after automatic optimization of their cardiac resynchronization therapy are scarce. We observed a rapid and important change in the clinical status of our non-responding patient following activation of a sensor capable of weekly atrioventricular and interventricular delays' optimization. A 78-year-old Caucasian man presented with dilated cardiomyopathy, left bundle branch block, a left ventricular ejection fraction of 35 %, New York Heart Association class III/IV heart failure, and paroxysmal atrial fibrillation. Our patient was implanted with a cardiac resynchronization device with a defibrillator and the SonRtip atrial lead. Right ventricular and left ventricular leads were also implanted. Because of the recurrence of atrial fibrillation, the automatic optimization was set off at discharge. Consequently, the device did not optimize atrioventricular and interventricular delays (programming at discharge: 125 ms for the atrioventricular delay and 0 ms for the interventriculardelay). Our patient was treated with an anti-arrhythmic drug. Five months after implantation, his clinical status remained impaired (left ventricular ejection fraction = 30 %). The SonR signal amplitude had also decreased from 0.52 g to 0.29 g. Nevertheless, because our patient was no longer presenting with atrial fibrillation, the anti-arrhythmic treatment was stopped and the SonR optimization system was activated. After 2 months of automatic cardiac resynchronization therapy with defibrillator optimization, our patient's clinical status had significantly improved (left ventricular ejection fraction = 60 %, New York Heart Association class II) and the SonR signal amplitude had doubled shortly after the first weekly automatic optimization. In this non-responding patient, device-based automatic cardiac resynchronization therapy optimization was shown to significantly improve his clinical status.

A comparison of the histopathologic pattern of the left atrium in canine dilated cardiomyopathy and chronic mitral valve disease.

PubMed

Janus, Izabela; Noszczyk-Nowak, Agnieszka; Nowak, Marcin; Ciaputa, Rafał; Kandefer-Gola, Małgorzata; Pasławska, Urszula

2016-01-05

Dilated cardiomyopathy (DCM) and chronic mitral valve disease (CMVD) in dogs are associated with heart chamber enlargement, also of the left atrium. DCM is often accompanied by rhythm disturbances (mainly atrial fibrillation or ventricular arrhythmias). In CMVD, arrhythmias are observed less frequently. It is still unclear whether left atrial enlargement in these diseases results from volume overload or if it is also connected with other factors (e.g. rhythm disturbances). This study was conducted on the left atrial myocardial specimens from 31 dogs, including those from 16 dogs with clinically diagnosed DCM and 15 dogs with CMVD. After fixation and staining (using haematoxylin-eosin and Masson-Goldner trichrome stain), the specimens underwent evaluation. Parenchymal changes (fibrosis, fatty infiltration, and vessel narrowing), degenerative changes (loss of striation, changes in cardiomyocyte structure, and abnormal cell nuclei) and the presence of inflammatory infiltrates were assessed. More interstitial fibrosis (median 4 vs. 2.5 grid fields; p < 0.05) and less perivascular fibrosis (median score 1 vs. 2; p < 0.05) was observed in the DCM group compared to the CMVD group. Moreover, less distinct vessel narrowing was observed in the DCM group than in the CMVD group (median lumen area ratio 0.3 vs. 0.26 respectively; p < 0.05). Dogs with DCM showed more strongly defined degenerative changes than the CMVD dogs (median nuclei enlargement score 3 vs. 1, median loss of striation score 3 vs. 2 and median structural alterations score 3 vs. 2, respectively; p < 0.05). The obtained results indicate a different nature of changes occurring in the left atrial myocardium of dogs with DCM compared to dogs with mitral valve disease, including differences in vessel narrowing, cardiomyocyte degeneration and in the distribution of connective tissue.

The importance of integrated left atrial evaluation: From hypertension to heart failure with preserved ejection fraction.

PubMed

Beltrami, Matteo; Palazzuoli, Alberto; Padeletti, Luigi; Cerbai, Elisabetta; Coiro, Stefano; Emdin, Michele; Marcucci, Rossella; Morrone, Doralisa; Cameli, Matteo; Savino, Ketty; Pedrinelli, Roberto; Ambrosio, Giuseppe

2018-02-01

Functional analysis and measurement of left atrium are an integral part of cardiac evaluation, and they represent a key element during non-invasive analysis of diastolic function in patients with hypertension (HT) and/or heart failure with preserved ejection fraction (HFpEF). However, diastolic dysfunction remains quite elusive regarding classification, and atrial size and function are two key factors for left ventricular (LV) filling evaluation. Chronic left atrial (LA) remodelling is the final step of chronic intra-cavitary pressure overload, and it accompanies increased neurohormonal, proarrhythmic and prothrombotic activities. In this systematic review, we aim to purpose a multi-modality approach for LA geometry and function analysis, which integrates diastolic flow with LA characteristics and remodelling through application of both traditional and new diagnostic tools. The most important studies published in the literature on LA size, function and diastolic dysfunction in patients with HFpEF, HT and/or atrial fibrillation (AF) are considered and discussed. In HFpEF and HT, pulsed and tissue Doppler assessments are useful tools to estimate LV filling pressure, atrio-ventricular coupling and LV relaxation but they need to be enriched with LA evaluation in terms of morphology and function. An integrated evaluation should be also applied to patients with a high arrhythmic risk, in whom eccentric LA remodelling and higher LA stiffness are associated with a greater AF risk. Evaluation of LA size, volume, function and structure are mandatory in the management of patients with HT, HFpEF and AF. A multi-modality approach could provide additional information, identifying subjects with more severe LA remodelling. Left atrium assessment deserves an accurate study inside the cardiac imaging approach and optimised measurement with established cut-offs need to be better recognised through multicenter studies. © 2017 John Wiley & Sons Ltd.

Correlation of right atrial appendage velocity with left atrial appendage velocity and brain natriuretic Peptide.

PubMed

Kim, Bu-Kyung; Heo, Jung-Ho; Lee, Jae-Woo; Kim, Hyun-Soo; Choi, Byung-Joo; Cha, Tae-Joon

2012-03-01

Left atrial appendage (LAA) anatomy and function have been well characterized both in healthy and diseased people, whereas relatively little attention has been focused on the right atrial appendage (RAA). We sought to evaluate RAA flow velocity and to compare these parameters with LAA indices and with a study of biomarkers, such as brain natriuretic peptide, among patients with sinus rhythm (SR) and atrial fibrillation (AF). In a series of 79 consecutive patients referred for transesophageal echocardiography, 43 patients (23 with AF and 20 controls) were evaluated. AF was associated with a decrease in flow velocity for both LAA and RAA [LAA velocity-SR vs. AF: 61 ± 22 vs. 29 ± 18 m/sec (p < 0.01), RAA velocity-SR vs. AF: 46 ± 20 vs. 19 ± 8 m/sec (p < 0.01)]. Based on simple linear regression analysis, LAA velocity and RAA velocity were positively correlated, and RAA velocity was inversely correlated with brain natriuretic peptide (BNP). AF was associated with decreased RAA and LAA flow velocities. RAA velocity was found to be positively correlated with LAA velocity and negatively correlated with BNP. The plasma BNP concentration may serve as a determinant of LAA and RAA functions.

Current status of the surgical treatment of atrial fibrillation.

PubMed

Geha, Alexander S; Abdelhady, Khaled

2008-03-01

Atrial fibrillation (AF) affects several million patients worldwide and is associated with a number of heart conditions, particularly coronary artery disease, rheumatic heart disease, hypertension, and congestive heart failure. The treatment of AF and its complications is quite costly. Atrial fibrillation usually results from multiple macro-re-entrant circuits in the left atrium. Very frequently, particularly in association with mitral valve disease, these circuits arise from the area of the junction of the pulmonary venous endothelium and the left atrial endocardium. Pharmacological therapy is at best 50% effective. Therapeutic options for AF include antiarrhythmic drugs, cardioversion, atrioventricular (A-V) node block, pacemaker insertion, and ablative surgery. In 1987, Cox developed an effective surgical procedure to achieve ablation. Current ablative procedures include the classic cut-and-sew Maze operation or a modification of it, namely through catheter ablation, namely, cryoablation, radiofrequency ablation (dry or irrigated), and other forms of ablation (e.g., laser, microwave). These procedures will be described, along with the indications, advantages and disadvantages of each. Special emphasis on the alternative means to cutting and sewing to achieve appropriate effective atrial scars will be stressed, and our experience with these approaches in 50 patients with AF and associated cardiac lesions and their outcomes is presented.

[Transthoracic and transesophageal echocardiography in the pre- and postoperative assessment of interatrial communication].

PubMed

San Román, J A; Vilacosta, I; Zamorano, J; Castillo, J A; Rollán, M J; Villanueva, M A; Almería, C; Sánchez-Harguindey, L

1993-12-01

Transthoracic echocardiography is the most useful noninvasive method to diagnose atrial septal defect. It is suggested by some authors that transesophageal echocardiography is more accurate than transthoracic echocardiography in this setting. Our aim was to compare the usefulness of both techniques in: 1) diagnosing atrial septal defect, 2) detecting associated anomalies and 3) postoperative assessment. Pre and postoperative transthoracic and transesophageal echocardiography were performed in 27 patients in whom diagnosis of atrial septal defect was confirmed at surgery. Transthoracic echocardiography demonstrated the defect in 20 patients (74%) (8 ostium primum, 10 ostium secundum and 2 sinus venosus). The 27 patients (100%) were correctly diagnosed by transesophageal echocardiography (8 ostium primum, 12 ostium secundum and 7 sinus venosus). Defect size determined by transthoracic echocardiography had a poor correlation with the surgical measurement (r = 0.34). A good correlation was obtained when transesophageal versus surgical defect size measurements were compared (r = 0.85; p < 0.05). Transesophageal echocardiography was superior in detecting associated anomalies (5 patients with anomalous partial pulmonary venous drainage, 3 persistence of left superior vena cava and 1 atrial septal aneurysm). Moreover, this technique better determined residual atrial septal defect, and detected a postsurgical inferior vena cava connection to the left atrium. Transesophageal echocardiography is superior to transthoracic echocardiography in diagnosing atrial septal defect sinus venosus type, detecting associated anomalies and postoperative assessment. Transthoracic echocardiography is diagnostic in the majority of patients with atrial septal defect ostium primum and ostium secundum types.

History of surgery for atrial fibrillation.

PubMed

Edgerton, Zachary J; Edgerton, James R

2009-12-01

There is a rich history of surgery for atrial fibrillation. Initial procedures were aimed at controlling the ventricular response rate. Later procedures were directed at converting atrial fibrillation to normal sinus rhythm. These culminated in the Cox Maze III procedure. While highly effective, the complexity and morbidity of the cut and sew Maze III limited its adoption. Enabling technology has developed alternate energy sources designed to produce a transmural atrial scar without cutting and sewing. Termed the Maze IV, this lessened the morbidity of the procedure and widened the applicability. Further advances in minimal access techniques are now being developed to allow totally thorascopic placement of all the left atrial lesions on the full, beating heart, using alternate energy sources.

Bi-atrial fibrosis detected using three-dimensional late gadolinium enhancement magnetic resonance imaging in a patient with cardiac sarcoidosis.

PubMed

Spence, Stewart; Pena, Elena; Thornhill, Rebecca E; Nery, Pablo B; Birnie, David H

2018-05-01

Presented is the case of a 62-year old male with a history of sarcoidosis and sinus node dysfunction, who underwent late gadolinium enhancement magnetic resonance imaging, which demonstrated left ventricular hyperenhancement and bi-atrial fibrosis.

Effect of left atrial volume and pulmonary vein anatomy on outcome of nMARQ™ catheter ablation of paroxysmal atrial fibrillation.

PubMed

Stabile, Giuseppe; Anselmino, Matteo; Soldati, Ezio; De Ruvo, Ermengildo; Solimene, Francesco; Iuliano, Assunta; Sciarra, Luigi; Bongiorni, Maria Grazia; Calò, Leonardo; Gaita, Fiorenzo

2017-03-01

Left atrial volume (LA) and pulmonary vein (PV) anatomy may potentially relate to technical challenges in achieving stable and effective catheter position in case of atrial fibrillation (AF) ablation by means of "one-shot" catheters. The aim of this study was to investigate whether LA volume and PV anatomy, evaluated by computed tomography (CT) or magnetic resonance (MR) prior to ablation, predict acute and midterm outcome of AF ablation by nMARQ™. We included 75 patients (mean age 58 ± 11 years, 67 % male) with symptomatic paroxysmal AF. All patients underwent CT/MR scanning prior to catheter ablation to evaluate LA volume and PV anatomy. All the patients underwent PV isolation by nMARQ™, an open-irrigated mapping and radiofrequency (RF) decapolar ablation catheter. Ablation was guided by electroanatomic mapping allowing RF energy delivery in the antral region of PVs from ten irrigated electrodes simultaneously. Mean LA volume was 75 ± 40 ml. A normal anatomy (4 PVs) was documented in 40 (53 %) patients and abnormal anatomy (common truncus or accessory PVs) in 35 patients. Mean procedural and fluoroscopy times were 94 ± 55 and 8 ± 5 min, respectively, without significant differences among patients with normal or abnormal anatomy (92 ± 45 vs 95 ± 64 min, p = 0.85 and 6 ± 3 vs 8 ± 4 min, p = 0.65, respectively). Mean ablation time was 14 ± 3 min, and 99 % of the targeted veins were isolated with a mean of 23 ± 5 RF pulses per patient. After a mean follow-up of 17 ± 8 months, 23 (31 %) patients had an atrial arrhythmia recurrence. Neither LA volume nor PV anatomy was a predictor of outcome. LA volume and PV anatomy did not affect procedural data and outcome in patients who underwent PV isolation by an open-irrigated mapping and RF decapolar ablation catheter.

Left ventricular ejection fraction and left atrium diameter related to new-onset atrial fibrillation following acute myocardial infarction: a systematic review and meta-analysis.

PubMed

Zeng, Rui-Xiang; Chen, Mao-Sheng; Lian, Bao-Tao; Liao, Peng-Da; Zhang, Min-Zhou

2017-10-06

New-onset atrial fibrillation (NOAF) occurs frequently in patients with acute myocardial infarction (AMI), and is associated with increased subsequent cardiovascular mortality. However, only a few studies directly evaluated the relationship of left ventricular ejection fraction (LVEF) or left atrium diameter (LAD) and NOAF following AMI. MEDLINE ® , EMBASE ® and the Cochrane Library were carried out to find studies until January 2017. Pooled mean difference (MD) and 95% confidence interval (CI) were calculated to evaluate the value of LVEF and LAD in the prediction of NOAF after AMI. We performed sensitivity analyses to explore the potential sources of heterogeneity. Statistical analyses were carried out using the Revman 5.3. We included 10 qualifying studies comprising a total of 708 patients with NOAF and 6785 controls. Overall, decreased LVEF and increased LAD levels had a significant positive association with NOAF in patients with AMI. The MD in the LVEF levels between the patients with and those without NOAF was -4.91 units (95% Cl: -5.70 to -4.12), test for overall effect z-score = 12.18 ( p < 0.00001, I 2 = 35%). Moreover, in a subgroup analysis, the MD for LAD and NOAF was 2.55 units (95% Cl: 1.91 to 3.19), test for overall effect z-score = 7.80 ( p < 0.00001, I 2 = 57%). Our meta-analysis demonstrated that both decreased LVEF and increased LAD levels were associated with greater risk of NOAF following AMI.

Role of Echocardiography in the Management and Prognosis of Atrial Fibrillation

PubMed Central

Silverman, David I; Ayirala, Srilatha R; Manning, Warren J

2012-01-01

Echocardiography plays a longstanding and vital role in the management of atrial fibrillation (AF). Advances in 2D imaging, Doppler echocardiography and strain imaging have all contributed to major progress in AF treatment. Echocardiographically measured left atrial (LA) volume is a powerful predictor of maintenance of sinus rhythm following cardioversion as well as risk of thrombus formation and thromboembolism. Doppler derived parameters of atrial mechanical function including atrial ejection force provide related prognostic information. Transesophageal echocardiocardiograpy (TEE) guided cardioversion of AF allows for rapid conversion to sinus rhythm without prolonged oral anticoagulation, and TEE serves as a useful tool during catheter ablation of AF and atrial flutter. Newer measures derived from speckle tracking offer great promise in further improving the care of patients with AF. PMID:28496715

The reduction of central sleep apnoea severity in the left lateral position is not due to an improvement in cardiac haemodynamics in patients with chronic heart failure.

PubMed

Traversi, Egidio; Rossi, Davide; Maestri, Roberto; Olmetti, Francesca; La Rovere, Maria Teresa; Pinna, Gian Domenico

2017-06-01

The severity of central sleep apnoea (CSA), a common comorbidity in patients with chronic heart failure (CHF) and reduced ejection fraction, markedly decreases from the supine to the lateral sleeping position, with no difference between the left and right positions. The mechanisms responsible for this beneficial effect have not yet been elucidated. We tested the hypothesis that CSA attenuation in the left lateral position is due, at least in part, to an improvement in cardiac haemodynamics. Sixteen CHF patients (male, aged 60 ± 7 years, New York Heart Association class 2.6 ± 0.5, left ventricular ejection fraction [LVEF] 30% ± 5%) with moderate-to-severe CSA underwent two consecutive tissue Doppler echocardiography examinations in random order, one in the left lateral position (90°) and the other in the supine position (0°). The following parameters were obtained: left ventricular end-diastolic volume (LVEDV) and LVEF, left atrial volume (LAV) and right atrial volume (RAV), mitral regurgitation (MR), cardiac output (CO), transmitral protodiastolic (E) wave deceleration time (DT), E/e' ratio, tricuspid annular plane systolic excursion (TAPSE), and right ventricular-atrial gradient (RVAG). The LAV, MR, E/e', RAV, and RVAG significantly increased, whereas the LVEF and TAPSE significantly decreased in the left lateral position. All changes, however, were of negligible clinical significance. No significant changes were observed in CO, DT, and LVEDV. This study shows that the reduction of CSA severity from the supine to the left lateral position in patients with CHF is not due to an improvement in cardiac haemodynamics. Other, noncardiac factors are likely to represent the main cause. Copyright © 2017 Elsevier B.V. All rights reserved.

Electrocardiographic Predictors of Incident Atrial Fibrillation

PubMed Central

Nguyen, Kaylin T.; Vittinghoff, Eric; Dewland, Thomas A.; Mandyam, Mala C.; Stein, Phyllis K.; Soliman, Elsayed Z.; Heckbert, Susan R.; Marcus, Gregory M.

2017-01-01

Atrial fibrillation (AF) is likely secondary to multiple different pathophysiological mechanisms that are increasingly, but incompletely understood. Motivated by the hypothesis that 3 previously described electrocardiographic (ECG) predictors of AF identify distinct AF mechanisms, we sought to determine if these ECG findings independently predict incident disease. Among Cardiovascular Health Study participants without prevalent AF, we determined whether left anterior fascicular block (LAFB), a prolonged QTC, and atrial premature complexes (APCs) each predicted AF after adjusting for each other. We then calculated the attributable risk in the exposed for each ECG marker. LAFB and QTC intervals were assessed on baseline 12-lead ECG (n=4,696). APC count was determined using 24-hour Holter recordings obtained in a random subsample (n=1,234). After adjusting for potential confounders and each ECG marker, LAFB (hazard ratio [HR. 2.1, 95% confidence interval [CI. 1.1–3.9, p=0.023), a prolonged QTC (HR 2.5, 95% CI 1.4–4.3, p=0.002), and every doubling of APC count (HR 1.2, 95% CI 1.1–1.3, p<0.001) each remained independently predictive of incident AF. The attributable risk of AF in the exposed was 35% (95% CI 13–52%) for LAFB, 25% (95% CI 0.6–44%) for a prolonged QTC, and 34% (95% CI 26–42%) for APCs. In conclusion, in a community-based cohort, 3 previously established ECG-derived AF predictors were each independently associated with incident AF, suggesting they may represent distinct mechanisms underlying the disease. PMID:27448684

Anomalies of the systemic venous return: a review.

PubMed

Mazzucco, A; Bortolotti, U; Stellin, G; Gallucci, V

1990-06-01

Congenital anomalies of the systemic venous connection to the heart represent a rather wide and heterogeneous group of malformations, whose physiological consequences may vary from nil to the most severe form of systemic arterial desaturation. The malformations may be summarized as follows: (1) Left superior vena cava connected to the coronary sinus, interrupted inferior vena cava and absent right superior vena cava that do not indicate surgical repair 'per se', but require some technical attention during open heart surgery performed for other anomalies; (2) Left superior vena cava connected to the left atrium, due to incorporation of the coronary sinus into the left atrial cavity, resulting in a right-to-left-shunt; (3) Right superior vena cava or inferior vena cava draining into the left atrium, both are extremely rare and require treatment for the ensuing right-to-left shunt; (4) Total anomalous systemic venous connection to the left atrium, usually combined with atrial isomerism and other very complex heart malformations; (5) Cor triatriatum dexter, which has been frequently diagnosed as an anomalous venous connection for its similar hemodynamic consequences. Such anomalies are reviewed with particular respect to their surgical implications.

5-Year Outcomes After Left Atrial Appendage Closure: From the PREVAIL and PROTECT AF Trials.

PubMed

Reddy, Vivek Y; Doshi, Shephal K; Kar, Saibal; Gibson, Douglas N; Price, Matthew J; Huber, Kenneth; Horton, Rodney P; Buchbinder, Maurice; Neuzil, Petr; Gordon, Nicole T; Holmes, David R

2017-12-19

The PROTECT AF (WATCHMAN Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation) trial demonstrated that left atrial appendage closure (LAAC) with the Watchman device (Boston Scientific, St. Paul, Minnesota) was equivalent to warfarin for preventing stroke in atrial fibrillation, but had a high rate of complications. In a second randomized trial, PREVAIL (Evaluation of the WATCHMAN LAA Closure Device in Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy), the complication rate was low. The warfarin cohort experienced an unexpectedly low ischemic stroke rate, rendering the efficacy endpoints inconclusive. However, these outcomes were based on relatively few patients followed for a relatively short time. The final results of the PREVAIL trial, both alone and as part of a patient-level meta-analysis with the PROTECT AF trial, are reported with patients in both trials followed for 5 years. PREVAIL and PROTECT AF are prospective randomized clinical trials with patients randomized 2:1 to LAAC or warfarin; together, they enrolled 1,114 patients for 4,343 patient-years. Analyses are by intention-to-treat, and rates are events per 100 patient-years. For the PREVAIL trial, the first composite coprimary endpoint of stroke, systemic embolism (SE), or cardiovascular/unexplained death did not achieve noninferiority (posterior probability for noninferiority = 88.4%), whereas the second coprimary endpoint of post-procedure ischemic stroke/SE did achieve noninferiority (posterior probability for noninferiority = 97.5%); the warfarin arm maintained an unusually low ischemic stroke rate (0.73%). In the meta-analysis, the composite endpoint was similar between groups (hazard ratio [HR]: 0.820; p = 0.27), as were all-stroke/SE (HR: 0.961; p = 0.87). The ischemic stroke/SE rate was numerically higher with LAAC, but this difference did not reach statistical significance (HR: 1.71; p = 0.080). However, differences in hemorrhagic stroke, disabling/fatal stroke, cardiovascular/unexplained death, all-cause death, and post-procedure bleeding favored LAAC (HR: 0.20; p = 0.0022; HR: 0.45; p = 0.03; HR: 0.59; p = 0.027; HR: 0.73; p = 0.035; HR: 0.48; p = 0.0003, respectively). These 5-year outcomes of the PREVAIL trial, combined with the 5-year outcomes of the PROTECT AF trial, demonstrate that LAAC with Watchman provides stroke prevention in nonvalvular atrial fibrillation comparable to warfarin, with additional reductions in major bleeding, particularly hemorrhagic stroke, and mortality. (WATCHMAN Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation; NCT00129545; and Evaluation of the WATCHMAN LAA Closure Device in Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy; NCT01182441). Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

The predictive role of E/e' on ischemic stroke and atrial fibrillation in Japanese patients without atrial fibrillation.

PubMed

Arai, Riku; Suzuki, Shinya; Semba, Hiroaki; Arita, Takuto; Yagi, Naoharu; Otsuka, Takayuki; Sagara, Koichi; Sasaki, Kenichi; Kano, Hiroto; Matsuno, Shunsuke; Kato, Yuko; Uejima, Tokuhisa; Oikawa, Yuji; Kunihara, Takashi; Yajima, Junji; Yamashita, Takeshi

2018-07-01

The predictive role of E/e' on ischemic stroke (IS) and atrial fibrillation (AF) in Japanese patients without AF are unclear. Shinken database includes all the new patients visiting the Cardiovascular Institute Hospital in Tokyo, Japan. E/e' has been routinely measured since 2007. Patients without AF for whom E/e' was measured at the initial visit between 2007 and 2014 (n=11 477, mean age 57.2 years old, men 59.5%) were divided into E/e' tertiles (<8.04, 8.04-11.00, >11.00). During the mean follow-up period of 1.8 years, 58 IS and 140 new appearances of AF were observed. High E/e' tertile was associated with more prevalence of atherothrombotic risks. The cumulative incidence of IS events and new appearance of AF at 6 years in low, middle, and high E/e' tertiles were 0.5%, 1.4%, and 3.0%/year (log-rank test, p<0.001), and 2.5%, 2.9%, and 4.2%/year (log-rank test, p=0.007), respectively. In multivariate analysis, high E/e' tertile was independently associated with IS (HR, 2.857, 95%CI 1.257-6.495, p=0.012). Although high E/e' tertile was independently associated with new appearance of AF when adjusted for coexistence of atherothrombotic risk factors (HR, 1.694, 95%CI, 1.097-2.616, p=0.017), the association was attenuated after adjustment for left atrial dimension. E/e' was significantly associated with incidence of IS and new appearance of AF in non-AF patients. Copyright © 2018 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

Mechanistic Comparison of "Nearly Missed" Versus "On-Target" Rotor Ablation.

PubMed

Yamazaki, Masatoshi; Avula, Uma Mahesh R; Berenfeld, Omer; Kalifa, Jérôme

2015-08-01

This study used advanced optical mapping techniques to examine atrial fibrillation (AF) dynamics before and after 2 distinct electrogram-based ablation strategies: complex fractionated atrial electrograms (CFAEs) and DFmax/rotor ablation. Among the electrogram analytical features proposed to unravel the atrial regions that perpetuate AF, CFAEs, highest dominant frequency sites (DFmax), and, more recently, phase analysis-enabled rotor mapping have received the largest attention. Still, the mechanisms by which these approaches modulate AF dynamics and lead to AF termination are unknown. In Langendorff-perfused sheep hearts, AF was maintained by the continuous perfusion of acetylcholine and high-resolution endocardial-epicardial optical videos were recorded from the left atrial free wall and the posterior left atrium. Then, DFmax/rotor regions (n = 7), or CFAE regions harboring the highest wavebreak density (HWD) (n = 5), were targeted with a 4F ablation catheter (5 to 15 W, 30 to 60 s/point). Thereafter, we examined the changes in AF dynamics and whether AF terminated. DFmax/rotor point ablation resulted in a significant decrease in DFmax values. In 2 animals AF terminated, whereas in the remaining 5 animals the post-ablation DFmax domain remained in the vicinity of its pre-ablation location. However, after HWD/CFAEs density ablation, DFmax values did not change, AF did not terminate, and post-ablation DFmax domains relocated from the left atrial free wall to the pulmonary vein-posterior left atrium region. In another group of hearts (n = 12), we observed that upon a progressive increase in acetylcholine concentration-mimicking the acute electrophysiological changes occurring after ablation-3-dimensional rotors drifted from one atrial region to another along large gradients of myocardial thickness. "On-target" DFmax/rotor ablation leads to the annihilation of the fibrillation-driving rotor. This translates into large decreases in AF frequency or AF termination. In contrast, "nearly missed" HWD/CFAEs ablation spares the fibrillation-driving rotor, and set the stage for rotor drift along large myocardial thickness gradients. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

P-wave characteristics on routine preoperative electrocardiogram improve prediction of new-onset postoperative atrial fibrillation in cardiac surgery.

PubMed

Wong, Jim K; Lobato, Robert L; Pinesett, Andre; Maxwell, Bryan G; Mora-Mangano, Christina T; Perez, Marco V

2014-12-01

To test the hypothesis that including preoperative electrocardiogram (ECG) characteristics with clinical variables significantly improves the new-onset postoperative atrial fibrillation prediction model. Retrospective analysis. Single-center university hospital. Five hundred twenty-six patients, ≥ 18 years of age, who underwent coronary artery bypass grafting, aortic valve replacement, mitral valve replacement/repair, or a combination of valve surgery and coronary artery bypass grafting requiring cardiopulmonary bypass. Retrospective review of medical records. Baseline characteristics and cardiopulmonary bypass times were collected. Digitally-measured timing and voltages from preoperative electrocardiograms were extracted. Postoperative atrial fibrillation was defined as atrial fibrillation requiring therapeutic intervention. Two hundred eight (39.5%) patients developed postoperative atrial fibrillation. Clinical predictors were age, ejection fraction<55%, history of atrial fibrillation, history of cerebral vascular event, and valvular surgery. Three ECG parameters associated with postoperative atrial fibrillation were observed: Premature atrial contraction, p-wave index, and p-frontal axis. Adding electrocardiogram variables to the prediction model with only clinical predictors significantly improved the area under the receiver operating characteristic curve, from 0.71 to 0.78 (p<0.01). Overall net reclassification improvement was 0.059 (p = 0.09). Among those who developed postoperative atrial fibrillation, the net reclassification improvement was 0.063 (p = 0.03). Several p-wave characteristics are independently associated with postoperative atrial fibrillation. Addition of these parameters improves the postoperative atrial fibrillation prediction model. Copyright © 2014 The Authors. Published by Elsevier Inc. All rights reserved.

Automatic classification of scar tissue in late gadolinium enhancement cardiac MRI for the assessment of left-atrial wall injury after radiofrequency ablation

PubMed Central

Morris, Alan; Burgon, Nathan; McGann, Christopher; MacLeod, Robert; Cates, Joshua

2013-01-01

Radiofrequency ablation is a promising procedure for treating atrial fibrillation (AF) that relies on accurate lesion delivery in the left atrial (LA) wall for success. Late Gadolinium Enhancement MRI (LGE MRI) at three months post-ablation has proven effective for noninvasive assessment of the location and extent of scar formation, which are important factors for predicting patient outcome and planning of redo ablation procedures. We have developed an algorithm for automatic classification in LGE MRI of scar tissue in the LA wall and have evaluated accuracy and consistency compared to manual scar classifications by expert observers. Our approach clusters voxels based on normalized intensity and was chosen through a systematic comparison of the performance of multivariate clustering on many combinations of image texture. Algorithm performance was determined by overlap with ground truth, using multiple overlap measures, and the accuracy of the estimation of the total amount of scar in the LA. Ground truth was determined using the STAPLE algorithm, which produces a probabilistic estimate of the true scar classification from multiple expert manual segmentations. Evaluation of the ground truth data set was based on both inter- and intra-observer agreement, with variation among expert classifiers indicating the difficulty of scar classification for a given a dataset. Our proposed automatic scar classification algorithm performs well for both scar localization and estimation of scar volume: for ground truth datasets considered easy, variability from the ground truth was low; for those considered difficult, variability from ground truth was on par with the variability across experts. PMID:24236224

Pulmonary vein anatomy predicts freedom from atrial fibrillation using remote magnetic navigation for circumferential pulmonary vein ablation.

PubMed

Sohns, Christian; Sohns, Jan M; Bergau, Leonard; Sossalla, Samuel; Vollmann, Dirk; Lüthje, Lars; Staab, Wieland; Dorenkamp, Marc; Harrison, James L; O'Neill, Mark D; Lotz, Joachim; Zabel, Markus

2013-08-01

Multidetector computed tomography (MDCT) is frequently used to guide circumferential pulmonary vein ablation (PVA) for treatment of atrial fibrillation (AF) as it offers accurate visualization of the left atrial (LA) and pulmonary vein (PV) anatomy. This study aimed to identify if PV anatomy is associated with outcomes following PVA using remote magnetic navigation (RMN). We analysed data from 138 consecutive patients and 146 ablation procedures referred for PVA due to drug-refractory symptomatic AF (age 63 ± 11 years; 57% men; 69% paroxysmal AF). The RMN using the stereotaxis system and open-irrigated 3.5 mm ablation catheters was used in all procedures. Prior to PVA, all patients underwent electrocardiogram-gated 64-MDCT for assessment of LA dimensions, PV anatomy, and electro-anatomical image integration during the procedure. Regular PV anatomy was found in 68%, a common left PV ostium was detected in 26%, and variant anatomy of the right PVs was detected in 6%. After a mean follow-up of 337 ± 102 days, 63% of the patients maintained sinus rhythm after the initial ablation, and 83% when including repeat PVA. Although acutely successful PV isolation did not differ between anatomical subgroups (regular 3.5 ± 0.8 vs. variant 3.2 ± 1.3; P = 0.31), AF recurrence was significantly higher in patients with non-regular PV anatomy (P = 0.04, hazard ratio 1.72). Pulmonary vein anatomy did not influence complication rates. Pulmonary vein anatomy assessed by MDCT is a good predictor of AF recurrence after PVA using RMN.

Automatic classification of scar tissue in late gadolinium enhancement cardiac MRI for the assessment of left-atrial wall injury after radiofrequency ablation

NASA Astrophysics Data System (ADS)

Perry, Daniel; Morris, Alan; Burgon, Nathan; McGann, Christopher; MacLeod, Robert; Cates, Joshua

2012-03-01

Radiofrequency ablation is a promising procedure for treating atrial fibrillation (AF) that relies on accurate lesion delivery in the left atrial (LA) wall for success. Late Gadolinium Enhancement MRI (LGE MRI) at three months post-ablation has proven effective for noninvasive assessment of the location and extent of scar formation, which are important factors for predicting patient outcome and planning of redo ablation procedures. We have developed an algorithm for automatic classification in LGE MRI of scar tissue in the LA wall and have evaluated accuracy and consistency compared to manual scar classifications by expert observers. Our approach clusters voxels based on normalized intensity and was chosen through a systematic comparison of the performance of multivariate clustering on many combinations of image texture. Algorithm performance was determined by overlap with ground truth, using multiple overlap measures, and the accuracy of the estimation of the total amount of scar in the LA. Ground truth was determined using the STAPLE algorithm, which produces a probabilistic estimate of the true scar classification from multiple expert manual segmentations. Evaluation of the ground truth data set was based on both inter- and intra-observer agreement, with variation among expert classifiers indicating the difficulty of scar classification for a given a dataset. Our proposed automatic scar classification algorithm performs well for both scar localization and estimation of scar volume: for ground truth datasets considered easy, variability from the ground truth was low; for those considered difficult, variability from ground truth was on par with the variability across experts.

Ablation of Persistent Atrial Fibrillation Targeting Low-Voltage Areas With Selective Activation Characteristics.

PubMed

Jadidi, Amir S; Lehrmann, Heiko; Keyl, Cornelius; Sorrel, Jérémie; Markstein, Viktor; Minners, Jan; Park, Chan-Il; Denis, Arnaud; Jaïs, Pierre; Hocini, Mélèze; Potocnik, Clemens; Allgeier, Juergen; Hochholzer, Willibald; Herrera-Sidloky, Claudia; Kim, Steve; Omri, Youssef El; Neumann, Franz-Josef; Weber, Reinhold; Haïssaguerre, Michel; Arentz, Thomas

2016-03-01

Complex-fractionated atrial electrograms and atrial fibrosis are associated with maintenance of persistent atrial fibrillation (AF). We hypothesized that pulmonary vein isolation (PVI) plus ablation of selective atrial low-voltage sites may be more successful than PVI only. A total of 85 consecutive patients with persistent AF underwent high-density atrial voltage mapping, PVI, and ablation at low-voltage areas (LVA < 0.5 mV in AF) associated with electric activity lasting > 70% of AF cycle length on a single electrode (fractionated activity) or multiple electrodes around the circumferential mapping catheter (rotational activity) or discrete rapid local activity (group I). The procedural end point was AF termination. Arrhythmia freedom was compared with a control group (66 patients) undergoing PVI only (group II). PVI alone was performed in 23 of 85 (27%) patients of group I with low amount (< 10% of left atrial surface area) of atrial low voltage. Selective atrial ablation in addition to PVI was performed in 62 patients with termination of AF in 45 (73%) after 11 ± 9 minutes radiofrequency delivery. AF-termination sites colocalized within LVA in 80% and at border zones in 20%. Single-procedural arrhythmia freedom at 13 months median follow-up was achieved in 59 of 85 (69%) patients in group I, which was significantly higher than the matched control group (31/66 [47%], P < 0.001). There was no significant difference in the success rate of patients in group I with a low amount of low voltage undergoing PVI only and patients requiring PVI+selective low-voltage ablation (P = 0.42). Ablation of sites with distinct activation characteristics within/at borderzones of LVA in addition to PVI is more effective than conventional PVI-only strategy for persistent AF. PVI only seems to be sufficient to treat patients with left atrial low voltage < 10%. © 2016 American Heart Association, Inc.

Atrial and ventricular function after cardioversion of atrial fibrillation.

PubMed Central

Xiong, C.; Sonnhag, C.; Nylander, E.; Wranne, B.

1995-01-01

OBJECTIVE--Previous studies on atrial recovery after cardioversion of atrial fibrillation have not taken into account new knowledge about the pathophysiology of transmitral and transtricuspid flow velocity patterns. It is possible to shed further light on this problem if atrioventricular inflow velocity, venous filling pattern, and atrioventricular annulus motion are recorded and interpreted together. DESIGN--Prospective examinations of mitral and tricuspid transvalvar flow velocities, superior caval and pulmonary venous filling, and mitral and tricuspid annulus motion were recorded using Doppler echocardiography. Examinations were performed before and 24 hours, 1 month, and 20 months after cardioversion. SETTING--Tertiary referral centre for cardiac disease with facilities for invasive and non-invasive investigation. PATIENTS--16 patients undergoing cardioversion of atrial fibrillation in whom sinus rhythm had persisted for 24 hours or more. RESULTS--Before conversion there was no identifiable A wave in transvalvar flow recordings. The total motion of the tricuspid and mitral annulus was subnormal and there was no identifiable atrial component. Venous flow patterns in general showed a low systolic velocity. After conversion, A waves and atrial components were seen in all patients and increased significantly (P < 0.01) with time. There was a similar time course for the amplitude of annulus atrial components, an increased systolic component of venous inflow, an increased A wave velocity, and a decreased E/A ratio of the transvalvar velocity curves. The ventricular component of annulus motion was unchanged. Changes in general occurred earlier on the right side than the left. CONCLUSIONS--This study indicates that, in addition to the previously known electromechanical dissociation of atrial recovery that exists after cardioversion of atrial fibrillation, there may also be a transient deterioration of ventricular function modulating the transvalvar inflow velocity recordings. Function on the right side generally becomes normal earlier than on the left. Integration of information from transvalvar inflow curves, annulus motion, and venous filling patterns gives additional insight into cardiac function. PMID:7547019

A three-dimensional finite element model of human atrial anatomy: New methods for cubic Hermite meshes with extraordinary vertices

PubMed Central

Gonzales, Matthew J.; Sturgeon, Gregory; Krishnamurthy, Adarsh; Hake, Johan; Jonas, René; Stark, Paul; Rappel, Wouter-Jan; Narayan, Sanjiv M.; Zhang, Yongjie; Segars, W. Paul; McCulloch, Andrew D.

2013-01-01

High-order cubic Hermite finite elements have been valuable in modeling cardiac geometry, fiber orientations, biomechanics, and electrophysiology, but their use in solving three-dimensional problems has been limited to ventricular models with simple topologies. Here, we utilized a subdivision surface scheme and derived a generalization of the “local-to-global” derivative mapping scheme of cubic Hermite finite elements to construct bicubic and tricubic Hermite models of the human atria with extraordinary vertices from computed tomography images of a patient with atrial fibrillation. To an accuracy of 0.6 millimeters, we were able to capture the left atrial geometry with only 142 bicubic Hermite finite elements, and the right atrial geometry with only 90. The left and right atrial bicubic Hermite meshes were G1 continuous everywhere except in the one-neighborhood of extraordinary vertices, where the mean dot products of normals at adjacent elements were 0.928 and 0.925. We also constructed two biatrial tricubic Hermite models and defined fiber orientation fields in agreement with diagrammatic data from the literature using only 42 angle parameters. The meshes all have good quality metrics, uniform element sizes, and elements with aspect ratios near unity, and are shared with the public. These new methods will allow for more compact and efficient patient-specific models of human atrial and whole heart physiology. PMID:23602918

Analysis of left atrial respiratory and cardiac motion for cardiac ablation therapy

NASA Astrophysics Data System (ADS)

Rettmann, M. E.; Holmes, D. R.; Johnson, S. B.; Lehmann, H. I.; Robb, R. A.; Packer, D. L.

2015-03-01

Cardiac ablation therapy is often guided by models built from preoperative computed tomography (CT) or magnetic resonance imaging (MRI) scans. One of the challenges in guiding a procedure from a preoperative model is properly synching the preoperative models with cardiac and respiratory motion through computational motion models. In this paper, we describe a methodology for evaluating cardiac and respiratory motion in the left atrium and pulmonary veins of a beating canine heart. Cardiac catheters were used to place metal clips within and near the pulmonary veins and left atrial appendage under fluoroscopic and ultrasound guidance and a contrast-enhanced, 64-slice multidetector CT scan was collected with the clips in place. Each clip was segmented from the CT scan at each of the five phases of the cardiac cycle at both end-inspiration and end-expiration. The centroid of each segmented clip was computed and used to evaluate both cardiac and respiratory motion of the left atrium. A total of three canine studies were completed, with 4 clips analyzed in the first study, 5 clips in the second study, and 2 clips in the third study. Mean respiratory displacement was 0.2+/-1.8 mm in the medial/lateral direction, 4.7+/-4.4 mm in the anterior/posterior direction (moving anterior on inspiration), and 9.0+/-5.0 mm superior/inferior (moving inferior with inspiration). At end inspiration, the mean left atrial cardiac motion at the clip locations was 1.5+/-1.3 mm in the medial/lateral direction, and 2.1+/-2.0 mm in the anterior/posterior and 1.3+/-1.2 mm superior/inferior directions. At end expiration, the mean left atrial cardiac motion at the clip locations was 2.0+/-1.5mm in the medial/lateral direction, 3.0+/-1.8mm in the anterior/posterior direction, and 1.5+/-1.5 mm in the superior/inferior directions.

Simulation of Left Atrial Function Using a Multi-Scale Model of the Cardiovascular System

PubMed Central

Pironet, Antoine; Dauby, Pierre C.; Paeme, Sabine; Kosta, Sarah; Chase, J. Geoffrey; Desaive, Thomas

2013-01-01

During a full cardiac cycle, the left atrium successively behaves as a reservoir, a conduit and a pump. This complex behavior makes it unrealistic to apply the time-varying elastance theory to characterize the left atrium, first, because this theory has known limitations, and second, because it is still uncertain whether the load independence hypothesis holds. In this study, we aim to bypass this uncertainty by relying on another kind of mathematical model of the cardiac chambers. In the present work, we describe both the left atrium and the left ventricle with a multi-scale model. The multi-scale property of this model comes from the fact that pressure inside a cardiac chamber is derived from a model of the sarcomere behavior. Macroscopic model parameters are identified from reference dog hemodynamic data. The multi-scale model of the cardiovascular system including the left atrium is then simulated to show that the physiological roles of the left atrium are correctly reproduced. This include a biphasic pressure wave and an eight-shaped pressure-volume loop. We also test the validity of our model in non basal conditions by reproducing a preload reduction experiment by inferior vena cava occlusion with the model. We compute the variation of eight indices before and after this experiment and obtain the same variation as experimentally observed for seven out of the eight indices. In summary, the multi-scale mathematical model presented in this work is able to correctly account for the three roles of the left atrium and also exhibits a realistic left atrial pressure-volume loop. Furthermore, the model has been previously presented and validated for the left ventricle. This makes it a proper alternative to the time-varying elastance theory if the focus is set on precisely representing the left atrial and left ventricular behaviors. PMID:23755183

Right ventricular performance and mass by use of cine MRI late after atrial repair of transposition of the great arteries.

PubMed

Lorenz, C H; Walker, E S; Graham, T P; Powers, T A

1995-11-01

The long-term adaptation of the right ventricle after atrial repair of transposition of the great arteries (TGA) remains a subject of major concern. Cine magnetic resonance imaging (MRI), with its tomographic capabilities, allows unique quantitative evaluation of both right and left ventricular function and mass. Our purpose was to use MRI and an age-matched normal population to examine the typical late adaptation of the right and left ventricles after atrial repair of TGA. Cine MRI was used to study ventricular function and mass in 22 patients after atrial repair of TGA. Images were obtained in short-axis sections from base to apex to derive normalized right and left ventricular mass (RVM and LVM, g/m2), interventricular septal mass (IVSM, g/m2), RV and LV end-diastolic volumes (EDV, mL/m2), and ejection fractions (EF). Results 8 to 23 years after repair were compared with analysis of 24 age- and sex-matched normal volunteers and revealed markedly elevated RVM, decreased LVM and IVSM, normal RV size, and only mildly depressed RVEF. Only 1 of 22 patients had clinical RV dysfunction, and this patient had increased RVM. Cine MRI allows quantitative evaluation of both RV and LV mass and function late after atrial repair of TGA. Longitudinal studies that include these measurements should prove useful in determining the mechanism of late RV failure in these patients. On the basis of these early data, inadequate hypertrophy does not appear to be the cause of late dysfunction in this patient group.

Evaluation of structural remodeling of the atria with OCT in a chronic rat model of myocardial infarction (Conference Presentation)

NASA Astrophysics Data System (ADS)

Eberle, Melissa M.; Thorn, Stephanie; Young, Lawerence; Pfau, Daniel; Madwed, Jeffrey; Small, Kersten; Kilmas, Michael; Choma, Michael A.; Sinusas, Albert J.

2017-02-01

Atrial fibrillation (AF) occurs following myocardial infarction (MI) and is associated with left ventricular dysfunction, which promotes the development of atrial remodeling and permanent atrial fibrosis. The purpose of this study was determining the effects of MI on left atrial (LA) remodeling with and without therapy with an angiotensin converting enzyme inhibition (ACEi) utilizing optical coherence tomography (OCT). As the composition of the myocardial tissue changes during LA remodeling the optical attenuation of the light will also change providing a metric to quantify the structural remodeling process. Lewis rats (240-275 g) underwent either surgical ligation of left coronary artery creating chronic MI, or SHAM surgery. 13 weeks post-surgery, ex vivo OCT imaging was performed of the LA appendage. Depth-resolved, attenuation coefficient volumes were calculated and the resulting atrial wall attenuation values were analyzed for four experimental groups: SHAM, SHAM with ACEi, MI no ACEi, and MI with ACEi. Quantification of tissue attenuation was performed and shown to significantly increase with MI in association with increases in collagen as verified with corresponding histological sectioning. Fractal analysis of the LA wall trabeculation patterns, 100 µm below the surface, was performed to quantify wall thickening associated with LA remodeling. A significant increase in fractal dimension was determined post MI compared to SHAM corresponding to a loss of the trabeculation pattern and wall thickening. The results from this study demonstrate OCT as an imaging technique capable of investigate LA remodeling with high resolution and label-free optical contrast processing.

The prognostic significance of cardiac structure and function in atrial fibrillation: the ENGAGE AF-TIMI 48 Echocardiographic Substudy

PubMed Central

Gupta, Deepak K; Giugliano, Robert P; Ruff, Christian T; Claggett, Brian; Murphy, Sabina; Antman, Elliott; Mercuri, Michele F.; Braunwald, Eugene; Solomon, Scott D

2016-01-01

Background Atrial fibrillation (AF) is associated with increased risk for thromboembolism and death; however, the relationships between cardiac structure and function and adverse outcomes among individuals with AF are incompletely understood. Methods The ENGAGE AF –TIMI 48 study tested the once-daily oral factor Xa inhibitor edoxaban in comparison to warfarin for the prevention of stroke (ischemic or hemorrhagic) or systemic embolism in 21,105 subjects with nonvalvular AF and increased risk for thromboembolic events (CHADS2 ≥ 2). In a prospective substudy of 971 subjects who underwent transthoracic echocardiography at baseline, we used Cox proportional hazards models to evaluate the associations between cardiac structure and function and the risks for death and thromboembolism (ischemic stroke, TIA, or systemic embolism). Results Over a median follow up of 2.5 years, 89 (9.2%) deaths and 48 (4.9%) incident thromboembolic events occurred in 971 subjects. In models adjusted for CHADS2 score, aspirin use, and randomized treatment, larger LV end diastolic volume index (HR: 1.49 [95%CI: 1.16,1.91] per 1 SD [12.9 ml/m2]) and higher LV filling pressures measured by E/′e (HR: 1.32 [95%CI: 1.08,1.61] per 1 SD [4.6]) were independently associated with increased risks for death. E/e′ > 13 significantly improved prediction of death beyond clinical factors alone. No features of cardiac structure and function were independently associated with thromboembolism in this population. Findings were similar when adjusted for CHA2DS2-VASc in place of CHADS2. Conclusions In a contemporary population of patients with atrial fibrillation at increased risk for thromboembolic events, larger LV size and higher filling pressures were significantly associated with increased risk for death, but neither left atrial nor left ventricular measures were associated with thromboembolic risk. LV size and filling pressures may help identify AF patients at increased risk of death. PMID:27106009

Organized Atrial Tachycardias after Atrial Fibrillation Ablation

PubMed Central

Castrejón-Castrejón, Sergio; Ortega, Marta; Pérez-Silva, Armando; Doiny, David; Estrada, Alejandro; Filgueiras, David; López-Sendón, José L.; Merino, José L.

2011-01-01

The efficacy of catheter-based ablation techniques to treat atrial fibrillation is limited not only by recurrences of this arrhythmia but also, and not less importantly, by new-onset organized atrial tachycardias. The incidence of such tachycardias depends on the type and duration of the baseline atrial fibrillation and specially on the ablation technique which was used during the index procedure. It has been repeatedly reported that the more extensive the left atrial surface ablated, the higher the incidence of organized atrial tachycardias. The exact origin of the pathologic substrate of these trachycardias is not fully understood and may result from the interaction between preexistent regions with abnormal electrical properties and the new ones resultant from radiofrequency delivery. From a clinical point of view these atrial tachycardias tend to remit after a variable time but in some cases are responsible for significant symptoms. A precise knowledge of the most frequent types of these arrhythmias, of their mechanisms and components is necessary for a thorough electrophysiologic characterization if a new ablation procedure is required. PMID:21941669

Altered transient outward current in human atrial myocytes of patients with reduced left ventricular function.

PubMed

Schreieck, J; Wang, Y; Overbeck, M; Schömig, A; Schmitt, C

2000-02-01

Electrophysiologic remodeling is involved in the self-perpetuation of atrial fibrillation. To define whether differences in atrial electrophysiology already are present in patients with increased susceptibility for atrial fibrillation, we compared patients in sinus rhythm with and without heart failure. Atrial specimens were obtained from patients with reduced left ventricular ejection fraction (LVEF; n = 10) and normal LVEF (n = 16) who were undergoing aortocoronary bypass surgery and from donor hearts (n = 4). Enzymatically isolated atrial myocytes were investigated by whole cell, patch clamp techniques. Total outward current was significantly larger in myocytes of hearts with low LVEF than normal LVEF (19.4 +/- 1.3 vs 15.1 +/- 1.2 pA/pF at pulses to +60 mV, respectively). Analysis of inactivation time courses of different outward current components revealed that the observed current difference is due to the transient calcium-independent outward current I(to1) which is twice as large in the low LVEF group than in the normal LVEF group (9.4 +/- 0.9 vs 4.7 +/- 0.4 pA/pF at pulses to +60 mV, respectively). I(to1) recovery from inactivation was significantly more rapid in myocytes of hearts with low LVEF, and action potential plateau in these cells was significantly shorter. The results of I(to1) and action potential measurements in atrial myocytes of donor hearts were very similar to the results of patients with preserved heart function. I(to1) in human atrial myocytes of patients with reduced LVEF has an increased density and altered kinetics in sinus rhythm. These differences in outward current may explain the reduced plateau phase of action potentials.

Long-term endurance sport is a risk factor for development of lone atrial flutter.

PubMed

Claessen, Guido; Colyn, Erwin; La Gerche, André; Koopman, Pieter; Alzand, Becker; Garweg, Christophe; Willems, Rik; Nuyens, Dieter; Heidbuchel, Hein

2011-06-01

To evaluate whether in a population of patients with 'lone atrial flutter', the proportion of those engaged in long-term endurance sports is higher than that observed in the general population. An age and sex-matched retrospective case-control study. A database with 638 consecutive patients who underwent ablation for atrial flutter at the University of Leuven. Sixty-one patients (55 men, 90%) fitted the inclusion criteria of 'lone atrial flutter', ie, aged 65 years or less, without documented atrial fibrillation and without identifiable underlying disease (including hypertension). Sex, age and inclusion criteria-matched controls, two for each flutter patient, were selected in a general practice in the same geographical region. Sports activity was evaluated by detailed questionnaires, which were available in 58 flutter patients (95%). A transthoracic echocardiogram was performed in all lone flutter patients. Types of sports, number of years of participation and average number of hours per week. The proportion of regular sportsmen (≥3 h of sports practice per week) among patients with lone atrial flutter was significantly higher than that observed in the general population (50% vs 17%; p<0.0001). The proportion of sportsmen engaged in long-term endurance sports (participation in cycling, running or swimming for ≥3 h/week) was also significantly higher in lone flutter patients than in controls (31% vs 8%; p=0.0003). Those flutter patients performing endurance sports had a larger left atrium than non-sportsmen (p=0.04, by one-way analysis of variance). A history of endurance sports and subsequent left atrial remodelling may be a risk factor for the development of atrial flutter.

The modified stepwise ablation guided by low-dose ibutilide in chronic atrial fibrillation trial (The MAGIC-AF Study).

PubMed

Singh, Sheldon M; d'Avila, Andre; Kim, Young-Hoon; Aryana, Arash; Mangrum, J Michael; Michaud, Gregory F; Dukkipati, Srinivas R; Barrett, Conor D; Heist, E Kevin; Parides, Michael K; Thorpe, Kevin E; Reddy, Vivek Y

2016-05-21

Complex fractionated atrial electrograms (CFAE) are targeted during persistent atrial fibrillation (AF) ablation. However, many CFAE sites are non-specific resulting in extensive ablation. Ibutilide has been shown to reduce left atrial surface area exhibiting CFAE. We hypothesized that ibutilide administration prior to CFAE ablation would identify sites critical for persistent AF maintenance allowing for improved procedural efficacy and long-term freedom from atrial arrhythmias. Two hundred patients undergoing a first-ever persistent AF catheter ablation procedure were randomly assigned to receive either 0.25 mg of intravenous ibutilide or saline placebo upon completion of pulmonary vein isolation. Complex fractionated atrial electrogram sites were then targeted with ablation. The primary efficacy endpoint was the 1-year single procedure freedom from atrial arrhythmia off anti-arrhythmic drugs. Similar procedural characteristics (procedure, fluoroscopy, and ablation times) were observed with both strategies despite a greater reduction in left atrial surface area with CFAE sites (8 vs. 1%, P < 0.0001) and AF termination during CFAE ablation with ibutilide compared with placebo (75 vs. 57%, P = 0.007). The primary efficacy endpoint was achieved in 56% of patients receiving ibutilide and 49% receiving placebo (P = 0.35). No significant differences in peri-procedural complications were observed in both groups. Despite a reduction in CFAE area and greater AF termination during CFAE ablation, procedural characteristics and clinical outcomes were unchanged when CFAE ablation was guided by ibutilide administration. ClinicalTrials.gov number: NCT01014741. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.

Infective Endocarditis of the Left Main to Right Atrial Coronary Cameral Fistula.

PubMed

Mishra, Ramesh Chandra; Barik, Ramachandra; Patnaik, Amar Narayana

2016-01-01

A 7-year-old female child presented with pyrexia of unknown origin. She had received an empirical regimen of antibiotic for possible endocarditis. Evaluation included multiple imaging supports and blood culture. She had left main coronary artery to right atrium coronary cameral fistula, restricted patent ductus arteriosus, vegetation at the right atrial exit of fistula and negative blood culture. Ongoing fever more than 2 weeks, oscillating vegetation in the echo and histopathological evidence of healing vegetation suggested definite diagnosis of infective endocarditis. She was treated successfully by surgical closure of fistula from the right atrial approach. Device closure in this case would have resulted in a large residual cul-de-sac with or without tiny residual high-velocity jets, either being a threat for future enlargement, rupture of the residual aneurysmal sac, thromboembolism, prolonged anticoagulation, and infective endocarditis.

The left atrial appendage: from embryology to prevention of thromboembolism.

PubMed

Patti, Giuseppe; Pengo, Vittorio; Marcucci, Rossella; Cirillo, Plinio; Renda, Giulia; Santilli, Francesca; Calabrò, Paolo; De Caterina, Alberto Ranieri; Cavallari, Ilaria; Ricottini, Elisabetta; Parato, Vito Maurizio; Zoppellaro, Giacomo; Di Gioia, Giuseppe; Sedati, Pietro; Cicchitti, Vincenzo; Davì, Giovanni; Golia, Enrica; Pariggiano, Ivana; Simeone, Paola; Abbate, Rosanna; Prisco, Domenico; Zimarino, Marco; Sofi, Francesco; Andreotti, Felicita; De Caterina, Raffaele

2017-03-21

The left atrial appendage (LAA) is the main source of thromboembolism in patients with non-valvular atrial fibrillation (AF). As such, the LAA can be the target of specific occluding device therapies. Optimal management of patients with AF includes a comprehensive knowledge of the many aspects related to LAA structure and thrombosis. Here we provide baseline notions on the anatomy and function of the LAA, and then focus on current imaging tools for the identification of anatomical varieties. We also describe pathogenetic mechanisms of LAA thrombosis in AF patients, and examine the available evidence on treatment strategies for LAA thrombosis, including the use of non-vitamin K antagonist oral anticoagulants and interventional approaches. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.

Are left ventricular ejection fraction and left atrial diameter related to atrial fibrillation recurrence after catheter ablation?

PubMed Central

Jin, Xiao; Pan, Jianke; Wu, Huanlin; Xu, Danping

2018-01-01

Abstract Atrial fibrillation (AF), the most common form of arrhythmia, is associated with the prevalence of many common cardiovascular and cerebrovascular diseases. Catheter ablation is considered the first-line therapy for AF; however, AF recurrence is very common after catheter ablation. Studies have been performed to analyze the factors associated with AF recurrence, but none have reached a consistent conclusion on whether left ventricular ejection fraction (LVEF) and left atrial diameter (LA diameter) affect AF recurrence after catheter ablation. The databases PubMed, Embase, and the Cochrane Library were used to search for relevant studies up to September 2017. RevMan 5.3.5 software provided by the Cochrane Collaboration Network was used to conduct this meta-analysis. Thirteen studies involving 2825 patients were included in this meta-analysis. Overall, the results revealed that elevated LA diameter values were significantly associated with AF recurrence in patients after catheter ablation (MD = 2.19, 95% CI: 1.63–2.75, P < .001), while baseline LVEF levels were not significantly positively associated with AF recurrence in patients after catheter ablation (MD = −0.91, 95% CI: −1.18 to 1.67, P = .14). Overall, elevated LA diameter may be associated with AF recurrence after catheter ablation; however, there was no direct relationship between LVEF values and AF recurrence after catheter ablation when baseline LVEF values are normal or mildly decreased. Besides, because of publication bias, further studies should be performed to explore the mechanisms underlying AF recurrence. PMID:29768386

A clinical comparison between a new dual-chamber pacing mode-AAIsafeR and DDD mode.

PubMed

Xue-Jun, Ren; Zhihong, Han; Ye, Wang; Huifeng, Du; Jinrong, Zhang; Fang, Chen; Jihong, Guo

2010-02-01

The aim of this study was to compare the cross-follow-up results in DDD or AAISafeR mode and to describe the safety and effectiveness of this pacing mode. The Symphony 2450/2550 cardiac pacemakers were implanted in 30 patients with sick sinus syndrome between February 2006 and September 2006. They were randomized to the DDD mode or AAISafeR mode for 3 months and then crossed over to the alternate pacing modality for an additional 3 months. No AAISafeR-related adverse event was observed. All documented episodes of paroxysmal atrial ventricular block caused the immediate switch of the pacing mode from AAI to DDD. The cumulative percent ventricular pacing was significantly reduced in the AAISafeR mode compared with the DDD mode (0.9% [0%-3%] versus 51.3% [2%-91%] P = 0.001; 2.94% [0%-18%] versus 41.18% [0%-65%] P = 0.0001). After 3 months in DDD mode, left atrial diameter, left ventricular enddiastolic diameter, and left ventricular end-systolic diameter increased significantly and left ventricular ejection fraction decreased. However, no obvious changes appeared in 3 months of AAISafeR mode. Switches to DDD occurred during follow-up in 21 patients due to different-degree atrial ventricular block. The AAISafeR mode substantially reduces the amount of unnecessary right ventricular pacing in the bradycardia population and effectively prevents the deleterious effects on cardiac performance. An international randomized study will further ascertain the efficacy of this new pacing mode specifically in the prevention of heart failure hospitalization and atrial fibrillation.

Small, smooth, nonmobile cardiac myxoma detected by transesophageal echocardiography following recurrent cerebral infarction: a case report.

PubMed

Saito, Yuki; Aizawa, Yoshihiro; Monno, Koyuru; Nagashima, Koichi; Kurokawa, Sayaka; Osaka, Shunji; Akimoto, Takayoshi; Kamei, Satoshi; Tanaka, Masashi; Hirayama, Atsushi

2017-05-10

Cardiac myxoma is known to cause repeated events of cerebral embolism. Soft and irregularly shaped myxomas with high mobility are associated with a higher occurrence of cerebral embolism. In contrast, nonmobile cardiac myxomas with a round regular shape are rarely considered to be a cause of cerebral embolism. In this case, we present a patient with recurrent cerebral embolism associated with a small and nonmobile cardiac myxoma of round regular shape. A 76-year-old Japanese man presented to our hospital with weakness in his right upper extremity. He had a history of right frontal lobe infarction in the previous month. T2-weighted magnetic resonance imaging revealed an area of hyperintensity in the left precentral gyrus, indicating acute cerebral infarction. Transthoracic echocardiography revealed normal left ventricular function and no abnormalities. However, transesophageal echocardiography showed a small and nonmobile left atrial tumor with round regular shape attached to the ostium secundum of the atrial septum. Based on these findings, we diagnosed recurrent cerebral infarction due to embolization caused by left atrial myxoma, and cardiac tumor extraction was performed on hospitalization day 36. The excised tumor measured 0.6 × 0.6 × 0.5 cm and was diagnosed as cardiac myxoma by histologic examination. Even small and nonmobile cardiac myxomas with a round regular shape may cause recurrent cerebral infarction. The diagnosis of this type of atrial myxoma is elusive and transesophageal echocardiography was an effective method of detection. In a clinical situation, this type of cardiac myxoma may be overlooked as a cause of cerebral infarction.

Transthoracic 3D echocardiographic left heart chamber quantification in patients with bicuspid aortic valve disease.

PubMed

van den Hoven, Allard T; Mc-Ghie, Jackie S; Chelu, Raluca G; Duijnhouwer, Anthonie L; Baggen, Vivan J M; Coenen, Adriaan; Vletter, Wim B; Dijkshoorn, Marcel L; van den Bosch, Annemien E; Roos-Hesselink, Jolien W

2017-12-01

Integration of volumetric heart chamber quantification by 3D echocardiography into clinical practice has been hampered by several factors which a new fully automated algorithm (Left Heart Model, (LHM)) may help overcome. This study therefore aims to evaluate the feasibility and accuracy of the LHM software in quantifying left atrial and left ventricular volumes and left ventricular ejection fraction in a cohort of patients with a bicuspid aortic valve. Patients with a bicuspid aortic valve were prospectively included. All patients underwent 2D and 3D transthoracic echocardiography and computed tomography. Left atrial and ventricular volumes were obtained using the automated program, which did not require manual contour detection. For comparison manual and semi-automated measurements were performed using conventional 2D and 3D datasets. 53 patients were included, in four of those patients no 3D dataset could be acquired. Additionally, 12 patients were excluded based on poor imaging quality. Left ventricular end-diastolic and end-systolic volumes and ejection fraction calculated by the LHM correlated well with manual 2D and 3D measurements (Pearson's r between 0.43 and 0.97, p < 0.05). Left atrial volume (LAV) also correlated significantly although LHM did estimate larger LAV compared to both 2DE and 3DE (Pearson's r between 0.61 and 0.81, p < 0.01). The fully automated software works well in a real-world setting and helps to overcome some of the major hurdles in integrating 3D analysis into daily practice, as it is user-independent and highly reproducible in a group of patients with a clearly defined and well-studied valvular abnormality.

The effect of atrial pacing site on electrophysiological properties of the atrioventricular junction and induction of atrioventricular nodal reentry in patients with typical atrioventricular nodal reentrant tachycardia.

PubMed

Kiedrowicz, Radosław M; Kaźmierczak, Jarosław; Wielusiński, Maciej

2017-01-01

Clinical studies in humans have shown the site of atrial stimulation to influence atrioventricular (AV) conduction times and refractory periods, the demonstration of dual AV nodal (AVN) pathways, and induction of AVN reentry. These studies often found conflicting results. Moreover, among enrolled patients a minority of them were found to have AVN reentrant tachycardia (AVNRT). The purpose of this study was to investigate the effect of right and left atrial pacing on the electrophysiological properties of the AV junction in the typical AVNRT population. Ninety-two consecutive patients with typical AVNRT were included. Atrial pacing was performed from the high right atrium (HRA) and the left atrium via the proximal coronary sinus (CS). Stimulation from either the HRA or the CS could result in dual AVN physiology and AVNRT. No site-dependent differences in the ease of induction of dual AVN pathways with variability of initiation from either site were found. However, AVNRT was easier to induce from the HRA. With CS pacing the leftward but not the rightward AVN approaches were the entry point to the AV node because of significantly shorter AH conduction times compared to HRA pacing. Conduction over the leftward AVN extensions could initiate the tachycardia with significantly shorter critical AH interval compared to conduction over the rightward AVN extensions; however, the AH interval during AVNRT and its cycle length were not significantly different. Rightward and leftward AVN extensions are regular features of the AV node. Their different electrophysiological properties lead to variation in the demonstration of discontinuous AVN conduction and AVNRT during right and left atrial pacing. Despite the observation that the left AVN extensions could compose the entry point to the reentrant circuit, there is no evidence that they constitute the critical component of sustained typical AVNRT.

Management of a large atrial septal occluder embolized to the left ventricular outflow tract without the use of cardiac surgery.

PubMed

Loh, Joshua P; Satler, Lowell F; Slack, Michael C

2014-09-01

Transcatheter closure of secundum-type atrial septal defects (ASDs) using the AMPLATZER™ Septal Occluder (ASO) has been in use for more than a decade since its US Food and Drug Administration approval in 2001. Device embolization remains an uncommon complication, which can sometimes occur after the initial deployment. Previous reports of ASO devices embolized to the left ventricle have primarily been managed by open-heart surgical retrieval. We present a case of an ASO device embolized to the left ventricular outflow tract (LVOT) 18 hr after initial implantation, which was successfully retrieved percutaneously, followed by successful closure of the ASD using a larger device. © 2014 Wiley Periodicals, Inc.

Three-Dimensional Echocardiographic Assessment of Left Heart Chamber Size and Function with Fully Automated Quantification Software in Patients with Atrial Fibrillation.

PubMed

Otani, Kyoko; Nakazono, Akemi; Salgo, Ivan S; Lang, Roberto M; Takeuchi, Masaaki

2016-10-01

Echocardiographic determination of left heart chamber volumetric parameters by using manual tracings during multiple beats is tedious in atrial fibrillation (AF). The aim of this study was to determine the usefulness of fully automated left chamber quantification software with single-beat three-dimensional transthoracic echocardiographic data sets in patients with AF. Single-beat full-volume three-dimensional transthoracic echocardiographic data sets were prospectively acquired during consecutive multiple cardiac beats (≥10 beats) in 88 patients with AF. In protocol 1, left ventricular volumes, left ventricular ejection fraction, and maximal left atrial volume were validated using automated quantification against the manual tracing method in identical beats in 10 patients. In protocol 2, automated quantification-derived averaged values from multiple beats were compared with the corresponding values obtained from the indexed beat in all patients. Excellent correlations of left chamber parameters between automated quantification and the manual method were observed (r = 0.88-0.98) in protocol 1. The time required for the analysis with the automated quantification method (5 min) was significantly less compared with the manual method (27 min) (P < .0001). In protocol 2, there were excellent linear correlations between the averaged left chamber parameters and the corresponding values obtained from the indexed beat (r = 0.94-0.99), and test-retest variability of left chamber parameters was low (3.5%-4.8%). Three-dimensional transthoracic echocardiography with fully automated quantification software is a rapid and reliable way to measure averaged values of left heart chamber parameters during multiple consecutive beats. Thus, it is a potential new approach for left chamber quantification in patients with AF in daily routine practice. Copyright © 2016 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

Acquired cyanotic heart disease secondary to traumatic tricuspid regurgitation. Case report with a review of the literature.

PubMed

Bardy, G H; Talano, J V; Meyers, S; Lesch, M

1979-12-01

A case of traumatic tricuspid insufficiency leading to right atrial enlargement and to a patent foramen ovale with right to left shunting is presented. Six similar cases previously reported are reviewed. The time course of clinical deterioration was related to the type of tricuspid valve damage incurred. Papillary muscle rupture led to surgery within a year, whereas less severe chordal damage allowed a more benign course that lasted from 10 to 25 years from the time of injury to the time of surgery. Surgical repair of the incompetent tricuspid valve and closure of the atrial septal defect led to significant improvement. The diagnostic usefulness of radionuclide imaging and echocardiography is demonstrated in this case. A mechanism of right to left interatrial shunting in the presence of normal pulmonary arterial pressures is proposed; this invokes phasic increases in right atrial pressure from tricuspid insufficiency and streaming of blood from the inferior vena cava into the left atrium across a patent foramen ovale in a manner that resembles conditions in the fetal circulation.

Magnetic electroanatomical mapping for ablation of focal atrial tachycardias.

PubMed

Marchlinski, F; Callans, D; Gottlieb, C; Rodriguez, E; Coyne, R; Kleinman, D

1998-08-01

Uniform success for ablation of focal atrial tachycardias has been difficult to achieve using standard catheter mapping and ablation techniques. In addition, our understanding of the complex relationship between atrial anatomy, electrophysiology, and surface ECG P wave morphology remains primitive. The magnetic electroanatomical mapping and display system (CARTO) offers an on-line display of electrical activation and/or signal amplitude related to the anatomical location of the recorded sites in the mapped chamber. A window of electrical interest is established based on signals timed from an electrical reference that usually represents a fixed electrogram recording from the coronary sinus or the atrial appendage. This window of electrical interest is established to include atrial activation prior to the onset of the P wave activity associated with the site of origin of a focal atrial tachycardia. Anatomical and electrical landmarks are defined with limited fluoroscopic imaging support and more detailed global chamber and more focal atrial mapping can be performed with minimal fluoroscopic guidance. A three-dimensional color map representing atrial activation or voltage amplitude at the magnetically defined anatomical sites is displayed with on-line data acquisition. This display can be manipulated to facilitate viewing from any angle. Altering the zoom control, triangle fill threshold, clipping plane, or color range can all enhance the display of a more focal area of interest. We documented the feasibility of using this single mapping catheter technique for localizing and ablating focal atrial tachycardias. In a consecutive series of 8 patients with 9 focal atrial tachycardias, the use of the single catheter CARTO mapping system was associated with ablation success in all but one patient who had a left atrial tachycardia localized to the medial aspect of the orifice of the left atrial appendage. Only low power energy delivery was used in this patient because of the unavailability of temperature monitoring in the early version of the Navistar catheter, the location of the arrhythmia, and the history of arrhythmia control with flecainide. No attempt was made to limit fluoroscopy time in our study population. Nevertheless, despite data acquisition from 120-320 anatomically distinct sites during global and more detailed focal atrial mapping, total fluoroscopy exposure was typically < 30 minutes and was as little as 12 minutes. The detailed display capabilities of the CARTO system appear to offer the potential of enhancing our understanding of atrial anatomy, atrial activation, and their relationship to surface ECG P wave morphology during focal atrial tachycardias.

Atrial electromechanical conduction delay in patients with neurocardiogenic syncope.

PubMed

Sucu, Murat; Ercan, Suleyman; Uku, Okkes; Davutoglu, Vedat; Altunbas, Gokhan

2014-05-01

We aimed to investigate the presence of atrial electromechanical conduction delay in patients with neurocardiogenic syncope, which was diagnosed with head-up tilt table test (HUTT). A total of 29 patients (mean age: 30.6 ± 15.9 years) with vasovagal syncope, as diagnosed by HUTT, and 23 healthy control subjects (mean age: 34.7 ± 16.3 years) with a negative HUTT were enrolled to the study. Atrial electromechanical conduction delay was defined as the time elapsed from the beginning of the P wave in the electrogardiogram to the beginning of the Am wave in tissue Doppler. There was no statistically significant difference between the groups in terms of interatrial conduction delay, whereas the difference was significant with regard to the right intraatrial electromechanical conduction delay (P < 0.01) and the left intraatrial electromechanical conduction delay (P < 0.0001). There was a negative correlation between the left intraatrial electromechanical conduction delay and the right intraatrial electromechanical conduction delay (r = -0.486, P = 0.001), whereas a positive correlation was present with the interatrial electromechanical conduction delay (r = 0.507, P = 0.001). In this study, the tissue Doppler method revealed that there is left and right intraatrial electromechanical conduction delay in patients with vasovagal syncope. The impact and role of atrial conduction delay as a pathophysiological determinant should be confirmed in further studies. ©2013 Wiley Periodicals, Inc.

Association between atrial fibrillation, atrial enlargement, and left ventricular geometric remodeling.

PubMed

Seko, Yuta; Kato, Takao; Haruna, Tetsuya; Izumi, Toshiaki; Miyamoto, Shoichi; Nakane, Eisaku; Inoko, Moriaki

2018-04-23

This study investigated the relationship between atrial fibrillation (AF) and left ventricular (LV) geometric patterns in a hospital-based population in Japan. We retrospectively analyzed 4444 patients who had undergone simultaneous scheduled transthoracic echocardiography (TTE) and electrocardiography during 2013. A total of 430 patients who had findings of previous myocardial infarctions (n = 419) and without the data on body surface area (n = 11) were excluded from the study. We calculated the LV mass index (LVMI) and relative wall (RWT) and categorized 4014 patients into four groups as follows: normal geometry (n = 3046); concentric remodeling (normal LVMI and high RWT, n = 437); concentric hypertrophy (high LVMI and high RWT, n = 149); and eccentric remodeling (high LVMI and normal RWT, n = 382). The mean left atrial volume indices (LAVI) were 22.5, 23.8, 33.3, and 37.0 mm/m 2 in patients with normal geometry, concentric remodeling, concentric hypertrophy, and eccentric hypertrophy, respectively. The mean LV ejection fractions (LVEF) were 62.7, 62.6, 60.8, and 53.8%, respectively, whereas the prevalence of AF was 10.4%, 10.5%, 14.8%, and 16.8% in patients with normal geometry, concentric remodeling, concentric hypertrophy, and eccentric hypertrophy, respectively. In conclusion, the prevalence of AF was increasing according to LV geometric remodeling patterns in association with LA size and LVEF.

[New technology for prevention of embolic events in atrial fibrillation: a systematic review on percutaneous endovascular left atrial appendage closure].

PubMed

Danna, Paolo; Sagone, Antonio; Proietti, Riccardo; Arensi, Andrea; Viecca, Maurizio; Santangeli, Pasquale; Di Biase, Luigi; Natale, Andrea

2012-09-01

Atrial fibrillation (AF) is the most common cardiac arrhythmia. The mortality rate of patients with AF is doubled as compared to non-fibrillating controls. The most relevant complication of AF is a major increase in the risk of stroke. The gold standard in reducing cerebrovascular events in AF is warfarin therapy, which is not free from contraindications and limitations. The left atrial appendage (LAA) is the main source of emboli causing stroke in AF. LAA closure is a seducing approach to stroke risk reduction in AF without anticoagulation. Since 1949, heart surgeons have performed LAA closure or amputation in patients with AF. Percutaneous endovascular LAA closure is a new, less invasive, technique to reach the goal. Several devices have been used to perform this intervention, and the results of published trials are encouraging in terms of effectiveness and relative safety of this attractive technique. In this review we examine the published trials and data on percutaneous LAA closure, with particular attention to the risks and benefits of this procedure.

Determinants of plasma NT-pro-BNP levels in patients with atrial fibrillation and preserved left ventricular ejection fraction.

PubMed

Letsas, Konstantinos P; Filippatos, Gerasimos S; Pappas, Loukas K; Mihas, Constantinos C; Markou, Virginia; Alexanian, Ioannis P; Efremidis, Michalis; Sideris, Antonios; Maisel, Alan S; Kardaras, Fotios

2009-02-01

The present study aimed to investigate the clinical and echocardiographic determinants of plasma NT-pro-BNP levels in patients with atrial fibrillation (AF) and preserved left ventricular ejection fraction (LVEF). NT-pro-BNP levels were measured in 45 patients with paroxysmal AF, 41 patients with permanent AF and 48 controls. NT-pro-BNP levels were found significantly elevated in patients with paroxysmal (215+/-815 pg/ml) and permanent AF (1,086+/-835 pg/ml) in relation to control population (86.3+/-77.9 pg/ml) (P<0.001). According to the univariate linear regression analysis, age, hypertension, beta-blocker use, left atrial diameter (LAD), LVEF and AF status (paroxysmal or permanent or both) were significantly associated with NT-pro-BNP levels (P<0.05). In multiple linear regression analysis, LVEF (B coefficient: -53.030; CI: -95.738 to -10.322; P: 0.015) and LAD (B coefficient: 285.858; CI: 23.731-547.986; P: 0.033) were significant and independent determinants of NT-pro-BNP levels. Plasma NT-pro-BNP levels were significantly higher in patients with paroxysmal and permanent AF compared to those with sinus rhythm in the setting of preserved left ventricular systolic function. LVEF and LAD were independent predictors of NT-pro-BNP levels.

Pathology of myxomatous mitral valve disease in the dog.

PubMed

Fox, Philip R

2012-03-01

Mitral valve competence requires complex interplay between structures that comprise the mitral apparatus - the mitral annulus, mitral valve leaflets, chordae tendineae, papillary muscles, and left atrial and left ventricular myocardium. Myxomatous mitral valve degeneration is prevalent in the canine, and most adult dogs develop some degree of mitral valve disease as they age, highlighting the apparent vulnerability of canine heart valves to injury. Myxomatous valvular remodeling is associated with characteristic histopathologic features. Changes include expansion of extracellular matrix with glycosaminoglycans and proteoglycans; valvular interstitial cell alteration; and attenuation or loss of the collagen-laden fibrosa layer. These lead to malformation of the mitral apparatus, biomechanical dysfunction, and mitral incompetence. Mitral regurgitation is the most common manifestation of myxomatous valve disease and in advanced stages, associated volume overload promotes progressive valvular regurgitation, left atrial and left ventricular remodeling, atrial tears, chordal rupture, and congestive heart failure. Future studies are necessary to identify clinical-pathologic correlates that track disease severity and progression, detect valve dysfunction, and facilitate risk stratification. It remains unresolved whether, or to what extent, the pathobiology of myxomatous mitral valve degeneration is the same between breeds of dogs, between canines and humans, and how these features are related to aging and genetics. Copyright © 2012 Elsevier B.V. All rights reserved.

Is Doppler tissue velocity during early left ventricular filling preload independent?

NASA Technical Reports Server (NTRS)

Yalcin, F.; Kaftan, A.; Muderrisoglu, H.; Korkmaz, M. E.; Flachskampf, F.; Garcia, M.; Thomas, J. D.

2002-01-01

BACKGROUND: Transmitral Doppler flow indices are used to evaluate diastolic function. Recently, velocities measured by Doppler tissue imaging have been used as an index of left ventricular relaxation. OBJECTIVE: To determine whether Doppler tissue velocities are influenced by alterations in preload. METHODS: Left ventricular preload was altered in 17 patients (all men, mean (SD) age, 49 (8) years) during echocardiographic measurements of left ventricular end diastolic volume, maximum left atrial area, peak early Doppler filling velocity, and left ventricular myocardial velocities during early filling. Preload altering manoeuvres included Trendelenberg (stage 1), reverse Trendelenberg (stage 2), and amyl nitrate (stage 3). Systolic blood pressure was measured at each stage. RESULTS: In comparison with baseline, left ventricular end diastolic volume (p = 0.001), left atrial area (p = 0.003), peak early mitral Doppler filling velocity (p = 0.01), and systolic blood pressures (p = 0.001) were all changed by preload altering manoeuvres. Only left ventricular myocardial velocity during early filling remained unchanged by these manoeuvres. CONCLUSIONS: In contrast to standard transmitral Doppler filling indices, Doppler tissue early diastolic velocities are not significantly affected by physiological manoeuvres that alter preload. Thus Doppler tissue velocities during early left ventricular diastole may provide a better index of diastolic function in cardiac patients by providing a preload independent assessment of left ventricular filling.

Assessment of atrial electromechanical delay and left atrial mechanical functions in patients with psoriasis vulgaris.

PubMed

Aksan, Gökhan; Nar, Gökay; Soylu, Korhan; İnci, Sinan; Yuksel, Serkan; Ocal, Hande Serra; Yuksel, Esra Pancar; Gulel, Okan

2015-04-01

Increased frequency of atrial fibrillation (AF) has been demonstrated in psoriasis cases. Prolongation of the duration of atrial electromechanical delay (AEMD) is a well-known characteristic of the atrium, which is vulnerable to AF. In the current study, our aims are to investigate AEMD durations and mechanical functions of the left atrium (LA) in patients with psoriasis. A total of 90 patients, 45 with psoriasis vulgaris and 45 as the control group, were included in the study. Atrial electromechanical coupling (PA) and intra- and inter-atrial electromechanical delay (IA-AEMD) were measured with tissue Doppler echocardiography. P-wave dispersion (PWD) was calculated from the 12-lead electrocardiogram. The severity of the disease was evaluated by the Psoriasis Area and Severity Index. The durations of PA lateral and PA septal were significantly high in the psoriasis group when compared with the control group (47.7 ± 9.8 vs. 57.1 ± 8.4 msec, P < 0.001 and 38.6 ± 9.9 vs. 43.6 ± 8 msec, P = 0.016, respectively). The durations of IA-AEMD, intra-right electromechanical delay, and intra-left electromechanical delay in the psoriasis group were significantly prolonged compared with the control group (15.2 ± 4.1 vs. 21.7 ± 5.6 msec, P < 0.001; 6 ± 2.5 vs. 8.7 ± 2.7 msec, P < 0.001; and 9.1 ± 3.9 vs. 13.5 ± 5.2 msec, P < 0.001; respectively). PWD was significantly higher in patients with psoriasis vulgaris compared with controls (36.1 ± 7.9 vs. 40.2 ± 9.1 msec, P = 0.043). In the present study, we found prolongation in the durations of AEMD and PWD in the psoriasis group compared with the control group. These results might be an early predictor of AF and other arrhythmias. © 2014, Wiley Periodicals, Inc.

Cardiac cycle-dependent left atrial dynamics: implications for catheter ablation of atrial fibrillation.

PubMed

Patel, Amit R; Fatemi, Omid; Norton, Patrick T; West, J Jason; Helms, Adam S; Kramer, Christopher M; Ferguson, John D

2008-06-01

Left atrial (LA) volume determines prognosis and response to therapy for atrial fibrillation. Integration of electroanatomic maps with three-dimensional images rendered from computed tomography and magnetic resonance imaging (MRI) is used to facilitate atrial fibrillation ablation. The purpose of this study was to measure LA volume changes and regional motion during the cardiac cycle that might affect the accuracy of image integration and to determine their relationship to standard LA volume measurements. MRI was performed in 30 patients with paroxysmal atrial fibrillation. LA time-volume curves were generated and used to divide LA ejection fraction into pumping ejection fraction and conduit ejection fraction and to determine maximum LA volume (LA(max)) and preatrial contraction volume. LA volume was measured using an MRI angiogram and traditional geometric models from echocardiography (area-length model and ellipsoid model). In-plane displacement of the pulmonary veins, anterior left atrium, mitral annulus, and LA appendage was measured. LA(max) was 107 +/- 36 mL and occurred at 42% +/- 5% of the R-R interval. Preatrial contraction volume was 86 +/- 34 mL and occurred at 81% +/- 4% of the R-R interval. LA ejection fraction was 45% +/- 10%, and pumping ejection fraction was 31% +/- 10%. LA volume measurements made from MRI angiogram, area-length model, and ellipsoid model underestimated LA(max) by 21 +/- 25 mL, 16 +/- 26 mL, and 35 +/- 22 mL, respectively. Anterior LA, mitral annulus, and LA appendage were significantly displaced during the cardiac cycle (8.8 +/- 2.0 mm, 13.2 +/- 3.8 mm, and 10.2 +/- 3.4 mm, respectively); the pulmonary veins were not displaced. LA volume changes significantly during the cardiac cycle, and substantial regional variation in LA motion exists. Standard measurements of LA volume significantly underestimate LA(max) compared to the gold standard measure of three-dimensional volumetrics.

Cost-Effectiveness of Percutaneous Closure of the Left Atrial Appendage in Atrial Fibrillation Based on Results From PROTECT AF Versus PREVAIL.

PubMed

Freeman, James V; Hutton, David W; Barnes, Geoffrey D; Zhu, Ruo P; Owens, Douglas K; Garber, Alan M; Go, Alan S; Hlatky, Mark A; Heidenreich, Paul A; Wang, Paul J; Al-Ahmad, Amin; Turakhia, Mintu P

2016-06-01

Randomized trials of left atrial appendage (LAA) closure with the Watchman device have shown varying results, and its cost effectiveness compared with anticoagulation has not been evaluated using all available contemporary trial data. We used a Markov decision model to estimate lifetime quality-adjusted survival, costs, and cost effectiveness of LAA closure with Watchman, compared directly with warfarin and indirectly with dabigatran, using data from the long-term (mean 3.8 year) follow-up of Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation (PROTECT AF) and Prospective Randomized Evaluation of the Watchman LAA Closure Device in Patients With Atrial Fibrillation (PREVAIL) randomized trials. Using data from PROTECT AF, the incremental cost-effectiveness ratios compared with warfarin and dabigatran were $20 486 and $23 422 per quality-adjusted life year, respectively. Using data from PREVAIL, LAA closure was dominated by warfarin and dabigatran, meaning that it was less effective (8.44, 8.54, and 8.59 quality-adjusted life years, respectively) and more costly. At a willingness-to-pay threshold of $50 000 per quality-adjusted life year, LAA closure was cost effective 90% and 9% of the time under PROTECT AF and PREVAIL assumptions, respectively. These results were sensitive to the rates of ischemic stroke and intracranial hemorrhage for LAA closure and medical anticoagulation. Using data from the PROTECT AF trial, LAA closure with the Watchman device was cost effective; using PREVAIL trial data, Watchman was more costly and less effective than warfarin and dabigatran. PROTECT AF enrolled more patients and has substantially longer follow-up time, allowing greater statistical certainty with the cost-effectiveness results. However, longer-term trial results and postmarketing surveillance of major adverse events will be vital to determining the value of the Watchman in clinical practice. © 2016 American Heart Association, Inc.

Atrial fibrillation and isolated systolic hypertension: the systolic hypertension in the elderly program and systolic hypertension in the elderly program-extension study.

PubMed

Vagaonescu, Tudor D; Wilson, Alan C; Kostis, John B

2008-06-01

We performed a post hoc analysis of the Systolic Hypertension in the Elderly Program database to assess the incidence of atrial fibrillation in the elderly hypertensive population, its influence on cardiovascular events, and whether antihypertensive treatment can prevent its onset. The Systolic Hypertension in the Elderly Program was a double-blind placebo-controlled trial in 4736 subjects with isolated systolic hypertension aged >or=60 years. Atrial fibrillation was an exclusion criterion from the trial. Participants were randomly assigned to stepped care treatment with chlorthalidone and atenolol (n=2365) or placebo (n=2371). The occurrence of atrial fibrillation and cardiovascular events over 4.7 years as well as the determination of cause of death at 4.7 and 14.3 years were followed. Ninety-eight subjects (2.06%) developed atrial fibrillation over 4.7 years mean follow-up, without significant difference between treated and placebo groups. Atrial fibrillation increased the risk for: total cardiovascular events (RR 1.69; 95% CI 1.21 to 2.36), rapid death (RR 3.29; 95% CI 1.08 to 10.00), total (RR 5.10; 95% CI 3.12 to 8.37) and nonfatal left ventricular failure (RR 5.31; 95% CI 3.09 to 9.13). All-cause and total cardiovascular death were significantly increased in the atrial fibrillation group at 4.7 years (HR 3.44; 95% CI 2.18 to 5.42; HR 2.39; 95% CI 1.05 to 5.43) and 14.3 years follow-up (HR 2.33; 95% CI 1.83 to 2.98; HR 2.21; 95% CI 1.54 to 3.17). Atrial fibrillation increased the risk for total cardiovascular events, rapid death, and left ventricular failure. All-cause mortality and total cardiovascular mortality were significantly increased in hypertensives with atrial fibrillation at 4.7 and 14.3 years follow-up.

Evaluation of Right Ventricular Myocardial Mechanics Using Velocity Vector Imaging of Cardiac MRI Cine Images in Transposition of the Great Arteries Following Atrial and Arterial Switch Operations.

PubMed

Thattaliyath, Bijoy D; Forsha, Daniel E; Stewart, Chad; Barker, Piers C A; Campbell, Michael J

2015-01-01

The aim of the study was to determine right and left ventricle deformation parameters in patients with transposition of the great arteries who had undergone atrial or arterial switch procedures. Patients with transposition are born with a systemic right ventricle. Historically, the atrial switch operation, in which the right ventricle remains the systemic ventricle, was performed. These patients have increased rates of morbidity and mortality. We used cardiac MRI with Velocity Vector Imaging analysis to characterize and compare ventricular myocardial deformation in patients who had an atrial switch or arterial switch operation. Patients with a history of these procedures, who had a clinically ordered cardiac MRI were included in the study. Consecutive 20 patients (75% male, 28.7 ± 1.8 years) who underwent atrial switch operation and 20 patients (60% male, 17.7 ± 1.9 years) who underwent arterial switch operation were included in the study. Four chamber and short-axis cine images were used to determine longitudinal and circumferential strain and strain rate using Vector Velocity Imaging software. Compared with the arterial switch group, the atrial switch group had decreased right ventricular ejection fraction and increased end-diastolic and end-systolic volumes, and no difference in left ventricular ejection fraction and volumes. The atrial switch group had decreased longitudinal and circumferential strain and strain rate. When compared with normal controls multiple strain parameters in the atrial switch group were reduced. Myocardial deformation analysis of transposition patients reveals a reduction of right ventricular function and decreased longitudinal and circumferential strain parameters in patients with an atrial switch operation compared with those with arterial switch operation. A better understanding of the mechanisms of right ventricle failure in transposition of great arteries may lead to improved therapies and adaptation. © 2015 Wiley Periodicals, Inc.

[Successful repair of total anomalous pulmonary venous connection and incomplete endocardial cushion defect associated with left isomerism].

PubMed

Mizuno, A; Nakamura, Y; Takayasu, H; Saitoh, H

1993-05-01

Successful repair of a 8-month-old girl with polysplenia was reported. The cardiovascular anomalies were TAPVC (II b), incomplete ECD, interruption of inferior vena cava with hemiazygos continuation, bilateral superior vena cava, and left superior vena cava draining into the coronary sinus. Cardiopulmonary bypass was established with ascending aortic perfusion and caval cannulation. A left superior vena cava was directly cannulated after establishing partial bypass. In this case the left pulmonary vein drained into the right atrium near the orifice of the coronary sinus, so the atrial septal flap was made and sutured between the orifice of the left pulmonary vein and the coronary sinus in order to avoid late pulmonary vein obstruction. Then, atrium was separated by an intraatrial baffle which was sutured to the atrial septal flap. Recently, it becomes possible to surgical repair of polysplenia syndrome according to the advancements of the diagnostic methods, cardiopulmonary bypass, and the technique of the open heart surgery.

Noninvasive evaluation of reverse atrial remodeling after catheter ablation of atrial fibrillation by P wave dispersion.

PubMed

Fujimoto, Yuhi; Yodogawa, Kenji; Takahashi, Kenta; Tsuboi, Ippei; Hayashi, Hiroshi; Uetake, Shunsuke; Iwasaki, Yu-Ki; Hayashi, Meiso; Miyauchi, Yasushi; Shimizu, Wataru

2017-11-01

Atrial fibrillation (AF) itself creates structural and electrophysiological changes such as atrial enlargement, shortening of refractory period and decrease in conduction velocity, called "atrial remodeling", promoting its persistence. Although the remodeling process is considered to be reversible, it has not been elucidated in detail. The aim of this study was to assess the feasibility of P wave dispersion in the assessment of reverse atrial remodeling following catheter ablation of AF. Consecutive 126 patients (88 males, age 63.0 ± 10.4 years) who underwent catheter ablation for paroxysmal AF were investigated. P wave dispersion was calculated from the 12 lead ECG before, 1 day, 1 month, 3 months and 6 months after the procedure. Left atrial diameter (LAD), left atrial volume index (LAVI), left ventricular ejection fraction (LVEF), transmitral flow velocity waveform (E/A), and tissue Doppler (E/e') on echocardiography, plasma B-type natriuretic peptide (BNP) concentrations, serum creatinine, and estimated glomerular filtration rate (eGFR) were also measured. Of all patients, 103 subjects remained free of AF for 1 year follow-up. In these patients, P wave dispersion was not changed 1 day and 1 month after the procedure. However, it was significantly decreased at 3 and 6 months (50.1 ± 14.8 to 45.4 ± 14.4 ms, p < 0.05, 45.2 ± 9.9 ms, p < 0.05, respectively). Plasma BNP concentrations, LAD and LAVI were decreased (81.1 ± 103.8 to 44.8 ± 38.3 pg/mL, p < 0.05, 38.2 ± 5.7 to 35.9 ± 5.6 mm, p < 0.05, 33.3 ± 14.2 to 29.3 ± 12.3 mL/m 2 , p < 0.05) at 6 months after the procedure. There were no significant changes in LVEF, E/A, E/e', serum creatinine, and eGFR during the follow up period. P wave dispersion was decreased at 3 and 6 months after catheter ablation in patients without recurrence of AF. P wave dispersion is useful for assessment of reverse remodeling after catheter ablation of AF.

Imaging Techniques in Percutaneous Cardiac Structural Interventions: Atrial Septal Defect Closure and Left Atrial Appendage Occlusion.

PubMed

Rodríguez Fernández, Antonio; Bethencourt González, Armando

2016-08-01

Because of advances in cardiac structural interventional procedures, imaging techniques are playing an increasingly important role. Imaging studies show sufficient anatomic detail of the heart structure to achieve an excellent outcome in interventional procedures. Up to 98% of atrial septal defects at the ostium secundum can be closed successfully with a percutaneous procedure. Candidates for this type of procedure can be identified through a systematic assessment of atrial septum anatomy, locating and measuring the size and shape of all defects, their rims, and the degree and direction of shunting. Three dimensional echocardiography has significantly improved anatomic assessments and the end result itself. In the future, when combined with other imaging techniques such as cardiac computed tomography and fluoroscopy, 3-dimensional echocardiography will be particularly useful for procedure guidance. Percutaneous closure of the left atrial appendage offers an alternative for treating patients with atrial fibrillation and contraindication for oral anticoagulants. In the future, the clinical focus may well turn to stroke prevention in selected patients. Percutaneous closure is effective and safe; device implantation is successful in 94% to 99% of procedures. However, the procedure requires an experienced cardiac structural interventional team. At present, 3-dimensional echocardiography is the most appropriate imaging technique to assess anatomy suitability, select device type and size, guide the procedure alongside fluoroscopy, and to follow-up the patient afterwards. Copyright © 2016 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

Evolving anatomic and electrophysiologic considerations associated with Fontan conversion.

PubMed

Mavroudis, Constantine; Backer, Carl Lewis; Deal, Barbara J; Stewart, Robert D; Franklin, Wayne H; Tsao, Sabrina; Ward, Kendra

2007-01-01

The principles of Fontan conversion with arrhythmia surgery are to restore the cardiac anatomy by converting the original atriopulmonary connection to a total cavopulmonary artery extracardiac connection and treat the underlying atrial arrhythmias. Successful outcomes of this procedure are dependent on a thorough understanding of several factors: the patient's fundamental diagnosis of single-ventricle anatomy, the resultant cardiac configuration from the original atriopulmonary Fontan connection, right atrial dilatation that leads to atrial flutter or fibrillation, and associated congenital cardiac anomalies. The purpose of this article is to present some of the more challenging anatomic and electrophysiologic problems we have encountered with Fontan conversion and arrhythmia surgery and the innovative solutions we have used to treat them. The cases reviewed herein include: takedown of a Bjork-Fontan modification, right ventricular hypertension and tricuspid regurgitation after atriopulmonary Fontan for pulmonary atresia and intact ventricular septum, takedown of atrioventricular valve isolation patch for right-sided maze procedure, resultant hemodynamic considerations leading to intraoperative pulmonary vein stenosis after Fontan conversion, unwanted inferior vena cava retraction during the extracardiac connection, right atrial cannulation in the presence of a right atrial clot, distended left superior vena cava causing left pulmonary vein stenosis, dropped atrial septum, and the modified right-sided maze procedure for various single-ventricle pathology. Since 1994 we have performed Fontan conversion with arrhythmia surgery on 109 patients with a 0.9% mortality rate. We attribute our program's success in no small measure to the strong collaborative efforts of the cardiothoracic surgery and cardiology teams.

Correlative anatomy for the electrophysiologist: ablation for atrial fibrillation. Part II: regional anatomy of the atria and relevance to damage of adjacent structures during AF ablation.

PubMed

Macedo, Paula G; Kapa, Suraj; Mears, Jennifer A; Fratianni, Amy; Asirvatham, Samuel J

2010-07-01

Ablation procedures for atrial fibrillation have become an established and increasingly used option for managing patients with symptomatic arrhythmia. The anatomic structures relevant to the pathogenesis of atrial fibrillation and ablation procedures are varied and include the pulmonary veins, other thoracic veins, the left atrial myocardium, and autonomic ganglia. Exact regional anatomic knowledge of these structures is essential to allow correlation with fluoroscopy and electrograms and, importantly, to avoid complications from damage of adjacent structures within the chest. We present this information as a series of 2 articles. In a prior issue, we have discussed the thoracic vein anatomy relevant to paroxysmal atrial fibrillation. In the present article, we focus on the atria themselves, the autonomic ganglia, and anatomic issues relevant for minimizing complications during atrial fibrillation ablation.

Myotonic Dystrophy Initially Presenting as Tachycardiomyopathy Successful Catheter Ablation of Atrial Flutter

PubMed Central

Asbach, S.; Gutleben, K. J.; Dahlem, P.; Brachmann, J.; Nölker, G.

2010-01-01

Myotonic dystrophy is a genetic muscular disease that is frequently associated with cardiac arrhythmias. Bradyarrhythmias, such as sinus bradycardia and atrioventricular block, are more common than tachyarrhythmias. Rarely, previously undiagnosed patients with myotonic dystrophy initially present with a tachyarrhythmia. We describe the case of a 14-year-old boy, who was admitted to the hospital with clinical signs and symptoms of decompensated heart failure and severely reduced left ventricular function. Electrocardiography showed common-type atrial flutter with 2 : 1 conduction resulting in a heart rate of 160 bpm. Initiation of medical therapy for heart failure as well as electrical cardioversion led to a marked clinical improvement. Catheter ablation of atrial flutter was performed to prevent future cardiac decompensations and to prevent development of tachymyopathy. Left ventricular function normalized during followup. Genetic analysis confirmed the clinical suspicion of myotonic dystrophy as known in other family members in this case. PMID:20871860

Infective Endocarditis of the Left Main to Right Atrial Coronary Cameral Fistula

PubMed Central

Mishra, Ramesh Chandra; Barik, Ramachandra; Patnaik, Amar Narayana

2016-01-01

A 7-year-old female child presented with pyrexia of unknown origin. She had received an empirical regimen of antibiotic for possible endocarditis. Evaluation included multiple imaging supports and blood culture. She had left main coronary artery to right atrium coronary cameral fistula, restricted patent ductus arteriosus, vegetation at the right atrial exit of fistula and negative blood culture. Ongoing fever more than 2 weeks, oscillating vegetation in the echo and histopathological evidence of healing vegetation suggested definite diagnosis of infective endocarditis. She was treated successfully by surgical closure of fistula from the right atrial approach. Device closure in this case would have resulted in a large residual cul-de-sac with or without tiny residual high-velocity jets, either being a threat for future enlargement, rupture of the residual aneurysmal sac, thromboembolism, prolonged anticoagulation, and infective endocarditis. PMID:28465978

Supra hepatic inferior vena cava and right atrial thrombosis following a traffic car crash.

PubMed

Sabzi, Feridoun; Karim, Hosein; Haghi, Marjan

2016-07-01

We present a case of nephrotic syndrome associated with right atrial and supra hepatic vein part of inferior vena caval thrombosis. This patient presented with dyspena, lower extremity edema and back pain after a vehicle accident and blunt trauma to the abdomen. Trauma should be considered not only as a thrombophilic pre-disposition, but also as a predisposing factor to IVC endothelium injury and thrombosis formation. Echocardiography revealed supra hepatic vein IVC thrombosis floating to the right atrium. A C-T scan with contrast also showed pulmonary artery emboli to the left upper lobe. With open heart surgery, the right atrial and IVC clot were extracted and the main left and right pulmonary arteries were evaluated for possible clot lodging. The patient had an uneventful postoperative recovery and thrombosis has not reoccurred with periodical follow-up examinations. © 2016 KUMS, All rights reserved.

Complicated rheumatic mitral stenosis presenting in an elderly patient and the challenges in its management.

PubMed

Ganeshpure, Swapnil; Vaidya, Gaurang Nandkishor; Gattani, Vipul

2012-12-05

A 76 -year-old lady with a recent diagnosis of rheumatic heart disease (RHD), and a history of repeated lower respiratory tract infections, came with symptoms of gastritis unrelated to the primary disease but further diagnostic study in the hospital revealed poorly controlled atrial fibrillation, grossly dilated left atrium with two large left atrial thrombi and mitral valve area<1 cm(2). It was decided that the best approach in our patient would be mitral valve replacement with mechanical prosthesis. Despite the usual trend of using bioprosthesis in the elderly, our decision was influenced by the fact that the patient would need chronic anticoagulation for atrial fibrillation in any case. The purpose of our case presentation is to illustrate a late-presenting case of RHD with unusual associations and the challenges to choose the best possible management.

Assessment of ventricular and left atrial mechanical functions, atrial electromechanical delay and P wave dispersion in patients with scleroderma.

PubMed

Aktoz, Meryem; Yilmaztepe, Mustafa; Tatli, Ersan; Turan, Fatma Nesrin; Umit, Elif G; Altun, Armagan

2011-01-01

The aim of this study was to investigate ventricular functions and left atrial (LA) mechanical functions, atrial electromechanical coupling, and P wave dispersion in scleroderma patients. Twenty-six patients with scleroderma and twenty-four controls were included. Left and right ventricular (LV and RV) functions were evaluated using conventional echocardiography and tissue Doppler imaging (TDI). LA volumes were measured using the biplane area- -length method and LA mechanical function parameters were calculated. Inter-intraatrial electromechanical delays were measured by TDI. P wave dispersion was calculated by 12-lead electrocardiograms. LV myocardial performance indices (MPI) and RV MPI were higher in patients with scleroderma (p = 0.000, p = 0.000, respectively) while LA passive emptying fraction was decreased and LA active emptying fraction was increased (p = 0.051, p = 0.000, respectively). P wave dispersion and inter-intraatrial electromechanical delay were significantly higher in patients with scleroderma (25 [10-60] vs 20 [0-30], p = 0.000, 16.50 [7.28-26.38] vs 9.44 [3.79-15.78] and 11.33 [4.88-16.06] vs 4.00 [0-12.90], p < 0.05, respectively). Interatrial electromechanical delay was negatively correlated with LV E wave, (p = 0.018). LV E wave was demonstrated to be a factor independent of the interatrial electromechanical delay (R² = = 0.270, b = -0.52, p = 0.013). This study showed that in scleroderma patients, global functions of LV, RV and mechanical functions of LA were impaired, intra-interatrial electromechanical delays were prolonged and P wave dispersion was higher. LV E wave was demonstrated to be a factor that is independent of the interatrial electromechanical delay. Reduced LV E wave may also give additional information on the process of risk stratification of atrial fibrillation.

Predictors of Long-term Success After Concomitant Surgical Ablation for Atrial Fibrillation.

PubMed

Pecha, Simon; Ghandili, Susanne; Hakmi, Samer; Willems, Stephan; Reichenspurner, Hermann; Wagner, Florian Mathias

2017-01-01

According to guidelines, atrial fibrillation (AF) ablation success should be measured by 24-hour Holter electrocardiogram (ECG). However, information on long-term success, especially obtained by 24-hour Holter ECG, is rare. We therefore analyzed rhythm course and long-term outcomes of our patients undergoing concomitant surgical AF ablation. Between January 2003 and April 2011, 486 patients underwent concomitant surgical AF ablation in our institution. Patients with 24-hour Holter ECG rhythm status available between 5 and 10 years postoperatively were included in this retrospective data analysis (n = 155). Ablation lesions were limited to either a pulmonary vein isolation (n = 31, 20%), a more complex left atrial lesion set (n = 89, 57%), or biatrial lesions (n = 35, 23%). Primary end point of the study was freedom from AF during long-term follow-up. Mean patient age was 68.1 ± 8.4 years; 57.4% were male. Mean follow-up time was 5.9 years. Surgical AF ablation provided freedom from AF rate of 56.6% during long-term follow-up, with significantly better results in patients with paroxysmal than in those with persistent AF (67.2% vs 51.8% P = 0.03). A stable rhythm course was observed during follow-up, without statistically significant differences between 12 months and latest follow-up (63.2% vs 56.6%; P = 0.25). In multivariate analysis, preoperative paroxysmal AF, duration of AF, and left atrial diameter were predictors of long-term ablation success. Surgical AF ablation provided freedom from AF rate of 56.6% during long-term follow-up. Statistically significant predictors of ablation success at latest follow-up were preoperative paroxysmal AF, duration of AF, and a preoperative smaller left atrial diameter. Copyright © 2017. Published by Elsevier Inc.

Comparisons of the underlying mechanisms of left atrial remodeling after repeat circumferential pulmonary vein isolation with or without additional left atrial linear ablation in patients with recurrent atrial fibrillation.

PubMed

Yang, Chia-Hung; Chou, Chung-Chuan; Hung, Kuo-Chun; Wen, Ming-Shien; Chang, Po-Cheng; Wo, Hung-Ta; Lee, Cheng-Hung; Lin, Fen-Chiung

2017-02-01

Radiofrequency catheter ablation (RFCA) is a potentially curative treatment for atrial fibrillation (AF), however, whether or not additional left atrial (LA) linear ablation for recurrent AF adversely affects LA remodeling is unknown. Thirty-eight patients experiencing AF recurrence after the 1st circumferential pulmonary vein isolation (CPVI) underwent a repeat RFCA, including 20 and 18 patients receiving a repeat CPVI (group I) or CPVI plus LA linear ablation (group II), respectively. 2-D echocardiography was performed during sinus rhythm within 24h, at 1-m and 6-m after RFCA. Longitudinal strains and strain rate were measured with speckle-tracking echocardiography. The standard deviation of contraction duration was defined as LA mechanical dispersion. One and two patients experienced AF recurrence after the 2nd RFCA in group I and II, respectively (P=NS). The 1st CPVI with AF recurrence did not reduce LA size significantly in two groups. After a repeat CPVI, LA diameter but not LA maximal and minimal volume was significantly reduced in group I; additional LA linear ablation significantly decreased LA diameter, maximal and minimal volume in group II. However, there was no significant difference in LA emptying function, global and segmental LA strain and strain rate among the baseline, 1-m and 6-m follow-up in two groups. RFCA did not significantly increase LA mechanical dispersion regardless of the AF ablation strategies. In patients with recurrent AF, a successful repeat CPVI with or without additional LA linear ablation reduced LA size without significant deleterious effects on LA function and mechanical dispersion. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Association of Left Atrial Function and Left Atrial Enhancement in Patients with Atrial Fibrillation: A Cardiac Magnetic Resonance Study

PubMed Central

Habibi, Mohammadali; Lima, Joao A.C.; Khurram, Irfan M.; Zimmerman, Stefan L.; Zipunnikov, Vadim; Fukumoto, Kotaro; Spragg, David; Ashikaga, Hiroshi; Rickard, John; Marine, Joseph E.; Calkins, Hugh; Nazarian, Saman

2015-01-01

Background Atrial fibrillation (AF) is associated with left atrial (LA) structural and functional changes. Cardiac magnetic resonance (CMR) late gadolinium enhancement (LGE) and feature-tracking are capable of noninvasive quantification of LA fibrosis and myocardial motion, respectively. We sought to examine the association of phasic LA function with LA enhancement in patients with AF. Methods and Results LA structure and function was measured in 90 AF patients (age 61 ± 10 years, 76% male) referred for ablation and 14 healthy volunteers. Peak global longitudinal LA strain (PLAS), LA systolic strain rate (SR-s), and early (SR-ed) and late diastolic (SR-ld) strain rates were measured using cine-CMR images acquired during sinus rhythm. The degree of LGE was quantified. Compared to patients with paroxysmal AF (60% of cohort), those with persistent AF had larger maximum LA volume index (LAVImax, 56 ± 17ml/m2 versus 49 ± 13ml/m2 p=0.036), and increased LGE (27.1± 11.7% versus 36.8 ± 14.8% p<0.001). Aside from LA active emptying fraction, all LA parameters (passive emptying fraction, PLAS, SR-s, SR-ed and SR-ld) were lower in patients with persistent AF (p< 0.05 for all). Healthy volunteers had less LGE and higher LA functional parameters compared to AF patients (p<0.05 for all). In multivariable analysis, increased LGE was associated with lower LA passive emptying fraction, PLAS, SR-s, SR-ed, and SR-ld (p<0.05 for all). Conclusions Increased LA enhancement is associated with decreased LA reservoir, conduit, and booster pump functions. Phasic measurement of LA function using feature-tracking CMR may add important information regarding the physiological importance of LA fibrosis. PMID:25652181

The incidence and characteristics of supraventricular tachycardia in left atrial isomerism: a high incidence of atrial fibrillation in young patients.

PubMed

Miyazaki, Aya; Sakaguchi, Heima; Ohuchi, Hideo; Yamamoto, Tetsuya; Igarashi, Takehiro; Negishi, Jun; Toyota, Naoki; Kagisaki, Koji; Yagihara, Toshikatsu; Yamada, Osamu

2013-06-20

In left atrial isomerism (LAI), both atria show left atrial morphology. Although bradyarrhythmias are frequent and highly complex in LAI patients, previous studies have reported a low incidence of supraventricular tachycardia (SVT). To evaluate the incidence and characteristics of SVT in LAI, we retrospectively evaluated the clinical characteristics of SVTs in 83 patients with LAI (age at last follow-up, 15.3±10.5 years). There were 27 SVTs in 19 patients (23%), including nine episodes of atrial fibrillation (AF) and eight non-reentrant SVTs. Sixteen of the 19 patients with SVT had histories of atriotomy, but the three patients with AF or non-reentrant tachycardia had no history of atriotomy. The rates of freedom from SVT were 66% and 59% at ages of 20 and 30 years, respectively; the corresponding rates for freedom from AF were 89% and 74%. In multivariate analysis, the predictors of SVT were age (OR, 1.14; 95% CI, 1.06-1.26; p=0.003) and sinus node dysfunction (SND) (OR, 3.88; 95% CI, 1.57-13.34; p=0.01). In patients with LAI, SVTs are common, and AF and non-reentrant SVTs are the major type of SVTs. The incidence of AF was high in young patients with LAI. The lack of anatomical barriers in the atria that allow the formation of macro-reentrant circuits may account for the higher incidence of AF and non-reentrant SVT than macro-reentrant tachycardia. Moreover, the increasing prevalence of SND with age should contribute to a higher incidence of SVT. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Contemporary Diagnosis and Management of Atrial Flutter: A Continuum of Atrial Fibrillation and Vice Versa?

PubMed

Manolis, Antonis S

Atrial flutter (AFlu) is usually a fast (>240 bpm) and regular right atrial macroreentrant tachycardia, with a constrained critical region of the reentry circuit located at the cavotricuspid isthmus (CTI; typical CTI-dependent AFlu). However, a variety of right and left atrial tachycardias, resulting from different mechanisms, can also present as AFlu (atypical non-CTI-dependent AFlu). The electrocardiogram can provide clues to its origin and location; however, additional entrainment and more sophisticated electroanatomical mapping techniques may be required to identify its mechanism, location, and target area for a successful ablation. Although atrial fibrillation and AFlu are 2 separate arrhythmias, they often coexist before and after drug and/or ablation therapies. Indeed, there appears to be a close interrelationship between these 2 arrhythmias, and one may "transform" into the other. These issues are discussed in this overview, and practical algorithms are proposed to guide AFlu localization and illustrate the AFlu and atrial fibrillation continuum.

Impact of catheter ablation with remote magnetic navigation on procedural outcomes in patients with persistent and long-standing persistent atrial fibrillation.

PubMed

Jin, Qi; Pehrson, Steen; Jacobsen, Peter Karl; Chen, Xu

2015-11-01

The objectives of this study were to assess the procedural outcomes of persistent and long-standing persistent atrial fibrillation (PsAF and L-PsAF) ablation guided by remote magnetic navigation (RMN), and to detect factors predicting acute restoration of sinus rhythm (SR) by ablation with RMN. A total of 313 patients (275 male, age 59 ± 9.5 years) with PsAF (187/313) or L-PsAF (126/313) undergoing ablation using RMN were included. Patients' disease history, pulmonary venous anatomy, left atrial (LA) volume, procedure time, mapping plus ablation time, radiofrequency (RF) ablation time, fluoroscopy time, radiation dose, and complications were assessed. Stepwise regression was used to predict which variable could best predict acute restoration from AF to SR by ablation. Compared to PsAF, procedure time and RF ablation time were significantly increased in patients with L-PsAF (P = 0.01 and P < 0.001, respectively). No major complications occurred during the procedures in either PsAF or L-PsAF patients. Fifty five of 313 patients converted directly to SR by ablation. Compared to L-PsAF, the rate of SR restoration was significantly higher in PsAF (21 vs 12%, P = 0.03). Stepwise regression analysis showed LA volume was the primary parameter affecting SR restoration (P = 0.01). The LA volume of patients without direct SR restoration by ablation was 24% greater than that of patients with SR restoration (P < 0.001). Catheter ablation using RMN is a safe and effective method for PsAF and L-PsAF. LA volume could be a predictor of direct restoration of SR from sustaining AF by ablation using RMN.

Galectin-3 levels relate in children to total body fat, abdominal fat, body fat distribution, and cardiac size.

PubMed

Dencker, Magnus; Arvidsson, Daniel; Karlsson, Magnus K; Wollmer, Per; Andersen, Lars B; Thorsson, Ola

2018-03-01

Galectin-3 has recently been proposed as a novel biomarker for cardiovascular disease in adults. The purpose of this investigation was to assess relationships between galectin-3 levels and total body fat, abdominal fat, body fat distribution, aerobic fitness, blood pressure, left ventricular mass, left atrial size, and increase in body fat over a 2-year period in a population-based sample of children. Our study included 170 children aged 8-11 years. Total fat mass and abdominal fat were measured by dual-energy x-ray absorptiometry (DXA). Body fat distribution was expressed as abdominal fat/total fat mass. Maximal oxygen uptake was assessed by indirect calorimetry during a maximal exercise test and scaled to body mass. Systolic and diastolic blood pressure and pulse pressure were measured. Left atrial size, left ventricular mass, and relative wall thickness were measured by echocardiography. Frozen serum samples were analyzed for galectin-3 by the Proximity Extension Assay technique. A follow-up DXA scan was performed in 152 children 2 years after the baseline exam. Partial correlations, with adjustment for sex and age, between galectin-3 versus body fat measurements indicated weak to moderate relationships. Moreover, left atrial size, left ventricular mass, and relative wall thickness and pulse pressure were also correlated with galectin-3. Neither systolic blood pressure nor maximal oxygen uptake was correlated with galectin-3. There was also a correlation between galectin-3 and increase in total body fat over 2 years, while no such correlations were found for the other fat measurements. More body fat and abdominal fat, more abdominal body fat distribution, more left ventricular mass, and increased left atrial size were all associated with higher levels of galectin-3. Increase in total body fat over 2 years was also associated with higher levels of galectin-3. What is Known: • Galectin-3 has been linked to obesity and been proposed to be a novel biomarker for cardiovascular disease in adults. • Information on this subject in children is very scarce. What is New: • The present study demonstrates a relationship between galectin-3 levels and total body fat, abdominal fat, body fat distribution, cardiac size and geometry, and increase in total body fat over 2 years in young children.

Calibration and evaluation of a magnetically tracked ICE probe for guidance of left atrial ablation therapy

NASA Astrophysics Data System (ADS)

Linte, Cristian A.; Rettmann, Maryam E.; Dilger, Ben; Gunawan, Mia S.; Arunachalam, Shivaram P.; Holmes, David R., III; Packer, Douglas L.; Robb, Richard A.

2012-02-01

The novel prototype system for advanced visualization for image-guided left atrial ablation therapy developed in our laboratory permits ready integration of multiple imaging modalities, surgical instrument tracking, interventional devices and electro-physiologic data. This technology allows subject-specific procedure planning and guidance using 3D dynamic, patient-specific models of the patient's heart, augmented with real-time intracardiac echocardiography (ICE). In order for the 2D ICE images to provide intuitive visualization for accurate catheter to surgical target navigation, the transducer must be tracked, so that the acquired images can be appropriately presented with respect to the patient-specific anatomy. Here we present the implementation of a previously developed ultrasound calibration technique for a magnetically tracked ICE transducer, along with a series of evaluation methods to ensure accurate imaging and faithful representation of the imaged structures. Using an engineering-designed phantom, target localization accuracy is assessed by comparing known target locations with their transformed locations inferred from the tracked US images. In addition, the 3D volume reconstruction accuracy is also estimated by comparing a truth volume to that reconstructed from sequential 2D US images. Clinically emulating validation studies are conducted using a patient-specific left atrial phantom. Target localization error of clinically-relevant surgical targets represented by nylon fiducials implanted within the endocardial wall of the phantom was assessed. Our studies have demonstrated 2.4 +/- 0.8 mm target localization error in the engineering-designed evaluation phantoms, 94.8 +/- 4.6 % volume reconstruction accuracy, and 3.1 +/- 1.2 mm target localization error in the left atrial-mimicking phantom. These results are consistent with those disseminated in the literature and also with the accuracy constraints imposed by the employed technology and the clinical application.

Multistage electrotherapy delivered through chronically-implanted leads terminates atrial fibrillation with lower energy than a single biphasic shock.

PubMed

Janardhan, Ajit H; Gutbrod, Sarah R; Li, Wenwen; Lang, Di; Schuessler, Richard B; Efimov, Igor R

The goal of this study was to develop a low-energy, implantable device-based multistage electrotherapy (MSE) to terminate atrial fibrillation (AF). Previous attempts to perform cardioversion of AF by using an implantable device were limited by the pain caused by use of a high-energy single biphasic shock (BPS). Transvenous leads were implanted into the right atrium (RA), coronary sinus, and left pulmonary artery of 14 dogs. Self-sustaining AF was induced by 6 ± 2 weeks of high-rate RA pacing. Atrial defibrillation thresholds of standard versus experimental electrotherapies were measured in vivo and studied by using optical imaging in vitro. The mean AF cycle length (CL) in vivo was 112 ± 21 ms (534 beats/min). The impedances of the RA-left pulmonary artery and RA-coronary sinus shock vectors were similar (121 ± 11 Ω vs. 126 ± 9 Ω; p = 0.27). BPS required 1.48 ± 0.91 J (165 ± 34 V) to terminate AF. In contrast, MSE terminated AF with significantly less energy (0.16 ± 0.16 J; p < 0.001) and significantly lower peak voltage (31.1 ± 19.3 V; p < 0.001). In vitro optical imaging studies found that AF was maintained by localized foci originating from pulmonary vein-left atrium interfaces. MSE Stage 1 shocks temporarily disrupted localized foci; MSE Stage 2 entrainment shocks continued to silence the localized foci driving AF; and MSE Stage 3 pacing stimuli enabled consistent RA-left atrium activation until sinus rhythm was restored. Low-energy MSE significantly reduced the atrial defibrillation thresholds compared with BPS in a canine model of AF. MSE may enable painless, device-based AF therapy. Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Multistage Electrotherapy Delivered Through Chronically-Implanted Leads Terminates Atrial Fibrillation With Lower Energy Than a Single Biphasic Shock

PubMed Central

Janardhan, Ajit H.; Gutbrod, Sarah R.; Li, Wenwen; Lang, Di; Schuessler, Richard B.; Efimov, Igor R.

2014-01-01

Objectives The goal of this study was to develop a low-energy, implantable device–based multistage electrotherapy (MSE) to terminate atrial fibrillation (AF). Background Previous attempts to perform cardioversion of AF by using an implantable device were limited by the pain caused by use of a high-energy single biphasic shock (BPS). Methods Transvenous leads were implanted into the right atrium (RA), coronary sinus, and left pulmonary artery of 14 dogs. Self-sustaining AF was induced by 6 ± 2 weeks of high-rate RA pacing. Atrial defibrillation thresholds of standard versus experimental electrotherapies were measured in vivo and studied by using optical imaging in vitro. Results The mean AF cycle length (CL) in vivo was 112 ± 21 ms (534 beats/min). The impedances of the RA–left pulmonary artery and RA–coronary sinus shock vectors were similar (121 ± 11 Ω vs. 126 ± 9 Ω; p = 0.27). BPS required 1.48 ± 0.91 J (165 ± 34 V) to terminate AF. In contrast, MSE terminated AF with significantly less energy (0.16 ± 0.16 J; p < 0.001) and significantly lower peak voltage (31.1 ± 19.3 V; p < 0.001). In vitro optical imaging studies found that AF was maintained by localized foci originating from pulmonary vein–left atrium interfaces. MSE Stage 1 shocks temporarily disrupted localized foci; MSE Stage 2 entrainment shocks continued to silence the localized foci driving AF; and MSE Stage 3 pacing stimuli enabled consistent RA–left atrium activation until sinus rhythm was restored. Conclusions Low-energy MSE significantly reduced the atrial defibrillation thresholds compared with BPS in a canine model of AF. MSE may enable painless, device-based AF therapy. PMID:24076284

Coronary Sinus Activation and ECG Characteristics of Roof-Dependent Left Atrial Flutter After Pulmonary Vein Isolation.

PubMed

Casado Arroyo, Ruben; Laţcu, Decebal Gabriel; Maeda, Shingo; Kubala, Maciej; Santangeli, Pasquale; Garcia, Fermin Carlos; Enache, Bogdan; Eljamili, Mohammed; Hayashi, Tatsuya; Zado, Erica S; Saoudi, Nadir; Marchlinski, Francis E

2018-06-01

The electrocardiographic and intracardiac activation features of left atrial roof-dependent macroreentrant flutter have been incompletely characterized. Patients post-pulmonary vein (PV) isolation with roof-dependent atrial flutter based on activation and entrainment mapping were included. ECG and coronary sinus activation were compared with mitral annular (MA) flutter. The roof-dependent left atrial flutter circled the right PVs in 32 of 33 cases. Two forms of roof flutters were identified, posteroanterior, ascendant on posterior wall and descendant on anterior wall (n=24); and anteroposterior, ascendant on the anterior wall and descendent on the posterior wall (n=9). Both forms had positive large amplitude P waves in V 1 through V 2 with decreasing amplitude in V 3 through V 6 . Posteroanterior roof flutters had positive P wave in the inferior and negative P wave in leads I and aVL similar to counterclockwise MA flutter, but coronary sinus activation was simultaneous for roof and proximal to distal for counterclockwise. Anteroposterior roof flutters were similar to clockwise MA flutter with negative P in inferior leads and transition to flat or negative P in V 3 through V 6 . Coronary sinus activation time ≤39 ms identified roof versus MA flutter (sensitivity: 100% and specificity: 97%). Roof-dependent flutter around right PVs is more common than around left PVs. The ECG pattern for roof-dependent flutter around right PVs is similar to MA flutter with frontal plane axis dictated by septal activation. Roof-dependent flutter can be distinguished from MA flutter by more simultaneous rather than sequential coronary sinus activation. © 2018 American Heart Association, Inc.

[Clinical, electrocardiographic and echocardiographic aspects in elderly hypertensive patients in Senegal].

PubMed

Sarr, Simon Antoine; Babaka, Kana; Mboup, Mouhamadou Cherif; Fall, Pape Diadie; Dia, Khadidiatou; Bodian, Malick; Ndiaye, Mouhamadou Bamba; Kane, Adama; Diao, Maboury; Ba, Serigne Abdou

2016-01-01

Arterial hypertension (HTA) in the elderly is an independent risk factor for cardiovascular disease. Our study aims to describe the clinical, electrocardiographic and echocardiographic aspects of Arterial hypertension in elderly patients. We conducted a descriptive, cross-sectional study from January to September 2013. Hypertensive patients =60 years treated in Outpatient Cardiology Department at the Principal Hospital in Dakar were included in the study. Statistical data were analyzed using Epi Info 7 software and a p-value < 0.05 was taken as significant. A total of 208 patients were enrolled in the study. The average age was 69.9 years with a female predominance (sex ratio 0.85). Average blood pressure was 162/90 mm Hg. HTA was under control in 13% of cases. The ECG showed evidence of rhythm disturbance (17.78%), left atrial enlargement (45.19%), left ventricular hypertrophy (28.85%) and complete atrioventricular block in 2 cases. Holter ECG revealed non-sustained ventricular tachycardia (Lown class IVb) in 4 cases, paroxysmal atrial fibrillation in 6 cases and paroxysmal atrial flutter in 1 case. Echocardiography performed in 140 patients showed mainly concentric left ventricular hypertrophy in 25 patients, occuring more frequently in males (p=0,04) and dilated left atrium in 56,42% of cases, occuring more frequently in elderly patients (p= 0,01). Electrocardiographic and echocardiographic aspects in elderly hypertensive population are characterized by concentric left ventricular hypertrophy and by the frequency of arrhythmias sometimes revealed by long-term continuous external electrocardiographic recording.

A region-specific quantitative profile of autonomic innervation of the canine left atrium and pulmonary veins.

PubMed

Gao, Chong-han; Wang, Fei; Jiang, Rong; Zhang, Jin; Mou, Huamin; Yin, Yue-hui

2011-07-05

The aim of the present study was to determine and quantify the cardiac autonomic innervation of the canine atria and pulmonary vein. Tissue specimens were taken from the canine pulmonary veins (PVs), posterior left atrium (PLA), left atrial roof (LAR), anterior left atrium (ALA), interatrial septum (IAS), and left atrial appendage (LAA) respectively for immunohistochemical analysis and nerve density determination. Both sympathetic and parasympathetic nerve densities decreased in the order: PLA>PV>IAS>LAR>ALA>LAA. For sympathetic nerve, multiple comparisons between any two regions showed a significant difference (P<0.05-P<0.01) except for PV vs. PLA, IAS vs. LAR, and LAR vs. ALA; for parasympathetic nerve, all the differences between any pair of regions were statistically significant (P<0.05-P<0.01) with the exception of PV vs. PLA, IAS vs. LAR, LAR vs. ALA, and ALA vs. LAA. For both nerve types, there was a decreasing gradient of nerve densities from the external to internal layer (P<0.001, for each comparisons). Nerve density at the ostia for either nerve type was significantly higher than at the distal segments of PVs (P<0.001). In summary, the LA and PVs are innervated by sympathetic and parasympathetic nerves in a regionally heterogeneous way, which may be important for the pathophysiological investigation and ablation therapy of atrial fibrillation (AF). Copyright © 2011 Elsevier B.V. All rights reserved.

The effect of transient balloon occlusion of the mitral valve on left atrial appendage blood flow velocity and spontaneous echo contrast.

PubMed

Wang, J; Chung Ann Choo, D; Zhang, X; Yang, Q; Xian, T; Lu, D; Jiang, S

2000-07-01

Spontaneous echo contrast (SEC) is a phenomenon that is commonly seen in areas of blood stasis. It is a slowly moving, cloud-like swirling pattern of "smoke" or increased echogenicity recorded on echocardiography. SEC is commonly seen in the left atrium of patients with mitral stenosis or atrial fibrillation. The presence of SEC has been shown to be a marker of increased thromboembolic risk. By using transesophageal echocardiography during percutaneous balloon mitral valvotomy (PBMV), the study investigated the relationship between SEC and varying left atrial appendage (LAA) blood flow velocity in the human heart. Thirty-five patients with rheumatic mitral stenosis underwent percutaneous balloon mitral valvotomy with intraoperative transesophageal echocardiography monitoring. We alternatively measured LAA velocities and observed the left atrium for various grades of SEC (0 = none to 4 = severe) before and after each balloon inflation. Left atrial appendage maximal ejection velocity was reduced from 35 +/- 14 to 6 +/- 2 mm/s at peak balloon inflation and increased to 40 +/- 16 mm/s after balloon deflation. In comparison with the values before balloon inflation and after balloon deflation, LAA velocities were significantly lower (p < 0.001). New or increased SEC grade was observed during 54 of 61 (88%) inflations and unchanged in 7 (12%) inflations at peak balloon inflation. Spontaneous echo contrast became lower in grade after 55 balloon deflations (90%), completely disappeared after 18 deflations (30%), and remained unchanged after 6 deflations (10%). The mean time to achieve maximal SEC grade (2.5 +/- 1.2 s) coincided with the mean time to trough LAA velocities (2.3 +/- 1.1 s) after balloon inflation. Upon deflation, the mean time to lowest SEC grade (2.9 +/- 1.8 s) coincided with mean time to achieve maximal LAA velocities (2.7 +/- 1.6 s). During balloon inflation, the severity of SEC was enhanced with corresponding reduction in LAA flow velocity. Upon balloon deflation, SEC lightens or disappears with increase in LAA flow velocity.

[Doppler echocardiographic investigation of left ventricular diastolic function in preterm infants with and without a patent ductus arteriosus].

PubMed

Schmitz, L; Stiller, B; Koehne, P; Koch, H; Lange, P E

2004-01-01

We studied the influence of preload augmentation on Doppler-derived left ventricular diastolic function parameters in infants with a birth weight <1500 g. In 44 neonates with a closed duct and 29 neonates with an open ductus arteriosus a complete echocardiographic study including Doppler investigations of the mitral inflow signals and analysis of diastolic time intervals was performed. Neonates with an open duct had a lower median gestational age (27.1 vs. 29, P<0.01), a higher cardiac index (425 vs. 260 ml/min/kg, P<0.001), and a different M-mode left atrial to aortic diameter ratio (1.36 vs. 0.79, P<0.001), but birth weight, age at examination (6.6 vs. 7.9 days), and heart rate were similar compared to the neonates with a closed duct. Main differences in diastolic indexes existed in early and atrial filling integrals and peak velocities, early filling acceleration time, and isovolumic relaxation time. Most informative in neonates with an open ductus peak early filling velocity (41.2 vs. 30.4 cm, P<0.01) and peak atrial filling velocity (49.2 vs. 35.9, P<0.001) are higher, and isovolumic relaxation time is shorter (45 vs. 53 ms, P<0.001) than in closed duct peers. Isovolumic relaxation time is inversely correlated with the cardiac index (R = -0.78). These parameter changes can be interpreted as incipient left ventricular diastolic failure in extremely low birth weight infants in the presence of a preload challenge. The coincidence of higher peak velocities with a shortened isovolumic relaxation time is very likely a result of left atrial pressure elevation. Preload mismatch has to be considered in preterm infants with a persistent ductus arteriosus. The results of this study can be helpful to find the indication for PDA-closure and to adjust volume replacement therapy, and catecholamine medication to a level appropriate for the individual cardiac performance.