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Campora A, Lisi M, Pastore MC, Mandoli GE, Ferrari Chen YF, Pasquini A, Rubboli A, Henein MY, Cameli M. Atrial Fibrillation, Atrial Myopathy, and Thromboembolism: The Additive Value of Echocardiography and Possible New Horizons for Risk Stratification. J Clin Med 2024; 13:3921. [PMID: 38999487 PMCID: PMC11242512 DOI: 10.3390/jcm13133921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 06/22/2024] [Accepted: 07/01/2024] [Indexed: 07/14/2024] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac sustained arrhythmia, and it is associated with increased stroke and dementia risk. While the established paradigm attributes these complications to blood stasis within the atria and subsequent thrombus formation with cerebral embolization, recent evidence suggests that atrial myopathy (AM) may play a key role. AM is characterized by structural and functional abnormalities of the atria, and can occur with or without AF. Moving beyond classifications based solely on episode duration, the 4S-AF characterization has offered a more comprehensive approach, incorporating patient's stroke risk, symptom severity, AF burden, and substrate assessment (including AM) for tailored treatment decisions. The "ABC" pathway emphasizes anticoagulation, symptom control, and cardiovascular risk modification and emerging evidence suggests broader benefits of early rhythm control strategies, potentially reducing stroke and dementia risk and improving clinical outcomes. However, a better integration of AM assessment into the current framework holds promise for further personalizing AF management and optimizing patient outcomes. This review explores the emerging concept of AM and its potential role as a risk factor for stroke and dementia and in AF patients' management strategies, highlighting the limitations of current risk stratification methods, like the CHA2DS2-VASc score. Echocardiography, particularly left atrial (LA) strain analysis, has shown to be a promising non-invasive tool for AM evaluation and recent studies suggest that LA strain analysis may be a more sensitive risk stratifier for thromboembolic events than AF itself, with some studies showing a stronger association between LA strain and thromboembolic events compared to traditional risk factors. Integrating it into routine clinical practice could improve patient management and targeted therapies for AF and potentially other thromboembolic events. Future studies are needed to explore the efficacy and safety of anticoagulation in AM patients with and without AF and to refine the diagnostic criteria for AM.
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Affiliation(s)
- Alessandro Campora
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale Bracci 1, 53100 Siena, Italy
| | - Matteo Lisi
- Department of Emergency, Internal Medicine and Cardiology-AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Viale Randi 5, 48121 Ravenna, Italy
| | - Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale Bracci 1, 53100 Siena, Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale Bracci 1, 53100 Siena, Italy
| | - Yu Fu Ferrari Chen
- Cardiovascular Division, Pisa University Hospital and University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Annalisa Pasquini
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Andrea Rubboli
- Department of Emergency, Internal Medicine and Cardiology-AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Viale Randi 5, 48121 Ravenna, Italy
| | - Michael Y Henein
- Department of Public Health and Clinical Medicine, Umeå University, 90187 Umeå, Sweden
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale Bracci 1, 53100 Siena, Italy
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Raniga D, Goda M, Hattingh L, Thorning S, Rowe M, Howes L. Left atrial volume index: A predictor of atrial fibrillation recurrence following direct current cardioversion - A systematic review and meta-analysis. IJC HEART & VASCULATURE 2024; 51:101364. [PMID: 38426114 PMCID: PMC10902144 DOI: 10.1016/j.ijcha.2024.101364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 02/09/2024] [Accepted: 02/11/2024] [Indexed: 03/02/2024]
Abstract
This systematic review and meta-analysis was conducted to determine the clinical relevance of echocardiographically measured left atrial (LA) size to predict the recurrence of atrial fibrillation (AF) after direct current cardioversion (DCCV). A search was performed on Medline (Ovid), Embase (Elsevier), Cochrane Central Register of Controlled Trials (CENTRAL) in Cochrane Library, Wiley and Web of Science (Clarivate) to identify relevant studies. Amongst the initial 4066 citations identified, 31 fulfilled the criteria for inclusion in the data analysis incorporating 2725 patients with a mean follow-up period of 6.5 months. The weighted mean left atrial volume index (LAVI) was 40.56 ml/m2 (95 %CI:37.24-43.88) in the sinus rhythm (SR) maintenance group versus 48.69 ml/m2 (95 % CI: 44.42-52.97) in the AF recurrence group with P value of < 0.001, left atrial diameter (LAD) was 42.06 mm (95 %CI: 41.08-43.05) in the SR maintenance group versus 45.13 mm (95 %CI: 44.09-46.16) in the AF recurrence group, P value < 0.001. Effect size analysis of LAVI showed that each unit increase in LAVI resulted in an increase in the risk of AF recurrence by 6 % (95 % CI: 3 %-10 %). Age and AF duration were also statistically significant between the two groups however comorbidities, use of beta blockers or amiodarone were not significantly different. This meta-analysis shows that AF duration, LAVI, LAD and age predict the risk of recurrence of atrial fibrillation post electrical cardioversion with LAVI being the most clinically relevant echocardiographic feature.
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Affiliation(s)
- Dipesh Raniga
- Department of Cardiology, Division of Specialist Medical Services, Gold Coast Hospital and Health Services, Southport, QLD 4215, Australia
| | - Mina Goda
- Department of Cardiology, Division of Specialist Medical Services, Gold Coast Hospital and Health Services, Southport, QLD 4215, Australia
| | - Laetitia Hattingh
- Allied Health Research, Gold Coast Hospital and Health Services, Southport, QLD 4215, Australia
- School of Pharmacy, The University of Queensland, QLD 4102, Australia
- School of Pharmacy and Medical Sciences, Griffith University, QLD 4222, Australia
| | - Sarah Thorning
- Office of Research, Gold Coast Hospital and Health Services, Southport, QLD 4215, Australia
| | - Matthew Rowe
- Department of Cardiology, Division of Specialist Medical Services, Gold Coast Hospital and Health Services, Southport, QLD 4215, Australia
| | - Laurie Howes
- Department of Cardiology, Division of Specialist Medical Services, Gold Coast Hospital and Health Services, Southport, QLD 4215, Australia
- School of Medicine, Griffith University, QLD 4222, Australia
- School of Medicine, Bond University, QLD 4226, Australia
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Pozios I, Vouliotis AI, Dilaveris P, Tsioufis C. Electro-Mechanical Alterations in Atrial Fibrillation: Structural, Electrical, and Functional Correlates. J Cardiovasc Dev Dis 2023; 10:jcdd10040149. [PMID: 37103028 PMCID: PMC10141162 DOI: 10.3390/jcdd10040149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/28/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Atrial fibrillation is the most common arrhythmia encountered in clinical practice affecting both patients’ survival and well-being. Apart from aging, many cardiovascular risk factors may cause structural remodeling of the atrial myocardium leading to atrial fibrillation development. Structural remodelling refers to the development of atrial fibrosis, as well as to alterations in atrial size and cellular ultrastructure. The latter includes myolysis, the development of glycogen accumulation, altered Connexin expression, subcellular changes, and sinus rhythm alterations. The structural remodeling of the atrial myocardium is commonly associated with the presence of interatrial block. On the other hand, prolongation of the interatrial conduction time is encountered when atrial pressure is acutely increased. Electrical correlates of conduction disturbances include alterations in P wave parameters, such as partial or advanced interatrial block, alterations in P wave axis, voltage, area, morphology, or abnormal electrophysiological characteristics, such as alterations in bipolar or unipolar voltage mapping, electrogram fractionation, endo-epicardial asynchrony of the atrial wall, or slower cardiac conduction velocity. Functional correlates of conduction disturbances may incorporate alterations in left atrial diameter, volume, or strain. Echocardiography or cardiac magnetic resonance imaging (MRI) is commonly used to assess these parameters. Finally, the echocardiography-derived total atrial conduction time (PA-TDI duration) may reflect both atrial electrical and structural alterations.
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Echocardiography-derived total atrial conduction time (PA-TDI duration): risk stratification and guidance in atrial fibrillation management. Clin Res Cardiol 2021; 110:1734-1742. [PMID: 34453577 PMCID: PMC8563556 DOI: 10.1007/s00392-021-01917-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 08/02/2021] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation (AF) is a major cause of cardiovascular morbidity and mortality. To early detect and to avoid AF-related complications, several cardiac imaging modalities and approaches aim to quantify the severity of the underlying atrial cardiomyopathy (i.e., the extent of atrial remodeling). However, most established cardiac imaging modalities just incorporate single components of atrial remodeling and do not reflect the complete multifactorial process, which may contribute to their limited predictive value. Echocardiography-derived PA-TDI duration is a sophisticated echocardiographic parameter to assess total atrial conduction time and directly reflects both electrical and structural changes to the atria. Therefore, PA-TDI duration provides a more comprehensive quantification of the extent of atrial remodeling than other imaging modalities. In this article we review the role of PA-TDI duration as a marker of atrial remodeling and summarize the available data on PA-TDI duration to identify patients at risk for AF, as well as to guide AF management. Moreover, we discuss how to assess PA-TDI duration and provide recommendations on the implementation of PA-TDI duration into routine clinical care.
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Thomas L, Muraru D, Popescu BA, Sitges M, Rosca M, Pedrizzetti G, Henein MY, Donal E, Badano LP. Evaluation of Left Atrial Size and Function: Relevance for Clinical Practice. J Am Soc Echocardiogr 2020; 33:934-952. [DOI: 10.1016/j.echo.2020.03.021] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 03/31/2020] [Accepted: 03/31/2020] [Indexed: 01/05/2023]
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Hori Y, Nakahara S, Fukuda R, Sato H, Ukaji T, Koshikawa Y, Nishiyama N, Ishikawa T, Kobayashi S, Taguchi I. Atrial reverse remodeling represented by the atrial conduction time in persistent atrial fibrillation patients after catheter ablation: its impact on predicting late atrial fibrillation recurrence. J Cardiol 2019; 75:521-528. [PMID: 31666177 DOI: 10.1016/j.jjcc.2019.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/18/2019] [Accepted: 09/30/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND The aim of this study was to examine the reduction in the atrial conduction time during the follow-up phase of catheter ablation in persistent atrial fibrillation (PsAF) patients, which would suggest atrial reverse remodeling, and to investigate its impact on predicting AF recurrence. METHODS Fifty-seven PsAF patients underwent radiofrequency catheter ablation. The P-wave to left atrial appendage (LAA) conduction time was measured by transthoracic echocardiography using tissue Doppler imaging (P-LAA TDI), within 24 h and 6 months after ablation. RESULTS The accuracy of the P-LAA TDI was confirmed by measuring the actual electrophysiological data during the ablation (90 ± 13 ms, r = 0.754, p < 0.001). The P-LAA TDI was significantly reduced (170 ± 18 msec to 159 ± 19 msec, p < 0.001) at the 6-month follow-up. Sixteen patients (28%) had an AF recurrence by 12 months of follow-up. The no-AF recurrence group had a significantly reduced P-LAA TDI 6 months later (165 ± 15 msec to 155 ± 18 msec, p < 0.001), while there was no significance in the AF recurrence group (184 ± 21 msec to 174 ± 16 msec, p = 0.091). The P-LAA TDI was a predictive factor of AF recurrence after ablation with a cut-off value of >175 msec (sensitivity = 0.750, specificity = 0.780) when measured within 24 h after ablation and >166 msec (sensitivity = 0.750, specificity = 0.756) when calculated at 6 months of follow-up. CONCLUSIONS In PsAF patients, a significant reduction in the P-LAA TDI was observed at 6 months of follow-up, which may have represented the occurrence of left atrial reverse remodeling. These findings suggested that the P-LAA TDI time in the follow-up was appropriate for predicting late AF recurrences.
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Affiliation(s)
- Yuichi Hori
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Shiro Nakahara
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan.
| | - Reiko Fukuda
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Hirotsugu Sato
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Tomoaki Ukaji
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Yuri Koshikawa
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Naoki Nishiyama
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Tetsuya Ishikawa
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Sayuki Kobayashi
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Isao Taguchi
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
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Lancellotti P, Galderisi M. Prediction of ischaemic stroke in non-valvular atrial fibrillation if advanced echocardiography plays the game. Eur Heart J 2018; 39:1426-1428. [PMID: 29438511 DOI: 10.1093/eurheartj/ehy025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Patrizio Lancellotti
- University of Liège Hospital, Department of Cardiology and Cardiovascular Surgery, Heart Valve Clinic, and GIGA Cardiovascular Sciences, Centre Hospitalier de Liège du Sart Tilman, Liège, Belgium.,Gruppo Villa Maria Care and Research, Anthea Hospital, Bari, Italy
| | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
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Leung M, van Rosendael PJ, Abou R, Ajmone Marsan N, Leung DY, Delgado V, Bax JJ. Left atrial function to identify patients with atrial fibrillation at high risk of stroke: new insights from a large registry. Eur Heart J 2017; 39:1416-1425. [DOI: 10.1093/eurheartj/ehx736] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 12/11/2017] [Indexed: 12/19/2022] Open
Affiliation(s)
- Melissa Leung
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2300RC, The Netherlands
- Department of Cardiology, Ingham Institute at Liverpool Hospital, University of New South Wales, Corner of Elizabeth and Goulburn Streets, Liverpool NSW 2170, Sydney, Australia
| | - Philippe J van Rosendael
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2300RC, The Netherlands
| | - Rachid Abou
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2300RC, The Netherlands
| | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2300RC, The Netherlands
| | - Dominic Y Leung
- Department of Cardiology, Ingham Institute at Liverpool Hospital, University of New South Wales, Corner of Elizabeth and Goulburn Streets, Liverpool NSW 2170, Sydney, Australia
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2300RC, The Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, Leiden 2300RC, The Netherlands
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