Measurement of Left Atrial Volume from Transthoracic Three-Dimensional Echocardiographic Datasets Using the Biplane Simpson’s Technique

Family screening for hypertrophic cardiomyopathy: Initial cardiologic assessment, and long-term follow-up of genotype-positive phenotype-negative individuals

AIMS

(i) Investigate the prevalence of hypertrophic cardiomyopathy (HCM) in individuals with pathogenic/likely pathogenic (P/LP) gene variants detected through family cascade testing in relatives, and (ii) evaluate phenotypic progression in genotype-positive phenotype-negative (G+/P-) individuals during follow-up.

RESULTS

From 2000 to 2023, 273 individuals underwent cardiologic evaluation following P/LP variant detection through family screening. Upon initial evaluation, HCM was diagnosed in 128 (47 %) individuals. Comparing with 145 G+/P- individuals, HCM patients were older (48 vs 38 years, p < 0.001) and more likely male (57 % vs 34 %, p < 0.001). During follow-up (median 11 years), 14 (11 %) of the HCM patients died (two from sudden cardiac death), four (3 %) underwent myectomy, 15 (12 %) developed atrial fibrillation and 17 (13 %) required implantable cardioverter-defibrillator implantation (15 primary prevention, 88 %). HCM-related adverse outcomes correlated with younger diagnosis age. During follow-up (median 8 years) of 118 (out of 145) G+/P- subjects with at least one year of follow-up, seven (6 %) individuals (71 % female, diagnosed age 39-77, after median follow-up 6 years) developed HCM (mean maximal wall thickness increasing from 10.2 mm to 13.3 mm). In this G+/P- cohort, significant echocardiographic changes from baseline to last visit were negligible. Over half (56 %) had <1 mm change of maximal wall thickness. No adverse cardiac outcomes occurred.

CONCLUSION

The initial evaluation was high-yield, with HCM being diagnosed in 47 % of G+ individuals, more frequently in older males. Over a median 8-year follow-up, 6 % of G+/P- individuals developed mild HCM, with no adverse cardiac outcomes. These data support initial screening in all first degree relatives, but (very) low-frequency cardiologic evaluations for G+/P- individuals thereafter.

The prognostic and diagnostic significance of echocardiographic parameters on acute ischemic stroke

OBJECTIVE

To comprehensively explore the prognostic significance of transthoracic echocardiography (TTE) and three-dimensional speckle-tracking echocardiography (3D STE) parameters in AIS and their role in distinguishing cardioembolic stroke.

METHODS

301 acute ischemic stroke (AIS) patients were enrolled. TTE and 3D STE were employed to evaluate cardiac function and structure, also left atrial strain. Patients were categorized into two groups based on functional outcome at discharge and 3 months post-stroke, respectively. Models combining variables related to unfavorable outcome were established, and their predictive efficacy was assessed using receiver operating characteristic (ROC) curves. Additionally, AIS patients were stratified into cardioembolic and non-cardioembolic stroke groups. Logistic regression identified predictors for cardioembolic stroke, and ROC curves assessed their diagnostic performance.

RESULTS

We found that a decrease in early diastolic peak velocity of the mitral valve (E value) was independently associated with adverse outcomes at both discharge (P = 0.014, OR = 0.126, 95% CI 0.024-0.657) and 3 months post-stroke in AIS patients (P = 0.004, OR = 0.054, 95% CI 0.007-0.403). Adding E value significantly improved predictive ability for adverse outcome at discharge and 3 months post-onset (0.807 vs. 0.794; 0.834 vs. 0.815). Moreover, left atrial diameter (LAD) [area under the curve (AUC) = 0.705] was the most valuable TTE parameter, and left atrial reservoir circumferential strain (LASr-c) (AUC = 0.766) was the most valuable STE parameter, even among all echocardiographic parameters for prediction of cardioembolic stroke.

CONCLUSIONS

This study indicates reduced E value was associated with unfavorable outcome at discharge and 3 months post-onset of AIS patients. LAD, especially LASr-c exhibited optimal diagnostic performance on cardioembolic stroke.

Efficiency and feasibility of semi-automated software for measuring left atrial volume in routine echocardiography in a pediatric population

PURPOSE

The traditional method for measuring left atrial volume (LAV) involves manual tracing. Recently, semi-automated techniques for measuring LAV, based on 2D speckle tracking echocardiography (STE) and 3D echocardiography (3DE), have become commercially available. This study aimed to investigate the efficiency and feasibility of these semi-automated software methods for LAV measurement in pediatric patients.

METHODS

We analyzed 207 pediatric patients with 2D and 3D echocardiographic images of the left atrium. The maximum LAV was measured using three techniques: (1) manual tracing, (2) STE-based semi-automated measurement, and (3) 3DE-based semi-automated measurement. We compared both LAV and the time required for LAV measurement among these three techniques. Intra- and inter-observer reproducibility of the LAV measurements was assessed using the intraclass correlation (ICC).

RESULTS

There was no difference in the LAV between the manual tracing and the STE-based method, but the LAV measured by 3DE-based method was slightly smaller than manual tracing. The measurement time was 32.6 ± 3.5, 53.8 ± 10.8, and 33.8 ± 13.0 s for manual tracing, STE-based, and 3DE-based techniques, respectively. There was no difference the time for LAV measurement between the manual tracing and the 3D-based technique. The agreement and ICC for intra-observer reproducibility was similar across all three techniques, but inter-observer reproducibility was superior with the 3DE-based technique.

CONCLUSIONS

Although the maximum LAV obtained through the 3DE-based techniques was slightly smaller compared with the traditional manual tracing method, the 3DE-based technique is anticipated to be integrated into routine examinations owing to its short measurement time and superior reproducibility.

Multimodal Cardiac Imaging in the Assessment of Patients Who Have Suffered a Cardioembolic Stroke: A Review

Cardioembolic strokes account for 20-25% of all ischaemic strokes, with their incidence increasing with age. Cardiac imaging plays a crucial role in identifying cardioembolic causes of stroke, with early and accurate identification affecting treatment, preventing recurrence, and reducing stroke incidence. Echocardiography serves as the mainstay of cardiac evaluation. Transthoracic echocardiography (TTE) is the first line in the basic evaluation of structural heart disorders, valvular disease, vegetations, and intraventricular thrombus. It can be used to measure chamber size and systolic/diastolic function. Trans-oesophageal echocardiography (TOE) yields better results in identifying potential cardioembolic sources of stroke and should be strongly considered, especially if TTE does not yield adequate results. Cardiac computed tomography and cardiac magnetic resonance imaging provide better soft tissue characterisation, high-grade anatomical information, spatial and temporal visualisation, and image reconstruction in multiple planes, especially with contrast. These techniques are useful in cases of inconclusive echocardiograms and can be used to detect and characterise valvular lesions, thrombi, fibrosis, cardiomyopathies, and aortic plaques. Nuclear imaging is not routinely used, but it can be used to assess left-ventricular perfusion, function, and dimensions and may be useful in cases of infective endocarditis. Its use should be considered on a case-by-case basis. The accuracy of each imaging modality depends on the likely source of cardioembolism, and the choice of imaging approach should be tailored to individual patients.

The use of dedicated long-axis views focused on the left atrium improves the accuracy of left atrial volumes and emptying fraction measured by cardiovascular magnetic resonance

BACKGROUND

The use of apical views focused on the left atrium (LA) has improved the accuracy of LA volume evaluation by two-dimensional (2D) echocardiography. However, routine cardiovascular magnetic resonance (CMR) evaluation of LA volumes still uses standard 2- and 4-chamber cine images focused on the left ventricle (LV). To investigate the potential of LA-focused CMR cine images, we compared LA maximuml (LAVmax) and minimum (LAVmin) volumes, and emptying fraction (LAEF), calculated on both standard and LA-focused long-axis cine images, with LA volumes and LAEF obtained by short-axis cine stacks covering the LA. LA strain was also calculated and compared between standard and LA-focused images.

METHODS

LA volumes and LAEF were obtained from 108 consecutive patients by applying the biplane area-length algorithm to both standard and LA-focused 2- and 4-chamber cine images. Manual segmentation of a short-axis cine stack covering the LA was used as the reference method. In addition, LA strain reservoir (εs), conduit (εe) and booster pump (εa) were calculated using CMR feature-tracking.

RESULTS

Compared to the reference method, the standard approach significantly underestimated LA volumes (LAVmax: bias - 13 ml; LOA =  + 11, - 37 ml; LAVmax i: bias - 7 ml/m2; LOA =  + 7, - 21 ml/m2; LAVmin; bias - 10 ml, LOA: + 9, - 28 ml; LAVmin i: bias - 5 ml/m2, LOA: + 5, - 16 ml/m2), and overestimated LA-EF (bias 5%, LOA: + 23, - 14%). Conversely, LA volumes (LAVmax: bias 0 ml; LOA: + 10, - 10 ml; LAVmax i: bias 0 ml/m2; LOA: + 5, - 6 ml/m2; LAVmin: bias - 2 ml; LOA: + 7, - 10 ml; LAVmin i: bias - 1 ml/m2; LOA: + 3, - 5 ml/m2) and LAEF (bias 2%, LOA: + 11, - 7%) by LA-focused cine images were similar to those measured using the reference method. LA volumes by LA-focused images were obtained faster than using the reference method (1.2 vs 4.5 min, p < 0.001). LA strain (εs: bias 7%, LOA = 25, - 11%; εe: bias 4%, LOA = 15, - 8%; εa: bias 3%, LOA = 14, - 8%) was significantly higher in standard vs. LA-focused images (p < 0.001).

CONCLUSION

LA volumes and LAEF measured using dedicated LA-focused long-axis cine images are more accurate than using standard LV-focused cine images. Moreover, LA strain is significantly lower in LA-focused vs. standard images.

Obesity and Body Mass Components Influence Exercise Tolerance and the Course of Hypertension in Perimenopausal Women

The aim of this study was to identify the potential influence of obesity and body mass components on exercise tolerance assessed in cardiopulmonary exercise testing (CPET), biochemical and echocardiographic parameters and factors correlated with oxygen absorption at the anaerobic threshold in hypertensive women with low levels of physical activity in the perimenopausal period. The study comprised 188 hypertensive women divided, based on body mass index (BMI), into an obesity group and a non-obesity group. Women with BMI ≥ 30 kg/m2 had significantly higher parameters of left ventricular diastolic dysfunction in echocardiography, lower total body water (TBC) in percentage assessed by bioimpedance and significantly worse exercise capacity assessed by CPET. In the study group, VO2 AT (mL/kg/min) correlated positively with TBW (r = 0.4, p < 0.0001) and with the ratio of extracellular water to total body water (ECW/TBW) (r = 0.4, p < 0.00001) and negatively with fat (% and kg) (r = −0.4, p < 0.0001 for both). Obesity negatively affects parameters of diastolic left ventricular function, as well as exercise tolerance in CPET in hypertensive females during the perimenopausal period. The oxygen uptake at anaerobic threshold correlates positively with total body water and ECW/TBW and negatively with body fat; this connection is more pronounced in women without obesity. ClinicalTrials.gov Identifier: NCT04802369.

Left atrial volume index predicts future improvement of B-type natriuretic peptide levels after transcatheter aortic valve replacement

In patients with symptomatic severe aortic stenosis (AS), those who experienced readmission due to heart failure after transcatheter aortic valve replacement (TAVR) showed poor prognosis. Furthermore, poor B-type natriuretic peptide (BNP) improvement is associated with increased morbidity and mortality. However, little is known about the clinical parameters related to the change in BNP levels after TAVR procedure. This study population consisted of 127 consecutive patients of symptomatic severe AS with preserved ejection fraction (EF) who underwent transfemoral TAVR (TF-TAVR). Comprehensive transthoracic echocardiography was performed prior to the day of TF-TAVR. BNP was measured serially before and 1 year after TF-TAVR. The median BNP level was significantly decreased from 252.5 pg/ml to 146.8 pg/ml in all 127 patients 1 year after TF-TAVR (P < 0.01). However, the patients could be divided into 2 groups according to decrease (72%) or increase (28%) in plasma BNP level. Multivariate logistic regression analysis revealed that Aortic valve (AV) peak velocity, pre-procedural BNP, and larger left atrial volume index (LAVI) were found to be an independent predictor of increased BNP level 1 year after TAVR (OR 0.55, 95% CI 0.38-0.77; P < 0.01). LAVI were negatively correlated with the change in BNP level before and 1 year after TAVR (r = 0.47, P < 0.01). The ROC analysis demonstrated that 52.9 ml/m2 was the optimal cut-off value of LAVI for decreasing BNP 1 year after TAVR (area under the curve 0.69) with 64% sensitivity and 70% specificity. In addition to AV peak velocity and pre-procedural BNP, LAVI independently predicts future improvement of BNP levels 1 year after TAVR. Our findings indicate an additive predictive value of assessment of LAVI before TAVR procedure for risk stratification.

A Review of the Role of Transthoracic and Transesophageal Echocardiography, Computed Tomography, and Magnetic Resonance Imaging in Cardioembolic Stroke

Stroke is a major source of morbidity and mortality worldwide, accounting for the second largest cause of mortality and the third greatest cause of disability. Stroke is frequently preceded by a transient ischemic attack (TIA). The etiologies of 20-30% of ischemic strokes are unknown, and thus are termed "cryptogenic strokes". About 25% of ischemic strokes are cardioembolic. Strokes occur at a rate of around 2% per year in individuals with heart failure with reduced ejection fraction (HFrEF), with a strong correlation between stroke risk and the degree of ventricular impairment. Furthermore, stroke risk is augmented in the absence of anticoagulation therapy. Cardioembolic strokes, when treated inadequately, have a greater predilection for recurrences than atherothrombotic strokes, both early and late in life. The role of a patent foramen ovale in strokes, specifically in "cryptogenic strokes", is a matter of concern that deserves due attention. The use of tissue-engineered heart valves and aspirin for minimizing the risk of stroke is recommended. Transthoracic echocardiography (TTE) is advantageous for assessing heart function in the acute phase of ischemic stroke. Transesophageal echocardiography (TEE) is considered the criterion standard procedure for detecting LAA thrombi. Computed tomography (CT) scans are good imaging modalities for identifying and excluding bleeding. Magnetic resonance imaging (MRI) images are by far the most effective imaging technique available for assessing the brain parenchymal state. We conducted a thorough review of the literature on the use of imaging modalities, highlighting the important contribution of TTE, TEE, CT, and MRI in the evaluation of cardioembolic stroke.

Effects of uric acid-lowering therapy in patients with essential arterial hypertension

OBJECTIVES

Asymptomatic hyperuricemia (AHU) is elevated serum uric acid (UA) without symptoms. This study aimed to determine the effects of AHU treatment with allopurinol on selected hypertension-mediated organ damage (HMOD) indices in patients with uncomplicated essential arterial hypertension (AH).

METHODS

Patients aged 30-70 years with AHU and AH grade 1-2 with adequate blood pressure (BP) control, without previous urate-lowering therapy (ULT), were divided into two groups: (a) ULT (receiving allopurinol) and (b) control (age- and sex-matched patients without ULT). Both received a UA-lowering diet. BP (office, 24 h and central), echocardiographic parameters, carotid intima-media thickness (IMT) and lab tests [high-sensitivity C-reactive protein (hs-CRP)] were measured at baseline and at 6 months follow-up.

RESULTS

Of 100 participants, 87 (44 ULT, 43 controls) completed the study. At 6 months follow-up, there was a greater reduction in serum UA concentration in the ULT group than in the control group. Patients receiving allopurinol had significant reductions in office systolic and diastolic BP, central systolic BP, pulse pressure, IMT (0.773 ± 0.121 vs. 0.752 ± 0.13 mm, P = 0.044) and hs-CRP (3.36 ± 2.73 vs. 2.74 ± 1.91 mg/L, P = 0.028) compared to controls. Multivariate regression analysis revealed the independent relationship between reduction in IMT and UA lowering (P < 0.026).

CONCLUSION

In patients with AH and AHU, treatment with allopurinol leads to improvement in BP control and reduction in HMOD intensity, in particular IMT. The decrease in hs-CRP concentration associated with ULT may have a beneficial effect on a patient's long-term prognosis.

Prognostic Value of the Three-Dimensional Right Ventricular Ejection Fraction in Patients With Asymptomatic Aortic Stenosis

Background: The right ventricular (RV) function is an important prognostic marker of asymptomatic aortic stenosis (AS). However, previous publications have not addressed the additive value of conventional RV parameters over left heart parameters. Whether three-dimensional echocardiography (3DE)-derived RV ejection fraction (RVEF) has prognostic utility independent of 3DE derived left heart parameters is also unknown. We investigated the prognostic utility of 3DE RVEF in patients with asymptomatic AS.

Methods: We retrospectively selected 392 asymptomatic AS patients. RVEF, left ventricular ejection fraction (LVEF) and left atrial volumes (LAVs) were measured using 3DE datasets. We determined the association of those parameters, as well as of aortic valve replacement (AVR), and Charlson's comorbidity index with cardiac events. We also analyzed whether RVEF has incremental value over two-dimensional echocardiography (2DE) RV parameters.

Results: During a median follow-up of 27 months, 57 patients developed cardiac events, and 68 patients received AVR. Univariate Cox proportional hazard analysis revealed that RVEF was associated with cardiac events (p < 0.001). Multivariate analysis revealed that RVEF was significantly associated with cardiac events (p < 0.001) even after adjusting for AVR, Charlson's comorbidity index, LVEF, LAV, E/e', and indexed aortic valve area (iAVA). An incremental value of RVEF over left heart parameters was also demonstrated using a nested regression model. Classification and regression-tree analysis selected RVEF first with a cut-off value of 41%. RVEF had incremental value over iAVA, LVEF, and 2DE conventional RV parameters for its association with future outcomes.

Conclusions: 3DE RVEF had significant prognostic value even after adjusting for comorbidities, left heart parameters, and conventional 2DE RV parameters in asymptomatic aortic stenosis.

Left atrial-left ventricular angle, a new measure of left atrial and left ventricular remodeling

We assessed the left atrial-left ventricular (LA-LV) long axis angulation value as a new measure of LA remodeling, and studied its predictors, its effect on two-dimensional LA volume (2D LAVol) estimation, and optimization techniques for 2D LAVol values. Retrospective electrocardiogram-gated coronary computed tomographic angiograms of 164 consecutive patients were reviewed. The LA–LV angle was measured in reconstructed 3-chamber views, and its predictors were determined. The LAVol measured by the area-length method after image optimization along the LV long axis (AL) and the LA long axis (AC–AL), was compared with that measured by the three-dimensional (3D)-volumetric method. LAVol calculation was modified to minimize differences from the 3D values. LA–LV angles ranged from 0° to 63°. In the univariate analysis, decreasing angulation was significantly associated with increasing LV end-diastolic volume (LVEDV), mitral regurgitation grade, LV and LA anteroposterior dimensions, and decreasing LV ejection fraction (LVEF). On multivariate analysis, increasing LVEDV, MR, and LA anteroposterior dimension inversely correlated with angulation; LVEF was positively correlated. The AL and 3D methods significantly differed only for patients with angles ≤ 29.9°. Conversely, LAVol was overestimated for all angules by AC–AL. Modification of AL LAVol using a regression equation, or by substituting the shortest with the longest and average LA lengths in patients with angles ≤ 29.9° and 30–39.9°, respectively neutralized the difference. The LA–LV angle is a new measure of LA and LV remodeling predicted by LV size and function, MR, and LA-anteroposterior dimension. AL formula modifications based on angulation in LV-optimized views better correlate with the 3D method than LA-view modification.

Reliability of left atrial strain reference values: A 3D echocardiographic study

Background

Standard apical four-chamber and two-chamber views often maximize the long-axis of the left ventricle, resulting in artifactitious foreshortening of the left atrium (LA), which may overestimate LA longitudinal reservoir strain (LALS). We compared LALS values between 2D echocardiography (2DE) and 3D echocardiography (3DE) in healthy subjects to determine whether 2DE speckle tracking analysis overestimates the reference value of LALS.

Methods and results

In this study, 4 types of cohorts were included: 1. 105 normal subjects (retrospectively), 2. 53 patients with cardiovascular diseases (retrospectively), 3. 15 patients who received cardiac magnetic resonance (prospectively), and 4. 20 normal subjects (prospectively). LALS and LA length were measured using both 2DE and 3DE in 105 healthy subjects (median age: 42 years). Biplane LALS was measured in apical four- and two-chamber views using 2DE speckle tracking software, and 3DE LALS was measured using new 3DE LA strain software. To determine sensitivity, we also performed the same analysis in 53 patients with cardiovascular disease. The mean value of biplane LALS was 39.6%. LA length at both end-diastole (r = -0.43) and end-systole (r = -0.54) was negatively correlated with biplane LALS. Multivariate regression analysis revealed that both end-diastolic and end-systolic LA length had significant negative relationships with biplane LALS after adjusting for anthropometric and echocardiographic image quality parameters. 3DE LALS (23.7±7.6%) gave significantly lower values than 2DE LALS (39.5±12.0%, p<0.001) with a weak correlation (r = 0.33). LA length measured by 2DE was significantly shorter than that measured by 3DE. The same trend was observed in diseased patients.

Conclusions

Our results revealed that in 2DE, the LA cavity consistently appears longitudinally foreshortened in apical views, potentially overestimating LALS. 3DE may overcome this limitation.

Left atrial volume indexed for height2 is a new sensitive marker for subclinical cardiac organ damage in female hypertensive patients

Left atrial enlargement (LAe) is a subclinical marker of hypertensive-mediated organ damage, which is important to identify in cardiovascular risk stratification. Recently, LA indexing for height was suggested as a more accurate marker of defining LAe. Our aim was to test the difference in LAe prevalence using body surface area (BSA) and height² definitions in an essential hypertensive population. A total of 441 essential hypertensive patients underwent complete clinical and echocardiographic evaluation. Left atrial volume (LAV), left ventricular morphology, and systolic-diastolic function were evaluated. LAe was twice as prevalent when defined using height² (LAe_h2) indexation rather than BSA (LAe_BSA) (51% vs. 23%, p < 0.001). LAe_h2, but not LAe_BSA, was more prevalent in females (p < 0.001). Males and females also differed in left ventricular hypertrophy (p = 0.046) and left ventricular diastolic dysfunction (LVDD) indexes (septal Em/Etdi: p = 0.009; lateral Em/Etdi: p = 0.003; mean Em/Etdi: p < 0.002). All patients presenting LAe_BSA also met the criteria for LAe_h2. According to the presence/absence of LAe, we created three groups (Norm = BSA-/h²-; DilH = BSA-/h²+; DilHB = BSA+/h²+). The female sex prevalence in the DilH group was higher than that in the other two groups (Norm: p < 0.001; DilHB: p = 0.036). LVH and mean and septal Em/Etdi increased from the Norm to the DilH group and from the DilH to the DilHB group (p < 0.05 for all comparisons). These results show that LAe_h2 identified twice as many patients as comparing LAe to LAe_BSA, but that both LAe_h2 and LAe_BSA definitions were associated with LVH and LVDD. In female patients, the LAe_h2 definition and its sex-specific threshold seem to be more sensitive than LAe_BSA in identifying chamber enlargement.

Feasibility and Reproducibility of Left Atrium Measurements Using Different Three-Dimensional Echocardiographic Modalities

Left atrium (LA) volume is a biomarker of cardiovascular outcomes. Three-dimensional echocardiography (3DE) provides an accurate LA evaluation, but data regarding the optimal 3DE method is scarce. We assessed the feasibility and reproducibility of LA measurements using different 3DE methods. One hundred and ninety-four patients were prospectively analyzed. Conventional 3DE and two semi-automatic 3DE algorithms (Tomtec™ and Dynamic Heart Model (DHM)) were used in 110 patients. Intra- and interobserver reproducibility and intervendor comparison were performed in additional patients' subsets. Forty patients underwent cardiac magnetic resonance (CMR). Feasibility was 100% for Tomtec, 98.2% for DHM, and 72.8% for conventional 3DE. Tomtec volumes were higher than 3DE and DHM (p < 0.001). Reproducibility was better for DHM (intraobserver LA maximum volume (LAmax) ICC 0.99 (95% CI 1.0-0.99), LA minimum volume (LAmin) 0.98 (95% CI 0.95-0.99), LApreA 0.96 (95% CI 0.91-0.98); interobserver LAmax ICC 0.98 (95% CI 0.96-0.99), LAmin 0.99 (95% CI 0.99-1.00), and LApreA 0.97 (95% CI 0.94-0.99)). Intervendor comparison showed differences between left ventricle (LV) software adapted for LA (p < 0.001). Tomtec underestimated the least LA volumes compared to CMR. These findings emphasize that dedicated software should be used for LA assessment, for consistent clinical longitudinal follow-up and research.

Atrial appendages’ mechanics assessed by 3D transoesophageal echocardiography as predictors of atrial fibrillation recurrence after pulmonary vein isolation

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Data on atrial appendages' mechanics as predictors of AF recurrence after PVI is scarce.

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3D and 2D-TEE have potential to provide additional data on LAA function.

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Patients with AFR had significantly lower LAA tissue velocity and ostium surface area.

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RAA tissue velocity and SVC ostium surface area were not correlated to AF recurrence.

Background

Although there are numerous studies reflecting predictors of atrial fibrillation (AF) recurrence (AFR) after pulmonary vein isolation (PVI), data on atrial appendages' mechanics is scarce. This study aimed to assess atrial appendages' mechanics by 2-dimensional (2D) and 3-dimenssional (3D) transoesphageal echocardiography (TEE) and to explore its value to predict AFR after PVI.

Methods

Consecutive patients with paroxysmal AF undergoing first PVIwere analysed. 3D and 2D-TEE with tissue Doppler imaging (TDI) and strain analysis was obtained prior to the PVI, including: left atrial appendage (LAA) TDI and strain analysis, LAA ostium surface area, right atrial appendage’s TDI velocity and superior vena cava (SVC) ostium surface area. The primary end-point was freedom from any documented recurrence of atrial arrhythmia lasting > 30 s.

Results

This single-centre, prospective study included 74 patients with paroxysmal AF (median age 59 years; 36% female; BMI 27.4 ± 4.1 kg/m², LA volume index 32 ± 11 mL/m²). After a median follow-up of 14 (IQR 10–22) months, 21 (28%) patients had AFR. In a univariate and multivariate Cox-regression analysis LAA TDI velocity (HR 1.48, 95%CI 1.28–1.62, p < 0.001) and LAA ostium surface area(HR 1.58, 95%CI 1.06–1.81, p = 0.033) both independently predicted AFR after single PVI. RAA TDI velocity and SVC ostium surface area were not correlated to AFR.

Conclusion

Paroxysmal AF patients with lower LAA TDI tissue velocity and LAA ostium surface area have higher risk of developing AFR after PVI. To our knowledge, this is the first study assessing atrial appendages’ mechanics in predicting AFR after PVI.

Clinical trial registration: www.drks.de(Identifier: DRKS00010495)

Assessment of left ventricular diastolic function by three-dimensional transthoracic echocardiography

Doppler echocardiography assessment of left ventricular (LV) filling pressures at rest and during exercise is the most widely used imaging technique to assess LV diastolic function in clinical practice. However, a sizable number of patients evaluated for suspected LV diastolic function show an inconsistency between the various parameters included in the flowchart recommended by current Doppler echocardiography guidelines and results in an undetermined LV diastolic function. Current three-dimensional echocardiography technology allows obtaining accurate measurements of the left atrial volumes and functions that have been shown to improve the diagnostic accuracy and prognostic value of the algorithms recommended for assessing both LV diastolic dysfunction and heart failure with preserved ejection fraction. Moreover, current software packages used to quantify LV size and function provide also volume-time curves showing the dynamic LV volume change throughout the cardiac cycle. Examining the diastolic part of these curves allows the measurement of several indices of LV filling that have been reported to be useful to differentiate patients with normal LV diastolic function from patients with different degrees of diastolic dysfunction. Finally, several software packages allow to obtain also myocardial deformation parameters from the three-dimensional datasets of both the left atrium and the LV providing additional functional parameters that may be useful to improve the diagnostic yield of three-dimensional echocardiography for the LV diastolic dysfunction. This review summarizes the current applications of three-dimensional echocardiography to assess LV diastolic function.

Sex differences and higher upper normal limits for left atrial end-systolic volume in individuals in their mid-60s: data from the ACE 1950 Study

Aims

The current study aimed to describe normal values of left atrial (LA) volumes and LA emptying fraction (LAEF) in a large sample in their mid-60s from the general population and to explore sex differences.

Methods and results

In the Akershus Cardiac Examination (ACE) 1950 Study, body surface area-indexed LA maximum (LAVimax) and minimum (LAVimin) volumes and LAEF were measured in 3489 individuals aged 63.9 ± 0.6 years from the general population. A healthy group of 832 individuals was defined. Data are presented as mean ± standard deviation (SD) and a normal range of mean ± 2 SD. T-tests were used for comparisons. In the healthy group, mean LAVimax was 25.5 ± 6.2 mL/m2 and the normal range was 13.1–37.9 mL/m2. Men had significantly larger body surface area-indexed volumes than women, but there was no difference in LAEF. The mean LAVimax for healthy men was 26.4 ± 6.5 mL/m2, for healthy women 24.9 ± 5.8 mL/m2 (P &lt; 0.001) and the upper normal limits were 39.4 and 36.5 mL/m2, respectively. In the healthy group, 13.0% of all men and 5.4% of all women had LAVimax above the current upper normal limit of 34 mL/m2.

Conclusion

A large proportion of healthy individuals, in particular men, had LAVimax &gt;34 mL/m2. Our findings suggest that the recommended cut-off may be too low at the age of 65 years and above and that sex-specific cut-offs should be considered.

The impact of catheter ablation of atrial fibrillation on the left atrial volume and function: study using three-dimensional echocardiography

Purpose

The exact correlation between the baseline left atrial (LA) volume (LAV) and atrial fibrillation (AF) radiofrequency catheter ablation (RFCA) outcomes and changes to the LA after AF RFCA has not yet been fully understood. We sought to evaluate the serial changes in the LAV and LA function after RFCA using 3D echocardiography.

Methods

Consecutive patients who received RFCA of paroxysmal (PAF) or persistent AF (PeAF) at our center between January 2013 and March 2016 were included. Real-time 3D apical full-volume images were acquired, and a 3D volumetric assessment was performed using an automated three-beat averaging method. The LAV index (LAVI) was calculated and the LA ejection fraction (LAEF) was calculated as [LAVmax − LAVmin]/LAVmax.

Results

Ninety-nine total patients were enrolled, and the mean age was 58.0 ± 8.2 years and 75 (74.7%) were male. There were 59 (59.6%) PAF patients and the remaining 40 (40.4%) had PeAF. AF recurred in 5 of 59 (8.5%) PAF and in 10 of 40 (25%) PeAF patients. The LAVImax increased on 1 day, decreased at 3 months, and then increased again at 1 year but was lower than that at baseline. The LAEF changes were similar to the volume changes but were more prominent in PeAF than PAF patients. The baseline 3D LAVImax was an independent predictor of AF recurrence after RFCA and the cut-off value was 44.13 ml/m².

Conclusion

In our study, even after 3 months of scar formation due to ablation, structural remodeling of the LA continued. The changes were more prominent in the non-recurrent, PeAF patients.

Electronic supplementary material

The online version of this article (10.1007/s10840-019-00696-8) contains supplementary material, which is available to authorized users.

Relation of Left Atrial Volumes in Patients With Myocardial Infarction to Left Ventricular Filling Pressures and Outcomes

The inter-relationships between minimal and maximal left atrial volume index (LAVI), left ventricular filling pressures and survival have not been well studied. This study aimed to compare LAVImin with LAVImax with respect to (1) relative prognostic value, and (2) correlation with left ventricular end-diastolic pressures (LVEDP), in patients with myocardial infarction (MI). A retrospective study involving consecutive patients with a first-ever MI (n = 419) was undertaken. LAVIs were determined using Simpson's biplane method from 2D echocardiography performed the day after admission. LAVmin ≥ 18 mls/m² and LAVImax ≥ 34 mls/m² were considered enlarged. The primary end point was composite major adverse cardiovascular events (MACE) (death/MI/heart failure). Correlation between LVEDP and LAVI was assessed in 120 patients who underwent echocardiography and cardiac catheterization either simultaneously (n = 30) or same-day (n = 90). At a median follow-up of 24 months, there were 61 MACE events. On Cox proportional hazards multivariate analysis incorporating significant clinical predictors and LVEF, whereas both LAVImin ≥ 18 mls/m² (hazard ratio 3.15 [95% confidence interval 1.70 to 5.54], p <0.001) and LAVImax ≥ 34 mls/m² (hazard ratio 1.79 [95% confidence interval 1.02 to 3.14], p = 0.041) were independent predictors of MACE, LAVImin showed a stronger association. Intermodel comparisons of the model chi-square and Harrell's C-statistic confirmed better prognostication with LAVImin. In the invasive cohort, because LAVImin and LAVImax had a similar correlation with LVEDP ≥ 15 mm Hg (r = 0.41 [p <0.001] vs r = 0.42 [p <0.001]), LAVmin ≥ 18 mls/m² had a greater sensitivity for LVEDP ≥ 15 mm Hg than LAVImax ≥ 34 mls/m² (sensitivity 59.4% vs 34.4%). In conclusion, utilizing thresholds of ≥18 and ≥34 mls/m², respectively, LAVImin was a better predictor of survival than LAVImax, the pathophysiologic basis of which relates to a better sensitivity for elevated left ventricular filling pressures with LAVImin at these thresholds. There may be incremental clinical value in measuring LAVImin alongside LAVImax.

Evaluation of left atrial volume and function in patients with coronary slow flow phenomenon using real-time three-dimensional echocardiography

This study aimed to evaluate the left atrial (LA) volume and phasic functions using real-time three-dimensional echocardiography (RT3DE) in coronary slow flow phenomenon (CSFP) patients with preserved left ventricular ejection fraction (LVEF). 56 patients with CSFP (36 males, 20 females) and 48 controls with normal coronary flow (27 males, 21 females) were prospectively enrolled. Comprehensive transthoracic echocardiographic examination and RT3DE for the assessment of LA dynamics were performed in all participants. LA maximum, minimum, and pre-atrial contraction volumes (LAV-max, LAV-min, and LAV-preA) were obtained for every subject. Conventional echocardiographic parameters, except for isovolumetric relaxation time and transmitral deceleration time, did not differ in two groups. RT3DE demonstrated higher LAV-max, LAV-min, LAV-preA, indexed LAV-max (LAVi-max), LA total emptying volume, and LA active emptying volume and fraction for CSFP patients compared with controls (all P < 0.05). In addition, LA total emptying fraction and LA passive emptying fraction were found to be lower in CSFP patients than in controls (all P < 0.05). Moreover, there were positive correlations between mean thrombolysis in myocardial infarction frame count values and LAV-max, LAV-min, LAV-preA, LAVi-max, and LA total and active emptying volumes. CSFP was associated with enlarged LA volumes, impaired LA reservoir and conduit function and enhanced contractile function. Evaluation of LA dynamics using RT3DE could facilitate recognition of subtle myocardial alterations related with CSFP.

Diagnostic accuracy of left atrial remodelling and natriuretic peptide levels for preclinical heart failure

AIMS

Left atrial (LA) remodelling is an important predictor of cardiovascular events of heart failure (HF) and atrial fibrillation. Data regarding diagnostic value of LA remodelling on diastolic dysfunction (DD) and preclinical HF remain largely unexplored.

METHODS AND RESULTS

We assessed LA dimension (LAD) in 8368 consecutive asymptomatic Asians (mean age: 49.7, 38.9% women) and related such measure to updated American Society of Echocardiography (ASE) DD criteria and newly revised N-terminal pro-brain natriuretic peptide (NT-proBNP) cut-off (≥125 pg/mL) and HF with preserved ejection fraction criteria incorporating NT-proBNP and echocardiography parameters by the European Society of Cardiology (ESC). LAD and indexed LAD (LADi) were both inversely correlated with myocardial relaxation e' and positively associated with indexed LA volume, left ventricular E/e', and tricuspid regurgitation velocity (all P < 0.001) and showed significantly graded increase across ASE-defined 'normal', 'inconclusive', and 'DD' categories (30.9, 34.4, and 36.5 mm; 16.7, 19.1, and 20.6 mm/m² , for LAD/LADi, both P for trend: <0.001, respectively). Substantial differences of LAD/LADi (31.3 vs. 33.6 mm/16.7 vs. 19.2 mm/m² , both P < 0.001) between ESC low and high HF probability using NT-proBNP cut-off were also observed. Multivariate linear and logistic models demonstrated that LAD set at 34 mm was independently associated with ASE-defined diastolic indices, DD existence, and elevated NT-proBNP (all P < 0.05). The use of LAD further yielded high diagnostic accuracy in DD (area under receiving operative characteristic curve: 0.77, 95% confidence interval [0.73, 0.80]; negative predictive value: 97.9%) and in ESC-recommended HF with preserved ejection fraction criteria (area under receiving operative characteristic curve: 0.70, 95% confidence interval [0.65, 0.75]; negative predictive value: 98.7%) with high predictive value in LA remodelling (>34 mL/m² ; positive predictive value: 96%) and well-discriminated ESC-recommended NT-proBNP (≥125 pg/mL, LAD: 37 mm) for HF.

CONCLUSIONS

Single utilization of atrial remodelling is highly useful for ruling out presence of DD and provides practical threshold for identifying preclinical HF based on most updated guidelines.

Importance of the Left Atrium: More Than a Bystander?

Left atrial size and function parameters are associated with adverse outcomes in multiple disease states, including heart failure with reduced and preserved ejection fraction. Recent data suggest that phasic left atrial function and left atrial stain measurements also hold prognostic information. Three-dimensional echocardiography provides more accurate and reproducible quantification of left atrial volumes than 2-dimensional echocardiography when compared with cardiac magnetic resonance reference standards. Greater accessibility to these advanced imaging techniques allows for the integration of these parameters into routine clinical practice.

Real-time three-dimensional echocardiographic left heart parameters in healthy indian adults

OBJECTIVE

Cardiac chamber dimensions are race and anthropometry dependent. We determined the age and gender specific 3-Dimensional echocardiographic (3DE) reference values for dimensions and function of left ventricle (LV) and left atrium (LA) in normal Indian adults.

METHODS

This single center prospective study enrolled 133 adult Indians free of heart disease and/or hypertensions, subjecting them to 3DE measurements of left atrial (LA) & left ventricular (LV) volumes, function and left ventricular mass (LVM). The higher limits of normal cut-offs were determined for these parameters and their dependency on age, gender and anthropometry were analyzed.

RESULTS

The body surface area (BSA) corrected higher limit cut-offs were: 59.37ml/m2 for LV end diastolic volume (59.19ml/m2 and 59.61ml/m2 for men and women, respectively; P=NS); 23.48ml/m2 for LV end systolic volume (23.27ml/m2 and 23.11ml/m2 for men and women, P=NS). Mean LVEF was 64.79%±7.26 (62.99%±6.51 and 67.05%±7.58 in men and women, P=NS). Men had higher LVM than women (119.79g±23.95 vs. 103.26g±23.76, P<0.001), this difference disappeared after BSA indexing. The higher limit cut-offs for normal LA volumes were 20.49ml for minimum volume (21.18ml and 19.46ml for men and women, P=NS) and 39.76ml for maximum volume (39.60ml and 40.03ml in men and women, P=NS). The parameters were smaller compared to western populations but the differences attenuated after BSA indexing.

CONCLUSIONS

The study reports normal 3DE parameters of size and function of left heart chambers in Indians.

Prognostic Value of Right Ventricular Ejection Fraction Assessed by Transthoracic 3D Echocardiography

Background—

Cardiac magnetic resonance is the gold standard for the evaluation of right ventricular (RV) volumes, but it is impractical to perform in every patient. Although reference values of RV volumes and RV ejection fraction by 3D transthoracic echocardiography (3DTTE) have been established, their prognostic values have not been elucidated yet. We hypothesized that RV ejection fraction measured by 3DTTE (3DRVEF) predicts future cardiovascular events.

Methods and Results—

In protocol 1, we determined the accuracy of RV volumes and RV ejection fraction measurements by 3DTTE against cardiac magnetic resonance in 60 subjects. In protocol 2, 3DRVEF was measured in 446 patients with various cardiovascular diseases. Study subjects were followed up to record cardiac death and major adverse cardiovascular events. In protocol 1, 3DTTE-determined RV end-diastolic volume, end-systolic volume, and RV ejection fraction had good correlations to those by cardiac magnetic resonance ( r =0.74–0.90). In protocol 2, 38 cardiac deaths and 88 major adverse cardiovascular events occurred during a median follow-up of 4.1 years. Univariable Cox proportional analysis revealed that 3DRVEF was associated with both cardiac death ( P <0.0001) and major adverse cardiovascular event ( P <0.0001). 3DRVEF remained as an independent predictor for cardiac death ( P <0.0001) and major adverse cardiovascular event ( P <0.0001) even in a stepwise multivariable Cox proportional hazard analysis. Classification and regression-tree analysis demonstrated that 3DRVEF played an important role for risk stratification.

Conclusions—

3DTTE-determined RV ejection fraction was independently associated with cardiac outcomes in patients with diverse backgrounds. 3DRVEF offered incremental value over clinical risk factors and the other echocardiographic parameters including left ventricular systolic and diastolic function for predicting future adverse outcome.

Assessment of left atrial volume and function by real time three-dimensional echocardiography in obese patients

OBJECTIVE

To evaluate left atrial (LA) volume and functions in obese subjects using real time three-dimensional echocardiography (RT3DE) and also the relationship between LA mechanical functions and N-terminal pro-atrial natriuretic peptide (NT-proANP).

METHODS

This study included 40 obese (26 females and 14 males, mean age 51.9 years) and 40 normal weight subjects (23 females and 16 males, mean age 53.5 years) with normal coronary angiograms. All the study participants underwent RT3DE to assess LA volume and mechanical function. Plasma NT-proANP was determined by ELISA method.

RESULTS

There was no significant difference between groups in left ventricular (LV) diameters and ejection fraction, which reflect LV systolic function. However, transmitral deceleration time, isovolumetric relaxation time, and peak late diastolic tissue Doppler velocity values, which reflect LV diastolic function, were found to be significantly higher in obese subjects when compared with controls. LA maximum volume (LAVmax), LAVmax index (LAVI), LA minimal volume (LAVmin), before atrial contraction volume (LAVpreA), LA active emptying volume, LA total emptying volume, and LA active emptying fraction, which reflect LA reservoir and pump functions, were also higher in obese subjects when compared with controls. LA passive emptying fraction was significantly lower in obese subjects than in controls. NT-proANP levels were similar between groups. There were positive correlations between NT-proANP level and LAVI, LAVmax, LAVmin, LAVpreA, and LA total and active emptying volumes.

CONCLUSIONS

Left atrial mechanical functions and volumes are impaired in obese subjects. These findings may be regarded as early markers of subclinical cardiac failure in obese subjects who have not yet exhibited any clinical evidence of cardiovascular disease.

Atrial-focused views improve the accuracy of two-dimensional echocardiographic measurements of the left and right atrial volumes: a contribution to the increase in normal values in the guidelines update

Current guidelines recommend that the atria be measured in 2D echocardiographic (2DE) apical views using the method-of-disks (MOD) or area-length (AL) technique as an alternative, although no definitive data exists that these are interchangeable. However, standard apical views maximize the long-axis of the left ventricle, rather than the dimensions of the atria, resulting in atrial foreshortening. We hypothesized that the increase in normal values of atrial volumes in the recent guidelines update was driven by data obtained using either the AL technique or dedicated atrial-focused views, which maximize the longitudinal dimension of the atria and thus provide larger volumes than the MOD measurements in standard apical views. We prospectively studied 30 patients (Philips iE33) to compare 2DE measurements of left and right atrial volumes (LAV, RAV) using the MOD and AL techniques in standard and atrial-focused views, against 3D echocardiography (3DE) derived volumes (QLab) as a reference. Compared to standard views, atrial-focused views provided significantly larger MOD volumes for both atria, which were in better agreement with 3DE, as reflected by higher correlation coefficients (LAV: r = 0.95 vs. 0.89; RAV: r = 0.89 vs. 0.84), smaller biases (LAV: -1 ml vs. 7 ml; RAV: 3 ml vs. 7 ml) and tighter limits of agreement. This was also the case for the AL measurements, which were minimally larger than the MOD values (NS) for both atria. In conclusion, atrial-focused views are a more accurate alternative to standard apical views, which provides larger volumes. This finding can explain the increase in the normal values in the recent guidelines update, which was mostly driven by the use of atrial-focused views, rather than by the differences between MOD and AL techniques. This understanding is essential in order to correctly integrate the revised normal values into clinical practice.

Three-Dimensional Echocardiographic Assessment of Left Heart Chamber Size and Function with Fully Automated Quantification Software in Patients with Atrial Fibrillation

BACKGROUND

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.

METHODS

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.

RESULTS

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%).

CONCLUSIONS

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.

Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging

The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.

Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging

The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.

Evaluation of left atrial volume and function in systemic sclerosis patients using speckle tracking and real-time three-dimensional echocardiography

Objective:

The aim of the present study was to evaluate left atrial (LA) volume and functions using real-time three-dimensional echocardiography (RT3DE) and speckle tracking in systemic sclerosis (SSc) patients.

Methods:

The study was designed as a cross-sectional observational study. We studied 41 consecutive SSc patients (38 females, mean age: 49.5±11.6 years) and 38 healthy controls (35 females, mean age: 48.5±10.8 years). Patients with evidence or history of cardiovascular disease and patients with risk factors as hypertension, diabetes and chronic renal failure were excluded from the study. All study subjects underwent standard echocardiography; LA speckle tracking and RT3DE was performed to assess LA volume and phasic functions. Differences between numeric variables were tested using the independent sample Student’s t-test or Mann-Whitney U test, where appropriate.

Results:

There were no significant differences between SSC patients and controls regarding left ventricular (LV) systolic functions and two-dimensional (2-D) atrial diameters. Presence of LV diastolic dysfunction (LVDD) was evaluated and graded according to recommendations of the American Society of Echocardiography. Accordingly, LVDD was observed to be significantly more frequent in SSc patients; 16 SSc patients (39%) and 5 controls (12.8%) were observed to have LVDD (p=0.007). With regard to results obtained from RT3DE, LA maximum, minimum, and before atrial contraction volumes were significantly higher (40.5±14.6 vs. 32.6±8.9, 15.5±8.4 vs. 9.9±3.5 and 28.7±11.7 vs. 21.4±7.0 mL respectively, p<0.05 for all), whereas LA active emptying fraction, LA total emptying fraction, LA expansion index, and passive emptying fraction values were significantly (47.1±12.0 vs. 52.9±10.1%, 62.8±10.5 vs. 69.5±6.7%, 187.5±76.0 vs. 246.6±96.0, 29.6±9.3 vs. 34.4±11.0% respectively, p<0.05 for all) in SSc patients than in controls. In addition, regarding results obtained from speckle tracking echocardiography, atrial peak-systolic longitudinal strain (e), early negative strain rate (SR), late negative SR, and peak positive SR values were observed to be significantly lower in SSc patients.

Conclusion:

LA volumes were significantly increased, and LA reservoir, conduit, and contractile functions were significantly impaired in SSc patients compared with controls. LA volume and functional analyses with RT3DE and speckle tracking may facilitate the recognition of subtle LA dysfunction in SSc patients.

Effect of acute sleep deprivation on left atrial mechanics assessed by three-dimensional echocardiography

BACKGROUND

Although sleep deprivation (SD) affects cardiovascular system in many ways, physio-pathological changes in cardiac chamber volume and function have not been described well. The aim of the present study was to investigate the effect of SD on left atrial (LA) and ventricular function with three-dimensional (3D) echocardiography.

METHODS

Thirty-two healthy individuals (12 females, mean age 33.25 ± 8.18) were evaluated. Echocardiographic examination was performed once after a night of regular sleep and a night of sleep debt. Beside conventional parameters, 3D phasic volumes and function were measured using a commercially available 3D echocardiography system and offline analysis software.

RESULTS

Mean sleep duration of the study group was 8.15 ± 2.19 h in the day of regular sleep and 2.56 ± 2.25 h in the day of sleep deprivation. There was a significant prolongation in deceleration time (180.83 ± 15.34 vs. 166.44 ± 26.12; p = 0.044) and increase in E/e' (6.95 ± 1.26 vs. 6.38 ± 0.85; p = 0.005). Among 3D measurements, the difference in left ventricular ejection fraction (EF), LA EF, LA reservoir function and LA active EF were not significant. Mean LA passive EF of the individuals was significantly lower after night shift (24.10 ± 7.66 vs. 31.49 ± 7.75; p = 0.006).

CONCLUSION

Acute SD is associated with a reduction in LA passive emptying function in healthy adults. 3D-derived indices were sufficient to show subclinical diastolic dysfunction according to impairment in passive phase of LA ejection. Prospective large-scale studies are needed to enlighten this issue.

Left atrial volume and function in patients with atrial fibrillation

PURPOSE OF REVIEW

This review of emerging approaches to left atrial imaging in atrial fibrillation is relevant because there has been considerable recent development in the noninvasive characterization of left atrial structure and function. Concurrently, the identification and treatment of atrial fibrillation and the prevention of thromboembolism are evolving. Thus, it is timely to summarize how the advances in these two areas might be synergistic in the treatment of atrial fibrillation.

RECENT FINDINGS

This article will summarize recent developments in left atrial imaging that play a role in patients with atrial fibrillation, with particular emphasis on echocardiography, and with reference made to important advances in cardiac computed tomography and cardiac magnetic resonance. The evidence that these modalities can predict who will develop atrial fibrillation, who will achieve sustained sinus rhythm after cardioversion or catheter ablation, and who will have thromboembolic risk will be reviewed.

SUMMARY

Although existing evidence is promising, the clinical role of cardiac imaging to predict atrial fibrillation occurrence, atrial fibrillation recurrence after treatment, and thromboembolism from atrial fibrillation remains to be confirmed in large-scale studies and clinical trials.

Left atrial volumes: two-dimensional, three-dimensional, cardiac magnetic resonance and computed tomography measurements

PURPOSE OF REVIEW

Evaluation of left atrial volume is important, as it is a biomarker of cardiovascular disease and outcomes and correlates with diastolic dysfunction severity. Left atrial volume measurements by different imaging modalities, including 2D and 3D echocardiography (2DE and 3DE), cardiac magnetic resonance (CMR) and computed tomography (CT), are reviewed in regard to recent advances, methodology, prognostic value and limitations.

RECENT FINDINGS

Left atrial volume assessments correlate well between the different imaging modalities; however, 2DE significantly underestimates left atrial measurements. Assessment of the left atrial minimum volume and left atrial phasic function derived volumetrically have reported superior predictive value for major adverse cardiovascular events and elevated left ventricular diastolic pressure compared with the left atrial maximum volume.

SUMMARY

The different imaging modalities used to assess left atrial volumes are not interchangeable, particularly for serial measurements. Although 2DE underestimates left atrial volumes, most normative as well as predictive data have been obtained using this modality. Standardization, with established normative data and classification criteria, needs to be established for other imaging modalities, additionally incorporating assessment of left atrial minimum and phasic volumes. Despite the limitations of the more simplistic 2DE, its measurements are well defined with significant prognostic value. The incremental prognostic value of the more complex imaging techniques needs to be further validated.

Compensatory increase of left atrial external work to left ventricular dysfunction caused by afterload increase

Afterload mismatch can cause acute decompensation leading to an occurrence of acute heart failure. We investigated how the left atrium (LA) and left ventricle (LV) react to acute increases in afterload using speckle tracking echocardiography (STE). LA strain and volume were obtained by STE in 10 dogs during banding of descending aorta (AoB). Simultaneously, LA pressure was measured by a micromanometer-tipped catheter. LA peak negative strain during LA contraction, strain change during LA relaxation (early reservoir strain), and that during LA dilatation (late reservoir strain) were obtained from LA longitudinal strain-volume curves. From pressure-strain curves, the areas of A-loop and V-loops were computed as the work during active contraction and relaxation (A-work) and that during passive filling and emptying (V-work). AoB increased LV systolic pressure (105 ± 15 vs. 163 ± 12 mmHg, P < 0.01) and mean LA pressure (3.8 ± 1.2 vs. 7.1 ± 2.0 mmHg, P < 0.01). LV global circumferential strain decreased (−18.8 ± 3.5 vs. −13.2 ± 3.5%, P < 0.01), but LV stroke volume was maintained (8.4 ± 2.3 vs. 9.6 ± 3.6 ml). LA peak negative strain (−2.9 ± 2.3 vs. −9.8 ± 4.0%, P < 0.01) and early reservoir strain (4.5 ± 2.1 vs. 7.7 ± 2.4%, P < 0.05) increased by AoB, but late reservoir strain did not change (8.9 ± 3.4 vs. 6.1 ± 3.4%). A-work significantly increased (3.2 ± 2.0 vs. 19.2 ± 15.1 mmHg %, P < 0.01), whereas V-work did not change (13.3 ± 7.1 vs. 13.1 ± 7.7 mmHg %). In conclusion, LA external work during active contraction and relaxation increased as compensation for LV dysfunction during aortic banding. Atrial dysfunction may lead failure of this mechanism and hemodynamic decompensation.

Effects of diabetes mellitus on left atrial volume and functions in normotensive patients without symptomatic cardiovascular disease

PURPOSE

Left atrial (LA) size has been shown to be a predictor of adverse cardiovascular outcomes. The aim of the study was to evaluate the direct effect of diabetes mellitus (DM) on left atrial volume and phasic functions by using real-time three-dimensional echocardiography (RT3DE) in a population of patients free of symptomatic cardiovascular disease and hypertension.

METHODS

Comprehensive transthoracic echocardiographic examination was performed on 40 consecutive patients with DM (20 male, age: 50.5±7.3 years) and 40 healthy controls (20 male, age: 48.4±6.7 years). In addition to conventional 2D echocardiographic measurements RT3DE was performed to assess LA volumes and phasic functions.

RESULTS

There were no significant difference between groups regarding parameters reflecting LV systolic function as LV diameters and ejection fraction. However, regarding parameters reflecting LV diastolic function; transmitral deceleration time and E/E' ratio values were significantly higher and majority of early diastolic tissue Doppler velocity values were significantly lower in diabetic patients compared with controls. RT3DE demonstrated significantly higher LA maximum and minimum volumes for diabetic patients compared with controls (40.9±11.9 vs 34.6±9.3 mL, p: 0.009 and 15.6±5.9 vs 11.9±4.6 mL, p: 0.002, consecutively). LA total emptying fraction (TEF), expansion index (EI) and active emptying fraction (AEF) were found to be significantly lower in diabetics reflecting depressed LA reservoir and pump functions. There was no significant difference between groups regarding passive emptying fraction (PEF) which is assumed to be a marker of left atrial conduit function.

CONCLUSION

Patients with type 2 diabetes mellitus were found to have increased LA volume and impaired atrial compliance and contractility. Evaluation of asymptomatic diabetic patients by using RT3DE atrial volume analysis may facilitate recognition of subtle myocardial alterations related with type 2 diabetes.

Time-Course of the Effects of QSYQ in Promoting Heart Function in Ameroid Constrictor-Induced Myocardial Ischemia Pigs

We aim to investigate the therapeutic effects of QSYQ on a pig myocardial ischemia (MI) model and to determine its mechanism of action. The MI model was induced by Ameroid constriction of the left anterior descending coronary (LAD) in Ba-Ma miniature pigs. Four groups were created: model group, digoxin group, QSYQ group, and sham-operated group. Heart function, Ang II, CGMP, TXB2, BNP, and cTnT were evaluated before (3 weeks after operation: 0 weeks) and at 2, 4, and 8 weeks after drug administration. After 8 weeks of administration, the pigs were sacrificed for cardiac injury measurements. Pigs with MI showed obvious histological changes, including BNP, cTnT, Ang II, CGRP, TXB2, and ET, deregulated heart function, and increased levels of apoptotic cells in myocardial tissue. Treatment with QSYQ improved cardiac remodeling by counteracting those events. The administration of QSYQ was accompanied by a restoration of heart function and of the levels of Ang II, CGRP, TXB2, ET BNP, and cTnT. In addition, QSYQ attenuated administration, reduced the apoptosis, and decreased the level of TNF- α and active caspase-3. In conclusion, administration of QSYQ could attenuate Ameroid constrictor induced myocardial ischemia, and TNF- α and active caspase-3 seemed to be the critical potential target of QSYQ.

Prognostic value of LA volumes assessed by transthoracic 3D echocardiography: comparison with 2D echocardiography

OBJECTIVES

The hypothesis of this study was that minimal left atrial volume index (LAVImin) by 3-dimensional echocardiography (3DE) is the best predictor of future cardiovascular events.

BACKGROUND

Although maximal left atrial volume index (LAVImax) by 2-dimensional echocardiography (2DE) is a robust index for predicting prognosis, the prognostic value of LAVImin and the superiority of measurements by 3DE over 2DE have not been determined in a large group of patients.

METHODS

In protocol 1, we assessed age and sex dependency of LAVIs using 2DE and 3DE in 124 normal subjects and determined their cutoff values (mean + 2 SD). In protocol 2, 2-dimensional (2D) and 3-dimensional (3D) LAVImax/LAVImin were measured in 556 patients with high prevalence of cardiovascular disease. After excluding patients with atrial fibrillation, mitral valve disease, and age <18 years, 439 subjects were followed to record major adverse cardiovascular events (MACE). Patients were divided into 2 groups by the cutoff criteria of LAVI in each method.

RESULTS

In protocol 1, there was no significant age and sex dependency for each 2D and 3D LAVI. In protocol 2, during a mean of 2.5 years of follow-up, MACE developed in 88 patients, including 32 cardiac deaths. Kaplan-Meier survival analyses showed that all 4 LAVI cutoff criteria had significant predictive power of MACE. After variables were adjusted for clinical variables and left ventricular ejection fraction, all 4 methods were still independently and significantly associated with MACE, but 3D-derived LAVImin had the highest risk ratio. 3D LAVImin also had an incremental prognostic value over 3D LAVImax.

CONCLUSIONS

LAVIs by both 2DE and 3DE are powerful predictors of future cardiac events. 3D LAVImin tended to have a stronger and additive prognostic value than 3D LAVImax.

Serum biomarkers and the prognosis of AMI patients

BACKGROUND

It has been proven that serum lactate dehydrogenase (LDH) and total bilirubin (TB) increase during acute myocardial infarction (AMI). However, how they influence the prognosis of AMI patients is still not completely known.

METHODS

A total of 239 patients diagnosed with AMI and admitted to the Fourth Clinical Hospital of Harbin Medical University, between 2007 and 2008, were enrolled in this study. All the patients had not undergone primary percutaneous coronary intervention (PCI) because the time window (24 h) was missed. They all underwent PCI 1 week after the onset of symptoms. Serum high-sensitivity C-reactive protein (hs-CRP), TB, LDH, and other biomarkers were determined between 24 and 48 h of symptom onset. All of the patients were followed up for an average of 3.2±0.4 years for occurrence of major adverse cardiac events (MACE).

RESULTS

Patients with MACE had significantly higher levels of hs-CRP, LDH, cystatin C, uric acid, a higher ratio of LDH and TB (LDH/TB), and a lower level of TB: 8.48±3.84 vs. 2.13±1.32 μmol/l, p<0.01; 1,355.8±654.3 vs. 1,151.7±415.4 U/l, p<0.01; 1.69±0.76 vs. 1.00±0.46 mg/l, p<0.01; 419.6±109.2 vs. 343.2±108.2 μmol/l, p<0.01 and 141.1±46.2 vs. 61.2±26.5, p<0.01; 18.3±6.7 vs. 14.8±6.6 mg/l, p<0.01, respectively. In the multivariate COX analysis, LDH, cystatin C, and LDH/TB were significantly associated with the prognosis of these patients.

CONCLUSIONS

Patients under higher oxidative stress tend to have more MACE. LDH, cystatin C, and LDH/TB are strongly related to the prognosis of AMI patients undergoing elective PCI.