Left Atrial Mechanical Dispersion Assessed by Strain Echocardiography as an Independent Predictor of New-Onset Atrial Fibrillation: A Case-Control Study

Association of atrial mechanical dispersion with atrial fibrillation recurrence following catheter ablation: results of the ASTRA-AF pilot study

AIMS

For patients with symptomatic drug-refractory atrial fibrillation (AF), catheter ablation to achieve rhythm control is an important therapeutic option. The atrial mechanical dispersion measured as standard deviation of the time to peak strain (SD-TPS) is associated with the risk of AF recurrence following catheter ablation.

METHODS

The study cohort prospectively enrolled n = 132 consecutive patients with paroxysmal (n = 88) or persistent AF (n = 44) presenting for de novo pulmonary vein isolation (PVI) and followed for 1 year. We related left atrial (LA) volume, LA ejection fraction, SD-TPS, and global longitudinal strain of the left ventricle and clinical variables (sex, age, and type of AF) to AF recurrence.

RESULTS

Kaplan-Meier curves showed higher AF recurrence rate with an increase of SD-TPS with the calculated cut-off of 38.6 ms. Uni- and multivariable Cox regression analysis could show that SD-TPS had the highest relevance regarding AF recurrence with a HR of 1.05 (95% CI, 1.01; 1.09, p = 0.01) and HR of 1.05 (95% CI, 1.01; 1.09, p = 0.02) per 10 ms increase. In the additional analyses for the model including the clinical variables age, sex, and type of AF with paroxysmal or persisting AF, SD-TPS did only show a trend and after adjusting for covariates, SD-TPS showed a HR of 1.04 (95% CI, 0.99; 1.09, p = 0.09) per 10 ms increase.

CONCLUSION

Atrial mechanical dispersion was associated with recurrent AF.

Incremental diagnostic and prognostic utility of left atrial deformation in heart failure using speckle tracking echocardiography

Left atrium (LA) is a very important component of cardiovascular performance. The assessment of LA function has gathered the interest with expanding research supporting the utility as a biomarker for outcomes in heart failure (HF). Echocardiography is the main imaging modality which helps in a qualitative and quantitative assessment of the LA size and function. Recent advances in probe technology and software analysis have provided a better understanding of LA anatomy, physiology, pathology, and function. A variety of parameters have been defined as markers of LA function but there is no single parameter that best defines LA function. Speckle tracking echocardiography-derived analysis of LA deformation provides a window on all phases of LA function (reservoir, conduit, and booster pump). There is accumulative published data that supported the diagnostic and prognostic values of LA deformation integration during echo assessment of LA in HF. This review article summarized the clinical utility of LA deformation that may help in prediction, diagnosis, categorization, risk stratification, and guiding the proper selection of therapy in HF patients in daily practice.

Left atrial mechanics evaluated by two-dimensional strain analysis: alterations in essential hypertension

BACKGROUND

Hypertension is a cardiovascular risk factor that predisposes to cardiac structural alterations namely increased left ventricular (LV) wall thickness, reduced LV compliance and diastolic dysfunction, with consequent left atrial (LA) dilation and functional impairment. In this article, we evaluated differences in left atrial structure and function using two-dimensional speckle tracking echocardiography in patients with hypertension compared with controls.

METHODS

This was a retrospective cross-sectional study of 208 hypertensive patients and 157 controls who underwent a comprehensive transthoracic echocardiogram. Patients with hypertension were stratified by the presence of left ventricular hypertrophy (LVH).

RESULTS

Non-LVH hypertension patients had lower left atrial reservoir strain (LAS RES ) (34.78 ± 29.78 vs. 29.78 ± 6.08; P  = 0.022) and conduit strain (LAS CD ) (19.66 ± 7.29 vs. 14.23 ± 4.59; P  = 0.014) vs. controls despite similar left atrial volumes (LAV) . Left atrial contractile strain (LAS CT ) was not significantly different between non-LVH hypertension patients and controls (15.12 ± 3.77 vs. 15.56 ± 3.79; P  = 0.601). Left atrial mechanical dispersion was significantly higher in the LVH group compared with the non-LVH hypertension group (42.26 ± 13.01 vs. 50.06 ± 14.95; P  = 0.009). In multivariate regression analysis, LVH correlated with left atrial mechanical dispersion ( P  = 0.016). An age-hypertension interaction independently correlated with LAS CT ( P  < 0.001).

CONCLUSION

Hypertension results in functional left atrial changes even before development of LV hypertrophy and structural left atrial changes with increased left atrial volume. We demonstrate both a likely hypertension-associated left atrial myopathy that prevents age-related compensatory increase in left atrial contractile function, and impact of LVH in hypertension on left atrial dyssynchrony.

Functional reserve and contractile phenotype of atrial myocardium from patients with atrial remodeling without and with atrial fibrillation

Atrial contractility and functional reserve in atrial remodeling (AR) without (AR/-AF) or with atrial fibrillation (AR/+AF) are not well characterized. In this study, functional measurements were performed in right atrial muscle strips (n = 71) obtained from patients (N = 22) undergoing routine cardiac surgery with either no AR [left atrial (LA) diameter < 40 mm and no history of AF (hAF)], AR/-AF (LA diameter ≥ 40 mm, no hAF), or AR/+AF (hAF and LA diameter ≥ 40 mm or LAEF < 45%). AR/-AF and AR/+AF were associated with a prolongation of half-time-to-peak (HTTP, P < 0.001) and time-to-peak (TTP) contraction (P < 0.01) when compared with no AR. This effect was seen at baseline and during β-adrenergic stimulation with isoproterenol (Iso). Early relaxation assessed by half-relaxation time (HRT) was prolonged in AR/-AF (P = 0.03) but not in AR/+AF when compared with no AR at baseline, but this delay in relaxation in AR/-AF was attenuated with Iso. Late relaxation (τ) did not differ between AR/-AF and no AR but was consistently shorter in AR/+AF than no AR before (P = 0.04) and during Iso (P = 0.01), indicating accelerated late relaxation in AR/+AF. Relative force increase during Iso was higher (P = 0.01) and more dispersed (P = 0.047) in patients with AR/+AF. Relative adrenergic response was unaltered in the myocardium of patients with AR/-AF and AR/+AF. In conclusion, AR/-AF and AR/+AF are associated with changes in myocardial inotropic reserve and contractility. The changes are particularly pronounced in patients with AR/+AF, suggesting that the progression from AR/-AF to AR/+AF is associated with progressive alterations in atrial function that may contribute to arrhythmogenesis.NEW & NOTEWORTHY Mechanical alterations in atrial remodeling without (AR/-AF) and with atrial fibrillation (AR/+AF) have not been studied in detail in human atrial tissue preparations. To our knowledge, this is the first study to compare the mechanical phenotype and inotropic reserve in human atrial myocardial preparations from patients with no atrial remodeling, AR/-AF, and AR/+AF. We identify specific patterns of contractile dysfunction and heterogeneity for both, AR/-AF and AR/+AF, indicating the progression of atrial disease.

Comparison of left atrial and left atrial appendage mechanics in the recurrence of atrial fibrillation after radiofrequency catheter ablation

OBJECTIVES

Although radiofrequency catheter ablation (RFCA) has become an important treatment strategy for paroxysmal or persistent atrial fibrillation (AF), AF recurrence after RFCA remains an important issue that plagues clinicians and patients. This study aimed to investigate the association of left atrial (LA) and left atrial appendage (LAA) mechanics with AF recurrence after RFCA and to compare their prognostic values in patients with AF undergoing RFCA.

METHODS

A total of 160 patients with non-valvular AF who underwent RFCA for the first time were included in this study. All patients underwent transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) before the procedure. All patients were followed up for one year after RFCA, and AF recurrence was recorded. Speckle-tracking echocardiography was used to measure LA and LAA global longitudinal strain (GLS). LA and LAA mechanical dispersion (MD) were defined as the standard deviation of time to peak strain at each segment standardized by the R-R interval. Logistic regression analysis was used to analyze independent contributors for AF recurrence after RFCA. The prediction efficiency of factors associated with the presence of AF recurrence was evaluated by the receiver operating characteristic (ROC) curve with area under curve (AUC).

RESULTS

During 1-year follow-up, 45 (28%) patients had recurrence, and 115 (72%) patients had no recurrence. The age, CHA2 DS2 -VASc score, NT-proBNP, LA volume index (LAVI), LA MD, and LAA MD of patients in recurrence group were significantly higher than those in no recurrent group (p < .05). The LAA emptying fraction (LAAEF), LA GLS, and LAA GLS in recurrence group were significantly lower than those in no recurrent group (p < .05). Logistic regression analysis showed that LA and LAA GLS were independent contributors for AF recurrence (p < .05), providing incremental values. The AUCs of LA and LAA GLS in predicting AF recurrence were higher than that of other factors, and the LA GLS+LAA GLS joint model had higher prediction efficiency.

CONCLUSION

This study demonstrated the LA and LAA GLS were independent contributors for AF recurrence after RFCA and provided incremental values. LA and LAA GLS can be used as the predictor of AF recurrence after RFCA, and they may be beneficial for the risk stratification of AF recurrence.

Atrial cardiomyopathy: Current and future imaging methods for assessment of atrial structure and function

Changes in atrial size and function have historically been considered a surrogate marker of ventricular dysfunction. However, it is now recognized that atrial cardiomyopathy (ACM) may also occur as a primary myocardial disorder. Emerging evidence that ACM is a major risk factor for atrial fibrillation, heart failure, and thromboembolic stroke, has highlighted the significance of this disorder and the need for better assessment of atrial metrics in clinical practice. Key barriers in this regard include a lack of standardized criteria or hierarchy for the diagnosis of ACM and lack of consensus for the most accurate phenotyping methods. In this article we review existing literature on ACM, with a focus on current and future non-invasive imaging methods for detecting abnormalities of atrial structure and function. We discuss the relative advantages and disadvantages of transthoracic echocardiography and cardiac magnetic resonance imaging for assessing a range of parameters, including atrial size and contractile function, strain, tissue characteristics, and epicardial adipose tissue. We will also present the potential application of novel imaging methods such as sphericity index and four- or five-dimensional flow.

Left atrial strain assessment using cardiac computed tomography in patients with hypertrophic cardiomyopathy

PURPOSE

To evaluate left atrial (LA) function in patients with hypertrophic cardiomyopathy (HCM) by LA strain assessment using cardiac computed tomography (CT-derived LA strain).

MATERIALS AND METHODS

This was a retrospective study of 34 patients with HCM and 31 non-HCM patients who underwent cardiac computed tomography (CT) using retrospective electrocardiogram-gated mode. CT images were reconstructed every 5% (0-95%) of the RR intervals. CT-derived LA strain (reservoir [LASr], conduit [LASc], and booster pump strain [LASp]) were semi-automatically analyzed using a dedicated workstation. We also measured the left atrial volume index (LAVI) and left ventricular longitudinal strain (LVLS) for the left atrial and ventricular functional parameters to assess the relationship with CT-derived LA strain.

RESULTS

CT-derived LA strain significantly correlated with LAVI: r = - 0.69, p < 0.001 for LASr; r = - 0.70, p < 0.001 for LASp; and r = - 0.35, p = 0.004 for LASc. CT-derived LA strain also significantly correlated with LVLS: r = - 0.62, p < 0.001 for LASr; r = - 0.67, p < 0.001 for LASc; and r = - 0.42, p = 0.013 for LASp. CT-derived LA strain in patients with HCM was significantly lower than that in non-HCM patients: LASr (20.8 ± 7.6 vs. 31.7 ± 6.1%, p < 0.001); LASc (7.9 ± 3.4 vs. 14.2 ± 5.3%, p < 0.001); and LASp (12.8 ± 5.7 vs. 17.6 ± 4.3%, p < 0.001). Additionally, CT-derived LA strain showed high reproducibility; inter-observer correlation coefficients were 0.94, 0.90, and 0.89 for LASr, LASc, and LASp, respectively.

CONCLUSION

CT-derived LA strain is feasible for quantitative assessment of left atrial function in patients with HCM.

Screening, Diagnosis and Management of Atrial Fibrillation in Cancer Patients: Current Evidence and Future Perspectives

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in the general population, carrying a high morbimortality burden, and this also holds true in cancer patients. The association between AF and cancer goes even further, with some studies suggesting that AF can be a marker of occult cancer. There is, however, a remarkable paucity of data concerning specific challenges of AF management in cancer patients. AF prompt recognition and management in this special population can lessen the arrhythmia-related morbidity and have an important prognostic benefit. This review will focus on current AF diagnosis and management challenges in cancer patients, with special emphasis on AF screening strategies and devices, and anticoagulation therapy with non-vitamin K antagonist oral anti-coagulants (NOACs) for thromboembolic prevention in these patients. Some insights concerning future perspectives for AF prevention, diagnosis, and treatment in this special population will also be addressed.

Left Atrial Cardiomyopathy - A Challenging Diagnosis

Left atrial cardiomyopathy (LACM) has been an ongoing focus of research for several years. There is evidence that LACM is responsible for atrial fibrillation and embolic strokes of undetermined sources. Therefore, the correct diagnosis of LACM is of clinical importance. Various techniques, including electrocardiography, echocardiography, cardiac magnetic resonance imaging, computed tomography, electroanatomic mapping, genetic testing, and biomarkers, can both identify and quantify structural, mechanical as well as electrical dysfunction in the atria. However, the question arises whether these techniques can reliably diagnose LACM. Because of its heterogeneity, clinical diagnosis is challenging. To date, there are no recommendations for standardized diagnosis of suspected LACM. However, standardization could help to classify LACM more precisely and derive therapeutic directions to improve individual patient management. In addition, uniform diagnostic criteria for LACM could be important for future studies. Combining several parameters and relating them seems beneficial to approach the diagnosis of LACM. This review provides an overview of the current evidence regarding the diagnosis of LACM, in which several potential parameters are discussed and, consequently, a proposal for a diagnostic algorithm is presented.

The Predictive Value of Left Atrial Strain Following Transcatheter Aortic Valve Implantation on Anatomical and Functional Reverse Remodeling in a Multi-Modality Study

Introduction

Transcatheter aortic valve implantation (TAVI) can improve left ventricular (LV) mechanics and survival. Data on the predictive value of left atrial (LA) strain following TAVI are scarce. We aimed to evaluate the association of LA strain measured shortly post-TAVI with functional and anatomical reverse remodeling of the LA and LV, and its association with mortality.

Methods

We prospectively investigated 90 patients who underwent TAVI. Transthoracic echocardiography including strain analysis was performed shortly after TAVI and repeated 6 months later. CT angiography (CTA) was performed for pre-TAVI planning and 6 months post-TAVI. Speckle tracking echocardiography was used to determine LA peak reservoir strain (LASr) and LV global longitudinal strain (LV-GL), LA volume index (LAVi) was measured by TTE. LV mass index (LVMi) was calculated using CTA images. LA reverse remodeling was based on LASr and LAVi changes, whereas LV reverse remodeling was defined as an improvement in LV-GLS or a reduction of LVMi. The association of severely reduced LASr (&lt;20%) at baseline with changes (Δ) in LASr, LAVi, LV-GLS and LVMi were analyzed using linear regression, and Cox proportional hazard model for mortality.

Results

Mean LASr and LV-GLS were 17.7 ± 8.4 and −15.3 ± 3.4% at baseline and 20.2 ± 10.2 and −16.6 ± 4.0% at follow-up (p = 0.024 and p &lt; 0.001, respectively). Severely reduced LASr at baseline was associated with more pronounced ΔLASr (β = 5.24, p = 0.025) and LVMi reduction on follow-up (β = 5.78, p = 0.036), however, the majority of the patients had &lt;20% LASr on follow-up (44.4%). Also, ΔLASr was associated with ΔLV-GLS (adjusted β = 2.10, p &lt; 0.001). No significant difference in survival was found between patients with baseline severely reduced LASr (&lt;20%) and higher LASr (≥20%) (p = 0.054).

Conclusion

LV reverse remodeling based on LVMi was present even in patients with severely reduced LASr following TAVI, although extensive LA damage based on LA strain was demonstrated by its limited improvement over time.

Clinical Trial Registration

(ClinicalTrials.gov number: NCT02826200).

Evaluation of left atrial function and mechanical dispersion in breast cancer patients after chemotherapy

BACKGROUND

Left atrial (LA) function and mechanical dispersion changes in breast cancer patients treated with chemotherapy remain unclear.

HYPOTHESIS

LA function and LA mechanical dispersion in breast cancer patients would be impaired after chemotherapy.

METHODS

This single-center retrospective study included 91 consecutive breast cancer patients treated with chemotherapy and 30 controls. Patients were examined by echocardiography three times at intervals. Conventional parameters, left ventricular strain, LA strain, and LA mechanical dispersion were evaluated and compared.

RESULTS

LA strain during reservoir phase (LASr), conduit phase (LAScd), and contraction phase (LASct) all decreased markedly after chemotherapy and were lower than those of the controls (all p < .01). The standard deviation of time to peak positive strain during LA reservoir phase corrected by R-R interval (LA SD-TPSr) was significantly increased after chemotherapy and was higher than that of the controls (p < .001). The change of LA function was expressed as Δ. Multivariate linear regression analyses showed that LAVIp (0.399, 95% confidence interval [CI]: 0.610, 1.756, p = .000) was independently associated with ΔLASr, LAPEF (-0.325, 95% CI: -45.123, -10.676, p = .002) and age (0.227, 95% CI: 0.021, 0.350, p = .027) were independently associated with ΔLAScd, and LAVImax (0.341, 95% CI: 0.192, 0.723, p = .001) was independently associated with ΔLASct. LAVImax (0.505, 95% CI: 0.000, 0.001, p = .039) and mitral E (-0.256, 95% CI: 0.000, 0.000, p = .024）were independently associated with ΔLA SD-TPSr.

CONCLUSIONS

Mechanical function of LA declined after chemotherapy in breast cancer patients. With the decrease of LA mechanical function, LA mechanical dispersion assessed by two-dimensional speckle-tracking echocardiography increased significantly, and its clinical value needs to be further studied.

Echocardiographic Assessment of Atrial Function: From Basic Mechanics to Specific Cardiac Diseases

The left and right atria serve as buffer chambers to control the flow of venous blood for ventricular filling. If an atrium is absent, blood does not flow effectively into the ventricle, leading to venous blood retention and low cardiac output. The importance of atrial function has become increasingly recognized, because left atrial (LA) function contributes to cardiac performance, and loss of LA function is associated with heart failure. LA volume change has been used for LA function assessment in experimental and clinical studies. In conjunction with LA pressure, the LA pressure–volume relationship provides a better understanding of LA mechanics. LA strain measurement by speckle tracking echocardiography was introduced to evaluate three components of LA function as a (booster) pump, reservoir and conduit. Furthermore, increasing evidence supports the theory that LA reservoir strain has prognostic utility in various cardiac diseases. In this review, we summarize LA contribution to maintain cardiac performance by evaluating LA function with echocardiography according to our experiences and previous reports. Furthermore, we discuss LA dysfunction in challenging cardiac diseases of cardiac amyloidosis and adult congenital heart disease.

Strain Echocardiography to Predict Postoperative Atrial Fibrillation

Postoperative atrial fibrillation (POAF) complicates 15% to 40% of cardiovascular surgeries. Its incidence progressively increases with aging, reaching 50% in octogenarians. This arrhythmia is usually transient but it increases the risk of embolic stroke, prolonged hospital stay, and cardiovascular mortality. Though many pathophysiological mechanisms are known, POAF prediction is still a hot topic of discussion. Doppler echocardiogram and, lately, strain echocardiography have shown significant capacity to predict POAF. Alterations in oxidative stress, calcium handling, mitochondrial dysfunction, inflammation, fibrosis, and tissue aging are among the mechanisms that predispose patients to the perfect “atrial storm”. Manifestations of these mechanisms have been related to enlarged atria and impaired function, which can be detected prior to surgery. Specific alterations in the atrial reservoir and pump function, as well as atrial dyssynchrony determined by echocardiographic atrial strain, can predict POAF and help to shed light on which patients could benefit from preventive therapy.

The value of atrial electromechanical delay in predicting atrial fibrillation development after coronary artery bypass surgery

OBJECTIVE

Predicting postoperative atrial fibrillation (PoAF) in the preoperative period will provide a serious advantage in preventing the morbidity and mortality associated with this arrhythmia and in planning the treatment. In this study, we investigated the value of atrial electromechanical delay (AEMD) in predicting the development of PoAF.

METHODS

A total of 93 patients who underwent isolated coronary artery bypass grafting (CABG) operation were included in this prospective study. Patients' demographic characteristics, laboratory parameters, echocardiographic data, and AEMD durations that could be measured by the co-use of electrocardiography and echocardiography were recorded. The patients at sinus rhythm during the postoperative period were identified as "Group 1", and those who developed PoAF were identified as "Group 2".

RESULTS

PoAF incidence was 26.88% (n = 25). Left ventricle (LV) lateral AEMD, LV medial AEMD, right ventricle lateral AEMD, and left atrium (LA) lateral AEMD durations of Group 2 were significantly higher than Group 1 (p < 0.001, p = 0.004, p = 0.004, p < 0.001; respectively). In Univariate Logistic Regression Analysis, the age, hypertension, LA maximum volume, LA lateral AEMD and pulmonary artery pressure were significantly associated with PoAF development (p = 0.01, p = 0.004, p = 0.004, p = 0.001, p = 0.01; respectively). However, only LA lateral AEMD was found as an independent predictive factor for the development of PoAF in the Multivariate Logistic Regression Analysis (OR:1.03, 95% CI:1.001-1.06, p = 0.04). AUC was .741 for LA lateral AEMD in ROC Curve Analysis (95% CI: .633-.849, p < 0.001).

CONCLUSIONS

The development of PoAF can be predicted by AEMD durations measured in the preoperative period in patients undergoing isolated CABG.

Echocardiographic diagnosis of atrial cardiomyopathy allows outcome prediction following pulmonary vein isolation

BACKGROUND

Relevant atrial cardiomyopathy (ACM), defined as a left atrial (LA) low-voltage area ≥ 2 cm2 at 0.5 mV threshold on endocardial contact mapping, is associated with new-onset atrial fibrillation (AF), higher arrhythmia recurrence rates after pulmonary vein isolation (PVI), and an increased risk of stroke. The current study aimed to assess two non-invasive echocardiographic parameters, LA emptying fraction (EF) and LA longitudinal strain (LAS, during reservoir (LASr), conduit (LAScd) and contraction phase (LASct)) for the diagnosis of ACM and prediction of arrhythmia outcome after PVI.

METHODS

We prospectively enrolled 60 consecutive, ablation-naive patients (age 66 ± 9 years, 80% males) with persistent AF. In 30 patients (derivation cohort), LA-EF and LAS cut-off values for the presence of relevant ACM (high-density endocardial contact mapping in sinus rhythm prior to PVI at 3000 ± 1249 sites) were established in sinus rhythm and tested in a validation cohort (n = 30). Arrhythmia recurrence within 12 months was documented using 72-h Holter electrocardiograms.

RESULTS

An LA-EF of < 34% predicted ACM with an area under the curve (AUC) of 0.846 (sensitivity 69.2%, specificity 76.5%) similar to a LASr < 23.5% (AUC 0.878, sensitivity 92.3%, specificity 82.4%). In the validation cohort, these cut-offs established the correct diagnosis of ACM in 76% of patients (positive predictive values 87%/93% and negative predictive values 73%/75%, respectively). Arrhythmia recurrence in the entire cohort was significantly more frequent in patients with LA-EF < 34% and LASr < 23.5% (56% vs. 29% and 55% vs. 26%, both p < 0.05).

CONCLUSION

The echocardiographic parameters LA-EF and LAS allow accurate, non-invasive diagnosis of ACM and prediction of arrhythmia recurrence after PVI.

The importance of calibration method in determining the association between central blood pressure with left ventricular and left atrial strain

Afterload is an important determinant of left ventricular (LV) and atrial (LA) function, including myocardial strain. Central blood pressure (CBP) is the major component of cardiac afterload and independently associated with cardiovascular risk. However, the optimal means of calibrating CBP is unclear-standard CBP assessment uses systolic (SBP) and diastolic blood pressure (DBP) from brachial waveforms, but calibration with mean pressure (MAP) and DBP purports to be more accurate. Therefore, we sought to determine which CBP is best associated with LA and LV strain. CBP was measured using both standard and MAP based calibration methods in 546 participants (age 70.7 ± 4.7 years, 45% male) with risk factors for heart failure. Echocardiography was performed in all patients and strain analysis conducted to assess LA/LV function. The associations of CBP with LA and LV strain were assessed using linear regression. MAP-derived CSBP (150 ± 20 mmHg) was higher than standard CSBP (128 ± 15 mmHg) and brachial SBP (140 ± 17 mmHg, p < 0.001), whereas DBPs were similar (84 ± 10, 83 ± 10, and 82 ± 10 mmHg). MAP-derived CSBP was not independently associated with LV strain (p > 0.05), however was independently associated with LA reservoir strain (p < 0.05). Brachial and central DBP were more strongly associated with LA reservoir/conduit and LV strain than brachial and central SBP. LA pump strain was not independently associated with any SBP or DBP parameter (p > 0.05). MAP-derived CBP was more accurate in identifying patients with abnormal LA and LV strain than brachial SBP and standard CBP calibration. In conclusion, CBP calibrated using MAP and DBP may be more accurate in identifying patients with abnormal LA and LV function than standard brachial calibration methods.

Paradoxical association between lipoprotein cholesterol levels and left atrial function in hypertensive diabetic patients: A speckle tracking study

BACKGROUND

Studies have shown that subclinical left atrial (LA) dysfunction can be diagnosed with two-dimensional speckle tracking echocardiography (2D-STE). Although low-density lipoprotein cholesterol (LDL-C) is a risk factor for cardiovascular diseases, recent studies have reported a paradoxical relationship between LDL-C level and atrial fibrillation. In this study, we investigated the relationship between LDL-C levels and LA function.

METHODS

In 168 patients with the diagnosis of hypertension and diabetes, transthoracic echocardiography with LA 2D-STE was performed. The patients were then divided into two groups: normal LA-strain (n = 94) or impaired LA-strain (n = 74). The relationship between LDL-C and LA function was analyzed.

RESULTS

Patients with impaired LA-strain had higher body mass index (BMI) (p = 0.029), higher statin usage (p = 0.003), and lower LDL-C levels (p = 0.001) than patients with normal LA-strain. They also had lower left ventricle ejection fraction (LVEF) (p = 0.047) and higher E-wave velocity (mitral e, m/s) (p = 0.020). Multivariate logistic regression analysis showed that lower LDL-C (p = 0.034), higher BMI (p = 0.004), lower LVEF (p = 0.004), and higher E-wave velocity (p = 0.003) values were independently associated with impaired LA-strain. The area under the receiver operating curve of LDL-C in predicting impaired LA-strain was 0.645 (0.564-0.730, p < 0.05). LDL-C ≤ 112.5 mg/dl was found to be the optimal cut-off value with 74.5% sensitivity and 51.2% specificity in predicting impaired LA strain.

CONCLUSION

In patients with hypertension and diabetes, LDC-C levels are moderately but independently and paradoxically associated with impaired LA function assessed by 2D-STE.

FEV1 is independently related with impaired left atrial strain in chronic obstructive pulmonary disease patients: A speckle tracking study

BACKGROUND

Atrial fibrillation (AF) is common in chronic obstructive pulmonary disease (COPD) patients. It is known that impaired forced expiratory volume in 1 s (FEV1) is one of the risk factors of cardiovascular disease. Two-dimensional speckle tracking echocardiography (2D-STE) can detect deterioration of left atrial mechanical functions in the subclinical stage. We hypothesized that reduced lung functions, measured by FEV1 in COPD patients, may be associated with impaired left atrial (LA) mechanical functions.

OBJECTIVES

Present study included 127 consecutive COPD patients. We divided study population into two groups: patients with normal LA strain (n = 20) or with impaired LA strain (n = 107).

RESULTS

In univariate logistic regression analysis, age (p: 0.001), FEV1% (p < 0.001), FEV1 (p < 0.001), FEV1/forced vital capacity (FVC) (p: 0.014), white blood cell (p: 0.012), LA Max vol (p: 0.026), C-reactive protein (p :0.001), arterial oxygen pressure (PaO₂ ) (p: 0.019), arterial oxygen saturation (SO₂ ) (p: 0.021), left ventricle ejection fraction (LVEF) (p: 0.042), and mitral A-wave velocity (p: 0.017) were associated with impaired LA-strain. In multivariate logistic regression analysis, age (p: 0.043), FEV1 (p < 0.001), LA Max vol (p: 0.004), and LVEF (p: 0.004) were independently associated with impaired LA strain.

CONCLUSION

FEV1 is associated with impaired left atrial strain independently of arterial blood gas and left ventricular diastolic dysfunction parameters in COPD patients with preserved left ventricular systolic function.

Speckle-tracking echocardiography can predict atrial fibrillation in patients with supraventricular tachycardia

PURPOSE

Atrioventricular nodal reentry tachycardia (AVNRT) is the most common supraventriculer arrhythmia in daily clinical practice. Comorbidity of AVNRT and atrial fibrillation (AF) has been well documented in some patients and AF development has been observed more frequently in AVNRT patients during their long-term follow-up. This study was conducted in order to investigate the left atrial two-dimensional-speckle-tracking echocardiographic (STE) parametres as the predictors of the occurence of AF in long-term follow-up in patients with spontaneously developed AF during AVNRT ablation.

METHODS

Two hundred and thirty two consecutive AVNRT patients who developed spontaneous AF during ablation procedure were included in the study. The patients were followed up for a mean follow-up period of 6.2 ± 2.1 years. All patients were evaluated using the 2D-STE method. AF was developed in 34 patients during the follow-up period. Cox regression analysis was performed in order to identify the independent predictors of AF occurence.

RESULTS

Left atrial LA-res, LA-pump, LA-SRs, LA-SRe, and LA-SRa values were found to be significantly decreased in the group of patients that developed AF during the follow-up period (p < .001 for all aforementioned values). Multivariate cox regression analysis revealed that LA-res (hazard ratio [HR], 0.367; 95% confidence interval [CI], 0.161-0.0.683, p < .001) and SRe (HR, 0.472; 95% CI, 0.346-0.825, p = .006) were independent risk factors associated with the occurrence of AF.

CONCLUSION

In conclusion, it was demonstrated for the first time with this study that 2D-STE can effectively predict the development of AF in long-term follow-up in patients with spontaneously developed AF during AVNRT ablation.

Is Adiponectin Elevation Associated with Left Atrial Remodeling and Impaired Mechanical Functions? (a Speckle Tracking Study)

Objectives    Recent studies demonstrated that elevated adiponectin levels predicted an increased risk of atrial fibrillation (AF) and stroke; however, a causal relationship is yet to be unknown. Reduced left atrium (LA) functions detected by two-dimensional echocardiographic speckle tracking (2D-STE) can predict AF development. We aimed to investigate the relationship between adiponectin level and LA functions in hypertensive and diabetic patients at high risk for incident AF.Material and methods    The study consisted of 80 hypertensive diabetic patients. All patients underwent echocardiography, and venous blood samples were taken. The relationship between adiponectin levels and LA functions was analyzed.Results    We divided patients into two groups according to the mean adiponectin level (13.63 ng / ml). In the high adiponectin group, the mean age (p=0.001) and high-density lipoprotein (HDL) cholesterol (p=0.015) were higher, whereas estimated glomerular filtration rate (eGFR) (p=0.036) and hemoglobin (p=0.014) levels were lower. Although LA maximum volume, LA minimum volume, and LA pre-A volume were higher in the group with high adiponectin levels, they did not reach a statistical significance. Peak early diastolic LA strain (S-LAe) (p=0.048) and strain rate (SR-LAe) (p=0.017) were lower in this group. Multivariate logistic regression analysis demonstrated that age (p=0.003) and hemoglobin (p=0.006) were predictors of elevated adiponectin levels. On the contrary, S-LAe, HDL cholesterol, and eGFR lost their statistical significance.Conclusion    In patients with HT and DM, elevated adiponectin level is associated with impaired LA mechanical functions. Increased age and hemoglobin level are independent predictors of elevated adiponectin levels.

Assessment of right atrial dyssynchrony by 2D speckle-tracking in healthy young men following high altitude exposure at 4100 m

Background

High altitude exposure induces overload of right-sided heart and may further predispose to supraventricular arrhythmia. It has been reported that atrial mechanical dyssynchrony is associated with atrial arrhythmia. Whether high altitude exposure causes higher right atrial (RA) dyssynchrony is still unknown. The aim of study was to investigate the effect of high altitude exposure on right atrial mechanical synchrony.

Methods

In this study, 98 healthy young men underwent clinical examination and echocardiography at sea level (400 m) and high altitude (4100 m) after an ascent within 7 days. RA dyssynchrony was defined as inhomogeneous timing to peak strain and strain rate using 2D speckle-tracking echocardiography.

Results

Following high altitude exposure, standard deviation of the time to peak strain (SD-TPS) [36.2 (24.5, 48.6) ms vs. 21.7 (12.9, 32.1) ms, p<0.001] and SD-TPS as percentage of R–R’ interval (4.6 ± 2.1% vs. 2.5 ± 1.8%, p<0.001) significantly increased. Additionally, subjects with higher SD-TPS (%) at high altitude presented decreased right ventricular global longitudinal strain and RA active emptying fraction, but increased RA minimal volume index, which were not observed in lower group. Multivariable analysis showed that mean pulmonary arterial pressure and tricuspid E/A were independently associated with SD-TPS (%) at high altitude.

Conclusion

Our data for the first time demonstrated that high altitude exposure causes RA dyssynchrony in healthy young men, which may be secondary to increased pulmonary arterial pressure. In addition, subjects with higher RA dyssynchrony presented worse RA contractile function and right ventricular performance.

Changes in left atrial phasic strain and mechanical dispersion: Effects of age and gender

PURPOSE

Left atrial (LA) function by two-dimensional (2D) strain is an emerging tool with increasing clinical utility. Age and gender are key modulators of strain parameters; however, the specific time course for LA structural and functional changes is not clearly defined.

METHODS

A total of 147 healthy individuals (20-69 years) underwent transthoracic echocardiography; subjects were evaluated by age (decade) and gender. LA and left ventricular (LV) volumetric and strain measurements were performed.

RESULTS

Left atrial reservoir (ƐR) and conduit strain (ƐCD) with negatively correlated with age (r =-.36; r = -.56; P < .001, respectively) being significantly lower by the 6th and 5th decades, respectively. Contractile strain (ƐCT) positively correlated with age (r = .36; P < .001), being significantly higher by the 6th decade. ƐR and ƐCD were higher in young females (20-34 years) compared to young males (P = .033 and P < .001, respectively). ƐCT was significantly higher in middle-aged adult males (35-50yrs; P = .010), though seen later in females (≥51 years; P = .005). Standard deviation of time to positive strain (SD-TPS) significantly higher by the 5th decade and correlated with age in both males (r = .44; P <.001) and females (r = .40; P = .001).

CONCLUSION

We demonstrate that ƐR and ƐCD are lower with age, with differing rates between males and females. As a compensatory mechanism for decline in ƐCD, ƐCT is higher, more notably in males; comparatively, females display a more prominent decline in ƐR and ƐCD with age. Alteration in electromechanical properties occurred in both genders with SD-TPS becoming higher with age.

Left atrial fibrosis in atrial fibrillation: Mechanisms, clinical evaluation and management

Atrial fibrillation (AF), the commonest arrhythmia, shows associations with various disease conditions. Mounting evidence indicates that atrial fibrosis is an important part of the arrhythmogenic substrate, with an essential function in the generation of conduction abnormalities that underlie the transition from paroxysmal to persistent AF, which in turn contributes to AF perpetuation. Left atrial (LA) fibrosis is considered a possible major factor and predictor in AF treatment. The present review provides insights into LA fibrosis’ association with AF. The information is focused on clinical aspects and mechanisms, clinical evaluating methods that evaluate fibrosis changes and examining possible options for the prevention of atrial fibrosis.

Comparison of left atrial and left atrial appendage mechanics in the risk stratification of stroke in patients with atrial fibrillation

Background

Left atrial (LA) and left atrial appendage (LAA) dysfunction has been demonstrated to contribute to atrial fibrillation (AF)-related stroke. However, usefulness of LA and LAA mechanics has not been fully compared. We sought to investigate the association of LA and LAA mechanics with stroke and to compare their diagnostic values in the risk stratification of stroke in patients with nonvalvular AF.

Methods

A total of 208 consecutive patients with AF (63.58 ± 10.37 years, 63.9% male,57.7% persistent AF) who underwent echocardiography before catheter ablation were prospectively enrolled. Speckle-tracking was used to measure LA and LAA global longitudinal strain (GLS). LA and LAA mechanical dispersions (MD) were defined as the standard deviation (SD) of time to peak positive strain corrected by the R-R interval.

Results

Patients with prior stroke/ transient ischemic attack (TIA) (n = 31) had significantly higher LA and LAA MD than those without (n = 177) (11.56 ± 4.38% vs. 8.43 ± 3.44%, 15.15 ± 5.46% vs. 10.94 ± 4.40%, both P < 0.01). In multivariable analysis, LA and LAA MD were independently associated with stroke/TIA (odds ratio, 1.18–1.29, 1.19–1.22, respectively, both P < 0.01), providing incremental values over clinical and standard echocardiographic parameters. In a subgroup analysis, LA MD was more useful than LAA MD in patients with normal LA volumes, while LAA MD was superior to LA MD in patients with LA enlargement.

Conclusions

Higher LA and LAA mechanical dispersion are independently associated with stroke/TIA in AF patients and had incremental values over clinical and conventional echocardiographic parameters. What’s more, priorities of dispersion assessment are different depending on patients’ LA size.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12947-020-00232-z.

Feasibility, Reproducibility, and Clinical Implications of the Novel Fully Automated Assessment for Global Longitudinal Strain

BACKGROUND

Despite evidence of its usefulness, measurement of global longitudinal strain (GLS) has not been widely accepted as a clinical routine, because it requires proficiency and is time consuming. Automated assessment of GLS may be the solution for this situation. The aim of this study was to investigate the feasibility, reproducibility, and predictive value of automated strain analysis compared with semiautomated and manual assessment of GLS.

METHODS

In this validation study, different methods for the assessment of GLS were applied to echocardiograms from 561 asymptomatic subjects (mean age, 71 ± 5 years) with heart failure risk factors, recruited from the community. All patients had both data on follow-up outcomes (new heart failure and cardiac death) and interpretable echocardiographic images for strain analysis. Measurement of GLS was repeated using the same apical images with three different measurement packages as follows: (1) fully automated GLS (AutoStrain), (2) semiautomated GLS (automated, corrected by a trained investigator), and (3) manual GLS (standard manual assessment by a trained investigator).

RESULTS

AutoStrain measurements were technically feasible in 99.5% of patients. Calculation times for automated (0.5 ± 0.1 min/patient) and semiautomated assessment (2.7 ± 0.6 min/patient) were significantly shorter than for manual assessment (4.5 ± 1.6 min/patient; P < .001 for both). Approximately 40% of patients were thought to need manual correction after automatic calculation of GLS. Therefore, there was considerable discordance between automated and semiautomated and manual GLS. Over a median of 12 months of follow-up, cardiovascular events (new heart failure and cardiac death) occurred in 66 patients (11.8%). Automated GLS showed the potential to correctly detect normal and abnormal systolic function and predict cardiac events; the predictive value was inferior to that of semiautomated GLS.

CONCLUSIONS

A novel fully automated assessment for GLS may provide a technically feasible, rapidly reproducible, and clinically applicable means of assessing left ventricular function, but a substantial number of automatic traces still need manual correction by experts. At the present stage, the semiautomated approach using this novel automated software seems to provide a better balance between feasibility and clinical relevance.

Impaired left atrial mechanical functions as indicators for increased aortic root diameter in hypertensive and diabetic patients

OBJECTIVES

Previous studies have demonstrated that increased aortic root diameter (ARD) is frequently associated with increased cardiovascular (CV) events and is a predictor of stroke. Two-dimensional speckle tracking echocardiography (2D-STE) provides a better evaluation of left atrial (LA) functions. Left atrial mechanical dispersion is a useful predictor of new-onset atrial fibrillation (AF) independent of LA enlargement and dysfunction. We aimed to investigate the relationship between ARD and LA mechanical functions.

METHODS

The present study included 93 consecutive patients with hypertension and diabetes. The relationships between ARD and LA functions was evaluated.

RESULTS

Study population was divided into two groups according to the mean ARD values: group 1 (ARD ≤30.03 mm, n = 53) and group 2 (ARD >30.03 mm, n = 40). In group 2, age, LA max volume (vol), LA pre A vol, LA min vol, LA emptying fraction, LA active ejection fraction (EF), and LA expansion index were significantly higher compared to group 1. S‑LAs and SR-LAs (peak LA strain and strain rate, respectively, during ventricular systole) and S‑LAe and SR-LAe (peak early diastolic LA strain and strain rate, respectively) were significantly lower in group 2 compared to group 1. Age, LA max vol, LA pre A vol, LA min vol, LA emptying fraction, LA active EF, LA expansion index, S‑LAs, S‑LAe, SR-LAs, and SR-LAe were significantly associated with increased ARD. In multivariate logistic regression analysis, age, LA expansion index, and SR-LAe were independent predictors for ARD.

CONCLUSION

Impaired LA mechanical functions determined by speckle tracking methods are related with increased ARD independent of LV diastolic dysfunction.

Catheter ablation of atrial fibrillation after pericardiectomy: multi-center experience in China

Background

To study the effectiveness and safety of atrial fibrillation (AF) catheter ablation after pericardiectomy.

Methods

Data of 24 consecutive AF patients after pericardiectomy underwent catheter ablation from five centers were collected and analyzed retrospectively. All patients were followed up at 1, 3, and 12 months after catheter ablation. Results of a repeated blood test, electrocardiogram, and echocardiography during follow-up were also collected. Adverse events such as recurrence of AF, heart failure, stroke/transient ischemic attack (TIA) and minor, and major bleeding were recorded. All patients underwent brain magnetic resonance imaging (MRI) at the end of 12 months follow-up.

Results

Patients were young (20-73 years old, 48.1±11.0). Fifteen (62.5%) patients were male. CHA2DS2-VASc score (0-3, 0.21±0.41) was low in these 24 patients. Among these patients, 11 (45.8%) were paroxysmal AF, 8 (33.3%) were persistent AF, and 5 (20.8%) were long-lasting persistent AF. Left atrium diameter over 45 mm was detected in 17 (70.8%) patients. All patients underwent catheter ablation successfully. No peri-ablation procedure-related complication happened. Oral anticoagulant therapy was stopped 3 months after the final ablation. Anti-arrhythmia drugs were continued for all patients after ablation. For 12 months follow-up, AF recurred in 10 (41.7%) patients 3-7 months after the first ablation. MRI detected silent cerebral infarction (SCI) in 2 (8.3%) patients. No other adverse events occurred during follow-up.

Conclusions

It is safe for AF patients to undergo catheter ablation after pericardiectomy, but the rate of recurrence of AF is high.

Serum osteoprotegerin level is independently related to subclinical left atrial mechanical function in patients with hypertension and diabetes

OBJECTIVES

Previous studies showed that subclinical abnormal left atrial (LA) function could be diagnosed with LA speckle tracking evaluation long before chamber enlargement. Osteoprotegerin (OPG) is a member of the tumor necrosis factor (TNF) receptor superfamily and was recently found to be an indicator for adverse cardiovascular outcomes and a risk factor for new onset atrial fibrillation. The authors hypothesized that OPG values could predict LA mechanical dysfunction and LA remodeling assessed by two-dimensional speckle tracking echocardiography (2D-STE) in patients with hypertension (HT) and diabetes mellitus (DM).

METHODS

A single center study was conducted including consecutive patients presenting to the authors' outpatient clinic. Enrolled patients needed to have been treated for HT and DM for at least 1 year.

RESULTS

The study included 80 patients (mean age, 57.5 ± 8.3 years). Patients in the impaired LA strain group were older (p = 0.035), had lower low density lipoprotein (LDL) cholesterol (mg/dl) (p = 0.021), and higher OPG (pmol/l) (p = 0.004) values than patients in the normal LA strain group. Univariate logistic regression analysis demonstrated that age (p = 0.039), LDL cholesterol (mg/dl) (p = 0.025), and OPG (pmol/l) (p = 0.008) values were associated with impaired LA strain. Backward multivariate logistic regression analysis showed that LDL cholesterol (mg/dl) (OR: 0.982, CI 95% 0.964-0.999, p = 0.049) and OPG (pmol/l) (OR: 1.438, CI 95% 1.043-1.983, p = 0.027) were independently associated with impaired LA strain.

CONCLUSION

In hypertensive and diabetic patients, higher OPG values were associated with impaired LA function assessed by 2D-STE. In this high-risk patient group, serum OPG can be used as a risk predictor for LA mechanical dysfunction.