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Robinson S, Ring L, Oxborough D, Harkness A, Bennett S, Rana B, Sutaria N, Lo Giudice F, Shun-Shin M, Paton M, Duncan R, Willis J, Colebourn C, Bassindale G, Gatenby K, Belham M, Cole G, Augustine D, Smiseth OA. The assessment of left ventricular diastolic function: guidance and recommendations from the British Society of Echocardiography. Echo Res Pract 2024; 11:16. [PMID: 38825710 PMCID: PMC11145885 DOI: 10.1186/s44156-024-00051-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 05/13/2024] [Indexed: 06/04/2024] Open
Abstract
Impairment of left ventricular (LV) diastolic function is common amongst those with left heart disease and is associated with significant morbidity. Given that, in simple terms, the ventricle can only eject the volume with which it fills and that approximately one half of hospitalisations for heart failure (HF) are in those with normal/'preserved' left ventricular ejection fraction (HFpEF) (Bianco et al. in JACC Cardiovasc Imaging. 13:258-271, 2020. 10.1016/j.jcmg.2018.12.035), where abnormalities of ventricular filling are the cause of symptoms, it is clear that the assessment of left ventricular diastolic function (LVDF) is crucial for understanding global cardiac function and for identifying the wider effects of disease processes. Invasive methods of measuring LV relaxation and filling pressures are considered the gold-standard for investigating diastolic function. However, the high temporal resolution of trans-thoracic echocardiography (TTE) with widely validated and reproducible measures available at the patient's bedside and without the need for invasive procedures involving ionising radiation have established echocardiography as the primary imaging modality. The comprehensive assessment of LVDF is therefore a fundamental element of the standard TTE (Robinson et al. in Echo Res Pract7:G59-G93, 2020. 10.1530/ERP-20-0026). However, the echocardiographic assessment of diastolic function is complex. In the broadest and most basic terms, ventricular diastole comprises an early filling phase when blood is drawn, by suction, into the ventricle as it rapidly recoils and lengthens following the preceding systolic contraction and shortening. This is followed in late diastole by distension of the compliant LV when atrial contraction actively contributes to ventricular filling. When LVDF is normal, ventricular filling is achieved at low pressure both at rest and during exertion. However, this basic description merely summarises the complex physiology that enables the diastolic process and defines it according to the mechanical method by which the ventricles fill, overlooking the myocardial function, properties of chamber compliance and pressure differentials that determine the capacity for LV filling. Unlike ventricular systolic function where single parameters are utilised to define myocardial performance (LV ejection fraction (LVEF) and Global Longitudinal Strain (GLS)), the assessment of diastolic function relies on the interpretation of multiple myocardial and blood-flow velocity parameters, along with left atrial (LA) size and function, in order to diagnose the presence and degree of impairment. The echocardiographic assessment of diastolic function is therefore multifaceted and complex, requiring an algorithmic approach that incorporates parameters of myocardial relaxation/recoil, chamber compliance and function under variable loading conditions and the intra-cavity pressures under which these processes occur. This guideline outlines a structured approach to the assessment of diastolic function and includes recommendations for the assessment of LV relaxation and filling pressures. Non-routine echocardiographic measures are described alongside guidance for application in specific circumstances. Provocative methods for revealing increased filling pressure on exertion are described and novel and emerging modalities considered. For rapid access to the core recommendations of the diastolic guideline, a quick-reference guide (additional file 1) accompanies the main guideline document. This describes in very brief detail the diastolic investigation in each patient group and includes all algorithms and core reference tables.
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Affiliation(s)
| | - Liam Ring
- West Suffolk Hospital NHS Trust, Bury St Edmunds, UK
| | | | - Allan Harkness
- East Suffolk and North Essex NHS Foundation Trust, Colchester, UK
| | - Sadie Bennett
- University Hospital of the North Midlands, Stoke-On-Trent, UK
| | - Bushra Rana
- Imperial College Healthcare NHS Trust, London, UK
| | | | | | | | | | - Rae Duncan
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | | | | | | | | | - Mark Belham
- Addenbrookes Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Graham Cole
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Otto A Smiseth
- Division of Cardiovascular and Pulmonary Diseases, Oslo University Hospital, Rikshospitalet and University of Oslo, Oslo, Norway
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Sawaya F, Abi-Saleh B, Hoteit A, Jdaidany J, Moumneh MB, Harbieh B, Khoury M, Aramouni S, Abdulhai F, Refaat M. Safety of Amulet Left Atrial Appendage Occluder and Watchman Device for Left Atrial Appendage Closure in Patients With Atrial Fibrillation. Cureus 2024; 16:e55531. [PMID: 38576630 PMCID: PMC10993002 DOI: 10.7759/cureus.55531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Left atrial appendage (LAA) closure is an alternative to chronic anticoagulation for stroke prevention in patients with nonvalvular atrial fibrillation. Multiple devices were used for LAA closure, with the Amplatzer Amulet LAA Occluder (Abbott, Chicago, IL, USA) and Watchman device (Boston Scientific, Marlborough, MA, USA) being the most commonly used in clinical practice. In August 2021, the FDA approved the use of the Amplatzer Amulet LAA Occluder. There is still a knowledge gap in the safety profile of the Amplatzer Amulet LAA Occluder device in comparison to the Watchman device. OBJECTIVE The aim of this study was to assess and compare the safety profile peri-procedure and post-procedure between the Amplatzer Amulet LAA Occluder and Watchman devices. METHODS Patients who underwent LAA closure using Watchman or Amulet devices from July 2015 to August 2020 at the American University of Beirut Medical Center were included in the analysis. Primary endpoints included peri-operative and post-procedural complications (thromboembolic events, bleeding complications, vascular access complications, pericardial effusion/tamponade, device positional complications and in-hospital death). RESULTS The study included 37 patients (21 had Watchman devices, 16 had Amplatzer Amulet LAA Occluder devices, and 28 were men, mean age 76.57 ± 9.3 years). Seven patients developed post-procedural iatrogenic atrial septal defects (four in the Watchman group vs three in the Amulet group, p-value=0.982). Three patients developed pericardial effusion (one in the Watchman vs two in the Amulet group, p-value=0.394). Only one patient developed peri-device leak (one in the Watchman group vs none in the Amulet group, p-value=0.283). One device could not be deployed (one in the Amulet group vs none in the Watchman group, p-value=0.191). None of the patients developed in-hospital death, cardiac tamponade, device embolism, device thrombosis, stroke/transient ischemic attack (TIA), cranial bleeding, or arrhythmias after the procedure. The rate of peri-operative complications was similar between both groups. Both groups displayed low rates of adverse events in the peri-operative and post-operative periods. CONCLUSION There was no significant difference in the safety profile of Amplatzer Amulet LAA Occluders and Watchman devices. There was a low incidence of peri-operative and post-operative adverse events with the implanted devices.
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Affiliation(s)
- Fadi Sawaya
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Bernard Abi-Saleh
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Abbas Hoteit
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Jennifer Jdaidany
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | | | - Bernard Harbieh
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Maurice Khoury
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Salim Aramouni
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Farah Abdulhai
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Marwan Refaat
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 571] [Impact Index Per Article: 571.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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Wu X, Sun F, Ma S, Wang Z, Xu S. Application of computed tomographic angiography and echocardiography in predicting left atrial appendage thrombosis in patients with non-valvular atrial fibrillation. Cardiovasc J Afr 2023; 34:231-236. [PMID: 36383152 PMCID: PMC10870313 DOI: 10.5830/cvja-2022-052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 09/06/2022] [Indexed: 06/16/2023] Open
Abstract
AIM We aimed to explore the application of computed tomographic angiography (CTA) and echocardiography in predicting left atrial appendage (LAA) thrombosis in patients with non-valvular atrial fibrillation. METHODS The clinical data of 164 atrial fibrillation patients receiving cardiac CTA and real-time three-dimensional transoesophageal echocardiography (RT-3D-TEE) were retrospectively analysed. The patients were divided into group A (anticoagulant treatment group, n = 112) and group B (selective anticoagulant treatment group, n = 52) according to the CHA2DS2-VASc score, which scored for the presence or absence of congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke/transient ischaemic attack, vascular disease, age 65-74 years and gender (female). The CHA2DS2-VASc score was used to predict risk of thromboembolism from atrial fibrillation. The correlations of CHA2DS2-VASc score with CTA-based LAA classification and RT-3D-TEE measurement parameters were explored using Spearman's analysis. Receiver operating characteristic (ROC) curves were plotted to explore the predictive value of CTA and RT-3D-TEE for LAA thrombus. RESULTS There were significant differences in age, disease course, hypertension, diabetes mellitus, coronary heart disease, heart failure, stroke/transient ischaemic attack/thromboembolism, vascular disease, B-type natriuretic peptide and serum uric acid levels, CHA2DS2-VASc score, LAA classification, left ventricular ejection fraction (LVEF), left atrial diameter (LAD), maximum diameter of LAA orifice, minimum diameter of LAA orifice and LAA length (p < 0.05). CHA2DS2- VASc score was positively correlated with cauliflower LAA, LAD, maximum diameter of LAA orifice, minimum diameter of LAA orifice and LAA length, and negatively correlated with LVEF (p < 0.001). ROC curve analysis indicated that CTA, RT-3D-TEE and CHA2DS2-VASc score had similar predictive values for risk of LAA thrombosis in atrial fibrillation patients, with the areas under the curve being 0.778, 0.814 and 0.792, respectively. CONCLUSIONS Both CTA and RT-3D-TEE had high predictive values for LAA thrombosis in atrial fibrillation patients.
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Affiliation(s)
- Xiaodan Wu
- Department of Ultrasound, Shenzhen University General Hospital, Shenzhen, China.
| | - Fan Sun
- Department of Ultrasound, Affiliated Hospital of Beihua University, Jilin, China
| | - Shoucheng Ma
- Department of Radiology, Jilin City TCM-WM Hospital, Jilin, China
| | - Zhichen Wang
- Department of Cardiovascular Surgery, Jilin Central General Hospital, Jilin, China
| | - Shenghai Xu
- Department of Ultrasound, Jilin Longtan District Tiedong Hospital, Jilin, China
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Outcomes of cardiac surgery with left atrial appendage occlusion versus no Occlusion, direct oral Anticoagulants, and vitamin K Antagonists: A systematic review with Meta-analysis. IJC HEART & VASCULATURE 2022; 40:100998. [PMID: 35655531 PMCID: PMC9152299 DOI: 10.1016/j.ijcha.2022.100998] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 02/21/2022] [Accepted: 03/07/2022] [Indexed: 01/13/2023]
Abstract
Surgical left atrial appendage occlusion (LAAO) is being used increasingly in the setting of atrial fibrillation but has been associated with procedural complications. This systematic review and meta-analysis compared the outcomes of surgical LAAO with those of no LAAO and the use of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) using the PRISMA guidelines. A literature search was undertaken for relevant studies published between January 1, 2003, and August 15, 2021. Primary clinical outcomes were all-cause mortality, embolic events, and stroke. Secondary clinical outcomes included major adverse cardiac events (MACE), postoperative atrial fibrillation, postoperative complications, reoperation for bleeding, and major bleeding. There was a statistically significant 34% reduction in incidence of embolic events (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.57–0.77, p < 0.001) and a significant 42% reduction in risk of MACE (OR 0.58, 95% CI 0.38–0.88, p = 0.01) in patients who underwent LAAO.Surgical LAAO has the potential to reduce embolic events and MACE in patients undergoing cardiac surgery for atrial fibrillation. However, complete replacement of DOACs and warfarin therapy with surgical LAAO is unlikely despite its non-inferiority in terms of minimizing all-cause mortality, embolic events, MACE, major bleeding, and stroke in patients on oral anticoagulation therapies.
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Yosefy O, Sharon B, Yagil C, Shlapoberski M, Livoff A, Novitski I, Beeri R, Yagil Y, Yosefy C. Diabetes induces remodeling of the left atrial appendage independently of atrial fibrillation in a rodent model of type-2 diabetes. Cardiovasc Diabetol 2021; 20:149. [PMID: 34301258 PMCID: PMC8306366 DOI: 10.1186/s12933-021-01347-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/15/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Diabetic patients have an increased predisposition to thromboembolic events, in most cases originating from thrombi in the left atrial appendage (LAA). Remodeling of the LAA, which predisposes to thrombi formation, has been previously described in diabetic patients with atrial fibrillation, but whether remodeling of the LAA occurs in diabetics also in the absence of atrial fibrillation is unknown. To investigate the contribution of diabetes, as opposed to atrial fibrillation, to remodeling of the LAA, we went from humans to the animal model. METHODS We studied by echocardiography the structure and function of the heart over multiple time points during the evolution of diabetes in the Cohen diabetic sensitive rat (CDs/y) provided diabetogenic diet over a period of 4 months; CDs/y provided regular diet and the Cohen diabetic resistant (CDr/y), which do not develop diabetes, served as controls. All animals were in sinus rhythm throughout the study period. RESULTS Compared to controls, CDs/y developed during the evolution of diabetes a greater heart mass, larger left atrial diameter, wider LAA orifice, increased LAA depth, greater end-diastolic and end-systolic diameter, and lower E/A ratio-all indicative of remodeling of the LAA and left atrium (LA), as well as the development of left ventricular diastolic dysfunction. To investigate the pathophysiology involved, we studied the histology of the hearts at the end of the study. We found in diabetic CDs/y, but not in any of the other groups, abundance of glycogen granules in the atrial appendages , atria and ventricles, which may be of significance as glycogen granules have previously been associated with cell and organ dysfunction in the diabetic heart. CONCLUSIONS We conclude that our rodent model of diabetes, which was in sinus rhythm, reproduced structural and functional alterations previously observed in hearts of human diabetics with atrial fibrillation. Remodeling of the LAA and of the LA in our model was unrelated to atrial fibrillation and associated with accumulation of glycogen granules. We suggest that myocardial accumulation of glycogen granules is related to the development of diabetes and may play a pathophysiological role in remodeling of the LAA and LA, which predisposes to atrial fibrillation, thromboembolic events and left ventricular diastolic dysfunction in the diabetic heart.
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Affiliation(s)
- Or Yosefy
- Department of Cardiology, Barzilai University Medical Center, 2 Hahistadrut Street, 78278, Ashkelon, Israel
| | - Barucha Sharon
- Department of Cardiology, Barzilai University Medical Center, 2 Hahistadrut Street, 78278, Ashkelon, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Chana Yagil
- Laboratory for Molecular Medicine and Israeli Rat Genome Center, Barzilai University Medical Center, 2 Hahistadrut Street, 78278, Ashkelon, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Mark Shlapoberski
- Department of Pathology, Barzilai University Medical Center, Ashkelon, Israel
| | - Alejandro Livoff
- Department of Pathology, Barzilai University Medical Center, Ashkelon, Israel
| | - Ilana Novitski
- Department of Pathology, Barzilai University Medical Center, Ashkelon, Israel
| | - Ronen Beeri
- Diagnostic Cardiology Unit, Heart Institute, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Yoram Yagil
- Laboratory for Molecular Medicine and Israeli Rat Genome Center, Barzilai University Medical Center, 2 Hahistadrut Street, 78278, Ashkelon, Israel.
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel.
| | - Chaim Yosefy
- Department of Cardiology, Barzilai University Medical Center, 2 Hahistadrut Street, 78278, Ashkelon, Israel.
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel.
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Clinical predictors and sequelae of computed tomography defined leaflet thrombosis following transcatheter aortic valve replacement at medium-term follow-up. Heart Vessels 2021; 36:1374-1383. [PMID: 33660057 DOI: 10.1007/s00380-021-01803-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 02/05/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The clinical predictors and sequelae of leaflet thrombosis (LT) following transcatheter aortic valve replacement (TAVR) is still unclear. Therefore, our aim was to determine the clinical predictors and sequelae at mid-term follow-up of computed tomography (CT)-defined LT following TAVR. METHODS AND RESULTS We performed a prospective evaluation with a 320-multislice CT following TAVR for the presence of LT, defined as hypo-attenuated leaflet thickening (HALT). Four-dimensional CT image-rendering was performed to determine the presence of reduced leaflet motion (RELM). 172 patients [89 (51.7%) male, mean age 82.8 ± 5.7 years] treated with commercially available TAVR device (Lotus 54%, CoreValve 32% and Sapien 3 14%) were included, with median CT-scan at 6.0 weeks post-TAVR. Prevalence of HALT was 14.0% (24 cases) and RELM was 9.8% (17 cases). On multivariate analysis, patients with HALT were less prescribed oral anticoagulation (OAC) (OR 9.9), received larger TAVR prostheses (OR 5.7) and higher rates of moderate-severe para-valvular regurgitation (PVR) (OR 16.3). There was no difference in clinical outcomes at a median follow-up of 2.3 years. Patients with RELM had significantly higher transvalvular gradients after discharge when compared to those without RELM. CONCLUSIONS Absence of OAC, large TAVR prostheses and moderate-severe PVR were predictors for LT. Transvalvular gradients were higher in patients that developed RELM but not HALT. Further studies are warranted to determine the long-term impact of LT on TAVR durability. Prevalence of different sub-types of CT-defined LT (HALT and RELM) and the clinical predictors of developing LT following TAVR. CT computed tomography, HALT hypo-attenuated leaflet thickening, LT leaflet thrombosis, RELM reduced leaflet motion, TAVR transcatheter aortic valve replacement.
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