1
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Noubiap JJ, Nyaga UF, Middeldorp ME, Stokes MB, Sanders P. Cardiac imaging correlates and predictors of stroke in patients with atrial fibrillation: a meta-analysis. J Cardiovasc Med (Hagerstown) 2024; 25:280-293. [PMID: 38407860 DOI: 10.2459/jcm.0000000000001608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
BACKGROUND New nonclinical parameters are needed to improve the current stroke risk stratification schemes for patients with atrial fibrillation. This study aimed to summarize data on potential cardiac imaging correlates and predictors of stroke or systemic embolism in patients with atrial fibrillation. METHODS MEDLINE, EMBASE, and Web of Science were searched to identify all published studies providing relevant data through 16 November 2022. Random effects meta-analysis method was used to pool estimates. RESULTS We included 64 studies reporting data from a pooled population of 56 639 patients. Left atrial spontaneous echo-contrast [adjusted odds ratio (aOR) 3.32, 95% confidence interval (CI) 1.98-5.49], nonchicken wing left atrial appendage (LAA) morphology (aOR 2.15, 95% CI 1.11-4.18), left atrial enlargement (aOR 2.12, 95% CI 1.45-3.08), and higher LAA orifice diameter (aOR 1.56, 95% CI 1.18-2.05) were highly associated with stroke. Other parameters associated with stroke included higher left atrial sphericity (aOR 1.14, 95% CI 1.01-1.29), higher left atrial volume (aOR 1.03, 95% CI 1.01-1.04), higher left atrial volume index (aOR 1.014, 95% CI 1.004-1.023), lower left atrial reservoir strain [adjusted hazard ratio (aHR) 0.86, 95% CI 0.76-0.98], higher left ventricular mass index (aOR 1.010, 95% CI 1.005-1.015) and E / e' ratio (aOR 1.12, 95% CI 1.07-1.16). There was no association between LAA volume (aOR 1.37, 95% CI 0.85-2.21) and stroke. CONCLUSION These cardiac imaging parameters identified as potential predictors of thromboembolism may improve the accuracy of stroke risk stratification schemes in patients with atrial fibrillation. Further studies should evaluate the performance of holistic risk scores including clinical factors, biomarkers, and cardiac imaging.
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Affiliation(s)
- Jean Jacques Noubiap
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
| | | | - Melissa E Middeldorp
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Smidt Heart Institute, Cedar-Sinai Medical Centre, Los Angeles, California, USA
| | - Michael B Stokes
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, Adelaide, Australia
- Department of Cardiology, Royal Adelaide Hospital, Adelaide, Australia
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2
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Weerts J, Bisbal F, Bayés-Genís A, Delgado V, Cediel G, Teis A. Simplified left atrial sphericity evaluation by cardiac magnetic resonance. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:178-181. [PMID: 37783369 DOI: 10.1016/j.rec.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/01/2023] [Indexed: 10/04/2023]
Affiliation(s)
- Jerremy Weerts
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain; Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre + (MUMC +), Maastricht, The Netherlands
| | - Felipe Bisbal
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Antoni Bayés-Genís
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Departamento de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Victoria Delgado
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain; Centre de Medicina Comparativa i Bioimatge (CMCiB), Badalona, Barcelona, Spain
| | - German Cediel
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | - Albert Teis
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain.
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3
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Hopman LH, Bhagirath P, Mulder MJ, Demirkiran A, Mathari SE, van der Laan AM, van Rossum AC, Kemme MJ, Allaart CP, Götte MJ. Left atrial sphericity in relation to atrial strain and strain rate in atrial fibrillation patients. Int J Cardiovasc Imaging 2023; 39:1753-1763. [PMID: 37515682 PMCID: PMC10520187 DOI: 10.1007/s10554-023-02866-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/29/2023] [Indexed: 07/31/2023]
Abstract
PURPOSE Left atrial (LA) sphericity is a novel, geometry-based parameter that has been used to visualize and quantify LA geometrical remodeling in patients with atrial fibrillation (AF). This study examined the association between LA sphericity, and LA longitudinal strain and strain rate measured by feature-tracking in AF patients. METHODS 128 AF patients who underwent cardiovascular magnetic resonance (CMR) imaging in sinus rhythm prior to their pulmonary vein isolation (PVI) procedure were retrospectively analyzed. LA sphericity was calculated by segmenting the LA (excluding the pulmonary veins and the LA appendage) on a 3D contrast enhanced MR angiogram and comparing the resulting shape with a perfect sphere. LA global reservoir strain, conduit strain, contractile strain and corresponding strain rates were derived from cine images using feature-tracking. For statistical analysis, Pearson correlations, multivariable logistic regression analysis, and Student t-tests were used. RESULTS Patients with a spherical LA (dichotomized by the median value) had a lower reservoir strain and conduit strain compared to patients with a non-spherical LA (-15.4 ± 4.2% vs. -17.1 ± 3.5%, P = 0.02 and - 8.2 ± 3.0% vs. -9.5 ± 2.6%, P = 0.01, respectively). LA strain rate during early ventricular diastole was also different between both groups (-0.7 ± 0.3s- 1 vs. -0.9 ± 0.3s- 1, P = 0.001). In contrast, no difference was found for LA contractile strain (-7.2 ± 2.6% vs. -7.6 ± 2.2%, P = 0.30). CONCLUSIONS LA passive strain is significantly impaired in AF patients with a spherical LA, though this relation was not independent from LA volume.
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Affiliation(s)
- Luuk H.G.A. Hopman
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Pranav Bhagirath
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Mark J. Mulder
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Ahmet Demirkiran
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Sulayman El Mathari
- Department of Cardiothoracic Surgery, Amsterdam UMC, Amsterdam, The Netherlands
| | - Anja M. van der Laan
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Albert C. van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Michiel J.B. Kemme
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Cornelis P. Allaart
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Marco J.W. Götte
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
- Dept. of Cardiology, Amsterdam UMC, De Boelelaan 1118, 1081 HV Amsterdam, The Netherlands
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4
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Katic J, Borovac JA. Treatment of Persistent Left Atrial Appendage Thrombus in Patients with Atrial Fibrillation on Adequate Oral Anticoagulation: Pathways of Care for All-comers and Heart Failure Patients. Card Fail Rev 2023; 9:e05. [PMID: 37397240 PMCID: PMC10311400 DOI: 10.15420/cfr.2022.28] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/27/2023] [Indexed: 07/04/2023] Open
Abstract
In patients with AF, the presence of left atrial/left atrial appendage (LA/LAA) thrombus is related to an increased risk of thromboembolic events. Anticoagulation therapy, either with vitamin K antagonists or novel oral anticoagulants (NOACs) is therefore mandatory in AF with LA/LAA thrombus in order to lower the risk of stroke or other systemic embolic events. Despite the efficacy of these treatments, some patients will have persistent LAA thrombus remaining or may have contraindications to oral anticoagulation. Currently, little is known about the occurrence, risk factors and resolution rate of LA/LAA thrombus in patients who are already under optimal chronic oral anticoagulation, including vitamin K antagonists or NOACs. The common action in clinical practice in this scenario is switching from one to another anticoagulant drug exhibiting a different mechanism of action. Repeated cardiac imaging is then advised within several weeks to visually verify thrombus dissolution. Finally, there is a substantial scarcity of data on the role and optimal use of NOACs after LAA occlusion. The aim of this review is to critically evaluate data and provide up-to-date information on the best antithrombotic strategies in this challenging clinical scenario.
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Affiliation(s)
- Josip Katic
- Cardiovascular Diseases Department, University Hospital of Split Split, Croatia
| | - Josip Andelo Borovac
- Cardiovascular Diseases Department, University Hospital of Split Split, Croatia
- Department of Pathophysiology, University of Split School of Medicine Split, Croatia
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5
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Schnabel RB, Marinelli EA, Arbelo E, Boriani G, Boveda S, Buckley CM, Camm AJ, Casadei B, Chua W, Dagres N, de Melis M, Desteghe L, Diederichsen SZ, Duncker D, Eckardt L, Eisert C, Engler D, Fabritz L, Freedman B, Gillet L, Goette A, Guasch E, Svendsen JH, Hatem SN, Haeusler KG, Healey JS, Heidbuchel H, Hindricks G, Hobbs FDR, Hübner T, Kotecha D, Krekler M, Leclercq C, Lewalter T, Lin H, Linz D, Lip GYH, Løchen ML, Lucassen W, Malaczynska-Rajpold K, Massberg S, Merino JL, Meyer R, Mont L, Myers MC, Neubeck L, Niiranen T, Oeff M, Oldgren J, Potpara TS, Psaroudakis G, Pürerfellner H, Ravens U, Rienstra M, Rivard L, Scherr D, Schotten U, Shah D, Sinner MF, Smolnik R, Steinbeck G, Steven D, Svennberg E, Thomas D, True Hills M, van Gelder IC, Vardar B, Palà E, Wakili R, Wegscheider K, Wieloch M, Willems S, Witt H, Ziegler A, Daniel Zink M, Kirchhof P. Early diagnosis and better rhythm management to improve outcomes in patients with atrial fibrillation: the 8th AFNET/EHRA consensus conference. Europace 2022; 25:6-27. [PMID: 35894842 PMCID: PMC9907557 DOI: 10.1093/europace/euac062] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/11/2022] [Indexed: 11/13/2022] Open
Abstract
Despite marked progress in the management of atrial fibrillation (AF), detecting AF remains difficult and AF-related complications cause unacceptable morbidity and mortality even on optimal current therapy. This document summarizes the key outcomes of the 8th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA). Eighty-three international experts met in Hamburg for 2 days in October 2021. Results of the interdisciplinary, hybrid discussions in breakout groups and the plenary based on recently published and unpublished observations are summarized in this consensus paper to support improved care for patients with AF by guiding prevention, individualized management, and research strategies. The main outcomes are (i) new evidence supports a simple, scalable, and pragmatic population-based AF screening pathway; (ii) rhythm management is evolving from therapy aimed at improving symptoms to an integrated domain in the prevention of AF-related outcomes, especially in patients with recently diagnosed AF; (iii) improved characterization of atrial cardiomyopathy may help to identify patients in need for therapy; (iv) standardized assessment of cognitive function in patients with AF could lead to improvement in patient outcomes; and (v) artificial intelligence (AI) can support all of the above aims, but requires advanced interdisciplinary knowledge and collaboration as well as a better medico-legal framework. Implementation of new evidence-based approaches to AF screening and rhythm management can improve outcomes in patients with AF. Additional benefits are possible with further efforts to identify and target atrial cardiomyopathy and cognitive impairment, which can be facilitated by AI.
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Affiliation(s)
- Renate B Schnabel
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | | | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain,IDIBAPS, Institut d'Investigació August Pi i Sunyer, Barcelona, Spain,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Polyclinic of Modena, Modena, Italy
| | - Serge Boveda
- Cardiology—Heart Rhythm Management Department, Clinique Pasteur, 45 Avenue de Lombez, 31076 Toulouse, France,Universiteit Ziekenhuis, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | | | - A John Camm
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George's University of London, London, UK
| | - Barbara Casadei
- RDM, Division of Cardiovascular Medicine, British Heart Foundation Centre of Research Excellence, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Winnie Chua
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Mirko de Melis
- Medtronic Bakken Research Center, Maastricht, The Netherlands
| | - Lien Desteghe
- Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium,Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium,Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Søren Zöga Diederichsen
- Department of Cardiology, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - David Duncker
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Lars Eckardt
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Division of Electrophysiology, Department of Cardiology and Angiology, Münster, Germany
| | | | - Daniel Engler
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Larissa Fabritz
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK,University Center of Cardiovascular Science Hamburg, Hamburg, Germany
| | - Ben Freedman
- Heart Research Institute, The University of Sydney, Sydney, Australia
| | | | - Andreas Goette
- Atrial Fibrillation Network (AFNET), Muenster, Germany,St Vincenz Hospital, Paderborn, Germany
| | - Eduard Guasch
- Arrhythmia Section, Cardiology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain,IDIBAPS, Institut d'Investigació August Pi i Sunyer, Barcelona, Spain,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Karl Georg Haeusler
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Jeff S Healey
- Population Health Research Institute, McMaster University Hamilton, ON, Canada
| | - Hein Heidbuchel
- Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium,Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
| | - Gerhard Hindricks
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | | | | | - Dipak Kotecha
- University of Birmingham & University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | | | - Thorsten Lewalter
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Hospital Munich South, Department of Cardiology, Munich, Germany,Department of Cardiology, University of Bonn, Bonn, Germany
| | - Honghuang Lin
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Dominik Linz
- Department of Cardiology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands,Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Maja Lisa Løchen
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Wim Lucassen
- Amsterdam UMC (location AMC), Department General Practice, Amsterdam, The Netherlands
| | | | - Steffen Massberg
- Department of Cardiology, University Hospital, LMU Munich, Munich, Germany,German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Jose L Merino
- Arrhythmia & Robotic EP Unit, La Paz University Hospital, IDIPAZ, Madrid, Spain
| | | | - Lluıs Mont
- Arrhythmia Section, Cardiology Department, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain,IDIBAPS, Institut d'Investigació August Pi i Sunyer, Barcelona, Spain,CIBERCV, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | | | - Lis Neubeck
- Arrhythmia & Robotic EP Unit, La Paz University Hospital, IDIPAZ, Madrid, Spain
| | - Teemu Niiranen
- Medtronic, Dublin, Ireland,Centre for Cardiovascular Health Edinburgh Napier University, Edinburgh, UK
| | - Michael Oeff
- Atrial Fibrillation Network (AFNET), Muenster, Germany
| | - Jonas Oldgren
- University of Turku and Turku University Hospital, Turku, Finland
| | | | - George Psaroudakis
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Helmut Pürerfellner
- School of Medicine, Belgrade University, Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Ursula Ravens
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Bayer AG, Leverkusen, Germany
| | - Michiel Rienstra
- Ordensklinikum Linz, Elisabethinen, Cardiological Department, Linz, Austria
| | - Lena Rivard
- Institute of Experimental Cardiovascular Medicine, University Hospital Freiburg, Freiburg, Germany
| | - Daniel Scherr
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ulrich Schotten
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Montreal Heart Institute, University of Montreal, Montreal, Canada
| | - Dipen Shah
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Moritz F Sinner
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Amsterdam UMC (location AMC), Department General Practice, Amsterdam, The Netherlands,Royal Brompton Hospital, London, UK
| | | | - Gerhard Steinbeck
- Atrial Fibrillation Network (AFNET), Muenster, Germany,MUMC+, Maastricht, The Netherlands
| | - Daniel Steven
- Atrial Fibrillation Network (AFNET), Muenster, Germany,University Hospital of Geneva, Cardiac Electrophysiology Unit, Geneva, Switzerland
| | - Emma Svennberg
- Center for Cardiology at Clinic Starnberg, Starnberg, Germany
| | - Dierk Thomas
- Atrial Fibrillation Network (AFNET), Muenster, Germany,University Hospital Cologne, Heart Center, Department of Electrophysiology, Cologne, Germany,Karolinska Institutet, Department of Medicine Huddinge, Karolinska University Hospital, Stockholm, Sweden,Department of Cardiology, Medical University Hospital, Heidelberg, Germany
| | - Mellanie True Hills
- HCR (Heidelberg Center for Heart Rhythm Disorders), Medical University Hospital Heidelberg, Heidelberg, Germany
| | - Isabelle C van Gelder
- DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Burcu Vardar
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Elena Palà
- StopAfib.org, American Foundation for Women’s Health, Decatur, TX, USA
| | - Reza Wakili
- Atrial Fibrillation Network (AFNET), Muenster, Germany,Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Karl Wegscheider
- Atrial Fibrillation Network (AFNET), Muenster, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany,Neurovascular Research Laboratory, Vall d’Hebron Institute of Research (VHIR), Autonomous University of Barcelona, Barcelona, Spain
| | - Mattias Wieloch
- Department of Cardiology and Vascular Medicine, Westgerman Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany,Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Stephan Willems
- Atrial Fibrillation Network (AFNET), Muenster, Germany,German Centre for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany,Department of Coagulation Disorders, Skane University Hospital, Lund University, Malmö, Sweden
| | | | | | - Matthias Daniel Zink
- Asklepios Hospital St Georg, Department of Cardiology and Internal Intensive Care Medicine, Faculty of Medicine, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Paulus Kirchhof
- Corresponding author. Tel: +49 40 7410 52438; Fax: +49 40 7410 55862. E-mail address:
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Woo JS, Woo Y, Jang JY, Ha SJ. Effect of vitamin D on endothelial and ventricular function in chronic heart failure patients: A prospective, randomized, placebo-controlled trial. Medicine (Baltimore) 2022; 101:e29623. [PMID: 35866799 PMCID: PMC9302363 DOI: 10.1097/md.0000000000029623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Low 25-hydroxyvitamin D (25OHD) levels are common in patients with chronic heart failure (HF) and are associated with increased mortality risk. This study aimed to establish the safety and efficacy of oral vitamin D3 (cholecalciferol) supplementation and its effect on endothelial and ventricular function in patients with stable HF. METHODS This study was an investigator-initiated, multicenter, prospective, randomized, placebo-controlled trial. Seventy-three HF patients with 25OHD levels < 75 nmol/L (30 ng/mL) were randomized to receive 4000 IU vitamin D daily or a placebo for 6 months. The primary endpoint was a change in endothelial function between the baseline and after 6 months as assessed using EndoPAT. Secondary endpoints included changes in echocardiographic parameters and differences in quality of life (6-min walking test and New York Heart Association functional status) at 6 months. RESULTS There were no adverse events in either group during the study period. Vitamin D supplementation did not improve endothelial dysfunction (EndoPAT: baseline, 1.19 ± 0.4 vs 6 months later, 1.22 ± 0.3, P = .65). However, patients' blood pressure, 6-min walking distance, and EQ-5D questionnaire scores improved after vitamin D treatment. In addition, a significant reduction in the left atrial diameter was observed. CONCLUSION A daily vitamin D dose of 4000 IU for chronic HF appears to be safe. This dosage did not improve endothelial function but did improve the 6-min walk distance, symptoms, and left atrial diameter at 6 months.
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Affiliation(s)
- Jong Shin Woo
- Division of Cardiology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University, Seoul, Republic of Korea
| | - Yeongmin Woo
- Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
| | - Jeong Yoon Jang
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Sang Jin Ha
- Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
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7
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Peters DC, Lamy J, Sinusas AJ, Baldassarre LA. Left atrial evaluation by cardiovascular magnetic resonance: sensitive and unique biomarkers. Eur Heart J Cardiovasc Imaging 2021; 23:14-30. [PMID: 34718484 DOI: 10.1093/ehjci/jeab221] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/12/2021] [Indexed: 12/12/2022] Open
Abstract
Left atrial (LA) imaging is still not routinely used for diagnosis and risk stratification, although recent studies have emphasized its importance as an imaging biomarker. Cardiovascular magnetic resonance is able to evaluate LA structure and function, metrics that serve as early indicators of disease, and provide prognostic information, e.g. regarding diastolic dysfunction, and atrial fibrillation (AF). MR angiography defines atrial anatomy, useful for planning ablation procedures, and also for characterizing atrial shapes and sizes that might predict cardiovascular events, e.g. stroke. Long-axis cine images can be evaluated to define minimum, maximum, and pre-atrial contraction LA volumes, and ejection fractions (EFs). More modern feature tracking of these cine images provides longitudinal LA strain through the cardiac cycle, and strain rates. Strain may be a more sensitive marker than EF and can predict post-operative AF, AF recurrence after ablation, outcomes in hypertrophic cardiomyopathy, stratification of diastolic dysfunction, and strain correlates with atrial fibrosis. Using high-resolution late gadolinium enhancement (LGE), the extent of fibrosis in the LA can be estimated and post-ablation scar can be evaluated. The LA LGE method is widely available, its reproducibility is good, and validations with voltage-mapping exist, although further scan-rescan studies are needed, and consensus regarding atrial segmentation is lacking. Using LGE, scar patterns after ablation in AF subjects can be reproducibly defined. Evaluation of 'pre-existent' atrial fibrosis may have roles in predicting AF recurrence after ablation, predicting new-onset AF and diastolic dysfunction in patients without AF. LA imaging biomarkers are ready to enter into diagnostic clinical practice.
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Affiliation(s)
- Dana C Peters
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Jérôme Lamy
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Albert J Sinusas
- Department of Cardiology, Yale School of Medicine, New Haven, CT, USA
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8
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Dudzińska-Szczerba K, Zalewska M, Niemiro W, Michałowska I, Piotrowski R, Sikorska A, Kułakowski P, Baran J. Association of Left Atrial Sphericity with Risk of Stroke in Patients with Atrial Fibrillation. Sub-Analysis of the ASSAM Study. Cardiovasc Eng Technol 2021; 13:419-427. [PMID: 34750781 PMCID: PMC9197816 DOI: 10.1007/s13239-021-00587-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 10/19/2021] [Indexed: 11/28/2022]
Abstract
Purpose The study was designed to evaluate the value of left atrial (LA) sphericity (LASP) in the identification of patients with atrial fibrillation (AF) who had prior ischemic stroke. The secondary aim was to investigate the possibility of improving stroke risk assessment based on six geometrical variables of LA. Methods This prospective observational study involved 157 patients: 74 in the stroke group and 83 in the control. All patients had cardiac computed tomography (CT) performed to analyze LA volume and dimensions. LASP and the discriminant function of six geometrical measurements were calculated. Results Multivariate logistic regression analysis showed a significant association of stroke with and gender, diabetes, CHA2DS2-VASc score, LA anteroposterior diameter, and LA sphericity. Patients with prior stroke had lower LASP than those without (66.6 ± 10.3% vs. 70.5 ± 7%; p = 0.0062). The most accurate identification of patients with a history of ischemic stroke was achieved by using a function of six geometrical measurements, the sphericity and volume coefficient. The C-statistic was higher for the above discriminant function (0.7273) than for LASP (0.3974). The addition of the discriminant function to the CHA2DS2-VASc score increased the performance of the risk score alone. Conclusion LASP is associated with prior stroke in AF patients. The proposed new formula for identification of AF patients who are at risk of stroke, based on geometrical measurements of LA, is superior to the basic LASP in identification of AF patients with a history of stroke. Supplementary Information The online version contains supplementary material available at 10.1007/s13239-021-00587-y.
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Affiliation(s)
| | - Marta Zalewska
- Department of Environmental Hazards Prevention and Allergology, Medical University of Warsaw, Warsaw, Poland
| | - Wojciech Niemiro
- Faculty of Mathematics, Informatics and Mechanics, University of Warsaw, Warsaw, Poland
| | | | - Roman Piotrowski
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Grenadierów Street 51/59, 04-073 Warsaw, Poland
| | - Agnieszka Sikorska
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Grenadierów Street 51/59, 04-073 Warsaw, Poland
| | - Piotr Kułakowski
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Grenadierów Street 51/59, 04-073 Warsaw, Poland
| | - Jakub Baran
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Grenadierów Street 51/59, 04-073 Warsaw, Poland
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9
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Bhat A, Mahajan V, Chen HHL, Gan GCH, Pontes-Neto OM, Tan TC. Embolic Stroke of Undetermined Source: Approaches in Risk Stratification for Cardioembolism. Stroke 2021; 52:e820-e836. [PMID: 34706562 DOI: 10.1161/strokeaha.121.034498] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Ischemic stroke is a leading cause of morbidity and mortality worldwide. Embolic stroke of undetermined source has been recently proposed to categorize nonlacunar ischemic strokes without confirmed etiology after adequate investigation with a likely embolic stroke mechanism. A strategy of empirical anticoagulation for embolic stroke of undetermined source patients is attractive but may only be beneficial in a select subset of patients. Strategies which would help identify the subset of embolic stroke of undetermined source patients most likely to have cardioembolic origin of stroke, and hence benefit from anticoagulation, are needed. This article will review current evidence which may be useful in the development of a risk stratification approach based on arrhythmia monitoring, cardiac imaging, and clinical risk stratification. This approach may be beneficial in clinical practice in improving patient outcomes and reducing stroke recurrence in this population; however, further work is required with active trials underway.
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Affiliation(s)
- Aditya Bhat
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Public Health and Community Medicine (A.B., T.C.T.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
| | - Vipul Mahajan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.)
| | - Henry H L Chen
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.)
| | - Gary C H Gan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Medicine (G.C.H.G.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
| | - Octavio M Pontes-Neto
- Stroke Service, Neurology Division, Department of Neuroscience and Behavior, Ribeirão Preto Medical School, University of São Paulo, Brazil (O.M.P.-N.)
| | - Timothy C Tan
- Department of Cardiology, Blacktown Hospital, Sydney, Australia (A.B., V.M., H.H.L.C., G.C.H.G., T.C.T.).,School of Public Health and Community Medicine (A.B., T.C.T.), University of New South Wales, Sydney, Australia.,School of Medicine, Western Sydney University, Australia (A.B., G.C.H.G., T.C.T.)
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10
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Lim J, Yu CJ, Yu H, Ha SJ. Erythropoietin therapy improves endothelial function in patients with non-dialysis chronic kidney disease and anemia (EARNEST-CKD): A clinical study. Medicine (Baltimore) 2021; 100:e27601. [PMID: 34678911 PMCID: PMC8542142 DOI: 10.1097/md.0000000000027601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 10/01/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND This study investigated whether administering erythropoiesis-stimulating agents (ESAs) improves endothelial function in patients with non-dialysis chronic kidney disease (CKD) and anemia. METHODS This single-center, prospective, single-arm comparison study enrolled patients with non-dialysis CKD (stages 4-5) and hemoglobin levels <10 g/dL. ESA administration followed the Kidney Disease: Improving Global Outcomes guideline. The primary endpoint was the change in flow-mediated dilatation after ESA administration in individual patients. The secondary endpoints were changes in 6-minute walk test results, blood pressure, New York Heart Association class, and echocardiographic parameters. The echocardiographic parameters examined included chamber quantification, Doppler parameters, and systolic and diastolic function parameters. RESULTS Initially, 13 patients were screened, but 2 discontinued due to either heart failure or voluntary withdrawal. The mean flow-mediated dilatation values significantly increased by 10.59% (from 1.36% ± 1.91% to 11.95% ± 8.11%, P = .001). Echocardiographic findings showed that the left ventricular mass index decreased by 11.9 g/m2 (from 105.8 ± 16.3 to 93.9 ± 19.5 g/m2, P = .006), and the left atrial volume index decreased by 10.8 mL/m2 (from 50.1 ± 11.3 to 39.3 ± 11.3 mL/m2, P = .004) after 12 weeks of ESA administration. There were no significant differences between pre- and post-ESA treatment 6-minute walk test results. No significant side effects were observed during the study period. CONCLUSIONS This is the first clinical study to demonstrate that an ESA improves endothelial dysfunction, left ventricular hypertrophy, and left atrial volume in patients with non-dialysis CKD. Thus, ESAs may be considered as adjunctive therapy for reducing cardiovascular risk in these patients.
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Affiliation(s)
- Jina Lim
- Department of Internal Medicine-Nephrology, GangNeung Asan Hospital, GangNeung, Republic of Korea
| | - Chung Jo Yu
- Department of Internal Medicine-Cardiology, GangNeung Asan Hospital, GangNeung, Republic of Korea
| | - Hoon Yu
- Department of Internal Medicine-Nephrology, GangNeung Asan Hospital, GangNeung, Republic of Korea
| | - Sang Jin Ha
- Department of Internal Medicine-Cardiology, GangNeung Asan Hospital, GangNeung, Republic of Korea
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11
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Nedios S, Lindemann F, Heijman J, Crijns HJGM, Bollmann A, Hindricks G. Atrial remodeling and atrial fibrillation recurrence after catheter ablation : Past, present, and future developments. Herz 2021; 46:312-317. [PMID: 34223914 DOI: 10.1007/s00059-021-05050-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 12/30/2022]
Abstract
The term "atrial remodeling" is used to describe the electrical, mechanical, and structural changes associated with the presence of an arrhythmogenic substrate for atrial fibrillation. Rhythm control therapy may slow down or even reverse progressive atrial remodeling. Atrial remodeling has long been recognized as an important predictor of clinical outcomes and therapeutic success, but recent advances have highlighted its clinical relevance and revealed the implications of specific anatomical changes such as atrial asymmetry or shape. This has opened the path to computational precision medicine that captures these data in detail and combines them with other factors, to provide patient-specific solutions. The goal of precision medicine lies in improving clinical outcomes, reducing costs, and avoiding unnecessary procedures. In this article, we review the history of atrial remodeling and we summarize the insights from our research on anatomical atrial remodeling and its association with rhythm outcomes after catheter ablation. Finally, we present recent advances in the field, reflecting the beginning of a new technological era that will enable us to improve patient care by personalized patient-specific medicine.
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Affiliation(s)
- Sotirios Nedios
- Department of Electrophysiology, Heart Center at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany.
| | - Frank Lindemann
- Department of Electrophysiology, Heart Center at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany
| | - Jordi Heijman
- Department of Cardiology, CardiovascularResearch Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, CardiovascularResearch Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Andreas Bollmann
- Department of Electrophysiology, Heart Center at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center at University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany
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12
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Characteristics of left atrial remodeling in patients with atrial fibrillation and hypertrophic cardiomyopathy in comparison to patients without hypertrophy. Sci Rep 2021; 11:12411. [PMID: 34127728 PMCID: PMC8203718 DOI: 10.1038/s41598-021-91892-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 06/01/2021] [Indexed: 01/15/2023] Open
Abstract
Atrial fibrillation (AF) leads to remodeling characterized by changes in both size and shape of the left atrium (LA). Here we aimed to study the effect of hypertrophic cardiomyopathy (HCM) on the pattern of LA remodeling in AF-patients. HCM-patients (n = 23) undergoing AF ablation (2009–2012) were matched and compared with 125 Non-HCM patients from our prospective registry. Pre-procedural CT data were analyzed (EnSite Verismo, SJM, MN) to determine the maximal sagittal (anterior–posterior, AP), coronal (superior-inferior, SI and transversal, TV) dimensions and the sphericity index (LAS). Volume (LAV) was rendered after appendage (LAA) and pulmonary vein (PV) exclusion. A cutting plane, between PV ostia/LAA and parallel to the posterior wall, divided LAV into anterior- (LAA) and posterior-LA (LAP) parts. The ratio LA-A/LAV was defined as asymmetry index (ASI). HCM patients had a wider inter-ventricular septum and a smaller LV than Non-HCM patients. LA volume (LAV 166 ± 72 vs. 130 ± 36 ml, p = 0.03) and LA diameters were significantly larger in HCM patients. Anterior volume (LA-A: 112 ± 48 vs. 83 ± 26 ml, p < 0.001) differed significantly between groups, whereas the posterior volume LA-P (55 ± 28 vs. 47 ± 13 ml, p = 0.23) and LAS (75% vs. 78%, p = 0.089) was similar in both groups. As a result, ASI was significantly higher (67 ± 6 vs. 63 ± 6%, p = 0.01) in HCM than in Non-HCM patients. In conclusion, LA remodeling in patients with AF and HCM is characterized by asymmetric dilatation, driven by an anterior rather than a posterior dilatation. This can be characterized by three-dimensional imaging and could be used as surrogate of advanced atrial remodeling.
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13
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Statistical shape analysis of the left atrial appendage predicts stroke in atrial fibrillation. Int J Cardiovasc Imaging 2021; 37:2521-2527. [PMID: 33956285 DOI: 10.1007/s10554-021-02262-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/27/2021] [Indexed: 10/21/2022]
Abstract
The shape of the left atrium (LA) and left atrial appendage (LAA) have been shown to predict stroke in patients with atrial fibrillation (AF). Prior studies rely on qualitative assessment of shape, which limits reproducibility and clinical utility. Statistical shape analysis (SSA) allows for quantitative assessment of shape. We use this method to assess the shape of the LA and LAA and predict stroke in patients with AF. From a database of AF patients who had previously undergone MRI of the LA, we identified 43 patients with AF who subsequently had an ischemic stroke. We also identified a cohort of 201 controls with AF who did not have a stroke after the MRI. We performed SSA of the LA and LAA shape to quantify the shape of these structures. We found three of the candidate LAA shape parameters to be predictive of stroke, while none of the LA shape parameters predicted stroke. When the three predictive LAA shape parameters were added to a logistic regression model that included the CHA2DS2-VASc score, the area under the ROC curve increased from 0.640 to 0.778 (p = .003). The shape of the LA and LAA can be assessed quantitatively using SSA. LAA shape predicts stroke in AF patients, while LA shape does not. Additionally, LAA shape predicts stroke independent of CHA2DS2-VASc score. SSA for assessment of LAA shape may improve stroke risk stratification and clinical decision making for AF patients.
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14
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Nedios S, Sanatkhani S, Oladosu M, Seewöster T, Richter S, Arya A, Heijman J, J G M Crijns H, Hindricks G, Bollmann A, Menon PG. Association of low-voltage areas with the regional wall deformation and the left atrial shape in patients with atrial fibrillation: A proof of concept study. IJC HEART & VASCULATURE 2021; 33:100730. [PMID: 33718586 PMCID: PMC7933256 DOI: 10.1016/j.ijcha.2021.100730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/03/2021] [Accepted: 01/30/2021] [Indexed: 11/30/2022]
Abstract
Background Left atrium (LA) remodeling is associated with atrial fibrillation (AF) and reduced success after AF ablation, but its relation with low-voltage areas (LVA) is not known. This study aimed to evaluate the relation between regional LA changes and LVAs in AF patients. Methods Pre-interventional CT data of patients (n = 24) with LA-LVA (<0.5 mV) in voltage mapping after AF ablation were analyzed (Surgery Explorer, QuantMD LLC). To quantify asymmetry (ASI = LA-A/LAV) a cutting plane parallel to the rear wall and along the pulmonary veins divided the LA-volume (LAV) into anterior (LA-A) and posterior parts. To quantify sphericity (LAS = 1-R/S), a patient-specific best-fit LA sphere was created. The average radius (R) and the mean deviation (S) from this sphere were calculated. The average local deviation (D) was measured for the roof, posterior, septum, inferior septum, inferior-posterior and lateral walls. Results The roof, posterior and septal regions had negative local deviations. There was a correlation between roof and septum (r = 0.42, p = 0.04), lateral and inferior-posterior (r = 0.48, p = 0.02) as well as posterior and inferior-septal deviations (r = −0.41, p = 0.046). ASI correlated with septum deformation (r = −0.43, p = 0.04). LAS correlated with dilatation (LAV, r = 0.49, p = 0.02), roof (r = 0.52, p = 0.009) and posterior deformation (r = −0.56, p = 0.005). Extended LVA correlated with local deformation of all LA walls, except the roof and the septum. LVA association with LAV, ASI and LAS did not reach statistical significance. Conclusion Extended LVA correlates with local wall deformations better than other remodeling surrogates. Therefore, their calculation could help predict LVA presence and deserve further evaluation in clinical studies.
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Key Words
- AF, atrial fibrillation
- AR, average radius
- ASI, asymmetry index
- Atrial fibrillation
- Atrial remodeling
- CA, catheter ablation
- CT, computed tomography
- Computer tomography
- IQR, inter-quartile range
- LA, left atrium
- LA-A, left atrial anterior (LA-A) partial volume
- LA-P, left atrial posterior (LA-P) partial volume
- LAA, left atrial appendage
- LAV, left atrial volume with anterior (LA-A) and posterior (LA-P) partial volumes
- LV, left ventricle
- LV-EF, left ventricular ejection fraction
- LVA, low-voltage area
- LVDD, left ventricular diastolic dysfunction
- MRI, magnetic resonance imaging
- PVI, pulmonary vein isolation
- S, mean deviation
- SD, standard deviation
- Sphericity
- Voltage mapping
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Affiliation(s)
- Sotirios Nedios
- Heart Center, University of Leipzig, Germany.,Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, MA, USA.,Department of Cardiology and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands
| | | | | | | | | | - Arash Arya
- Heart Center, University of Leipzig, Germany
| | - Jordi Heijman
- Department of Cardiology and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands
| | - Harry J G M Crijns
- Department of Cardiology and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands
| | | | | | - Prahlad G Menon
- University of Pittsburgh, Pittsburgh, PA, USA.,Duquesne University, Pittsburgh, PA, USA.,QuantMD LLC, Pittsburgh, PA, USA
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15
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Abstract
AF is the most common arrhythmia in clinical practice. In addition to the severe effect on quality of life, patients with AF are at higher risk of stroke and mortality. Recent studies have suggested that atrial and ventricular substrate play a major role in the development and maintenance of AF. Cardiac MRI has emerged as a viable tool for interrogating the underlying substrate in AF patients. Its advantage includes localisation and quantification of structural remodelling. Cardiac MRI of the atrial substrate is not only a tool for management and treatment of arrhythmia, but also to individualise the prevention of stroke and major cardiovascular events. This article provides an overview of atrial imaging using cardiac MRI and its clinical implications in the AF population.
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Affiliation(s)
- Yan Zhao
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), Heart and Vascular Institute, Tulane University School of Medicine, LA, US
| | - Lilas Dagher
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), Heart and Vascular Institute, Tulane University School of Medicine, LA, US
| | - Chao Huang
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), Heart and Vascular Institute, Tulane University School of Medicine, LA, US
| | - Peter Miller
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), Heart and Vascular Institute, Tulane University School of Medicine, LA, US
| | - Nassir F Marrouche
- Tulane Research Innovation for Arrhythmia Discoveries (TRIAD), Heart and Vascular Institute, Tulane University School of Medicine, LA, US
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16
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Yazaki M, Nabeta T, Inomata T, Maemura K, Oki T, Fujita T, Ikeda Y, Ishii S, Naruke T, Inoue Y, Ako J. Clinical significance of left atrial geometry in dilated cardiomyopathy patients: A cardiovascular magnetic resonance study. Clin Cardiol 2020; 44:222-229. [PMID: 33295044 PMCID: PMC7852162 DOI: 10.1002/clc.23529] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/21/2020] [Accepted: 12/02/2020] [Indexed: 12/26/2022] Open
Abstract
Background Clinical significance of left atrial (LA) function and geometry in patients with dilated cardiomyopathy (DCM) remains uncertain. Hypothesis LA geometric parameters assessed by cardiac magnetic resonance (CMR) predict the prognosis in patients with DCM. Methods The present study included patients with DCM and sinus rhythm who underwent CMR between December 2007 and April 2018. LA volume was measured using CMR. LA sphericity index was computed as the ratio of the measured maximum LA volume by the volume of a sphere with maximum LA length diameter. Results We included 255 patients in this study. During the mean follow‐up of 3.92 years, hospitalization for HF occurred in 37 patients. The LA sphericity index was significantly higher in patients with hospitalization for HF than in those without (0.78 ± 0.35 vs. 0.58 ± 0.18, p < .001). Multivariable Cox regression analysis identified a higher LA sphericity index as an independent predictor of hospitalization for HF. Patients were categorized based on the median of LA sphericity index. The Kaplan–Meier curve showed that patients with a high LA sphericity index (≥0.57) had a significantly higher risk of hospitalization for HF than those with a low LA sphericity index (<0.57). Conclusion LA sphericity index was an independent predictor of hospitalization for HF. Assessment of LA geometric parameters might be useful for risk stratification in patients with DCM.
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Affiliation(s)
- Mayu Yazaki
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Takeru Nabeta
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Kenji Maemura
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Takumi Oki
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Teppei Fujita
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Yuki Ikeda
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Shunsuke Ishii
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Takashi Naruke
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Yusuke Inoue
- Department of Diagnostic Radiology, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
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17
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Ghannam M, Yun HJ, Ficaro EP, Ghanbari H, Lazarus JJ, Konerman M, Shah RV, Weinberg R, Corbett JR, Oral H, Murthy VL. Multiparametric assessment of left atrial remodeling using 18F-FDG PET/CT cardiac imaging: A pilot study. J Nucl Cardiol 2020; 27:1547-1562. [PMID: 30191438 PMCID: PMC6411463 DOI: 10.1007/s12350-018-1429-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 08/08/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Left atrial (LA) remodeling is associated with structural, electric, and metabolic LA changes. Integrated evaluation of these features in vivo is lacking. METHODS Patients undergoing 18F-fluorodeoxyglucose (FDG) PET-CT during a hyperinsulinemic-euglycemic clamp were classified into sinus rhythm (SR), paroxysmal AF (PAF), and persistent AF (PerAF). The LA was semiautomatically segmented, and global FDG uptake was quantified using standardized uptake values (SUVmax and SUVmean) in gated, attenuation-corrected images and normalized to LA blood pool activity. Regression was used to relate FDG data to AF burden and critical patient factors. Continuous variables were compared using t-tests or Mann-Whitney tests. RESULTS 117 patients were included (76% men, age 66.4 ± 11.0, ejection fraction (EF) 25[22-35]%) including those with SR (n = 48), PAF (n = 55), and PerAF (n = 14). Patients with any AF had increased SUVmean (2.3[1.5-2.4] vs 2.0[1.5-2.5], P = 0.006), SUVmax (4.4[2.8-6.7] vs 3.2[2.3-4.3], P < 0.001), uptake coefficient of variation (CoV) 0.28[0.22-0.40] vs 0.25[0.2-0.33], P < 0.001), and hypometabolic scar (32%[14%-53%] vs 16.5%[0%-38.5%], P = 0.01). AF burden correlated with increased SUVmean, SUVmax, CoV, and scar independent of age, gender, EF, or LA size (P < 0.03 for all). CONCLUSIONS LA structure and metabolism can be assessed using FDG PET/CT. Greater AF burden correlates with the increased LA metabolism and scar.
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Affiliation(s)
- Michael Ghannam
- Department of Medicine (Division of Cardiovascular Medicine), University of Michigan, 1500 E. Medical Center Dr. SPC 5873, Ann Arbor, MI, 48109, USA
| | - Hong Jun Yun
- Department of Medicine (Division of Cardiovascular Medicine), University of Michigan, 1500 E. Medical Center Dr. SPC 5873, Ann Arbor, MI, 48109, USA
| | - Edward P Ficaro
- INVIA Medical Imaging Solutions, Ann Arbor, MI, USA
- Division of Nuclear Medicine, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Hamid Ghanbari
- Department of Medicine (Division of Cardiovascular Medicine), University of Michigan, 1500 E. Medical Center Dr. SPC 5873, Ann Arbor, MI, 48109, USA
| | - John J Lazarus
- Department of Medicine (Division of Cardiovascular Medicine), University of Michigan, 1500 E. Medical Center Dr. SPC 5873, Ann Arbor, MI, 48109, USA
| | - Matthew Konerman
- Department of Medicine (Division of Cardiovascular Medicine), University of Michigan, 1500 E. Medical Center Dr. SPC 5873, Ann Arbor, MI, 48109, USA
| | - Ravi V Shah
- Department of Medicine (Division of Cardiovascular Medicine), Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard Weinberg
- Department of Medicine (Division of Cardiovascular Medicine), University of Michigan, 1500 E. Medical Center Dr. SPC 5873, Ann Arbor, MI, 48109, USA
| | - James R Corbett
- Department of Medicine (Division of Cardiovascular Medicine), University of Michigan, 1500 E. Medical Center Dr. SPC 5873, Ann Arbor, MI, 48109, USA
- INVIA Medical Imaging Solutions, Ann Arbor, MI, USA
- Division of Nuclear Medicine, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Hakan Oral
- Department of Medicine (Division of Cardiovascular Medicine), University of Michigan, 1500 E. Medical Center Dr. SPC 5873, Ann Arbor, MI, 48109, USA
| | - Venkatesh L Murthy
- Department of Medicine (Division of Cardiovascular Medicine), University of Michigan, 1500 E. Medical Center Dr. SPC 5873, Ann Arbor, MI, 48109, USA.
- Division of Nuclear Medicine, Department of Radiology, University of Michigan, Ann Arbor, MI, USA.
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18
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Packer M. Characterization, Pathogenesis, and Clinical Implications of Inflammation-Related Atrial Myopathy as an Important Cause of Atrial Fibrillation. J Am Heart Assoc 2020; 9:e015343. [PMID: 32242478 PMCID: PMC7428644 DOI: 10.1161/jaha.119.015343] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Historically, atrial fibrillation has been observed in clinical settings of prolonged hemodynamic stress, eg, hypertension and valvular heart disease. However, recently, the most prominent precedents to atrial fibrillation are metabolic diseases that are associated with adipose tissue inflammation (ie, obesity and diabetes mellitus) and systemic inflammatory disorders (ie, rheumatoid arthritis and psoriasis). These patients typically have little evidence of left ventricular hypertrophy or dilatation; instead, imaging reveals abnormalities of the structure or function of the atria, particularly the left atrium, indicative of an atrial myopathy. The left atrium is enlarged, fibrotic and noncompliant, potentially because the predisposing disorder leads to an expansion of epicardial adipose tissue, which transmits proinflammatory mediators to the underlying left atrium. The development of an atrial myopathy not only leads to atrial fibrillation, but also contributes to pulmonary venous hypertension and systemic thromboembolism. These mechanisms explain why disorders of systemic or adipose tissue inflammation are accompanied an increased risk of atrial fibrillation, abnormalities of left atrium geometry and an enhanced risk of stroke. The risk of stroke exceeds that predicted by conventional cardiovascular risk factors or thromboembolism risk scores used to guide the use of anticoagulation, but it is strongly linked to clinical evidence and biomarkers of systemic inflammation.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute Baylor University Medical Center Dallas TX.,Imperial College London United Kingdom
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19
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Mulder MJ, Kemme MJB, Visser CL, Hopman LHGA, van Diemen PA, van de Ven PM, Götte MJW, Danad I, Knaapen P, van Rossum AC, Allaart CP. Left atrial sphericity as a marker of atrial remodeling: Comparison of atrial fibrillation patients and controls. Int J Cardiol 2020; 304:69-74. [PMID: 32005449 DOI: 10.1016/j.ijcard.2020.01.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 01/07/2020] [Accepted: 01/20/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Left atrial (LA) sphericity has been proposed as a more sensitive marker of atrial fibrillation (AF)-associated atrial remodeling compared to traditional markers such as LA size. However, mechanisms that underlie changes in LA sphericity are not fully understood and studies investigating the predictive value of LA sphericity for AF ablation outcome have yielded conflicting results. The present study aimed to assess correlates of LA sphericity and to compare LA sphericity in subjects with and without AF. METHODS Measures of LA size (LA diameter, LA volume, LA volume index), LA sphericity and thoracic anteroposterior diameter (APd) at the level of the LA were determined using computed tomography (CT) imaging data in 293 AF patients (62% paroxysmal AF) and 110 controls. RESULTS LA diameter (40.1 ± 6.8 mm vs. 35.2 ± 5.1 mm; p < 0.001), LA volume (116.0 ± 33.0 ml vs. 80.3 ± 22.6 ml; p < 0.001) and LA volume index (56.1 ± 15.3 ml/m2 vs. 41.6 ± 11.1 ml/m2; p < 0.001) were significantly larger in AF patients compared to controls, also after adjustment for covariates. LA sphericity did not differ between AF patients and controls (83.7 ± 2.9 vs. 83.9 ± 2.4; p = 0.642). Multivariable linear regression analysis demonstrated that LA diameter, LA volume, female sex, body length and thoracic APd were independently associated with LA sphericity. CONCLUSIONS The present study suggests that thoracic constraints rather than the presence of AF determine LA sphericity, implying LA sphericity to be unsuitable as a marker of AF-related atrial remodeling.
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Affiliation(s)
- Mark J Mulder
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Michiel J B Kemme
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Charlotte L Visser
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Luuk H G A Hopman
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Pepijn A van Diemen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Peter M van de Ven
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Marco J W Götte
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Ibrahim Danad
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Albert C van Rossum
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Cornelis P Allaart
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands.
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20
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Tan TC, Nunes MCP, Handschumacher M, Pontes-Neto O, Park YH, O'Brien C, Piro V, Kim GM, Helenius J, Zeng X, Padilha da Silva JL, Furie K, Ay H, Hung J. Left atrial cross-sectional area is a novel measure of atrial shape associated with cardioembolic strokes. Heart 2020; 106:1176-1182. [PMID: 31980438 DOI: 10.1136/heartjnl-2019-315964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 12/23/2019] [Accepted: 01/02/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Cardioembolic (CE) stroke carries significant morbidity and mortality. Left atrial (LA) size has been associated with CE risk. We hypothesised that differential LA remodelling impacts on pathophysiological mechanism of major CE strokes. METHODS A cohort of consecutive patients hospitalised with ischaemic stroke, classified into CE versus non-CE strokes using the Causative Classification System for Ischaemic Stroke were enrolled. LA shape and remodelling was characterised by assessing differences in maximal LA cross-sectional area (LA-CSA) in a cohort of 40 prospectively recruited patients with ischaemic stroke using three-dimensional (3D) echocardiography. Flow velocity profiles were measured in spherical versus ellipsoidal in vitro models to determine if LA shape influences flow dynamics. Two-dimensional (2D) LA-CSA was subsequently derived from standard echocardiographic views and compared with 3D LA-CSA. RESULTS A total of 1023 patients with ischaemic stroke were included, 230 (22.5%) of them were classified as major CE. The mean age was 68±16 years, and 464 (45%) were women. The 2D calculated LA-CSA correlated strongly with the LA-CSA measured by 3D in both end-systole and end-diastole. In vitro flow models showed shape-related differences in mid-level flow velocity profiles. Increased LA-CSA was associated with major CE stroke (adjusted relative risk 1.10, 95% CI 1.04 to 1.16; p<0.001), independent of age, gender, atrial fibrillation, left ventricular ejection fraction and CHA2DS2-VASc score. Specifically, the inclusion of LA-CSA in a model with traditional risk factors for CE stroke resulted in significant improvement in model performance with the net reclassification improvement of 0.346 (95% CI 0.189 to 0.501; p=0.00001) and the integrated discrimination improvement of 0.013 (95% CI 0.003 to 0.024; p=0.0119). CONCLUSIONS LA-CSA is a marker of adverse LA shape associated with CE stroke, reflecting importance of differential LA remodelling, not simply LA size, in the mechanism of CE risk.
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Affiliation(s)
- Timothy C Tan
- Cardiology, Blacktown Hospital, Blacktown, New South Wales, Australia.,Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria Carmo Pereira Nunes
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Internal Medicine, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Mark Handschumacher
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Octavio Pontes-Neto
- University of São Paulo Department of Neurosciences and Behaviour Sciences, Ribeirao Preto, São Paulo, Brazil.,Neurology and Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yong-Hyun Park
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Cardiovascular Center, Pusan National University, Yangsan Hospital, Yangsan, Republic of Korea
| | - Cashel O'Brien
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Victoria Piro
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Unidad de Imagen Cardiaca, Hospital Universitario San Roque, Las Palmas, España
| | - Gyeong-Moon Kim
- Neurology and Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Cardiovascular Center, Pusan National University, Yangsan Hospital, Yangsan, Republic of Korea
| | - Johanna Helenius
- Neurology and Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Lahey Hospital and Medical Center Burlington, Burlington, Massachusetts, USA
| | - Xin Zeng
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Karen Furie
- Brown University Division of Biology and Medicine, Providence, Rhode Island, USA
| | - Hakan Ay
- Neurology and Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Judy Hung
- Cardiac Ultrasound Lab, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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21
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Atrial Failure as a Clinical Entity. J Am Coll Cardiol 2020; 75:222-232. [DOI: 10.1016/j.jacc.2019.11.013] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 10/09/2019] [Accepted: 11/05/2019] [Indexed: 12/16/2022]
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22
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Embolic Stroke of Undetermined Source: A Population with Left Atrial Dysfunction. J Stroke Cerebrovasc Dis 2019; 28:1891-1896. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/04/2019] [Accepted: 04/04/2019] [Indexed: 11/21/2022] Open
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23
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Herm J, Schurig J, Martinek MR, Höltgen R, Schirdewan A, Kirchhof P, Wieczorek M, Pürerfellner H, Heuschmann PU, Fiebach JB, Haeusler KG. MRI-detected brain lesions in AF patients without further stroke risk factors undergoing ablation - a retrospective analysis of prospective studies. BMC Cardiovasc Disord 2019; 19:58. [PMID: 30871479 PMCID: PMC6419420 DOI: 10.1186/s12872-019-1035-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 02/27/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) without other stroke risk factors is assumed to have a low annual stroke risk comparable to patients without AF. Therefore, current clinical guidelines do not recommend oral anticoagulation for stroke prevention of AF in patients without stroke risk factors. We analyzed brain magnetic resonance imaging (MRI) imaging to estimate the rate of clinically inapparent ("silent") ischemic brain lesions in these patients. METHODS We pooled individual patient-level data from three prospective studies comprising stroke-free patients with symptomatic AF. All study patients underwent brain MRI within 24-48 h before planned left atrial catheter ablation. MRIs were analyzed by a neuroradiologist blinded to clinical data. RESULTS In total, 175 patients (median age 60 (IQR 54-67) years, 32% female, median CHA2DS2-VASc = 1 (IQR 0-2), 33% persistent AF) were included. In AF patients without or with at least one stroke risk factor, at least one silent ischemic brain lesion was observed in 4 (8%) out of 48 and 10 (8%) out of 127 patients, respectively (p > 0.99). Presence of silent ischemic brain lesions was related to age (p = 0.03) but not to AF pattern (p = 0.77). At least one cerebral microbleed was detected in 5 (13%) out of 30 AF patients without stroke risk factors and 25 (25%) out of 108 AF patients with stroke risk factors (p = 0.2). Presence of cerebral microbleeds was related to male sex (p = 0.04) or peripheral artery occlusive disease (p = 0.03). CONCLUSION In patients with symptomatic AF scheduled for ablation, brain MRI detected silent ischemic brain lesions in approximately one in 12 patients, and microbleeds in one in 5 patients. The prevalence of silent ischemic brain lesions did not differ in AF patients with or without further stroke risk factors.
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Affiliation(s)
- Juliane Herm
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Johannes Schurig
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Martin R Martinek
- Department of Cardiology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Reinhard Höltgen
- Department of Cardiology and Electrophysiology, St. Agnes-Hospital Bocholt, Bocholt, Germany
| | | | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Marcus Wieczorek
- Department of Cardiology and Electrophysiology, St. Agnes-Hospital Bocholt, Bocholt, Germany.,Witten/Herdecke University, School of Medicine, Witten, Germany
| | | | - Peter U Heuschmann
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany.,Clinical Trial Center Würzburg, University Hospital Würzburg, Würzburg, Germany.,Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Josef-Schneider-Str. 11 97080, Würzburg, Germany.
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24
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Niku AD, Shiota T, Siegel RJ, Rader F. Prevalence and Resolution of Left Atrial Thrombus in Patients With Nonvalvular Atrial Fibrillation and Flutter With Oral Anticoagulation. Am J Cardiol 2019; 123:63-68. [PMID: 30360887 DOI: 10.1016/j.amjcard.2018.09.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 09/05/2018] [Accepted: 09/11/2018] [Indexed: 11/30/2022]
Abstract
Left atrial appendage (LAA) thrombus in nonvalvular atrial fibrillation or flutter (AF) is a major cause of stroke and presents a therapeutic dilemma in a rhythm-control strategy. The prevalence and resolution of LAA thrombus has not been studied well in the era of non-vitamin K antagonist oral anticoagulant use. This study sought to establish (1) the prevalence of LAA thrombus (2) the prevalence of LAA thrombus despite antithrombotic therapy, (3) the rate of persistence of LAA thrombus despite appropriate anticoagulant prescriptions, and (4) determinants of LAA thrombus persistence. Consecutive transesophageal echocardiograms (TEE) performed in patients with AF were reviewed to estimate the overall prevalence of LAA thrombus and the resolution rate in those with repeat studies. Multivariable logistic regression was used to identify clinical and echocardiographic predictors of thrombus resolution. Of 1,485 patients with AF, 117 (8%) had LAA thrombus. Of those, 62 had repeat TEE within 1 year and 58 (94%) were prescribed adequate anticoagulation in TEE studies (mean interval 96 ± 72 days). Thirty-seven patients (60%) had LAA thrombus resolution. Thrombus resolution rate was only 79% in patients considered on appropriate anticoagulation. Patients with persistent LAA thrombus were more likely to have diabetes; no other clinical or echocardiographic variable was independently associated with thrombus resolution. There was no significant difference in LAA thrombus resolution between non-vitamin K antagonist oral anticoagulants and warfarin. LAA thrombus persistence despite adequate anticoagulation is relatively common and difficult to predict clinically; TEE before electrical cardioversion should be considered regardless of anticoagulation status.
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Affiliation(s)
- Adam D Niku
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Takahiro Shiota
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Robert J Siegel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Florian Rader
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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25
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Todaro MC, Solazzo A, Senatore G, Zito C, Di Bella G, Carerj ML, Oreto G, Carerj S. Multimodality imaging for thromboembolic risk assessment in atrial fibrillation. J Cardiovasc Med (Hagerstown) 2018; 19:698-705. [PMID: 30320725 DOI: 10.2459/jcm.0000000000000727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
: Atrial fibrillation is the most widely represented sustained arrhythmia in the world. Thromboembolic risk assessment represents the main clinical challenge associated with this condition, requiring enormous medical, social and economical efforts. Several pieces of evidence in literature highlight how clinical risk factors are not enough for a correct thromboembolic risk stratification of patients with atrial fibrillation, since thromboembolic events have been proven to occur even in patients with low clinical risk scores. A comprehensive multimodality imaging approach, with special regard to echocardiography and new technologies seems to be the best method for this purpose. The aim of this review is to propose a hybrid thromboembolic risk stratification system that combinines clinical evaluation with instrumental clues on left atrial remodeling, fibrosis and deformation which, could be useful especially for patients classified at low thromboembolic risk according to clinical scores.
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Affiliation(s)
| | | | | | - Concetta Zito
- Department of Clinical and Experimental Medicine, Cardiology Section
| | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine, Cardiology Section
| | - Maria L Carerj
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | - Giuseppe Oreto
- Department of Clinical and Experimental Medicine, Cardiology Section
| | - Scipione Carerj
- Department of Clinical and Experimental Medicine, Cardiology Section
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26
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Bisbal F, Alarcón F, Ferrero-de-Loma-Osorio A, González-Ferrer JJ, Alonso C, Pachón M, Tizón H, Cabanas-Grandío P, Sanchez M, Benito E, Teis A, Ruiz-Granell R, Pérez-Villacastín J, Viñolas X, Arias MA, Vallés E, García-Campo E, Fernández-Lozano I, Villuendas R, Mont L. Left atrial geometry and outcome of atrial fibrillation ablation: results from the multicentre LAGO-AF study. Eur Heart J Cardiovasc Imaging 2018; 19:1002-1009. [DOI: 10.1093/ehjci/jey060] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 04/03/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Felipe Bisbal
- Heart Institute (iCor), University Hospital Germans Trias i Pujol, Ctra Canyet s/n, Badalona, Barcelona, Spain
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Francisco Alarcón
- Atrial Fibrillation Unit (UFA), Hospital Clinic, Universitat de Barcelona, IDIBAPS, Villarroel 170, Barcelona, Spain
| | | | - Juan Jose González-Ferrer
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
- Hospital Clinico San Carlos, Calle del Prof Martín Lagos, s/n, Madrid, Spain
| | - Concepción Alonso
- Hospital de la Santa Creu i Sant Pau, Carrer de Sant Quintí, 89, Barcelona, Spain
| | - Marta Pachón
- Hospital Virgen de la Salud, Av. de Barber, 30, Toledo, Spain
| | - Helena Tizón
- Hospital del Mar, Passeig Marîtim, 25-29, Barcelona, Spain
| | | | - Manuel Sanchez
- Hospital Puerta de Hierro, Calle Manuel de Falla, 1, Majadahonda, Madrid, Spain
| | - Eva Benito
- Atrial Fibrillation Unit (UFA), Hospital Clinic, Universitat de Barcelona, IDIBAPS, Villarroel 170, Barcelona, Spain
| | - Albert Teis
- Heart Institute (iCor), University Hospital Germans Trias i Pujol, Ctra Canyet s/n, Badalona, Barcelona, Spain
| | | | - Julián Pérez-Villacastín
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
- Hospital Clinico San Carlos, Calle del Prof Martín Lagos, s/n, Madrid, Spain
| | - Xavier Viñolas
- Hospital de la Santa Creu i Sant Pau, Carrer de Sant Quintí, 89, Barcelona, Spain
| | | | | | | | | | - Roger Villuendas
- Heart Institute (iCor), University Hospital Germans Trias i Pujol, Ctra Canyet s/n, Badalona, Barcelona, Spain
| | - Lluís Mont
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
- Atrial Fibrillation Unit (UFA), Hospital Clinic, Universitat de Barcelona, IDIBAPS, Villarroel 170, Barcelona, Spain
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27
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den Uijl DW, Cabanelas N, Benito EM, Figueras R, Alarcón F, Borràs R, Prat S, Guasch E, Perea R, Sitges M, Brugada J, Berruezo A, Mont L. Impact of left atrial volume, sphericity, and fibrosis on the outcome of catheter ablation for atrial fibrillation. J Cardiovasc Electrophysiol 2018. [PMID: 29528532 DOI: 10.1111/jce.13482] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION To investigate the relation between left atrial (LA) volume, sphericity, and fibrotic content derived from contrast-enhanced cardiac magnetic resonance imaging (CE-CMR) and their impact on the outcome of catheter ablation for atrial fibrillation (AF). METHODS AND RESULTS In 83 patients undergoing catheter ablation for AF, CE-CMR was used to assess LA volume, sphericity, and fibrosis. There was a significant correlation between LA volume and sphericity (R = 0.535, P < 0.001) and between LA volume and fibrosis (R = 0.241, P = 0.029). Multivariate analyses demonstrated that LA volume was the strongest independent predictor of AF recurrence after catheter ablation (1.019, P = 0.018). CONCLUSION LA volume, sphericity, and fibrosis were closely related; however, LA volume was the strongest predictor of AF recurrence after catheter ablation.
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Affiliation(s)
- Dennis W den Uijl
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Nuno Cabanelas
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Eva M Benito
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Rosa Figueras
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Francisco Alarcón
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Roger Borràs
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Susanna Prat
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Eduard Guasch
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Rosario Perea
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Marta Sitges
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Josep Brugada
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Antonio Berruezo
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Lluís Mont
- Institut Clínic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
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28
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Hammond-Haley M, Providência R, Lambiase PD. Temporal pattern/episode duration-based classification of atrial fibrillation as paroxysmal vs. persistent: is it time to develop a more integrated prognostic score to optimize management? Europace 2017; 20:f288-f298. [PMID: 29016766 DOI: 10.1093/europace/eux178] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 05/01/2017] [Indexed: 12/30/2022] Open
Affiliation(s)
| | - Rui Providência
- Bart’s Heart Centre, Bart’s Health NHS Trust, St. Bartholomew's Hospital, West Smithfield, London, UK
| | - Pier D Lambiase
- Bart’s Heart Centre, Bart’s Health NHS Trust, St. Bartholomew's Hospital, West Smithfield, London, UK
- Institute of Cardiovascular Science, University College & Barts Heart Centre, Paul O’Gorman Building, Huntley St, London, UK
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29
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30
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Affiliation(s)
- Brian D. Hoit
- From the Department of Medicine, Case Western Reserve University, Cleveland, OH; and Harrington Heart and Vascular Center, University Hospitals Cleveland Medical Center, Cleveland, OH
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31
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KOCHHÄUSER SIMON, ALIPOUR POURIA, HAIG-CARTER TANJAH, TROUGHT KATHLEEN, HACHE PHILIP, KHAYKIN YAARIV, WULFFHART ZAEV, PANTANO ALFREDO, TSANG BERNICE, BIRNIE DAVID, VERMA ATUL. Risk of Stroke and Recurrence After AF Ablation in Patients With an Initial Event-Free Period of 12 Months. J Cardiovasc Electrophysiol 2017; 28:273-279. [DOI: 10.1111/jce.13138] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 11/07/2016] [Accepted: 11/28/2016] [Indexed: 11/28/2022]
Affiliation(s)
| | - POURIA ALIPOUR
- Southlake Regional Health Centre; Newmarket Ontario Canada
| | | | | | - PHILIP HACHE
- Southlake Regional Health Centre; Newmarket Ontario Canada
| | - YAARIV KHAYKIN
- Southlake Regional Health Centre; Newmarket Ontario Canada
| | - ZAEV WULFFHART
- Southlake Regional Health Centre; Newmarket Ontario Canada
| | | | - BERNICE TSANG
- Southlake Regional Health Centre; Newmarket Ontario Canada
| | - DAVID BIRNIE
- Arrhythmia Service, Division of Cardiology; University of Ottawa Heart Institute; Ontario Canada
| | - ATUL VERMA
- Southlake Regional Health Centre; Newmarket Ontario Canada
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Hanley CM, Kowey PR. Darned If You Do…Darned If You Don't. J Cardiovasc Electrophysiol 2016; 27:811-2. [PMID: 27108489 DOI: 10.1111/jce.12998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Colleen M Hanley
- Cardiology Division, Lankenau Medical Center, Wynnewood, Pennsylvania, USA
| | - Peter R Kowey
- Cardiology Division, Lankenau Medical Center, Wynnewood, Pennsylvania, USA.,Lankenau Institute for Medical Research, Lankenau Medical Center, Wynnewood, Pennsylvania, USA
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