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Phrommintikul A, Pongbangli N, Gunaparn S, Prasertwitayakij N, Nantsupawat T, Wongcharoen W. Association of the interatrial block and left atrial fibrosis in the patients without history of atrial fibrillation. PLoS One 2024; 19:e0297920. [PMID: 38329999 PMCID: PMC10852280 DOI: 10.1371/journal.pone.0297920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/14/2024] [Indexed: 02/10/2024] Open
Abstract
Presence of left atrial (LA) fibrosis reflects underlying atrial cardiomyopathy. Interatrial block (IAB) is associated with LA fibrosis in patients with atrial fibrillation (AF). The association of IAB and LA fibrosis in the patients without history of AF is unknown. We examined association of IAB and LA fibrosis in the patients without AF history. This is a retrospective analysis of 229 patients undergoing cardiac magnetic resonance imaging (CMR). LA fibrosis was reported from spatial extent of late gadolinium enhancement of CMR. IAB was measured from 12-lead electrocardiography using digital caliper. Of 229 patients undergoing CMR, prevalence of IAB was 50.2%. Patients with IAB were older (56.9±13.9 years vs. 45.9±19.2 years, p<0.001) and had higher prevalence of co-morbidities. Left ventricular ejection fraction was lower in IAB group. LA volume index (LAVI) was greater in IAB group (54.6±24.9 ml/m2 vs. 43.0±21.1 ml/m2, p<0.001). Patients with IAB had higher prevalence of LA fibrosis than those without IAB (70.4% vs. 21.2%; p<0.001). After multivariable analysis, only IAB and LAVI were independent factors that predict LA fibrosis. Prevalence of IAB in patients undergoing CMR was high. IAB was highly associated with LA fibrosis and larger LA size in patients without AF history.
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Affiliation(s)
- Arintaya Phrommintikul
- Division of Cardiology, Department of Internal medicine, Chiang Mai University, Chiang Mai, Thailand
- Center for Medical Excellence, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Natnicha Pongbangli
- Division of Cardiology, Department of Internal Medicine, Chiangrai Prachanukroh Hospital, Chiang Rai, Thailand
| | - Siriluck Gunaparn
- Division of Cardiology, Department of Internal medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Narawudt Prasertwitayakij
- Division of Cardiology, Department of Internal medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Teerapat Nantsupawat
- Division of Cardiology, Department of Internal medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Wanwarang Wongcharoen
- Division of Cardiology, Department of Internal medicine, Chiang Mai University, Chiang Mai, Thailand
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2
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Zghaib T, Quinaglia A. C. Silva T, Ambale-Venkatesh B, Xie E, Ostovaneh MR, Habibi M, Bluemke DA, Soliman EZ, Wu CO, Heckbert SR, Nazarian S, Lima JAC. Association between Left Atrial Late Gadolinium Enhancement and Atrial Fibrillation: The Multi-Ethnic Study of Atherosclerosis (MESA). Radiol Cardiothorac Imaging 2023; 5:e220047. [PMID: 37693199 PMCID: PMC10483245 DOI: 10.1148/ryct.220047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 03/26/2023] [Accepted: 05/10/2023] [Indexed: 09/12/2023]
Abstract
Purpose To determine the prevalence and correlates of left atrial (LA) late gadolinium enhancement (LGE) at cardiac MRI and its association with atrial fibrillation (AF) in a population-based sample from the Multi-Ethnic Study of Atherosclerosis (MESA). Materials and Methods In this secondary post hoc analysis of the MESA cohort (ClinicalTrials.gov no. NCT00005487), participants without AF underwent LGE cardiac MRI at the fifth examination (2010-2012). LA LGE burden was quantified using the image intensity ratio technique on biplane long-axis two-dimensional (2D) LGE images without fat saturation. Survival analysis was performed with log-rank testing and Cox regression. Results Of 1697 participants (mean age, 67 years ± 9 [SD]; 872 men), 1035 (61%) had LA LGE, and 75 (4.4%) developed AF during follow-up (median, 3.95 years). At univariable analysis, LA LGE was associated with age (β = .010 [95% CI: .005, .015], P < .001), diastolic blood pressure (β = .005 [95% CI: .001, .009], P = .02), HbA1c level (β = .06 [95% CI: .02, .11], P = .009), heart failure (β = .60 [95% CI: .11, 1.08], P = .02), LA volume (β = .008 [95% CI: .004, .012], P < .001), and LA function (emptying fraction, LA global longitudinal strain, LA early diastolic peak longitudinal strain rate, and LA late diastolic peak strain rate; all P < .05). After adjusting for the variables in the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) AF score, LA LGE independently helped predict incident AF (hazard ratio = 1.46 [95% CI: 1.13, 1.88], P = .003). The highest tertile (LGE > 2%) was twice as likely to develop AF. Conclusion Although limited by the 2D LGE technique employed, LA LGE was associated with adverse atrial remodeling and helped predict AF in a multiethnic population-based sample.Clinical trial registration no. NCT00005487Keywords: MR Imaging, Cardiac, Epidemiology Supplemental material is available for this article. © RSNA, 2023.
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Affiliation(s)
- Tarek Zghaib
- From the Departments of Medicine (T.Z., E.X.) and Cardiology (T.Z.,
T.Q.A.C.S., M.R.O., M.H., J.A.C.L.), Johns Hopkins University School of
Medicine, 600 N Wolfe St, Blalock 524, Baltimore, MD 21287; Department of
Radiology and Radiological Science, Johns Hopkins University, Baltimore, Md
(B.A.V.); Department of Radiology, University of Wisconsin School of Medicine
and Public Health, Madison, Wis (D.A.B.); Department of Epidemiology and
Prevention, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); National
Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Md
(C.O.W.); Department of Epidemiology, University of Washington, Seattle, Wash
(S.R.H.); and Division of Cardiology, University of Pennsylvania Perelman School
of Medicine, Philadelphia, Pa (S.N.)
| | - Thiago Quinaglia A. C. Silva
- From the Departments of Medicine (T.Z., E.X.) and Cardiology (T.Z.,
T.Q.A.C.S., M.R.O., M.H., J.A.C.L.), Johns Hopkins University School of
Medicine, 600 N Wolfe St, Blalock 524, Baltimore, MD 21287; Department of
Radiology and Radiological Science, Johns Hopkins University, Baltimore, Md
(B.A.V.); Department of Radiology, University of Wisconsin School of Medicine
and Public Health, Madison, Wis (D.A.B.); Department of Epidemiology and
Prevention, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); National
Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Md
(C.O.W.); Department of Epidemiology, University of Washington, Seattle, Wash
(S.R.H.); and Division of Cardiology, University of Pennsylvania Perelman School
of Medicine, Philadelphia, Pa (S.N.)
| | - Bharath Ambale-Venkatesh
- From the Departments of Medicine (T.Z., E.X.) and Cardiology (T.Z.,
T.Q.A.C.S., M.R.O., M.H., J.A.C.L.), Johns Hopkins University School of
Medicine, 600 N Wolfe St, Blalock 524, Baltimore, MD 21287; Department of
Radiology and Radiological Science, Johns Hopkins University, Baltimore, Md
(B.A.V.); Department of Radiology, University of Wisconsin School of Medicine
and Public Health, Madison, Wis (D.A.B.); Department of Epidemiology and
Prevention, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); National
Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Md
(C.O.W.); Department of Epidemiology, University of Washington, Seattle, Wash
(S.R.H.); and Division of Cardiology, University of Pennsylvania Perelman School
of Medicine, Philadelphia, Pa (S.N.)
| | - Eric Xie
- From the Departments of Medicine (T.Z., E.X.) and Cardiology (T.Z.,
T.Q.A.C.S., M.R.O., M.H., J.A.C.L.), Johns Hopkins University School of
Medicine, 600 N Wolfe St, Blalock 524, Baltimore, MD 21287; Department of
Radiology and Radiological Science, Johns Hopkins University, Baltimore, Md
(B.A.V.); Department of Radiology, University of Wisconsin School of Medicine
and Public Health, Madison, Wis (D.A.B.); Department of Epidemiology and
Prevention, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); National
Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Md
(C.O.W.); Department of Epidemiology, University of Washington, Seattle, Wash
(S.R.H.); and Division of Cardiology, University of Pennsylvania Perelman School
of Medicine, Philadelphia, Pa (S.N.)
| | - Mohammad R. Ostovaneh
- From the Departments of Medicine (T.Z., E.X.) and Cardiology (T.Z.,
T.Q.A.C.S., M.R.O., M.H., J.A.C.L.), Johns Hopkins University School of
Medicine, 600 N Wolfe St, Blalock 524, Baltimore, MD 21287; Department of
Radiology and Radiological Science, Johns Hopkins University, Baltimore, Md
(B.A.V.); Department of Radiology, University of Wisconsin School of Medicine
and Public Health, Madison, Wis (D.A.B.); Department of Epidemiology and
Prevention, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); National
Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Md
(C.O.W.); Department of Epidemiology, University of Washington, Seattle, Wash
(S.R.H.); and Division of Cardiology, University of Pennsylvania Perelman School
of Medicine, Philadelphia, Pa (S.N.)
| | - Mohammadali Habibi
- From the Departments of Medicine (T.Z., E.X.) and Cardiology (T.Z.,
T.Q.A.C.S., M.R.O., M.H., J.A.C.L.), Johns Hopkins University School of
Medicine, 600 N Wolfe St, Blalock 524, Baltimore, MD 21287; Department of
Radiology and Radiological Science, Johns Hopkins University, Baltimore, Md
(B.A.V.); Department of Radiology, University of Wisconsin School of Medicine
and Public Health, Madison, Wis (D.A.B.); Department of Epidemiology and
Prevention, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); National
Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Md
(C.O.W.); Department of Epidemiology, University of Washington, Seattle, Wash
(S.R.H.); and Division of Cardiology, University of Pennsylvania Perelman School
of Medicine, Philadelphia, Pa (S.N.)
| | - David A. Bluemke
- From the Departments of Medicine (T.Z., E.X.) and Cardiology (T.Z.,
T.Q.A.C.S., M.R.O., M.H., J.A.C.L.), Johns Hopkins University School of
Medicine, 600 N Wolfe St, Blalock 524, Baltimore, MD 21287; Department of
Radiology and Radiological Science, Johns Hopkins University, Baltimore, Md
(B.A.V.); Department of Radiology, University of Wisconsin School of Medicine
and Public Health, Madison, Wis (D.A.B.); Department of Epidemiology and
Prevention, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); National
Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Md
(C.O.W.); Department of Epidemiology, University of Washington, Seattle, Wash
(S.R.H.); and Division of Cardiology, University of Pennsylvania Perelman School
of Medicine, Philadelphia, Pa (S.N.)
| | - Elsayed Z. Soliman
- From the Departments of Medicine (T.Z., E.X.) and Cardiology (T.Z.,
T.Q.A.C.S., M.R.O., M.H., J.A.C.L.), Johns Hopkins University School of
Medicine, 600 N Wolfe St, Blalock 524, Baltimore, MD 21287; Department of
Radiology and Radiological Science, Johns Hopkins University, Baltimore, Md
(B.A.V.); Department of Radiology, University of Wisconsin School of Medicine
and Public Health, Madison, Wis (D.A.B.); Department of Epidemiology and
Prevention, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); National
Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Md
(C.O.W.); Department of Epidemiology, University of Washington, Seattle, Wash
(S.R.H.); and Division of Cardiology, University of Pennsylvania Perelman School
of Medicine, Philadelphia, Pa (S.N.)
| | - Colin O. Wu
- From the Departments of Medicine (T.Z., E.X.) and Cardiology (T.Z.,
T.Q.A.C.S., M.R.O., M.H., J.A.C.L.), Johns Hopkins University School of
Medicine, 600 N Wolfe St, Blalock 524, Baltimore, MD 21287; Department of
Radiology and Radiological Science, Johns Hopkins University, Baltimore, Md
(B.A.V.); Department of Radiology, University of Wisconsin School of Medicine
and Public Health, Madison, Wis (D.A.B.); Department of Epidemiology and
Prevention, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); National
Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Md
(C.O.W.); Department of Epidemiology, University of Washington, Seattle, Wash
(S.R.H.); and Division of Cardiology, University of Pennsylvania Perelman School
of Medicine, Philadelphia, Pa (S.N.)
| | - Susan R. Heckbert
- From the Departments of Medicine (T.Z., E.X.) and Cardiology (T.Z.,
T.Q.A.C.S., M.R.O., M.H., J.A.C.L.), Johns Hopkins University School of
Medicine, 600 N Wolfe St, Blalock 524, Baltimore, MD 21287; Department of
Radiology and Radiological Science, Johns Hopkins University, Baltimore, Md
(B.A.V.); Department of Radiology, University of Wisconsin School of Medicine
and Public Health, Madison, Wis (D.A.B.); Department of Epidemiology and
Prevention, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); National
Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Md
(C.O.W.); Department of Epidemiology, University of Washington, Seattle, Wash
(S.R.H.); and Division of Cardiology, University of Pennsylvania Perelman School
of Medicine, Philadelphia, Pa (S.N.)
| | - Saman Nazarian
- From the Departments of Medicine (T.Z., E.X.) and Cardiology (T.Z.,
T.Q.A.C.S., M.R.O., M.H., J.A.C.L.), Johns Hopkins University School of
Medicine, 600 N Wolfe St, Blalock 524, Baltimore, MD 21287; Department of
Radiology and Radiological Science, Johns Hopkins University, Baltimore, Md
(B.A.V.); Department of Radiology, University of Wisconsin School of Medicine
and Public Health, Madison, Wis (D.A.B.); Department of Epidemiology and
Prevention, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); National
Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Md
(C.O.W.); Department of Epidemiology, University of Washington, Seattle, Wash
(S.R.H.); and Division of Cardiology, University of Pennsylvania Perelman School
of Medicine, Philadelphia, Pa (S.N.)
| | - João A. C. Lima
- From the Departments of Medicine (T.Z., E.X.) and Cardiology (T.Z.,
T.Q.A.C.S., M.R.O., M.H., J.A.C.L.), Johns Hopkins University School of
Medicine, 600 N Wolfe St, Blalock 524, Baltimore, MD 21287; Department of
Radiology and Radiological Science, Johns Hopkins University, Baltimore, Md
(B.A.V.); Department of Radiology, University of Wisconsin School of Medicine
and Public Health, Madison, Wis (D.A.B.); Department of Epidemiology and
Prevention, Wake Forest School of Medicine, Winston Salem, NC (E.Z.S.); National
Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Md
(C.O.W.); Department of Epidemiology, University of Washington, Seattle, Wash
(S.R.H.); and Division of Cardiology, University of Pennsylvania Perelman School
of Medicine, Philadelphia, Pa (S.N.)
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Larsen BS, Bertelsen L, Christensen H, Hadad R, Aplin M, Høst N, Christensen LM, Havsteen I, Prescott E, Dominguez H, Jensen GB, Vejlstrup N, Sajadieh A. Left atrial late gadolinium enhancement in patients with ischaemic stroke. Eur Heart J Cardiovasc Imaging 2023; 24:625-634. [PMID: 36691845 DOI: 10.1093/ehjci/jead008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/06/2023] [Indexed: 01/25/2023] Open
Abstract
AIMS To evaluate the extent of left atrial (LA) fibrosis in patients with a recent stroke without atrial fibrillation and controls without established cardiovascular disease. METHODS AND RESULTS This prospectively designed study used cardiac magnetic resonance to detect LA late gadolinium enhancement as a proxy for LA fibrosis. Between 2019 and 2021, we consecutively included 100 patients free of atrial fibrillation with recent ischaemic stroke (<30 days) and 50 age- and sex-matched controls. LA fibrosis assessment was achieved in 78 patients and 45 controls. Blinded to the cardiac magnetic resonance results, strokes were adjudicated according to modified Trial of Org 10172 in Acute Stroke Treatment classification as undetermined aetiology (n = 42) or as attributable to large- or small-vessel disease (n = 36). Patients with stroke had a larger extent of LA fibrosis [6.9%, interquartile range (IQR) 3.6-15.4%] than matched controls (4.2%, IQR 2.3-7.5%; P = 0.007). No differences in LA fibrosis were observed between patients with stroke of undetermined aetiology and those with large- or small-vessel disease (6.6%, IQR 3.8-16.0% vs. 6.9%, IQR 3.4-14.6%; P = 0.73). CONCLUSION LA fibrosis was more extensive in patients with stroke than in age- and sex-matched controls. A similar extent of LA fibrosis was observed in patients with stroke of undetermined aetiology and stroke classified as attributable to large- or small-vessel disease. Our findings suggest that LA structural abnormality is more frequent in patients with stroke than in controls independent of aetiological classification.
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Affiliation(s)
- Bjørn Strøier Larsen
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Litten Bertelsen
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Hanne Christensen
- Department of Neurology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Rakin Hadad
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Mark Aplin
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Nis Høst
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | | | - Inger Havsteen
- Department of Radiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Eva Prescott
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Helena Dominguez
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Gorm Boje Jensen
- Copenhagen City Heart Study, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Niels Vejlstrup
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Ahmad Sajadieh
- Department of Cardiology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
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4
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Escudero-Martínez I, Morales-Caba L, Segura T. Atrial fibrillation and stroke: A review and new insights. Trends Cardiovasc Med 2023; 33:23-29. [PMID: 34890796 DOI: 10.1016/j.tcm.2021.12.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/26/2021] [Accepted: 12/01/2021] [Indexed: 02/01/2023]
Abstract
The link between heart and brain continues to be a matter of great interest for the scientific community. One of the most established associations between the two is that the heart is a significant source of emboli and is responsible for 20-25% of all ischemic strokes. The most frequent underlying cause of cardioembolic stroke is atrial fibrillation (AF), a disease that affects almost 3 million people in the USA and 4.5 million in Europe. AF increases the risk of ischemic stroke by a factor of 3 to 5 times. It is estimated that AF is responsible for 15% of all strokes worldwide. A more comprehensive understanding of this association and development of intensive stroke prevention measures are needed, as we know that AF incidence and prevalence will increase over the coming years, becoming one of the largest epidemics and public health challenges we face.
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Affiliation(s)
- Irene Escudero-Martínez
- Stroke Unit, Department of Neurology, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Instituto de Investigación Sanitaria La Fe - Universidad de Valencia, Valencia, Spain.
| | - Lluis Morales-Caba
- Stroke Unit, Department of Neurology, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Instituto de Investigación Sanitaria La Fe - Universidad de Valencia, Valencia, Spain
| | - Tomás Segura
- Department of Medical Sciences, Faculty of Medicine of Albacete, University of Castilla-La Mancha, Albacete, Spain; Stroke Unit, Department of Neurology, Hospital General Universitario de Albacete, Spain
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5
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Olsen FJ, Bertelsen L, Vejlstrup N, Diederichsen SZ, Bjerregaard CL, Graff C, Brandes A, Krieger D, Haugan K, Køber L, Højberg S, Svendsen JH, Biering-Sørensen T. Association between four-dimensional echocardiographic left atrial measures and left atrial fibrosis assessed by left atrial late gadolinium enhancement. Eur Heart J Cardiovasc Imaging 2022; 24:152-161. [PMID: 34964463 DOI: 10.1093/ehjci/jeab275] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 12/09/2021] [Indexed: 12/24/2022] Open
Abstract
AIMS Left atrial (LA) fibrosis is a hallmark of atrial cardiomyopathy, and non-invasive surrogate measures of LA fibrosis are therefore needed. We investigated the association between four-dimensional (4D) echocardiographic LA measures and LA fibrosis. METHODS AND RESULTS A multimodality imaging substudy was performed in a randomized clinical trial (LOOP study), recruiting elderly participants with cardiovascular risk factors. LA late gadolinium enhancement (LGE) by cardiac magnetic resonance imaging was used as a surrogate for LA fibrosis. 4D echocardiographic LA quantification was used to measure maximal and minimal LA volume (LAVmax and LAVmin, respectively), LA emptying fractions (LAEFtotal), and strain. Logistic regression was used to relate LA measures to high LA LGE (≥17 cm2). Of the 44 participants (mean age 76 years, 64% men, median LA LGE 13.1 cm2), 14 exhibited high LA LGE. These participants exhibited abnormalities in several LA functional measures but not LAVmax. In linear regressions, only increasing LAVmin, and decreasing LAEFtotal, and reservoir strain were associated with increasing LA LGE. Furthermore, increasing LAVmin was associated with a higher likelihood of high LA LGE [odds ratio (OR) = 1.19 (1.04-1.37)]. Decreasing LAEFtotal and reservoir strain were also associated with higher likelihood of LA LGE [OR = 1.18 (1.05-1.33)] and OR = 1.15 (1.02-1.30), per 1% decrease in LAEFtotal and reservoir strain, respectively]. These findings were consistent after multivariable adjustments. LAEFtotal provided the highest performance for detecting high LA LGE (area under the curve of 0.78). CONCLUSION LAVmin, LAEFtotal, and reservoir strain measured by 4D echocardiography are significantly associated with LA LGE. LAEFtotal provides the best performance for detecting high LA LGE.
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Affiliation(s)
- Flemming Javier Olsen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark.,Department of Biomedical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Litten Bertelsen
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Niels Vejlstrup
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Søren Zöga Diederichsen
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Caroline Løkke Bjerregaard
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej 7 D2, 9220 Aalborg, Denmark
| | - Axel Brandes
- Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Winsløwparken 19, 5000 Odense C, Denmark
| | - Derk Krieger
- Department of Neurology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zürich, Switzerland.,Department of Neurology, Stroke Unit, Mediclinic City Hospital, Building 37, 26th St, Dubai, United Arab Emirates
| | - Ketil Haugan
- Department of Cardiology, Zealand University Hospital, Sygehusvej 10, 4000 Roskilde, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Søren Højberg
- Department of Cardiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark.,Department of Biomedical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
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6
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Rabbat MG, Kwong RY, Heitner JF, Young AA, Shanbhag SM, Petersen SE, Selvanayagam JB, Berry C, Nagel E, Heydari B, Maceira AM, Shenoy C, Dyke C, Bilchick KC. The Future of Cardiac Magnetic Resonance Clinical Trials. JACC Cardiovasc Imaging 2022; 15:2127-2138. [PMID: 34922874 DOI: 10.1016/j.jcmg.2021.07.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 05/17/2021] [Accepted: 07/27/2021] [Indexed: 01/13/2023]
Abstract
Over the past 2 decades, cardiac magnetic resonance (CMR) has become an essential component of cardiovascular clinical care and contributed to imaging-guided diagnosis and management of coronary artery disease, cardiomyopathy, congenital heart disease, cardio-oncology, valvular, and vascular disease, amongst others. The widespread availability, safety, and capability of CMR to provide corresponding anatomical, physiological, and functional data in 1 imaging session can improve the design and conduct of clinical trials through both a reduction of sample size and provision of important mechanistic data that may augment clinical trial findings. Moreover, prospective imaging-guided strategies using CMR can enhance safety, efficacy, and cost-effectiveness of cardiovascular pathways in clinical practice around the world. As the future of large-scale clinical trial design evolves to integrate personalized medicine, cost-effectiveness, and mechanistic insights of novel therapies, the integration of CMR will continue to play a critical role. In this document, the attributes, limitations, and challenges of CMR's integration into the future design and conduct of clinical trials will also be covered, and recommendations for trialists will be explored. Several prominent examples of clinical trials that test the efficacy of CMR-imaging guided pathways will also be discussed.
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Affiliation(s)
- Mark G Rabbat
- Division of Cardiology, Loyola University Chicago, Chicago, Illinois, USA; Division of Cardiology, Edward Hines Jr VA Hospital, Hines, Illinois, USA
| | - Raymond Y Kwong
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - John F Heitner
- Department of Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA
| | - Alistair A Young
- Department of Biomedical Engineering, King's College London, London, United Kingdom
| | - Sujata M Shanbhag
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Steffen E Petersen
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London, United Kingdom; National Institute for Health Research Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Joseph B Selvanayagam
- College of Medicine, Flinders University of South Australia, Department of Cardiovascular Medicine, Flinders Medical Centre, Southern Adelaide Local Health Network, and Cardiac Imaging Research Group, South Australian Health and Medical Research Institute, Adelaide, South Australia
| | - Colin Berry
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, and British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland, United Kingdom
| | - Eike Nagel
- Institute for Experimental and Translational Cardiovascular Imaging, Klinikum der Johann Wolfgang Goethe-Universitat Frankfurt, Frankfurt am Main, Germany
| | - Bobak Heydari
- Stephenson Cardiac Imaging Centre and Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, and Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Alicia M Maceira
- Cardiovascular Unit, Ascires Biomedical Group, and Department of Medicine, Health Sciences School, UCH-CEU University, Valencia, Spain
| | - Chetan Shenoy
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Christopher Dyke
- Division of Cardiology, National Jewish Health, Denver, Colorado, USA
| | - Kenneth C Bilchick
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
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7
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Zhou H, An DA, Ni Z, Xu J, Zhou Y, Fang W, Lu R, Ying L, Huang J, Yao Q, Li D, Hu J, Chen B, Shen J, Jin H, Wei Y, Ouchi E, Xu L, Wu LM, Mou S. Incremental diagnostic value of CMR-derived LA strain and strain rate in dialysis patients with HFpEF. Eur J Radiol 2022; 151:110285. [DOI: 10.1016/j.ejrad.2022.110285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 03/01/2022] [Accepted: 03/30/2022] [Indexed: 11/03/2022]
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8
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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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9
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Tseng AS, Noseworthy PA. Prediction of Atrial Fibrillation Using Machine Learning: A Review. Front Physiol 2021; 12:752317. [PMID: 34777014 PMCID: PMC8581234 DOI: 10.3389/fphys.2021.752317] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/04/2021] [Indexed: 02/01/2023] Open
Abstract
There has been recent immense interest in the use of machine learning techniques in the prediction and screening of atrial fibrillation, a common rhythm disorder present with significant clinical implications primarily related to the risk of ischemic cerebrovascular events and heart failure. Prior to the advent of the application of artificial intelligence in clinical medicine, previous studies have enumerated multiple clinical risk factors that can predict the development of atrial fibrillation. These clinical parameters include previous diagnoses, laboratory data (e.g., cardiac and inflammatory biomarkers, etc.), imaging data (e.g., cardiac computed tomography, cardiac magnetic resonance imaging, echocardiography, etc.), and electrophysiological data. These data are readily available in the electronic health record and can be automatically queried by artificial intelligence algorithms. With the modern computational capabilities afforded by technological advancements in computing and artificial intelligence, we present the current state of machine learning methodologies in the prediction and screening of atrial fibrillation as well as the implications and future direction of this rapidly evolving field.
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Affiliation(s)
| | - Peter A. Noseworthy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
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10
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Hanna B, Akoum N. Assessment of Atrial Fibrosis and Its Implications in Atrial Fibrillation and Stroke. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00952-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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11
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Fibrosis, the Bad Actor in Cardiorenal Syndromes: Mechanisms Involved. Cells 2021; 10:cells10071824. [PMID: 34359993 PMCID: PMC8307805 DOI: 10.3390/cells10071824] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/08/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023] Open
Abstract
Cardiorenal syndrome is a term that defines the complex bidirectional nature of the interaction between cardiac and renal disease. It is well established that patients with kidney disease have higher incidence of cardiovascular comorbidities and that renal dysfunction is a significant threat to the prognosis of patients with cardiac disease. Fibrosis is a common characteristic of organ injury progression that has been proposed not only as a marker but also as an important driver of the pathophysiology of cardiorenal syndromes. Due to the relevance of fibrosis, its study might give insight into the mechanisms and targets that could potentially be modulated to prevent fibrosis development. The aim of this review was to summarize some of the pathophysiological pathways involved in the fibrotic damage seen in cardiorenal syndromes, such as inflammation, oxidative stress and endoplasmic reticulum stress, which are known to be triggers and mediators of fibrosis.
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12
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Dagher L, Shi H, Zhao Y, Mitlacher M, Schnupp S, Ajmi I, Forkmann M, Marrouche N, Mahnkopf C. Atrial fibrosis progression in patients with no history of atrial fibrillation. J Cardiovasc Electrophysiol 2021; 32:2140-2147. [PMID: 34191382 DOI: 10.1111/jce.15140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 05/24/2021] [Accepted: 06/21/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Unexpected high levels of atrial fibrosis are found in individuals with no history of atrial fibrillation (AF). The temporal behavior of atrial fibrosis in this population is still unknown. We sought to investigate the progression and predictors of atrial fibrosis in non-AF individuals. METHODS Non-AF individuals at baseline who underwent late gadolinium enhancement magnetic resonance imaging (LGE-MRI) for assessment of left atrial (LA) fibrosis at least twice were retrospectively included in this study. The incidence of AF was assessed using review of medical records. RESULTS In 42 non-AF patients (15 females, 65.9 ± 8.6 years old), all patients had a detectable level of LA fibrosis at baseline, ranging from 4.5% to 28.8%, with a mean of 12.9 ± 5.9%. LA fibrosis in the second LGE-MRI was significantly higher in all patients compared to the first measurement (mean value of 12.9 ± 5.9% vs. 17.34 ± 6.8%; p < .05). Congestive heart failure was a significant clinical predictor of atrial fibrosis progression. The seven patients (16.6%) who developed new-onset AF during follow-up showed a significantly higher degree of LA fibrosis on their second MRI, compared to individuals who stayed in sinus rhythm (20.5 ± 6.9% vs. 16.7 ± 6.7%, p < .05). CONCLUSION Atrial fibrotic remodeling is a dynamic process that is progressively increasing in non-AF patients, accentuated by congestive heart failure. The higher extent of LA remodeling observed in patients who developed AF could highlight either the fact that AF is an expression of a highly dynamic left atrial substrate, or that remodeling processes are accelerated by AF.
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Affiliation(s)
- Lilas Dagher
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Hanyuan Shi
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Yan Zhao
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | | | | | | | | | - Nassir Marrouche
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Louisiana, USA
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13
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Lin Y, Fu S, Yao Y, Li Y, Zhao Y, Luo L. Heart failure with preserved ejection fraction based on aging and comorbidities. J Transl Med 2021; 19:291. [PMID: 34229717 PMCID: PMC8259336 DOI: 10.1186/s12967-021-02935-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/10/2021] [Indexed: 12/25/2022] Open
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) is a leading cause of hospitalizations and mortality when diagnosed at the age of ≥ 65 years. HFpEF represents multifactorial and multisystemic syndrome and has different pathophysiology and phenotypes. Its diagnosis is difficult to be established based on left ventricular ejection fraction and may benefit from individually tailored approaches, underlying age-related changes and frequent comorbidities. Compared with the rapid development in the treatment of heart failure with reduced ejection fraction, HFpEF presents a great challenge and needs to be addressed considering the failure of HF drugs to improve its outcomes. Further extensive studies on the relationships between HFpEF, aging, and comorbidities in carefully phenotyped HFpEF subgroups may help understand the biology, diagnosis, and treatment of HFpEF. The current review summarized the diagnostic and therapeutic development of HFpEF based on the complex relationships between aging, comorbidities, and HFpEF.
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Affiliation(s)
- Ying Lin
- Department of Cardiology, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, 572013, China
| | - Shihui Fu
- Department of Cardiology, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, 572013, China.
- Department of Geriatric Cardiology, Chinese People's Liberation Army General Hospital, Beijing, 100853, China.
| | - Yao Yao
- Centre for the Study of Ageing and Human Development and Geriatrics Division, Medical School of Duke University, Durham, NC, 27708, USA
- Centre for Healthy Ageing and Development Studies, National School of Development, Peking University, Beijing, 100871, China
| | - Yulong Li
- Department of Geriatric Cardiology, Chinese People's Liberation Army General Hospital, Beijing, 100853, China
| | - Yali Zhao
- Central Laboratory, Hainan Hospital of Chinese People's Liberation Army General Hospital, Sanya, 572013, China.
| | - Leiming Luo
- Department of Geriatric Cardiology, Chinese People's Liberation Army General Hospital, Beijing, 100853, China.
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14
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Toupin S, Pezel T, Bustin A, Cochet H. Whole-Heart High-Resolution Late Gadolinium Enhancement: Techniques and Clinical Applications. J Magn Reson Imaging 2021; 55:967-987. [PMID: 34155715 PMCID: PMC9292698 DOI: 10.1002/jmri.27732] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 12/15/2022] Open
Abstract
In cardiovascular magnetic resonance, late gadolinium enhancement (LGE) has become the cornerstone of myocardial tissue characterization. It is widely used in clinical routine to diagnose and characterize the myocardial tissue in a wide range of ischemic and nonischemic cardiomyopathies. The recent growing interest in imaging left atrial fibrosis has led to the development of novel whole‐heart high‐resolution late gadolinium enhancement (HR‐LGE) techniques. Indeed, conventional LGE is acquired in multiple breath‐holds with limited spatial resolution: ~1.4–1.8 mm in plane and 6–8 mm slice thickness, according to the Society for Cardiovascular Magnetic Resonance standardized guidelines. Such large voxel size prevents its use in thin structures such as the atrial or right ventricular walls. Whole‐heart 3D HR‐LGE images are acquired in free breathing to increase the spatial resolution (up to 1.3 × 1.3 × 1.3 mm3) and offer a better detection and depiction of focal atrial fibrosis. The downside of this increased resolution is the extended scan time of around 10 min, which hampers the spread of HR‐LGE in clinical practice. Initially introduced for atrial fibrosis imaging, HR‐LGE interest has evolved to be a tool to detect small scars in the ventricles and guide ablation procedures. Indeed, the detection of scars, nonvisible with conventional LGE, can be crucial in the diagnosis of myocardial infarction with nonobstructed coronary arteries, in the detection of the arrhythmogenic substrate triggering ventricular arrhythmia, and improve the confidence of clinicians in the challenging diagnoses such as the arrhythmogenic right ventricular cardiomyopathy. HR‐LGE also offers a precise visualization of left ventricular scar morphology that is particularly useful in planning ablation procedures and guiding them through the fusion of HR‐LGE images with electroanatomical mapping systems. In this narrative review, we attempt to summarize the technical particularities of whole‐heart HR‐LGE acquisition and provide an overview of its clinical applications with a particular focus on the ventricles.
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Affiliation(s)
- Solenn Toupin
- Siemens Healthcare France, Saint-Denis, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Université de Bordeaux, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Théo Pezel
- Division of Cardiology, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Cardiology, Lariboisiere Hospital, APHP, University of Paris, Paris, France
| | - Aurélien Bustin
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Université de Bordeaux, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France.,Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Hubert Cochet
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France.,Université de Bordeaux, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France.,Bordeaux University Hospital (CHU), Pessac, France
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15
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Rashid HN, Layland J. Modification of the left atrial appendage and its role in stroke risk reduction with non-valvular atrial fibrillation. IJC HEART & VASCULATURE 2021; 32:100688. [PMID: 33354620 PMCID: PMC7744943 DOI: 10.1016/j.ijcha.2020.100688] [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: 09/15/2020] [Revised: 11/21/2020] [Accepted: 11/27/2020] [Indexed: 12/30/2022]
Abstract
Atrial fibrillation is one of the most common cardiovascular disorders encountered by clinicians in clinical practice. Patients with atrial fibrillation are at risk of cerebrovascular and systemic embolic events, which may be attenuated by commencement of anticoagulation therapy. Even so, due to extremely high bleeding risk certain patients may not be suitable for long-term anticoagulation therapy. The left atrial appendage is a common site for thrombus formation in patients with atrial fibrillation. Left atrial appendage exclusion, either surgical or percutaneous, has been performed to ostensibly reduce the risk of cerebrovascular events and potentially minimise or omit anticoagulation therapy in select patients. This review summarises the role of the left atrial appendage in cerebrovascular events, current evidence with modification of the left atrial appendage and future trials that may change practice with these procedures.
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Key Words
- ACC, American College of Cardiology
- AF, Atrial fibrillation
- AHA, American Heart Association
- Atrial fibrillation
- DRT, Device related thrombus
- ESC, European Society of Cardiology
- FDA, Food and Drug Administation
- HR, Hazard ratio
- LAA, Left atrial appendage
- LAAE, Left atrial appendage exclusion
- LGE, Late gadolinium enhancement
- Left atrial appendage occluder
- Left atrial appendage occlusion
- OAC, Oral anticoagulation
- OR, Odds ratio
- Stroke
- TOE, Trans-oesopheageal echocardiogram
- Thrombosis
- Watchman device
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Affiliation(s)
- Hashrul N. Rashid
- Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia
- Department of Cardiovascular Research, Peninsula Health, Melbourne, Australia
| | - Jamie Layland
- Department of Cardiovascular Research, Peninsula Health, Melbourne, Australia
- Peninsula Clinical School, Monash University, Melbourne, Australia
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16
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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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17
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Ezeani M, Hagemeyer CE, Lal S, Niego B. Molecular imaging of atrial myopathy: Towards early AF detection and non-invasive disease management. Trends Cardiovasc Med 2020; 32:20-31. [DOI: 10.1016/j.tcm.2020.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 12/07/2020] [Accepted: 12/07/2020] [Indexed: 12/14/2022]
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18
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Mangiafico V, Saberwal B, Lavalle C, Raharja A, Ahmed Z, Papageorgiou N, Ahsan S. The role of CT in detecting AF substrate. Trends Cardiovasc Med 2020; 31:457-466. [PMID: 33068722 DOI: 10.1016/j.tcm.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 09/29/2020] [Accepted: 10/10/2020] [Indexed: 10/23/2022]
Abstract
Despite technological advancements and evolving ablation strategies, atrial fibrillation catheter ablation outcome remains suboptimal for a cohort of patients. Imaging-based biomarkers have the potential to play a pivotal role in the overall assessment and prognostic stratification of AF patients, allowing for tailored treatments and individualized care. Alongside consolidated evaluation parameters, novel imaging biomarkers that can detect and stage the remodelling process and correlate it to electrophysiological phenomena are emerging. This review aims to provide a better understanding of the different types of atrial substrate, and how Computed Tomography can be used as a pre-ablation risk stratification tool by assessing the various novel imaging biomarkers, providing a valuable insight into the mechanisms that sustain AF and potentially allowing for a patient-specific ablation strategy.
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Affiliation(s)
- Valentina Mangiafico
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy.
| | - Bunny Saberwal
- Barts Heart Centre, West Smithfield, London, EC1A 7BE, England.
| | - Carlo Lavalle
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy.
| | - Antony Raharja
- Barts Heart Centre, West Smithfield, London, EC1A 7BE, England.
| | - Zuhair Ahmed
- Queen Mary University of London, London, England.
| | | | - Syed Ahsan
- Barts Heart Centre, West Smithfield, London, EC1A 7BE, England.
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19
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Kim J, Yum B, Palumbo MC, Sultana R, Wright N, Das M, You C, Moskowitz CS, Levine RA, Devereux RB, Weinsaft JW. Left Atrial Strain Impairment Precedes Geometric Remodeling as a Marker of Post-Myocardial Infarction Diastolic Dysfunction. JACC Cardiovasc Imaging 2020; 13:2099-2113. [PMID: 32828776 PMCID: PMC7554167 DOI: 10.1016/j.jcmg.2020.05.041] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 05/12/2020] [Accepted: 05/22/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVES The aims of this study were to test the magnitude of agreement between echocardiography (echo)- and cardiac magnetic resonance (CMR)-derived left atrial (LA) strain and to study their relative diagnostic performance in discriminating diastolic dysfunction (DD) and predicting atrial fibrillation (AF). BACKGROUNDS Peak atrial longitudinal strain (PALS) is a novel performance index. Utility of echo-quantified LA strain has yet to be prospectively tested in relation to current DD guidelines or compared to CMR. METHODS The study population comprised 257 post-myocardial infarction (MI) patients undergoing echo and CMR, including prospective derivation (n = 157) and clinical validation (n = 100) cohorts. DD was graded on echo using established consensus guidelines blinded to strain results. RESULTS PALS on both echo and CMR was nearly 2-fold lower among patients with versus no DD (p < 0.001) and was significantly different in those with mild versus no DD (p < 0.01). In contrast, LA geometric parameters including echo- and CMR-derived volumes were significantly different between advanced versus no DD groups (p < 0.001) but not between groups with mild versus no DD (all p > 0.05). Echo and CMR PALS yielded small differences irrespective of orientation and similar diagnostic performance for DD in the derivation (area under the curve [AUC]: 0.70 to 0.78) and validation (AUC: 0.75 to 0.78) cohorts. Impaired PALS on both modalities was independently associated with MI size (p < 0.001). During 4.4 ± 3.8 years of follow-up in the derivation cohort, 8% developed AF. Both 2-chamber echo- and CMR-derived PALS stratified arrhythmic risk (p = 0.004 and p = 0.02, respectively), including a 4-fold difference among patients in the lowest versus remainder of quartiles of echo-derived PALS (24% vs. 6%). Similarly, echo and CMR PALS were lower (both p < 0.05) among patients with subsequent heart failure hospitalizations. CONCLUSIONS Echo-derived PALS parallels results of CMR, yields incremental diagnostic utility versus LA geometry for stratifying presence and severity of DD, and improves prediction of AF and congestive heart failure after MI.
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Affiliation(s)
- Jiwon Kim
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medicine, New York, New York.
| | - Brian Yum
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Maria C Palumbo
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Razia Sultana
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Nathaniel Wright
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Mukund Das
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Cindy You
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Chaya S Moskowitz
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert A Levine
- Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Richard B Devereux
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Jonathan W Weinsaft
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medicine, New York, New York; Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
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20
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Wang Z, Cheng L, Zhang J, Liang Z, Dong R, Hang F, Wang X, Wang Z, Wu Y, Du J. Serum-Soluble ST2 Is a Novel Biomarker for Evaluating Left Atrial Low-Voltage Zone in Paroxysmal Atrial Fibrillation. Med Sci Monit 2020; 26:e926221. [PMID: 32898129 PMCID: PMC7500126 DOI: 10.12659/msm.926221] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Paroxysmal atrial fibrillation (pAF) recurrence after radiofrequency catheter ablation (RFCA) is linked to low-voltage zone (LVZ). This study explored whether serum soluble ST2 (sST2) levels can predict the size of LVZs in patients with pAF. MATERIAL AND METHODS A total of 177 patients with pAF treated with RFCA were consecutively enrolled in this study. One hundred twenty-five patients (70.6%) with <20% LVZ were assigned to Group A, and 52 patients (29.4%) with a LVZ >20% were assigned to Group B. Levels of soluble ST2 (sST2), growth and differentiation factor (GDF-15) and tissue inhibitor of MMP1 (TIMP-1) were measured. RESULTS The sST2 levels were higher in Group B than in Group A (23.9±3.3 vs. 30.9±5.0 ng/mL, P<0.000). In multivariable logistic regression analysis, sST2 was the only independent parameter for predicting left atrial LVZ (odds ratio, 1.611 [1.379-1.882]; P<0.001). The cut-off value of sST2 obtained by receiver operating characteristic (ROC) analysis was 26.65 ng/mL for prediction of LVZ (sensitivity: 86.5%, specificity: 84.8%). The under-curve area was 0.895 (0.842-0.948) (P<0.001). At 12-month follow-up, patients with sST2 <26.65 ng/mL had more patients free from atrial arrhythmias compared to patients with sST2 >26.65 ng/mL (88.6% vs. 69.8%, P<0.01). CONCLUSIONS We demonstrated that sST2 levels are higher in pAF patients with LVZ >20% compared to those with a smaller LVZ. Also increased sST2 levels can serve as a novel predictor of AF recurrence rate in patients who have undergone RFCA.
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Affiliation(s)
- Zefeng Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China (mainland)
| | - Liting Cheng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China (mainland)
| | - Junmeng Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China (mainland)
| | - Zhuo Liang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China (mainland)
| | - Ruiqing Dong
- Department of Cardiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China (mainland)
| | - Fei Hang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China (mainland)
| | - Xinlu Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China (mainland)
| | - Ziyu Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China (mainland)
| | - Yongquan Wu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China (mainland)
| | - Jie Du
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China (mainland)
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21
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Saraiva RM, Pacheco NP, Pereira TOJS, Costa AR, Holanda MT, Sangenis LHC, Mendes FSNS, Sousa AS, Hasslocher-Moreno AM, Xavier SS, Mediano MFF, Veloso HH. Left Atrial Structure and Function Predictors of New-Onset Atrial Fibrillation in Patients with Chagas Disease. J Am Soc Echocardiogr 2020; 33:1363-1374.e1. [PMID: 32747223 DOI: 10.1016/j.echo.2020.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 05/19/2020] [Accepted: 06/03/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) carries ominous consequences in patients with Chagas disease. The aim of this study was to determine whether left atrial (LA) volume and function assessed using three-dimensional echocardiographic (3DE) imaging and two-dimensional speckle-tracking echocardiographic deformation analysis of strain (ε) could predict new-onset AF in patients with Chagas disease. METHODS A total of 392 adult patients with chronic Chagas disease (59% women; mean age, 53 ± 11 years) who underwent echocardiography were consecutively enrolled in this prospective longitudinal study. Echocardiographic evaluation included two-dimensional (2D) Doppler echocardiography, with evaluation of left ventricular systolic and diastolic function, LA size, and LA and left ventricular function on 3DE and ε analyses. Multivariate Cox proportional-hazards regression analysis models adjusting for age, sex, hypertension, presence of a pacemaker, and 2D Doppler echocardiographic parameters were used to test if the variables of interest had independent prognostic value for AF prediction. RESULTS Patients with Chagas disease were followed for 5.6 ± 2.7 years. Among these, 139 (35.5%) had the indeterminate form, 224 (57.1%) had the cardiac form, five (1.3%) had the digestive form, and 24 (6.1%) had the cardiodigestive form. The study end point of AF occurred in 45 patients. Total LA emptying fraction (hazard ratio, 0.93; 95% CI, 0.89-0.98; P = .002), passive LA emptying fraction (HR, 0.95; 95% CI, 0.91-0.99; P = .02), and peak negative global LA ε (HR, 1.22; 95% CI, 1.05-1.41; P = .01) were predictors of new-onset AF independent of clinical and 2D Doppler echocardiographic parameters. CONCLUSIONS LA function assessed on 3DE and ε analyses predicts new-onset AF in patients with Chagas disease independent of clinical and 2D Doppler echocardiographic indexes.
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Affiliation(s)
- Roberto M Saraiva
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil.
| | - Nicole P Pacheco
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Thayanne O J S Pereira
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Andréa R Costa
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Marcelo T Holanda
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Luiz Henrique C Sangenis
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Fernanda S N S Mendes
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Andréa S Sousa
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | | | - Sergio S Xavier
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Mauro Felippe F Mediano
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Henrique H Veloso
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
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22
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Antoniou CK, Manolakou P, Arsenos P, Dilaveris P, Gatzoulis K, Tousoulis D. Antithrombotic Treatment after Atrial Fibrillation Ablation. Curr Pharm Des 2020; 26:2703-2714. [DOI: 10.2174/1381612826666200407154329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/17/2020] [Indexed: 01/06/2023]
Abstract
:Atrial fibrillation is a major cause of debilitating strokes and anticoagulation is an established and indispensable therapy for reducing their rate. Ablation of the arrhythmia has emerged as a putative means of disrupting its natural course by isolating its triggers and modifying its substrate, dependent on the chosen method. An important dilemma lies in the need for continuation of anticoagulation therapy in those previously receiving it following an, apparently, successful intervention, purportedly preventing arrhythmia recurrence with considerably high rates. Current guidance, given scarcity of high-quality data from randomized trials, focuses on established knowledge and recommends anticoagulation continuation based solely on estimated thromboembolic risk. In the present review, it will be attempted to summarize the pathophysiological rationale for maintaining anticoagulation post-successful ablation, along with the latter’s definition, including the two-fold effects of the procedure per se on thrombogenicity. Available evidence pointing to an overall clinical benefit of anticoagulation withdrawal following careful patient assessment will be discussed, including ongoing randomized trials aiming to offer definitive answers. Finally, the proposed mode of post-ablation anticoagulation will be presented, including the emerging, guideline-endorsed, role of direct oral anticoagulants in the field, altering cost/benefit ratio of anticoagulation and potentially affecting the very decision regarding its discontinuation.
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Affiliation(s)
| | - Panagiota Manolakou
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, Athens, Greece
| | - Petros Arsenos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, Athens, Greece
| | - Polychronis Dilaveris
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, Athens, Greece
| | - Konstantinos Gatzoulis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokrateion Hospital, Athens, Greece
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23
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Bertelsen L, Diederichsen SZ, Haugan KJ, Brandes A, Graff C, Krieger D, Kronborg C, Køber L, Peters DC, Olesen MS, Højberg S, Vejlstrup N, Svendsen JH. Left Atrial Late Gadolinium Enhancement is Associated With Incident Atrial Fibrillation as Detected by Continuous Monitoring With Implantable Loop Recorders. JACC Cardiovasc Imaging 2020; 13:1690-1700. [PMID: 32563642 DOI: 10.1016/j.jcmg.2020.03.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/12/2020] [Accepted: 03/20/2020] [Indexed: 01/31/2023]
Abstract
OBJECTIVES The authors hypothesized that left atrial (LA) fibrosis was associated with incident atrial fibrillation (AF) as detected by continuous long-term monitoring in an at-risk population. BACKGROUND LA late gadolinium enhancement (LGE) measured with cardiac magnetic resonance is emerging as a marker of atrial fibrosis and has been associated with worse outcomes in AF ablation procedures; however, the prognostic value of LA LGE for incident AF remains unknown. METHODS Cardiac magnetic resonance, including measurement of left ventricular and LA volumes and function, as well as left ventricular extracellular volume fraction and LA LGE, was acquired in 68 patients aged at least 70 years with risk factors for stroke. All included patients received an implantable loop recorder and were continuously monitored for previously unknown AF. Incident AF was adjudicated by senior cardiologists. RESULTS Patients were monitored for AF with an implantable loop recorder during a median of 41 (interquartile range: 7) months. AF episodes lasting ≥6 min were detected in 32 patients (47%), and 16 patients (24%) experienced AF episodes lasting ≥5.5 h. In Cox regression analyses adjusted for sex, age, and comorbidities, we found that LA volumes and function and LA LGE were independently associated with incident AF. For LA LGE, the hazard ratios for time to AF episodes lasting ≥6 min and ≥5.5 h were 1.40 (95% CI: 1.03 to 1.89) per 10 cm2 increase (p = 0.03) and 1.63 (95% CI: 1.11 to 2.40) per 10 cm2 increase (p = 0.01), respectively. LA LGE was significantly associated with high burden of AF. The addition of LA LGE to a multivariable risk prediction model for incident AF significantly increased the predictive value. CONCLUSIONS Extent of LA fibrosis measured by LA LGE was significantly associated with incident AF detected by implantable loop recorder. (Atrial Fibrillation Detected by Continuous ECG Monitoring [LOOP]; NCT02036450).
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Affiliation(s)
- Litten Bertelsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Søren Zöga Diederichsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ketil Jørgen Haugan
- Department of Cardiology, Sjaelland University Hospital Roskilde, Roskilde, Denmark
| | - Axel Brandes
- Department of Cardiology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Derk Krieger
- University Hospital Zurich, University of Zurich, Switzerland; Stroke Unit, Mediclinic City Hospital, Dubai, UAE
| | - Christian Kronborg
- Department of Business and Economics, University of Southern Denmark, Odense, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Dana C Peters
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Morten Salling Olesen
- Laboratory for Molecular Cardiology, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Søren Højberg
- Department of Cardiology, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Niels Vejlstrup
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Laboratory for Molecular Cardiology, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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24
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Habibi M, Chrispin J, Spragg DD, Zimmerman SL, Tandri H, Nazarian S, Halperin H, Trayanova N, Calkins H. Utility of Cardiac MRI in Atrial Fibrillation Management. Card Electrophysiol Clin 2020; 12:131-139. [PMID: 32451098 DOI: 10.1016/j.ccep.2020.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Advances in cardiac magnetic resonance (CMR) techniques and image acquisition have made it an excellent tool in the assessment of atrial myopathy. Remolding of the left atrium is the mainstay of atrial fibrillation (AF) development and its progression. CMR can detect phasic atrial volumes, atrial function, and atrial fibrosis using cine, and contrast-enhanced or non-contrast-enhanced images. These abilities make CMR a versatile and extraordinary tool in management of patients with AF including for risk stratification, ablation prognostication and planning, and assessment of stroke risk. We review the latest advancements in utility of CMR in management of patients with AF.
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Affiliation(s)
- Mohammadali Habibi
- Division of Cardiology, Section for Cardiac Electrophysiology, Johns Hopkins University, Baltimore, MD, USA
| | - Jonathan Chrispin
- Division of Cardiology, Section for Cardiac Electrophysiology, Johns Hopkins University, Baltimore, MD, USA
| | - David D Spragg
- Division of Cardiology, Section for Cardiac Electrophysiology, Johns Hopkins University, Baltimore, MD, USA
| | | | - Harikrishna Tandri
- Division of Cardiology, Section for Cardiac Electrophysiology, Johns Hopkins University, Baltimore, MD, USA
| | - Saman Nazarian
- Division of Cardiology, Section for Cardiac Electrophysiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Henry Halperin
- Division of Cardiology, Section for Cardiac Electrophysiology, Johns Hopkins University, Baltimore, MD, USA; Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Natalia Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Hugh Calkins
- Division of Cardiology, Section for Cardiac Electrophysiology, Johns Hopkins University, Baltimore, MD, USA.
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25
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Mouselimis D, Tsarouchas AS, Pagourelias ED, Bakogiannis C, Theofilogiannakos EK, Loutradis C, Fragakis N, Vassilikos VP, Papadopoulos CE. Left atrial strain, intervendor variability, and atrial fibrillation recurrence after catheter ablation: A systematic review and meta-analysis. Hellenic J Cardiol 2020; 61:154-164. [DOI: 10.1016/j.hjc.2020.04.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 03/22/2020] [Accepted: 04/06/2020] [Indexed: 12/24/2022] Open
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26
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Dilaveris P, Tsivgoulis G, Aggeli C, Latsios G, Antoniou CK, Theodorou A, Manolakou P, Gatzoulis KA, Tousoulis D. Investigating recurrent cryptogenic strokes in a young female-An unexpected journey. Hellenic J Cardiol 2020; 62:76-80. [PMID: 32305496 DOI: 10.1016/j.hjc.2020.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/28/2020] [Accepted: 04/07/2020] [Indexed: 12/19/2022] Open
Affiliation(s)
- Polychronis Dilaveris
- Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, "Hippokrateion" General Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Department of Neurology, School of Medicine, National and Kapodistrian, University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Constantina Aggeli
- Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, "Hippokrateion" General Hospital, Athens, Greece
| | - George Latsios
- Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, "Hippokrateion" General Hospital, Athens, Greece
| | - Christos-Konstantinos Antoniou
- Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, "Hippokrateion" General Hospital, Athens, Greece.
| | - Aikaterini Theodorou
- Department of Neurology, School of Medicine, National and Kapodistrian, University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Panagiota Manolakou
- Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, "Hippokrateion" General Hospital, Athens, Greece
| | - Konstantinos A Gatzoulis
- Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, "Hippokrateion" General Hospital, Athens, Greece
| | - Dimitrios Tousoulis
- Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, "Hippokrateion" General Hospital, Athens, Greece
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27
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Abstract
Left atrial fibrosis plays an important role in the pathophysiology of atrial fibrillation. Left atrial ablation is an effective and increasingly used strategy to restore and maintain sinus rhythm in patients with atrial fibrillation. Late gadolinium enhancement (LGE) MRI and custom image analysis software have been used to visualize and quantify preablation atrial fibrosis and postablation scar and new fibrosis formation. This article reviews technical aspects of imaging atrial fibrosis/scar by LGE-MRI; use of atrial fibrosis and scar in predicting outcomes; applications of LGE-MRI to assess ablation lesions and optimize ablation parameters while avoiding collateral damage.
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Affiliation(s)
- Eugene G Kholmovski
- Comprehensive Arrhythmia Research & Management (CARMA) Center, University of Utah, 729 Arapeen Drive, Salt Lake City, Ut 84108, USA; Utah Center for Advanced Imaging Research (UCAIR), University of Utah, Salt Lake City, UT, USA; Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Alan K Morris
- Comprehensive Arrhythmia Research & Management (CARMA) Center, University of Utah, 729 Arapeen Drive, Salt Lake City, Ut 84108, USA
| | - Mihail G Chelu
- Comprehensive Arrhythmia Research & Management (CARMA) Center, University of Utah, 729 Arapeen Drive, Salt Lake City, Ut 84108, USA; Division of Cardiovascular Medicine, Section of Electrophysiology, University of Utah, Salt Lake City, UT, USA.
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28
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Bertelsen L, Diederichsen SZ, Haugan KJ, Brandes A, Graff C, Krieger D, Kronborg C, Køber L, Højberg S, Vejlstrup N, Svendsen JH. Left atrial volume and function assessed by cardiac magnetic resonance imaging are markers of subclinical atrial fibrillation as detected by continuous monitoring. Europace 2020; 22:724-731. [DOI: 10.1093/europace/euaa035] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 01/27/2020] [Indexed: 12/25/2022] Open
Abstract
Abstract
Aims
We aimed to investigate whether left atrial (LA) markers from cardiovascular magnetic resonance (CMR) were able to predict atrial fibrillation (AF) in elderly patients with risk factors for stroke.
Methods and results
At baseline, 203 participants with stroke risk factors but without history of AF underwent advanced CMR and received an implantable loop recorder. During a median of 40 (37–42) months of continuous monitoring, incident AF was detected in 79 patients (39%). With regards to CMR markers, a steep increase in incidence rate of AF was seen with LA maximum volume (LAmax) above 55 mL/m2, LA minimum volume (LAmin) above 30 mL/m2, LA total emptying fraction (LA TEF) below 45%, LA active emptying fraction (LA AEF) below 37%, LA strain S below 25%, LA strain A below 17%, and LA strain rate A above −1.7 s−1. After multivariate adjustment, the above-mentioned CMR markers remained associated with AF incidence: hazard ratio (95% confidence interval) 1.25 (1.06–1.48) and 1.51 (1.22–1.87) per 10 mL/m2 increase of LAmax and LAmin, respectively, 1.49 (1.26–1.76) and 1.46 CI (1.25–1.71) per 5% decrease in LA TEF and LA AEF, respectively, 1.23 (1.05–1.44) and 1.56 (1.18–2.06) per 5% decrease in LA strain S and A, respectively, and 2.06 (1.31–3.23) per s−1 increase in LA strain rate A. In prediction analyses, LA functional indices increased area under the receiver operating characteristic curve significantly.
Conclusion
The risk of AF, including asymptomatic AF, increases significantly with increasing LA volumes and worsening LA function.
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Affiliation(s)
- Litten Bertelsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Søren Zöga Diederichsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Ketil Jørgen Haugan
- Department of Cardiology, Sjaelland University Hospital Roskilde, Sygehusvej 10, 4000 Roskilde, Denmark
| | - Axel Brandes
- Department of Cardiology, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Winsløwparken 19, 5000 Odense C, Denmark
| | - Claus Graff
- Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej 7 D2, 9220 Aalborg, Denmark
| | - Derk Krieger
- Department of Neurology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091 Zürich, Switzerland
- Stroke Unit, Mediclinic City Hospital, Building 37—26th St, Dubai, UAE
| | - Christian Kronborg
- Department of Business and Economics, University of Southern Denmark, Campusvej 55, 5230 Odense, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Søren Højberg
- Department of Cardiology, Bispebjerg Hospital, Copenhagen University Hospital, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Niels Vejlstrup
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Jesper Hastrup Svendsen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
- Laboratory for Molecular Cardiology, Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
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29
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Left Atrial Structural Remodelling in Non-Valvular Atrial Fibrillation: What Have We Learnt from CMR? Diagnostics (Basel) 2020; 10:diagnostics10030137. [PMID: 32131455 PMCID: PMC7151417 DOI: 10.3390/diagnostics10030137] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 02/20/2020] [Accepted: 02/27/2020] [Indexed: 12/28/2022] Open
Abstract
Left atrial structural, functional and electrical remodelling are linked to atrial fibrillation (AF) pathophysiology and mirror the phrase “AF begets AF”. A structurally remodelled left atrium (LA) is fibrotic, dysfunctional and enlarged. Fibrosis is the hallmark of LA structural remodelling and is associated with increased risk of stroke, heart failure development and/or progression and poorer catheter ablation outcomes with increased recurrence rates. Moreover, increased atrial fibrosis has been associated with higher rates of stroke even in sinus-rhythm individuals. As such, properly assessing the fibrotic atrial cardiomyopathy in AF patients becomes necessary. In this respect, late-gadolinium enhancement cardiac magnetic resonance (LGE-CMR) imaging is the gold standard in imaging myocardial fibrosis. LA structural remodelling extension offers both diagnostic and prognostic information and influences therapeutic choices. LGE-CMR scans can be used before the procedure to better select candidates and to aid in choosing the ablation technique, during the procedure (full CMR-guided ablations) and after the ablation (to assess the ablation scar). This review focuses on imaging several LA structural remodelling CMR parameters, including size, shape and fibrosis (both extension and architecture) and their impact on procedure outcomes, recurrence risk, as well as their utility in relation to the index procedure timing.
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30
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The Atrium and Embolic Stroke. JACC Clin Electrophysiol 2020; 6:251-261. [DOI: 10.1016/j.jacep.2019.12.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 11/25/2019] [Accepted: 12/20/2019] [Indexed: 12/30/2022]
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31
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Packer M. Do most patients with obesity or type 2 diabetes, and atrial fibrillation, also have undiagnosed heart failure? A critical conceptual framework for understanding mechanisms and improving diagnosis and treatment. Eur J Heart Fail 2019; 22:214-227. [PMID: 31849132 DOI: 10.1002/ejhf.1646] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 09/14/2019] [Accepted: 09/20/2019] [Indexed: 02/06/2023] Open
Abstract
Obesity and diabetes can lead to heart failure with preserved ejection fraction (HFpEF), potentially because they both cause expansion and inflammation of epicardial adipose tissue and thus lead to microvascular dysfunction and fibrosis of the underlying left ventricle. The same process also causes an atrial myopathy, which is clinically evident as atrial fibrillation (AF); thus, AF may be the first manifestation of HFpEF. Many patients with apparently isolated AF have latent HFpEF or subsequently develop HFpEF. Most patients with obesity or diabetes who have AF and exercise intolerance have increased left atrial pressures at rest or during exercise, even in the absence of diagnosed HFpEF. Among patients with AF, those who also have latent HFpEF have increased risk for systemic thromboembolism and death. The identification of HFpEF in patients with obesity or diabetes alters the risk-to-benefit relationship of commonly prescribed treatments. Bariatric surgery and statins can ameliorate AF and reduce the risk for HFpEF. Conversely, antihyperglycaemic drugs that promote adipogenesis or cause sodium retention (insulin and thiazolidinediones) may increase the risk for heart failure in patients with an underlying ventricular myopathy. Patients with obesity and diabetes who undergo catheter ablation for AF are at increased risk for AF recurrence and for post-ablation increases in pulmonary venous pressures and worsening heart failure, especially if HFpEF coexists. Therefore, AF may be the earliest indicator of HFpEF in patients with obesity or type 2 diabetes, and recognition of HFpEF alters the management of these patients.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA.,Imperial College London, London, UK
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Packer M. Disease-treatment interactions in the management of patients with obesity and diabetes who have atrial fibrillation: the potential mediating influence of epicardial adipose tissue. Cardiovasc Diabetol 2019; 18:121. [PMID: 31551089 PMCID: PMC6760044 DOI: 10.1186/s12933-019-0927-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 09/12/2019] [Indexed: 12/23/2022] Open
Abstract
Both obesity and type 2 diabetes are important risk factors for atrial fibrillation (AF), possibly because they both cause an expansion of epicardial adipose tissue, which is the source of proinflammatory adipocytokines that can lead to microvascular dysfunction and fibrosis of the underlying myocardium. If the derangement of epicardial fat adjoins the left atrium, the result is an atrial myopathy, which is clinically manifest as AF. In patients with AF, there is a close relationship between epicardial fat volume and the severity of electrophysiological abnormalities in the adjacent myocardial tissues, and epicardial fat mass predicts AF in the general population. The expansion of epicardial adipose tissue in obesity and type 2 diabetes may also affect the left ventricle, impairing its distensibility and leading to heart failure with a preserved ejection fraction (HFpEF). Patients with obesity or type 2 diabetes with AF often have HFpEF, but the diagnosis may be missed, if dyspnea is attributed to increased body mass or to the arrhythmia. The expected response to the treatment for obesity, diabetes or AF may be influenced by their effects on epicardial inflammation and the underlying atrial and ventricular myopathy. Bariatric surgery and metformin reduce epicardial fat mass and ameliorate AF, whereas insulin promotes adipogenesis and cardiac fibrosis, and its use is accompanied by an increased risk of AF. Rate control strategies for AF may impair exercise tolerance, because they allow for greater time for ventricular filling in patients who cannot tolerate volume loading because of cardiac fibrosis and HFpEF. At the same time, both obesity and diabetes decrease the expected success rate of rhythm control strategies for AF (e.g., electrical cardioversion or catheter ablation), because increased epicardial adipose tissue volumes and cardiac fibrosis are important determinants of AF recurrence following these procedures.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, 621 N. Hall Street, Dallas, TX, 75226, USA. .,Imperial College, London, UK.
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