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Kronenberger R, Tanaka K, de Asmundis C, Meir ML. Stiff left atrial syndrome with pulmonary veins occlusion after percutaneous radiofrequency ablation: a life-long complication that can lead to heart transplantation. J Cardiothorac Surg 2023; 18:181. [PMID: 37193996 DOI: 10.1186/s13019-023-02193-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 03/29/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Stiff left atrial syndrome (SLAS) and pulmonary vein (PV) occlusion are rare yet potentially major life-long complications after radiofrequency ablation for atrial fibrillation. While mostly controlled by medical management, SLAS can progress to refractory congestive heart failure. Treatment of PV stenosis and occlusion remains a challenging problem with ongoing risk for recurrence regardless of techniques employed. Herein we present the case of a now 51-year-old male with acquired PV occlusion and SLAS who, over the course of eleven years, despite multiple interventions, ultimately required heart transplantation. CASE PRESENTATION After undergoing three radiofrequency catheter procedures for paroxysmal atrial fibrillation (AF), a hybrid ablation was planned due to reappearance of symptomatic AF. Preoperative echocardiography and chest computed tomography (CT) revealed an occlusion of both left PVs. Furthermore, left atrial dysfunction, high pulmonary artery and pulmonary wedge pressures were diagnosed as well as an important reduction of the left atrial volume. The diagnosis of stiff left atrial syndrome was made. Primary surgical repair of the left-sided PVs was performed using a pericardial patch as a tubular neo-vein, combined with cryoablation in the left and right atrium to treat the patient's arrhythmia. Initial results were favorable, however, after two years the patient experienced progressive restenosis with hemoptysis. Therefore, stenting of the common left PV was performed. Over the years, progressive right heart failure with severe tricuspid regurgitation developed, despite maximal medical therapy, which led to the need for heart transplantation. CONCLUSION The impact of PV occlusion and SLAS after percutaneous radiofrequency ablation can be lifelong and devastating for the clinical course of the patient. Since the presence of a small left atrium could be an important predictor for SLAS in case of redo ablation, preprocedural imaging should guide the operator to an algorithm of a decision-making containing lesion set, energy source, and safety of re-ablation.
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Affiliation(s)
- Rani Kronenberger
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussels, 1090, Belgium
| | - Kaoru Tanaka
- Radiology Department, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussels, 1090, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussels, 1090, Belgium
| | - Mark La Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussels, 1090, Belgium.
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2
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Yan C. Is combined use of radiofrequency ablation and balloon dilation the future of interatrial communications? Expert Rev Cardiovasc Ther 2022; 20:895-903. [PMID: 36329641 DOI: 10.1080/14779072.2022.2144233] [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] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Personalized and stable interatrial communication is an important palliative therapy for patients with heart failure. However, this remains a technically challenging task. AREAS COVERED In the past decades, substantial advancements in atrial septostomy for the creation of controllable and durable interatrial communication have been made, and numerous novel devices and techniques are in various stages of development. In this review, we discuss the evolving indications for atrial septostomy, current approaches with or without device implantation, and indicators for optimal interatrial communication. The combined use of radiofrequency ablation and balloon dilation (CURB) is an individualized management approach based on underlying hemodynamics, which demonstrates unique advantages in creating a sufficient interatrial communication with satisfactory stability. The advantages and disadvantages of this implant-free procedure are analyzed and its clinical prospects are assessed. EXPERT OPINION With ready availability, high safety, and efficacy, CURB is a promising procedure for creating personalized and stable interatrial communication without device implantation. Further research is required to simplify the procedure, screen optimal reference parameters for personalized therapy, and evaluate the long-term outcome in a large population of patients.
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Affiliation(s)
- Chaowu Yan
- Department of Structural Heart Disease, Fuwai Hospital, 100037, Beijing, China
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3
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Bregasi A, Freeman JV, Curtis JP, Akar JG, Ortiz-Leon XA, Maia JH, Higgins AY, Matthews RV, Sinusas AJ, McNamara RL, Sugeng L, Lin BA. Abnormal left atrial body stiffness is predicted by appendage size: impact of appendage occlusion on left atrial mechanics assessed by pressure-volume analysis. Am J Physiol Heart Circ Physiol 2022; 323:H559-H568. [PMID: 35960632 PMCID: PMC9576173 DOI: 10.1152/ajpheart.00083.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Atrial cardiomyopathy has been recognized as having important consequences for cardiac performance and clinical outcomes. The pathophysiological role of the left atrial (LA) appendage and the effect of percutaneous left atrial appendage occlusion (LAAO) upon LA mechanics is incompletely understood. We evaluated if changes in LA stiffness due to endocardial LAAO can be detected by LA pressure-volume (PV) analysis and whether stiffness parameters are associated with baseline characteristics. Patients undergoing percutaneous endocardial LAAO (n = 25) were studied using a novel PV analysis using near-simultaneous three-dimensional LA volume measurements by transesophageal echocardiography (TEE) and direct invasive LA pressure measurements. LA stiffness (dP/dV, change in pressure with change in volume) was calculated before and after LAAO. Overall LA stiffness significantly increased after LAAO compared with baseline (median, 0.41-0.64 mmHg/mL; P ≪ 0.001). LA body stiffness after LAAO correlated with baseline LA appendage size by indexed maximum depth (Spearman's rank correlation coefficient Rs = 0.61; P < 0.01). LA stiffness change showed an even stronger correlation with baseline LA appendage size by indexed maximum depth (Rs = 0.70; P < 0.001). We found that overall LA stiffness increases after endocardial LAAO. Baseline LA appendage size correlates with the magnitude of increase and LA body stiffness. These findings document alteration of LA mechanics after endocardial LAAO and suggest that the LA appendage modulates overall LA compliance.NEW & NOTEWORTHY Our study documents a correlation of LA appendage remodeling with the degree of chronically abnormal LA body stiffness. In addition, we found that LA appendage size was the baseline parameter that best correlated with the magnitude of a further increase in overall LA stiffness after appendage occlusion. These findings offer insights about the LA appendage and LA mechanics that are relevant to patients at risk for adverse atrial remodeling, especially candidates for LA appendage occlusion.
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Affiliation(s)
- Alda Bregasi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - James V Freeman
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Joseph G Akar
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Julia H Maia
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Angela Y Higgins
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Ray V Matthews
- Division of Cardiovascular Medicine, Department of Internal Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Albert J Sinusas
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut
- Department of Biomedical Engineering, Yale University School of Engineering and Applied Science, New Haven, Connecticut
| | - Robert L McNamara
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Lissa Sugeng
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Ben A Lin
- Division of Cardiovascular Medicine, Department of Internal Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California
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4
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Interatrial stent to treat stiff left atrium syndrome. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 40S:337-340. [DOI: 10.1016/j.carrev.2022.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/06/2022] [Accepted: 01/06/2022] [Indexed: 11/16/2022]
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5
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Bhardwaj A, Parikh VY, Nair A. Transcatheter Interatrial Shunts for the Treatment of Heart Failure with Preserved Ejection Fraction. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2021. [DOI: 10.36660/ijcs.20200236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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6
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Baratto C, Caravita S, Perego GB, Parati G. Stiff left atrial syndrome after low-dose radiotherapy for right breast cancer: The need for invasive hemodynamics at exercise. Catheter Cardiovasc Interv 2020; 95:1059-1061. [PMID: 31194281 DOI: 10.1002/ccd.28348] [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: 12/21/2018] [Revised: 03/26/2019] [Accepted: 05/16/2019] [Indexed: 11/11/2022]
Abstract
Stiff left atrial (LA) syndrome is a distinct phenotype of heart failure with preserved ejection fraction, characterized by predominant high LA pressure. We describe the case of a middle-aged woman who developed exertional breathlessness during low-dose radiotherapy for right breast cancer and who was eventually found to be affected by stiff LA syndrome. Invasive hemodynamics allowed the recognition of pathognomonic tall V waves in the wedge position during exercise, in spite of inconclusive noninvasive investigations.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Giovanni B Perego
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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7
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Offen S, Sivasubramaniam V, Granger E, Macdonald P. Stiff left atrial syndrome and heart transplantation. J Heart Lung Transplant 2019; 38:675-676. [PMID: 30685235 DOI: 10.1016/j.healun.2018.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/19/2018] [Accepted: 12/24/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Sophie Offen
- Heart Transplant Unit, St. Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | | | - Emily Granger
- Heart Transplant Unit, St. Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Peter Macdonald
- Heart Transplant Unit, St. Vincent's Hospital, Darlinghurst, New South Wales, Australia
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8
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Chaudhry MA, Johnson A, Heywood JT. Stiff Left Atrial Syndrome; Prospects and Possibilities. Retrospective Analysis and Review of the Literature. Curr Hypertens Rev 2018; 15:17-21. [PMID: 30221604 DOI: 10.2174/1573402114666180917095654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 08/24/2018] [Accepted: 09/01/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Stiff left atrial syndrome is an intriguing clinical phenomena characterized by reduced left atrial compliance, pulmonary venous hypertension and exacerbations of volume overload. We conducted a retrospective review of patients diagnosed with stiff left atrial syndrome at our center. METHODS All patients admitted to our hospital with volume overload and pulmonary venous hypertension who were diagnosed with stiff left atrial syndrome based on evidence by echocardiogram and right heart catheterization between July 2011 and July 2013 were included in this retrospective review. RESULTS Twentythree patients (mean age 73 ± 11 years, 39% male and 61% female) were diagnosed with stiff left atrial syndrome at our center. Thirty-five percent had persistent while 39% had permanent atrial fibrillation. Mean duration of atrial fibrillation was 7.6 ± 2.1 years. Forty-three percent of patients had long standing hypertension. There was no mitral regurgitation in 39% of patients while 48% had mild mitral regurgitation. On right heart catheterization, mean right atrial pressure was 12.6±4.8 mm of Hg, mean pulmonary arterial pressure was 33±7.2 mm of Hg, mean pulmonary capillary wedge pressure was 24.8± 4.2mm of Hg while peak V waves were seen at mean of 37.8± 5.3 mm of Hg. Mean left atrial volume index was 49.8±17.1 mL/m 2. After the initial diagnosis with a two year follow- up, there were no readmissions in 65% of patients who were on appropriate diuretic therapy and had regular clinical visits. Frequent readmissions were seen in 35% of patients inspite of appropriate diuretic therapy. All-cause mortality rate was 4.3% at two year follow up. CONCLUSION In patients with stiff left atrial syndrome, the presence of left atrial dilation, long standing atrial fibrillation and hypertension are the key factors associated with pathogenesis and clinical course. Close follow up and monitoring of volume status is essential to prevent hospital readmissions and improve long term prognosis.
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Affiliation(s)
- Muhammad Ali Chaudhry
- Division of Cardiovascular Medicine, Aultman Hospital, Canton, Ohio-44710 OH, United States
| | - Allen Johnson
- Division of Cardiovascular Medicine, Heart Failure Recovery and Research, Scripps Green Hospital, La Jolla-90033, CA 92037, United States
| | - James Thomas Heywood
- Division of Cardiovascular Medicine, Heart Failure Recovery and Research, Scripps Green Hospital, La Jolla-90033, CA 92037, United States
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Abstract
Catheter ablation is a well-established treatment for atrial fibrillation (AF). A subset of patients developed dyspnea secondary to loss of left atrial (LA) compliance after ablation, which is referred as the stiff LA syndrome.1 Stiff left atrium syndrome has traditionally been associated with profound eccentric LA remodeling. We report the case of a patient with this clinical syndrome who developed giant V-waves during exercise but had a strikingly small LA.
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Affiliation(s)
- Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Jeong Hoon Yang
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Brandon M Wiley
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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10
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Caravita S, Mariani D, Blengino S, Branzi G, Crotti L, Parati G. Pulmonary hypertension due to a stiff left atrium: Speckle tracking equivalents of large V-waves. Echocardiography 2018; 35:1464-1466. [PMID: 30079533 DOI: 10.1111/echo.14117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 06/20/2018] [Accepted: 07/07/2018] [Indexed: 11/27/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a widely heterogeneous clinical condition. Left ventricular diastolic dysfunction is the leading etiology of HFpEF, but there might be patients presenting with a predominant disease of the left atrium (LA). We report a case of HFpEF secondary to a stiff LA, in which we corroborated invasive hemodynamic assessment with LA strain analysis. Pathognomonic, tall V-waves were observed in the wedge position in the absence of mitral regurgitation and with a near-normal QRS-gated, pre-V-wave pressure, indicating that left ventricular diastolic dysfunction was not a major issue in this case. These hemodynamic findings were mirrored by very low LA strain values, compatible with a stiff and noncompliant chamber.
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Affiliation(s)
- Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale San Luca IRCCS Istituto Auxologico Italiano, Milano, Italy
| | - Davide Mariani
- Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale San Luca IRCCS Istituto Auxologico Italiano, Milano, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Simonetta Blengino
- Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale San Luca IRCCS Istituto Auxologico Italiano, Milano, Italy
| | - Giovanna Branzi
- Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale San Luca IRCCS Istituto Auxologico Italiano, Milano, Italy
| | - Lia Crotti
- Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale San Luca IRCCS Istituto Auxologico Italiano, Milano, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Ospedale San Luca IRCCS Istituto Auxologico Italiano, Milano, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
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11
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Left atrial compliance: an overlooked predictor of clinical outcome in patients with mitral stenosis or atrial fibrillation undergoing invasive management. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2018; 14:120-127. [PMID: 30008763 PMCID: PMC6041835 DOI: 10.5114/aic.2018.76402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 04/29/2018] [Indexed: 01/06/2023] Open
Abstract
In the assessment of cardiovascular disease, the clinical significance of left atrial (LA) pressure-volume relations has largely been overlooked in contrast to left ventricular (LV) compliance. However, LA compliance has recently gained more attention. Net atrioventricular compliance (Cn), a joint measure of LA and LV compliance, can be calculated non-invasively by a previously validated method using parameters from standard echocardiography. Compliance measurement may be of relevance in selected clinical settings. First, subjects with low Cn are more likely to have their mitral valve area overestimated by the traditional mitral pressure half-time method. Consequently, low Cn in mitral stenosis, usually resulting from reduced LA compliance, can be mistaken for mild mitral stenosis. Second, low Cn independently predicted pulmonary hypertension and disease progression in medically treated mitral stenosis, and late cardiovascular complications after successful percutaneous mitral valvuloplasty. Decreased LA compliance also accounts for stiff LA syndrome, a rare complication of radiofrequency catheter ablation for atrial fibrillation, manifesting as otherwise unexplained heart failure with elevated LA pressure and pulmonary hypertension. Finally, depressed pre-ablation LA stiffness index, i.e. the ratio of the change in LA pressure to the corresponding change in LA volume during passive LA filling, was an independent predictor of arrhythmia recurrence. Thus, LA stiffening translates into adverse clinical outcomes in patients with mitral stenosis or atrial fibrillation undergoing interventional procedures. Whether reduced LA compliance after LA appendage occlusion can result in the LA stiff syndrome, has not been reported so far.
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12
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Naksuk N, Asirvatham SJ. Iatrogenic atrial septal defect: reassurance or inquisitiveness. J Interv Card Electrophysiol 2018; 52:137-140. [DOI: 10.1007/s10840-018-0369-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 04/03/2018] [Indexed: 10/17/2022]
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13
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Reddy YNV, El Sabbagh A, Packer D, Nishimura RA. Evaluation of shortness of breath after atrial fibrillation ablation-Is there a stiff left atrium? Heart Rhythm 2018; 15:930-935. [PMID: 29408677 DOI: 10.1016/j.hrthm.2018.01.029] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Indexed: 01/21/2023]
Affiliation(s)
- Yogesh N V Reddy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | | | - Douglas Packer
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Rick A Nishimura
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
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Maeder MT, Nägele R, Rohner P, Weilenmann D. Pulmonary hypertension in stiff left atrial syndrome: pathogenesis and treatment in one. ESC Heart Fail 2017; 5:189-192. [PMID: 29115016 PMCID: PMC5793980 DOI: 10.1002/ehf2.12234] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 09/05/2017] [Accepted: 10/02/2017] [Indexed: 11/09/2022] Open
Abstract
We present the rare case of a patient with pulmonary hypertension in the context of the stiff left atrial syndrome after extensive catheter ablation, a unique constellation characterized by high pulmonary artery and pulmonary artery wedge pressures due to left atrial dysfunction but normal left ventricular end‐diastolic pressure, normal mitral valve, and absence pulmonary vein stenosis. This patient was surprisingly oligosymptomatic, however, which may have been due to a persistent post‐puncture atrial septal defect, which may have allowed for controlled left atrial decompression, which is in line with the novel concept of the catheter‐based creation of an intracardiac shunt as a treatment for heart failure.
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Affiliation(s)
- Micha T Maeder
- Cardiology Department, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
| | - Reto Nägele
- Cardiology Department, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland.,Department of Internal Medicine, Spital Grabs, Grabs, Switzerland
| | - Philipp Rohner
- Department of Internal Medicine, Spital Grabs, Grabs, Switzerland
| | - Daniel Weilenmann
- Cardiology Department, Kantonsspital St. Gallen, Rorschacherstrasse 95, 9007, St. Gallen, Switzerland
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