Incremental value of left atrial strain to predict atrial fibrillation recurrence after cryoballoon ablation

Chemotherapy Related Cardiotoxicity Evaluation-A Contemporary Review with a Focus on Cardiac Imaging

The long-term survivorship of patients diagnosed with cancer has improved due to accelerated detection and rapidly evolving cancer treatment strategies. As such, the evaluation and management of cancer therapy related complications has become increasingly important, including cardiovascular complications. These have been captured under the umbrella term "cardiotoxicity" and include left ventricular dysfunction and heart failure, acute coronary syndromes, valvular abnormalities, pericardial disease, arrhythmia, myocarditis, and vascular complications. These complications add to the burden of cardiovascular disease (CVD) or are risk factors patients with cancer treatment are presenting with. Of note, both pre- and newly developing CVD is of prognostic significance, not only from a cardiovascular perspective but also overall, potentially impacting the level of cancer therapy that is possible. Currently, there are varying recommendations and practices regarding CVD risk assessment and mitigating strategies throughout the cancer continuum. This article provides an overview on this topic, in particular, the role of cardiac imaging in the care of the patient with cancer. Furthermore, it summarizes the current evidence on the spectrum, prevention, and management of chemotherapy-related adverse cardiac effects.

Effect of volume infusion on left atrial strain in acute circulatory failure

BACKGROUND

Left atrial strain (LAS) is a measure of atrial wall deformation during cardiac cycle and reflects atrial contribution to cardiovascular performance. Pathophysiological significance of LAS in critically ill patients with hemodynamic instability has never been explored. This study aimed at describing LAS and its variation during volume expansion and to assess the relationship between LAS components and fluid responsiveness.

METHODS

This prospective observational study was performed in a French ICU and included patients with acute circulatory failure, for whom the treating physician decided to proceed to volume expansion (rapid infusion of 500 mL of crystalloid solution). Trans-thoracic echocardiography was performed before and after the fluid infusion. LAS analysis was performed offline. Fluid responsiveness was defined as an increase in velocity-time integral (VTI) of left ventricular outflow tract ≥ 10%.

RESULTS

Thirty-eight patients were included in the final analysis. Seventeen (45%) patients were fluid responders. LAS analysis had a good feasibility and reproducibility. Overall, LAS was markedly reduced in all its components, with values of 19 [15 - 32], -9 [-19 - -7] and - 9 [-13 - -5] % for LAS reservoir (LASr), conduit (LAScd) and contraction (LASct), respectively. LASr, LAScd and LASct significantly increased during volume expansion in the entire population. Baseline value of LAS did not predict fluid responsiveness and the changes in LAS and VTI during volume expansion were not significantly correlated.

CONCLUSIONS

LAS is severely altered during acute circulatory failure. LAS components significantly increase during fluid administration, but cannot be used to predict or assess fluid responsiveness.

Nomogram to predict recurrence risk factors in patients with non-valvular paroxysmal atrial fibrillation after catheter radiofrequency ablation

BACKGROUND

Radiofrequency catheter ablation (RFCA) is an effective method for controlling the heart rate of paroxysmal atrial fibrillation (PAF). However, recurrence is trouble under the RFCA. To gain a deeper understanding of the risk factors for recurrence in patients, we created a nomogram model to provide clinicians with treatment recommendations.

METHODS

A total of two hundred thirty-three patients with PAF treated with RFCA at Guizhou Medical University Hospital between January 2021 and December 2022 were consecutively included in this study, and after 1 year of follow-up coverage, 166 patients met the nadir inclusion criteria. Patients with AF were divided into an AF recurrence group and a non-recurrence group. The nomogram was constructed using univariate and multivariate logistic regression analyses. By calculating the area under the curve, we analyzed the predictive ability of the risk scores (AUC). In addition, the performance of the nomogram in terms of calibration, discrimination, and clinical utility was evaluated.

RESULTS

At the 12-month follow-up, 48 patients (28.92%) experienced a recurrence of AF after RFCA, while 118 patients (71.08%) maintained a sinus rhythm. In addition to age, sex, and TRV, LAD, and TTPG were independent predictors of recurrence of RFCA. The c-index of the nomogram predicted AF recurrence with an accuracy of .723, showing good decision curves and a calibrated nomogram, as determined by internal validation using a bootstrap sample size of 1000.

CONCLUSION

We created a nomogram based on multifactorial logistic regression analysis to estimate the probability of recurrence in patients with atrial fibrillation 1 year after catheter ablation. This plot can be utilized by clinicians to predict the likelihood of recurrence.

Impact of enzyme replacement therapy and migalastat on left atrial strain and cardiomyopathy in patients with Fabry disease

Aims

Cardiomyopathy in Fabry disease (FD) is a major determinant of morbidity and mortality. This study investigates the effects of FD-specific treatment using enzyme replacement therapy (ERT) and chaperone therapy on left atrial (LA) function using two-dimensional speckle tracking echocardiography (2DSTE).

Methods and results

In this prospective observational single-center study, 20 FD patients [10 (50%) females] treated with migalastat, 48 FD patients [24 (50%) females] treated with ERT (agalsidase-alfa and agalsidase-beta), and 30 untreated FD patients (all females) as controls were analyzed. The mean follow-up time ranged from 26 to 81 months. 2DSTE was performed for left ventricle strain, right ventricle strain, and LA strain (LAS). FD-specific treated patients presented with increased left ventricular mass index (LVMi) and higher frequency of left ventricular hypertrophy at baseline, whereas untreated control patients showed normal baseline values. FD-specific treated (including migalastat and ERT) patients showed stabilization of LAS over time (p > 0.05). LVMi was also stable in treated FD patients during observation (p > 0.05).

Conclusion

In patients with FD, treated with either ERT or chaperone therapy, LAS values measured by echocardiographic speckle tracking were stable over time, pointing toward disease stabilization.

Unmasking Pandemic Echoes: An In-Depth Review of Long COVID's Unabated Cardiovascular Consequences beyond 2020

At the beginning of 2020, coronavirus disease 2019 (COVID-19) emerged as a new pandemic, leading to a worldwide health crisis and overwhelming healthcare systems due to high numbers of hospital admissions, insufficient resources, and a lack of standardized therapeutic protocols. Multiple genetic variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been detected since its first public declaration in 2020, some of them being considered variants of concern (VOCs) corresponding to several pandemic waves. Nevertheless, a growing number of COVID-19 patients are continuously discharged from hospitals, remaining symptomatic even months after their first episode of COVID-19 infection. Long COVID-19 or 'post-acute COVID-19 syndrome' emerged as the new pandemic, being characterized by a high variability of clinical manifestations ranging from cardiorespiratory and neurological symptoms such as chest pain, exertional dyspnoea or cognitive disturbance to psychological disturbances, e.g., depression, anxiety or sleep disturbance with a crucial impact on patients' quality of life. Moreover, Long COVID is viewed as a new cardiovascular risk factor capable of modifying the trajectory of current and future cardiovascular diseases, altering the patients' prognosis. Therefore, in this review we address the current definitions of Long COVID and its pathophysiology, with a focus on cardiovascular manifestations. Furthermore, we aim to review the mechanisms of acute and chronic cardiac injury and the variety of cardiovascular sequelae observed in recovered COVID-19 patients, in addition to the potential role of Long COVID clinics in the medical management of this new condition. We will further address the role of future research for a better understanding of the actual impact of Long COVID and future therapeutic directions.

Left atrial functions in the early period after cryoballoon ablation for paroxysmal atrial fibrillation

PURPOSE

In patients with paroxysmal atrial fibrillation (PAF), functional changes are observed in the left atrium (LA) after pulmonary vein isolation (PVI) procedure. Although previous studies have investigated the altered mechanical functions of the LA with radiofrequency (RF) ablation, changes in the LA functions in the early period after cryoablation (CB-2) have not been clearly demonstrated. This study aims to explore the early periodical changes in mechanical functions of the LA in patients with PAF who underwent CB-2 based ablation through the help of echocardiographic methods which contain Doppler and strain parameters.

METHODS

Consecutive 77 patients (mean age: 57.5 ±  11.2; 57% men) with PAF underwent CB-2 were prospectively analyzed. All patients were in sinus rhythm before and after the procedure. The LA dimensions, the LA reservoir strain, the LA atrial contractile strain and the LA conduit strain and left ventricular diastolic function parameters were evaluated by Doppler echocardiography before and 3 months after the procedure.

RESULTS

Acute procedural success was achieved in all cases. No major complications were observed. LA reservoir strain and LA contractile strain showed significant recovery after the procedure. (28.3 ± 12.8 vs. 34.6 ± 13.8, p < .001 and -10.8 ± 7.9 vs. -13.9 ± 9.3, p = .014 respectively). No significant change was demonstrated in other echocardiographic parameters.

CONCLUSION

Significant improvement in mechanical functions may occur even in the early period after cryoballoon ablation in patients with PAF.

Value of Left Atrial Strain in Predicting Recurrence after Atrial Fibrillation Ablation

This study tested the relationship between left atrial (LA) function parameters and the results of pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). Consecutive patients undergoing PVI for the first time between 2019 and 2021 were included. Patients underwent radiofrequency ablation using contact force catheters and an electroanatomical system. Follow-up consisted of ambulatory visits/televisits and 7-day Holter monitoring (at 6 and 12 months after ablation). On the day of ablation, all patients underwent transesophageal and transthoracic echocardiography with LA strain analysis. The primary endpoint was atrial tachyarrhythmia recurrence during the follow-up period. Of 221 patients, 22 did not meet the echocardiographic quality criteria, leaving 199 patients. The median follow-up period was 12 months, and 12 patients were lost to follow-up. Recurrences were observed in 67 patients (35.8%) after a mean of 1.06 procedures per patient. The patients were divided into a sinus rhythm (SR, n = 109) group and an AF (n = 90) group based on their cardiac rhythm at the time of echocardiography. In the SR group, univariable analysis showed that LA reservoir strain, LA appendage emptying velocity (LAAV), and LA volume index predicted AF recurrence, with only LAAV being significant in the multivariable analysis. In AF patients, univariable analysis revealed no LA strain parameters predicting AF recurrence.

Imaging in atrial fibrillation: A way to assess atrial fibrosis and remodeling to assist decision-making

The 2020 ESC atrial fibrillation (AF) guidelines suggest the novel 4S-AF scheme for the characterization of AF. Imaging techniques could be helpful for this objective in everyday clinical practice, and information derived from these techniques reflects basic aspects of the pathophysiology of AF, which may facilitate treatment decision-making, and optimal management of AF patients. The aim of this review is to provide an overview of the mechanisms associated with atrial fibrosis and to describe imaging techniques that may help the management of AF patients in clinical practice. Transthoracic echocardiography is the most common procedure given its versatility, safety, and simplicity. Transesophageal echocardiography provides higher resolution exploration, and speckle tracking echocardiography can provide incremental functional and prognostic information over conventional echocardiographic parameters. In addition, LA deformation imaging, including LA strain and strain rate, are related to the extent of fibrosis. On the other hand, multidetector-row computed tomography and cardiac magnetic resonance provide higher resolution data and more accurate assessment of the dimensions, structure, and spatial relationships of the LA. Imaging is central when deciding on catheter ablation or cardioversion, and helps in selecting those patients who will really benefit from these procedures. Moreover, imaging enhances the understanding of the underlying mechanisms of atrial remodeling and might assists in refining the risk of stroke, which help to select the best medical therapies/interventions. In summary, evaluation of LA enlargement, LA remodeling and fibrosis with imaging techniques adds clinical and prognostic information and should be assessed as a part of routine comprehensive AF evaluation.

Additional value of left atrium remodeling assessed by three-dimensional echocardiography for the prediction of atrial fibrillation recurrence after cryoballoon ablation

Cryoballoon ablation (CBA) is a safe and efficient therapeutic option for atrial fibrillation (AF). However, AF recurrence occurs in 25% of the patients, leading to repeated ablations and complications. Previous reports have shown that left atrium (LA) assessed by M-Mode and two-dimensional echocardiography (2DE) predicts AF recurrence. Nevertheless, these methods imply geometrical assumptions of the LA remodeling, which is a three-dimensional process. We hypothesized that LA remodeling by three-dimensional echocardiography (3DE) has an additional value for AF recurrence prediction post-CBA. 172 consecutive patients (62.2 ± 12.2 years, 61% male) were prospectively recruited. Echocardiography was performed before CBA. Blanking period was defined as the first three months post-ablation. The primary endpoint was AF recurrence after the blanking period. 50 (29%) patients had AF recurrence. 3DE LA maximum volume index (LAVI) had the highest incremental predictive value for AF recurrence (HR 5.50, 95% CI 1.34 -22.45, p < 0.001). In patients with non-dilated LA diameter index and LAVI by 2DE, LAVI by 3DE was able to discriminate AF recurrence with a sensitivity of 90% and a specificity of 66%, for an optimal cut-off value of 30.4 ml/m2. LA remodeling by 3DE predicted AF recurrence, even in patients with non-dilated LA by M-Mode and 2DE, suggesting that 3DE might reflect better and earlier the asymmetric and variable nature of LA remodeling and it should be considered for systematic use to evaluate AF recurrence risk post-CBA.

The Added Value of Atrial Strain Assessment in Clinical Practice

Speckle tracking echocardiography has emerged as a sensitive tool to analyze myocardial function with improved diagnostic accuracy and prognostic value. Left atrial strain assessment has become a novel imaging method in cardiology with superior prognostic value compared to conventional left atrial volume indices. Left atrial function is divided into three phases, reservoir function being the most important. This review summarizes the added value of speckle tracking echocardiography derived left atrial strain assessment in clinical practice. Recently published data suggest the prognostic value of left atrial reservoir function in heart failure, atrial fibrillation, stroke and valvular heart disease. Furthermore, left atrial reservoir strain proved to be a predictor of cardiovascular morbidity and mortality in the general population. Thus, routine assessment of left atrial function can be an optimal strategy to improve cardiovascular risk prediction and supplement the current risk prediction models.