Abstract
The pathophysiology behind thrombus formation in paroxysmal atrial fibrillation (AF) patients is very complex. This can be due to left atrial (LA) flow changes, remodeling, or both. We investigated differences for cardiovascular magnetic resonance (CMR)-derived LA 4D flow and remodeling characteristics between paroxysmal AF patients and patients without cardiac disease. In this proof-of-concept study, the 4D flow data were acquired in 10 patients with paroxysmal AF (age = 61 ± 8 years) and 5 age/gender matched controls (age = 56 ± 1 years) during sinus rhythm. The following LA and LA appendage flow parameters were obtained: flow velocity (mean, peak), stasis defined as the relative volume with velocities < 10 cm/s, and kinetic energy (KE). Furthermore, LA global strain values were derived from b-SSFP cine images using dedicated CMR feature-tracking software. Even in sinus rhythm, LA mean and peak flow velocities over the entire cardiac cycle were significantly lower in paroxysmal AF patients compared to controls [(13.1 ± 2.4 cm/s vs. 16.7 ± 2.1 cm/s, p = 0.01) and (19.3 ± 4.7 cm/s vs. 26.8 ± 5.5 cm/s, p = 0.02), respectively]. Moreover, paroxysmal AF patients expressed more stasis of blood than controls both in the LA (43.2 ± 10.8% vs. 27.8 ± 7.9%, p = 0.01) and in the LA appendage (73.3 ± 5.7% vs. 52.8 ± 16.2%, p = 0.04). With respect to energetics, paroxysmal AF patients demonstrated lower mean and peak KE values (indexed to maximum LA volume) than controls. No significant differences were observed for LA volume, function, and strain parameters between the groups. Global LA flow dynamics in paroxysmal AF patients appear to be impaired including mean/peak flow velocity, stasis fraction, and KE, partly independent of LA remodeling. This pathophysiological flow pattern may be of clinical value to explain the increased incidence of thromboembolic events in paroxysmal AF patients, in the absence of actual AF or LA remodeling.
Highlights
The pathophysiology behind thrombus formation in paroxysmal atrial fibrillation (AF) patients is very complex
Kinetic energy values indexed to maximum left atrial (LA) volume revealed markedly lower values in patients with paroxysmal AF compared to controls
We have found that all mean and peak flow velocities determined over the whole cardiac cycle in the left atrium were significantly lower in patients with paroxysmal AF and stasis fraction was higher compared to age/gender matched controls
Summary
The pathophysiology behind thrombus formation in paroxysmal atrial fibrillation (AF) patients is very complex. Global LA flow dynamics in paroxysmal AF patients appear to be impaired including mean/peak flow velocity, stasis fraction, and KE, partly independent of LA remodeling This pathophysiological flow pattern may be of clinical value to explain the increased incidence of thromboembolic events in paroxysmal AF patients, in the absence of actual AF or LA remodeling. With subclinical AF, no clear temporal relation was found between the occurrence of stroke and episodes of A F7 These observations suggest that reduced LA global flow may persist during sinus rhythm and may increase the risk of thromboembolic events, even in the absence of AF. Cardiovascular magnetic resonance (CMR) allows detailed assessment of atrial remodeling and four-dimensional (4D) flow a nalysis[12] This 4D flow analysis enables an elaborate description of intra-atrial 3-directional flow velocities during the cardiac cycle and its derivatives, including stasis fraction and kinetic energy (KE). Combined with CMR feature tracking13, 4D flow analysis may provide new insights into atrial hemodynamics in paroxysmal AF, leading to a better understanding of mechanisms of reduced LA blood flow
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