Assessment of Left Atrial Pressure–Area Relation in Humans by Means of Retrograde Left Atrial Catheterization and Echocardiographic Automatic Boundary Detection: Effects of Dobutamine

Abstract

Objectives. This study sought to validate and apply a new method for obtaining the left atrial (LA) pressure–area relation.Background. In physiologic investigations, the pressure–area relation is the most accurate and representative index of LA hemodynamic status.Methods. We applied real-time two-dimensional echocardiographic imaging with automatic boundary detection to estimate LA area changes. To obtain LA pressure, a catheter-tipped micromanometer was introduced retrogradely into the left atrium using a steerable cardiac catheter developed at our institution. Twenty-five patients (11 normal subjects, 7 patients with an enlarged left atrium due to heart failure, 7 patients with atrial fibrillation) were studied before and after dobutamine administration. From the LA pressure–area relation, the area of the A loop (the first counterclockwise loop) and the V loop (the second clockwise loop), the pressure–minimal area relation and the LA passive elastic chamber stiffness constant were measured.Results. Normalized pressure–minimal area relation was highly linear and sensitive to changes in inotropic state (normal subjects: from 0.96 to 1.27 mm Hg/cm2, p < 0.01; patients with heart failure: from 0.59 to 0.68 mm Hg/cm2, p = NS; patients with atrial fibrillation: from 0.80 to 1.06 mm Hg/cm2, p < 0.05). The LA stroke work index was accurately calculated, and a very good correlation was found with LA preload. LA stroke work index was lower in patients with heart failure (3.9 ± 0.8 cm2·mm Hg, p < 0.001), whereas the LA stiffness constant was increased in patients with heart failure (0.801 ± 0.097 cm−2, p < 0.01) and atrial fibrillation (0.796 ± 0.091 cm−2, p < 0.01) compared with normal subjects (stroke work index 7.3 ± 1.9 cm2·mm Hg, stiffness constant 0.623 ± 0.107 cm−2, respectively). In addition, increased inotropic state after dobutamine administration resulted in improved LA pump function (stroke work index) in normal subjects (from 10.2 ± 0.9 to 13.8 ± 1.9 cm2·mm Hg, p < 0.001) and patients with heart failure (from 4.3 ± 0.4 to 7.6 ± 0.4 cm2·mm Hg, p < 0.001), as well as in decreased stiffness constant in all groups of patients (normal subjects: from 0.712 ± 0.141 to 0.473 ± 0.089 cm−2; patients with heart failure: from 0.896 ± 0.181 to 0.494 ± 0.093 cm−2; patients with atrial fibrillation: from 0.779 ± 0.145 to 0.467 ± 0.086 cm−2, p < 0.001).Conclusions. The method described here is both safe and reproducible for obtaining the LA pressure–area relation. LA function is impaired in patients with heart failure and in those with atrial fibrillation and may be acutely improved with inotropic agents in both normal and diseased atria.