Atrial Abnormalities Research Articles

The relationship between “Normal” transesophageal color-flow doppler-defined tricuspid regurgitation and thermodilution right ventricular ejection fraction measurements

Twenty coronary artery revascularization patients, aged 58 ± 15 years, were studied intraoperatively to define the impact of Doppler-defined tricuspid regurgitation on measurement of thermodilution right ventricular ejection fraction (50 msec response pulmonary artery catheter). Right ventricular function was also estimated using a measurement technique independent of flow patterns across the tricuspid valve (transesophageal two-dimensional echocardiographic 5.0 MHz phased-array transducer). Measurements included transverse plane long- and short-axis planimetered area ratio, respectively, and tricuspid annular plane systolic excursion ratio (ratio = end-diastolic minus end-systolic value divided by end-diastolic value). Data were expressed as thermodilution-echocardiographic gradients, ie, thermodilution ejection fraction minus long-axis planimetered area ratio, short-axis planimetered area ratio, and tricuspid annular plane systolic excursion ratio, respectively. Tricuspid regurgitation was quantified by color-flow Doppler perimetry of maximal regurgitation jet area and analysis of transduced right atrial pressure waveform. Doppler estimates were expressed as absolute values and as a function of corresponding atrial area (tricuspid regurgitation index = planimetered jet area divided by right atrial area). Data were obtained following endotracheal intubation, sternotomy, pericardiotomy, cardiopulmonary bypass, and chest closure. Data were evaluated by regression analysis, with separate analyses performed for each time period. Profiles were unassociated with right atrial pressure waveform abnormalities. There was no significant relationship between thermodilution ejection fraction variance values and tricuspid regurgitation jet area or regurgitation index, respectively. In each measurement period, thermodilution-echocardiographic gradients were also unrelated to the tricuspid regurgitation estimates. These findings suggest that transesophageal color-flow Doppler evidence of tricuspid regurgitation, without atrial pressure waveform abnormalities, does not invalidate thermodilution right ventricular ejection fraction data.

Pitfalls in the echo-Doppler diagnosis of prosthetic valve disorders.

Assessment of artificial heart valves is a classic example of pitfalls in Doppler and color flow echocardiography. These limitations should be analyzed in the context of the most common clinical conditions associated with prosthetic valve dysfunction, that is, assessment of stenosis, regurgitation, endocarditis, and source of emboli. Estimation of the mean transvalvular gradient in addition to valve areas may avoid potential problems of over- or underestimation of stenotic lesions. The combination of acoustic attenuation, acoustic shadowing, and jet(s) eccentricity makes accurate grading of prosthetic regurgitation difficult and often frustrating. Reverberations and side lobe are frequent artifacts that decrease the ability of two-dimensional echocardiography to identify endocarditis-induced lesions such as vegetations and abscesses, as well as potential sources of emboli such as thrombus and atrial septal abnormalities. Transesophageal echocardiography has provided a new window in the evaluation of prosthetic cardiac valve function. With this approach, high frequency, high resolution transducers greatly improve the quality of ultrasound and color flow Doppler images that result in a higher diagnostic yield. In patients with suspected mitral prosthesis malfunction, transesophageal echocardiography is the method of choice. Contrast study during the transesophageal examination increases the sensitivity to detect potential sources of emboli such as patent foramen ovale. The improvement in diagnostic accuracy may allow one to avoid further diagnostic tests and, in selected patients, it may facilitate optimal timing of a surgical intervention.

Sinus node disease. Current concepts in diagnosis and therapy.

Sinus node disease (SND) encompasses a number of abnormalities of sinus impulse generation and transmission within the atria and may lead to both bradyarrhythmias and tachycardias. Such abnormalities may be due to primary atrial electrophysiological abnormalities, or be secondary to drugs or abnormal autonomic control. The diagnosis may be readily established from the surface ECG or Holter recordings in many cases, but invasive electrophysiological study or assessment of the effects of autonomic blockade may be required in symptomatic patients in whom the diagnosis is suspected but not confirmed by simple electrocardiographic monitoring. Treatment should be restricted to those patients in whom clear correlation between symptoms and electrocardiographic or electrophysiological abnormalities has been established. Although a number of pharmacological agents have been assessed, the treatment of bradyarrhythmias should be permanent pacing. There is now substantial evidence that physiological (atrial or dual chamber) pacing reduces atrial arrhythmias, systemic embolisation, progression to heart failure and mortality, compared to single chamber ventricular pacing. Antiarrhythmic therapy may be required to control atrial tachyarrhythmias if they persist following pacing. In patients with uncontrolled atrial arrhythmias, especially those with ventricular pacemakers, long term oral anticoagulation should be considered to reduce the risk of systemic embolisation which is a common complication in patients with the bradycardia/tachycardia syndrome.

Lipomatous Hypertrophy of the Interatrial Septum

Lipomatous hypertrophy of the interatrial septum is a clinicopathological entity defined as an accumulation of fatty tissue exceeding 15 mm in thickness in the interatrial septum above the fossa ovalis. It is clinically associated with atrial electric abnormalities, interference with venous return, and sudden death. Transesophageal echocardiography is superior to transthoracic echocardiography for the study of the interatrial septum. We describe one case of lipomatous hypertrophy of the interatrial septum in which transesophageal echocardiography was used, we believe for the first time, to study the interatrial septal anatomy.

Initial clinical experience with a 48 by 48 element biplane transesophageal probe

Recent technologic advances in ultrasound have resulted in the capability of transesophageal echocardiographic imaging in both transverse and longitudinal planes. Previous biplane probes suffered from inferior images because of reduced scan elements. We evaluated the utility of a prototype 48 × 48 element biplane transesophageal probe in 23 consecutive patients. Examinations were well tolerated with no side effects. In comparison to the single transverse plane, imaging with the longitudinal plane gave superior information on prosthetic valve pathology, atrial septal abnormalities, and pathoanatomy of the ascending aorta and mitral valve. Complementary information was provided by the longitudinal plane in patients with endocarditis and vegetations and in mitral protheses. Images obtained with this 48 × 48 element biplane probe along with color and spectral Doppler information were not perceptibly inferior to those obtained by single-plane probes. In conclusion, biplane transesophageal echocardiography with a 48 × 48 element probe indicates a great potential for enhanced three-dimensional understanding of cardiac pathology and diagnostic yield in specific pathologies.

Electrocardiographic signs of atrial overload in hypertensive patients: Indexes of abnormality of atrial morphology or function?

Left atrial electrocardiographic (ECG) abnormalities have been reported as common findings in hypertension; however, their relationships with atrial anatomy are still uncertain. In addition, in arterial hypertension several studies demonstrated an abnormal left ventricular filling. The aim of this study was to investigate the relationships of the ECG signs of left atrial abnormality to atrial anatomy and left ventricular filling as evaluated by pulsed-wave (PW) Doppler in a group of patients with uncomplicated essential hypertension. To this end, 53 untreated essential hypertensive patients (age 44 ± 8 years; blood pressure 160.5 ± 21.5/104.7 ± 13.5 mm Hg) underwent a complete 12-lead ECG and a PW Doppler study of the transmitral flow velocities. The ECG criteria of left atrial abnormality were: P wave wider than 0.12 (or 0.10) second or higher than 0.25 mV in lead II; P wave/PR segment ratio (Macruz index) greater than 1.6 in lead II; and P wave terminal forces in lead V 1 equal to or more negative than 0.04. Echocardiographic measurements were made according to American Society of Echocardiography (ASE) convention. Doppler parameters of left ventricular filling were measured as E and A peak velocity, A E ratio, and the ratio between the velocity-time integral under the E peak and that of the whole diastolic flow, which represents the rapid filling fraction (RFF). At least one ECG sign of atrial abnormality was present in 34 patients (64%); the Macruz index gave the most common ECG index of atrial abnormality (31 patients). The group of patients with a Macruz index greater than 1.6 had a significantly greater relative contribution to left ventricular filling, thicker left ventricular walls, a faster heart rate but no different atrial dimensions ( p from <0.05 to <0.001). In a subgroup matched for R-R interval, significant differences between patients with normal and abnormal Macruz index were still observed for interventricular septum thickness and A peak. Echocardiographic left atrial (LA) dimension did not show any significant correlation with the ECG parameters of LA involvement. On the contrary, significant correlations were observed between several ECG indexes of atrial abnormality and A, A E , RFF, and heart rate. In conclusion, our results suggest that, at least in hypertensive patients, the ECG signs of LA abnormality are more related to increased atrial work, possibly secondary to an impaired ventricular filling, rather than to LA enlargement.

Sustained intraatrial reentrant tachycardia: Clinical, electrocardiographic and electrophysiologic characteristics and long-term follow-up

Although intraatrial reentry has been traditionally listed as a mechanism for supraventricular tachycardia, few reports describing the clinical features of this arrhythmia exist. Nineteen patients with a clinical history of sustained supraventricular tachycardia were diagnosed as having intraatrial reentrant tachycardia. Seventeen (89%) patients of the 19 had underlying structural heart disease and 17 had echocardiographic evidence of atrial enlargement; the mean left ventricular ejection fraction was 51 +/- 16%. A history of concomitant atrial fibrillation or flutter was present in 13 patients (68%). The mean atrial cycle length during tachycardia was 326 +/- 57 ms (range 260 to 460). Fourteen patients had 1:1 atrioventricular (AV) conduction during tachycardia, of whom 50% had an RP'/RR' ratio greater than 0.5. Intravenous adenosine (dose range 37.5 to 150 micrograms/kg) and verapamil (dose range 5 to 10 mg) had no effect on atrial tachycardia cycle length in 13 of 14 and 9 of 9 patients, respectively, despite induction of second degree AV block. Type 1a antiarrhythmic drugs achieved long-term suppression of intraatrial reentrant tachycardia in only 6 patients, whereas amiodarone (326 +/- 145 mg/day) was successful in 11 patients during a 32 +/- 20 month follow-up period. The remaining two patients and one patient who later developed amiodarone toxicity either progressed to (n = 1) or had (n = 2) catheter-induced high grade AV block and were treated with long-term ventricular pacing. It is concluded that intraatrial reentrant tachycardia is often associated with structural heart disease, particularly of types that cause atrial abnormalities, but left ventricular dysfunction is not a requisite finding. Other arrhythmias are frequently observed in these patients. This arrhythmia responds poorly to type 1a antiarrhythmic drugs, but is effectively treated with amiodarone. Catheter ablation of the AV junction offers a therapeutic option for patients who are refractory to medical therapy.

Mode of onset of atrial fibrillation in the Wolff-Parkinson-White syndrome: How important is the accessory pathway?

The mode of onset of 103 episodes of atrial fibrillation lasting ≥30 s was studied in 79 patients with the Wolff-Parkinson-White syndrome during electrophysiologic study. No patient had organic heart disease, and 31 had clinical atrial fibrillation before study. These 79 patients were then compared with a control group of 53 patients with Wolf-Parkinson-White syndrome in whom atrial fibrillation could not be induced.Ninety-five of the 103 episodes were technically suitable for analysis. Atrial fibrillation invariably began with rapid atrial tachycardia that became progressively disorganized within 10 to 20 cycles. It was initiated during right atrial stimulation (n = 52), right ventricular stimulation (n = 8), reciprocating tachycardia (n = 33) and spontaneously (n = 2). Most episodes started at a high right atrial site regardless of accessory pathway location, with only 19% of episodes starting at the electrode closest to the accessory pathway. During reciprocating tachycardia (n = 33), either atrial (n = 8) or ventricular (n = 5) extrastimuli initiated atrial fibrillation. Atrial fibrillation started at the accessory pathway site in 6 of 20 episodes occurring spontaneously during reciprocating tachycardia. Patients with atrial fibrillation had a longer PA interval (54 ± 14 versus 42 ± 12 ms, p < 0.0001), shorter atrial functional refractory period (226 ± 38 versus 240 ± 30 ms, p = 0.049) and shorter anterograde effective refractory period of the accessory pathway (279 ± 26 versus 304 ± 75 ms, p = 0.03). Clinical reciprocating tachycardia was documented with equal frequency in both the atrial fibrillation and control groups (59.5% versus 52.9%, p = 0.58).These data suggest that atrial abnormalities independent of the accessory pathway play an important role in the onset of atrial fibrillation in the Wolff-Parkinson-White syndrome.

Giant P wave in a patient with right ventricular cardiomyopathy

A P wave of 7.5 mm in lead I and 12.5 in V1 was detected in a 28-year-old man, with a progressive cardiomegaly since the age of 14 years. At last admission he had minor symptoms, and a systolic murmur consistent with tricuspid regurgitation. The electrocardiogram showed an extremely tall P wave and a QRS of a very low amplitude; T waves were inverted on the precordial leads. These ECG features, and subsequent investigations, were consistent with right ventricular cardiomyopathy with massive tricuspid regurgitation, and right atrial abnormality.

Umbilical catheter masquerading at echocardiography as a left atrial

The case of a newborn who had an umbilical catheter inserted in the intensive care unit is discussed. This catheter was meant to be inserted into the umbilical artery, but was instead inadvertently inserted into the umbilical vein. It crossed a patent foramen ovale into the left atrium. This fact was not known at the time of echocardiographic evaluation. At echocardiography, abnormal echoes within the left atrium were seen. Findings were typical for a catheter within the heart, and the umbilical catheter was subsequently withdrawn. There is a potential for mistaking the echocardiographic findings for a left atrial abnormality and echocardiographers should be alert to this possibility.

Predictors of rhythm disturbances and subsequent morbidity after the Fontan operation

The electrocardiographic, hemodynamic and surgical data of 30 patients who underwent a Fontan operation between 1977 and 1986 were retrospectively reviewed to identify the incidence and predictors of immediate and late postoperative arrhythmias and associated morbidity in long-term survivors. Of 4 patients who died <1 year after operation (mortality 13%), 1 death was related to an arrhythmia. Three patients were not in sinus rhythm before operation and were excluded from the statistical analysis that examined predictors of arrhythmias. The remaining 23 long-term survivors have been followed 6.3 ± 2.6 years (mean ± standard deviation) since surgery and all remain in New York Heart Association functional class I or II. Ten patients (43%) developed immediate postoperative arrhythmias (≤ 30 days) whereas 11 (48%) had late arrhythmias. With up to 10.7 years of followup, the proportion of patients free from late arrhythmias continues to decline. Arrhythmias included bradyarrhythmias, atrial tachyarrhythmias, the tachy-brady syndrome and supraventricular ectopic activity. Immediate postoperative arrhythmias predicted late arrhythmias (p = 0.022). The preoperative electrocardiogram was the only variable useful in predicting both immediate and late postoperative arrhythmias. A more negative P-wave deflection in lead V 1 (-2.4 ± 0.7 vs -1.4 ± 1.2 mV, p = 0.02) predicted patients with immediate postoperative arrhythmias, whereas both greater P-wave duration and a more negative deflection in this lead predicted late arrhythmias (103 ± 14 vs 83 ± 20 ms, p = 0.01, and -2.5 ± 0.8 vs −1.3 ±1.0 mV, p = 0.005, respectively). Of the 26 surviving patients, 10 (38%) have required ≥1 hospitalizations for control of late arrhythmias. Eight patients are receiving maintenance therapy with multiple antiarrhythmic drugs including amiodarone (1 patient) and 5 have received permanent epicardial pacemakers. Thus, despite excellent functional results after the Fontan operation, postoperative arrhythmias are frequent and cause significant morbidity that will continue to increase with time. Atrial abnormalities on the preoperative electrocardiogram predict those patients who will develop arrhythmias both in the immediate and late postoperative periods. The appearance of an immediate postoperative arrhythmia also predicts the subsequent development of late arrhythmias. Recognition of these predictors may facilitate monitoring and therapy of such patients.

Epidemiology of rheumatic heart disease among primary school children in Western Kenya

A community survey was conducted to determine the prevalence of rheumatic heart disease in Kenyan children in all primary schools in 2 sublocations in Western Kenya. In total, 3631 children (97% school attendance) aged from 5 to 15 years were examined by one experienced physician and 2 cardiologists between September and December 1985. Six children were found to have evidence of rheumatic heart disease, giving a prevalence rate of 1.7 1000 . As all cases occurred in the age group between 10 and 15 years, the rate was calculated for this group as 2.4 1000 . None of these patients had previously been diagnosed as having rheumatic fever. There were 3 males and 3 females. Four patients had mitral regurgitation, one had aortic regurgitation and one had mitral stenosis. Three had electrocardiographic evidence of left atrial abnormality and one showed findings of left ventricular hypertrophy but two patients had normal tracings. Half were symptomatic with dyspnoea on exertion and two gave a history of fleeting polyarthritis. The socio-economic status (peasant), family size (mean = 6 siblings) and the number of children sleeping per room were the same in both the cases with rheumatic heart disease and their controls. The health workers achieved low scores (mean 26%) with regard to the clinical diagnosis, treatment and prevention of rheumatic fever at the level of primary health care. Rheumatic heart disease, nonetheless, was relatively insignificant in the overall picture of health care of school children in Western Kenya.

Left atrial enlargement: An early sign of hypertensive heart disease

Left atrial abnormality on the electrocardiogram (ECG) has been considered an early sign of hypertensive heart disease. In order to determine if echocardiographic left atrial enlargement is an early sign of hypertensive heart disease, we evaluated 10 normal and 14 hypertensive patients undergoing routine diagnostic cardiac catheterization for echocardiographic left atrial enlargement. All patients had normal coronary arteriography, sinus rhythm, normal left ventricular volumes and function, no valvular disease, and no echocardiographic or ECG left ventricular hypertrophy. No patient met ECG criteria for left atrial abnormality. The mean left atrial dimension was 3.46 ± 0.3 cm in normal individuals versus 4.04 ± 0.3 cm in the hypertensive patients ( p < 0.01). The left atrial index was also higher in the hypertensive group, 2.18 ± 0.45 versus 1.88 ± 0.10 cm/m 2 ( p < 0.05), and the left atrial-to-aortic root dimension ratio was significantly higher in the hypertensive group, 1.36 ± 0.20 versus 1.17 ± 0.07 ( p < 0.01). We conclude that echocardiographic left atrial enlargement may be an early sign of hypertensive heart disease in patients with no other discernible cause of left atrial enlargement.

Significance of electrocardiographic isolated abnormal terminal P-wave force (left atrial abnormality). An echocardiographic and clinical correlation

Significance of electrocardiographic isolated abnormal terminal P-wave force (left atrial abnormality). An echocardiographic and clinical correlation

Significance of Electrocardiographic Isolated Abnormal Terminal P-Wave Force (Left Atrial Abnormality)

An abnormal terminal negative deflection in precordial lead V1 (PTFV1) is occasionally present as an isolated electrocardiographic finding. To determine the significance of this, 41 patients with PTFV1 greater than or equal to 0.04 mms were recalled for a repeated electrocardiogram as well as an echocardiographic examination. Patients were classified as cardiovascular normal (n = 15) or abnormal (n = 26). Left atrial enlargement was the most common echocardiographic abnormality found, but represented less than a third of the total. P-wave prolongation (greater than 110 ms) was present in 30 of the 41 patients and 21 of the 26 abnormal patients. This persisted into the second study, while the PTFV1 fell significantly in both the normal and abnormal groups. Among the P-wave abnormalities found, combinations were used to identify patients most likely to have cardiovascular disease. The most discriminating was an initial abnormal PTFV1 in combination with P-wave prolongation (sensitivity, 82%; specificity, 40%; positive predictive value, 70%; and negative predictive value, 55%). Maximal specificity (93%) and positive predictive value (88%) were achieved when P-wave prolongation and PTFV1 greater than or equal to 0.06 mms were present in both studies, although the sensitivity for this criterion was only 27%. The isolated P-wave abnormality described may be helpful in suggesting the presence of underlying cardiovascular disease and indicate the need for further evaluation.

Relationship between plasma atrial natriuretic peptide and left atrial and left ventricular involvement in essential hypertension.

In order to investigate the role of cardiac hypertrophy in atrial natriuretic peptide (ANP) secretion in patients with essential hypertension, plasma levels of ANP were measured after overnight rest in 36 patients with untreated hypertension and in 31 normotensive controls. In the hypertensive subjects, plasma levels were correlated with left ventricular (LV) and left atrial abnormalities detected by chest X-ray, electrocardiogram (ECG) and M-mode echocardiography. Plasma ANP levels in patients with hypertension averaged 146 +/- 27 pg/ml compared to 46 +/- 7 pg/ml in the normotensive subjects (P less than 0.001). In patients with hypertension a significant correlation was found between ANP and supine systolic blood pressure (r = 0.54, P less than 0.001) and between ANP and diastolic blood pressure (r = 0.38, P less than 0.05). Furthermore, plasma ANP levels were correlated with total heart volume (r = 0.68, P less than 0.01), LV mass (r = 0.525, P less than 0.001), LV posterior wall thickness (r = 0.39, P less than 0.05), Sokolow-Lyon index (r = 0.721, P less than 0.001) and end-diastolic diameter of the left atrium (r = 0.334, P less than 0.05). The results suggest a contribution of LV and left atrial abnormalities to ANP secretion in essential hypertension.

Left Atrial Abnormalities Indicating Diastolic Ventricular Dysfunction in Cardiopathy of Obesity

Electrocardiograms and M-mode echocardiograms were evaluated in lean and obese patients, either normotensive or hypertensive, who were paired for mean arterial pressure, age, and sex. Electrocardiographic evidence of left atrial abnormalities (LAA) occurred more frequently (p less than 0.01) and left atrial size was greater in the obese than in the lean patients (p less than 0.01). The left atrial emptying index, an indicator of early diastolic ventricular function, was reduced in obese patients (p less than 0.01), most markedly in those with obesity-hypertension. The left atrial emptying index was reduced in obese patients with electrocardiographic LAA compared to obese patients without this electrocardiographic sign (p less than 0.02). A close correlation (r = 0.61, p less than 0.001) was obtained between the left atrial emptying index and atrial ECG abnormalities. These left atrial abnormalities in obesity and particularly in obesity-hypertension indicate diastolic ventricular dysfunction.

Superior vena cava Doppler: a non-invasive method for the diagnosis of pericardial disease

Superior vena cava Doppler flow velocities were assessed in two patients presenting with cardiac tamponade. Abnormal Doppler flow patterns correlated with right atrial pressure abnormalities characteristic of tamponade and constriction. During tamponade diastolic superior vena cava flow was abolished, and only systolic flow occurred. After pericardiocentesis diastolic flow reappeared. In one patient dominant diastolic flow velocities after pericardiocentesis suggested residual constriction. The flow pattern returned to normal after pericardiectomy, with systolic velocity exceeding diastolic velocity. Serial studies in these patients suggest that Doppler evaluation of superior vena cava blood flow is a useful method for evaluating pericardial disease.

Atrial dissociation: An electrophysiologic finding in a patient with transposition of the great arteries

Complete interatrial block with two independent atrial rhythms is demonstrated by intracardiac electrograms in a patient with transposition of the great arteries who had undergone a Mustard operation. The atrial conduction abnormalities produced by the Mustard procedure with subsequent baffle revision are related to damaged anatomic interatrial connections and are similar to conduction abnormalities produced in experimental models of interatrial block.

Sensitivity of electrocardiographic criteria for left ventricular hypertrophy according to type of cardiac disease

The sensitivity of 30 electrocardiographic criteria for left ventricular (LV) hypertrophy, isolated or combined, was examined to determine the relation to the underlying disease. Patients with coronary artery disease (CAD), systemic hypertension, valvular heart disease and cardiomyopathy were evaluated. A cardiac partition technique was used to define ventricular hypertrophy. Single electrocardiographic criteria often showed high sensitivity for 1 disease state, but not for others. Precordial voltage criteria were most sensitive for those with hypertensive and valvular disease. A QRS axis of more than −30 ° occurred most often in patients with CAD. Both left atrial abnormality and abnormal T-wave inversion of more than 1 mm in V 6 occurred with a high sensitivity in general; however, T-wave inversion of more than 1 mm in V 6 had a low sensitivity in cardiomyopathy. Methods using combinations of various electrocardiographic criteria improved sensitivity. Using these methods, sensitivity of the electrocardiogram for LV hypertrophy was excellent for patients with systemic hypertension and valvular heart disease and acceptable by usual standards for patients with CAD and cardiomyopathy. Because the use of a single criterion is often ineffective, methods using multiple electrocardiographic criteria to detect LV hypertrophy are recommended when the patients under study have diverse cardiac diseases.