Left Atrial Abnormality Research Articles

Evaluation of Left Atrial Mechanical Functions and Atrial Conduction Abnormalities in Maras Powder (Smokeless Tobacco) Users and Smokers

PP-184 Smokeless tobacco can be found in preparations for chewing or for being absorbed by nasal and oral mucosae. In Turkey a type of smokeless tobacco called Maras Powder (MP) is widely used in the southeastern region. The purpose of this study was to investigate whether MP damages intra- and

Early detection of left atrial strain abnormalities by speckle-tracking in patients with chronic kidney disease and normal left atrial size

Early detection of left atrial strain abnormalities by speckle-tracking in patients with chronic kidney disease and normal left atrial size

Echocardiography in newly diagnosed atrial fibrillation patients: a systematic review and economic evaluation

To investigate the clinical effectiveness and cost-effectiveness of transthoracic echocardiography (TTE) in all patients who are newly diagnosed with atrial fibrillation (AF). Narrative synthesis reviews were conducted on the prognostic and diagnostic accuracy of TTE for, and prevalence of, pathologies in patients with AF. Databases were searched from inception. MEDLINE searches were conducted from March to August 2010, and reference lists of articles checked. There were 44 diagnostic accuracy studies, five prognostic studies, and 16 prevalence studies accepted into the review. Given the complexity of the many pathologies identified by TTE, the variety of potential changes to clinical management, and paucity of data, the model focused on changes to oral anticoagulation (OAC). The mathematical model assessed the cost-effectiveness of TTE for patients with AF who were not routinely given OAC, assuming, if left atrial abnormality was detected, that the higher risk of stroke warranted OAC; this meant that patients with a CHADS2 (cardiac failure, hypertension, age, diabetes, stroke doubled) score of 0 [dabigatran etexilate (Pradaxa, Boehringer Ingelheim)/rivaroxaban (Xarelto, Bayer Schering)] or 0/1 (warfarin) were included. A simplified approach evaluated the additional quality-adjusted life-years (QALYs) required in order for TTE to be perceived as cost-effective at a threshold of £20,000 per QALY. Transthoracic echocardiography is usually performed in cardiology clinics but may be used in primary or non-specialist secondary care. Patients with newly diagnosed AF. Transthoracic echocardiography. Prognosis, diagnostic sensitivity or specificity of TTE, prevalence of pathologies in patients with AF, cost-effectiveness and QALYs. Prognostic studies indicated that TTE-diagnosed left ventricular dysfunction, increased left atrial diameter and valvular abnormality were significantly associated with an increased risk of stroke, mortality or thromboembolism. There was a high prevalence (around 25-30%) of ischaemic heart disease, valvular heart disease and heart failure in patients with AF. Diagnostic accuracy of TTE was high, with most pathologies having specificity of ≥ 0.8 and sensitivity of ≥ 0.6. The mathematical model predicted that when the CHADS2 tool is used the addition of TTE in identifying patients with left atrial abnormality appears to be cost-effective for informing some OAC decisions. In the simplified approach a threshold of 0.0033 was required for a TTE to be cost-effective. When CHADS2 was used, the addition of TTE in identifying patients with left atrial abnormality was cost-effective for informing some OAC decisions. A simple analysis indicates that the number of QALYs required for TTE to be cost-effective is small, and that if benefits beyond those associated with a reduction in stroke are believed probable then TTE is likely to be cost-effective in all scenarios. Our findings suggest that further research would be useful, following up newly diagnosed patients with AF who have undergone TTE, to study treatments given as a result of TTE diagnoses and subsequent cardiovascular events. This could identify additional benefits of routine testing, beyond stroke prevention. Studies assessing the proportion of people with a CHADS2 score of 0 or 1 that have left atrial abnormality would provide better estimates of the cost-effectiveness of TTE, and allow more accurate estimates of the sensitivity and specificity of TTE for identifying left atrial abnormality in AF to be obtained. PROSPERO CRD42011001354. The National Institute for Health Research Health Technology Assessment programme.

Correlation of Echocardiographic Left Atrial Abnormality With Myocardial Ischemia During Myocardial Perfusion Assessment in the Presence of Known Left Ventricular Hypertrophy

Left atrial (LA) abnormality, an easily quantifiable parameter of left ventricular (LV) diastolic dysfunction, has been associated with cardiovascular risk similar to that of LV hypertrophy. The correlation between LV hypertrophy and LA abnormality among patients undergoing myocardial perfusion (MP) study has not been described. We prospectively studied 78 consecutive patients with LV hypertrophy who underwent MP study after screening for electrocardiographic and echocardiographic LA abnormality over a 6-month period. Of those, 48 had a positive MP imaging result, and 30 did not. LA size (p = 0.002) and P-wave duration (p = 0.017) were significantly increased in the former. The differential change in LA size (no defect = 35 ± 4, mild = 36 ± 5, moderate = 38 ± 5, severe = 44 ± 5 mm; p <0.0001) and P-wave duration (no defect = 107 ± 14, mild = 110 ± 17, moderate = 113 ± 15, severe = 127 ± 22 ms; p = 0.003) was greatest when the MP study defect exceeded moderate severity. In conclusion, the presence of LA abnormality could assist during MP study interpretation among patients with LV hypertrophy when such markers appear to be correlated with the severity of the MP study defect.

Correlation of Echocardiographic Left Atrial Abnormality With Myocardial Ischemia During Myocardial Perfusion Assessment in Patients With Left Bundle Branch Block

Left atrial (LA) abnormality, an easily quantifiable parameter of left ventricular (LV) diastolic dysfunction, has been associated with cardiovascular risk. Because during myocardial perfusion study (MPS), the abnormal LV activation pattern in patients with left bundle branch block (LBBB) frequently induces perfusion defects, a clinical correlate of early myocardial ischemia such as LA enlargement could alleviate some of these inherent challenges. We prospectively studied 144 consecutive patients with LBBB who underwent MPS after screening for electrocardiographic and echocardiographic LA enlargement over a 6-month period. Of those, 114 had a positive MPS result. We found that LA size (p <0.0001) and P-wave duration (p = 0.001) were significantly increased in patients as the severity of the defects increased on MPS, whereas LV ejection fraction was decrementally reduced (p = 0.001). Importantly, LA size (≥43.5 mm; sensitivity 70%, specificity 89%) and P-wave duration (≥135 milliseconds; sensitivity 63%, specificity 90%) were greatest when the MPS defect was severe. In conclusion, the presence of LA enlargement appears significantly correlated with myocardial ischemia among patients with LBBB and could therefore assist during MPS interpretation among patients in whom MPS interpretation could be challenging.

Mean platelet volume is associated with the presence of left atrial stasis in patients with non-valvular atrial fibrillation

BackgroundMean platelet volume has been associated with stroke in patients with atrial fibrillation. However, its role as a predictor of left atrial stasis, assessed by transesophageal echocardiography, in patients with non-valvular atrial fibrillation has not yet been clarified.MethodsSingle center cross-sectional study comprising 427 patients admitted to the emergency department due to symptomatic atrial fibrillation and undergoing transesophageal echocardiogram evaluation for exclusion of left atrial appendage thrombus before cardioversion. All patients had a complete blood count performed in the 12 hours prior to transesophageal echocardiogram. Markers of left atrial stasis were sought: left atrial appendage thrombus, dense spontaneous echocardiographic contrast and low flow velocities in the left atrial appendage. The presence of at least one of the former markers of left atrial stasis was designated left atrial abnormality. Binary logistic multivariate analysis was used for obtaining models for the prediction of transesophageal echocardiogram endpoints.ResultsLeft atrial appendage thrombus was found in 12.2%, dense spontaneous echocardiographic contrast in 29.7%, low flow velocities in 15.3% and left atrial abnormality in 34.2%. Mean platelet volume (exp β = 3.41 p = 0.048) alongside with previous stroke or transient ischemic attack (exp β = 5.35 p = 0.005) and troponin I (exp β = 5.07 p = 0.041) were independent predictors of left atrial appendage thrombus. Mean platelet volume was also incorporated in the predictive models of dense spontaneous echocardiographic contrast, low flow velocities and left atrial abnormality, adding predictive value to clinical, echocardiographic and laboratory variables.ConclusionsThese findings suggest that mean platelet volume may be associated with the presence of markers of left atrial stasis, reinforcing a likely cardioembolic mechanism for its association with stroke in patients with non-valvular atrial fibrillation.

Predictors of the atrial fibrillation following catheter ablation of typical atrial flutter

Background:Despite technical refinements and improved long-term efficacy of the ablation procedure for treating AFL (AFL), the subsequent occurrence of AF (AF) following this procedure remains a significant clinical problem.Objectives:To determine long-term incidence and predictors of AF after catheter ablation of typical AFL.Material and Methods:Between March 2005 and February 2010, a total of 84 consecutive patients who underwent catheter ablation of documented typical AFL were enrolled.Results:Cavotricuspid isthmus ablation was successful in terminating and preventing the re-induction of AFL in all 84 patients (100%). The mean follow-up duration for study was 26± 22 months. During the follow-up period, early AF occurred in 5% after successful catheter ablation of AFL and late AF in 11% of the patients. The clinical variables associated with the occurrence of AF after catheter ablation of AFL were female, a history of AF before AFL ablation, body mass index (BMI), and left atrial abnormality. However, logistic multivariate analysis demonstrated that only BMI was independently associated with the late AF (OR 1.36, 95% CI 1.11-1.70, P = 0.004).Conclusions:Catheter ablation of flutter circuit will not prevent later manifestation of AF in 16% of the patients undergoing catheter ablation of the typical AFL. BMI was the only independent predictor of AF following catheter ablation of the typical AFL.

Negative Impact of Cardiovascular Risk Factors on Left Atrial and Left Ventricular Function Related to Aortic Stiffness

The aim of the present study was to detect earlier the negative effect of cardiovascular risk (CVR) factors on left atrial (LA) and left ventricular (LV) function related to abdominal aortic (AAO) stiffness using 2-dimensional speckle-tracking echocardiography (2DSTE) in asymptomatic patients. One hundred and twelve patients with CVR factors and 56 healthy individuals were studied. 2DSTE data were acquired for determination of LA and LV myocardial and AAO wall deformations. LA volume index, LV mass index, ratio of early diastolic transmitral flow to mitral annular velocity (E/e')/peak systolic LA strain (S-LAs), and AAO stiffness were greater, and peak early diastolic LV longitudinal strain rate (SR-LVe) was lower in the patient group. Among the significantly correlated variables with AAO stiffness on univariate analysis, multivariate linear regression analysis identified SR-LVe and (E/e')/S-LAs in the patient group, and only age in the healthy group, as independent predictor of AAO stiffness. Structural and functional changes in the LA and LV and AAO stiffening were accelerated with CVR factors, and higher AAO stiffness was associated with deteriorated LA compliance and impaired LV relaxation in asymptomatic patients with CVR factors. 2DSTE has a potential for earlier detection of abnormal LA and LV function related to increased AAO stiffness.

Decreased Glomerular Filtration Rate and Markers of Left Atrial Stasis in Patients with Nonvalvular Atrial Fibrillation

Background: It is currently unknown if the increased risk of stroke in subjects with chronic kidney disease and atrial fibrillation (AF) is due to the presence of left atrial stasis or to any other vascular or systemic conditions. Methods: This was a retrospective study of 372 subjects undergoing evaluation during an AF episode. The following markers of left atrial stasis were sought on transesophageal echocardiogram: left atrial or left atrial appendage thrombus (LAAT), dense spontaneous echocardiographic contrast (DSEC), and low flow velocities (LFV) in the left atrial appendage. Subgroup comparisons were performed according to the level of estimated glomerular filtration rate (eGFR) using the Chronic Kidney Disease Epidemiology Collaboration equation as follows: ≥90, 45–89.9, and <45 ml/min/1.73 m². Results: LAAT was found in 11.6%, DSEC in 29.0%, and LFV in 14.9% of cases. A significant increase in the prevalence of DSEC was observed in the lower categories of eGFR: 37.8% in eGFR <45 ml/min, 30.7% in eGFR 45–89.9 ml/min, and 17.0% in eGFR ≥90 ml/min (p = 0.009; γ for trend = 0.297, p = 0.002). The same was observed when assessing left atrial abnormality, i.e. the presence of at least one of the former transesophageal echocardiogram changes. On multivariate analysis, clinical parameters from CHADS₂ (congestive heart failure, hypertension, age ≥75, diabetes mellitus and stroke) and CHA₂DS₂-VASc (age 65–74, history of vascular disease, and female gender along with the clinical variables from CHADS₂) were predictors of transesophageal echocardiogram changes and an additive predictive value was found for eGFR. Conclusions: Our results suggest an association between compromised renal function as assessed through eGFR and markers of left atrial stasis in patients with AF. The increased risk of stroke in this population may be due to thromboembolism.

Depressed Atrial Function in Diastolic Dysfunction: A Speckle Tracking Imaging Study

Two-dimensional speckle tracking imaging (STI) has recently been applied to the study of left atrial (LA) reservoir function. We utilized STI to analyze LA function in diastolic dysfunction (DD), hypothesizing that LA strain abnormality is part of the pathogenesis of diastolic dysfunction. We applied STI to 50 patients with Grade 1-2 DD, comparing these results to 100 normal controls. Complete Doppler analysis of filling was made using peak E, peak A and tissue Doppler e' velocities; E/e' was used as a surrogate for LA pressure and LA stiffness index was calculated. In analysis of covariance, adjusting for age and gender, compared with controls, DD patients had higher E/e', greater LA volume and greater LA stiffness, but lower E/A ratio and global LA strain. LA strain appears to be inversely related to LA volume, but not to other indices of LV diastolic function. In subgroup analysis, LA strain was significantly lower, and stiffness significantly higher in DD, even after correction for differences in LA volume and E/A ratio. Analysis of ROC curves suggests that abnormal LA strain is a better marker for diastolic dysfunction than LA enlargement. LA strain by STI is significantly reduced in early diastolic dysfunction and is related to higher LA stiffness and LA size. Reduction in LA strain is partially independent of LA volume; accordingly we hypothesize that reduced atrial strain indicates impaired atrial distensibility.

Acute mitral regurgitation due to flail mitral leaflet mimicking: a diagnosis of pneumonia

A 47-year-old man admitted to our department with the persisting complaints of shortness of breath and dry cough. He had been treated with sulbactam-ampicillin with the diagnosis of pneumonia for 3 weeks. He began to define paroxysmal nocturnal dyspnea and orthopnea despite treatment for 4 days. On physical examination, he had an apical systolic murmur and fine crackles heard over the mid-upper chest. Electrocardiography demonstrated sinus rhythm with left atrial abnormality. Chest X-ray revealed bilateral symmetric pulmonary infiltration and pleural effusion with normal cardiac contours (Fig. 1a). Transthoracic echocardiography was obtained immediately and showed probable ruptured chorda tendineae resulting in severe mitral regurgitation with normal systolic functions. Further investigation with transesophageal echocardiography disclosed flail posterior mitral leaflet with eccentric mitral insufficiency jet flow directing to opposite site of affected leaflet (Fig. 1b,c). The patient responded well to mitral valve repair after an uneventful surgery. This case is a very good example of the radiographic features of bilateral mid-upper lobe pulmonary edema caused by mitral valve regurgitation mimicking pneumonia. The pulmonary edema associated with mitral valve regurgitation is usually bilateral but can also be seen isolated or predominantly in right upper lobe [1–3]. Because our patient presented with a confusing medical history and the possibility of cardiac disease is not considered, the initial diagnosis of pneumonia was made incorrectly. We think that careful cardiac auscultation might help the exact diagnosis, in fact the centerpiece of physical examination. In conclusion, this presenting case emphasizes the mitral regurgitation as an etiologic factor in the differential diagnosis of bilateral pulmonary infiltration and the role of proper cardiac auscultation. So, familarity with the pulmonary findings in patients with acute mitral regurgitation is crucial for rapid diagnosis and optimal patient care.

Clinical and transesophageal echocardiographic variables for prediction of thromboembolic events in patients with nonvalvular atrial fibrillation at low-intermediate risk

BackgroundThere is no clear consensus about antithrombotic treatment in atrial fibrillation (AF) patients at low-intermediate thromboembolic risk. Transesophageal echocardiography (TEE) is useful for prediction of thromboembolic events in AF. Methods and resultsOf 498 patients with nonvalvular AF, incidence of stroke, cardiac events, and mortality was investigated in 280 patients with CHADS2 score 0 or 1 (mean age 64 years, mean follow-up 6.4±3.1 years). Left atrial abnormality (low left atrial appendage flow, spontaneous echo contrast, or thrombi), complex aortic plaque (mobile, ulcerated, pedunculate, or thickness≥4mm), or both were defined as TEE risk. The incidences of ischemic stroke, cardiovascular events, and death were higher in patients with TEE risk than in those without the risk (2.0%/year vs. 0.5%/year, p<0.05; 4.7%/year vs. 1.9%/year, p<0.01; and 4.7%/year vs. 2.0%/year, p<0.01, respectively). This was also true for patients with CHADS2 score of 0 (1.7%/year vs. 0.3%/year, p<0.05; 4.1%/year vs. 1.6%/year, p<0.05; and 3.9%/year vs. 1.4%/year, p<0.01; respectively). On multivariate analysis, TEE risk predicted ischemic stroke, cardiovascular events, and mortality independently of clinical variables or CHADS2 score. ConclusionsTEE could be useful for further stratification of patients with nonvalvular AF stratified at low-intermediate risk (CHADS2 score 0 or 1) and could indicate who should receive anticoagulation treatment.

Relationship between atrial conduction delay and obstructive sleep apnea

Prolonged P-wave duration, indicating atrial conduction delay, is a marker of left atrial abnormality and is reported as a potent precursor of atrial fibrillation (AF). Several studies have shown that obstructive sleep apnea (OSA) is associated with AF. We evaluated the relationship between OSA and prolonged P-wave duration. Consecutive subjects who underwent overnight polysomnography and showed a normal sinus rhythm, had no history of AF or ischemic heart disease, and showed no evidence of heart failure were enrolled. Apnea-hypopnea index (AHI) is defined as the number of apnea and hypopnea events per hour of sleep. P-wave duration was determined on the basis of the mean duration of three consecutive beats in lead II from a digitally stored electrocardiogram. A total of 250 subjects (middle-aged, predominantly male, mildly obese, with a mean P-wave duration of 106 ms) were enrolled. In addition to age, male gender, body mass index (BMI), hypertension, dyslipidemia, and uric acid and creatinine levels, AHI (r = 0.56; P < 0.001) had significant univariable relationship with P-wave duration. Multivariate regression analysis showed that age, BMI, male gender, and AHI (partial correlation coefficient, 0.47; P < 0.001) were significantly independently correlated to P-wave duration. Severity of OSA is significantly associated with delayed atrial conduction time. Obstructive sleep apnea may lead to progression of atrial remodeling as an AF substrate.

Early Left Atrial Mechanics and Volume Abnormalities in Subjects with Prehypertension: A Real Time Three-Dimensional Echocardiography Study

The aim of this study was to evaluate left atrial (LA) volume and mechanical functions by real time three-dimensional echocardiography (RT3DE) in prehypertensive subjects. The study included 54 (34 male and 20 female) prehypertensive subjects and 36 (14 male and 22 female) healthy control subjects. Transthoracic echocardiography and RT3DE were performed in all patients. Interventricular septum thickness and isovolumetric relaxation time were significantly higher in prehypertensives than in controls (10.7 ± 0.7 vs. 10.1 ± 0.8 P = 0.001 and 89.9 ± 10 vs. 82.4 ± 11 P = 0.002, respectively). LA maximum volume, volume before atrial contraction, total and active stroke volume, total and active emptying fractions, expansion index, and LA max volume index were significantly higher in prehypertensives when compared with controls (P < 0.0001 for all). However, the passive emptying fraction was significantly lower in prehypertensives than controls (45.7 ± 5.6 vs. 48.6 ± 4.1, P = 0.006), and the minimum LA volume between the two groups was similar. The main finding of this study was that although LA volume and LA active systolic functions were significantly increased in prehypertensive people, there was a reduction in passive LA systolic functions. These parameters may be important in showing hemodynamic and structural changes in cardiac tissue caused by prehypertension.

Left atrial structure and function and clinical outcomes in the general population

Left atrial (LA) structural and functional abnormalities may be subclinical phenotypes, which identify individuals at increased risk of adverse outcomes. Maximum LA volume (LAmax) and LA emptying fraction (LAEF) were measured via cardiac magnetic resonance imaging in 1802 participants in the Dallas Heart Study. The associations of LAEF and LAmax indexed to body surface area (LAmax/BSA) with traditional risk factors, natriuretic peptide levels, and left ventricular (LV) structure [end-diastolic volume (EDV) and concentricity(0.67) (mass/EDV(0.67))] and function (ejection fraction) were assessed using linear regression analysis. The incremental prognostic value of LAmax/BSA and LAEF beyond traditional risk factors, LV ejection fraction, and LV mass was assessed using the Cox proportional-hazards model. Both increasing LAmax/BSA and decreasing LAEF were associated with hypertension and natriuretic peptide levels (P < 0.05 for all). In multivariable analysis, LAmax/BSA was most strongly associated with LV end-diastolic volume/BSA, while LAEF was strongly associated with LV ejection fraction and concentricity(0.67). During a median follow-up period of 8.1 years, there were 81 total deaths. Decreasing LAEF [hazard ratio (HR) per 1 standard deviation (SD) (8.0%): 1.56 (1.32-1.87)] but not increasing LAmax/BSA [HR per 1 SD (8.6 mL/m(2)): 1.14 (0.97-1.34)] was independently associated with mortality. Furthermore, the addition of LAEF to a model adjusting Framingham risk score, diabetes, race, LV mass, and ejection fraction improved the c-statistic (c-statistics: 0.78 vs. 0.77; P < 0.05, respectively), whereas the addition of LAmax/BSA did not (c-statistics: 0.76, P = 0.20). In the general population, both LAmax/BSA and LAEF are important subclinical phenotypes but LAEF is superior and incremental to LAmax/BSA.

Resting electrocardiogram predicts mortality in postmenopausal women with coronary heart disease or with risk factors for coronary heart disease

Information about prognostic utility is limited for numerous electrocardiogram (ECG) abnormalities and is particularly scarce in women with coronary heart disease (CHD) or at increased risk of CHD occurrence. This study used a prospectively planned observational post-hoc analysis of a negative randomised trial designed for other purposes. ECGs of 9789 postmenopausal women were analysed at a core laboratory. ECG abnormalities were determined and evaluated for mortality risk on top of established clinical risk factors and simultaneously with all other ECG abnormalities. During a median follow-up of 5.6 years, 500 women sustained coronary death. Normal versus abnormal baseline ECGs were associated with an annual rate of 0.53% versus 1.28% coronary deaths. Ten clinically common ECG abnormalities, including left atrial abnormality, fragmented QRS, and Cornell voltage-only left ventricular hypertrophy, emerged as independent significant predictors of coronary death, eight of them also predicted all-cause mortality. Each ECG abnormality acted as a risk multiplier for a coexisting ECG abnormality. Two or three of any of the ECG abnormalities simultaneously present on the baseline ECG identified subsets with hazard ratios for coronary death of 3.3 or 5.5 respectively. Consideration of ECG abnormalities significantly improved risk stratification by common clinical parameters. The presence of ECG abnormalities provides independent risk information over and above that of established risk factors, both for women with CHD or at increased risk of occurrence of CHD. Normal ECG assures a low mortality risk regardless of whether CHD exists or not. The data derived could be applied to corresponding postmenopausal women in daily clinical practice.

Prevalence of left atrial anatomical abnormalities in patients with recurrent atrial fibrillation compared with patients in sinus rhythm using multi-slice CT

Enlargement of the LA is known to increase the risk of atrial fibrillation (AF) and its associated complications. However, the relation between other left atrial (LA) anatomical abnormalities and the risk of developing AF is less well described. The aim of this study was to compare the prevalence of LA anatomical abnormalities between a group of patients with recurrent AF and a group of patients in sinus rhythm (SR) with the use of cardiac computed tomography (CT). The cardiac CT prevalence, location, and size of LA accessory appendages and diverticula were assessed in 200 patients with recurrent AF referred for radiofrequency catheter ablation and compared with a control group of 200 patients in SR. The prevalence and mean length and width for diverticula were 23.5%, 8.1 mm, and 8.1 mm, in the AF group and 20.5%, 7.8 mm, and 7.2 mm in the SR group, respectively, and for accessory appendages 6.5%, 8 mm, and 6.3 mm in the AF group and 6.5%, 9.4 mm, and 5.7 mm in the SR group, respectively. In both groups, the most common location for a diverticulum or an accessory appendage was the right anterosuperior LA wall. The prevalence, location, and size of accessory appendages and diverticula were not significantly different (P > 0.05) between cohorts. This study found no difference in the prevalence and anatomic characteristics of LA accessory appendages and diverticula between patients in recurrent AF and patients in SR.

Cardiographic conundrum: Adding insult to injury

The patient was a 78-year-old woman monitored for carbon dioxide retention after laparotomy. She was admitted a day earlier with bowel obstruction due to adhesions. Her rhythm on admission was coarse atrial fibrillation with ventricular response of 100 beats/min, which reverted spontaneously to sinus rhythm. Her postoperative trace is shown in Figure 1. The trace shows sinus tachycardia 100 beats/min with 3 atrial ectopic beats and 1 ventricular ectopic beat; the tachycardia is conducted in Wenckebach sequences. There is also well-marked left atrial abnormality, small frontal leads voltage, and nonspecific T-wave changes. Sinus P waves are conducted with PR intervals of 0.24 to 0.48 seconds, inscribing typical Wenckebach sequences, with acceleration of the distal chamber due to decremental increases in the conducted PR intervals. There are no “dropped beats” because atrial premature waves, P’s, are in front of the last QRS before the pause.

Severity of aortic stenosis predicts early post-operative normalization of left atrial size and function detected by myocardial strain

BackgroundAortic stenosis (AS) causes significant disturbances in left ventricular (LV) and left atrial (LA) function irrespective of the extent of myocardial hypertrophy which associates the increased afterload. We hypothesize that aortic valve replacement (AVR) and removal of LV outflow tract obstruction should result in LA size and function recovery, even partial, and were set to study this in a group of patients with AVR for AS. MethodsPeak atrial longitudinal strain (PALS) was evaluated in 43 patients with severe isolated AS and normal EF (56.6±3.8%) and no obstructive coronary artery disease candidates for AVR, pre-operatively and then 40days and 3months after surgery. Results were compared with those from 34 age- and gender-matched healthy controls. ResultsLVEF remained unchanged and LV mass regressed after AVR. Global PALS was reduced pre-operatively and increased 40days after surgery (p=0.002) and showed only a slight further increase at 3months follow-up (p<0.0001). Indexed LA volume was increased before surgery, but significantly fell 40days after surgery (p<0.0001) and showed only a slight further reduction after 3months (p<0.0001). Trans-aortic mean gradient change after surgery was the only independent predictor of the recovery of LA size and function. ConclusionsAVR reverses LA abnormalities and regains normal atrial function, a behavior which is directly related to the severity of pre-operative LV outflow tract obstruction. Early identification of LA size enlargement and functional disturbances might contribute to better patient's recruitment for AVR.

Hypertensive disorders during pregnancy

Hypertensive disorders during pregnancy