Left Atrial Diastolic Dysfunction Research Articles

Pulmonary Hypertension due to Radiofrequency Catheter Ablation (RFCA) for Atrial Fibrillation: The Lungs, the Atrium or the Ventricle?

Atrial fibrillation is the most common heart rhythm disorder in United States, characterised by rapid and irregular beating of both the atria resulting in the similar ventricular response. While rate and rhythm control using pharmacological regimens remain the primary management strategies in these patients, radiofrequency catheter ablation (RFCA) is rapidly rising as an alternative modality of treatment. Increase in the incidence of RFCA has shed light on complications associated with this procedure. Pulmonary hypertension (PH) is one of the long-term complications that has been observed postcatheter ablation. There have been multiple mechanisms which have been proposed to explain these elevated pulmonary pressures. These include the involvement of the lungs due to pulmonary vein stenosis, pulmonary vein occlusion and, rarely, pulmonary embolism. Radiofrequency catheter ablation can also lead to scarring of the atrium which can cause left atrial diastolic dysfunction leading to elevated pulmonary pressures. Recently, it was also proposed that elevated pulmonary pressure was related to the unmasking of left ventricular diastolic dysfunction occurring after this procedure. In this article, we review all the mechanisms that are associated with the development of pulmonary hypertension in patients undergoing RCFA for atrial fibrillation and the approach to diagnosis and management of such patients.

Left Atrial Function in Preclinical Diastolic Dysfunction: Two-Dimensional Speckle-Tracking Echocardiography–Derived Results from the BEFRI Trial

Patients with preclinical left ventricular (LV) diastolic dysfunction (DD) are prone to develop heart failure with preserved ejection fraction. Although left atrial (LA) enlargement and deterioration of LA function in apparent DD and heart failure with preserved ejection fraction have been previously described, data regarding phasic LA strain (LAS) in preclinical DD are scarce. In a cross-sectional trial, echocardiographic parameters of DD, LA volume index, and global LA reservoir, conduit, and pump function were prospectively analyzed in 473 women from the general population in Berlin, Germany (BErlin Female RIsk evaluation (BEFRI) study), using standard and two-dimensional speckle-tracking echocardiography. One hundred thirty-one women (29.7%) showed early-stage DD (impaired relaxation [DD1]) and 22 (5.0%) showed an echocardiographically more advanced stage of DD (pseudonormal filling [DD2]). Compared with women with normal diastolic function (DD0), those with DD1 displayed lower LA reservoir and conduit function (DD0, 43.2±8.5% and 27.2±8.0%; DD1, 33.3±8.0% and 16.1±7.1%; P<.001) but significantly higher LA pump function (DD0, 17.6±5.4%; DD1, 18.9±5.5%; P<.05). In patients with DD2, all three phases of LAS were markedly impaired compared with those with DD0 (reservoir, conduit, and pump function, 29.0±6.3%, 15.1±5.4% [P<.001], and 14.9±4.1% [P<.05], respectively). LA reservoir and conduit function was significantly associated with DD; in receiver operating characteristic curve analysis, these parameters showed higher diagnostic accuracy in detecting early DD compared with LA volume index. In multivariate analysis, LA reservoir strain remained significantly associated with DD. All three components of LAS showed specific alterations in different stages of DD. LA reservoir and conduit function was markedly reduced before symptoms, LA enlargement, and elevations of noninvasively estimated LV filling pressures occurred. Analysis of LA function featured higher discriminative strength in diagnosing early-stage DD compared with the well-established parameter LA volume index. Assessment of LAS allows diagnosis of impaired LA function and DD in a subclinical stage and might enable timely preventive and therapeutic interventions.

Left Atrial Diastolic Dysfunction And Pulmonary Venous Hypertension In Atrial Fibrillation: Clinical, Hemodynamic And Echocardiographic Characteristics.

Left ventricular diastolic dysfunction has been well described; diastolic abnormalities of the LA are less frequently recognized and poorly understood. The purpose of this study was to investigate the clinical, hemodynamic and echocardiographic features of left atrial (LA) diastolic dysfunction. Patients with atrial fibrillation (AF), severe LA enlargement, and pulmonary venous hypertension (PVH, Group 1) were compared to patients with pulmonary arterial hypertension (PAH), normal LA size and sinus rhythm (Group 2). All underwent right heart catheterization and transthoracic echo to evaluate hemodynamics and LA function. Mitral regurgitation was evaluated by transesophageal echocardiography. LA diastolic function was measured by comparing filling fraction, pulmonary venous flow and compliance. Right atrial, pulmonary artery systolic and mean pressures were similar. Mean wedge pressure were increased in Group 1, 20.8±2.6 versus 9.7±2.8 mm of Hg (p<0.0001). The most striking hemodynamic difference was large V wave in Group 1 without significant mitral regurgitation. LA filling fraction was abnormal in Group 1, 11.4%±8.5 compared to Group 2, 111.5%±44 (p<0.0001). LA compliance was 0.39±0.27 ml/m2/mmHg in Group 1 versus 6.8±4.54 ml/m2/mmHg in Group 2 (p=0.001). There was a strong negative correlation between the V wave and LA filling fraction (r= 0.756, p<0.001). The ratio of the height of the transmitral E wave divided by the S/D ratio (the LA diastolic dysfunction index) correlated very strongly with the V wave (r=0.907, p<0.001). LA diastolic dysfunction is present in some patients with long standing AF and PVH. LA diastolic dysfunction, in addition to left ventricular diastolic dysfunction, may contribute to the syndrome of heart failure with preserved left ventricular systolic function.

Abstract 19078: Pre-Existing Left Atrial Fibrosis and Diastolic Dysfunction is Associated With Deterioration in Diastolic Function Following Left Atrial Ablation In Patients With Recurrent Atrial Fibrillation

Background: Radiofrequency (RF) ablation for treatment of atrial fibrillation (AF) is known to induce left atrial (LA) fibrosis. LA diastolic dysfunction has been associated with AF and has shown predictive value for AF recurrence post ablation. This study is designed to evaluate the pattern of change in LA diastolic function following RF ablation. Methods: A total of 127 consecutive AF patients were enrolled in the AF Ablation MRI cohort. Fourteen underwent a repeat ablation for recurrent AF and were selected. During routine ablation procedure, LA pressures were acquired in sinus rhythm following trans-septal puncture and prior to ablation. LA diastolic function was evaluated by measuring the slope of the passive LA filling curve and was quantified using diastolic function scores defined by the ratio of change of LA pressure (as defined by invasive pressure measurements) to volume (as defined by MRI) during passive filling of LA (ΔP/ΔV) mmHg/ml and was measured prior to both ablations. The change in LA diastolic function was considered significant if &gt;25% change from baseline was observed. Percent left atrial fibrosis was quantified by using the image intensity ratio as previously described. Results: The mean diastolic function score for the 14 AF patients (62±7yrs, 79% male) was 0.76±0.28 mmHg/ml (Paroxysmal AF 0.58±0.18 and persistent AF 0.90±0.28, p=0.031). Of these, 4 (28.6%) patients had no substantial change &gt;25% in their diastolic function score (grp A) at repeat imaging. Six had improvement, 4 remained stable, grp B and 4 had deterioration-grp C. When compared with group A, group C had worse baseline LA diastolic function (0.6±0.2 v 1.1±0.3, p0.019) and greater baseline fibrosis (8.0±2.4% v 15.3±7.0, p0.042). Conclusion: Deterioration of diastolic function in patients with AF recurrence after LA ablation is associated with more extensive baseline fibrosis and worse baseline LA diastolic function.

Clinical Significance of the Assessment of the Systolic and Diastolic Myocardial Function of the Left Atrium in Patients With Paroxysmal Atrial Fibrillation and Low CHADS2 Index Treated With Catheter Ablation Therapy

The purpose of this study was to determine the clinical significance of the assessment of the diastolic and systolic myocardial function of the left atrium in patients with paroxysmal atrial fibrillation (AF) and low CHADS(2) scores treated with catheter ablation therapy. In a cohort of 84 symptomatic patients with paroxysmal AF and low CHADS(2) scores (≤1), the clinical significance of the systolic and diastolic myocardial function of the left atrium (assessed using 2-dimensional speckle-tracking echocardiography) were studied to predict the risk for recurrence of AF after catheter ablation therapy in the course of a follow-up period of ≥1 year. During a mean follow-up period of 19.2 ± 5.4 months, patients with left atrial (LA) myocardial diastolic dysfunction (LA strain <18.8%) had a significantly higher rate of recurrence of AF (42.4% vs 9.8%, p <0.05) compared to those without LA diastolic dysfunction. In line with this finding, patients with impaired LA myocardial systolic function (LA strain rate >-0.85 s(-1)) had worse outcomes after catheter ablation therapy than those with normal LA systolic function (rate of recurrence of AF 42.9% vs 12.5%, respectively, p <0.05). In relation to these results, in a logistic regression analysis including co-morbidities, left ventricular dysfunction, LA enlargement, and LA myocardial alterations, diastolic and systolic LA myocardial dysfunction were the principal variable associated with the recurrence of AF (odds ratios 6.8 and 5.2, respectively). In conclusion, in symptomatic patients with paroxysmal AF and low CHADS(2) scores, these findings suggest that the assessment of diastolic and systolic LA myocardial function using 2-dimensional speckle-tracking echocardiography could be of great utility to distinguish those patients with high or low risk for recurrence of AF after catheter ablation therapy.

Left Atrial Diastolic Dysfunction following Catheter Ablation of Atrial Fibrillation.

Radiofrequency catheter ablation (RFCA)-induced thermal injury may cause and/or worsen left atrial (LA) diastolic dysfunction leading to pulmonary hypertension and heart failure in patients with atrial fibrillation (AF), the incidence of which is probably more common than is generally realized. Biplane 2-dimensional echocardiography coupled with tissue Doppler (velocity) imaging and Doppler-derived strain (rate) imaging can be applied to provide quantitative assessment of the LA function (both systolic and diastolic) relative to pulmonary venous circulation and left ventricular function. Information so obtained is useful for guiding follow-up management of patients undergoing RFCA of AF.

Left Atrial Diastolic Dysfunction, an Underappreciated Cause of Pulmonary Venous Hypertension and Decompensated Heart Failure

Left Atrial Diastolic Dysfunction, an Underappreciated Cause of Pulmonary Venous Hypertension and Decompensated Heart Failure

Left atrial diastolic dysfunction: A new complication after catheter ablation for atrial fibrillation?

a c p d t ( p n d P r p r n Atrial fibrillation (AF) is a complex phenomenon associated with electrical, contractile, and structural remodeling. Alhough paroxysmal AF may occur in patients with apparently tructurally normal atria, the most frequent clinical setting of ersistent AF is hypertension, coronary artery disease, heart ailure, and valvular heart disease. A common pathophysiolgy of these risk factors for AF is volume or pressure overload f the left atrium (LA). According to the concept termed echano-electrical feedback, increased hemodynamic load ay be associated with changes in myocardial segment length, hich in turn result in decreased resting diastolic potential, hanges in cardiac action potential (AP) contour, shortening of P duration, and development of afterdepolarizations that riginate in the region of greatest stretch. As shown in an animal model, excessive loading conditions lead to increased dispersion of atrial refractory periods, which predisposes to atrial fibrillation. A recent study by Yoshida et al showed that F dominant frequency (DF) is directly related to LA pressure n patients with persistent AF, and that LA pressure is an ndependent predictor of DFmax in the LA appendage. These ndings support the notion that atrial stretch may stabilize igh-frequency sources necessary for maintenance of AF. It is widely accepted that AF causes many hemodynamic bnormalities, including an irregular and often rapid venricular rate, decreased stroke volume, increased LA presure and volume, shortened diastolic ventricular filling eriod, and atrioventricular valvular regurgitation. To counter these deleterious hemodynamic consequences, AF ablation has evolved as an effective therapeutic strategy for patients with symptomatic AF. The goal of AF ablation is to allow synchronized and efficient transport of blood from the atria to the ventricles. In accordance with the Frank-Starling principle, atrial systole augments left ventricular (LV) stroke volume and cardiac performance. In theory, one of the benefits of radiofrequency catheter ablation for AF is more effective LA function. Given that ablation lesions, by their nature, result in LA scarring, prior studies have investigated the impact of radiofrequency

Stiff left atrial syndrome after catheter ablation for atrial fibrillation: Clinical characterization, prevalence, and predictors

There have been no studies of atrial diastolic function after catheter ablation of atrial fibrillation (AF). We encountered a few patients with symptomatic left atrial (LA) diastolic dysfunction and associated pulmonary hypertension (PH) that developed after catheter ablation for atrial fibrillation. Similar findings were described in patients after cardiac surgery and were referred to as the "stiff left atrial syndrome." The purpose of this study was to prospectively quantify the incidence of patients developing PH associated with diastolic hemodynamic abnormalities of the LA after radiofrequency ablation of AF and to identify the possible predictors. Between January 2009 and July 2010, data on 1,380 consecutive patients were prospectively collected. Before ablation and at follow-up, all patients had an echocardiogram to assess for the presence of PH. Patients with no echocardiographic evidence of PH but complaining of unexplained dyspnea with LA diastolic abnormalities were evaluated with right heart catheterization (RHC). Patients were included in the analysis if they developed new or worsening PH postablation with evidence of LA diastolic dysfunction by RHC or direct LA pressure measurement. All patients were evaluated for pulmonary vein stenosis and excluded if this condition was identified. The mean age was 62 ± 11 (75% male), and nonparoxysmal AF was the predominant arrhythmia (71%). New or worsening PH with associated LA diastolic abnormalities was detected in 19 (1.4%) patients after ablation. The prevalence of PH did not differ between AF types (P = .612). Compared with patients who did not develop PH, LA scarring (P <.001), diabetes (P = .026), and obstructive sleep apnea (OSA; P = .006) were more frequently observed among those who developed PH. In a multivariable logistic model, preprocedure LA size ≤45 mm (odds ratio [OR] = 6.13; P = .033), mean LA pressure (OR 1.14; P = .025), severe LA scarring (OR = 4.4; P = .046), diabetes mellitus (OR = 9.5; P = .004), and OSA (OR = 6.2; P = .009) were independently associated with the development of PH postablation. After radiofrequency catheter ablation of atrial fibrillation (RFCAF), PH with LA diastolic dysfunction or the so-called stiff LA syndrome is a rare but potentially significant complication of AF ablation. Severe LA scarring, LA ≤45 mm, diabetes mellitus, OSA, and high LA pressure are clinical variables that predict the development of this syndrome. The main clinical findings include dyspnea, congestive heart failure, PH, and large V waves on pulmonary capillary wedge pressure (PCWP) or LA pressure tracings in the absence of mitral regurgitation.

Left Atrial Diastolic Dysfunction and Pulmonary Venous Hypertension: Hemodynamic and Echocardiographic Characteristics

Objective: Investigate hemodynamic and echocardiographic features of left atrial (LA) diastolic dysfunction (DD). Background: Left ventricular DD is well characterized; diastolic abnormalities of the LA are less frequently recognized. Methods: Patients with atrial fibrillation (AF), LA enlargement, and pulmonary venous hypertension (PVH, G1) and heart failure were compared to patients with pulmonary arterial hypertension (PAH), normal LA size and sinus rhythm (G2). All underwent catheterization and transthoracic echo for hemodynamics and LA function.

P349 Left atrial diastolic dysfunction as a factor predisposing to lone atrial fibrillation

P349 Left atrial diastolic dysfunction as a factor predisposing to lone atrial fibrillation