Left Atrial Width Research Articles

Long-term results of ablation index guided atrial fibrillation ablation: insights after 5+ years of follow-up from the MPH AF Ablation Registry.

Catheter ablation (CA) for symptomatic atrial fibrillation (AF) offers the best outcomes for patients. Despite the benefits of CA, a significant proportion of patients suffer a recurrence; hence, there is scope to potentially improve outcomes through technical innovations such as ablation index (AI) guidance during AF ablation. We present real-world 5-year follow-up data of AI-guided pulmonary vein isolation. We retrospectively followed 123 consecutive patients who underwent AI-guided CA shortly after its introduction to routine practice. Data were collected from the MPH AF Ablation Registry with the approval of the institutional research board. Our patient cohort was older, with higher BMI, greater CHA2DS2-VASc scores, and larger left atrial sizes compared to similar previously published cohorts, while gender balance and other characteristics were similar. The probability of freedom from atrial arrhythmia with repeat procedures is as follows: year 1: 0.95, year 2: 0.92, year 3: 0.85, year 4: 0.79, and year 5: 0.72. Age >75 years (p = 0.02, HR: 2.7, CI: 1.14-6.7), BMI >35 kg/m2 (p = 0.0009, HR: 4.6, CI: 1.8-11.4), and left atrial width as measured on CT in the upper quartile (p = 0.04, HR: 2.5, CI: 1-5.7) were statistically significant independent predictors of recurrent AF. AI-guided CA is an effective treatment for AF, with 95.8% of patients remaining free from atrial arrhythmia at 1 year and 72.3% at 5 years, allowing for repeat procedures. It is safe with a low major complication rate of 1.25%. Age >75 years, BMI >35 kg/m2, and markedly enlarged atria were associated with higher recurrence rates.

Methods of Radiographic Measurements of Heart and Left Atrial Size in Dogs with and without Myxomatous Mitral Valve Disease: Intra- and Interobserver Agreement and Practicability of Different Methods

Simple SummaryIn the present study, different radiographic measurements for evaluating the cardiac size and left atrial size in dogs with and without myxomatous mitral valve disease were evaluated. Veterinarians applied these measurements with different levels of experience to identify heart enlargement in conventional and inverted radiographs. The repeatability and ease of application were evaluated. It was shown that radiographic measurements can identify cardiac enlargement reliably and even potentially stage dogs with myxomatous mitral valve disease if echocardiography is unavailable. The measurements can be performed in conventional and inverted radiographs with reliable results by veterinarians with different degrees of experience.Dogs suffering from Myxomatous Mitral Valve Disease (MMVD) show a potential heart enlargement, especially in the left atrium, detectable by radiography. Due to digital radiography, different radiographic measurements estimate cardiac size quite uncomplicatedly. The Vertebral Heart Size (VHS), Radiographic Left Atrial Dimension (RLAD), Left Atrial Width (LAWidth), and the Vertebral Left Atrial Size (VLAS) used anatomical landmarks for measuring cardiac size in relation to the vertebral column. This study aimed to compare VHS, RLAD, LAWidth, and VLAS measured in conventional and inverted radiographs by veterinarians with different levels of experience in healthy dogs and dogs with MMVD. The reliability and user-friendliness of these measurements were evaluated, and the staging was compared to the echocardiography staging. A total of 50 unaffected dogs and 150 dogs with MMVD in stages B1, B2, and C were assessed. Three veterinarians with different levels of experience examined 200 conventional radiographs and their corresponding inverted radiographs blinded to the echocardiographic and clinical examination results. Analyses were performed to compare the measurements’ grading and determine anatomical landmarks with measurement difficulties. Additionally, inter- and intraobserver agreement was assessed using intraclass correlation coefficient, and the agreement between radiographic and echocardiographic staging was compared using the kappa coefficient. The VHS, LAWidth, and VLAS were easier to define than the RLAD. The interobserver agreement was almost perfect for VHS (0.962) and good for the other radiographic measurements (RLAD: 0.778, LAWidth: 0.772, VLAS: 0.858). The VHS assigned the most dogs to the correct stage. However, VHS, RLAD, LAWidth, and VLAS presented an almost perfect intraobserver agreement. The dorsal left atrial margin of the RLAD was the most difficult measurement point to identify. The VHS is the most reproducible radiographic method for measuring the canine heart size and shows the highest agreement with echocardiography. An observer-related influence could be detected for RLAD, LAWidth, and VLAS.

Comparison of different radiographic scores with associated echocardiographic measurements and prediction of heart enlargement in dogs with and without myxomatous mitral valve disease

IntroductionStaging of myxomatous mitral valve disease (MMVD) requires an echocardiographic examination along with thoracic radiographs. The aims of this study were to calculate mean values for radiographic scores vertebral heart size (VHS), left atrial width (LAWidth), radiographic left atrial dimension (RLAD), and vertebral left atrial size (VLAS) in conventional and grayscale inverted images in healthy dogs and dogs with different stages of MMVD, and to find cutoff values for a stage assignment. AnimalsOne hundred fifty dogs in different stages of MMVD and 50 unaffected dogs were evaluated. MethodsRadiographic scores, echocardiographic left atrium-to-aorta ratio and normalized left ventricular internal dimension at end-diastole, and results of a clinical examination were obtained. Analyses were performed to evaluate the correlation between radiographic scores and echocardiographic values, to determine cutoff values for a radiographic stage assignment, and to compare measurements in conventional and inverted radiographs. ResultsAfter excluding breed-specific higher VHS, the means of VHS, LAWidth, RLAD, and VLAS were similar in the control group and stage B1. All radiographic scores increased in stages B2 and C. The cutoff values identifying heart enlargement, and therefore differentiating stages B1 and B2, were 11.0 for VHS, 1.8 for LAWidth, 2.0 for RLAD, and 2.3 for VLAS. Besides RLAD, scores were similar in conventional and inverted radiographs. ConclusionCutoff values for the different radiographic scores for stage assignment were calculated. Radiographic cardiac scores using either conventional or inverted grayscale could be a tool to differentiate between different stages of MMVD when echocardiography is unavailable.

Effect of Sacubitril/Valsartan on renal function in patients with chronic kidney disease and heart failure with preserved ejection fraction: A real-world 12-week study

Patients with chronic kidney disease (CKD) are often complicated with heart failure with preserved ejection fraction (HFpEF). However, several drugs, including angiotensin-converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB), have not shown apparent benefits in terms of morbidity and mortality of HFpEF. PARAMOUNT and other studies have shown the potential benefits of Sacubitril/Valsartan on patients with HFpEF, but its effects on renal function and the effect of low-dose Sacubitril/Valsartan in actual clinical conditions have not been thoroughly evaluated. In our longitudinal and observational research, 353 patients were followed up for 12 weeks. We evaluated renal function [urinary protein, serum creatinine and estimated glomerular filtration rate (eGFR)] and cardiac function [NT-proBNP (brain natriuretic peptide), New York Heart Association (NYHA) classification, left ventricular ejection fraction (LVEF), left atrial width and left ventricular end-diastolic width] at baseline and during follow-up. Worsening renal function (WRF) was defined as an increased serum creatinine≥26.5umol/L or decreased eGFR≥20%. The decline of eGFR in the Sacubitril/Valsartan group was slower than that in the control group (p = 0.021). The outcome of proteinuria in the ACEI/ARB group was significantly better than that in the Sacubitril/Valsartan group (p = 0.001). In terms of echocardiogram, the average left atrial width in Sacubitril/Valsartan group decreased by 1.38 ± 3.02 mm, which was significantly lower than that in the ACEI/ARB group (p = 0.02). The increase of urine protein class in the ACEI/ARB group increased the risk of WRF with statistical significance (OR = 2.36, 95%CI 1.01–5.49, p = 0.047), but no statistical significance was found in all the patients or Sacubitril/Valsartan group. In conclusion, Sacubitril/Valsartan could more effectively slow down renal function decline and reverse myocardial remodeling in patients with CKD and HFpEF than ACEI/ARB, even at low doses, though its protective effect on urinary protein is not as good as that of ACEI/ARB.

Assessment of Structure, Function, and Rhythm of the Heart with Echocardiography and Electrocardiography in Adolescent Swimmers.

The aim of this study was to evaluate the cardiac parameters by using electrocardiography and echocardiography in adolescent swimmers. Twenty-two adolescent swimmers and 22 gender- and age-matched sedentary controls admitted to our center between November 2018 and May 2019 were included in this study. In addition to demographical characteristics, participants were assessed via a 12-lead electrocardiography and two-dimensional echocardiography for cardiac function. On the echocardiography, end-systolic and end-diastolic interventricular septum, end-systolic and end-diastolic left ventricular posterior wall thicknesses, left atrial width, Tricuspid E, left ventricular mass and left ventricular mass index were higher in the swimmers when compared to the sedentary controls (P < 0.05). On the electrocardiography, Tp-e duration which reflects ventricular transmural repolarization, and Tp-e/QT and Tp-e/corrected QT ratios were higher in the swimmers than the sedentary controls (P < 0.05). In conclusion, swimming exercise in children leads to concentric thickening of left ventricle and induces an increase in Tp-e duration, and Tp-e/QT and Tp-e/corrected QT ratios, which are the novel markers for risk of ventricular arrhythmias.

Use of radiographic measurements to diagnose stage B2 preclinical myxomatous mitral valve disease in dogs.

To investigate the usefulness of radiographic measures of the left atrium and ventricle as surrogates for echocardiographic criteria in identifying dogs with stage B2 preclinical myxomatous mitral valve disease (MMVD). 56 client-owned dogs with preclinical mitral regurgitation attributed to MMVD examined between April 19, 2016, and November 22, 2017. Medical records were retrospectively searched, and data collected included age, body weight, heart murmur grade, and echocardiographic and radiographic measurements. Dogs were grouped according to whether they did (case dogs) or did not (control dogs) meet echocardiographic criteria used to identify dogs with stage B2 MMVD. Measurements for lateral thoracic radiographic variables normalized to vertebral body units (VBUs) were obtained, and results were analyzed to identify variables that could best discriminate between case and control dogs. Three radiographic variables of left atrial size (vertebral left atrial size [VLAS], left atrial width, and the combined variable of VLAS + left atrial width) most accurately distinguished control dogs from case dogs, and the VLAS was the simplest and fastest to perform in a clinical setting. The optimal cutoff for VLAS was 2.5 VBUs (sensitivity, 70%; specificity, 84%; and likelihood ratio, 4.38), with VLAS ≥ 2.5 VBUs for case dogs. The maximum specificity cutoff for VLAS was 3.0 VBUs (sensitivity, 40%; specificity, 96%; and likelihood ratio, 10.0), with VLAS ≥ 3.0 VBUs for case dogs. Results indicated that when echocardiography is unavailable, radiographic VLAS ≥ 3 VBUs could be used with minimal risk of false-positive diagnosis of stage B2 MMVD in dogs.

Multiple paravalvular leak closures

Introduction 70 year old man with paroxysmal atrial fibrillation and heart failure with preserved ejection fraction with previous bioprosthetic aortic and mitral valve replacement in 2003 and 2008 presented for fatigue and dyspnea. He was an unsuitable candidate for surgery due a EuroSCORE II of 7.27%. Preoperative TEE showed posterior mitral periprosthetic regurgitation (peak gradient 73.3 mmHg) for which he underwent a transcatheter closure using an Amplatzer Vascular Plug (AVP) 2 size 12 mm and 18 mm with improved regurgitation. Methods Arterial line was placed and general anesthesia induced. Using a 6 french and 14 french catheters, the left femoral artery and right femoral vein were accessed, respectively. The septum was crossed posteriorly in order to avoid the aortic valve. TEE demonstrated a 1.4cm by 0.6cm mitral leak – almost 1/3 the circumference of the biopresthesis, as well as a left atrial width of 5.8cm. After placement of device, TEE demonstrated coverage of 2/3 of the original paravalvular orifice with regurgitation decreased significantly, as well as S wave blunting on pulmonary vein flow. Results A month postoperatively, the patient returned with worsening fatigue, shortness of breath, and weakness. In addition to anemia, patient showed hemolysis. Hematology was consulted and they believed that his PVL was again the etiology. Thus, he underwent repeat attempt at closure of the mitral in addition to early closure of the aortic paravalvular leak. Of note, TEE showed previously closed leak measuring 9mm by 9mm. There were no immediate postoperative complications. Several days later however, the patient suffered decompensated heart failure leading to multisystem organ failure. Discussion Transcatheter leak closure results in significant decrease in regurgitation. Moreover, mortality rate within 30 days averages 1.4-2.0% and 3-year survival rate is 64.5%. When both aortic and mitral prosthesis are involved, it is generally accepted to close the most regurgitant lesion and return in about 6 months for closure of the second lesion. Followup TTE/TEE and labs with close attention to hemolysis is also warranted for possible recurrence.

Feasibility, Within-Day and Between-Day Variability of Transthoracic Echocardiography in Sloths (Bradypus Variegatus and Choloepus Hoffmanni)

Bradypus variegatus (Xenarthra, Bradypodidae) and Choloepus hoffmanni (Xenarthra, Megalonychidae) are sloths from the tropical rain forest of the Caribbean and Pacific regions of Costa Rica. Because of their unique physiology and behavior, sloths have intrigued scientists, and several studies have already been conducted regarding blood pressure and heart rate variations. However, the use of transthoracic echocardiography (TTE) in these species has never been reported. The aim of the present study was therefore to determine the feasibility, and then the within-day (repeatability) and between-day (reproducibility) variability of TTE in sloths. A total of 36 TTE examinations (including a total of 1080 measurements) with continuous ECG monitoring were performed on 4 different days by a trained observer on 6 healthy, adult, sedated Choloepus hoffmanni (sexually intact females, age, mean ± SD [minmax] 5.1 ± 1.3 years [4.0-7.5]) from the Costa Rica Animal Rescue Centre. Standard transthoracic M-mode and two-dimensional mode measurements included left ventricular (LV) end-diastolic and endsystolic diameters and thicknesses, the LV fractional shortening, the E point-to-septal separation, the left atrium-to-aorta ratio, and the right atrial width-to-the left atrial width ratio. Pulsed-wave Doppler parameters included peak systolic aortic and pulmonary flow velocities as well as early and late diastolic mitral flow velocities. A general linear model was used to determine the within-day and between-day coefficients of variation (CV). The main results were the following: all measurements could be performed at each TTE examination. Most within- and between-day CV values (90%) were <15%, the lowest being observed for the right atrial width-to-left atrial width ratio (2.2%). These results suggest that TTE is feasible and reliable in sloths, and therefore can be part of the cardiovascular exploration in these species. Further studies are now required to determine the corresponding reference intervals.

Internet-based transfer of cardiac ultrasound images.

A drawback to large-scale multicentre studies is the time required for the centralized evaluation of diagnostic images. We evaluated the feasibility of digital transfer of echocardiographic images to a central laboratory for rapid and accurate interpretation. Ten patients undergoing trans-oesophageal echocardiographic scanning at three sites had representative single images and multiframe loops stored digitally. The images were analysed in the ordinary way. All images were then transferred via the Internet to a central laboratory and reanalysed by a different observer. The file sizes were 1.5-72 MByte and the transfer rates achieved were 0.6-4.8 Mbit/min. Quantitative measurements were similar between most on-site and central laboratory measurements (all P > 0.25), although measurements differed for left atrial width and pulmonary venous systolic velocities (both P < 0.05). Digital transfer of echocardiographic images and data to a central laboratory may be useful for multicentre trials.