Right Atrium Research Articles

Surgical treatment of cardiac lipoma: 20 years' experience in a single center.

Primary cardiac lipoma is very rare, and no consensus has been developed regarding its ideal treatment strategy. This study reviewed the surgical treatment of cardiac lipomas in 20 patients over 20 years. Twenty patients with cardiac lipomas were treated at Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College from January 1, 2002, to January 1, 2022. The patients' clinical data and pathological reports were retrospectively analyzed, and the follow-up with a range of 1 to 20 years was conducted. The cardiac lipomas were located in the right atrium (RA) or superior vena cava (SVC) in seven patients (35%) (atrium in six patiets and SVC in one patient), left ventricle in eight patients (40%) (left ventricular chamber in four patients and left ventricular subepicardium and myocardium in four patients), right ventricle in three patients (15%) (right ventricular chamber in one patient and right ventricular subepicardial layer and myocardium in two patients), subepicardial interventricular groove in one patient (5%), and pericardium in one patient (5%). Complete resection was achieved in 14 patients (70%), including seven patients with lipomas in the RA or SVC. Incomplete resection occurred in six patients (30%) with lipomas in the ventricles. No perioperative deaths occurred. Long-term follow-up was conducted for 19 patients (95%), including two (10%) who died. Both patients who died had lipomas incompletely resected due to ventricles involvement, and preoperative malignant arrhythmias persisted post-operatively. The complete resection rate was high, and the long-term prognosis was satisfactory in patients with cardiac lipomas that did not involve the ventricle. The complete resection rate was low in patients with cardiac lipomas in ventricles; and complications, including malignant arrhythmia, were common. Failure of complete resection and post-operative ventricular arrhythmia are correlated with post-operative mortality.

An unusual giant coronary artery aneurysm mimicking mediastinal mass.

A 55-year-old woman was admitted with complaints of recurrent chest pain for eight days. She had a history of intermittent chest tightness and pain for 5 years. Laboratory test showed increased hypersensitive cardiac troponin I of 0.14 μg/L. The ECG showed ST segment depression in leads V1, V2, V3, and V4. Acute non-ST segment elevation myocardial infarction was diagnosed. Echocardiography revealed a hypoechoic mass (8.9 × 7.0 cm) (asterisk, Panel A, see Supplementary material online, Video S1) in front of the right side of the heart. The right atrium (RA) and right ventricle (RV) were compressed and deformed. A cystic cavity (13 mm wide) can be observed in the mass (arrowhead, Panel B, see Supplementary material online, Video S2), which was connected to the dilated right coronary artery (RCA). Enhanced chest CT showed the obviously enhanced RCA entered into the mass (asterisk, Panels C and D), the distal of which was occlusive and dilated like ‘gallbladder’ (arrowhead, Panel C, D and E). Coronary artery aneurysm (CAA) was suspected. Coronary angiography showed abnormal neoplastic dilatation in the proximal segment of the RCA and complete occlusion in the middle segment (arrowhead, panel F, see Supplementary material online, Video S3). The left coronary artery provided collateral circulation to the RCA (see Supplementary material online, Video S4). The patient underwent resection of the mass. The giant mass was observed between RA and RV (panel G) with numerous thrombi inside (panels H and I). Coronary artery bypass surgery was performed successfully after CAA resection.

Mapping-guided atrial lead placement determines optimal conduction across Bachmann's bundle: a rationale for patient-tailored pacing therapy.

Conventional right atrial appendage (RAA) pacing is associated with increased atrial activation time resulting in higher incidences of atrial tachyarrhythmia. Optimal pacing sites ideally shorten inter-atrial conduction delay, thereby decreasing atrial excitation time. We therefore examined the impact of programmed electrical stimulation (PES) from the right atrium (RA) and left atrium (LA) on the electrophysiological properties of Bachmann's bundle (BB). High-resolution epicardial mapping of BB was performed during sinus rhythm (SR) and PES in 34 patients undergoing cardiac surgery. Programmed electrical stimulation was performed from the RAA, junction of the RA with inferior caval vein (LRA), and left atrial appendage (LAA). Pacing from either the RAA or LAA resulted in, respectively, right- and left-sided conduction across BB. However, during LRA pacing in most patients (n = 15), activation started in the centre of BB. The total activation time (TAT) of BB during RAA pacing [63 (55-78) ms] was similar to that of SR [61 (52-68) ms, P = 0.464], while it decreased during LRA [45 (39-62) ms, P = 0.003] and increased during LAA pacing [67 (61-75) ms, P = 0.009]. Reduction of both conduction disorders and TAT was most often achieved during LRA pacing (N = 13), especially in patients who already had a higher amount of conduction disorders during SR [9.8 (7.3-12.3) vs. 4.5 (3.5-6.6)%, P < 0.001]. Pacing from the LRA results in a remarkable decrease of TAT compared with pacing from the LAA or RAA. As the most optimal pacing site varies between patients, individualized positioning of the atrial pacing lead guided by mapping of BB may be one of the new frontiers for atrial pacing.

Evaluation of right atrial function by two-dimensional echocardiography and strain imaging in patients with RCA CTO recanalization

ObjectivesThe right heart is mainly supplied with blood by the right coronary artery (RCA). The impact of RCA chronic total occlusion (CTO) on the function of the right heart [right atrium (RA) and ventricle (RV)] and whether successful recanalization of a RCA CTO improves the function of the right heart is not clearly understood yet. We aimed to evaluate right atrial function after recanalization of the RCA using transthoracic echocardiography with additional strain imaging.Methods and resultsFifty-five patients undergoing RCA CTO recanalization at the University Medical Center of Mainz were included in the study. Right atrial strain was assessed before and 6 months after successful CTO revascularization. The median age of the total collective was 66 (50–90) years. We did not find difference in our analysis of RA Volume (p 0.086), RA area (p 0.093), RA major dimension (p 0.32) and RA minor dimension (p 0.139) at baseline and follow-up. Mean RA reservoir strain at baseline was 30.9% (21.1–43.0) vs. 33.4% (20.7–47.7) at follow up (p < 0.001). Mean RA conduit strain was − 17.5% (− 10.7–(− 29.7)) at baseline vs. − 18.2% (− 9.6–(− 31.7)) at follow-up (p = 0.346). Mean RA contraction strain was − 12.9% (− 8.0- (− 21.3)) at baseline vs. − 15.5% (− 8.7–(− 26.6)) at follow-up (p < 0.001).ConclusionRight atrial function was altered in patients with RCA CTO. Successful revascularisation of an RCA CTO improved RA function assessed by strain imaging at follow-up.

The predictive value of tissue response viewer for lesion transmurality in a porcine model

BackgroundThe tissue response viewer (TRV) is a multiparametric index that incorporates time, power, tissue pressure, impedance, and wall thickness data during radiofrequency catheter ablation (RFCA) and is used to predict the transmurality of lesions. This study aimed to evaluate the feasibility and accuracy of the TRV in a porcine model. MethodsTwelve pigs underwent preablation high-density voltage and activation mapping of two atria, and both were repeated after linear RFCA. Intentional gaps were kept in the left atrium (LA) and were touched up in the right atrium (RA). Standard and high powers were, respectively, performed in the LA ablation. Six pigs were immediately sacrificed for pathological examination after the mapping and ablation procedure (acute study). Another six pigs were kept for 4 weeks before remapping and pathological examination (chronic study). ResultsAll animals completed the planned procedure. The TRV function showed a sensitivity of 97.1% and a specificity of 76.9% in the acute study, and a sensitivity of 95.9% and a specificity of 72.5% in the chronic study to predict the transmural lesion. All positive and negative predictive values were over 80%. In addition, the TRV achieved higher sensitivity (92.3% vs. 85.0%) and specificity (88.2% vs. 78.9%) to predict the transmural lesion in LA ablation with high power compared with standard ablation. ConclusionsThis study presents the histopathological validation of TRV to predict transmural lesions. The use of TRV may guide a more individual ablation and a more precise touch-up of gaps for atrial arrhythmias.

Right atrial volumes and strains in healthy adults: is the Frank-Starling mechanism working?-detailed analysis from the three-dimensional speckle-tracking echocardiographic MAGYAR-Healthy Study.

With larger blood volume flowing into a cardiac chamber, by stretching muscle fibers, increased contraction force could be detected. This phenomenon is called Frank-Starling mechanism, allowing the output of a cardiac chamber to be synchronized without external regulation. The purpose of the present study was to investigate the Frank-Starling mechanism in the right atrium (RA) represented by its volumes, volume-based functional properties and strains respecting the cardiac cycle in healthy adults by three-dimensional (3D) speckle-tracking echocardiography (3DSTE). The present single center retrospective cohort study comprised 179 healthy adult volunteers (mean age: 33.2±12.0 years, 92 males), in whom complete two-dimensional Doppler echocardiography with 3DSTE was performed. Subjects were divided into 3 groups according to the mean value of maximum RA volume (Vmax) ± standard deviation: Vmax <30 mL, 30 mL ≤ Vmax <60 mL and Vmax ≥60 mL. All RA volumes respecting the cardiac cycle of all subjects and calculated separately for females and males and their indexed equivalents increased with Vmax. RA stroke volumes increased with Vmax regardless of the phase it was measured in. While total atrial emptying fraction representing the reservoir phase remained unchanged with the increase of Vmax, a significant increase in passive atrial emptying fraction representing the conduit phase could be detected, in case of Vmax >60 mL (28.9%±15.1% vs. 32.5%±12.6%, P<0.05). Active atrial emptying fraction representing the booster pump function did not change with the increase of Vmax. Most global and mean segmental peak RA strains did not show significant changes with increasing RA volumes except for the RA area strain, it was the largest when Vmax was larger than 60 mL (64.7%±44.9% vs. 83.3%±49.4%, P<0.05). RA circumferential, longitudinal and area strains at atrial contraction decreased with increasing Vmax, RA radial and 3D strains did not change significantly with increasing Vmax. Increasing RA volumes do not cause significant increase in RA contractility represented by strains, but reduction in strains in longitudinal and circumferential directions could be detected in end-diastolic booster pump function. In contrast to the left atrium, obvious signs of Frank-Starling mechanism could not be detected in case of the RA.

Elevated thrombin generation levels in the left atrial appendage in patients with atrial fibrillation

BackgroundAtrial Fibrillation (AF) is the most common sustained tachi-arrhythmia. Thrombus formation in the left atrial appendage (LAA) increases the risk of stroke and systemic embolism in patients with AF. ObjectivesThe aim of this study was to compare thrombin generation in the LAA to the LA among patients with AF. MethodsA cross-sectional study of consecutive patients with AF undergoing pulmonary veins catheter ablation. Blood samples from the femoral vein (FV), right atrium (RA), left atrium (LA), and LAA were collected during the catheter ablation procedures. Thrombin generation was assessed by a Calibrated Automated Thrombogram. The LAA-calibrated automated thrombogram parameters were compared with the RA, LA, and FV. ResultsA total of 47 consecutive patients were enrolled in the study. The endogenous thrombin potential and peak height were significantly higher in the LAA compared with the LA, the mean differences and 95% CI between the LA and LAA were -378.9 (-680.5, -77.2) (nM∗min) and -66.7 (-119.6, -13.8) (nM) in the endogenous thrombin potential and peak height respectively. ConclusionIn patients with AF undergoing catheter ablation, the LAA demonstrated increased thrombin generation compared with the LA. This finding might contribute to the understanding of why the LAA is more predisposed to thrombus formation than the LA. Clinical Trials RegistrationNCT03795883

Expression of Stem Cell Niche-Related Biomarkers at the Base of the Human Tricuspid Valve.

Stem cell niches have been thoroughly investigated in tissue with high regenerative capacity but not in tissues where cell turnover is slow, such as the human heart. The left AtrioVentricular junction (AVj), the base of the mitral valve, has previously been proposed as a niche region for cardiac progenitors in the adult human heart. In the present study, we explore the right side of the human heart, the base of the tricuspid valve, to investigate the potential of this region as a progenitor niche. Paired biopsies from explanted human hearts were collected from multi-organ donors (N = 12). The lateral side of the AVj, right atria (RA), and right ventricle (RV) were compared for the expression of stem cell niche-related biomarkers using RNA sequencing. Gene expression data indicated upregulation of genes related to embryonic development and extracellular matrix (ECM) composition in the proposed niche region, that is, the AVj. In addition, immunohistochemistry showed high expression of the fetal cardiac markers MDR1, SSEA4, and WT1 within the same region. Nuclear expression of HIF1α was detected suggesting hypoxia. Rare cells were found with the co-staining of the proliferation marker PCNA and Ki67 with cardiomyocyte nuclei marker PCM1 and cardiac Troponin T (cTnT), indicating proliferation of small cardiomyocytes. WT1+/cTnT+ and SSEA4+/cTnT+ cells were also found, suggesting cardiomyocyte-specific progenitors. The expression of the stem cell markers gradually decreased with distance from the tricuspid valve. No expression of these markers was observed in the RV tissue. In summary, the base of the tricuspid valve is an ECM-rich region containing cells with expression of several stem cell niche-associated markers. Co-expression of stem cell markers with cTnT indicates cardiomyocyte-specific progenitors. We previously reported similar data from the base of the mitral valve and thus propose that human adult cardiomyocyte progenitors reside around both atrioventricular valves.

Electrogram Morphology Recurrence for Mapping Persistent Atrial Fibrillation: Initial vs Redo Catheter Ablation

BackgroundElectrogram (EGM) morphology recurrence (EMR) mapping of persistent atrial fibrillation (AF) quantifies consistency of activation and is expected to be high and rapid near AF drivers. ObjectivesThe purpose of this study was to compare EMR in left atria (LA) and right atria (RA) in patients undergoing first vs redo ablation for persistent AF. MethodsMultisite LA/RA mapping (LA: 281 ± 176 sites/patient; RA: 239 ± 166 sites/patient) before persistent AF ablation was performed in 42 patients (30 males, age 63 ± 9 years) undergoing first (Group 1, n = 32) or redo ablation (Group 2, n = 10). After cross-correlation of each automatically detected EGM with every other EGM per recording, the most recurrent electrogram morphology was identified and its frequency (Rec%) and recurrence cycle length (CLR) were computed. ResultsIn Groups 1 and 2, minimum CLR was 172.8 ± 26.0 milliseconds (LA: 178.2 ± 37.6 milliseconds, RA: 204.4 ± 34.0 milliseconds, P = 0.0005) and 186.5 ± 28.3 milliseconds (LA: 196.1 ± 38.1 milliseconds vs RA: 199.0 ± 30.2 milliseconds, P = 0.75), with Rec% 94.7% ± 10% and 93.8% ± 9.2%. Group 2 minimum CLR was not different from Group 1 (P = 0.20). Shortest CLR was in the LA in 84% of Group 1 and 50% of Group 2 patients (P = 0.04). Only 1 of 10 patients in Group 2 had the shortest CLR in the pulmonary veins (PVs) compared with 19 of 32 in Group 1 (P = 0.01). Most sites (77.6%) had Rec% <50%. ConclusionsEMR identified the shortest CLR sites in the PVs in 59% of patients undergoing initial persistent AF ablation, consistent with reported success rates of ∼50% for PV isolation. The majority of sites have low recurrence and may reflect bystander sites not critical for maintaining AF. EMR provides a robust new method for quantifying consistency and rapidity of activation direction at multiple atrial sites.

Atrial tachycardia in a patient with severe pectus excavatum

A 68-year-old woman underwent catheter ablation of drug-refractory atrial tachycardia (AT; cycle length 490 ms). A computed tomography scan of her chest showed severe pectus excavatum (PEX) (Figure 1A ). A voltage map using a multipolar high-density mapping catheter with the EnSite X mapping system (Abbott Technologies, Minneapolis, MN) revealed severe distortion of the right atrium (RA) and an extensive low-voltage area (LVA; <0.5 mV), which occupied 32% of the RA surface (Figure 1B). The AT demonstrated a centrifugal activation pattern arising at the inferior portion of the cavotricuspid isthmus (Online Supplemental Video 1), and the AT was eliminated by ablation at the earliest activation site on the LVA. In PEX, distortion of the right heart cavities can cause traction on the myocardial wall resulting in wall thinning. 1 Oezcan S. Attenhofer Jost C.H. Pfyffer M. et al. Pectus excavatum: echocardiography and cardiac MRI reveal frequent pericardial effusion and right-sided heart anomalies. Eur Heart J Cardiovasc Imaging. 2012; 13: 673-679 Crossref PubMed Scopus (44) Google Scholar In the present case, an extensive LVA was found in the area apart from the RA free wall and thus in the lower part of the RA and in the entire peri-tricuspid annulus, where more tractions can exert than normal and may result in wall thinning (Figure 1B). This makes it likely that the mechanism of the AT was either abnormal automaticity or microreentry caused by damage to the RA by severe PEX. This report adhered to CARE case report guidelines (https://www.care-statement.org/).

Detecting and Quantifying Residual Intracardiac Shunts Using Oximetric Step-Up Methods: A Prospective Observational Study.

Background & aims Intracardiac shunts are abnormal channels of blood circulation within the heart that develop eitheras an additional blood flow pathway or as a replacement for the normal channels of blood circulation. They are the commonest types of congenital heart defects. Various methods are available in the present times to identify, localize or quantify left-to-right intracardiac shunts. Methods may vary in sensitivity, indicators, or types of equipment available. One such method used in almost all cardiac centers for a long time has been oximetry runto detect step-up differences in oxygen saturation values. In the oximetry runthe main approach to detect and estimate the left-to-right (L-->R) shuntsrequires the oxygen concentration expressed as a proportion of saturation to be evaluated in blood samples which are obtained from the right atrium (RA) and pulmonary artery (PA), respectively. A left-to-right shunt can be considered if there is a significant increase (step-up) in bloodsaturation. A significant step-up is defined as a substantial rise in blood oxygen content or saturation that is higher than normal values. Methods Using a prospective observational design, this article investigates the application of the step-up method in detecting intracardiac shunts. The study was conducted between 2021 and 2022 on 35 pediatric cardiac patients (males/females, 24/11) diagnosed with post-tricuspid shunts. The pulmonary artery and right atrium were sampled before and after cardiopulmonary bypass surgery and analyzed using a blood gas test. As a result, nearly 91% of the patients had a saturation below 8%. However, the difference between PA oxygen saturation (SO2) & RASO2 before and after surgery was significant. As a result, the difference in O2 saturation helped detect the residual ventricular septal defect (VSD) after the surgery. Results There were no deaths or complications in this study. There were no re-interventions for post-tricuspid shunt surgery, though one patient had a step-up of >15% and residual VSD status was moderate to large on two-dimensional (2D) echocardiography. Conclusion A combination of physical findings, chest radiography, electrocardiogram (ECG), and echocardiography is routinely done for all these patients undergoing pediatric cardiac surgery. Echocardiography can detect the occurrence of shunt but does not calculate the shunt ratio. Transesophageal or epicardial echocardiography is the standard of care but has its limitations like perception difference between the operating surgeon and the person performing echocardiography. In this study, we have added an oximetry analysis of blood-gas samples before and after surgery and compared it to 2D echocardiography to test the validation of oximetry in isolation and comparison to 2D echocardiography.

Dynamic assessment of the tricuspid annulus in a healthy Asian population: A four-dimensional echocardiography study.

Tricuspid annulus (TA) geometry and function reference values are limited, especially for Asian populations. We aimed to explore TA using four-dimensional echocardiography (4DE) in a healthy Asian population. A total of 355 healthy Asian volunteers (median age 34 years; 52% males) were prospectively enrolled. TA geometry and function were analyzed using 4DE throughout the cardiac cycle. The TA area, perimeter, and dimensions were smallest at end systole (ES) and largest at late diastole (LD). Normal TA parameters at end diastole (ED) in different sex and age groups were obtained. TA areas, perimeters, and dimensions in males were significantly larger than those in females at ED; BSA-indexed perimeters and BSA-indexed dimensions in males were significantly smaller than those in females at ED. TA parameters correlated well with tricuspid valve (TV) tenting, right ventricle (RV), and right atrium (RA) parameters. Reference values of TA parameters were obtained by 4DE in an Asian population. Quantitative data on TA geometry and function are essential for TA pathology and therapeutics.

Echocardiographic characterization of cardiac chambers and vasculatures in buffaloes (Bubalus bubalis) during diastolic and systolic phases.

Ultrasonography had diagnostic importance in the evaluation of different diseases in buffaloes, including cardiovascular diseases. The current work describes the normal echocardiographic findings in healthy buffaloes, along with establishing reference values for echocardiographic dimensions for both sides of the heart, i.e., left and right ones. About 30 healthy adult buffaloes that belonged to private farms in Assiut, Egypt, were included in this study. Each animal underwent a complete clinical evaluation as well as hematological analyses, lipid profile indices, liver functions, cardio-thoracic radiography, and echocardiography to confirm no diseased conditions were detected. The study was conducted on healthy buffaloes (n = 30) in Assiut Governorate, Egypt. The obtained results reported healthy buffaloes with normal clinical findings as well as indices of blood pictures and serum biochemicals that were within the reference intervals. Radiography revealed a free reticulum and a well-defined diaphragm. The heart was seen as a typical radio-opaque organ. Ultrasonographically, using grayscale B-mode and M-mode, the heart was commonly imaged from the left fourth intercostal space. Different echocardiographic views were described, including the four chamber view, i.e., right atrium (RA), right ventricle (RV), tricuspid valve (TCV), left atrium, left ventricle, mitral valve, and interventricular septum (IVS), and the right ventricular outflow tract, i.e., RA, TCV, RV, pulmonary artery (PA), and pulmonary valve. Cross sections in each of the apex and base of the heart were described. Echocardiographic dimensions during cardiac diastole and systole, including diameters and wall thickness of each of the atria and ventricles, were demonstrated. Interventricular septal thickness wall thickness as well as diameters of the aorta and PA, were stated. The work tried to put reference values on the normal echocardiographic dimensions using 2-D B-mode gray scale ultrasonography in healthy adult buffaloes. These echocardiographic reference dimensions with normal echocardiographic imaging will be very helpful in enhancing the diagnostic efficacy of ultrasounds for recognizing abnormal findings related to cardiac disorders.

Management of Acute Liver Dysfunction Due to Budd-Chiari Syndrome in the Setting of Tumor Thrombus and Advanced Renal Cell Carcinoma

A 53-year-old male presented with bilateral lower extremity (BLE) swelling, abdominal distention, dyspnea, and a newly identified, locally advanced 4.7 cm right renal mass with tumor thrombus (TT) extending into the inferior vena cava (IVC) up to the right atrium (RA) without evidence of distant metastases (Figure 1A). He was also found to have BLE deep vein thromboses (DVT) and was started on anticoagulation. Plans were made for nephrectomy with tumor thrombectomy; however, he developed transaminitis, worsening ascites, and BLE edema, necessitating transfer to the intensive care unit (ICU).

227 THE PROGNOSTIC VALUE OF RIGHT ATRIAL STRAIN IN PATIENTS WITH SECONDARY TRICUSPID REGURGITATION

Abstract Background in secondary tricuspid regurgitation (STR), the remodeling of the right ventricle (RV) and the right atrium (RA) is associated with different outcomes. However, the potential prognostic role of right RA function in this setting, assessed by 2D-speckle tracking echocardiography (2D-STE), remains to be tested. Accordingly, the aim of our study is to assess the prognostic value of RA 2D-STE in patients with significant (i.e. moderate or severe) STR. Methods we retrospectively studied 227 (mean age 74±14, 40% men, 59% sinus rhythm) consecutive patients with significant STR, acquired between May 2012 and June 2021. RA 2D-STE was obtained from a dedicated, non-foreshortened RV-focused apical 4-ch view, using a dedicated software package (AFI LA, EchoPAC 204, GE Vingmed, Horten, Norway). Among the three longitudinal strain components provided by the software package (reservoir, conduit and, contraction), we focused on RA longitudinal strain during reservoir (RASR). Patients were divided into two groups according to the median value of RARS (12%). A combined endpoint of heart failure hospitalization and all-cause mortality was defined. Results after a median follow-up period of 14 months (IQR, 1-27), 93 patients (41%) reached the combined endpoint. The predictive power of RARS&amp;lt;12% (AUC 0.64 [IC 95% 0.56-0.71]), was significantly higher than RA maximum volume (AUC 0.38 [IC 95% 0.31-0.47]). Patients with RARS ≤ 12% were more symptomatic (according to NYHA class), had larger RA volumes (119 vs 89 mL, p&amp;lt;0.001) and, a reduced right ventricular systolic function (TAPSE: 14.7 vs 18.9 mm; FAC 37.7 vs 42.4%; RV free-wall strain: 17.5 vs 20.8%; all p&amp;lt;0.001). In addition, patients with RARS&amp;lt;12% had more severe TR (corrected EROA: 0.85 vs 0.41 cm2; p&amp;lt;0.05). Prevalence of atrial fibrillation (58 vs 61%), left ventricular ejection fraction, and right ventricular size were similar between the groups. Patients with RARS ≤12% had a significant risk for death (log rank, p&amp;lt;0.001), even after correcting for confounding variables. Moreover, RA strain was independently associated with the combined endopoint in multivariate analysis (p &amp;lt; 0.001) Conclusions in patients with significant STR, RARS is an independent predictor of the combined endpoint of heart failure hospitalization and all-cause mortality and provides incremental prognostic value over RA volume.

897 PEAK RIGHT ATRIAL LONGITUDINAL STRAIN: A NEW PARAMETER IN PREDICTING VENOUS CONGESTION

Abstract Background tricuspid regurgitation (TR) of either organic or functional etiology can lead to systemic venous congestion particularly in its more severe forms. Little is known about the role of the right atrium (RA) which acts as an intermediate player between TR and systemic veins. Purpose to assess the influence of right atrial size and function on venous congestion in TR patients. Methods 101 stable patients with at least mild to moderate TR were enrolled at the time of echocardiography (age 74±13 years, 37% male). Systemic congestion was assessed by inferior vena cava (IVC) diameter and right atrial pressure (RAP) estimated according to inferior vena cava diameter and collapsibility. TR severity was quantified by means of proximal isovelocity surface area (PISA) derived effective regurgitant orifice area (EROA) and regurgitant volume (RVol). RA and right ventricular (RV) function were assessed respectively by peak atrial longitudinal strain (PALS) and free wall longitudinal strain (FWLS) while indexed RA volume (RAVi) by Simpson's disk summation method. Results TR was quantified mild or moderate in 52 patients and more than moderate in 49 patients (mean EROA 37±31 mm2; mean RVol 34±23 ml). Mean indexed RA volume was 58±31 ml/m2; mean RA strain was 18±11% and mean RV strain (free wall) was -21 ± 7%. Mean IVC diameter was 20±6 mm; estimated RAP was ≤5 mmHg in 32 patients, 6-10 mmHg in 26, 11-15 mmHg in 26 and greater than 15 mmHg in 17 patients. In univariate analysis both IVC diameter and RAP correlated significantly with EROA, RVol, RAVi and RA strain (p&amp;lt;0.0001 for all); only RAP correlated with RV strain. In linear multivariate analysis only RAVi and RA strain were independent predictors of IVC diameter (p=0.01 and &amp;lt;0.0001, respectively), and only RVol and RA strain were independent predictors of RAP (p=0.001 and 0.002, respectively). We found a RA strain cut-off of -15% to have a sensitivity of 82% and specificity of 70% to identify a RAP greater than 15 mmHg (area under the curve-AUC 0.842). Conclusions RA size and function together with the TR-related volume overload were independent predictors of venous congestion. Among these variables, only RA strain predicted both parameters of venous congestion.

281 CARDIAC RESYNCHRONIZATION TERHAPY IN PERSISTENT LEFT SUPERIOR VENA CAVA WITH A BRIDGING INNOMINATE VEIN

Abstract Background The Persistent Left (PL) Superior Vena Cava (SVC) is a congenital malformation of the thoracic venous return that has an incidence of 0.2-3% in the general population and an incidence of about 0.5% in patients undergoing cardiac implantable electronic device. In this case, the placement of the leads, especially for the Right Ventricle (RV) and Left Ventricle (LV) through one of the branches could be challenging. Methods A 66-year-old man with hypertension, diabetes and dyslipidemia, in optimal pharmacologic therapy for congestive heart failure (NYHA II), hospitalized for recurrent syncopal episodes, with extreme sinus bradycardia, first-degree AV block and Left Bundle Branch Block, The patient had a LV hypertrophy and mild global systolic function (LV ejection fraction of 40%) for these we opted for a pacemaker CRT device implantation. Results Isolation of left cephalic vein was used as venous access for right atrium (RA) and RV leads while Seldinger technique via subclavian vein was used as venous access for LV lead. The guidewire through the subclavian vein pointed out the presence of PLSVC. Left subclavian venogram confirmed PLSVC and revealed a bridging innominate vein. To pass through the innominate vein and reach the SVC, a 0.035-inch hydrophilic guidewire was used. A 6Fr-sheath was advanced through the hydrophilic guidewire, subsequently a second metallic guidewire was advanced through the same introducer by removing the dilator. The RV and RA leads were placed respectively on low right interventricular septum and RA appendage passing through bridging innominate vein. Electrical parameters were normal. For the placement of the LV lead a 9.5Fr sheath introducer was advanced over the guidewire through the PLSVC. A venogram showed a lateral and a postero-lateral branch of the coronary sinus with acute angulation. With a 6Fr quadripolar Josephson catheter the postero-lateral branch was entered, eventually a 9Fr peelable outer guide catheter was advanced through the electrophysiology catheter becoming selective with the interested branch. A quadripolar S shaped lead was used, it was advanced into the targeted vein through a 0,014fr hydrophilic guidewire. Adequate electrical parameters and stability were achieved. Conclusion Lead implantation in patient with PLSVC is challenging. Placing the RA and RV leads through SVC ensure a better stability along time. The cannulation of CS is easily achieved by approach via PLSVC while selective vein cannulation can be difficult due to the modified acute angulation.

972 PULMONARY HYPERTENSION AND EMBRYOLOGICAL REMNANT: WHAT DO THEY HAVE TO DO WITH EACH OTHER? A CASE REPORT

Abstract Background Pulmonary hypertension (PH) is defined as a resting mean pulmonary artery pressure of 20 mmHg or above. The importance of identifying the underlying causes of PH is well known for a correct management and treatment. In particular, any cardiac causes, included shunt, must be investigated. Case Summary A 73-year-old woman presented to the emergency room for asthenia and dyspnea. First line exams as ECG and X-ray were executed resulting normal. Laboratory assessment showed an elevated brain natriuretic peptide at 675 pg/ml and a D-dimer value of 1116 ng/mlFEU (n.v. &amp;lt; 500 ng/mlFEU) so with the suspect of pulmonary thromboembolism a CT-scan with contrast was performed. It was negative for acute thromboembolism, but it revealed an enlarged pulmonary artery (with a diameter of 39 mm), a possible defect of interatrial septum and an anomalous drainage of inferior vena cava (IVC) into the left atrium (LA). A transthoracic echocardiogram confirmed the anomalous drainage of IVC into the LA that appears dilated but was not diagnostic for the interatrial defect. Furthermore, PH was suspected (systolic peak tricuspid regurgitation velocity of 3,5 m/s, RA area of 24 cm2, tricuspid annular plane systolic excursion/systolic pulmonary arterial pressure of 0.26 mm/mmHg). A 6-minute walking distance was 376 m. The patient completed the exams with a transesophageal echocardiography that revealed an inferior-type caval vein defect and an over-developed Eustachian valve which divides the right atrium (RA) and connect the IVC with the LA directing the blood flow towards it through the inter-atrial septal defect. Discussion The Eustachian valve is an embryologic remnant at the junction of the IVC and RA. While it typically does not have any pathologic significance, veno-arterial shunting can rarely occur in patients with prominent eustachian valves and atrial septal defects.

Structural and functional features of the myocardium in residents of the industrial region of the Far North under the exposure to nickel and arsenic

The study of the role of chemicals of industrial origin in the development of cardiovascular pathology determines the relevance of this study. The purpose of the work is to study the features of cardiac structural and functional disorders in residents of the industrial region of the Far North under the exposure of nickel and arsenic. Materials and methods. The study included one hundred fifty eight women living in the industrial center of the Far North with the location of large metallurgical enterprises (observation group) and 65 women living in similar climatic and geographical conditions, but without the location of industrial enterprises (comparison group). An echocardiographic study was carried out with the measurement of structural and doppler parameters of the heart on an expert-class ultrasonic scanner “Vivid q”. Results. In the observation group the values of myocardial performance indices (MPI) values for mitral annulus (0.55 ± 0.09 vs. 0.48 ± 0.07, p=0.005) and tricuspid annulus (0.57 ± 0.10 vs. 0.48 ± 0.06, p=0.001) were higher than in the comparison group. A gain in the concentration of nickel in the blood is associated with an increase in isovolumic relaxation time (IVRT) of the mitral atrioventricular ring (p=0.0001) and systolic pressure in the pulmonary artery (p=0.00002). An increase in the concentration of arsenic in the blood is associated with an increase in the filling pressure of the left ventricle (E/Em) and end diastolic diameter of the left ventricle (EDD LV) (p=0.0001), the diameters of the right ventricle (RV) and right atrium (RA) (p=0.0001), and rate of late diastolic filling of the RV and MPI of the tricuspid atrio-ventricular ring (p=0.0001). Limitations. This study did not include middle aged and elderly women, and also did not include male patients and did not include the population of other territories except the Far North. Conclusion. The revealed changes in echocardiographic parameters indicate subclinical dysfunctions of the myocardium of the left and right ventricles, affecting both systolic and diastolic function in residents of the industrial city of the Far North, living under the influence of nickel and arsenic.

Safety of continuous left atrial phased-array intracardiac echocardiography during left atrial ablation for atrial fibrillation.

Pulmonary vein (PV) isolation using radiofrequency ablation (RFA) to treat atrial fibrillation (AF) requires delivery of contiguous transmural lesions at the PV antra while avoiding injury to the esophagus. Continuous 2-dimensional phased-array intracardiac echocardiography (ICE) from within the left atrium (LA) can provide consistent high-resolution images of catheter tip contact and location during ablation. The purpose of this study was to compare near-term safety outcomes of therapeutic AF ablation with and without ICE imaging from within the LA. The study cohort included 590 consecutive patients undergoing RFA for AF including continuous ICE imaging during ablation from within either the right atrium (RA) or the LA. Subjects were followed prospectively, and periprocedural complications within 30 days were identified and recorded. All subjects had RA ICE imaging to guide transseptal catheterization. Ultrasound imaging from both RA and LA was used in 243 (41.2%). Respectively, the LA vs RA only imaging cohorts were comparable with respect to age (median 64 [interquartile range 57.4-71.2] years vs 64 [56.2-70.6] years; P = .425); history of hypertension (64.0% vs 67.2%; P = .421); diabetes mellitus (23.1% vs 19.4%; P = .268); previous cerebrovascular accident/transient ischemic attack (10.8% vs 8.4%; P = .331); and AF type (P = .241). There were no significant differences in major complications within 30 days between the 2 cohorts (P = .649) and no identified cases of esophageal or phrenic nerve injury or PV stenosis. Routine continuous LA ICE imaging seems to be safe and holds potential to facilitate lesion delivery during RFA for AF.