Smaller Left Atrial Dimension Research Articles

Abstract 6977: Thrombi Located at the Apex of Left Atrial Appendage Tend to Disappear in Patients with Atrial Fibrillation

Background: Catheter ablation (CA) for atrial fibrillation (AF), or left atrial appendage (LAA) occlusion device to prevent stroke are contraindicated in patients with left atrial appendage thrombus (LAAT), and LAAT is required to disappear. However, LAAT do not disappear in some people, and the predictors for LAAT disappearance remains unclear. Methods: We retrospectively studied 65 LAAT patients taking anticoagulants out of 1381 consecutive patients who underwent transthoracic echocardiography (TEE) prior to cardioversion or CA for AF. Patients with significant valvular disease and coagulation disorder were excluded. Clinical data were evaluated at the time of TEE. The LAA was divided into three parts (the apex, middle and base), and the position of the LAAT were classified by three independent observers, and the size, shape and movability of LAAT were also evaluated. Results: Forty-six of 65 LAAT patients underwent re-TEE during follow-up (6.4±14.4 months), and LAAT disappeared in 20 out of 46 patients. Patients with disappearance of LAAT had LAAT located at the apex of LAA (apex: 16/24, 67%, middle: 2/10, 20%, base 2/12, 17%, p=0.0041), shorter left atrial dimension (LAD) (46.1±5.4 vs. 50.2±5.5 mm, p=0.0264) and longer period to re-TEE (9.6±20.5 vs. 4.0±6.4 months, p=0.0046). On multivariate analysis, LAAT located at the apex of LAA (p=0.0057, OR 6.9844833, 95%CI 1.6144805-30.215916) and smaller LAD (p=0.07614, OR 3.1453251 for each 10 mm decrease in LAD, 95%CI 0.8785845-0.988234) were associated with disappearance of LAAT. Disappearance rate of LAAT in patients with LAAT located at the apex of LAA and small LAD (<48mm) was 82% (9/11) [Figure]. Conclusion: Thrombi located at the apex of LAA might be easy to disappear in patients with atrial fibrillation.

Abstract 10982: The Impact of Successful Electrical Cardioversion for Atrial Fibrillation in Patients with Heart Failure and Preserved Ejection Fraction

Background: Although atrial fibrillation (AF) is the major comorbid condition in heart failure with preserved ejection fraction (HFpEF), the evidence, which supports the efficacy of rhythm control for AF in HFpEF is limited. Hypothesis: Electrical cardioversion (EC) of AF for maintenance of sinus rhythm (SR) improves recovery in patients with HFpEF. Methods: We analyzed 162 subjects hospitalized for acute decompensated heart failure which were documented AF on admission and left ventricular ejection fraction ≥ 50%. We defined the conservative treatment (CT) group as not attempting cardioversion during hospitalization and EC groups as successful EC of AF and maintenance of SR until discharge. Clinical characteristics, composite event of cardiovascular death and heart failure rehospitalization were compared between the two groups. Results: Among all patients with AF on admission, 24 subjects (14.8%) were succeeded in restoring and maintaining SR by EC. They exhibited younger (70.8 years vs. 80.3 years, p < 0.01) and a lower level of BNP (88.3 ng/L vs. 156.0 ng/L, p < 0.01) than the CT group (n = 111). The findings from echocardiography demonstrated a smaller left atrial dimension (44.7 mm vs. 55.7 mm, p < 0.01) and lower E wave levels (81.5 cm/s vs. 110.0 cm/s) in the EC group. Concerning medical therapy, the rate of using anti-arrhythmia drugs in the EC group was higher (41.7% vs. 5.2%, p < 0.01). During the observational period (median = 1.6 years), successful restoration of SR was associated with a less frequent incidence of a composite event of cardiovascular death and heart failure rehospitalization (hazard ratio = 0.19, 95% confidence interval = 0.06 - 0.60, p < 0.01). Conclusions: Our findings highlight those patients with HFpEF, and AF treated with rhythm control by EC may improve, healthwise. Randomized controlled studies should evaluate the efficacy of EC and the effect of rhythm control for AF about atrial remodeling in HFpEF.

Normal reference values of echocardiographic measurements in young Egyptian adults

Abstract Background Normal values for echocardiographic measurements are widely based on cohorts from North American populations. Differences have been shown to exist that could be attributed to racial and ethnic differences. Objective To define the normal echocardiographic reference values for various cardiac measurements in young, healthy Egyptian adults. Methods This study was performed on 1,364 healthy adults aged 18–35 years. Standard trans-thoracic echocardiographic studies were performed to obtain end diastole measurements of left ventricular (LV) posterior wall thickness (PWd), interventricular septum thickness (IVSd), LV internal dimensions at end diastole (LVEDD) and end systole (LVESD), left atrial (LA) diameter, aortic root diameter and right ventricular outflow dimension (RVd). LV ejection fraction (LVEF), LV mass and relative wall thickness were assessed. All measurements were then indexed to body surface area (BSA). Based on our results we proposed normal reference values for young Egyptian adults. Results On comparing subjects according to gender, absolute measurements showed males had significantly larger LVEDD, LVESD, IVSd, PWd, LV mass, LA anteroposterior diameter and aortic root diameter ( p p = 0.008). There was no difference regarding RVd ( p = 0.118). Females had larger indexed LVEDD ( p = 0.0003), indexed LA and aortic root diameters ( p = 0.0005 and 0.007 respectively) and indexed RVd ( p 2 ( p Conclusions Estimation of local reference values is important to define normalcy. The main difference from international values was a higher upper reference limit for LV mass especially in females and relatively smaller LA dimensions in young Egyptians.

Differences in catheter ablation of paroxysmal atrial fibrillation between males and females

Catheter ablation (CA) has become a standard treatment for patients with atrial fibrillation (AF). However, gender-related differences associated with CA of paroxysmal AF (PAF) remain unclear. We compared 1124 consecutive patients (mean age, 61 ± 10 years; male, n=864) with PAF scheduled for CA between the genders. Females were significantly older (p<0.0001), and had a lower body-mass-index (p=0.02), smaller left atrial dimension (LAD; p=0.04), larger LAD indexed by the body-surface-area (LADI; p<0.0001) and better left ventricular ejection fraction (p<0.0001) at baseline. Ischemic heart disease (p=0.007) was more frequent in males, whereas hypertrophic cardiomyopathy (p=0.007) and mitral stenosis (p=0.001) were more frequent in females. More additional procedures were performed to eliminate non-pulmonary vein foci in females than males (p<0.05), but those locations were similar between the genders. The incidence of procedure-related complications was similar between genders (p=0.73). Sinus rhythm was similarly maintained between females and males after the first CA (56.4% vs. 59.3% at 5 years, p=0.24), but was significantly lower in females after the last CA (76.5% vs. 81.3% at 5 years, p=0.007). More females did refuse multiple CA procedures (especially a second one) than males (37.8% in females vs. 27.4% in males, p=0.02). The age (HR, 0.98/y, p=0.01), duration of AF (HR, 1.04/y, p=0.0001), number of failed anti-arrhythmic-drugs (HR, 1.10, p=0.03) and LADI (HR, 1.89 per 10mm/m(2), p=0.001) were significantly associated with AF-recurrence in males, but not in females. Specific differences and similarities between the genders were observed in PAF patients undergoing CA.

Clinical correlates of immediate success and outcome at 1-year follow-up of real-world cardioversion of atrial fibrillation: the Euro Heart Survey

In atrial fibrillation (AF) cardioversion is the cornerstone of the rhythm management strategy despite the lack of contemporary data on acute and long-term success. We aim to describe present-day cardioversion of AF and identify characteristics associated with immediate and long-term outcome. Based on the 5333 AF patients enrolled in the multi-centre prospective Euro Heart Survey on AF we selected the 1801 patients undergoing cardioversion at enrolment. Sinus rhythm (SR) was restored in 630 of 712 (88%), 458 of 643 (71%), and 333 of 446 (75%) (P< 0.001) of the electrical (ECV), intravenous (ivCCV), and oral (oCCV) chemical cardioversions, respectively, at the cost of few (4.2%) major complications. In multivariate analysis, absence of chronic obstructive pulmonary disease (COPD) (P< 0.001), presence of paroxysmal AF (PAF) (P= 0.013), and use of biphasic waveform (P= 0.018) were predictors of successful ECV. For ivCCV PAF (P< 0.001), absence of valvular heart disease (P= 0.004), and heart failure (P= 0.009), the presence of hypertension (P= 0.018) and coronary artery disease (P= 0.007) were predictive. Success of oCCV was driven by PAF (P< 0.001) and a smaller left atrial dimension (P= 0.001). At 1-year follow-up 893 of 1271 (70%) patients were in SR. Multivariate analysis revealed PAF (P< 0.001), shorter total AF history (P< 0.001), continuous use of Class Ic drugs or amiodarone during follow-up (P< 0.001), absence of COPD (P= 0.003), younger age (P= 0.004), and smaller left atrial dimension (P= 0.005) as independent predictors of SR at 1-year follow-up. Contemporary cardioversion of AF is routinely successfully and safely performed with a high proportion of patients in SR at 1-year follow-up.

Changes in Mitral Regurgitation After Balloon Aortic Valvuloplasty

The coexistence of mitral regurgitation (MR) in patients with severe aortic stenosis (AS) is not infrequent and has been associated with adverse outcome. The aims of this study were to evaluate the change in MR severity and to identify the correlates of MR improvement in patients with severe AS and moderate to severe MR who underwent balloon aortic valvuloplasty (BAV). Patients with severe AS and at least moderate MR who underwent their first BAV procedures (n = 74) were divided into 2 groups: patients with improved- (n = 34 [46%]) and those without improved (n = 40 [54%]) MR after BAV on transthoracic echocardiography. The population had a mean age of 84 years and was more frequently female (63.5%), with a high risk profile (mean Society of Thoracic Surgeons score 15%, mean European System for Cardiac Operative Risk Evaluation score 57%). Baseline characteristics were balanced between the 2 groups. Patients with improved MR after BAV had smaller left atrial dimensions (45 ± 7 vs 49 ± 7 mm, p = 0.01) and lower peak aortic velocities (3.7 ± 0.6 vs 4.0 ± 0.8 m/s, p = 0.05) and mean transaortic valve gradients (33.2 ± 12.1 vs 40.6 ± 17.4 mm Hg, p = 0.05) at baseline. Left atrial dimension [odds ratio (OR) 3.37, p = 0.006], left ventricular end-diastolic dimension (OR 2.7, p = 0.04), and mean transaortic valve gradient (OR 1.04, p = 0.05), but not left ventricular systolic function or functional MR, were correlated with MR improvement by logistic regression analysis. In conclusion, nearly half of the patients with severe AS and coexistent MR showed improvement in the magnitude of MR after BAV. Larger left atrial and left ventricular end-diastolic dimensions and higher transaortic valve gradients were associated with lack of MR improvement.

Prospective Comparative Study of Intravenous Cibenzoline and Disopyramide Therapy in the Treatment of Paroxysmal Atrial Fibrillation After Cardiovascular Surgery

It has been reported that approximately one-third of patients undergoing cardiovascular surgery experience paroxysmal atrial fibrillation (AF) during the postoperative period. There is, however, little information on the selection of anti-arrhythmic drugs for terminating postoperative paroxysmal AF. Between April 2007 and March 2009, 118 patients (76 men, 42 women, mean age 68+/-10 years) who had postoperative paroxysmal AF lasting > or =30 min were randomly assigned to receive either iv cibenzoline (70 mg, n=60) or disopyramide (50 mg, n=58) for terminating postoperative paroxysmal AF. The success rate of iv cibenzoline therapy (47%) was significantly greater than that of iv disopyramide therapy (24%; P<0.05). To identify clinical factors to increase the termination efficacy of iv cibenzoline, multivariate logistic regression was used to adjust for several covariates and to generate adjusted odds ratios (OR). The significant variables for the termination of paroxysmal AF after iv cibenzoline therapy were pretreatment with oral beta-adrenergic blockers (OR =8.224, P=0.030) and smaller left atrial dimensions (OR =0.879, P=0.039). The efficacy of iv cibenzoline for the termination of postoperative paroxysmal AF was significantly better than that of disopyramide, especially in patients with pre-administration of oral beta-adrenergic blockers and those with smaller left atrium.

Treatment strategy and clinical outcome in Japanese patients with atrial fibrillation

Many large-scale randomized control trials (RCTs) have been performed regarding treatment strategy in atrial fibrillation (AF) in Western countries and also in Japan. However, limited data are available concerning real-world relationships between the treatment strategy and prognosis of AF patients. Out of a prospective cohort of The Shinken Database 2004 (n = 2 412), 286 AF patients (male 205, 64.1 +/- 12.3 years, paroxysmal form 165) were retrospectively investigated. The percentage of AF patients under the rhythm control strategy was evaluated using the Kaplan-Meier method, which showed the cumulative proportion of rhythm control strategy was approximately 30% at the 90th day after the initial visit and 40.0% at 1 year. The average time to the first rhythm control strategy was 68.3 +/- 106.7 days. Those under rhythm control strategy were associated with fewer coexisting organic cardiac diseases, a younger age, and smaller left atrial dimension. Consequently, they showed very good prognosis (cumulative incidence rate of cardiovascular events at 1 year was 0.0%). Careful induction of rhythm control strategy, which was adopted in approximately 40% of the patients in the real world, was associated with fewer comorbidities and therefore might lead to better prognosis, although this does not mean the direct effects of rhythm control strategy.

Effects of cavotricuspid isthmus catheter ablation on paroxysmal atrial fibrillation.

It has been demonstrated that successful cavotricuspid isthmus ablation of typical atrial flutter combined with atrial fibrillation (AF) sometimes influences the preablation history of paroxysmal AF. However, the effectiveness of only isthmus ablation on AF itself is unclear. Endocardial catheter mapping during induced AF was performed around the tricuspid annulus using duodecapolar clectrode catheters in 39 patients with drug-refractory paroxysmal AF. Isthmus ablation was performed in 16 patients (41%) in whom catheter mapping during AF showed an organized activation pattern around the tricuspid annulus. During a mean follow-up of 12.3 months, isthmus ablation was successful in preventing AF in 12 (75%) patients, 8 without medication and 4 with a previously ineffective drug. This success group had a significantly higher F wave amplitude in lead V1 (0.29+/-0.10 vs 0. 15+/-0.04 mV, p < 0.01), a higher left ventricular ejection fraction (74+/-9 vs 58+/-2%, p < 0.05), and a smaller left atrial dimension (35+/-6 vs 43+/-4 mm, p < 0.05) than the failure group. Isthmus ablation may be effective in preventing paroxysmal AF with an organized activation pattern around the tricuspid annulus. F wave amplitude, left ventricular ejection fraction, and left atrial dimension were significant predictors of success.

A Left Atrial Thrombus Is Not an Absolute Limitation to Balloon Mitral Commissurotomy for Patients with Mitral Stenosis

Previous reports did not encourage balloon mitral commissurotomy (BMC) when left atrial (LA) thrombi were located beyond LA appendage. We hypothesize that LA thrombi may be resolved in some patients after anticoagulant therapy, and BMC can be performed subsequently. In the present study, we used transesophageal echocardiography (TEE) to evaluate the effects of anticoagulant on LA thrombi in patients with mitral stenosis, to compare the clinical differences between patients with (group A) and without (group B) resolution of LA thrombi, and to evaluate the safety of subsequent BMC in these patients. TEE was performed on 190 consecutive patients with mitral stenosis; 14 (7.4%) of them were found with LA thrombi. Serial TEE was performed and optimal anticoagulant therapy was achieved in all 14 patients. The thrombi were located within the LA appendage in 6 cases, attached to the LA posterior wall in 5, posterior wall and interatrial septum in 1, and LA appendage and posterior wall in 2. Based on the 6-month TEE follow-up, we found that the LA thrombi disappeared in 8 (57.2%) patients (group A) and persisted in 6 patients (group B). LA thrombi resolved within 3 months in 7 group A patients (87.5%). Furthermore, the resolution of LA thrombi was more frequently observed in patients either with a smaller LA dimension (51.9 ± 3.4 vs. 57.8 ± 4.8 mm, p = 0.02) or with their thrombi located inside their LA appendage (p = 0.03). No differences in other clinical and echocardiographic variables were noted between these two groups. Subsequently, group A patients underwent BMC without complications of systemic embolization. In conclusion, LA thrombi can be resolved after optimal anticoagulant therapy in a considerable proportion of patients with mitral stenosis. Serial TEE studies are helpful to observe LA thrombus resolution; they may also be useful in planning the treatment strategy.

Prognosis of completely asymptomatic adult patients with hypertrophic cardiomyopathy

Objectives. We investigated the long-term prognosis of completely asymptomatic adult patients with hypertrophic cardiomyopathy (HC). Diagnosis of HC was suspected because of an abnormal electrocardiogram and/or cardiac murmur and confirmed by echocardiography and/or left ventricular angiography, and hemodynamic investigation.Background. Hypertrophic cardiomyopathy shows marked heterogeneity in clinical expression and prognosis. The prognosis of asymptomatic patients with HC has not been fully defined.Methods. Of 128 consecutive adult patients with HC, 58 asymptomatic patients (Group 1, mean age 42.8 years) and 70 symptomatic patients (Group 2, mean age 50.4 years) were studied to assess cardiac mortality. Mean follow-up periods were 11.0 years for Group 1 and 9.1 years for Group 2.Results. At presentation, Group 1 patients were younger and had smaller left atrial dimensions than did Group 2 patients. The annual cardiac mortality rate and the rate for sudden death alone in Group 1 were significantly lower than in Group 2 (0.9% vs. 1.9%, p < 0.05, 0.1% vs. 1.4%, p < 0.05, respectively). Although about one-third of the survivors in Group 1 had cardiac symptoms at their most recent evaluation, only one patient died suddenly compared with eight in Group 2. The annual mortality rate due to heart failure was similar in each group. Only a syncopal episode was associated with both cardiac death and sudden death for both groups combined.Conclusions. The cardiac mortality rate for completely asymptomatic adult patients with HC was very low, significantly lower than that of symptomatic patients, and there was a disproportionately low incidence of sudden death.

Disuse atrophy of the left ventricle in chronically bedridden elderly people.

In the elderly cardiac size and function are determined by their level of physical activity. In this study, we assessed by echocardiography, the anatomic and physiologic changes of the heart in 28 elderly patients who had no cardiac disease and who were chronically bedridden. The data obtained were compared to those obtained from a control group of 38 age and sex matched elderly people whose activities had not been restricted. Chronically bedridden patients had markedly smaller left ventricular dimensions in both end-diastole and end-systole and smaller left atrial dimensions than did control subjects (3.7 +/- 0.7 vs 4.7 +/- 0.6 cm, p less than 0.001, 2.4 +/- 0.8 vs 2.9 +/- 0.7 cm, p less than 0.02 and 3.2 +/- 0.5 vs 3.8 +/- 0.9 cm, p less than 0.01, respectively). Though the wall thickness of the interventricular septum did not differ between the study groups, the left ventricular posterior walls of the bedridden group were significantly thinner than in the control group (0.8 +/- 0.2 vs 1.0 +/- 0.2 cm, p less than 0.01). The bedridden group had a significantly lower stroke index (26.9 +/- 6.2 vs 47.0 +/- 11.1 ml/m2, p less than 0.001) and cardiac index (1.84 +/- 0.52 vs 3.15 +/- 0.63 l/min/m2, p less than 0.001) than did the control group. Left ventricular mass index and left ventricular systolic stress were significantly lower in bedridden patients than in control subjects (88.0 +/- 18.1 vs 143.5 +/- 30.9 g/m2, p less than 0.001, and 135.9 +/- 4.9 vs 186.6 +/- 35.7 10(3) dynes/cm2, p less than 0.001, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiovascular Findings in Quadriplegic and Paraplegic Patients and in Normal Subjects

Seven normal, 7 paraplegic and 7 quadriplegic patients underwent cross-sectional cardiovascular evaluation, including recording of sitting heart rate, blood pressure and echocardiography. Quadriplegic patients had a 26% lower left ventricular (LV) mass index (75 +/- 13 g/m2, p less than 0.01) compared with normal volunteers (102 +/- 16 g/m2) or paraplegic patients (110 +/- 26 g/m2). Six quadriplegic patients and 3 paraplegic patients had an unusual pattern of LV posterior wall asynergy, which was associated with a significant rightward shift of the frontal-plane QRS axis (92 +/- 22 degrees vs 42 +/- 41 degrees, p less than 0.005) and smaller left atrial dimensions (2.4 +/- 0.4 vs 3.0 +/- 0.3 cm, p less than 0.005). The quadriplegic group was characterized by a significantly reduced mean blood pressure (67 +/- 7 vs 88 +/- 8 mm Hg in normal subjects, p less than 0.002), high normal peripheral resistances (22 +/- 5 vs 17 +/- 5 units in normal subjects, difference not significant) and a markedly reduced calculated cardiac output (3.2 +/- 0.6 vs 5.4 +/- 1.4 liters/min in normal subjects, p less than 0.01). Hemodynamic data for the paraplegic patients were similar to those in the normal group. A decrease in LV wall stress, mediated primarily by a decrease in venous return, appeared to result in the adaptive cardiac atrophy seen in these quadriplegic patients. LV asynergy was common and also may be related to a decrease in cardiac filling.

Cardiovascular findings in quadriplegic and paraplegic patients and in normal subjects

Seven normal, 7 paraplegic and 7 quadriplegic patients underwent cross-sectional cardiovascular evaluation, including recording of sitting heart rate, blood pressure and echocardiography. Quadriplegic patients had a 26% lower left ventricular (LV) mass index (75 ± 13 g/m 2, p < 0.01) compared with normal volunteers (102 ± 16 g/m 2) or paraplegic patients (110 ± 26 g/m 2). Six quadriplegic patients and 3 paraplegic patients had an unusual pattern of LV posterior wall asynergy, which was associated with a significant rightward shift of the frontal-plane QRS axis (92 ± 22 ° vs 42 ± 41 °, p < 0.005) and smaller left atrial dimensions (2.4 ± 0.4 vs 3.0 ± 0.3 cm, p < 0.005). The quadriplegic group was characterized by a significantly reduced mean blood pressure (67 ± 7 vs 88 ± 8 mm Hg in normal subjects, p < 0.002), high normal peripheral resistances (22 ± 5 vs 17 ± 5 units in normal subjects, difference not significant) and a markedly reduced calculated cardiac output (3.2 ± 0.6 vs 5.4 ± 1.4 liters/min in normal subjects, p < 0.01). Hemodynamic data for the paraplegic patients were similar to those in the normal group. A decrease in LV wall stress, mediated primarily by a decrease in venous return, appeared to result in the “adaptive” cardiac atrophy seen in these quadriplegic patients. LV asynergy was common and also may be related to a decrease in cardiac filling.